The Controversy Surrounding Antifungal Treatments: Are They Causing More Harm Than Good?

The rise and spread of severe skin, scalp, and nail fungal infections in the United States have become a cause for concern, according to a report by the US Centers for Disease Control and Prevention (CDC). Dermatologists have recently detected the first known cases of highly contagious drug-resistant fungal infections, which do not respond to the few fungal treatments available. Initially concentrated in Southeast Asia, these drug-resistant infections have now spread to China and several US states.

To understand the situation better and potentially devise solutions, researchers at the CDC have conducted an in-depth analysis of antifungal prescriptions in the US. The study aimed to identify patterns in prescribing practices and provide insights into the potential overuse of antifungal medications. By doing so, the researchers hoped to take proactive measures before the fungal infection epidemic worsens.

Overuse of Antifungal Medications – A Double-Edged Sword?

The overuse of antifungal medications raises concerns similar to those surrounding antibiotic resistance. When antifungal treatments are prescribed incorrectly or without proper use, potentially pathogenic fungi have a higher chance of developing resistance. The CDC researchers, led by epidemiologist Kaitlin Benedict, believe that a better understanding of current prescribing practices would encourage judicious prescribing by clinicians and improve patient education about the appropriate use of antifungal treatments.

The scale of antifungal prescriptions discovered during the study is staggering. Data on approximately 1 million healthcare professionals who wrote prescriptions for nearly 49 million Medicare beneficiaries were analyzed. The researchers found that in 2021 alone, around 6.5 million topical antifungal prescriptions were filled in the US, amounting to a staggering cost of US$231 million. However, this figure likely represents an underestimation of the actual usage, as many topical antifungals can be purchased over the counter without a prescription.

A Dominance of Primary Care Physicians in Prescribing

Primary care physicians were found to be the largest prescribers of antifungal medications, accounting for 40 percent of all prescriptions in 2021. The remaining prescriptions were written by nurse practitioners, dermatologists, and podiatrists. What is particularly concerning is the fact that the top 10 percent of prescribers, comprising around 13,106 practitioners, accounted for nearly half of all dispensed medications. This suggests a potential case of overuse or liberal prescribing, as these doctors either encounter a high number of patients with suspected fungal infections or are prone to treating them without proper diagnostic measures.

One significant limitation of the study was the absence of diagnostic information on the types of fungal infections patients had. Consequently, the researchers were unable to determine whether the prescribed treatments were suitable for the specific conditions or if the doctors had conducted necessary tests before prescribing the medications. Of particular concern to Benedict and her colleagues were the high number of clotrimazole-betamethasone prescriptions, accounting for 15 percent of all topical antifungals prescribed. This combination treatment is suspected to be a driver for emerging drug-resistant fungal infections.

Promoting Proper Use of Topical Antifungal Treatments

To control the emergence and spread of drug-resistant superficial fungal infections, healthcare providers should aim to use diagnostic testing whenever possible. Confirming suspected fungal infections with proper diagnostic measures would ensure the appropriate use of topical antifungal medications. Healthcare professionals, including board-certified dermatologists, should refrain from relying solely on visual evaluations to diagnose skin conditions, as research suggests that they are frequently incorrect.

The CDC’s report sheds light on the alarming increase in drug-resistant fungal infections in the US and raises important questions regarding the overuse and potential misuse of antifungal treatments. The findings highlight the urgent need for healthcare providers to exercise caution in prescribing antifungal medications and to promote proper diagnostic testing to ensure accurate and appropriate treatment. Only by addressing these issues head-on can we hope to mitigate the spread of drug-resistant fungal infections and safeguard public health.