The Assessment of Antifungal Stewardship Implementation in a Tertiary Care Hospital in South Africa: Evaluating Knowledge, Attitudes and Practices of Healthcare Professionals and Developing Evidence-Based Guidelines

Abstract

Antifungal resistance is a growing concern in healthcare settings worldwide, driven by the overuse and misuse of antifungal agents. This issue is particularly severe in South Africa, where a high burden of fungal diseases is further complicated by a large immunocompromised population due to HIV and tuberculosis. Antifungal stewardship aims to optimise the use of antifungal medications to improve patient outcomes, reduce resistance, and minimize adverse effects. However, successful implementation of these programs requires a thorough understanding of healthcare professionals' knowledge, attitudes, and practices (KAP) regarding antifungal use. This study seeks to evaluate the current KAP of healthcare professionals, including doctors, pharmacists, and nurses, towards antifungal prescribing and management at a tertiary public healthcare setting, in Gauteng, South Africa. This research endeavours to enhance antifungal stewardship efforts, promote responsible antifungal use, and improve patient care outcomes within the hospital setting. A quantitative research approach was adopted to garner data on the KAP of the study population towards antifungal stewardship, whilst a retrospective prescription analysis undertaken to assess antifungal prescribing practices. Results from the KAP survey demonstrated that 60.6% of healthcare professionals lacked confidence in their knowledge and practices related to antifungal agents, with only 14.5% being familiar with local guidelines. A significant 96.0% agreed on the need for more education on invasive fungal infections, and 91.8% recognized the need for a rational use framework that is specific to the use of antifungal agents in addition to the Standard Treatment Guidelines. Study participants felt that the primary factor contributing to inappropriate antifungal use was the prescribers' lack of knowledge of antifungal agents which may include a broad spectrum of considerations such as indication, dose, dosing interval, duration of therapy or drug related interactions. An analysis of 370 antifungal prescriptions from the various departments within a tertiary care hospital setting revealed that only 37.0% of the patients receiving an antifungal agent were diagnosed with a fungal infection. A total of 75 prescription errors were observed ranging from duration to dosing interval errors. Microbiological culturing was only performed in 10.5% of cases, with susceptibility testing in only 0.3%. Fluconazole was the most frequently prescribed antifungal. vi As one of the earliest studies conducted in South Africa to focus exclusively on antifungal agents and antifungal stewardship, the findings highlight a critical need for improved antifungal stewardship and more comprehensive education for healthcare professionals to ensure positive antifungal treatment outcomes. This study emphasises the importance of a collaborative approach to antifungal stewardship, involving ongoing education and shared responsibility among all healthcare professionals.