Received: 7 February 2019 Revised: 23 July 2019
DOI: 10.1002/pbc.27963
RESEARCH ARTICLE
Effect of an intervention to improve the prescription
of antifungals in pediatric hematology-oncology
Begoña Santiago-García1 ∗
Yurena Aguilar de la Red2
Cecilia Martínez Fernández-Llamazares4
Teresa Hernández-Sampelayo Matos1
1 Pediatric Infectious Diseases Unit, Department
of Pediatrics, Gregorio Marañón Hospital,
Gregorio Marañón Health Research Institute,
Madrid, Spain
2 Department of Pediatrics, Gregorio Marañón
Hospital, Madrid, Spain
3 Pediatric Hematology-Oncology Unit,
Department of Pediatrics, Gregorio Marañón
Hospital, Madrid, Spain
4 Pediatric Pharmacy Unit, Pharmacy
Department, Gregorio Marañón Hospital,
Gregorio Marañón Health Research Institute,
Madrid, Spain
Correspondence
Elena María Rincón-López, Pediatric Infec-
tious Diseases Unit, Department of Pediatrics,
Gregorio Marañón Hospital, Gregorio Marañón
Health Research Institute, C/ O’Donnell
48-50, 28009 Madrid, Spain.
Email: elenarinconlopez@hotmail.com
∗ Begoña Santiago-García and Elena María
Rincón-López contributed equally to the study.
† A list of other contributors of the POPA (Pro-
gram to Optimize the Prescription of Antifungals
in Pediatric Hematology-Oncology) Study Group
is provided in the "Collaborators" section.
Abbreviations: AFS, antifungal stewardship; AMS, antimicrobial stewardship; HO,
hematology-oncology; HSCT, hematopoietic stem cell transplantation; IFD, invasive fungal
disease; IQR, interquartile range; PHOU, Pediatric Hematology-Oncology Unit.
Pediatr Blood Cancer. 2019;e27963.
https://doi.org/10.1002/pbc.27963
Accepted: 24 July 2019
Pediatric
Blood &
The American Society of
Cancer Pediatric Hematology/Oncology
Elena María Rincón-López1 ∗ Beatriz Ponce Salas2
Carmen Garrido Colino3
Jesús Saavedra-Lozano1
the POPA Study Group1 †
Abstract
Background: The use of antifungals has expanded in pediatric hematology-oncology, and the need
to develop pediatric-based surveillance and education activities is becoming crucial. The aims of
this study were to evaluate the impact of a multidisciplinary protocol on the adequacy of antifun-
gal prescription in a pediatric hematology-oncology unit and to assess the effect of an educational
intervention to improve the knowledge of prescribing pediatricians over time.
Methods: A multidisciplinary team established a protocol for the management of invasive fungal
disease (IFD). The use of antifungals before (January 2012-May 2013) and after the protocol (June
2013-December 2015) was evaluated. Prescribing pediatricians attended a training course on IFD
and were evaluated before 0, 6, and 12 months after the intervention.
Results: During the study period, antifungal agents were used in 185 episodes (56 children, 39.3%
females), and were administered as prophylaxis (58.9%), empiric (34.6%), or targeted therapy
(6.5%). Antifungal prescriptions were inadequate in 7% of the episodes, related to drug selection
(53.8%), dosage (38.5%) and route of administration (7.7%). After protocol implementation, inad-
equate prescriptions decreased 9.9% (15.2% vs 5.3%; P = .04). Following the educational activity,
the percentage of adequate responses to the questionnaire improved significantly compared to
baseline, and persisted over time (19.7% improvement at 0 months [P < .0001]; 21.1% at 6 months
[P < .0001]; 16.6% at 12 months [P = .002]).
Conclusions: The establishment of multidisciplinary protocols and education activities improved
the quality of antifungal prescription and the knowledge of prescribers regarding antifungal ther-
apy. Therefore, these activities may be important for the implementation of antifungal steward-
ship programs in pediatrics.
KEYWORDS
antifungal, antimicrobial stewardship, fungal infection, training course
1 INTRODUCTION
The incidence of invasive fungal diseases (IFD) has increased in child-
hood due to a greater number of susceptible patients.1,2 This new
group of children at risk includes very low birthweight infants, chil-
dren with congenital immunodeficiencies, and, more predominantly,
wileyonlinelibrary.com/journal/pbc 
c 2019 Wiley Periodicals, Inc. 1 of 8
2 of 8
children receiving immunosuppressive drugs for the treatment of
cancer, chronic diseases, or to prevent transplant rejection.3–5 As a
result, the use of antifungals has expanded widely in pediatrics, favored
by the difficulties in establishing a proven diagnosis in children, and
the importance of early therapy. Accordingly, the need of surveillance
and education programs to optimize the use of these drugs is becoming
crucial.
