Antibiotic use during the last days of life in cancer patients

Management of Infections in Palliative Care Patients at the End-of-Life and Active Process of Death: A Brazilian Retrospective Study

Background

There is a lack of specific studies on the management of infections in patients receiving palliative care (PC) in the final stages of life and during the active process of death, related to specific nursing care. There is clinical and social importance as patients in PC represent a vulnerable population, and adequate management of infections is crucial to improve quality of life and the experience of comfort.

Objective

This study analyzed how infections are managed in patients undergoing PC at the end-of-life and in the active process of death in two hospital health services.

Design

This is an observational, analytical, and retrospective study.

Settings

Data collection took place in two hospitals that assist individuals who are hospitalized under PC, located in Brazil, in a city in the interior of the state of São Paulo.

Measurements and Results

The sample consisted of 113 medical records, in which the oncological diagnosis was the most prevalent. There was a predominance of infection diagnoses based on the patient's clinical symptoms, the main focus being the pulmonary, in individuals at the end-of-life. The management of infection in the study sample occurred through care and procedures that generate physical discomfort, however aiming at relieving symptoms. Such findings must be documented, as they invite us to reflect on our practical attitudes and what it means to be comfortable for these people, making it possible to incorporate this information into the design of interventions focused on enhancing the experience of comfort.

Antibiotic Use at the End of Life: Current Practice and Ways to Optimize

Infections are common complications in end of life (EOL). However, clinicians have minimal guidance regarding antibiotic decision-making in EOL care, leading to the overuse of antibiotics. While symptom relief is frequently cited as a major reason for antibiotic use in EOL, antibiotics have not been shown to provide significant improvement in symptoms outside of urinary tract infections. In addition, when prognosis is expected to be in the range of days to weeks, antibiotics have not been shown to provide significant survival benefit. Antibiotics can be beneficial in EOL care in appropriate scenarios, but the current widespread use of antibiotics in EOL requires reevaluation. There needs to be broader efforts to think about antibiotics like other invasive medical procedures in which benefits and risks are weighed, recognizing that not all patients in EOL who receive antibiotics will benefit. In addition, during care planning process, discussing and documenting antibiotic preferences will be beneficial. Non-antibiotic symptom management should be incorporated to plan of care when infection is suspected. Ultimately, the use of antibiotics at EOL should be for the clear benefit for the recipient and should be guided by the type of infection and its clinical course, patients' primary disease and its prognosis, and the preferences of patients or surrogate decision makers.

Trends of antibiotic use at the end-of-life of cancer and non-cancer decedents: a nationwide population-based longitudinal study (2006-2018)

Objective

This study aimed to assess the actual burden of antibiotic use among end-of-life (EOL) patients in South Korea and to compare trends between cancer and non-cancer decedents.

Design

Population-based mortality follow-back study.

Setting

Data from the Korean National Health Insurance Database, covering the period from January1, 2006, to December 31, 2018, provided for research by the National Health Insurance Service (NHIS), were used.

Participants

All decedents from 2006 to 2018 were included and categorized as cancer decedents or non-cancer decedents.

Methods

Annual antibiotic consumption rates and prescription rates were calculated, and Poisson regression was used to estimate their trends.

Results

Overall antibiotic consumption rates decreased slightly among decedents in their final month with a less pronounced annual decrease rate among cancer decedents compared to non-cancer decedents (0.4% vs 2.3% per year, P <.001). Over the study period, although narrow spectrum antibiotics were used less, utilization and prescription of broad-spectrum antibiotics steadily increased, and prescription rates were higher in cancer decedents compared to non-cancer controls. Specifically, carbapenem prescription rates increased from 5.6% to 18.5%, (RR 1.087, 95% CI 1.085-1.088, P <.001) in cancer decedents and from 2.9% to 13.2% (RR 1.115, 95% CI 1.113-1.116, P <.001) in non-cancer decedents.

Conclusions

Our findings show that patients at the EOL, especially those with cancer, are increasingly and highly exposed to broad-spectrum antibiotics. Measures of antibiotic stewardship are required among this population.

Analysis of microbiological tests in patients withholding or withdrawing life-sustaining treatment at the end stage of life in 2 Korean hospitals

OBJECTIVE

We evaluated the adequacy of microbiological tests in patients withholding or withdrawing life-sustaining treatment (WLST) at the end stage of life.

SETTING

The study was conducted at 2 tertiary-care referral hospitals in Daegu, Republic of Korea.

