INTRODUCTION 

Antimicrobial stewardship practices are crucial in combating the growing threat of antimicrobial resistance (AMR) worldwide. While much attention has been given to the appropriate use of antibiotics, it is equally important to address the responsible use of antifungal agents. In the Indian setting, the need for antifungal stewardship has become increasingly evident due to the rising incidence of fungal infections, particularly among immunocompromised individuals.

India, with its diverse population and high burden of infectious diseases, faces unique challenges in implementing effective antifungal stewardship practices. The country has witnessed a surge in fungal infections, such as Candidiasis, Aspergillosis and Mucormycosis, especially in the post-COVID-19 era. These infections are associated with rapid progression and an increase in mortality if not treated at the right time appropriately.

To address this issue, the Indian healthcare system must prioritize antifungal stewardship initiatives. This involves establishing guidelines and protocols for the appropriate use of antifungal agents, promoting surveillance of fungal infections and fostering collaboration between healthcare professionals, microbiologists and pharmacists. Additionally, raising awareness among patients and the general public about the importance of responsible antifungal use can contribute to the overall success of stewardship efforts.

By implementing effective antifungal stewardship practices, India can mitigate the emergence and spread of antifungal resistance, improve patient outcomes, and optimize healthcare resources. 

In this context, the ASPICON 2023 was organized by All India Institute of Medical Sciences (Jodhpur), from 29th September to 1st October 2023 under the aegis of the Society of Antimicrobial Stewardship Practices (SASPI) in India with the following aim and objectives.

The theme of the event was ‘Antifungal Stewardship’.

AIM

The main aim of the ASPICON 2023 was to exchange knowledge, share best practices and collaborate to enhance the best antimicrobial stewardship practices in India, with a particular need to focus on ” Antifungal Stewardship.”

OBJECTIVES

1. Awareness: Raise awareness among healthcare professionals about the importance of antifungal stewardship and the appropriate use of antifungal agents.

2. Education and training: Development and implementation of educational programs and training initiatives to enhance the knowledge and skills of healthcare professionals regarding antifungal stewardship practices, including appropriate prescribing, dosage optimization and monitoring of antifungal therapy.

3. Guidelines and protocols: Develop evidence-based guidelines and protocols for appropriate use of antimicrobial and antifungal agents considering local epidemiology, resistance patterns and available resources.

4. Surveillance and monitoring: Establish robust surveillance systems to monitor antifungal resistance, utilization patterns and outcomes of antifungal therapy; regularly analyze and report data to identify trends, areas of improvement and potential interventions.

5. Antifungal stewardship teams: Establish multidisciplinary teams in healthcare facilities to promote collaboration, facilitate communication and implement strategies for optimizing antifungal therapy.

6. Antifungal formulary management: Develop and maintain an antifungal formulary that promotes the rational use of antifungal agents, considering efficacy, safety, cost-effectiveness and local resistance patterns.

7. Antifungal prescribing guidelines: Develop and disseminate evidence-based antifungal prescribing guidelines to assist healthcare professionals in making informed decisions regarding antifungal therapy, including appropriate drug selection, dosing and duration of treatment.

8. Evaluation and feedback

CONFERENCE DAY 1

Some of the key presentations of Day 1 of the conference are summarised below.

Antifungal stewardship long way to go….

One of the primary challenges in antifungal stewardship (AFS) is the need for more awareness and understanding among healthcare professionals regarding the appropriate use of antifungal agents. Unlike antibiotics, which are widely prescribed, antifungal medications are often reserved for specific indications, such as invasive fungal infections or severe cases of fungal diseases. However, inappropriate prescribing practices, including overuse, underuse or incorrect dosing, can contribute to the development of antifungal resistance.