In recent years, there has been increasing concern about the
inappropriate prescription of antimicrobials in pediatrics, and many
institutions have implemented antimicrobial stewardship (AMS) pro-
grams, mainly focused on the rational use of antibacterial agents.6–8
Studies in adults and children reveal that adherence to antifungal
drug recommendations is also poor,9–11 leading to increased costs,
unnecessary drug toxicity, and interactions, and to a shift toward
more resistant fungal species.12 Antifungal stewardship (AFS) pro-
grams have been successfully developed in adult institutions to ensure
drug selection, dose, and length of therapy,13–16 but pediatric reports
are scarce. Besides, children are unique in terms of underlying con-
ditions, epidemiology, diagnostic performance, and pharmacokinet-
ics, and specific strategies are needed to address their particular
needs.17,18
In this report, we describe two interventions prior to the estab-
lishment of an AFS program in our Pediatrics Department. In the
first intervention, which was carried out in the Pediatric Hematology-
Oncology Unit (PHOU), a multidisciplinary team implemented a con-
sensual guideline on the use of antifungals, and evaluated the impact
on the adequacy of antifungal use. In the second intervention, the team
conducted a specific training course on the use of antifungals in chil-
dren, targeting all junior and senior medical staff from the Pediatrics
Department, and assessed the baseline knowledge of the doctors and
the persistence of this knowledge over time.
2 MATERIALS AND METHODS
2.1 Ethics
This study has been conducted in accordance with the Declaration
of Helsinki and national standards. Written informed consent was
obtained from study participants or their parents/guardians. Ethics
approval was obtained from the Clinical Research Ethics Committee at
Gregorio Marañón Hospital (code HER-MIC-2014-01).
2.2 Study setting
This study was conducted in the Department of Pediatrics of Grego-
rio Marañón Hospital in Madrid, a tertiary university hospital with 120
pediatric beds and 7000 inpatient admissions per year. The Depart-
ment includes a PHOU that has approximately 40 new diagnostics
per year, including hematological malignancies and solid-organ tumors,
and has an active hematopoietic stem cell transplantation (HSCT) pro-
gram with 8-10 transplants per year.
SANTIAGO-GARCÍA ET AL .
2.3 Study design
2.3.1 Establishment of antifungal expert team and
antifungal protocol
In May 2013, a multidisciplinary team of physicians involved in
the management of IFD in children was created, including pedi-
atric hematology-oncology (HO) and infectious disease specialists, and
pharmacologists. This expert team established a consensus protocol
for the management of IFD based on local fungal epidemiology and on
the most recent international guidelines.19–22 Pediatric dosages and
indications were adapted considering the Summary of Product Char-
acteristics approved by either the European Medicine Agency or the
Food and Drug Administration (Table S1). The protocol was distributed
among all the physicians involved in the treatment of these children.
2.3.2 Evaluation of the impact of the protocol on
antifungal prescription
The baseline use of antifungals was assessed prior to protocol imple-
mentation (January 2012-May 2013, Period 1). To this end, children
younger than 18 admitted to the PHOU who had received systemic
antifungals in Period 1 were identified based on the Computerized
Physician Order Entry system (Prescriplant
R version 3.5.4). An exter-
nal evaluator not related to the prescribing team rated the suit-
ability of antifungal usage according to the protocol, based on four
parameters: (a) drug indication, (b) dosage, (c) route of administration
(oral/intravenous), and (d) duration of treatment.
In a second phase of the study, children receiving antifungals within
30 months after the protocol implementation (June 2013-December
2015, Period 2) were prospectively recruited. Antifungal prescriptions
were evaluated using the same strategy as in Period 1.
2.3.3 Antifungal training program and evaluation of
knowledge of IFD management over time
The impact of a specific training course to improve the knowledge of
pediatricians about IFD, and the persistence of this knowledge over
time, were assessed. For this purpose, the antifungal expert team orga-
nized a face-to-face training course on IFD and the rational use of anti-
fungals in children. The duration of the course was 8 h (divided into
two sessions) and included the following topics: epidemiology of fun-
gal infections in pediatrics, diagnosis, antifungal drugs, management of
Candida spp. and Aspergillus spp. infections, and antifungal prophylaxis.
