This study evaluated the effectiveness of universal decolonization in intensive care units to decrease hospital-acquired Staphylococcus aureus infections (HA-SAI). HA-SAI (primary endpoint) decreased from 158 patients to 80 patients, infections per 1000 patient days decreased from 5.36 to 2.47, and in-hospital mortality was significantly lower in the post-group (32% vs 16%; p = 0.008). Universal decolonization is a successful way to decrease HA-SAI and reduce in-hospital all-cause mortality amongst adult ICU patients.

Background/Objectives: Staphylococcus aureus bloodstream infections (SABSIs) are associated with significant morbidity and mortality and are often complicated by infective endocarditis (IE). During the COVID-19 pandemic, fewer transesophageal echocardiographs (TEEs) were performed for patients diagnosed with SABSI, and this study examined the impact on clinical outcomes associated with this change in practice. Methods: This retrospective observational study included adult patients treated for SABSI who were admitted pre-COVID-19 (1 March 2018 to 11 March 2020) and during COVID-19 (12 March 2020 to 1 March 2022). Primary outcomes were rates of confirmed IE and duration of antibiotic therapy (DOT). Results: Of 333 screened patients, 214 were included (107 per group). Patients in the COVID-19 group were older (51.49 vs. 56.31 years, p = 0.013); other baseline characteristics were similar. Catheter-related infections were the most common source in the pre-COVID-19 and COVID-19 groups (30.8% vs. 18.9%, p = 0.089). Rates of TEE procedures significantly declined during COVID-19 (72% vs. 50.9%, p = 0.002); rate of confirmed IE (9.4% vs. 12.1%; p = 0.660) and median DOT (28 vs. 28 days; p = 0.596) were similar. Ninety-day mortality was higher in the COVID-19 group (10.4% vs. 22.2%, p = 0.019); other outcomes were not statistically different. Conclusions: The COVID-19 pandemic led to a notable decline in TEEs performed for SABSI, but the majority of clinical outcomes were unchanged. Mortality was significantly higher in the COVID-19 group, but it is uncertain that this was solely due to the change in practices. In a healthcare system that universally recommends TEE, scoring systems may help identify which patients are highest priority for TEE versus those that could undergo a transthoracic echocardiogram.

Background Antibiotics are commonly prescribed in emergency departments but limited studies have been published describing antimicrobial stewardship interventions in this practice area. The purpose of this study was to assess the effectiveness of a multifaceted pharmacist-led antimicrobial stewardship intervention on selection and duration of antibiotics prescribed in the emergency department. Methods This single-center, quasi-experimental study evaluated patients discharged from the adult emergency department between October 1, 2021 to February 28, 2022 (preintervention group) and October 1, 2022 to February 28, 2023 (postintervention). Antibiotic default durations were removed from the electronic medical record in September 2022, and education was provided to emergency department prescribers on proper antibiotic selection and duration. Adult patients with a new presumed diagnosis of acute cystitis, acute pyelonephritis, community-acquired pneumonia (CAP), cellulitis, or skin abscess with a new prescription for an oral antibiotic at emergency department discharge were included. The primary outcome was the duration of antibiotic therapy prescribed. Results There were 220 patients included (110 preintervention; 110 postintervention). Baseline characteristics were similar between groups, and acute cystitis (45%) was the most common indication. The mean antibiotic duration was low in both groups, and there was no statistically significant difference between pre- and postgroups (6.60 vs. 6.35 days; P = 0.382). A 10% decrease in antibiotic inappropriateness was found in the preintervention to postintervention groups (P = 0.075). Conclusion Overall duration was lower than expected in the pre- and postgroups, with most patients receiving less than 7 days of antibiotics for multiple common infections. Several challenges were identified for performing stewardship in the emergency departments and further interventions have been planned based on the results of this study.