DESIGN

Retrospective cross-sectional study.

METHODS

Demographic findings, clinical and epidemiological characteristics, statistics of microbiological tests, and microbial species isolated from patients within 2 weeks before death were collected in 2 tertiary-care referral hospitals from January to December 2018. We also reviewed the antimicrobial treatment that was given within 3 days of microbiological testing in patients on WLST.

RESULTS

Of the 1,187 hospitalized patients included, 905 patients (76.2%) had WLST. The number of tests per 1,000 patient days was higher after WLST than before WLST (242.0 vs 202.4). Among the category of microbiological tests, blood cultures were performed most frequently, and their numbers per 1,000 patient days before and after WLST were 95.9 and 99.0, respectively. The positive rates of blood culture before and after WLST were 17.2% and 18.0%, respectively. Candida spp. were the most common microbiological species in sputum (17.4%) and urine (48.2%), and Acinetobacter spp. were the most common in blood culture (17.3%). After WLST determination, 70.5% of microbiological tests did not lead to a change in antibiotic use.

CONCLUSIONS

Many unnecessary microbiological tests are being performed in patients with WLST within 2 weeks of death. Microbiological testing should be performed carefully and in accordance with the patient's treatment goals.

Antibiotics use patterns in end-of-life cancer patients and medical staff's perception of antimicrobial stewardship programs

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.

Antibiotic prescription patterns during last days of hospitalized patients with advanced cancer: the role of palliative care consultation

OBJECTIVES

Issues regarding antibiotic use in end-of-life patients with advanced cancer present a challenging ethical dilemma in academic referral centres. This study aimed to investigate the role of palliative care consultation on antibiotic prescription patterns among hospitalized patients with advanced cancer during their last days of life.

METHODS

This retrospective cohort study included adult patients with metastatic solid cancer admitted to a tertiary referral hospital for at least 4 days and subsequently died and who were given antibiotics 4 days before death between January 2018 and December 2021. Patients were divided into palliative care consultation (PC) and non-consultation (non-PC) groups. The outcomes were the proportion of patients who received antibiotic combination treatment, antibiotic escalation and antibiotic de-escalation within 3 days of death. Propensity score analysis with the inverse probability of the treatment weighting method was used to compare the outcomes.

RESULTS

Among the 1177 patients enrolled, 476 (40.4%) received palliative care consultation and 701 (59.6%) did not. The PC group received considerably less antibiotic combination treatment (49.0% versus 61.1%, adjusted OR: 0.69, 95% CI: 0.53-0.90, P = 0.006) and antibiotic escalation (15.8% versus 34.8%, adjusted OR: 0.41, 95% CI: 0.30-0.57, P < 0.001) than the non-PC group. Additionally, the PC group reported significantly higher antibiotic de-escalation (30.7% versus 17.4%, adjusted OR: 1.74, 95% CI: 1.28-2.36, P < 0.001).

CONCLUSION

Receiving palliative care consultation may minimize aggressive antibiotic prescription patterns in the last days of patients with advanced cancer in an academic referral centre setting.

Use of Antibiotics Within the Last 14 Days of Life in Korean Patients: A Nationwide Study

BACKGROUND

Antimicrobial prescriptions for serious chronic or acute illness nearing its end stages raise concerns about the potential for futile use, adverse events, increased multidrug-resistant organisms, and significant patient and social cost burdens. This study investigated the nationwide situation of how antibiotics are prescribed to patients during the last 14 days of life to guide future actions.

METHODS

This nationwide multicenter retrospective cohort study was conducted at 13 hospitals in South Korea from November 1 to December 31, 2018. All decedents were included in the study. Antibiotic use during the last two weeks of their lives was investigated.

RESULTS

A total of 1,201 (88.9%) patients received a median of two antimicrobial agents during the last two weeks of their lives. Carbapenems were prescribed to approximately half of the patients (44.4%) in the highest amount (301.2 days of therapy per 1,000 patient-days). Among the patients receiving antimicrobial agents, 63.6% were inappropriate and only 327 patients (27.2%) were referred by infectious disease specialists. The use of carbapenem (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.13-2.03; P = 0.006), underlying cancer (OR, 1.56; 95% CI, 1.20-2.01, P = 0.047), underlying cerebrovascular disease (OR, 1.88; 95% CI, 1.23-2.89, P = 0.004), and no microbiological testing (OR, 1.79; 95% CI, 1.15-2.73; P = 0.010) were independent predictors for inappropriate antibiotic prescribing.