In order to attract the participation of residents and medical staff, the
course was included in the official Training Program of the Pediatrics
Department, and it was announced through the official training calls of
the hospital.
A 20-question multiple-choice survey was designed, including ques-
tions about IFD epidemiology, microbiology, antifungal pharmacol-
ogy, management of yeast/mold infections and antifungal prophylaxis.
The correct answers were selected by the antifungal expert team in
accordance with current international guidelines. The survey was dis-
tributed on paper immediately before and after the training course. In
order to assess the knowledge at 6 and 12 months, the trainees were
SANTIAGO-GARCÍA ET AL .
contacted by email, and were invited to participate in a survey devel-
oped in GoogleForms
R format.
2.4 Study definitions
We defined an episode of antifungal use as a new condition in a patient
that motivated the initiation or modification of antifungal treatment
based on the presence of clinical, radiological, or microbiological
findings.
Children were diagnosed with proven, probable, or possible IFD,
according to EORTC/MSG definitions.23 Children diagnosed with
mucocutaneous candidiasis were eligible for the study but were not
considered IFD.
Antifungal therapy was classified as follows:
1. Antifungal prophylaxis: Administration of antifungal drugs to
asymptomatic patients at risk of IFD in order to prevent this infec-
tion.
2. Empirical treatment: Initiation or modification of antifungal treat-
ment in patients with probable or possible IFD, who presented
with clinical, radiological, and/or laboratory parameters sugges-
tive of IFD without microbiological or histological confirmation. In
patients with neutropenia, empirical therapy was defined as the use
of antifungal drugs in children with persistent fever despite broad-
spectrum antibacterial therapy. In children without neutropenia,
empirical therapy was defined as an antifungal treatment initiated
in febrile patients with risk factors for developing an IFD, in the
absence of any other known cause of fever.
3. Targeted treatment: administration of antifungal drugs in children
diagnosed with proven IFD.
2.5 Data collection
In order to assess the adequacy of antifungal prescription, the follow-
ing parameters were collected: (a) demographics (age, gender, date of
birth, date of presentation); (b) underlying conditions (underlying dis-
ease, date of diagnosis, HSCT, date of HSCT, IFD in the last 12 months,
graft vs host disease); (c) antifungal therapy (drug, indication, dosage,
route of administration, days of treatment).
2.6 Statistical analysis
The quantitative variables are presented as means and standard devia-
tions if they had a normal distribution, or as medians and interquartile
ranges (IQR) if they had a nonnormal distribution. Qualitative variables
are summarized using their frequency of distribution or rate. Children’s
characteristics in Period 1 (before protocol) and Period 2 (after pro-
tocol) were compared using the t-test or U-Mann-Whitney test for
quantitative variables, and the 𝜒 2 /Fisher test for qualitative variables.
The proportion of inappropriate prescriptions in Periods 1 and 2, and
the reasons for inadequacy in both periods, were compared with the
𝜒 2 /Fisher tests. The scores obtained in the IFD surveys at baseline, at
3 of 8
3 and 6 months, were assessed using the t-test or analysis of variance
test.
The level of statistical significance was set at P < .05. All statistical
analyses were performed using SPSS software Version 20.0 (SPSS Inc.,
Chicago, IL).
3 RESULTS
3.1 Patient characteristics and antifungal therapy
During the study period, antifungal agents were used in 56 children
(39.3% females), corresponding to 185 episodes. The median age of the
children was 7.2 [IQR 2.7-11.4] years. The most frequent underlying
conditions were hematological malignancies (24 children, 42.9%), fol-
lowed by solid-organ tumors (17 children, 30.4%), children with sickle
cell disease undergoing HSCT (10 children, 17.9%), and other hema-
tological disorders (five children, 8.9%). Overall, 19 children (33.9%)
had undergone an HSCT (autologous, n = 8 [42.1%]; allogenic, n = 11
[57.9%]). The percentage of HSCT increased during the study period
(Period 1, 40%; Period 2, 77.8%).
Eleven of 56 patients (19.6%) were diagnosed with IFD: four
patients in Period 1 and seven patients in Period 2. Of these, four were
proven IFD (two Candida albicans, one Aspergillus, one Cunninghamella
bertholletiae), two were probable IFD, and four were possible IFD. In
addition, nine patients (16.1%; one in Period 1 and eight in Period
2) were diagnosed with mucocutaneous candidiasis and required sys-
temic antifungals because of its severity, but were not considered IFD.
The baseline characteristics of the episodes are presented in Table 1.
