Impacto Clínico e Econômico da Indicação de Broncocospia e Galactomanana com navegação farmacêutica em uma Linha de Cuidado de Infecções Fúngicas Invasivas

Abstract

Introduction (with objective): Invasive fungal infections (IFI) have high morbidity and mortality rates in immunocompromised patients. In children, they manifest with nonspecific symptoms, making early diagnosis difficult. In immunocompromised individuals, the main IFI is aspergillosis, with the lung being the most affected site. Due to the distribution of Aspergillus conidia in the air, the diagnosis of pulmonary aspergillosis relies on the use of samples from the lower respiratory tract, such as bronchoalveolar lavage (BAL). Thus, bronchoscopy with BAL collection is emphasized for infectious diagnosis. Despite this, the collection of sterile samples is difficult in patients with thrombocytopenia, requiring precise selection of eligible patients for the procedure. The invasive fungal infection care pathway (IFI-CLI) navigated by clinical pharmacy was conceived as a guide for the management of IFI in children, justified by the difficulty of diagnosis and the high cost of treatments. Objectives: To evaluate the clinical and economic impact of bronchoscopy with bronchoalveolar lavage and galactomannan testing indicated by the pharmacist navigator of the LC-IFI (Laboratory of Computed Fluid Infection) for patients with suspected pulmonary IFI (Infectious Fungal Infection). Material and Method: Descriptive, observational study, with analysis of seven months before and after the implementation of LC-IFI in a tertiary pediatric hospital. Data from patients admitted through the Brazilian Unified Health System (SUS) who underwent the galactomannan rapid test (Immy®) in bronchoalveolar lavage (GM-LBA) for pulmonary IFI screening were included. The positivity rate of the test was calculated per period and per sample, followed by the calculation of avoided costs with systemic antifungals provided by the Ministry of Health's Mycosis program for patients with galactomannan ≥ 0.8. CAAE: 83381224.9.0000.0097. Results: Sixty samples were included (pre: 24; post: 36). Before the implementation of the LC-IFI, bronchoscopy with bronchoalveolar lavage and galactomannan was performed for 12.5% (n=3/24) of patients with suspected IFI and 24.2% (n=8/33) in the post-intervention period. The positivity rate in the post-intervention period was 87.5% (n=7/8), compared to 0% in the period prior to the creation of the care pathway. Three patients with positive GM-LBA underwent the Micosis system, with subsequent release of amphotericin B lipid complex, voriconazole, and isavuconazole. The average cost for performing bronchoscopy with bronchoalveolar lavage and galactomannan totaled approximately R$ 12,000.00 for the hospital for the three procedures. The average GM-LBA score was 1.62. The Ministry of Health provided 144 capsules of isavuconazole 100 mg, 634 tablets of voriconazole 200 mg, and 30 vials of amphotericin B lipid complex 50 mg, at a cost of R$ 96,368.00. From a hospital perspective, the avoided cost of the three treatments was R$ 84,368.00, and the three patients were discharged with oral antifungal treatment and clinical follow-up with outpatient imaging control exams. Conclusions: Establishing LC-IFI with bronchoscopy indication for patients with suspected invasive fungal infection allowed for greater diagnostic accuracy and the establishment of targeted antifungal treatment. Furthermore, there was significant cost avoidance with systemic antifungals in SUS patients, emphasizing the strategic role of antifungal stewardship and highlighting the role of the clinical pharmacist as a navigator of care, both for patient clinical outcomes and for hospital sustainability.