2.3. Antimicrobial stewardship team

Participation in the AST was voluntary and open to any physician and clinical staff at our hospital. To implement a multidisciplinary team approach, the team comprised 13 members: 2 nephrologists, 2 surgeons, 1 general practitioner, 1 emergency physician, 1 gastroenterologist, 1 ophthalmologist, 2 pharmacists, 1 nurse, 1 microbiologist, and 1 administrative staff. The team did not include any IDPs. At the first in‐person meeting held in March 2009, members of the interdisciplinary AST shared evidence supporting various recommended practices for management of candidemia. During the next several months, the AST developed a candidemia care bundle based on the IDSA guideline.¹⁹ The bundle consisted of six key elements: appropriate empirical selection of antifungals, appropriate empirical dosaging of antifungals, appropriate duration of treatment, removal of existing central venous catheters (CVC), follow‐up blood cultures until clearance of candidemia, and ophthalmological examination (Table 1). Micafungin was selected as the empirical antifungal therapy, based on the IDSA guideline and its effectiveness for any potential fluconazole‐resistant C. glabrata and C. krusei, both of which have been previously identified at our hospital. However, the regimen was changed depending on the patient general condition, comorbidity, drug‐drug interaction, and clinical laboratory test results as needed. Based on the understanding of the team members of the project and the time frame that had been targeted for intervention implementation, November 2009 was selected as the start of the intervention time frame for analysis.

Bundle elements in patients with candidemia

bid, twice a day.

When the Gram stain revealed yeast consistent with Candida spp. from a positive blood culture, the staff of the microbiological laboratory informed the attending physician immediately by telephone during the preintervention and intervention periods. In addition, the AST members also received real‐time notification of positive culture results during the intervention period. This notification was via e‐mail and telephone for cases identified on Monday through Saturday from 08:00 to 17:00. After‐hours results were reviewed by the microbiological laboratory personnel the following business day. Then, a physician became the person in charge of the case and directly contacted the attending physician in charge of the patient, to discuss the management of candidemia and made prospective recommendations in accordance with the bundle until the patient was discharged from the hospital or died. The entire AST shared information about the patients with candidemia and the clinical course during the intervention period and discussed appropriate management online. For smooth integration of our recommendations into bedside clinical practice based on the needs of the attending physicians, we paid strict attention to communication with the attending physicians. When a patient from the Department of Surgery developed candidemia, the surgeon member of the AST became in charge of the patient. However, our recommendations were deferred to the discretion of the attending physicians. The project lasted 3 years due to shortage of physicians in our team. Thus, for analysis purposes, the preintervention period was defined as November 2006 through October 2009, and the intervention period, as November 2009 through October 2012.