CONCLUSION

A considerable number of antimicrobial agents are administered to patients with chronic or acute illnesses nearing their end-of-life, a high proportion of which are prescribed inappropriately. Consultation with an infectious disease specialist, in addition to an antimicrobial stewardship program, may be necessary to induce the optimal use of antibiotics.

Considering Patient, Family, and Provider Goals and Expectations in a Rapidly Changing Clinical Context: A Framework for Antimicrobial Stewardship at the End of Life

Antibiotic administration is often a part of end-of-life (EOL) care, including among patients who are not critically ill. Guideline-issuing bodies recommend that antimicrobial stewardship providers (ASPs) provide support to prescribers making decisions about whether or not to treat infections in this population. Relatively little is known about the rationale for antimicrobial prescribing during the EOL period in noncritical care settings, although patient and family preferences are often an influencing factor. The effectiveness of antimicrobials in improving quantity or quality of life in this population is unclear and likely context-specific.

Antibiotic Treatment in End Stage Cancer Patients; Advantages and Disadvantages

Aim:

In this study our aim was to elucidate whether advanced cancer patients benefit from antibiotic treatment in the last days of life in addition to reviewing the relevant costs and effects.

Materials And Methods:

We reviewed medical records from 100 end-stage cancer patients and their antibiotic use during the hospitalization in Imam Khomeini hospital. Patient’s medical records were analyzed retrospectively for cause and periodicity of infections, fever, increase in acute phase proteins, cultures, type and cost of antibiotic.

Results:

Microorganisms were found in only 29 patients (29%) and the most microorganism among the patients was E. coli (6%). About 78% of the patients had clinical symptoms. The highest dose of antibiotics was related to Ceftriaxone (40.2%) and in the second place was Metronidazole (34.7%) and the lowest dose was related to Levofloxacin, Gentamycin and Colistin (1.4%). Fifty-one patients (71%) did not have any side effects due to antibiotics. The most common side effect of antibiotics among patients was skin rash (12.5%). The average estimated cost for antibiotic use was 7 935 540 Rials (24.4 dollars).

Conclusion:

Prescription of antibiotics was not effective in symptom control in advanced cancer patients. The cost of using antibiotics during hospitalization is very high and also the risk of developing resistant pathogens during admission should be considered. Antibiotic side effects also occur in patients, causing more harm to the patient at the end of life. Therefore, the benefits of antibiotic advice in this time is less than its negative effects.

Perceptions and Reality of Antimicrobial Prescribing During the Transition to Comfort Measures Only at an Academic Medical Center

Background

Little is known about antimicrobial prescribing when patient care is transitioned to comfort measures only (CMO). We used a multidisciplinary survey and retrospective cohort study to gain insight into antimicrobial prescribing in this population at an academic medical center to inform future antimicrobial stewardship interventions.

Methods

A survey focusing on antimicrobial prescribing during the transition to CMO was electronically distributed to providers in medical subspecialities and responses were compared across specialties. A retrospective chart review was performed of patients admitted to an academic medical center in 2020 who were on antimicrobials in the 48 hours prior to CMO. We investigated the percentage of patients who remained on antimicrobials after the transition to CMO and rationale for continuing antimicrobials.

Results

We received 113 survey responses (35% response rate). Forty-one percent of respondents indicated that they "sometimes" or "often" continued antimicrobials during the transition to CMO. Patient/family preference and symptom palliation were the most common factors cited by respondents when deciding whether to continue antimicrobials in this population. Of the 546 patient charts reviewed, 140 (26%) patients were alive 48 hours after CMO order, and 19 (14%) of those patients remained on antimicrobials. Five of 19 (26%) patients had documentation that antimicrobials were continued due to patient/family preference and 5 of 19 (26%) patients had documentation that antimicrobials were continued for palliation of symptoms.

Conclusions

Patient/family preference and symptom palliation are important factors in prescribing antimicrobials when patient care is transitioned to CMO. More evidence is needed regarding palliative benefits of antibiotics to inform provider discussions of benefits and harms of antimicrobial use in this setting.

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

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.

[Survey on antibiotic prescription practices for palliative care terminally ill patients of 75 years old and more]

Infections commonly occur terminally ill oldest patients in palliative care and questioned about antimicrobial use. The aim of this study was to describe practitioners' habits.

METHOD

ancillary study on antibiotic modalities according to the setting of care from a national practices survey based on self administered questionnaire sent by e-mail in 2017.

