61 - Evaluation of the Impact of a Micafungin Time-Out Protocol for Hospitalized Patients

Background: Echinocandin overuse is associated with increased prevalence of non-albicans Candida spp, resistance, and high costs. Prospective review of micafungin prescribing by an Antimicrobial Stewardship Pharmacist (ASP) has shown reduced rates of inappropriate therapy. The aim of this study was to describe ASP’s interventions following introduction of a micafungin time out (MTO) protocol.

Methods: The approved MTO protocol was implemented in November 2019. Active micafungin orders for hospitalized patients were reviewed Monday through Friday at initiation and on day five. The MTO algorithm assessed micafungin use based on patient risk factors for Candida infection and de-escalation was guided by clinical status, culture data, and susceptibility testing. Micafungin use and ASP’s interventions were reviewed post-implementation between 12/01/2019 and 02/29/2020. Micafungin use was also characterized between 12/01/2018 and 02/28/2019 to serve as a control.

Results: A random sample of 50 patients who received micafungin for ≥ 48 hours during the pre- and post- protocol periods were included. 39 (78%) and 38 (76%) patients in the pre- and post-MTO cohort had indications for micafungin initiation according to algorithm. In the post-MTO group, 9 (75%) of the 12 micafungin initiations outside of algorithm approval were intervened on successfully by the ASP, increasing appropriate antifungal therapy to 47 (94%) patients. On day five, 18 (50%) and 25 (65.8%) (p=0.17) micafungin orders were according to algorithm in the pre- and post-MTO groups, respectively. Culture data on day five revealed 18 (50%) in the pre-MTO and 13 (34.2%) in the post-MTO group were eligible for de-escalation. An ASP-initiated MTO on day five identified 23 opportunities for antifungal therapy optimization in the post-MTO group. Interventions included de-escalation (13; 61.9%), discontinuation (6; 28.6%), and dose optimization (4; 19%). Of the 23 ASP interventions on day 5, 10 (43.4%) led to micafungin discontinuation or de-escalation, increasing the overall antifungal appropriateness to 35 (92.1%) patients.

Conclusion: An ASP-initiated MTO can facilitate appropriate and timely optimization of antifungal therapy. The most frequent interventions were de-escalation from micafungin or therapy discontinuation.