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Crowley PD, Whalen FX, Siegel LR, Challener DW. Antibiotics at End of Life: Where Are We Now and Where Are We Going? A Narrative Review. Am J Hosp Palliat Care 2024:10499091241282627. [PMID: 39250304 DOI: 10.1177/10499091241282627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND Antibiotics are frequently prescribed at the end of life, though the benefits and harms are not well understood. METHODS We abstracted relevant findings from articles published in English in the past 25 years to answer questions generated by discussion among the authors and with stakeholders in Palliative Care and Infectious Diseases. FINDINGS Prescribing practices vary based on individual situation and geographic location. Patients with cancer and those hospitalized receive more antibiotics than those enrolled in outpatient hospice. Urinary tract infections and pulmonary infections are the most common conditions treated with antibiotics at the end of life -most often with penicillin derivatives and vancomycin in the hospital, fluoroquinolones in outpatient, and cephalosporins in both settings. When asked, patients most often prefer limiting antibiotics to symptom management at the end of life. Physicians' over-estimation of patient preference for antibiotics and the increased probability of misdiagnosis increases antibiotic prescription rates. Antibiotics can improve symptoms when used for specific diseases at the cost of drug reactions, resistant organisms, and delayed discharge. Antibiotic use has variable results on survival duration. Antimicrobial stewardship exists in hospital and long-term care facilities, but not outpatient hospice groups. Stewardship interventions could increase proper use of antibiotics, but more information is needed to apply these interventions to hospice groups. CONCLUSIONS Antibiotics at the end of life are impactful and efforts to educate patients and providers will be invaluable in optimizing care.
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Affiliation(s)
- Patrick D Crowley
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francis X Whalen
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
- Department of Palliative and Supportive Care, Mayo Clinic, Rochester, MN, USA
| | - Leslie R Siegel
- Department of Palliative and Supportive Care, Mayo Clinic, Rochester, MN, USA
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Douglas W Challener
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
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Correia I, Fernandes S, Bernardino M, Gonçalves Pereira J. Infection on Frail Patients in the Intensive Care Unit: Insights From the PalMuSIC Study. Cureus 2024; 16:e63897. [PMID: 39099977 PMCID: PMC11298117 DOI: 10.7759/cureus.63897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Along with population aging, frailty is also increasingly common in the intensive care unit (ICU). However, the impact of frailty on the infection incidence, the risk of multidrug-resistant (MDR) microorganisms, and the potential benefits of broad-spectrum antibiotics are still poorly studied. METHODS This is a multicentric, prospective, observational study collecting data for 15 consecutive days of all consecutive adult patients admitted in each participating ICU. Exclusion criteria included admission for less than 24 hours or failure to obtain informed consent. The Clinical Frailty Score (CFS) was calculated both by the doctor and by the nurse in charge, and the patient's next of kin. Patients were considered frail if the mean of the three measured scores was ≥5. This is a post hoc analysis of the PALliative MUlticenter Study in Intensive Care (PalMuSIC) study. The Hospital de Vila Franca de Xira Ethics Committee approved the study (approval number: 63). RESULTS A total of 335 patients from 23 Portuguese ICUs were included. Frailty was diagnosed in 20.9%. More than 60% of the patients had a diagnosis of infection during their ICU stay, either present on admission or hospital-acquired. This included 25 (35.7%) frail and 75 (28.3%) non-frail (p=0.23) patients diagnosed with infection. In 34 patients, MDR microorganisms were isolated, which were more common in frail patients (odds ratio (OR): 2.65, 95% confidence interval (CI): 1.3-5.6, p=0.018). Carbapenems were started in 37 (18.1%) patients, but after adjusting for frailty and severity, no clear mortality benefit of this strategy was noted (odds ratio for ICU mortality: 1.61, 95% confidence interval: 0.49-5.31, p=0.43; odds ratio for hospital mortality: 1.61, 95% confidence interval: 0.61-4.21, p=0.33). CONCLUSION Frail patients had similar rates of infection to non-frail patients but were more prone to have MDR microorganisms as causative pathogens. The use of empirical therapy with large-spectrum antibiotics should be based on microbiological risk factors and not simply on the host characteristics.