RESULTS

220 practitioners/327 used antibiotic, 136 worked in hospital department (52 geriatricians), 20 nursing home and 64 general practitioners (GP). GP declared less palliative care patients (6/year). The antibiotic goal was symptomatic relief for 181 (82.3%) without statistically significant difference between groups. GP (25%) were the group that most collected patient opinion for antibiotic prescription. Nursing home (23%) and GP (18%) reported more urinary tract symptoms than others (11.7%) (P=0.003). Geriatricians (59.6%) declared significantly less urinary analysis than GP (90%) (P=0.0009). 212 doctor (96.4%) faced side effect (SI): more allergic reaction and less administration difficulties than the other groups. The stop decision was collegially took (156, 70,9%) significantly more in hospital (121, 89%) than in community (25, 39.1%) (P<0.001). Patient wishes were noted by 30 (46.96%) only GP.

CONCLUSION

Even if practice and number of patients follow up differ from each place of care, doctors' intention in antibiotic use respect palliative care goal to relieve discomfort. It is hard to diagnose infection and complementary exam are scarce. A repeated individualized evaluation with patient, his surrounding and his medical referent participation, is mandatory to give a constant adapted level of care in every place of care.

Treatment of Positive Urine Cultures at End-of-Life and the Effect on Terminal Delirium Management

Background: The decision to initiate antibiotics in hospice patients that are very near end-of-life is a complex ethical and stewardship decision. Antibiotics may be ordered to improve urinary tract infection-related symptoms, such as delirium. However, infection symptoms may be managed using antipsychotics, antipyretics, antispasmodics, and analgesics instead. Currently, there are no studies that compare symptom management between those who receive antibiotics and those who do not. Methods: A retrospective chart review was conducted for patients admitted to a hospice inpatient unit. Charts were included if the patient was admitted for delirium and had a Palliative Performance Scale score ≤40%, the urine culture was positive for organism growth, and the patient died while in the HIU. Clinical and demographic data was collected. Medication use was tallied for the 5 days prior to the date of death. Results: Sixty-one charts met the inclusion criteria. Thirty-five patients received antibiotics (ABX+) and 26 did not (ABX-). There was no difference in any medication consumption between groups during the 5 days prior to death. The ABX+ group died 8.2 days after obtaining the urine sample vs 6 days (P =0.046). The ABX+ group had more documented urinary tract-specific infection symptoms (66% vs 38%, P =0.042). More than half of antibiotic courses were discontinued prematurely. Conclusion: The results of this study do not show a difference in overall medication consumption between groups, which suggests that antibiotics may not help improve terminal delirium symptoms in those with a suspected urinary tract infection at end-of-life.

Title: Effects of Antibiotics on Respiratory Symptoms in Terminally Ill Cancer Patients With Pneumonia: A Multicenter Cohort Study

CONTEXT

Patients in the terminal stages of cancer are frequently affected by infection, especially pneumonia; but the effects of antibiotics on respiratory symptoms and factors associated with improvement are still unclear.

OBJECTIVES

This study aimed to clarify the effects of antibiotics on respiratory symptoms of terminally ill cancer patients with pneumonia, and to explore factors associated with the improvement.

METHODS

This was a prospective cohort study in which we consecutively recruited terminally ill cancer patients diagnosed with pneumonia and treated with antibiotics at one of 23 palliative care units across Japan. At the baseline and Day 3, primarily responsible palliative care specialists recorded patient backgrounds, the results of physical and laboratory examination, and patient symptoms using the Support Team Assessment Schedule. Improvement was defined as improvement of dyspnea, cough, and sputum production on Day 3.

RESULTS

Among all 1896 patients admitted during the study periods, 137 patients (7.2%) were enrolled into this study. Improvement was achieved in 65 patients (47.4%; 95% confidence intervals, 39-56). Univariate analyses revealed that the Palliative Prognostic Index (PPI), respiratory rate (RR), and oxygen requirement were significantly associated with the improvement. A multiple logistic regression analysis identified that PPI score of ≤ 6 and RR of <20 were independently associated with the improvement (odds ratios, 4.4 [1.6-12] and 2.5 [1.1-5.5], respectively).

CONCLUSION

Antibiotics may relieve respiratory symptoms from pneumonia in approximately half of the terminally ill cancer patients. PPI and respiratory rate are useful to identify the patients who received benefits of antibiotics.