Optimizing Antibiotic therapy in transplant settings – Impact of AMS

 Optimizing antibiotic therapy is of paramount importance in transplant settings, where patients are particularly vulnerable to infections due to immunosuppression. Antimicrobial stewardship (AMS) program is crucial in ensuring the appropriate and effective use of antibiotics in these settings. By implementing AMS strategies, healthcare providers can minimize the emergence of antibiotic resistance, reduce adverse events and improve patient outcomes.

AMS programs in transplant settings aim to optimize antibiotic therapy by promoting evidence-based prescribing practices. This involves the development of guidelines and protocols tailored to the unique needs of transplant patients, taking into account factors such as immunosuppression, organ type and risk of specific infections.

Enhancing care in Indian ICU- vital role of AMS in combating CRO

In India, the prevalence of CRO infections in ICUs has been on the rise, leading to increased morbidity, mortality and healthcare costs. Factors such as overuse and misuse of antibiotics, inadequate infection control practices and limited access to newer antimicrobial agents contribute to the emergence and spread of CRO.

 Role of combination antimicrobial therapy – When, Where & How?

The role of combination antimicrobial therapy is essential in managing certain infections, especially when the patient is in sepsis.

§  Empiric combination therapy: In some cases, empiric combination therapy may be recommended when the causative pathogen is unknown, or there is a high risk of multidrug-resistant organisms. This approach aims to provide broad-spectrum coverage and increase the likelihood of targeting the infecting organism.

§  Targeted Combination Therapy: once the causative pathogen is identified and its susceptibility profile is known, targeted combination therapy may be considered. This approach is often used for infections caused by certain organisms known to have intrinsic resistance mechanisms or infections that are difficult to treat or complicated persistent bacteremia. The combination of antibiotics with different mechanisms of action can enhance efficacy and prevent the development of resistance. 

        Synergy: Combination therapy may also be employed to achieve synergistic effects. Synergy refers to the enhanced antimicrobial activity when two or more drugs are used together, resulting in a more significant impact than the sum of individual effects.

It is important to note that combination antimicrobial therapy should be guided by current guidelines and tailored to the specific clinical scenario. The decision to use combination therapy should be based on factors such as the severity of infection, the likelihood of resistance and the individual patient’s characteristics. Regular assessment of therapy is necessary to ensure optimal treatment outcomes and minimize the risk of adverse effects.

 FDC – Rational & irrational antimicrobials

FDC (Fixed dose Combination) combines two or more active pharmaceutical ingredients in a single dosage form. Regarding antimicrobials, the rational use of FDCs is essential to ensure effective treatment and minimize the development of antimicrobial resistance. However, the irrational use of FDCs can harm patient health and contribute to the global problems of antimicrobial resistance.

 CONFERENCE DAY 2

 The day started with the preliminary round of the Quiz competition.

The honorary speaker, Dr Brad Spellberg, delivered the opening presentation on ‘Shorter is Better‘ through virtual mode.

It was followed by a session on ‘Community IAS practices- who are leaders and how‘.

It was followed by sharing experiences by representatives from different Institutes of National Importance (INI) on AMS activities.

 Some key presentations from Day 2 of the conference were as follows:

 Practical AMSP decision-making- case scenarios

Why do we want stewardship in our daily practices?

 Effect of antibiotic stewardship on the incidence of infection and resistant bacteria and Clostridioides difficile infection. 

Aspects of practical decision-making in  AMSP include indication of antibiotic, choice of antibiotic, dose and dosing interval, route of administration, appropriateness of culture, therapeutic drug monitoring, duration of treatment, de escalation, source control, infection prevention and control practices.

 All the above aspects were discussed in various clinical syndromes like acute bronchitis, rhino-sinusitis, community-acquired pneumonia, prosthetic joint infection, urinary tract infection, ventilator-associated pneumonia, CRBSI, Candidemia and Clostridiodes difficile infection through case based approach.

 The home messages from the session were

• Small steps of stewardship always have a high impact on patient outcome
•  Hand hygiene is the step of IPC in wards and ICU
•  Clinicians should be aware of updates about MIC of isolates
•  A combined approach would be the key to AMSP

 Therapeutic drug monitoring: is it essential or dispensable?