Antifungal agents were administered as prophylaxis in 58.9% of the
episodes, as empiric treatment in 34.6%, and as targeted therapy in
6.5%. The indication of antifungal drugs per study period is shown in
Figure 1. We did not find significant differences in the indication of
antifungals during the study periods (P = .1; Table 1). Overall, the most
frequently used antifungal agents were fluconazole (31.4%) and mica-
fungin (31.4%), followed by liposomal amphotericin B (23.2%), caspo-
fungin (7%), posaconazole (2.2%), and voriconazole (1.6%). A combina-
tion of two antifungals was used in five cases (2.7%). The indication of
antifungal drugs is shown in Figure 2.
3.2 Impact of the protocol on the adequacy
of antifungal prescription
The adequacy of antifungal prescriptions in Period 1 (19 children, cor-
responding to 33 episodes) and Period 2 (39 children, corresponding
to 152 episodes) was assessed. Overall, the percentage of inadequate
prescriptions during the study period was 7% (13/185), and decreased
significantly after the implementation of the protocol (9.9% decrease;
Period 1: 5/33 [15.2%], Period 2: 8/152 [5.3%]; P = .04). The reason for
inappropriate use of antifungals was related to inadequate indication
in seven of 13 episodes (53.8%), incorrect dosage in five of 13 episodes
(38.5%), and inadequate route of administration in one of 13 (7.7%)
episodes.
4 of 8 SANTIAGO-GARCÍA ET AL .

TA B L E 1 Clinical characteristics and adequacy of antifungal prescriptions according to the study period

Total Period 1 Period 2

n = 185a n = 33b n = 152c P
Clinical characteristics
Age (median, [IQR]) 7.7 [2.2-12.1] 5.7 [4.1-16.5] 6.2 [2.1-12.2] .5
Gender: female 68 (36.8%) 15 (45.5%) 53 (34.9%) .2
Underlying disease 97 (52.4%) 18 (54.5%) 79 (52%)
• Hematologic malignancies 44 (23.8%) 8 (24.2%) 36 (23.7%)
• Solid-organ tumors 25 (13.5%) 5 (15.2%) 20 (13.2%)
• Sickle cell disease d
19 (10.3%) 2 (6.1%) 17 (11.2%) .8
• Other hematological disorders 16 (22.2%) 9 (27.3%) 7 (4.6%)
HSCT 56 (77.8%) 7 (21.2%) 49 (32.2%) <.0001
• Autologous HSCT
• Allogenic HSCT
Indication of AF therapy
Antifungal prophylaxis 109 (58.9%) 14 (42.4%) 95 (62.5%)
Empiric therapy 64 (34.6%) 16 (48.5%) 48 (31.6%)
Targeted therapy 12 (6.5%) 3 (9.1%) 9 (5.9%) .1
AF agents
Fluconazole 58 (31.4%) 8 (24.2%) 50 (32.9%)
Micafungin 58 (31.4%) 8 (24.2%) 50 (32.9%)
Liposomal amphotericin B 43 (23.2%) 11 (33.3%) 32 (21.1%)
Voriconazole 13 (7.0%) 3 (9.1%) 10 (6.6%)
Posaconazole 4 (2.2%) 0 4 (2.6%)
Caspofungin 3 (1.6%) 1 (3%) 2 (1.3%) .4
Inadequacy of AF prescription 13 (7%) 5 (15.2%) 8 (5.3%) .04
Reason for inadequate AF prescription
Inadequate indication 7 (3.8%) 5 (15.2%) 2 (1.3%)
Inadequate dosage 5 (2.7%) 0 5 (3.2%)
Inadequate route of administration 1 (0.5%) 0 1 (0.6%)
Inadequate duration 0 0 0 0.03

Note. Data presented corresponds to n (%) unless otherwise indicated.

Abbreviations: IQR, interquartile range; HSCT, hematological stem cell transplantation; AF, antifungal.
a,b,c
Corresponding to 56, 19, and 39 children, respectively (two children included in Periods 1 and 2).
d
Children with sickle cell disease received antifungal agents in the setting of HSCT.

3.3 Impact of the antifungal training course on

improving prescribing physicians’ knowledge
Sixty doctors, including residents and medical staff, were approached
by email, and were invited to participate in the course. Forty-five
doctors attended the course and underwent the baseline assessment
(20.5% consultant physicians, 79.5% residents). At follow-up, 43 (95%)
doctors fulfilled the immediate postcourse assessment (18.9% consul-
tants, 81.1% residents), 30 (66.6%) completed the 6-month assess-
ment (43.3% consultants, 56.4% residents), and 12 (26.6%) completed
the 12-month assessment (33.3% consultants, 66.7% residents). A sub-
stantial number of residents did not perform the follow-up question-
FIGURE 1 Indication of antifungal therapy during the study period naires as they had completed their training periods.
