Key points:
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The CDC urged doctors to be cautious when prescribing topical antifungals in light of the recent detection of antimicrobial-resistant superficial fungal infections in the United States.
The warning accompanied new findings from a CDC review of topical antifungal prescriptions filled by Medicare Part D beneficiaries in 2021, which found that nearly half of the more than 6 million prescriptions were written by just 10%. of the prescribers.
What is already known about this topic?
Severe antimicrobial-resistant superficial fungal infections have recently been detected in the United States; Evaluation of the use of topical antifungals is an initial step in the development of strategies to prevent the emergence and global spread of these infections.
What does this report contribute?
In 2021, a total of 6.5 million topical antifungal prescriptions, costing $231 million, were filled for Medicare Part D beneficiaries, approximately one prescription for every eight beneficiaries. Most prescriptions were written by primary care physicians, nurse practitioners, or physician assistants.
What are the implications for public health practice?
The large volume of topical antifungal prescriptions in the context of emerging resistance highlights the need to better understand current prescribing practices and encourage judicious prescribing by clinicians and improve patient education on recommended use.
Superficial fungal skin infections have an estimated lifetime prevalence of more than 20% worldwide and are particularly common among adults ≥65 years of age. The emergence and spread of antimicrobial-resistant superficial fungal infections , especially dermatophytosis (also known as ringworm), has led to large outbreaks of extensive, recalcitrant skin infections in South Asia that frequently do not respond to topical antifungals or antifungals. top-of-the-line orals. therapies.
This emergence and spread is likely exacerbated by the overuse and misuse of topical antifungals, particularly combination antifungal and corticosteroid creams. Cases of antimicrobial-resistant dermatophytosis have been identified in at least 11 US states, with patients experiencing extensive lesions and delays in diagnosis. In the United States, prescribing of non-recommended topical antifungals is probably common, because diagnosis of fungal skin infections by visual inspection is often incorrect , even among board-certified dermatologists, and confirmatory diagnostic testing is rarely performed by physicians of all specialties .
Understanding prescribing patterns, including identifying physicians who prescribe a disproportionate volume of topical antifungals, could help establish and promote the correct use of these medications. Data from the Centers for Medicare and Medicaid Services (CMS) were used to characterize the prescription volume of topical antifungal medications among Medicare Part D beneficiaries in the United States during 2021.
Summary
Incorrect use of topical antifungals and antifungal-corticosteroid combinations likely contributes to the emergence and global spread of serious antimicrobial-resistant superficial fungal infections, which have recently been detected in the United States. Understanding prescribing patterns is an initial step in establishing and promoting the recommended use of these medications. Using 2021 Medicare Part D data, CDC examined prescription volumes, rates, and costs for topical antifungals (including topical combination antifungal and corticosteroid medications).
Total prescription volumes were compared between the highest volume prescribers (top 10% of topical antifungal prescribers by volume) and the lowest volume prescribers. During 2021, approximately 6.5 million topical antifungal prescriptions were filled (134 prescriptions per 1,000 beneficiaries), at a total cost of $231 million.
Among 1,017,417 unique prescribers, 130,637 (12.8%) prescribed topical antifungals. Primary care physicians issued the highest percentage of prescriptions (40.0%), followed by nurse practitioners or physician assistants (21.4%), dermatologists (17.6%), and podiatrists (14.1%). High-volume prescribers issued 44.2% (2.9 million) of all prescriptions.
This study found that enough topical antifungal prescriptions were written for about one in eight Medicare Part D beneficiaries in 2021, and 10% of antifungal prescribers prescribed nearly half of these medications.
In the context of emerging antimicrobial resistance , these findings highlight the importance of expanding efforts to understand current prescribing practices, while encouraging judicious prescribing by physicians and providing patient education about the proper use.
Discussion
This analysis of publicly available CMS data found that 6.5 million topical antifungal prescriptions (enough to provide a prescription to more than one-eighth of all beneficiaries) were issued in 2021 for Medicare Part D beneficiaries, at a cost of $231 million.
The actual volume of topical antifungal use among the study population is likely to be considerably higher than that identified in this study because most topical antifungals can be purchased without a prescription ; such use of topical antifungals is not recorded in CMS data and is an important consideration for potential antifungal stewardship efforts.
The large volume of topical antifungals used in the United States deserves greater attention given the infrequent use of confirmatory testing, the inaccuracy of diagnosis made by physical examination alone, and the recent emergence of serious, antimicrobial-resistant superficial skin infections .
To help control the emergence and spread of antimicrobial-resistant superficial fungal infections and help promote the appropriateness of topical antifungal prescribing, healthcare providers could use diagnostic testing whenever possible to confirm suspected fungal infections. superficial.
Additionally, healthcare providers can educate patients about the prognosis, benefits, and harms of topical antifungal treatment and combination antifungals and corticosteroids (both prescription and over-the-counter), and the importance of using these medications as prescribed. prescribed or according to the manufacturer’s instructions.
Reference: Benedict K, Smith DJ, Chiller T, Lipner SR, Gold JA. Topical Antifungal Prescribing for Medicare Part D Beneficiaries — United States, 2021. MMWR Morb Mortal Wkly Rep 2024;73:1–5. DOI: http://dx.doi.org/10.15585/mmwr.mm7301a1
