Skip to main content Accessibility help

The current state of antifungal stewardship among pediatric antimicrobial stewardship programs

  • Lourdes Eguiguren (a1), Jason G. Newland (a2), Matthew P. Kronman (a3), Adam L. Hersh (a4), Jeffrey S. Gerber (a5), Grace M. Lee (a1) and Hayden T. Schwenk (a1)...



To characterize the current state of antifungal stewardship practices and perceptions of antifungal use among pediatric antimicrobial stewardship programs (ASPs).


We developed and distributed an electronic survey, which included 17 closed-ended questions about institutional antifungal stewardship practices and perceptions, among pediatric ASPs.


ASP physicians and pharmacists of 74 hospitals participating in the multicenter Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative.


We sent surveys to 74 hospitals and received 68 unique responses, for a response rate of 92%. Overall, 63 of 68 the respondent ASPs (93%) reported that they conduct 1 or more antifungal stewardship activities. Of these 68 hospital ASPs, 43 (63%) perform prospective audit and feedback (PAF) of antifungals. The most common reasons reported for not performing PAF of antifungals were not enough time or resources (19 of 25, 76%) and minimal institutional antifungal use (6 of 25, 24%). Also, 52 hospitals (76%) require preauthorization for 1 or more antifungal agents. The most commonly restricted antifungals were isavuconazole (42 of 52 hospitals, 80%) and posaconazole (39 of 52 hospitals, 75%). Furthermore, 33 ASPs (48%) agreed or strongly agreed that antifungals are inappropriately used at their institution, and only 25 of 68 (37%) of ASPs felt very confident making recommendations about antifungals.


Most pediatric ASPs steward antifungals, but the strategies employed are highly variable across surveyed institutions. Although nearly half of respondents identified inappropriate antifungal use as a problem at their institution, most ASPs do not feel confident making recommendations about antifungals. Future studies are needed to determine the rate of inappropriate antifungal use and the best antifungal stewardship strategies.


Corresponding author

Author for correspondence: Hayden T. Schwenk, E-mail:


Hide All
1.Lestner, JM, Versporten, A, Doerholt, K, et al.Systemic antifungal prescribing in neonates and children: outcomes from the Antibiotic Resistance and Prescribing in European Children (ARPEC) Study. Antimicrob Agents Chemother 2015;59:782789.
2.Valerio, M, Rodriguez-Gonzalez, CG, Munoz, P, et al.Evaluation of antifungal use in a tertiary care institution: antifungal stewardship urgently needed. J Antimicrob Chemother 2014;69:19931999.
3.Prasad, PA, Coffin, SE, Leckerman, KH, Walsh, TJ, Zaoutis, TE.Pediatric antifungal utilization: new drugs, new trends. Pediatr Infect Dis J 2008;27:10831088.
4.Downes, KJ, Ellis, D, Lavigne, S, Bryan, M, Zaoutis, TE, Fisher, BT.The use of echinocandins in hospitalized children in the United States. Med Mycol 2018. doi: 10.1093/mmy/myy084.
5.Santiago-Garcia, B, Rincon-Lopez, EM, Ponce Salas, B, et al.Effect of an intervention to improve the prescription of antifungals in pediatric hematology-oncology. Pediatr Blood Cancer 2020;67:e27963. doi: 10.1002/pbc.27963.
6.Warris, A, European Paediatric Mycology Network. The European Paediatric Mycology Network (EPMyN): towards a better understanding and management of fungal infections in children. Curr Fungal Infect Rep 2016;10:79.
7.Goldman, JL, Ross, RK, Lee, BR, et al.Variability in antifungal and antiviral use in hospitalized children. Infect Control Hosp Epidemiol 2017;38:743746.
8.Stultz, JS, Kohinke, R, Pakyz, AL.Variability in antifungal utilization among neonatal, pediatric, and adult inpatients in academic medical centers throughout the United States of America. BMC Infect Dis 2018;18:501.
9.Ananda-Rajah, MR, Cheng, A, Morrissey, CO, et al.Attributable hospital cost and antifungal treatment of invasive fungal diseases in high-risk hematology patients: an economic modeling approach. Antimicrob Agents Chemother 2011;55:19531960. Souza, MC, Santos, AG, Reis, AM.Adverse drug reactions in patients receiving systemic antifungal therapy at a high-complexity hospital. J Clin Pharmacol 2016;56:15071515.
11.Shah, DN, Yau, R, Lasco, TM, et al.Impact of prior inappropriate fluconazole dosing on isolation of fluconazole-nonsusceptible Candida species in hospitalized patients with candidemia. Antimicrob Agents Chemother 2012;56:32393243.
12.Hersh, AL, De Lurgio, SA, Thurm, C, et al.Antimicrobial stewardship programs in freestanding children’s hospitals. Pediatrics 2015;135:3339.
13.Kronman, MP, Banerjee, R, Duchon, J, et al.Expanding existing antimicrobial stewardship programs in pediatrics: what comes next. J Pediatric Infect Dis Soc 2018;7:241248.
14.Barlam, TF, Cosgrove, SE, Abbo, LM, et al.Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62:e51e77.
15.Hamdy, RF, Zaoutis, TE, Seo, SK.Antifungal stewardship considerations for adults and pediatrics. Virulence 2017;8:658672.
16.Honarvar, B, Bagheri Lankarani, K, Taghavi, M, Vahedi, G, Mortaz, E.Biomarker-guided antifungal stewardship policies for patients with invasive candidiasis. Curr Med Mycol 2018;4:3744.
17.Menichetti, F, Bertolino, G, Sozio, E, et al.Impact of infectious diseases consultation as a part of an antifungal stewardship programme on candidemia outcome in an Italian tertiary-care, university hospital. J Chemother 2018;30:304309.
18.Hart, E, Nguyen, M, Allen, M, Clark, CM, Jacobs, DM.A systematic review of the impact of antifungal stewardship interventions in the United States. Ann Clin Microbiol Antimicrob 2019;18:24.
19.Mondain, V, Lieutier, F, Hasseine, L, et al.A 6-year antifungal stewardship programme in a teaching hospital. Infection 2013;41:621628.
20.Valerio, M, Munoz, P, Rodriguez, CG, et al.Antifungal stewardship in a tertiary-care institution: a bedside intervention. Clin Microbiol Infect 2015;21:492, e491499.
21.Stenehjem, E, Hersh, AL, Buckel, WR, et al.Impact of implementing antibiotic stewardship programs in 15 small hospitals: a cluster-randomized intervention. Clin Infect Dis 2018;67:525532.
22.Tamma, PD, Avdic, E, Keenan, JF, et al.What is the more effective antibiotic stewardship intervention: preprescription authorization or postprescription review with feedback? Clin Infect Dis 2017;64:537543.
23.Hersh, AL, Beekmann, SE, Polgreen, PM, Zaoutis, TE, Newland, JG.Antimicrobial stewardship programs in pediatrics. Infect Control Hosp Epidemiol 2009;30:12111217.
24.Johannsson, B, Beekmann, SE, Srinivasan, A, Hersh, AL, Laxminarayan, R, Polgreen, PM.Improving antimicrobial stewardship: the evolution of programmatic strategies and barriers. Infect Control Hosp Epidemiol 2011;32:367374.
25.Newland, JG, Gerber, JS, Weissman, SJ, et al.Prevalence and characteristics of antimicrobial stewardship programs at freestanding children’s hospitals in the United States. Infect Control Hosp Epidemiol 2014;35:265271.
26.Munoz, P, Bouza, E, COMIC (Collaboration Group on Mycosis) study group. The current treatment landscape: the need for antifungal stewardship programmes. J Antimicrob Chemother 2016;71 suppl 2:ii5–ii12.
27.Ross, RK, Hersh, AL, Kronman, MP, Newland, JG, Gerber, JS.Cost of antimicrobial therapy across US children’s hospitals. Infect Control Hosp Epidemiol 2015;36:12421244.
28.Ferreras-Antolin, L, Irwin, A, Atra, A, et al.Neonatal antifungal consumption is dominated by prophylactic use; outcomes from the Pediatric Antifungal Stewardship: Optimizing Antifungal Prescription Study. Pediatr Infect Dis J 2019;38:12191223.
29.Park, WB, Kim, NH, Kim, KH, et al.The effect of therapeutic drug monitoring on safety and efficacy of voriconazole in invasive fungal infections: a randomized controlled trial. Clin Infect Dis 2012;55:10801087.
30.Lachenmayr, SJ, Berking, S, Horns, H, Strobach, D, Ostermann, H, Berger, K.Antifungal treatment in haematological and oncological patients: need for quality assessment in routine care. Mycoses 2018;61:464471.
31.Soler-Palacin, P, Frick, MA, Martin-Nalda, A, et al.Voriconazole drug monitoring in the management of invasive fungal infection in immunocompromised children: a prospective study. J Antimicrob Chemother 2012;67:700706.
32.Cordonnier, C, Pautas, C, Maury, S, et al.Empirical versus preemptive antifungal therapy for high-risk, febrile, neutropenic patients: a randomized, controlled trial. Clin Infect Dis 2009;48:10421051.
33.Hebart, H, Klingspor, L, Klingebiel, T, et al.A prospective randomized controlled trial comparing PCR-based and empirical treatment with liposomal amphotericin B in patients after allo-SCT. Bone Marrow Transplant 2009;43:553561.
34.Morrissey, CO, Chen, SC, Sorrell, TC, et al.Galactomannan and PCR versus culture and histology for directing use of antifungal treatment for invasive aspergillosis in high-risk haematology patients: a randomised controlled trial. Lancet Infect Dis 2013;13:519528.
35.Forsberg, K, Woodworth, K, Walters, M, et al.Candida auris: The recent emergence of a multidrug-resistant fungal pathogen. Med Mycol 2019;57:112.
Type Description Title
Supplementary materials

Eguiguren et al. supplementary material
Table S1

 Word (17 KB)
17 KB

The current state of antifungal stewardship among pediatric antimicrobial stewardship programs

  • Lourdes Eguiguren (a1), Jason G. Newland (a2), Matthew P. Kronman (a3), Adam L. Hersh (a4), Jeffrey S. Gerber (a5), Grace M. Lee (a1) and Hayden T. Schwenk (a1)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.