Antifungal stewardship in a tertiary hospital | Revista Iberoamericana de Micología

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[ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] 7 => array:3 [ "nombre" => "Elena" "apellidos" => "Muñez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Department of Internal Medicine (Infectious Disease Unit), Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Internal Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Preventive Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Pharmacology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Department of Pharmacy, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Department of Microbiology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Asesoramiento en la prescripción de antifúngicos en un hospital terciario" ] ] "textoCompleto" => "Invasive fungal infections (IFI) are a major cause of morbidity and mortality in hospitalized patients in many countries worldwide.<a class="elsevierStyleCrossRefs" href="#bib0195">4,9</a> The prompt initiation of effective antifungal therapy reduces patient mortality.<a class="elsevierStyleCrossRef" href="#bib0185">2</a> The poor prognosis associated with IFI combined with suboptimal diagnostic tools has driven the overuse of antifungal drugs which account for an important and increasing part of the cost of drugs for inpatients.<a class="elsevierStyleCrossRefs" href="#bib0185">2,20,24</a> Inappropriate use of antifungals also contributes to the global increase in antifungal resistance and the incidence of IFI due to emerging fungi.<a class="elsevierStyleCrossRefs" href="#bib0190">3,10,16</a>According to previous studies, most inappropriate antifungal prescriptions are due to difficulties in distinguishing between colonization and infection, little knowledge of the local rate of fluconazole resistance, limited awareness of the first line of treatment for IFI, low switching from intravenous to oral antifungal administration, no adjustment after microbiological results, and excessive length of therapy.<a class="elsevierStyleCrossRefs" href="#bib0310">27,30,34,35</a> Among the strategies to improve this situation the use of new technology for a rapid identification of fungal species must be highlighted.<a class="elsevierStyleCrossRef" href="#bib0180">1</a>The important role of antifungal agents in the management of IFIs along with the high costs and their recognized toxicities has been addressed as the principal justification for antifungal stewardship.<a class="elsevierStyleCrossRefs" href="#bib0190">3,10,16</a> However, antifungal stewardship has received very little attention in comparison with antibiotic stewardship.<a class="elsevierStyleCrossRef" href="#bib0350">35</a> It should be noted that the antifungal stewardship programmes (ASP) conducted to date have promoted a reduction in spending on antifungal drugs but not in mortality.<a class="elsevierStyleCrossRefs" href="#bib0275">20,27</a>The aim of this study was to determine the usefulness of an ASP programme in a tertiary hospital with a high number of hematological and solid organ transplantation patients.MethodsBetween 1st October 2012 and 31st May 2013, a prospective study was carried out in the Hospital Puerta de Hierro, Madrid, a tertiary university hospital with 600 beds that includes a surgical ICU (20 beds), medical ICU (20 beds) and an active solid organ and hematopoietic stem cell transplantation programme. Electronic medical records are available; they contain computerized prescriptions and progress notes made by physicians. The Local Hospital Infections Committee created a team responsible for implementing the programme. The team was coordinated by two infectious diseases (ID) specialists, and included a pharmacist, a pharmacologist, a preventive medicine specialist and a microbiologist.The study protocol was approved by the Local Ethics Committee. Requirements for patients’ informed consent were waived because the study was directed at attending physicians with the primary objective of assessing their adherence to ID recommendations entered in the patients’ electronic record. The aim of the programme was presented and discussed in the hospital's main departments during clinical meetings between staff and internal medicine residents.During this eight-month study the main activity was to perform a programmed review of antifungals prescriptions in hospitalized patients. This review was carried out by two ID specialists together with an internal medicine resident. A list of patients who were prescribed an antifungal considered restricted was provided by the hospital pharmacy department. Lipid formulations of amphotericin B, echinocandins and voriconazole were considered restricted antifungals. Posaconazole was not included in the study because its use was specifically restricted to prophylactic indications in hematologic patients. In the case of patients who were prescribed inadequate systemic antifungal treatments, a recommendation was included in the electronic medical record during the first working day. In most cases, there were neither direct interviews with the prescribing doctor nor patient examinations. On average, the physicians responsible for reviewing the patients (two ID specialists) devoted approximately one hour per day to this activity. Patients could be included more than once if they received any antifungal several times during the study period. Fungal infections in study patients were classified as possible, probable or proven according to recent European Organization for Research and Treatment of Cancer criteria.<a class="elsevierStyleCrossRef" href="#bib0210">7</a> Antifungal prescriptions were regarded as amendable if they were not considered clinically justified and/or did not follow local, national or international guidelines.<a class="elsevierStyleCrossRefs" href="#bib0235">12,15,24,32</a> The identification of fungal species was performed by conventional cultures, implementing special techniques when necessary.<a class="elsevierStyleCrossRef" href="#bib0205">6</a> Antifungal susceptibility testing was performed on the isolates according to the microdilution broth procedures CLSI M27-A3 and EUCAST.<a class="elsevierStyleCrossRef" href="#bib0305">26</a>Special care was taken to neither criticize nor discredit current antifungal prescriptions due to the fact that several suitable options to treat the infections may exist, and also because the judgement of the investigators could not take into account certain patient characteristics only known by the treating clinicians.The record was reviewed again one week later in order to establish whether or not the prescribing physician had adhered to each recommendation. The physician was considered to have followed the recommendation if the appropriate modification had been made within 24h of the advice being given. The clinical records were reviewed six weeks later to assess complications and mortality. The quantities of the antifungals administered were recorded using defined daily doses (DDD).Paired categorical and continuous variables were compared using the chi-squared test and Mann–Whitney U-test, respectively. Significance was set at p<0.05.ResultsDuring the study period 280 restricted antifungals were prescribed for 262 patients. In 19 cases the patients were receiving two antifungal drugs (combined treatment). Mean age was 55 (±14) years and 101 patients (65%) were male. The mean hospital stay was 39.6 (±31.7) days. The indications for antifungal prescriptions were prophylactic in 85 cases (30.4%), pre-emptive in 10 cases (3.5%), empiric in 122 cases (43.6%), and directed in 63 cases (22.5%). Among this last group, 27 prescriptions (43%) corresponded to proven IFI (43%), 24 prescriptions (38%) to probable infection and 16 prescriptions (25%) to possible infection. Candida species were the most frequently isolated fungi followed by Aspergillus spp. (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Ten percent of the yeasts isolated were resistant to fluconazole: Candida krusei, 13 strains (100%), Candida glabrata, 4 strains (17%) and Rhodotorula spp., 2 strains (100%). Among those patients with Candida spp. in respiratory samples (129 cases), 19 patients (15%) received prophylactic treatment, 69 patients (53%) received empirical treatment, and 23 patients (18%) received a treatment directed against those fungal isolates from other samples. There were 18 cases (14%) that received inappropriate treatment, based only on yeast respiratory isolation.