Development of indicators for evaluating the appropriate use of triazoles for invasive fungal disease: A Delphi panel survey

What is known and objectives: Triazoles including fluconazole, itraconazole, voriconazole and posaconazole are now widely used, whereas in some countries, they are reportedly used in inappropriate way frequently; thus, it is clearly a matter of urgency to regulate the use of triazole drugs. Several studies have made good attempts to evaluate antifungal use, but they did not cover the entire medication process. This study aimed to establish indicators for the appropriate use of triazoles for invasive fungal disease, so as to produce a reference for evaluating and standardizing the rational application of triazole antifungals. Methods: A comprehensive analysis and literature review were conducted to construct an evaluation system for indications, therapeutic timing, duration of drug usage, drug dosage, administration method, drug interactions, medication in specific populations and pharmaceutical care. A Delphi questionnaire was designed based on the preliminary evaluation of an indicator system that comprised eight primary indicators, 29 secondary indicators and 54 tertiary indicators. A Delphi panel survey was completed by 28 and 26 experts in the first and second rounds, respectively, via e-mail. Agreement was considered to be reached when the median score was in the top tertile (4 or 5), and 80% of panel scores were in the top tertile. The experts mainly comprised physicians and clinical pharmacists from different regions. Based on expert opinions, the evaluation indicator system was modified and the final version was established. Results: The response rate was high in the first and second rounds, at 100% and 93%, respectively, as was the dependability coefficient (0.83). The expert opinions resulted in four secondary indicators and nine tertiary indicators being deleted, and 10 tertiary indicators being modified. After the two rounds of the Delphi survey, the final established system of indicators comprised eight primary indicators, 25 secondary indicators and 45 tertiary indicators. What is new and conclusions: Contrasted with previous studies that have only focused on a subset of indicators, this research establishes comprehensive indicators for evaluating the use of triazoles for invasive fungal disease and which cover most of the medication process: indications, therapeutic timing, duration of drug usage, drug dosage, administration method, drug interactions, medication in specific populations and pharmaceutical care. The indicators can reflect the characteristic of triazoles throughout the process of clinical administration for an invasive fungal disease, and it will be helpful as references when hospital administrators are regulating the use of antifungals.