Quality of prescribing and targets for improvement

This study found a high overall rate of appropriate prescribing for systemic antifungals, reflecting strong adherence to AMS principles across Australian hospitals. AMS programs are mandated under the Australian National Safety and Quality Health Service Standards ¹⁷ and form a core component of hospital accreditation. The high appropriateness rate observed suggests that these programs are effectively supporting high quality antifungal use. Notably, prescriptions with approval via local stewardship processes demonstrated higher appropriateness compared to those without approval, underscoring the value of stewardship interventions. This finding supports continued investment in AMS infrastructure.

Guideline compliance was also high, though generally lower than appropriateness. In hematology, bone marrow transplant, and solid organ transplant specialties, appropriateness and guideline compliance rates were closely aligned. This likely reflects the availability of detailed prescribing guidelines for these patient groups, ^{Reference Teh, Yeoh and Haeusler29–Reference Aslam and Rotstein36} the protocolized nature of prophylactic prescribing and the involvement of specialist clinicians in these high-risk populations.

Antifungal use was highest in principal referral hospitals, managing complex and immunocompromised patient populations. These hospitals also demonstrated the highest rates of appropriateness and guideline compliance, likely due to the presence of specialized teams and established protocols. In contrast, acute public hospitals, which provide a broad range of services but lack the same level of specialization, accounted for the second highest volume of antifungal prescribing but had the lowest rate of appropriateness. This may reflect more frequent prescribing in general medical and surgical units, where prescribing is less protocolized and national guidelines ²⁶ offer limited coverage.

Regional and remote hospitals demonstrated lower rates of appropriate prescribing, which may indicate disparities in access to infectious diseases expertise and AMS resources. These findings suggest a need for tailored support and capacity-building in non-metropolitan settings to ensure equitable stewardship practices nationwide.

Prescribing quality also varied by antifungal. Mold-active azoles, amphotericin B, and echinocandins—typically used in specialized settings—had high appropriateness, likely due to more stringent oversight and clearer guidelines. A national survey of Australian hospitals indicated that over 70% of surveyed facilities mandated preauthorization for these agents, with many conducting routine postprescription review and feedback (PPRF). ^{Reference Urbancic, Kong, Johnson, Yong, Slavin and Thursky37}

Fluconazole, the most prescribed antifungal, had one of the lowest percentage appropriateness. This may reflect its broader use across diverse indications, some of which are less clearly defined or supported by guidelines. The same national survey ^{Reference Urbancic, Kong, Johnson, Yong, Slavin and Thursky37} reported that fluconazole required preauthorization in fewer hospitals, and intravenous and oral fluconazole were excluded from expert PPRF in 26% and 42% of hospitals, respectively. Our study found that AMS approval for fluconazole was lower than for other agents, and prescriptions with approval had higher appropriateness. These findings suggest that fluconazole represents a key target for quality improvement, with enhanced stewardship oversight offering a potentially high-yield intervention.

Fluconazole use for urinary tract infections emerged as an area for improvement. Diagnostic stewardship strategies, such as including interpretive comments on microbiology reports may help educate clinicians and reduce inappropriate prescribing. ^{Reference Khanina, Tio and Ananda-Rajah18} Additionally, oral and dental indications often demonstrated prolonged therapy. Current guidelines recommend a duration of seven days for severe or refractory oropharyngeal candidiasis. ³⁸ Implementing PPRF for fluconazole prescriptions exceeding this duration may enhance appropriateness and reduce unnecessary exposure.