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The most frequent prescribed antifungal drugs in the studied patients were echinocandins and voriconazole (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Overall, 70 (25%) prescriptions in 61 patients were considered amendable. The reasons of inappropriateness are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. Proposed recommendations were addressed in 28 prescriptions (40%). In 49 cases the recommendation made was to change the antifungal drug (adherence 37%), in 15 cases it was to remove the antifungal agent (adherence 60%), in 5 cases to remove one of the antifungal agents in the combined treatment (adherence 20%), and finally the change in the administration route in 1 patient (adherence 0%, <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The adherence according to hospital departments and antifungal indications is expressed in <a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>. When the recommendation was to change the current antifungal treatment to liposomal amphotericin B, adherence was 71%; however, it was lower when the recommended antifungal was voriconazole (38%) or fluconazole (26%).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>The mortality among the patients treated according to the recommendations of the ASP was 17% (4 patients), and 30% in those whose treatment was not modified (11 patients, 2 due to infection) (p=0.393).Antifungal consumption from October 2011 to May 2012 was 5.06 daily defined doses (DDD) per 100 occupied bed-days, which decreased to 2.92 DDDs (42% lower) during October 2012 to May 2013. A decrease was detected in the use of all antifungal drugs during the second period (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>).<elsevierMultimedia ident="tbl0030"></elsevierMultimedia>DiscussionA quarter of the reviewed prescriptions were found to be amendable. As in similar studies, the most frequent causes of modifiable antifungal treatment were inadequate antifungal coverage, no confirmed infection, combined treatment not indicated or oral route indicated.<a class="elsevierStyleCrossRefs" href="#bib0185">2,21,27,34</a>The degree of adherence to recommendations in this study (40%) based on unsolicited consultations may be considered reasonable.<a class="elsevierStyleCrossRefs" href="#bib0230">11,17,22,34</a> This result may be encouraging taking into account the accused clinical severity of many patients, the suboptimal IFI diagnostic tools and the fact that the poor prognoses in many cases constitute relevant additional difficulties when giving antifungal advice.<a class="elsevierStyleCrossRefs" href="#bib0270">19,33</a> To improve adherence it is crucial that prescribing physicians rely on the wisdom and knowledge of the reviewer and maintain continual feedback.<a class="elsevierStyleCrossRefs" href="#bib0275">20,34</a> It should be considered that external reviewing physicians may be less compromised with the clinical evolution of the patient. This may explain why, even when susceptibility results are available to guide therapy, clinicians are often reluctant to de-escalate therapy when a seriously ill patient is improving with broad-spectrum treatment.<a class="elsevierStyleCrossRefs" href="#bib0270">19,33</a>The use of electronic clinical history record systems may help to save time when reviewing antimicrobial treatments and in optimizing the efficiency of this strategy.<a class="elsevierStyleCrossRef" href="#bib0340">33</a> Some factors that have previously been related to the success of such strategies are the knowledge of local fungal epidemiology and resistances, establishing therapeutic guidelines, implementation of treatment strategies for empirical, pre-emptive and prophylactic therapy in defined patient populations, catheter management guidelines and the rapid communication of test results from the microbiology laboratory personnel to the physician.<a class="elsevierStyleCrossRefs" href="#bib0245">14,18</a>The degree of adherence was higher when the recommendation was to remove the antifungal (60%), perhaps because in many of these cases the prescribing physician was persuaded that maintenance of the antifungal agent was not justified.<a class="elsevierStyleCrossRefs" href="#bib0255">16,17</a> Many of these recommendations are related to the lack of confirmatory microbiological results or to the limited diagnostic value of the isolation of Candida species in the respiratory tree, drainage or other locations other than the blood or sterile liquids.<a class="elsevierStyleCrossRef" href="#bib0195">4</a> Adherence was lower when the recommendation was to change the antifungal (37%). It should be noted that adherence was higher when the recommended antifungal agent was amphotericin B (which is perceived as a potent, broad-spectrum antifungal) than when the use of fluconazole was suggested.<a class="elsevierStyleCrossRefs" href="#bib0195">4,23,28</a> In one study, less than 40% of echinocandin-treated patients with fluconazole-susceptible organisms were de-escalated to fluconazole.<a class="elsevierStyleCrossRef" href="#bib0220">9</a> Knowledge of resistance in bloodstream yeast infection can be extremely helpful when making any recommendation.<a class="elsevierStyleCrossRef" href="#bib0220">9</a> Switching to oral route may be notable in the case of intravenous azoles because removing the intravenous line could prevent the development of blood stream infections.<a class="elsevierStyleCrossRef" href="#bib0240">13</a>The use of restricted antifungal during the intervention period was 42% lower than during the comparison period. These results are similar to other studies<a class="elsevierStyleCrossRefs" href="#bib0185">2,5</a> which observed that the main benefit of adherence to antifungal recommendations was reductions in hospital stays, adverse effects and cost,<a class="elsevierStyleCrossRefs" href="#bib0215">8,9</a> together with reduced resistance to antifungals in cases of community acquired candidiasis.<a class="elsevierStyleCrossRefs" href="#bib0215">8,9</a> It should be noted that, in the present study, the use of all restricted antifungals actually decreased but were more pronounced in the case of anidulafungin, micafungin and intravenous voriconazole. The reduction in the prescription of intravenous voriconazole could, in part, be explained by a change in the prescription from intravenous to oral treatment.<a class="elsevierStyleCrossRef" href="#bib0330">31</a> The lower mortality observed in patients treated according to the recommendations did not reach significance and may be more related to the severity of the patient with the persistence of antifungal treatment previously prescribed.<a class="elsevierStyleCrossRef" href="#bib0210">7</a> In addition, it should be noted that options other than those suggested by the researchers could have resulted in a favourable clinical outcome.Considering the marked use of antifungal treatments in hematologic and lung transplantation patients, it could be argued that ID consultations should be performed in services with the greatest consumption of antifungal agents such as hematology, transplant or the ICU,<a class="elsevierStyleCrossRefs" href="#bib0215">8,25,29</a> especially in hospitals that can only allocate limited human resources to ASPs. In addition, it would be preferable to target a few high cost antifungal drugs which may have suboptimal use, such as liposomal amphotericin, the echinocandins or intravenous voriconazole than to demonstrate an overall reduction in all antifungal drugs.