861 - Evolution of Antifungal Use Over Fifteen Years in a Burn Intensive Care Unit

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Presenting Author(s)

John L. Kiley

Associate Program Director
BAMC
San Antonio, Texas
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Co-Author(s)

Alice E. Barsoumian

Infectious Diseases Physician
Brooke Army Medical Center
San Antonio, TX
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
SG

Stephanie Giancola

ID Pharmacist
Brooke Army Medical Center
San Antonio, Texas
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Kaitlin A. Pruskowski

Clinical Pharmacist
US Army Institute of Surgical Research
JBSA Fort Sam Houston, Texas
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
JR

Julie Rizzo

Deputy Director ISR
USAISR
San Antonio, Texas
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Dana M. Blyth

Associate Professor
Walter Reed National Military Medical Center
Bethesda, MD
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Background: Systemic antifungals (AF) and surgery are the cornerstone of therapy for burn-related fungal infections. Multiple AFs were introduced in the last decade with broader spectrum and improved safety profiles, but use in burn patients has yet to be thoroughly described. Here we evaluate 15 years of AF prescribing patterns in a burn intensive care unit (BICU).

Methods: We included all US Army Institute of Surgical Research BICU patients who received > 1 dose of AF from 2004-18. First we sought to describe overall AF prescribing. Clinical features, mortality and AF use (including in combination) from 2004-8 (T1), 2009-2013 (T2), 2014-18 (T3) were compared.

Results: Between 2004-18, 361 patients with a median total body surface area (TBSA) of 45% (IQR: 25-60) received AF. Median duration of hospital stay prior to and duration of initial AF (AF1) were 13.5 (IQR: 7-22) and 4 days (IQR: 2-9), respectively. Patients prescribed AF had a median of 2 (IQR 1-3) different AFs. AF1 was most commonly fluconazole [FLC; n=141 (39%)], amphotericin [AMB; n=62 (17%)] and voriconazole [VRC; n=55 (15%)]. Of those who survived, (N=233) AF1 was AMB, 40 (17.2%); FLC, 102 (43.8%); itraconazole, 1 (0.4%); VRC, 35 (15%); posaconazole (POS), 6 (2.6%); isavuconazole (ISA), 4 (1.7%); caspofungin (CAS), 7 (3%); micafungin (MFG), 28 (12%), VRC/AMB, 8 (3.4%); FLC/AMB, 0; FLC/CSP, 1 (0.4%); and VCR/MFG 1 (0.4%). AF1 use differed across T1, T2, and T3 (Table). Notably, there was shift towards use of POS, ISA, and MFG. The use of AF1 combination therapy differed across T1, T2, and T3 (p = 0.002). 200 patients had a second AF (AF2) prescribed at a median of 4.15 days (IQR 1.1-12.5) after AF1 for a median duration of 5.3 days (IQR 2-9.7). AF2 were most commonly VRC (n=54, 27%), AMB (n =46, 23%) and FLC (n=44, 22%). There were no differences in AF2 over time. Table. Clinical characteristics and antifungal use by five year increments

Conclusion: AF use evolved to include echinocandins and broader spectrum triazoles and decreased use of AMB as part of AF1. However, AF2 remained most commonly VRC, AMB, and FLC.