Pharmacist involvement in antifungal stewardship programs: a systematic review of clinical, utilization, and economic outcomes

INTRODUCTION: Antifungal stewardship programs are increasingly implemented to optimize antifungal use. Pharmacists are frequently involved in these programs; however, their specific contributions and impact have not been systematically characterized. AIM: The aim of this systematic review was to synthesize the available evidence regarding the role and impact of pharmacists in antifungal stewardship programs, specifically focusing on clinical, utilization, and economic outcomes, using a narrative synthesis approach. METHOD: A systematic review was conducted. PubMed/MEDLINE and Scopus databases were searched for studies published from database inception to January 2026. Two reviewers independently screened titles, abstracts, and full texts according to predefined eligibility criteria. Data extraction was performed independently using a standardized form. Due to heterogeneity in study designs and outcomes, a narrative synthesis approach was applied. The review was reported in accordance with the PRISMA reporting guidelines. Risk of bias was assessed using the ROBINS-I tool for non-randomized studies. RESULTS: Fifteen studies met the inclusion criteria, the majority of which were quasi-experimental pre-post intervention studies conducted in tertiary care hospitals. Key pharmacist-driven interventions included antifungal dose optimization, de-escalation or discontinuation of therapy, facilitation of early appropriate antifungal treatment, therapeutic drug monitoring, and education or protocol development. Across studies, pharmacist involvement was associated with improvements in antifungal prescribing quality and stewardship process outcomes, including potential improvements in duration of antifungal therapy, antifungal consumption (measured by defined-daily-doses or days-of-therapy), time to appropriate therapy, and antifungal-related costs. Effects on clinical outcomes such as mortality and length of hospital stay were variable and generally not statistically significant. The overall certainty of the evidence is low to very low by the observational nature and the moderate-to-serious risk of bias of the included studies. CONCLUSION: Pharmacist participation in multidisciplinary antifungal stewardship teams may be associated with improved antifungal utilization and adherence to guidelines in hospitalized adults. The findings support that pharmacists are important members of multidisciplinary teams in antifungal stewardship.