 Therapeutic drug monitoring (TDM) involves using drug concentration measurements in body fluids to manage drug therapy for the cure/alleviation/prevention of disease.

The goal of the TDM is to individualize patient therapeutic regimens for optimal patient benefits, and it is achieved by maintaining the plasma/blood concentration of the drug within the therapeutic range, which is the dose range of the drug that has shown to be efficacious without causing toxic effects.

 Indications of TDM include the following.

• Drugs with narrow therapeutic index. e.g.- Phenytoin, Digoxin
• Drugs exhibiting large changes in response with small changes in plasma concentrations (i.e. non-linear kinetics), e.g., Theophylline
• Drugs with poor and erratic absorption.
• Drugs with wide inter-individual variability in metabolism.
• Patient exhibiting signs and symptoms of toxicity (e.g. persistent nausea with theophylline intake)
• To minimize the risk of toxicity and determine drug abuse.
• Patients on multiple drug therapy.
• Coexisting GI, hepatic or renal disease.
• To identify the poison and to determine its severity.
• Drugs with poorly defined endpoints (e.g. immunosuppressants) or where signs of overdose and underdose are challenging to distinguish.

§         To assess medicine compliance in certain cases.

 Plasma drug concentration measurements alone may be helpful in several circumstances, although each indication may not apply equally to every drug. TDM has proven benefits like

improved compliance, decreased toxicity, more time in therapeutic range, fewer adverse effects, and shorter ICU and hospital stays.

However, factors like high costs and invasiveness of the process limit its usage in routine clinical practice. Further, the processes that influence drug utilization in the body decrease the overall effectiveness of TDM.

Practice changing studies- Year 2022-23

Studies discussed in the session were as follows.

1.     MERCY Randomized clinical trial- comparing continuous versus intermittent meropenem administration in critically ill patients with sepsis. (JAMA, June 2023)

2.     AMBITION trial- Single-dose liposomal Amphotericin B treatment for cryptococcal meningitis. (NEJM, March 2022)

3.     OVERCOME trial- Colistin monotherapy versus combination therapy for carbapenem-resistant organisms. (NEJM, December 2022)

4.     Comparison of 8 versus 15 days of antibiotic therapy for Pseudomonas aeruginosa ventilator-associated pneumonia in adults: a randomized, controlled, open-label trial. (Intensive Care Medicine, 2022)

5.     1,3- ß-D- glucan- guided antifungal therapy in adults with sepsis: the CandiSep randomized clinical trial (Intensive care medicine, 2022)

 Also, the following seven categories of change barriers published by Cabana et al. in JAMA were discussed in this session.

1. Lack of awareness (don’t know guidelines exist)
2. Lack of familiarity (know guidelines exist but don’t know the details)
3. Lack of agreement (don’t agree with recommendations)
4. Lack of self-efficacy (don’t think they can do it)
5. Lack of outcome expectancy (don’t think it will work)
6. Inertia (don’t want to change)
7. External barriers (want to change but blocked by system factors)

Interactive case studies: Haemato-oncology, ICU & Pulmonology

 Three cases were discussed by the residents of the respective departments on invasive candidiasis, febrile neutropenia and VAP caused by CRE. Through the cases, interactive discussion was conducted on developing a syndromic approach and multidisciplinary management and choosing appropriate antibiotics, escalation and de-escalation.

 RESEARCH PRESENTATIONS AND COMPETITIONS

Around 30 posters were assessed by a panel of esteemed judges – Dr Sagar Khadanga, Dr Ketan Priyadarshi, Dr Amit kumar Rohilla and Dr Aliza Mittal.

Oral Research presentations were conducted under the moderation of Dr Prasan Kumar Panda.

The stage round of the Quiz was conducted in hall B on Day 2 of the conference.

 The conference finally concluded with a prize distribution ceremony and a vote of thanks from the organizers.