USE OF ANTIFUNGAL THERAPY IN HOSPITALIZED-PATIENTS .2. RESULTS AFTER THE MARKETING OF FLUCONAZOLE

OBJECTIVE: To evaluate the prescribing patterns of antifungal agents i n the hospital setting after the introduction of fluconazole, a new br oad-spectrum bis-triazole antifungal agent. Also compared are the pres cribing patterns of antifungal agents prior to (phase I) and following (phase II) fluconazole marketing. DESIGN: A prospective cohort of hos pitalized patients prescribed topical or systemic antifungal agents. D ata were collected from December 1990 to April 1991. SETTING: Fifty-se ven hospitals ranging in size from 100 to more than 500 beds. Sixty-th ree percent are affiliated with medical schools. PATIENTS: Participati ng pharmacists consecutively identified 15 patients receiving systemic antifungal therapy and 5 patients receiving topical antifungal therap y. INTERVENTIONS: Observational data on patient antifungal therapy, ri sk factors for fungal infections, comorbidities, concurrent medication s, and culture data were collected. MEASURES: Differences in prescribi ng patterns before and after the marketing of fluconazole were assesse d using t-tests and chi-square tests. RESULTS: Of 818 patients studied , 615 (75.2 percent) received systemic antifungal therapy. Five hundre d forty-six patients received a single antifungal agent; 348 (63.7 per cent) received fluconazole, 105 (19.2 percent) received ketoconazole, 92 (16.8 percent) received amphotericin B, and 1 (0.2 percent) receive d flucytosine. Sixty-nine patients received two or more systemic agent s either concurrently or consecutively. The use of parenteral amphoter icin B, alone or in combination with flucytosine and/or an azole, decl ined from 56.8 percent in the phase I study to 24.2 percent in the cur rent study. The use of parenteral therapy also declined from 56.8 to 4 0.2 percent. Ketoconazole was used in more than 90 percent of the oral and esophageal infections in the phase I study, but its use declined to only 33 percent in this study. Fluconazole was used most frequently across all sites of presumed or documented infections, with the excep tion of fungemia. Of the presumed or proven systemic or blood infectio ns, amphotericin B was used alone or in combination in 48.4 percent of the patients and fluconazole was used exclusively in 39.0 percent of the patients. Fluconazole was used more often than amphotericin B (22 vs. 3 patients, respectively) for prophylaxis of systemic infections. The overall use of antifungal prophylaxis also increased from the phas e I (9.5 percent) to phase II (13.7 percent). CONCLUSIONS: The introdu ction of fluconazole had a major impact on the prescribing patterns of antifungal therapy. Although amphotericin B remained the preferred ag ent for treatment of suspected or proven systemic, central nervous sys tem, or blood infections, use of fluconazole for these indications app roached nearly 40 percent. Further studies are needed to address the r ole of fluconazole in the prophylaxis and treatment of systemic mycose s.