The percentage of adequate answers to the questionnaire improved
overall after the training course, with an increase of 19.7% between the
SANTIAGO-GARCÍA ET AL .
FIGURE 2 Indication of antifungal drugs during the study period
baseline and the immediate postcourse assessment (P < .0001), 21.1%
between the baseline and the 6-month assessment (P < .0001), and
16.6% between the baseline and the 12-month assessment (P = .002).
However, after the postcourse assessment, there was no further
improvement (Figure 3A).
The comparison of the performance at baseline between consul-
tant physicians and residents revealed that the former had a better
percentage of adequate responses (83.9% vs 73.25%, P = .001). Both
participants experienced a significant increase in adequate responses
after the training course, which was particularly relevant between the
baseline and the immediate postcourse assessment, in both consul-
tants (14%, P = .035) and residents (20.8%, P < .0001). Medical resi-
dents experienced the greatest benefit from the educational interven-
tion, as depicted in Figure 3B.
The percentage of adequate responses increased in all the areas
concerning IFD and antifungal treatment, and persisted over time
(Figure 4), although there was a downward trend 12 months after
the training course. Notably, the categories with the worst level of
knowledge at baseline experienced the greatest increase in correct
responses, especially when comparing baseline and postcourse assess-
ment, as seen with antifungal pharmacology (40%, P < .0001), IFD
epidemiology (23.6%, P < .0001), and antifungal prophylaxis (23.3%,
P = .006).
4 DISCUSSION
This hospital-based study describes the usefulness of two strategies in
order to improve the prescription of antifungal drugs in pediatric HO.
The development of a local clinical practice guideline in combination
with an educational intervention improved prescriber knowledge and
was associated with a 9.9% reduction in the inadequate use of antifun-
gals. In addition, the provision of a specific educational intervention on
IFD and antifungal drugs enhanced significantly the knowledge of the
physicians involved in the management of these children, and persisted
5 of 8
F I G U R E 3 Assessment of prescribing physicians’ knowledge
within the study period (A), and comparison between medical
residents and consultant physicians (B)
over time. To our knowledge, this is the first study to describe the ben-
efits of such strategies in antifungal prescription in pediatrics.
IFDs continue to be associated with an unacceptably high mor-
tality rate in children with neutropenic HO, especially in those with
acute myeloid leukemia and in HSCT recipients. In the setting of HSCT,
the mortality rates of IFDs are 30-40% for yeast infections and up to
70% for mold infections.24,25 A single-day point prevalence study of
antimicrobial use in Europe revealed that less than half of the children
received antifungal drugs within the dosing range recommended in
current guidelines, and subtherapeutic doses were prescribed in 47%
of these children.10 These findings may contribute to suboptimal clini-
cal outcomes and to an increased predominance of resistant fungi.
AMS programs have been shown to enhance judicious antibacte-
rial prescribing practices in pediatrics, improving clinical outcomes and
reducing healthcare costs.6–8 Studies in adult population reveal that
AFS programs are also efficacious and cost-effective, without reduc-
ing the quality of care,11,13,14,16 but studies regarding AFS in childhood
population are scarce. Conversely, antifungal misuse entails specific
challenges in pediatrics, including high case-fatality rates, high costs,
random drug pharmacokinetics, adverse events and interactions, and
potential emergence of antifungal resistance.26–31 Therefore, it is of
utmost importance to establish pediatric-based strategies in order to
ensure optimal antifungal prescription to this vulnerable population.
6 of 8
FIGURE 4 Assessment of knowledge in specific aspects of IFD and antifungal agents
AFS strategies should involve a multidisciplinary team of experts,32
including clinical pharmacists, microbiologists, infectious disease spe-
cialists, and hematologists. In the pediatric setting, these expert teams
are of utmost importance because of the particularities of IFD epidemi-
ology and antifungal drugs in children, and also due to the paucity of
reference strategies for the management of IFD in this population.1,22
In this study, a multidisciplinary team created a consensus protocol
considering recent international guidelines19,20 and local epidemiol-
ogy, and it was distributed among the physicians potentially involved
in antifungal prescription. As a consequence, the overall misuse of anti-
fungals was reduced almost 10%, with a decrease up to 14% in terms of
inappropriate drug choice (Table 1). Thus, these results reveal that the
establishment of a multidisciplinary team with antifungal expertise and
the implementation of consensus protocols may be key steps to ensure
adequate prescriptions.