Background:Multidrug-resistant (MDR) gram-negative infections are a substantial threat to patients and public health. Imipenem-cilastatin-relebactam (IMI/REL) is a β-lactam/β-lactamase inhibitor with expanded activity against MDR Pseudomonas aeruginosa and carbapenem-resistant Enterobacterales. This study aims to describe the patient characteristics, prescribing patterns, and clinical outcomes associated with IMI/REL. Methods:This was a retrospective, multicenter, observational study of patients ≥18 years old who received IMI/REL for ≥48 hours for a suspected or confirmed gram-negative infection. The primary outcome was clinical success, defined as improvement or resolution of infection-related signs or symptoms while receiving IMI/REL and the absence of 30-day microbiologic failure. Multivariable logistic regression analysis was performed to identify independent predictors of clinical success. Results:The study included 151 patients from 24 US medical centers. IMI/REL was predominantly prescribed for lower respiratory tract infections, accounting for 52.3% of cases. Most patients were infected with a carbapenem-nonsusceptible pathogen (85.4%); P aeruginosa was frequently targeted (72.2%). Clinical success was achieved in 70.2% of patients. Heart failure, receipt of antibiotics within the past 90 days, intensive care unit admission at time of index culture collection, and isolation of difficult-to-treat resistant P aeruginosa were independently associated with a reduced odds of clinical success. Adverse events were reported in 6.0% of patients, leading to discontinuation of IMI/REL in 3 instances. Conclusions:This study provides a comprehensive analysis of the real-world effectiveness and safety of IMI/REL. Comparative studies and investigations of specific subgroups will further enhance our understanding of IMI/REL in treating MDR infections.

Abstract Background The escalating prevalence of multidrug-resistant (MDR) Pseudomonas aeruginosa presents a serious threat to patient care due to its limited treatment options. However, imipenem-cilastatin-relebactam (IMI/REL) is a promising beta-lactam/beta-lactamase inhibitor combination with expanded activity against MDR P. aeruginosa. This study aimed to explore the patient characteristics, efficacy and safety of IMI/REL for treatment of infections due to P. aeruginosa.Table 1.Patient and infection characteristics. Methods This was a retrospective, observational, multicenter cohort study that included patients ≥ 18 years old who received IMI/REL for ≥ 48 hours for the treatment of an infection due to P. aeruginosa. The primary outcome was clinical success, defined as the resolution of or improvement in infectious signs and symptoms following initiation of IMI/REL until the end of therapy. Secondary outcomes included 30-day all-cause mortality, 30-day microbiologic recurrence, 30-day symptomatic recurrence and incidence of adverse drug reactions (ADRs).Table 2.Infection management and IMI/REL prescribing. Results There were 104 patients from nine U.S. medical centers included. The mean (standard deviation) age was 56.6 (17.2) years and the majority of patients were non-Hispanic Caucasian (64.4%). IMI/REL was predominantly used to treat lower-respiratory tract infections (55.7%) and 12.5% of cases developed secondary bacteremia. MDR P. aeruginosa was isolated in most patients (84.6%), while four patients (3.8%) were infected with a difficult-to-treat isolate. IMI/REL was initiated at a median (interquartile range) of 100.5 (44.8-170.3) hours from the time of index culture collection and was primarily selected due to the presence of resistance to alternative agents. Clinical success occurred in 73.1% of patients and 16.3% experienced 30-day all-cause mortality. Thirty-day microbiologic recurrence occurred in 14.4% of patients. ADRs occurred in six patients resulting in IMI/REL discontinuation in two cases.Table 3.Clinical outcomes. Conclusion To our knowledge, this is the largest report to date describing the use of IMI/REL for infections due to P. aeruginosa. The promising results herein justify the need for larger and comparative studies investigating the use of IMI/REL in this setting. Disclosures Kaylee E. Caniff, PharmD, BCIDP, T2Biosystems: Honoraria Kevin W. Garey, PharmD, MS, Acurx: Grant/Research Support Travis J. Carlson, PharmD, BCIDP, Aimmune Therapeutics, Inc.: Speakers Bureau Tamara Krekel, PharmD, BCPS, BCIDP, Merck Inc: Honoraria Wesley D. Kufel, Pharm.D., BCPS, BCIDP, Merck & Co.: Grant/Research Support|Shionogi, Inc: Grant/Research Support Amy L. Carr, PharmD, BCIDP, Entasis: Advisor/Consultant|Ferring: Advisor/Consultant|Gilead: Advisor/Consultant|InflaRx: Advisor/Consultant|LaJolla: Advisor/Consultant|Melinta: Advisor/Consultant|MicroGenDx: Advisor/Consultant|Shionogi: Grant/Research Support Jillian Hayes, PharmD, BCIDP, GlaxoSmithKline: employee James Sanders, PhD, PharmD, Merck: Grant/Research Support|Shionogi: Grant/Research Support Julie Ann Justo, PharmD, MS, FIDSA, BCPS, Shionogi: Advisor/Consultant Russell J. Benefield, PharmD, BCPS-AQ ID, Paratek Pharmaceuticals: Grant/Research Support Michael J. Rybak, PharmD, PhD, MPH, Abbvie, Melinta, Sionogi, Merck, T2Biosystems: Advisor/Consultant|Abbvie, Melinta, Sionogi, Merck, T2Biosystems: Grant/Research Support|Abbvie, Melinta, Sionogi, Merck, T2Biosystems: Speaker

