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Volume 51, Number 3, June 2018

2016 guideline strategies for the use of antifungal agents in patients with hematological malignancies or hematopoietic stem cell transplantation recipients in Taiwan 


Bor-Sheng Ko, Wei-Ting Chen, Hsiang-Chi Kung, Un-In Wu, Jih-Luh Tang, Ming Yao, Yee-Chun Chen, Hwei-Fang Tien, Shan-Chwen Chang, Yin-Ching Chuang, Dong-Tsamn Lin on behalf of The Infectious Diseases Society of Taiwan, The Hematology Society of Taiwan, The Taiwan Society of Blood and Marrow Transplantation, Medical Foundation in Memory of Dr Deh-Lin Cheng, Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education, CY Lee's Research Foundation for Pediatric Infectious Diseases and Vaccines


 

Corresponding author:

Affiliations
Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
Department of Medicine, National Taiwan University, College of Medicine, Taipei, Taiwan
Correspondence
Corresponding author. Department of Internal Medicine, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei 100, Taiwan. Fax: +886 2 23971412. 



 

Background and purpose: 

The Infectious Diseases Society of Taiwan (IDST), the Hematology Society of Taiwan, the Taiwan Society of Blood and Marrow Transplantation, Medical Foundation in Memory of Dr. Deh-Lin Cheng, Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education, and CY Lee's Research Foundation for Pediatric Infectious Diseases and Vaccines cooperatively published this guideline for the use of antifungal agents in hematological patients with invasive fungal diseases (IFDs) in Taiwan. The guideline is the first one endorsed by IDST focusing on selection of antifungal strategies, including prophylaxis, empirical (or symptom-driven) and pre-emptive (or diagnostic-driven) strategy. We suggest a risk-adapted dynamic strategy and provide an algorithm to facilitate decision making in population level as well as for individual patient. Risk assessment and management accordingly is explicitly emphasized. In addition, we highlight the importance of diagnosis in each antifungal strategy among five elements of the antimicrobial stewardship (diagnosis, drug, dose, de-escalation and duration). The rationale, purpose, and key recommendations for the choice of antifungal strategy are summarized, with concise review of international guidelines or recommendation, key original articles and local epidemiology reports. We point out the interaction and influence between elements of recommendations and limitation of and gap between evidences and daily practice. The guideline balances the quality of evidence and feasibility of recommendation in clinical practice. Finally, this version introduces the concept of health economics and provides data translated from local disease burdens. All these contents hopefully facilitate transparency and accountability in medical decision-making, improvements in clinical care and health outcomes, and appropriateness of medical resource allocation. 



 

Key words:

Antifungal strategy, Risk assessment, Health economic, Antifungal stewardship, De-escalation, Therapeutic algorithm, Prophylaxis, Empirical therapy, Preemptive therapy, Symptom-driven strategy, Diagnosis-driven strategy, Definitive therapy