One of the main challenges of drug optimization programs is to
provide adequate training so that prescribing physicians are updated
and able to translate these policies into daily practice. The present
study revealed significant gaps in the knowledge of prescribing pedi-
atricians regarding antifungal drugs and IFD in children, even among
the consultant physicians who usually take care of these patients.
Because of the baseline evaluation, we identified the areas with poor-
est basal knowledge, including antifungal pharmacology, IFD epidemi-
ology, and antifungal prophylaxis. As expected, consultant physicians
were more knowledgeable about prescription of antifungal drugs, but
both consultants and residents experienced a significant increase in
their knowledge after the intervention. Interestingly, the results of the
prospective evaluations at 6 and 12 months suggested that knowl-
edge may decline over time, highlighting the importance of repeat-
ing these training programs periodically to improve and maintain the
knowledge of the antifungal prescribers in these areas. In our opin-
ion, these courses should be repeated at least once a year, includ-
ing new agents and indications, since the diagnosis and treatment
of IFD (especially, in oncology-hematology pediatric patients) is a
field in constant development. Ideally, these interventions should be
extensive to all the staff participating in the prescription of drugs,
including consultant and resident physician assistants, and nurse
practitioners.
SANTIAGO-GARCÍA ET AL .
The impact of the intervention on drug costs was not included in the
report, as we consider that drug expenditure is not an adequate indica-
tive of a good antifungal policy, especially in pediatrics, and may distort
the interpretation of the results.
This study has several limitations. First, the number of children
included in Periods 1 and 2 is limited, as this is a single-center study, and
because of the limited indications for antifungals in pediatrics. How-
ever, the study was conducted over long baseline and postintervention
periods, and thus, we believe that these positive results correspond
to a real effect rather than to a random variation. Second, at the time
when the study was conducted, our hospital had not implemented anti-
fungal audit strategies; we believe that our positive results would have
been even better if audit strategies had been done. Third, we did not
study all the patients admitted to the PHOU during the study period,
but only those who received systemic antifungals. Thus, it is possible
that some patients who met the criteria for antifungal prophylaxis or
treatment did not receive them. Finally, with regard to the effect of the
training course on the knowledge of prescribing doctors, a large num-
ber of residents were not available to perform the follow-up question-
naires due to the completion of their training periods and, therefore,
the results of the 6- and 12-month evaluations could be overestimated
due to a greater proportion of experienced consultants.
In conclusion, this study reveals that the establishment of multidis-
ciplinary teams with antifungal expertise and the development of spe-
cific protocols may be key strategies to improve the prescription of
antifungals in pediatrics. The evaluation of the basal knowledge of pre-
scribing physicians revealed important gaps in the knowledge about
IFD epidemiology and antifungal drugs in children, which improved
after the implementation of a specific training program. Both strate-
gies, multidisciplinary teams and continuing medical education activi-
ties, might be considered as part of AFS programs in pediatrics.
ACKNOWLEDGMENTS
The authors thank Mr. Martin J. Smyth, BA, for his help in correcting
the English. This work was supported by an unrestricted research grant
from Astellas Pharma Europe, Ltd. The sponsor did not participate in
the study design or interpretation of the results.
SANTIAGO-GARCÍA ET AL .
FUNDING INFORMATION
This work was supported by an unrestricted research grant from Astel-
las Pharma Europe, Ltd. The sponsor did not participate in the study
design or interpretation of the results.
CONFLICT OF INTEREST
BSG, EMRL, and THSM have received funds for speaking at a training
course organized with the financial support of Astellas Pharma. The
rest of the authors do not have conflicts of interest or financial rela-
tionships relevant to this article to disclose.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request
from the corresponding author. The data are not publicly available due
to privacy or ethical restrictions.
COLLABORATORS
Collaborators of POPA (Program to Optimize the Prescription of
Antifungals in Pediatric Hematology-Oncology) Study Group: María
Luisa Navarro Gómez, María del Mar Santos Sebastián, Elena Cela
de Julián, Cristina Beléndez Bieler, Cristina Mata Fernández, Jorge
Huerta Aragonés, Marina García Morín, María Inés Yeste Gómez, and
Sara Vigil Vázquez.
ORCID
Elena María Rincón-López https://orcid.org/0000-0002-0982-1636
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