Abstract Background Staphylococcus aureus can lead to severe infections, including bloodstream infections, which are associated with high mortality. Infective endocarditis (IE) is a concerning complication of S. aureus bloodstream infections (SABSIs), which is ruled out by transesophageal echocardiogram (TEE). The COVID-19 pandemic led to a decrease in TEEs at the University of Mississippi Medical Center (UMMC) for patients with SABSIs. This study explores the impact of reduced TEE rates on clinical decisions for SABSI patients. Methods This retrospective observational study assessed adult SABSI patients at UMMC, categorizing them into pre-COVID (admitted between 3/1/2018-3/11/2020) and COVID (admitted between 3/12/2020-3/1/2022) groups. A VIRSTA score, indicating IE risk and advocating TEE for high-risk patients (score ≥3), was calculated for patients. Primary outcomes included the rate of confirmed IE and antibiotic duration in pre-COVID and COVID groups. Secondary outcomes included hospital stay, correlation between VIRSTA score and TEE, 90-day mortality, and 60-day re-admission. Results Among 214 patients, baseline characteristics were comparable between groups. The rate of confirmed IE (9.4% pre-COVID vs. 12.1% COVID; p = 0.66) and median antibiotic duration (28 days in both groups) showed no significant differences. However, mortality was more likely in the COVID group (22.2% vs 10.4%; p=0.019). Notably, high VIRSTA score patients were less likely to undergo TEE COVID (3.8% vs 18.5%; p = 0.008). There were no differences in other secondary outcomes. Conclusion This retrospective study highlights the impact of reduced transesophageal TEE utilization during the COVID-19 pandemic on clinical decision-making for patients with SABSIs, including challenges in risk stratification based on VIRSTA score. Despite a decrease in TEE, there were no differences in confirmed IE diagnosis or duration of antibiotics, but mortality was higher in the COVID-19 group. Based on this study there is an opportunity to provide education related to VIRSTA score utility for risk stratification, which may preserve healthcare resources in select patients. Disclosures All Authors: No reported disclosures

Background Gram-negative bloodstream infections (GN BSIs) are associated with high rates of mortality and increased health care costs. Literature suggests that shorter courses (7 days) with the option to transition to highly bioavailable oral antibiotics are safe and efficacious. This project evaluated the impact of a direct stewardship intervention on prescribing practices for uncomplicated GN BSIs. Methodology This single-center, pre- and postintervention study was conducted at a large academic medical center. The intervention consisted of an uncomplicated GN BSI guideline followed by provider education and targeted prospective audit and feedback. Adult patients with uncomplicated GN BSIs from October 2021 to September 2022 (preintervention) and November 2022 to June 2023 (postintervention) were included, with October 2022 serving as a washout period. The primary outcome was calendar days of effective antibiotic therapy. Results A total of 142 uncomplicated GN BSIs (92 preintervention; 50 postintervention) were evaluated. Patients were predominantly African American (63%) with bloodstream infections primarily caused by Escherichia coli (42%) from a urinary source (66%). The median total duration of antibiotic therapy was 10 days (interquartile range [IQR] 8-11.5 days) in the preintervention group and 9 days (IQR 8-13 days) in the postintervention group (P = 0.514). Oral transition occurred in 41% versus 50% of patients in the pre- and postintervention groups, respectively (P = 0.319). In the postintervention group, 30-day mortality was significantly lower (9% vs. 0%, P = 0.05). There were no statistically significant differences in 30-day readmission or recurrence. Conclusions Implementation of guidelines with a direct stewardship intervention was associated with a numerically lower duration of therapy that was not statistically significant for GN BSIs, despite a nearly 10% increase in IV to oral transitions. No difference was seen in readmissions or recurrence between groups. This evaluation highlights the importance of antimicrobial stewardship interventions targeting the management of GN BSI and reveals an opportunity for a more focused intervention related to oral transition.

