Antifungal use and appropriateness: a study of Australian Hospital National Antimicrobial Prescribing Survey data

Abstract Objectives: To evaluate the quality of systemic antifungal prescribing in Australian hospitals using point-prevalence survey data from the Hospital National Antimicrobial Prescribing Survey (Hospital NAPS). Methods: Data were extracted from the Hospital NAPS dataset from January 2014 to December 2024. Systemic antifungal prescriptions were analyzed for antifungal use, guideline compliance, appropriateness, and reasons for inappropriateness according to the Hospital NAPS methodology. Demographic factors, hospital classifications, antifungals, and antifungal indication were compared. Results: A total of 7,830 systemic antifungal prescriptions from 372 healthcare facilities across all Australian states and territories were included. Overall 88.4% were guideline compliant and 92.3% of prescriptions were deemed appropriate. Fluconazole was the most commonly prescribed antifungal but had one of the lowest percentage appropriateness (88.4%). In contrast, mold-active azoles, echinocandins, and amphotericin B demonstrated appropriateness rates exceeding 90%. Prescriptions with approval through local antimicrobial stewardship (AMS) processes had significantly higher appropriateness than those without (95.9% vs. 82.9%, p < 0.001). Specialized facilities managing immunocompromised populations showed both higher antifungal use and higher prescribing quality compared to general acute public hospitals. Conclusion: This national evaluation highlights the overall high quality of systemic antifungal prescribing in Australian hospitals, reflecting the strength of AMS programs. However, variation across hospital types, specialties, and antifungal agents—particularly fluconazole—indicates opportunities for targeted stewardship interventions to further optimize antifungal use.