<a class="elsevierStyleCrossRef" href="#bib0195">4</a>Some limitations to our study must be noted. The results obtained in the intervention period were compared with those of the previous 12 months; thus, a bias resulting from a change in patient characteristics cannot be discharged. Another limitation is that not all the changes in antimicrobial treatments could be attributed to written recommendations because a deterrent factor cannot be ruled out due to prescribers being aware that the restricted antifungal treatment was to be reviewed. In addition, due to the fact that this was a time-limited study, an increased consumption of antifungals during the months following the intervention cannot be ruled out.In summary, ASP in admitted patients may be successfully implemented with a high degree of compliance. This approach may be cost effective and could be included as part of an antimicrobial stewardship programme in institutions that devote limited human resources to improve antimicrobial prescribing.Conflicts of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres572479" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Aims" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec589538" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres572478" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec589539" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Methods" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "xack192913" "titulo" => "Acknowledgements" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-06-08" "fechaAceptado" => "2014-11-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec589538" "palabras" => array:6 [ 0 => "Antifungal agents" 1 => "Echinocandins" 2 => "Liposomal amphotericin B" 3 => "Fluconazole" 4 => "Inappropriate prescribing" 5 => "Drug costs" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec589539" "palabras" => array:6 [ 0 => "Agentes antifúngicos" 1 => "Equinocandinas" 2 => "Anfotericina B liposomal" 3 => "Fluconazol" 4 => "Prescripción inadecuada" 5 => "Coste farmacológico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundThe inappropriate use of antifungals is an important health problem related to increasing adverse effects, unnecessary cost and promotion of resistant and emerging fungal infections. Despite its relevance, many health institutions assign few resources to improve prescribing practices. AimsTo evaluate the efficiency of an antifungal stewardship programme (ASP) centered on restricted antifungal agents. MethodsThe main activity during the eight-month study was to perform a programmed review of restricted antifungals (lipid formulations of amphotericin B, echinocandins and voriconazole) prescribed in hospitalized patients. In the case of amendable antifungal treatment, a recommendation was included in the electronic medical record. ResultsA total of 280 antifungal prescriptions for 262 patients were revised during the study period. The indications were prophylactic in 85 cases (30.4%), pre-emptive in 10 cases (3.5%), empiric in 122 cases (43.6%), and directed in 63 cases (22.5%). A total of 70 prescriptions (25%) in 61 patients were considered to be amendable. In most of these cases, treatment could have been reduced considering the patient's clinical improvement and microbiological results. The most common advice was antifungals change (70%), antifungal withdrawal (21%), removal of one antifungal drug in cases of combined therapy (7%), and switching to oral route (1%). Proposed recommendations were addressed in 28 cases (40%). There was no significant difference in adherence with respect to the type of recommendation (p=0.554). There was a 42% lower use of antifungals during the period of the study compared to that observed during a similar previous period. Mortality among patients who were treated according to the recommendations of the ASP was 17% and in whom treatment was not modified it was 30% (p=0.393). ConclusionsASPs centered on hospitalized patients may be an efficient strategy to ameliorate antifungal use in hospitals." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Aims" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "AntecedentesEl uso inadecuado de los antifúngicos es un problema de salud relevante que puede incrementar los efectos adversos y generar costes innecesarios, además de favorecer la aparición de resistencias y de infecciones micóticas emergentes. A pesar de su importancia, muchas instituciones sanitarias destinan escasos recursos para mejorar las prácticas de prescripción. ObjetivosEvaluar la eficiencia de un programa de asesoramiento sobre antifúngicos basado en la prescripción de agentes antifúngicos restringidos. MétodosLa principal actividad durante el estudio de ocho meses de duración fue la realización de una revisión programada de antifúngicos restringidos, prescritos en los pacientes hospitalizados (formulaciones lipídicas de anfotericina B, equinocandinas y voriconazol). En el caso del tratamiento antifúngico modificable, se procedió a anotar una recomendación en la historia clínica electrónica. ResultadosSe revisó un total de 280 prescripciones de antifúngicos en 262 pacientes durante el período de estudio. Las indicaciones fueron de tipo profiláctico en 85 casos (30,4%), anticipado en 10 (3,5%), empírico en 122 (43,6%) y dirigido en 63 (22,5%). Se consideraron modificables un total de 70 prescripciones (25%) en 61 pacientes. En la mayoría de estos casos, el tratamiento podía reducirse teniendo en cuenta la mejoría clínica y los resultados microbiológicos del paciente. La indicación más frecuentemente realizada fue el cambio de antifúngico (70%), seguido por la retirada de dicho fármaco (21%), la eliminación de uno de los fármacos antifúngicos en casos de tratamiento combinado (7%) y, finalmente, la sustitución del tratamiento por la administración oral (1%). Las recomendaciones propuestas se aceptaron en 28 casos (40%). No se produjo una diferencia significativa en la adherencia con respecto al tipo de recomendación (p=0,554). Durante el período de estudio se evidenció un descenso en el uso de antifúngicos del 42%, en comparación con el uso observado en un período previo similar. La mortalidad de los pacientes que fueron tratados de acuerdo con las recomendaciones fue del 17%, y del 30% en aquellos en los que no se modificó el tratamiento (p=0,393). ConclusionesEl programa de asesoramiento sobre los antifúngicos prescritos en pacientes hospitalizados puede resultar una estrategia eficaz para mejorar el uso de estos fármacos." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Blood \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Catheter \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Respiratory \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Urine \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Ascites fluid \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Other samples<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Aspergillus spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Candida albicans \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (40) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 (41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (38) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Candida glabrata \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (19) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Candida krusei \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Candida parapsilosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (23) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Candida spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Candida tropicalis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (29) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Scedosporium spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Rhodotorula mucilaginosa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other fungi<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">176 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab934280.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Other samples: wound exudate, stool, drainages." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Other fungi: Geotrichum spp. (1), Paecilomyces spp. (1) and Rhodotorula rubra (1)." ] ] ] "descripcion" => array:1 [ "en" => "Isolated fungi in microbiological samples." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Voriconazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99 (35) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Caspofungin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 (21) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Anidulafungin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (17) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Micafungin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Liposomal amphotericin B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (11) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Amphotericin B lipid complex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab934279.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "Posaconazole was not included because its use was restricted to prophylactic indications in hematologic patients." ] ] ] "descripcion" => array:1 [ "en" => "Restricted antifungal prescribed in 261 patients." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Reason of inappropriate treatment (proposed recommendation) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Inappropriate prescription \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Addressed recommendation \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Inadequate antifungal coverage (antifungal change) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (37) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Liposomal amphotericin B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (57) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Amphotericin B lipid complex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Echinocandins \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Voriconazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (20) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Non-confirmed infection (antifungal removal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (60) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Echinocandins \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (45) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Voriconazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Combined treatment not indicated (removal of one drug) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (20) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Liposomal amphotericin B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Echinocandins \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Oral route indicated (switch to oral route) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Voriconazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (40) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab934283.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Reasons of inappropriate antifungal treatment and addressed recommendation according to its indication." ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Department \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Surgical ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (29) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lung transplantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (26) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hematology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Internal Medicine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Liver transplantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other departments<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (17) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab934281.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "Medical ICU (6 patients), Pneumology (4 patients), General and digestive surgery (1 patient) and Heart transplantation (1 patient)." ] ] ] "descripcion" => array:1 [ "en" => "Patients with recommendations of antifungal treatment depending on hospital departments." ] ] 4 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Prophylactic: prescription due to risk factors for Invasive fungal infection (IFI). Pre-emptive: prescription due to the presence of a biochemical marker of IFI (galactomannan) in patients with risk factors. Empiric: prescription in patients with clinical manifestation suspected to be due to IFI. Directed: IFI attributed to an isolated fungal species." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antifungal indication \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Prophylactic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (11) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pre-emptive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Empiric \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (42) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Directed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (45) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab934282.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Adherence to the recommended antifungal treatment according to treatment indications." ] ] 5 => array:7 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antifungal drug \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">October 11–May 12 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">October 12–May 13 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Liposomal amphotericin B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Caspofungin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.76 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Anidulafungin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.63 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Micafungin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Voriconazole IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Voriconazole oral route \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.96 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab934278.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Antifungal use during October 11–May 12 and October 12–May 13 (DDD per 100 occupied bed-days)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib0180" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical practice patterns in hospitalized patients at risk for invasive candidiasis: role of antifungal stewardship programs in an era of rapid diagnostics" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.L. Aitken" 1 => "N.D. Beyda" 2 => "D.N. Shah" 3 => "H.R. Palmer" 4 => "T.M. Lasco" 5 => "H. Koo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/1060028014529928" "Revista" => array:6 [ "tituloSerie" => "Ann Pharmacother" "fecha" => "2014" "volumen" => "48" "paginaInicial" => "683" "paginaFinal" => "690" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24687545" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0185" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antifungal stewardship: implementation in a French teaching hospital" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Alfandari" 1 => "C. Berthon" 2 => "V. Coiteux" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medmal.2014.01.012" "Revista" => array:6 [ "tituloSerie" => "Med Mal Infect" "fecha" => "2014" "volumen" => "44" "paginaInicial" => "154" "paginaFinal" => "158" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24612504" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0190" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Emerging invasive zygomycosis in a tertiary care center: epidemiology and associated risk factors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Ambrosioni" 1 => "K. Bouchuiguir-Wafa" 2 => "J. Garbino" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Infect Dis" "fecha" => "2010" "numero" => "Suppl. 14" "paginaInicial" => "e100" "paginaFinal" => "e103" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0195" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The case for antifungal stewardship" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.R. Ananda-Rajah" 1 => "M.A. Slavin" 2 => "K.T. 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Bouza" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/jac/dku053" "Revista" => array:6 [ "tituloSerie" => "J Antimicrob Chemother" "fecha" => "2014" "volumen" => "69" "paginaInicial" => "1993" "paginaFinal" => "1999" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24659750" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0350" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Training should be the first step toward an antifungal stewardship program" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Valerio" 1 => "P. Muñoz" 2 => "C. Rodríguez-González" 3 => "M. Sanjurjo" 4 => "J. Guinea" 5 => "E. Bouza" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2014" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack192913" "titulo" => "Acknowledgements" "texto" => "Parts of this study were presented at 18th Spanish Society for Clinical Microbiology and Infectious Diseases Congress (Seville, Spain, 2014). This work was supported in part by unrestricted educational grants from the Spanish Ministry of Health [EC11-094]. The authors wish to thank Martin Hadley-Adams for assisting with the English language and preparation of the manuscript." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/11301406/0000003200000004/v1_201510211323/S113014061500039X/v1_201510211323/en/main.assets" "Apartado" => array:4 [ "identificador" => "7997" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Originales" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/11301406/0000003200000004/v1_201510211323/S113014061500039X/v1_201510211323/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S113014061500039X?idApp=UINPBA00004N"]