PURPOSE:This review explores the management of persistent methicillin-susceptible Staphylococcus aureus bacteremia (SAB), emphasizing the importance of timely intervention due to SAB's association with metastatic dissemination, relapse, and mortality. SUMMARY:The literature analysis first delves into risk factors for persistent SAB, highlighting the need for effective treatment strategies. The subsequent focus is on combination strategies for persistent SAB. Daptomycin, ertapenem, ceftaroline, fosfomycin, rifampin, and gentamicin are explored as adjuncts to cefazolin or antistaphylococcal penicillins. Daptomycin combination therapy is assessed through in vivo and clinical studies, indicating potential benefits, especially with higher-risk sources of infection. Ertapenem combination therapy has been demonstrated to have a synergistic effect with cefazolin, presenting a viable salvage option. Rifampin's ability to penetrate biofilm is examined, with discussion of inconclusive evidence on mortality benefits. The review also considers stewardship implications, discussing concerns such as resistance emergence, adverse events, and increased costs associated with combination therapy. Mathematical models suggest combination therapy as an effective approach to prevent resistance. Adverse events vary with each combination, and duration of therapy remains diverse across studies in the absence of well-established dosing guidelines. CONCLUSION:The review provides a thorough exploration of the literature on treatment of persistent SAB, underscoring the need for evidence-based guidelines, further studies, and clinical judgment in tailoring treatment strategies. The multifaceted analysis contributes valuable insights for clinicians managing this challenging condition.

Obesity can cause physiological changes resulting in antibiotic pharmacokinetic alterations and suboptimal drug exposures. This systematic review aimed to summarise the available evidence on this topic and provide guidance for dose adjustment of antibiotics in adult (age ≥18 years) patients with obesity (BMI >30 kg/m2). We searched PubMed, Embase, and CENTRAL databases to find relevant studies published between database inception and Dec 30, 2023. We initially identified 6113 studies, which became 4654 studies after duplicate removal, and 128 studies were included in the final review. β-lactam antibiotics were most commonly studied (57 studies), followed by the group of glycopeptides, lipoglycopeptides, and oxazolidinones (45 studies). The certainty of evidence was low or very low for all antibiotics and a meta-analysis was not possible due to the heterogeneity of study populations and methods. Obesity modestly alters the pharmacokinetics of β-lactam antibiotics, but evidence does not support routine dose adjustments. For aminoglycosides and glycopeptides, the impact of obesity on pharmacokinetics is evident and weight-based dosing is recommended. Data are sparse for other antibiotic classes and research needs are described. In the absence of robust pharmacokinetic data, therapeutic drug monitoring can be used to guide individualised dosing.

ObjectivesThe purpose of this study was to determine student perceptions versus actual level of test anxiety, as measured by the Cognitive Test Anxiety Scale-2 (CTAS-2), and student and faculty perceptions of test anxiety with regard to prevalence, impact, ease of treatment, and importance in pharmacy education. Methods:Two independent Qualtrics© questionnaires were distributed via email to all students and faculty in the professional pharmacy program (years 1-4) at the University of Mississippi. The first questionnaire evaluated pharmacy students’ perceptions of test anxiety and self-awareness of personal test anxiety. The second questionnaire evaluated faculty members’ perceptions of student test anxiety. The questionnaires had 50 and 21 questions, respectively, and were developed from validated, reliable questionnaires used in Cognitive Test Anxiety (CTA) research.ResultsQuestionnaires were completed by 123 students and 19 faculty. Overall, 46% of students had a self perception of “high test anxiety”, with 28% having a CTAS-2 score that correlated to severe test anxiety. A majority of faculty respondents (84%) believed severe test anxiety affects 30% or less of pharmacy students and may be associated with poor academic performance.ConclusionsStudent pharmacists’ self-perception of test anxiety and perception of difficulty mitigating test anxiety may be overestimated. Overall, faculty accurately estimated the degree of test anxiety, felt confident in being able to help students, and believed it should receive attention from both faculty and the university.