Comparison to existing literature

The appropriateness rate observed in our study is notably higher than that reported in previous PPS studies evaluating antifungal prescribing across entire hospital populations. For instance, a multicenter study conducted in Greece ^{Reference Papadimitriou-Olivgeris, Andrianaki and Marangos8} and a single-center study from India ^{Reference Kaur, Krishnamoorthi and Dhaliwal9} each reported overall appropriateness rates of approximately 75%. Similarly, a study conducted in a Spanish pediatric hospital found an appropriateness rate of 89%. ^{Reference Mendoza-Palomar, Garcia-Palop and Melendo10} In contrast, other observational studies assessing antifungal prescribing quality have focused on high-risk populations, ^{Reference Nivoix, Launoy and Lutun12,Reference Lachenmayr, Berking, Horns, Strobach, Ostermann and Berger13,Reference Abdel Fattah, Demore and Girardeau39} such as hematology, oncology, or critical care settings, or on high-cost antifungals. ^{Reference Calderon-Parra, Herraiz-Jimenez and Ramos-Martinez11,Reference Abdel Fattah, Demore and Girardeau39} These studies often excluded fluconazole and posaconazole from their assessments, and reported a broader range of appropriateness rates, from 38% to 92%. The higher appropriateness rate observed in our study may be attributable to differences in the definition of “appropriate therapy” and audit inclusion criteria. Additionally, the maturity of AMS programs in Australia may support more consistent and appropriate prescribing practices, potentially explaining the more favorable outcomes observed.

Strengths of the Hospital NAPS tool for assessing antifungal prescribing quality

The Hospital NAPS is a well-established program that has demonstrated long-term sustainability at a national level, encompassing a wide range of health service types for over a decade. One of its key strengths lies in its dual approach to evaluating prescribing quality, encompassing both guideline compliance and appropriateness. In this study, we observed that appropriateness consistently exceeded guideline compliance. This finding highlights the added value of appropriateness assessments, which allow for a more nuanced evaluation of prescribing practices by accounting for patient-specific factors and clinical judgment, elements that guideline compliance alone may not capture. The Hospital NAPS appropriateness assessment matrix provides a robust and consistent framework for evaluating prescribing quality. It incorporates metrics found to be important and feasible in an international Delphi consensus survey on AFS metrics. ^{Reference Khanina, Urbancic and Haeusler40}

Considerations for the use of PPS methodology

The PPS methodology captures a snapshot of prescribing and antifungals represent a small proportion of the total data set. The methodology does not capture the dynamic progression of prescribing, making it difficult to assess the appropriateness across the full course of treatment. As a result, the sample size may be insufficient and the data set may not adequately reflect the complexities of antifungal prescribing, restricting its usefulness for developing targeted stewardship interventions.

In response to the limitations of the PPS methodology, the National Center for AMS and the National Center for Infections in Cancer have collaboratively developed and validated the Antifungal NAPS, ^{Reference Khanina, Douglas and Yeoh41} a targeted, deep-dive audit integrated within the broader NAPS platform. This tool incorporates metrics deemed both important and feasible through international expert consensus, ^{Reference Khanina, Urbancic and Haeusler40} enabling comprehensive assessment of antifungal prescribing across the entire course of therapy. It includes evaluation of infection risk factors and clinical outcomes. The Antifungal NAPS was piloted in 2023 in eleven Australian hospitals, revealing an appropriateness rate of 77.1%. ^{Reference Khanina, Singh, James, Kong, Slavin and Thursky42} This Figure is notably lower than the appropriateness observed in the current evaluation. We hypothesize that this discrepancy is in part attributable to the period prevalence methodology, which considers a broader range of criteria and evaluates each prescription in greater detail. Additionally, the number of hospitals participating in the Antifungal NAPS was far smaller than the Hospital NAPS so may not be representative of national prescribing.

Limitations of this study

This study has several limitations that should be considered when interpreting the findings. First, temporal trends in the quality of antifungal prescribing were not assessed due to year-to-year variations in hospital participation which may confound the findings. Secondly, the evaluation of guideline compliance may be biased due to the high proportion of prescriptions classified as “directed therapy,” which were excluded from the guideline compliance analysis. Although these prescriptions were targeted toward identified organisms, relevant guidelines may still apply. This limitation has been acknowledged by the developers of the Hospital NAPS program and is a priority for future updates. Finally, topical antifungals were excluded. This decision was based on the focus of AFS interventions, which typically target systemic antifungals. Including topical prescriptions could obscure patterns relevant to systemic antifungal appropriateness.