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Original article

Antifungal stewardship in a tertiary hospital

Asesoramiento en la prescripción de antifúngicos en un hospital terciario

Antonio Ramosa,

Corresponding author

aramos220@gmail.com

Corresponding author.

, Claudia Pérez-Velillab, Angel Asensioc, Belén Ruiz-Antoránd, Carlos Folguerae, Mireia Canteroc, Beatriz Ordenf, Elena Muñeza

a Department of Internal Medicine (Infectious Disease Unit), Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain

b Department of Internal Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain

c Department of Preventive Medicine, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain

d Department of Pharmacology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain

e Department of Pharmacy, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain

f Department of Microbiology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain

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most inappropriate antifungal prescriptions are due to difficulties in distinguishing between colonization and infection&#44; little knowledge of the local rate of fluconazole resistance&#44; limited awareness of the first line of treatment for IFI&#44; low switching from intravenous to oral antifungal administration&#44; no adjustment after microbiological results&#44; and excessive length of therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">27&#44;30&#44;34&#44;35</span></a> Among the strategies to improve this situation the use of new technology for a rapid identification of fungal species must be highlighted&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The important role of antifungal agents in the management of IFIs along with the high costs and their recognized toxicities has been addressed as the principal justification for antifungal stewardship&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#44;10&#44;16</span></a> However&#44; antifungal stewardship has received very little attention in comparison with antibiotic stewardship&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">35</span></a> It should be noted that the antifungal stewardship programmes &#40;ASP&#41; conducted to date have promoted a reduction in spending on antifungal drugs but not in mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">20&#44;27</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study was to determine the usefulness of an ASP programme in a tertiary hospital with a high number of hematological and solid organ transplantation patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Between 1st October 2012 and 31st May 2013&#44; a prospective study was carried out in the Hospital Puerta de Hierro&#44; Madrid&#44; a tertiary university hospital with 600 beds that includes a surgical ICU &#40;20 beds&#41;&#44; medical ICU &#40;20 beds&#41; and an active solid organ and hematopoietic stem cell transplantation programme&#46; Electronic medical records are available&#59; they contain computerized prescriptions and progress notes made by physicians&#46; The Local Hospital Infections Committee created a team responsible for implementing the programme&#46; The team was coordinated by two infectious diseases &#40;ID&#41; specialists&#44; and included a pharmacist&#44; a pharmacologist&#44; a preventive medicine specialist and a microbiologist&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study protocol was approved by the Local Ethics Committee&#46; Requirements for patients&#8217; informed consent were waived because the study was directed at attending physicians with the primary objective of assessing their adherence to ID recommendations entered in the patients&#8217; electronic record&#46; The aim of the programme was presented and discussed in the hospital&#39;s main departments during clinical meetings between staff and internal medicine residents&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">During this eight-month study the main activity was to perform a programmed review of antifungals prescriptions in hospitalized patients&#46; This review was carried out by two ID specialists together with an internal medicine resident&#46; A list of patients who were prescribed an antifungal considered restricted was provided by the hospital pharmacy department&#46; Lipid formulations of amphotericin B&#44; echinocandins and voriconazole were considered restricted antifungals&#46; Posaconazole was not included in the study because its use was specifically restricted to prophylactic indications in hematologic patients&#46; In the case of patients who were prescribed inadequate systemic antifungal treatments&#44; a recommendation was included in the electronic medical record during the first working day&#46; In most cases&#44; there were neither direct interviews with the prescribing doctor nor patient examinations&#46; On average&#44; the physicians responsible for reviewing the patients &#40;two ID specialists&#41; devoted approximately one hour per day to this activity&#46; Patients could be included more than once if they received any antifungal several times during the study period&#46; Fungal infections in study patients were classified as possible&#44; probable or proven according to recent European Organization for Research and Treatment of Cancer criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">7</span></a> Antifungal prescriptions were regarded as amendable if they were not considered clinically justified and&#47;or did not follow local&#44; national or international guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">12&#44;15&#44;24&#44;32</span></a> The identification of fungal species was performed by conventional cultures&#44; implementing special techniques when necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">6</span></a> Antifungal susceptibility testing was performed on the isolates according to the microdilution broth procedures CLSI M27-A3 and EUCAST&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">26</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Special care was taken to neither criticize nor discredit current antifungal prescriptions due to the fact that several suitable options to treat the infections may exist&#44; and also because the judgement of the investigators could not take into account certain patient characteristics only known by the treating clinicians&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The record was reviewed again one week later in order to establish whether or not the prescribing physician had adhered to each recommendation&#46; The physician was considered to have followed the recommendation if the appropriate modification had been made within 24<span class="elsevierStyleHsp" style=""></span>h of the advice being given&#46; The clinical records were reviewed six weeks later to assess complications and mortality&#46; The quantities of the antifungals administered were recorded using defined daily doses &#40;DDD&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Paired categorical and continuous variables were compared using the chi-squared test and Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test&#44; respectively&#46; Significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">During the study period 280 restricted antifungals were prescribed for 262 patients&#46; In 19 cases the patients were receiving two antifungal drugs &#40;combined treatment&#41;&#46; Mean age was 55 &#40;&#177;14&#41; years and 101 patients &#40;65&#37;&#41; were male&#46; The mean hospital stay was 39&#46;6 &#40;&#177;31&#46;7&#41; days&#46; The indications for antifungal prescriptions were prophylactic in 85 cases &#40;30&#46;4&#37;&#41;&#44; pre-emptive in 10 cases &#40;3&#46;5&#37;&#41;&#44; empiric in 122 cases &#40;43&#46;6&#37;&#41;&#44; and directed in 63 cases &#40;22&#46;5&#37;&#41;&#46; Among this last group&#44; 27 prescriptions &#40;43&#37;&#41; corresponded to proven IFI &#40;43&#37;&#41;&#44; 24 prescriptions &#40;38&#37;&#41; to probable infection and 16 prescriptions &#40;25&#37;&#41; to possible infection&#46; <span class="elsevierStyleItalic">Candida</span> species were the most frequently isolated fungi followed by <span class="elsevierStyleItalic">Aspergillus</span> spp&#46; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Ten percent of the yeasts isolated were resistant to fluconazole&#58; <span class="elsevierStyleItalic">Candida krusei</span>&#44; 13 strains &#40;100&#37;&#41;&#44; <span class="elsevierStyleItalic">Candida glabrata</span>&#44; 4 strains &#40;17&#37;&#41; and <span class="elsevierStyleItalic">Rhodotorula</span> spp&#46;&#44; 2 strains &#40;100&#37;&#41;&#46; Among those patients with <span class="elsevierStyleItalic">Candida</span> spp&#46; in respiratory samples &#40;129 cases&#41;&#44; 19 patients &#40;15&#37;&#41; received prophylactic treatment&#44; 69 patients &#40;53&#37;&#41; received empirical treatment&#44; and 23 patients &#40;18&#37;&#41; received a treatment directed against those fungal isolates from other samples&#46; There were 18 cases &#40;14&#37;&#41; that received inappropriate treatment&#44; based only on yeast respiratory isolation&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The most frequent prescribed antifungal drugs in the studied patients were echinocandins and voriconazole &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Overall&#44; 70 &#40;25&#37;&#41; prescriptions in 61 patients were considered amendable&#46; The reasons of inappropriateness are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Proposed recommendations were addressed in 28 prescriptions &#40;40&#37;&#41;&#46; In 49 cases the recommendation made was to change the antifungal drug &#40;adherence 37&#37;&#41;&#44; in 15 cases it was to remove the antifungal agent &#40;adherence 60&#37;&#41;&#44; in 5 cases to remove one of the antifungal agents in the combined treatment &#40;adherence 20&#37;&#41;&#44; and finally the change in the administration route in 1 patient &#40;adherence 0&#37;&#44; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The adherence according to hospital departments and antifungal indications is expressed in <a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>&#46; When the recommendation was to change the current antifungal treatment to liposomal amphotericin B&#44; adherence was 71&#37;&#59; however&#44; it was lower when the recommended antifungal was voriconazole &#40;38&#37;&#41; or fluconazole &#40;26&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The mortality among the patients treated according to the recommendations of the ASP was 17&#37; &#40;4 patients&#41;&#44; and 30&#37; in those whose treatment was not modified &#40;11 patients&#44; 2 due to infection&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;393&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Antifungal consumption from October 2011 to May 2012 was 5&#46;06 daily defined doses &#40;DDD&#41; per 100 occupied bed-days&#44; which decreased to 2&#46;92 DDDs &#40;42&#37; lower&#41; during October 2012 to May 2013&#46; A decrease was detected in the use of