Background: Invasive fungal infections are responsible for a large number of infections in hospitalized patients annually and are responsible for high morbidity and mortality. Familiarity with novel agents or strategies in this area can be challenging. Objectives: To identify the top 10 manuscripts on the treatment of invasive fungal infections from 2018 to 2023. Design: Modified Delphi consensus-building technique. Methods: A three-stage consensus-building approach was used comprised of (1) identifying relevant articles; (2) voting by a panel of experts to establish consensus on the importance of these articles; and (3) finalizing the list of top articles by a small group. Members of the Southeastern Research Group Endeavor network served as content experts. Publications from 2018 to 2023 were evaluated if articles met the following inclusion criteria: (1) published between 2018 and 2023, (2) contained content related to fungal infections, and (3) included an actionable intervention. Results: A total of 6518 potential publications were assessed. After applying inclusion and exclusion criteria, 82 articles were reviewed. The top 10 publications related to invasive fungal infections, selected by a panel of experts, are summarized in this manuscript and include publications related to the treatment of invasive aspergillosis, candidiasis, and cryptococcosis. Conclusion: This article highlights the selected publications and may serve as a key resource for teaching and training. Clinicians may also employ these reported interventions to identify new opportunities to optimize antifungal therapeutic strategies within one’s institution.

Invasive fungal infections pose significant morbidity and mortality risks, particularly those caused by moulds. Available antifungal classes are limited by toxicities and are increasingly susceptible to resistance, particularly amongst challenging fungal pathogens. The purpose of this case series and literature review was to characterize the use of a high-dose lipid formulation of amphotericin B. A case series is presented including patients who received high-dose lipid formulation amphotericin B (≥7.5 mg/kg/day) between June 2012 and August 2021. Additionally, a systematic literature review was conducted by searching the PubMed database for English-language studies involving individuals who received high-dose amphotericin B therapy (≥7.5 mg/kg) using lipid formulations. Nine patients were included in the case series, receiving an average of 8.9 ± 1.3 mg/kg liposomal amphotericin B over a mean of 11.0 ± 10.8 days predominantly for mould infections including Mucorales, aspergillosis and Fusarium. The patients were primarily cared for in intensive care units, with varying treatment histories and outcomes. A total of 11 studies (n=260 patients) met inclusion criteria for the literature review. Responses to high-dose liposomal amphotericin B ranged from 8% to 100%, often showing favourable outcomes. High doses of liposomal amphotericin B were well tolerated both in the case series and in published literature, with serum creatinine changes being the most commonly reported adverse event. However, multi-patient studies continue to report less than favourable (range 8-62%) response rates. High-dose liposomal amphotericin B, either alone or in combination with other antifungal agents, might be a viable strategy for managing invasive fungal infections when few treatment choices exist. This article is part of the Challenges and strategies in the management of invasive fungal infections Special Issue: https://www.drugsincontext.com/special_issues/challenges-and-strategies-in-the-management-of-invasive-fungal-infections.

Purpose of Review Antimicrobial resistance is a growing threat to public health, leading to millions of antibiotic-resistant infections and thousands of deaths annually in the USA. One concerning issue is the rise of extended-spectrum beta-lactamase (ESBL)–producing Enterobacterales. Current treatments often involve intravenous carbapenems, leading to prolonged hospital stays and financial burdens. Recent Findings To address this, new oral penem agents, tebipenem and sulopenem, are being investigated. They are administered as prodrugs, enhancing bioavailability before becoming active in the gastrointestinal tract, potentially treating multidrug-resistant infections in outpatient settings. Despite promise in clinical trials, challenges exist, such as tebipenem’s renal excretion, requiring dose adjustments for kidney dysfunction. Additionally, sulopenem failed noninferiority margins in trials, and neither drug has established susceptibility testing standards. Summary Tebipenem and sulopenem offer potential oral solutions for antimicrobial resistance, especially in urinary tract infections, but further research is needed for optimal dosing and susceptibility testing.

Keeping abreast of the antimicrobial stewardship-related articles published each year is challenging. The Southeastern Research Group Endeavor identified antimicrobial stewardship-related, peer-reviewed literature that detailed an actionable intervention during 2022. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight actionable interventions used by antimicrobial stewardship programs to capture potentially effective strategies for local implementation.

The viridians group streptococci (VGS) are a large collection of closely related commensal streptococci, with many being opportunistic pathogens causing invasive diseases, such as bacteremia and infective endocarditis. Little is known about virulence determinants in these species, and there is a distinct lack of genomic information available for the VGS.

Daptomycin use for gram-positive infections has increased. This cost minimization analysis aimed to determine cost and/or time savings of daptomycin over vancomycin. The estimated hospital cost savings was US$166.41 per patient, and pharmacist time saved of almost 20 minutes per patient. Daptomycin has the potential to save both time and money.

