Pediatric Antifungal Utilization: New Drugs, New Trends

Priya A. Prasad, MPH; Susan E. Coffin, MD, MPH; Kateri H. Leckerman, MS; Thomas J. Walsh, MD; Theoklis E. Zaoutis, MD, MSCE

Disclosures

Pediatr Infect Dis J. 2008;27(12):1083-1088. 

In This Article

Abstract and Introduction

Abstract

Background: The frequency and severity of invasive fungal infections in immunocompromised patients has increased steadily over the last 2 decades. In response to the increased incidence and high mortality rates, novel antifungal agents have been developed to expand the breadth and effectiveness of treatment options available to clinicians. Despite these therapeutic advances, the impact of the availability of new antifungal agents on pediatric practice is unknown.
Methods: A retrospective cohort study was conducted using the Pediatric Health Information System database to describe the changes in pediatric antifungal therapy at 25 freestanding United States children's hospitals from 2000 to 2006. All pediatric inpatients who received a charge for one or more of the following agents were included in the analysis: conventional amphotericin B (AMB), lipid amphotericin B, fluconazole, itraconazole, voriconazole, flucytosine, caspofungin, and micafungin. Underlying conditions and fungal infection status were ascertained.
Results: A total of 62,842 patients received antifungal therapy, with prescriptions significantly increasing during the 7-year study period (P = 0.03). The most commonly prescribed antifungal agent was fluconazole (76%), followed by amphotericin preparations (26%). Prescription of AMB steadily decreased from 2000 to 2006 (P = 0.02). Prescription of voriconazole steadily increased during the study period and replaced AMB for the treatment of aspergillosis. The echinocandins steadily increased in prescription for treatment of fungal infections, particularly in disseminated/systemic candidiasis.
Conclusions: We found that the number of pediatric inpatients requiring antifungal therapy has increased significantly and the choice of treatment has changed dramatically with the introduction of newer antifungal agents.

Introduction

Invasive fungal infections are important causes of morbidity and mortality in immunocompromised children. As a result of advances in supportive medical care, children with life-threatening illnesses have experienced overall reductions in morbidity and mortality associated with cancer therapy and stem cell or solid organ transplantation. These same children, however, are now at increased risk for developing invasive fungal infections,[1,2] the majority of which are caused by Candida and Aspergillus species and are associated with significant crude and attributable mortality.[3,4,5,6,7,8,9,10]

In response to the increased incidence and high mortality rates associated with invasive fungal infections, novel antifungal agents have been developed to expand the breadth and effectiveness of treatment options available to clinicians.[3,11,12] Since its initial approval in 1958, conventional amphotericin B (AMB) deoxycholate has been considered the standard in treatment for invasive fungal infections.[1,11,13,14] Because of the dose-limiting toxicity of conventional amphotericin B deoxycholate, lipid formulations of amphotericin (LFABs) and newer agents have been developed to potentially improve outcomes and mitigate the adverse effects associated with antifungal therapy.

Despite these therapeutic advances, the impact of the availability of new antifungal agents on pediatric practice is unknown. The objective of this study was to describe the changes in pediatric antifungal therapy in hospitalized children from 2000 to 2006.

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