all antifungal drugs during the second period &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">A quarter of the reviewed prescriptions were found to be amendable&#46; As in similar studies&#44; the most frequent causes of modifiable antifungal treatment were inadequate antifungal coverage&#44; no confirmed infection&#44; combined treatment not indicated or oral route indicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">2&#44;21&#44;27&#44;34</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The degree of adherence to recommendations in this study &#40;40&#37;&#41; based on unsolicited consultations may be considered reasonable&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">11&#44;17&#44;22&#44;34</span></a> This result may be encouraging taking into account the accused clinical severity of many patients&#44; the suboptimal IFI diagnostic tools and the fact that the poor prognoses in many cases constitute relevant additional difficulties when giving antifungal advice&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">19&#44;33</span></a> To improve adherence it is crucial that prescribing physicians rely on the wisdom and knowledge of the reviewer and maintain continual feedback&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">20&#44;34</span></a> It should be considered that external reviewing physicians may be less compromised with the clinical evolution of the patient&#46; This may explain why&#44; even when susceptibility results are available to guide therapy&#44; clinicians are often reluctant to de-escalate therapy when a seriously ill patient is improving with broad-spectrum treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">19&#44;33</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The use of electronic clinical history record systems may help to save time when reviewing antimicrobial treatments and in optimizing the efficiency of this strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">33</span></a> Some factors that have previously been related to the success of such strategies are the knowledge of local fungal epidemiology and resistances&#44; establishing therapeutic guidelines&#44; implementation of treatment strategies for empirical&#44; pre-emptive and prophylactic therapy in defined patient populations&#44; catheter management guidelines and the rapid communication of test results from the microbiology laboratory personnel to the physician&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">14&#44;18</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The degree of adherence was higher when the recommendation was to remove the antifungal &#40;60&#37;&#41;&#44; perhaps because in many of these cases the prescribing physician was persuaded that maintenance of the antifungal agent was not justified&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">16&#44;17</span></a> Many of these recommendations are related to the lack of confirmatory microbiological results or to the limited diagnostic value of the isolation of <span class="elsevierStyleItalic">Candida</span> species in the respiratory tree&#44; drainage or other locations other than the blood or sterile liquids&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">4</span></a> Adherence was lower when the recommendation was to change the antifungal &#40;37&#37;&#41;&#46; It should be noted that adherence was higher when the recommended antifungal agent was amphotericin B &#40;which is perceived as a potent&#44; broad-spectrum antifungal&#41; than when the use of fluconazole was suggested&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">4&#44;23&#44;28</span></a> In one study&#44; less than 40&#37; of echinocandin-treated patients with fluconazole-susceptible organisms were de-escalated to fluconazole&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">9</span></a> Knowledge of resistance in bloodstream yeast infection can be extremely helpful when making any recommendation&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">9</span></a> Switching to oral route may be notable in the case of intravenous azoles because removing the intravenous line could prevent the development of blood stream infections&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The use of restricted antifungal during the intervention period was 42&#37; lower than during the comparison period&#46; These results are similar to other studies<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">2&#44;5</span></a> which observed that the main benefit of adherence to antifungal recommendations was reductions in hospital stays&#44; adverse effects and cost&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">8&#44;9</span></a> together with reduced resistance to antifungals in cases of community acquired candidiasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">8&#44;9</span></a> It should be noted that&#44; in the present study&#44; the use of all restricted antifungals actually decreased but were more pronounced in the case of anidulafungin&#44; micafungin and intravenous voriconazole&#46; The reduction in the prescription of intravenous voriconazole could&#44; in part&#44; be explained by a change in the prescription from intravenous to oral treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">31</span></a> The lower mortality observed in patients treated according to the recommendations did not reach significance and may be more related to the severity of the patient with the persistence of antifungal treatment previously prescribed&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">7</span></a> In addition&#44; it should be noted that options other than those suggested by the researchers could have resulted in a favourable clinical outcome&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Considering the marked use of antifungal treatments in hematologic and lung transplantation patients&#44; it could be argued that ID consultations should be performed in services with the greatest consumption of antifungal agents such as hematology&#44; transplant or the ICU&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">8&#44;25&#44;29</span></a> especially in hospitals that can only allocate limited human resources to ASPs&#46; In addition&#44; it would be preferable to target a few high cost antifungal drugs which may have suboptimal use&#44; such as liposomal amphotericin&#44; the echinocandins or intravenous voriconazole than to demonstrate an overall reduction in all antifungal drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Some limitations to our study must be noted&#46; The results obtained in the intervention period were compared with those of the previous 12 months&#59; thus&#44; a bias resulting from a change in patient characteristics cannot be discharged&#46; Another limitation is that not all the changes in antimicrobial treatments could be attributed to written recommendations because a deterrent factor cannot be ruled out due to prescribers being aware that the restricted antifungal treatment was to be reviewed&#46; In addition&#44; due to the fact that this was a time-limited study&#44; an increased consumption of antifungals during the months following the intervention cannot be ruled out&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In summary&#44; ASP in admitted patients may be successfully implemented with a high degree of compliance&#46; This approach may be cost effective and could be included as part of an antimicrobial stewardship programme in institutions that devote limited human resources to improve antimicrobial prescribing&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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            1 => "Echinocandins"
            2 => "Liposomal amphotericin B"
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            0 => "Agentes antif&#250;ngicos"
            1 => "Equinocandinas"
            2 => "Anfotericina B liposomal"
            3 => "Fluconazol"
            4 => "Prescripci&#243;n inadecuada"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The inappropriate use of antifungals is an important health problem related to increasing adverse effects&#44; unnecessary cost and promotion of resistant and emerging fungal infections&#46; Despite its relevance&#44; many health institutions assign few resources to improve prescribing practices&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Aims</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To evaluate the efficiency of an antifungal stewardship programme &#40;ASP&#41; centered on restricted antifungal agents&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The main activity during the eight-month study was to perform a programmed review of restricted antifungals &#40;lipid formulations of amphotericin B&#44; echinocandins and voriconazole&#41; prescribed in hospitalized patients&#46; In the case of amendable antifungal treatment&#44; a recommendation was included in the electronic medical record&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A total of 280 antifungal prescriptions for 262 patients were revised during the study period&#46; The indications were prophylactic in 85 cases &#40;30&#46;4&#37;&#41;&#44; pre-emptive in 10 cases &#40;3&#46;5&#37;&#41;&#44; empiric in 122 cases &#40;43&#46;6&#37;&#41;&#44; and directed in 63 cases &#40;22&#46;5&#37;&#41;&#46; A total of 70 prescriptions &#40;25&#37;&#41; in 61 patients were considered to be amendable&#46; In most of these cases&#44; treatment could have been reduced considering the patient&#39;s clinical improvement and microbiological results&#46; The most common advice was antifungals change &#40;70&#37;&#41;&#44; antifungal withdrawal &#40;21&#37;&#41;&#44; removal of one antifungal drug in cases of combined therapy &#40;7&#37;&#41;&#44; and switching to oral route &#40;1&#37;&#41;&#46; Proposed recommendations were addressed in 28 cases &#40;40&#37;&#41;&#46; There was no significant difference in adherence with respect to the type of recommendation &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;554&#41;&#46; There was a 42&#37; lower use of antifungals during the period of the study compared to that observed during a similar previous period&#46; Mortality among patients who were treated according to the recommendations of the ASP was 17&#37; and in whom treatment was not modified it was 30&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;393&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">ASPs centered on hospitalized patients may be an efficient strategy to ameliorate antifungal use in hospitals&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El uso inadecuado de los antif&#250;ngicos es un problema de salud relevante que puede incrementar los efectos adversos y generar costes innecesarios&#44; adem&#225;s de favorecer la aparici&#243;n de resistencias y de infecciones mic&#243;ticas emergentes&#46; A pesar de su importancia&#44; muchas instituciones sanitarias destinan escasos recursos para mejorar las pr&#225;cticas de prescripci&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Evaluar la eficiencia de un programa de