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Frieda Wiley, PharmD, BCGP, is a writer and pharmacist.
Anti-fungal resistance hasn't gotten much attention - but it's a big problem.
Each year, 23,000 of the approximately 2 million people who contract antibiotic-resistant infections will die.1 Such a death toll automatically draws attention to the antibiotic resistance crisis. Antifungal-resistant infections don’t have as high a body count. However, some fungal infections, such as those in the Candida and Aspergillus genera, are becoming less responsive to antifungal agents, and this warrants some much-needed attention.
The number of antifungal prescriptions has soared in the years following the 1990 approval of Diflucan (fluconazole).2 Systemic antifungal medications account for an estimated $5 billion in annual sales globally; Diflucan alone rakes in more than $1 billion in revenue.2 As with the increased use of any antimicrobial agent,
Frieda Wiley, PharmD, BCGPmedication resistance is guaranteed to follow. So, the fact that all classes of antifungals have shown some degree of resistance should come as no surprise. Antifungal overuse, unnecessary prescribing, and inappropriate administration contribute to the problem, but the excessive use of antifungals in agriculture also magnifies the issue.4 Azoles, in particular, have blazed the trail.
Pharmacists know that most superficial fungal infections often manifest more as a cosmetic flaw or bothersome itch. However, some bloodborne fungal infections have mortality rates that can reach as high as 60% and are expensive to treat. Outpatient care by pharmacists can help prevent such progression by successfully managing and referring patients who may be at risk for these more serious infections before their conditions reach more critical stages.2,6
Clinical pharmacists regularly head antimicrobial stewardship programs at hospitals and engage in other practices that help ensure judicious and appropriate prescribing of antifungal agents, with the simultaneous intent of curtailing antifungal resistance. But, meanwhile, community pharmacists are a largely untapped resource.
Community pharmacists are uniquely positioned as gatekeepers at the center of the health-care wheel. Mobilizing community pharmacists to engage in antifungal stewardship, through clinical interactions with other providers and patient education, can strike a major blow against antifungal resistance. The Society of Infectious Disease Pharmacists recognized the importance of community pharmacists when it published an article in the Journal of the American Pharmacists Association outlining the need for and opportunities in antibiotic stewardship in community practice.3 Given that overuse and inappropriate prescribing of antimicrobial agents is not limited to antibiotics, it seems only logical to extend such practices to include antifungal resistance, too.
Health-care communities across the globe are beginning to recognize the need to enlist community pharmacists in waging the battle against antifungal resistance. Studies have been conducted in Malaysia and South Africa regarding the recruitment and perception of community pharmacist engagement in antifungal medication use.2,6 For example, a Malaysian study conducted among community pharmacists found that 96.8% of responding pharmacists believe that antimicrobial stewardship is an important element in improving health care, and that pharmacists with more than 10 years of experience or who had completed postgraduate training were more likely to be involved in stewardship programs or have positive perceptions of their utility.6
Patient encounters that occur in community pharmacy practice offer many opportunities through which pharmacists can distinguish between fungal conditions that will resolve, those can be remedied with OTC treatment or take-home prescriptions, and those that are more serious and warrant referrals to other providers.
Pharmacists who work in outpatient settings other than community practice, such as ambulatory clinics and various managed-care settings can also facilitate such activities. It takes a village to curtail antifungal resistance. The onus lies on us as pharmacists and health-care providers not only to recognize the need to fight antifungal resistance, but to identify the opportunities through which we can make a difference.
Centers for Disease Control and Prevention. Antifungal resistance. Accessed December 21, 2017. Available at: https://www.cdc.gov/fungal/antifungal-resistance.html
Truter I, Graz M. Antifungal products dispensed by a group of community pharmacies in South Africa. Afr J Infect Dis. 2017:29(2):75-79.
Dobson, et al. Outpatient antibiotic stewardship: Interventions and opportunities. J Amer Pharm Assoc. 57 (2017) 464e473. http://www.japha.org/article/S1544-3191(17)30148-6/pdf
Berger S, Chazli Y, Babu A, Cost A. Azole resistance in Aspergillus fumigatus: A consequence of antifungal use in agriculture. Front Microbio. 2017; 8:1024. Doi: 10.3389/fmicb. 2017.01024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5461301/.
Sanglard D. Emerging threats in antifungal-resistance fungal pathogens. Front Med. 2016;3:11. Doi: 10.3389/fmed.2016.00011.
Khan M, Hassali M, Ahmad A, et al. Perceptions and practices of community pharmacists toward antimicrobial stewardship in the state of Selangor, Malaysia. PLOS. 2016. Available at http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0149623