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Affiliation(s)
- Iuri Correia
- Internal Medicine Department, Hospital Professor Doutor Fernando Fonseca, Amadora, PRT
- Palliative Medicine Unit, Hospital CUF Tejo, Lisbon, PRT
| | - Susana Fernandes
- Intensive Care Department, Hospital de Santa Maria, Lisbon, PRT
- Intensive Care University Clinic, Faculdade de Medicina da Universidade de Lisboa, Lisbon, PRT
| | - Mariana Bernardino
- Intensive Care University Clinic, Faculdade de Medicina da Universidade de Lisboa, Lisbon, PRT
| | - João Gonçalves Pereira
- Intensive Care Unit Department, Hospital de Vila Franca de Xira, Vila Franca de Xira, PRT
- Intensive Care University Clinic, Faculdade de Medicina da Universidade de Lisboa, Lisbon, PRT
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Alves J, Prendki V, Chedid M, Yahav D, Bosetti D, Rello J. Challenges of antimicrobial stewardship among older adults. Eur J Intern Med 2024; 124:5-13. [PMID: 38360513 DOI: 10.1016/j.ejim.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/06/2024] [Accepted: 01/15/2024] [Indexed: 02/17/2024]
Abstract
Older adults hospitalized in internal medicine wards or long-term care facilities (LTCF) are progressively increasing. Older adults with multimorbidity are more susceptible to infections, as well as to more vulnerable to adverse effects (and interactions) of antibiotics, resulting in a need for effective and safer strategies for antimicrobial stewardship (ASM), both in hospitalization wards and long-term care facilities. Studies on antimicrobial stewardship in older patients are scarce and guidelines are required. Given the peculiarities of the optimization of antimicrobial prescription in individual older adults for common infections, tactics to overcome barriers need an update. The use of rapid diagnosis tests, biomarkers, de-escalation and switching from intravenous to oral/subcutaneous therapy strategies are examples of successful AMS interventions. AMS interventions are associated with reduced side effects, lower mortality, shorter hospital stays, and reduced costs. The proposed AMS framework in LTCF should focus on five domains: strategic vision, team, interventions, patient-centred care and awareness. Internists can partner with geriatrists, pharmacists and infectious disease specialists to address barriers and to improve patient care.
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Affiliation(s)
- Joana Alves
- Infectious Diseases Specialist, Head of Local Unit of the Program for Prevention and Control of Infection and Antimicrobial Resistance, Hospital de Braga, Portugal.
| | - Virginie Prendki
- Department of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland; Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Marie Chedid
- Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Centre, Ramat Gan, Israel
| | - Davide Bosetti
- Department of Infectious Disease, Geneva University Hospital, Switzerland; Infection Control Programme and WHO Collaborating Centre for Infection Prevention and Control and Antimicrobial Resistance, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jordi Rello
- Medicine Department, Universitat Internacional de Catalunya, Spain; Clinical Research Pneumonia and Sepsis (CRIPS) Research Group-Vall d'Hebrón Institute Research (VHIR), Barcelona, Spain; Formation, Recherche, Evaluation (FOREVA), CHU Nîmes, Nîmes, France
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Pandey S, Wisniewski R, Morjaria S, Bianchi AL, Newman T, Tan C, Rosa WE, Finlayson CS. Factors Associated with Antimicrobial Use at the End-Of-Life Among Hospitalized Cancer Patients. Am J Hosp Palliat Care 2024; 41:8-15. [PMID: 36812451 PMCID: PMC10442462 DOI: 10.1177/10499091231160185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Background: Antimicrobials are frequently administered at end-of-life (EOL) and their non-beneficial use may subject patients to unnecessary harms. Studies analyzing factors for antimicrobial prescribing in solid tumor cancer patients at the EOL are lacking. Thus, we aimed to identify factors and patterns associated with antimicrobial use in hospitalized adults with cancer at EOL. Methods: We used a retrospective cohort design to review electronic medical records of terminal hospitalized patients ≥18 years with solid tumors admitted to non-intensive care units in a metropolitan comprehensive cancer center during 2019 and assessed antimicrobial use in the last 7 days of life. Results: Among 633 cancer patients, 59% (n = 376) received antimicrobials (AM+) within the last 7 days of life. AM + patients were older (P = .012), mostly of male gender (55%), and non-Hispanic ethnicity (87%). AM + patients were significantly more likely to have a foreign device, suspected signs of infection, neutropenia, positive blood culture result, documented advance directive; receive laboratory or radiologic testing, and a palliative care or infectious disease consultation (all P < .05). No statistically significant differences were observed in the presence of documented goals of care discussions, or EOL discussions/EOL care orders. Conclusion: Antimicrobial use at the EOL is common in solid tumor cancer patients at the EOL and is associated with increased utilization of invasive interventions. There is an opportunity for infectious disease specialists to build primary palliative care skills and partner with antimicrobial stewardship programs to better advise patients, decision makers, and primary teams on the use of antimicrobials at the EOL.