Background VRE infections increased in 2020. High-dose daptomycin (>= 10 mg/kg) has shown mortality benefit over other regimens, though daptomycin resistance is increasing. Limited data exist on the practice patterns of ID pharmacists for VRE bloodstream infections (VRE BSIs). Objectives To describe practice patterns for VRE BSI in ID pharmacists. Methods A 22-question REDCap survey was distributed to ID pharmacist members of the American College of Clinical Pharmacy (ACCP) Infectious Diseases Practice and Research Network (ID PRN) via e-mail listserv. The survey was distributed on 7 April 2022 and remained open for 4 weeks. Results Sixty-eight pharmacists responded. All pharmacists completed additional training or certification in infectious diseases past their PharmD, and most (70.5%) had been practising for 10 years or less. Pharmacists at academic medical centres (80.0%) were more likely (P = 0.001) to have implemented the updated CLSI breakpoints than pharmacists at other types of institutions (55.2%). Daptomycin was the preferred drug for VRE BSI (92.6%), with 10 mg/kg (72.1%) being the preferred dose. Adjusted body weight was the most common weight (61.2%) used for obese patients. Fourteen days (76.1%) was the most common treatment duration for VRE BSI. Pharmacists defined persistent VRE BSI as 5 days (68.7%) after first blood culture. Conclusions ID pharmacists overwhelmingly selected high-dose daptomycin for VRE BSI. There were variations in practice and response rate when selecting combination therapy, managing persistent bacteraemia, and treating patients with high daptomycin MICs or previous exposure to daptomycin.

Introduction: Staphylococcus aureus bacteremia (SAB) remains complex, in that optimal treatment for patients, including complicated or persistent infection, remains unclear. Two recent surveys have demonstrated practice variations in SAB among infectious diseases (ID) physicians. Objectives: The purpose of this survey was to examine practice variations in SAB among ID pharmacists. Methods: A thirty-five-question survey was electronically distributed to the American College of Clinical Pharmacy (ACCP) Infectious Diseases Practice and Research Network (IDPRN) in Fall 2019 to determine differences in SAB management. Data were analyzed utilizing Pearson’s Chi-Square or Fisher’s Exact Test. Results: A total of 106 ID pharmacists responded. Only 28% of pharmacists practiced at hospitals with mandatory ID consultation for SAB. A majority (75%) had rapid diagnostic technology (RDT) for identifying SABSI, but 32% of those facilities with RDT did not notify pharmacy with results. Anti-staphylococcal penicillins were preferred for MSSA blood stream infections (BSI) in patients with central nervous system infection and endocarditis, whereas cefazolin was favored for other MSSA BSI. For persistent MRSA BSI, 34% selected daptomycin alone while 38% elected to combine daptomycin and ceftaroline. Pharmacists at hospitals less than 500 beds were more likely to use daptomycin, while those at larger hospitals were more likely to use daptomycin and ceftaroline for persistent MRSA BSI (P < .05). Conclusions: A survey of ID pharmacists showed variation in the management of SABs, as well as the definition and treatment of persistent SAB. Mandatory ID consultation and RDT use to improve SAB management have not been optimized.

Delays in the treatment of proven invasive fungal disease have been shown to be harmful. However, empiric treatment for all patients at risk of infection has not demonstrated benefit. This study evaluates the effects of a micafungin stewardship initiative on the duration of therapy and clinical outcomes at the University of Mississippi Medical Center in Jackson, Mississippi. This single-center quasi-experiment evaluated patients who received micafungin. Adult inpatients who received at least one treatment dose of micafungin in the pre-intervention (1 October 2020 to 30 September 2021) or post-intervention (1 October 2021 to 30 April 2022) groups were included. Patients were placed on micafungin for prophylaxis and those who required definitive micafungin therapy were excluded. An algorithm was used to provide real-time recommendations in order to assess change in the treatment days of micafungin therapy. A total of 282 patients were included (141 pre-group versus 141 post-group). Over 80% of the patients included in the study were in an intensive care unit, and other baseline characteristics were similar. The median number of treatment days with micafungin was 4 [IQR 3-6] in the pre-group and 3 [IQR 2-6] in the post-group (p = 0.005). Other endpoints, such as time to discontinuation or de-escalation, hospital mortality, and hospital length of stay, were not significantly different between the groups. An antifungal stewardship initiative can be an effective way to decrease unnecessary empiric antifungal therapy for patients who are at risk of invasive fugal disease.