asesoramiento sobre antif&#250;ngicos basado en la prescripci&#243;n de agentes antif&#250;ngicos restringidos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La principal actividad durante el estudio de ocho meses de duraci&#243;n fue la realizaci&#243;n de una revisi&#243;n programada de antif&#250;ngicos restringidos&#44; prescritos en los pacientes hospitalizados &#40;formulaciones lip&#237;dicas de anfotericina B&#44; equinocandinas y voriconazol&#41;&#46; En el caso del tratamiento antif&#250;ngico modificable&#44; se procedi&#243; a anotar una recomendaci&#243;n en la historia cl&#237;nica electr&#243;nica&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se revis&#243; un total de 280 prescripciones de antif&#250;ngicos en 262 pacientes durante el per&#237;odo de estudio&#46; Las indicaciones fueron de tipo profil&#225;ctico en 85 casos &#40;30&#44;4&#37;&#41;&#44; anticipado en 10 &#40;3&#44;5&#37;&#41;&#44; emp&#237;rico en 122 &#40;43&#44;6&#37;&#41; y dirigido en 63 &#40;22&#44;5&#37;&#41;&#46; Se consideraron modificables un total de 70 prescripciones &#40;25&#37;&#41; en 61 pacientes&#46; En la mayor&#237;a de estos casos&#44; el tratamiento pod&#237;a reducirse teniendo en cuenta la mejor&#237;a cl&#237;nica y los resultados microbiol&#243;gicos del paciente&#46; La indicaci&#243;n m&#225;s frecuentemente realizada fue el cambio de antif&#250;ngico &#40;70&#37;&#41;&#44; seguido por la retirada de dicho f&#225;rmaco &#40;21&#37;&#41;&#44; la eliminaci&#243;n de uno de los f&#225;rmacos antif&#250;ngicos en casos de tratamiento combinado &#40;7&#37;&#41; y&#44; finalmente&#44; la sustituci&#243;n del tratamiento por la administraci&#243;n oral &#40;1&#37;&#41;&#46; Las recomendaciones propuestas se aceptaron en 28 casos &#40;40&#37;&#41;&#46; No se produjo una diferencia significativa en la adherencia con respecto al tipo de recomendaci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;554&#41;&#46; Durante el per&#237;odo de estudio se evidenci&#243; un descenso en el uso de antif&#250;ngicos del 42&#37;&#44; en comparaci&#243;n con el uso observado en un per&#237;odo previo similar&#46; La mortalidad de los pacientes que fueron tratados de acuerdo con las recomendaciones fue del 17&#37;&#44; y del 30&#37; en aquellos en los que no se modific&#243; el tratamiento &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;393&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El programa de asesoramiento sobre los antif&#250;ngicos prescritos en pacientes hospitalizados puede resultar una estrategia eficaz para mejorar el uso de estos f&#225;rmacos&#46;</p></span>"
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            "identificador" => "abst0035"
            "titulo" => "Objetivos"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "M&#233;todos"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Blood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Respiratory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Urine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Ascites fluid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Other samples<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Aspergillus</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Candida albicans</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75 &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Candida glabrata</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Candida krusei</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Candida parapsilosis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Candida</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Candida tropicalis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Scedosporium</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Rhodotorula mucilaginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Other fungi<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">176&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab934280.png"
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Other samples&#58; wound exudate&#44; stool&#44; drainages&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Other fungi&#58; <span class="elsevierStyleItalic">Geotrichum</span> spp&#46; &#40;1&#41;&#44; <span class="elsevierStyleItalic">Paecilomyces</span> spp&#46; &#40;1&#41; and <span class="elsevierStyleItalic">Rhodotorula rubra</span> &#40;1&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Isolated fungi in microbiological samples&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Voriconazole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99 &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Caspofungin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Anidulafungin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Micafungin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Liposomal amphotericin B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Amphotericin B lipid complex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Posaconazole was not included because its use was restricted to prophylactic indications in hematologic patients&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Restricted antifungal prescribed in 261 patients&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">Reason of inappropriate treatment &#40;proposed recommendation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Inappropriate prescription&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Addressed recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Inadequate antifungal coverage &#40;antifungal change&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Liposomal amphotericin B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;57&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Amphotericin B lipid complex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Echinocandins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Voriconazole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Non-confirmed infection &#40;antifungal removal&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Echinocandins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Voriconazole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Combined treatment not indicated &#40;removal of one drug&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Liposomal amphotericin B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Echinocandins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Oral route indicated &#40;switch to oral route&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Voriconazole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab934283.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Reasons of inappropriate antifungal treatment and addressed recommendation according to its indication&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Surgical ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Lung transplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hematology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Internal Medicine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Liver transplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Other departments<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0020"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Medical ICU &#40;6 patients&#41;&#44; Pneumology &#40;4 patients&#41;&#44; General and digestive surgery &#40;1 patient&#41; and Heart transplantation &#40;1 patient&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Patients with recommendations of antifungal treatment depending on hospital departments&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Prophylactic&#58; prescription due to risk factors for Invasive fungal infection &#40;IFI&#41;&#46; Pre-emptive&#58; prescription due to the presence of a biochemical marker of IFI &#40;galactomannan&#41; in patients with risk factors&#46; Empiric&#58; prescription in patients with clinical manifestation suspected to be due to IFI&#46; Directed&#58; IFI attributed to an isolated fungal species&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antifungal indication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Prophylactic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pre-emptive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Empiric&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Directed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Adherence to the recommended antifungal treatment according to treatment indications&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antifungal drug&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">October 11&#8211;May 12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">October 12&#8211;May 13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Liposomal amphotericin B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Caspofungin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Anidulafungin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Micafungin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Voriconazole IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Voriconazole oral route&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab934278.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Antifungal use during October 11&#8211;May 12 and October 12&#8211;May 13 &#40;DDD per 100 occupied bed-days&#41;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:35 [
            0 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical practice patterns in hospitalized patients at risk for invasive candidiasis&#58; role of antifungal stewardship programs in an era of rapid diagnostics"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;L&#46; Aitken"
                            1 => "N&#46;D&#46; Beyda"
                            2 => "D&#46;N&#46; Shah"
                            3 => "H&#46;R&#46; Palmer"
                            4 => "T&#46;M&#46; Lasco"
                            5 => "H&#46; Koo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/1060028014529928"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Pharmacother"
                        "fecha" => "2014"
                        "volumen" => "48"
                        "paginaInicial" => "683"
                        "paginaFinal" => "690"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24687545"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0185"
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        "texto" => "<p id="par0125" class="elsevierStylePara elsevierViewall">Parts of this study were presented at 18th Spanish Society for Clinical Microbiology and Infectious Diseases Congress &#40;Seville&#44; Spain&#44; 2014&#41;&#46; This work was supported in part by unrestricted educational grants from the <span class="elsevierStyleGrantSponsor" id="gs1">Spanish Ministry of Health</span> &#91;<span class="elsevierStyleGrantNumber" refid="gs1">EC11-094</span>&#93;&#46; The authors wish to thank Martin Hadley-Adams for assisting with the English language and preparation of the manuscript&#46;</p>"
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Article information