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Affiliation(s)
- Shila Pandey
- Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Renee Wisniewski
- Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sejal Morjaria
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Anabella Lucca Bianchi
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Employee Health & Wellness Services, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tiffanny Newman
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carrie Tan
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Kwon MK, Jung KH, Choi S, Kim H, Woo CY, Lee M, Ji JG, Son HJ. Antibiotics use patterns in end-of-life cancer patients and medical staff's perception of antimicrobial stewardship programs. Korean J Intern Med 2023; 38:758-768. [PMID: 37586810 PMCID: PMC10493437 DOI: 10.3904/kjim.2023.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/19/2023] [Accepted: 06/05/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND/AIMS While most cancer patients with end-of-life (EOL) care receive antibiotic treatments, antibiotic use should be decided appropriately considering the benefits, side effects, resistance, and cost effects. Antimicrobial stewardship programs (ASP) are important for patients with EOL care, but there is limited study analyzing actual antibiotic use in EOL care and the perceptions of Korean medical staff. METHODS Electronic medical records of 149 deceased cancer patients hospitalized in the medical hospitalist units at Asan Medical Center in Seoul from May 2019 to September 2021 were reviewed. Basic information, antibiotic use, duration, and changes were investigated. We surveyed medical staff's perceptions of antibiotics in cancer patients with EOL. RESULTS Of the 149 cancer patients with EOL care, 146 (98.0%) agreed with physician orders for life-sustaining treatment (POLST). In total, 143 (95.9%) received antibiotics, 110 (76.9%) received combination antibiotic treatment, and 116 (81.1%) were given antibiotics until the day of death. In a survey of 60 medical staff, 42 (70.0%) did not know about ASP, and 24 (40.0%) thought ASP was important in EOL care. Nineteen doctors (31.7%) discussed the use or discontinuation of antibiotics with patients or caregivers when writing POLST, but only 8 patients (5.6%) stopped antibiotics after POLST. CONCLUSION Most cancer patients with EOL care continue to receive antibiotics until just before their death. A careful approach is needed, considering the benefits and side effects of antibiotic use, and the patient's right to self-decision. It is necessary to actively improve awareness of ASP and its importance for medical staff.
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Affiliation(s)
- Min Kwan Kwon
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Kyung Hwa Jung
- Department of Infectious Diseases, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu,
Korea
| | - Sungim Choi
- Division of Infectious Diseases, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang,
Korea
| | - Hyeonjeong Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Chang-Yun Woo
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Mingee Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Jeong Geun Ji
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Hyo-Ju Son
- Department of Infectious Diseases, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu,
Korea
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Silva ÁJ, Silva P. Comment on "Treatment of Positive Urine Cultures at End-of-Life and the Effect on Terminal Delirium Management". Am J Hosp Palliat Care 2023; 40:1040-1041. [PMID: 36642987 DOI: 10.1177/10499091231151670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Álvaro José Silva
- Condestável Family Health Unit, General and Family Medicine Department, Regional Health Administration of the Center, Batalha, Portugal
- Faculty of Medicine of Porto University, Porto, Portugal
| | - Paula Silva
- Faculty of Medicine of Porto University, Porto, Portugal
- Portuguese Oncology Institute of Porto, Palliative Care Unit, Porto, Portugal
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Kim JH, Yoo SH, Keam B, Heo DS. The impact of palliative care consultation on reducing antibiotic overuse in hospitalized patients with terminal cancer at the end of life: a propensity score-weighting study. J Antimicrob Chemother 2022; 78:302-308. [PMID: 36424671 DOI: 10.1093/jac/dkac405] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 11/08/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES A substantial number of hospitalized patients with terminal cancer at the end-of-life phase receive antibiotics, even with imminent death. We evaluated the impact of palliative care consultation on antibiotic use in hospitalized patients with terminal cancer during the end-of-life phase. METHODS We identified adult patients with metastatic solid cancer who died at a tertiary medical centre in Seoul, Republic of Korea, following at least 4 days of hospitalization (January 2018-December 2020). Patients were divided into palliative and non-palliative care consultation groups. Propensity score-weighted, multivariable logistic regression analysis was used to compare the proportion of patients receiving antibiotics within 3 days before death between the two groups. RESULTS Among 1143 patients analysed, 940 (82.2%) received antibiotics within 3 days before death. The proportion of patients receiving antibiotics was significantly lower (propensity score-weighted P < 0.001) in the palliative care consultation group (344/468; 73.5%) than in the non-palliative care consultation group (596/675; 88.3%). The decrease in the proportion of patients receiving antibiotics in the palliative care consultation group was significant for a carbapenem (42.4% versus 22.4%; P < 0.001), a glycopeptide (23.3% versus 11.1%; P < 0.001) and a quinolone (30.5% versus 19.4%; P = 0.012). In the multivariable logistic regression analysis, receiving palliative care consultation (adjusted OR 0.46, 95% CI 0.33-0.65; P < 0.001) was independently associated with reduced antibiotic use during the end-of-life phase. CONCLUSIONS Palliative care consultation may reduce aggressive antibiotic use in hospitalized patients with terminal cancer during the end-of-life phase.
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Affiliation(s)
- Jeong-Han Kim
- Division of Infectious Diseases, Department of Internal Medicine, Ewha Woman University College of Medicine, Seoul Hospital, Seoul, Republic of Korea
| | - Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Bhumsuk Keam
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea.,Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dae Seog Heo
- Patient-Centered Clinical Research Coordinating Center, National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
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