| Summary: | Objective: The increasing incidence of invasive fungal infections (IFIs) in critically ill and immunocompromised populations, particularly in India, challenges antifungal management. Rising resistance and high ICU burden of invasive candidiasis and mould infections underscore the need for antifungal stewardship (AFS). This study evaluated AFS needs in the ICU of a tertiary oncology centre in Eastern India by assessing antifungal prescription appropriateness. Methods: A prospective pilot study was conducted from 12–31 August 2024, in the ICU/high dependency unit of an oncology/haematology hospital in Eastern India. All patients receiving systemic antifungals (SAF) were included. Appropriateness of SAF prescriptions, diagnostic workup and regimen modifications were assessed based on predefined criteria validated by external experts. Data were collected at SAF initiation and on day 5 or at discharge, whichever occurred first. Results: Among 25 patients (median age 56 years, interquartile range 49–64; 68% female; 80% solid cancers), SAF was empiric in 76%, targeted in 16% and prophylactic in 8%. Prescription appropriateness was optimal in 55%, suboptimal in 15% and inappropriate in 30%. Loading doses were administered in 85%. Diagnostic workup was insufficient in 75% of suspected invasive pulmonary aspergillosis (IPA) and 83% of invasive candidiasis (IC) cases. No SAF was discontinued within 5 d, and only 10% of patients had regimen modifications. Conclusion: Empiric antifungal prescriptions were frequently inappropriate, with insufficient diagnostic investigations, particularly for IC. The lack of de-escalation highlights the urgent need for an ICU-specific AFS programme to optimize antifungal use and improve diagnostics in high-risk patients.
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