Background and Aim The management of children with invasive fungal disease is challenging due to the difficulty of obtaining a microbiological proven diagnosis and the lack of diagnostic and therapeutic trials in children together with the emerging threat of antifungal resistance and increasing complexity of fungal infections. ^1–3 Therefore, we established a dedicated MDT meeting consisting of various specialists in the field to optimize management including antifungal stewardship, and provide a learning environment for junior doctors, consultants, nurses and pharmacists.

Method A monthly mycology MDT meeting (online) was established in 2021 in our children’s hospital in which a large cohort of immunocompromised patients are cared for, including children with leukaemias, those receiving a bone marrow or lung transplant, children with primary immunodeficiencies (PID), and those treated with a wide variety of immunosuppressive medicines and/or biologicals. These patients are considered to be at high risk of developing invasive fungal disease and a majority will receive antifungal prophylaxis and empiric antifungal therapy. A monthly calendar invite and conference link is disseminated to all teams as well as reminder email in the days before the MDT to promote and invite teams to discuss their patients. These patients are added to an MDT list on the electronic health system which can be accessed by all members of the MDT. The mycology MDT meetings are chaired by team of colleagues with complementary expertise including a pharmacist, a microbiologist, and a medical mycologist. Consultants and junior doctors in infectious diseases (ID), immunology, haemato-oncology, as well as other disciplines are invited to join as well as to ask specific advice on their patients. A local specialist guideline for the management of invasive fungal disease in neonates and children was previously developed to assist decision making.

Results Since implementing the mycology MDT there have been approximately 20 meetings and an average of 2–4 patients with invasive fungal disease or colonisation are discussed. Discussions include decision to treat, choice of antifungal agent, duration of therapy, optimal dosing, therapeutic drug monitoring, drug-interactions, monitoring and how and when to review the patient in terms of fungal biomarkers and imaging. The MDT discussion and recommendation is documented in the patient’s electronic patient record (EPR) by the ID or microbiology registrar or antimicrobial pharmacist. Outcomes of the MDT have included discussion, planning and implementation of novel therapies such as intralesional voriconazole for pulmonary aspergillosis (A. flavus), oral amphotericin to reduce gastro-intestinal burden of C. glabrata, C. albicans and C. tropicalis cultured in stool of a child with PID planned for bone marrow transplant and discussion and attainment of compassionate use olorofim, a novel class of antifungal, for treatment of disseminated azole resistant aspergillus (A. fumigatus TR34 mutation).

Conclusion Treating invasive fungal infections in children is challenging. Our mycology MDT is unique and improves the care of our patients, antifungal stewardship and knowledge and engagement of our treating teams. Going forward the MDT plan to capture more data on outputs and metrics.

References

1. Agrawal S, Barnes R, Bruggemann RJ, Rautemaa-Richardson R, Warris Al. The role of the multidisciplinary team in antifungal stewardship. Journal of Antimicrobial Chemotherapy 2016;71:ii37–ii42. doi:10.1093/jac/dkw395.

2. Lempers VJ, Bruggemann RJ. Antifungal therapy: drug-drug interactions at your fingertips. Journal of Antimicrobial Chemotherapy 2016;71:285–289.

3. Fisher M, Alastruey-Izquierdo A, Berman J, et al. Tackling the emerging threat of antifungal resistance to human health. Nature Reviews Microbiology 2022;20:557–571. doi:10.1038/s41579-022-00720-1.