ISSN: 11301406
Original language: English

DOI:10.1016/j.riam.2014.11.006

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Year/Month	Html	Pdf	Total

2024 October	9	1	10
2024 September	26	15	41
2024 August	22	2	24
2024 July	31	6	37
2024 June	30	12	42
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2021 September	11	16	27
2021 August	17	20	37
2021 July	19	14	33
2021 June	13	16	29
2021 May	27	23	50
2021 April	41	32	73
2021 March	18	18	36
2021 February	21	17	38
2021 January	15	19	34
2020 December	11	19	30
2020 November	11	13	24
2020 October	13	15	28
2020 September	17	20	37
2020 August	12	21	33
2020 July	9	9	18
2020 June	16	25	41
2020 May	26	18	44
2020 April	16	18	34
2020 March	27	10	37
2020 February	23	12	35
2020 January	29	14	43
2019 December	27	17	44
2019 November	15	11	26
2019 October	30	21	51
2019 September	28	13	41
2019 August	22	18	40
2019 July	20	22	42
2019 June	45	33	78
2019 May	102	40	142
2019 April	54	15	69
2019 March	2	8	10
2019 February	20	13	33
2019 January	14	9	23
2018 December	15	11	26
2018 November	22	8	30
2018 October	9	20	29
2018 September	11	10	21
2018 August	13	9	22
2018 July	6	6	12
2018 June	6	9	15
2018 May	8	6	14
2018 April	4	3	7
2018 March	5	8	13
2018 February	5	4	9
2018 January	12	6	18
2017 December	11	5	16
2017 November	5	6	11
2017 October	11	6	17
2017 September	10	12	22
2017 August	10	9	19
2017 July	18	8	26
2017 June	18	19	37
2017 May	19	10	29
2017 April	12	11	23
2017 March	18	14	32
2017 February	19	11	30
2017 January	13	3	16
2016 December	31	9	40
2016 November	23	10	33
2016 October	39	23	62
2016 September	41	7	48
2016 August	31	5	36
2016 July	22	4	26
2016 April	0	1	1
2016 March	0	1	1
2016 January	0	1	1
2015 November	0	2	2
2015 October	2	5	7

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