Frequency and Characteristics of Patients Prescribed Antibiotics on Admission to Hospice Care

Background: Little is known about antibiotic prescribing on hospice admission despite known risks and limited evidence for potential benefits. Objective: To describe the frequency and characteristics of patients prescribed antibiotics on hospice admission. Design: Cross-sectional study. Subjects: Adult (age ≥18 years) decedents of a national, for-profit hospice chain across 19 U.S. states who died between January 1, 2017 and December 31, 2019. Measures: The primary outcome was having an antibiotic prescription on hospice admission. Patient characteristics of interest were demographics, hospice referral location, hospice care location, census region, primary diagnosis, and infectious diagnoses on admission. We used multivariable logistic regression to quantify associations between study variables. Results: Among 66,006 hospice decedents, 6080 (9.2%) had an antibiotic prescription on hospice admission. Fluoroquinolones (22%) were the most frequently prescribed antibiotic class. Patients more likely to have an antibiotic prescription on hospice admission included those referred to hospice care from the hospital (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 1.00-1.29) compared with an assisted living facility, those receiving hospice care in a private home (aOR 3.85, 95% CI 3.50-4.24), nursing home (aOR 3.65, 95% CI 3.24-4.11), assisted living facility (aOR 4.04, 95% CI 3.51-4.64), or hospital (aOR 2.43, 95% CI 2.18-2.71) compared with inpatient hospice, and those with a primary diagnosis of liver disease (aOR 2.23, 95% CI 1.82-2.74) or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (aOR 3.89, 95% CI 2.27-6.66) compared with those without these diagnoses. Conclusions: Approximately 9% of hospice patients had an antibiotic prescription on hospice admission. Patients referred to hospice from a hospital, those receiving care in a noninpatient hospice facility, and those with liver disease or HIV/AIDS were more likely to have an antibiotic prescription. These results may inform future antimicrobial stewardship interventions among patients transitioning to hospice care.

Antibiotic stewardship program (ASP) in palliative care: antibiotics, to give or not to give

Antimicrobial therapy in terminally ill patients remains controversial as goals of care tend to be focused on optimizing comfort. International guidelines recommend for antibiotic stewardship program (ASP) involvement in antibiotic decisions in palliative patients. The primary objective was to evaluate the clinical impact of ASP interventions made to stop broad-spectrum intravenous antibiotics in terminally ill patients. This was a retrospective chart review of 459 terminally ill patients in Singapore General Hospital audited by ASP between December 2010 and December 2018. Antibiotic duration, time-to-terminal discharge for end-of-life care, time-to-mortality, and mortality rates of patients with antibiotics ceased or continued upon ASP recommendations were compared. A total of 283 and 176 antibiotic courses were ceased and continued post-intervention, respectively. The intervention acceptance rate was 61.7%. The 7-day mortality rate (47.3% vs 61.9%, p = 0.003) was lower in the ceased group, while 30-day mortality rate (76.0% vs 81.2%, p = 0.203) and time-to-mortality post-intervention (3 [0-24] vs 2 [0-27] days, p = 0.066) did not differ between the ceased and continued groups. After excluding the 57 patients who had antibiotics continued until death within 48 h of intervention, only time-to-mortality post-intervention was statistically significantly shorter in the ceased group (3 [0-24] vs 4 [0-27], p < 0.001). Of the 131 terminally discharged patients, antibiotic duration (4 [0-17] vs 6.5 [1-14] days, p = 0.001) and time-to-terminal discharge post-intervention (6 [0-74] vs 10.5 [3-63] days, p = 0.001) were shorter in the ceased group. Antibiotic cessation in terminally ill patients was safe, and was associated with a significantly shorter time-to-terminal discharge.

Association of Physician Orders for Life-Sustaining Treatment With Inpatient Antimicrobial Use at End of Life in Patients With Cancer

Background

Antimicrobial utilization at end of life is common, but whether advance directives correlate with usage is unknown. We sought to determine whether Washington State Physician Orders for Life Sustaining Treatment (POLST) form completion or antimicrobial preferences documented therein correlate with subsequent inpatient antimicrobial prescribing at end of life.

Methods

This was a single-center, retrospective cohort study of adult patients at a cancer center who died between January 1, 2016, and June 30, 2019. We used negative binomial models adjusted for age, sex, and malignancy type to test the relationship between POLST form completion ≥30 days before death, antimicrobial preferences, and antimicrobial days of therapy (DOT) per 1000 inpatient-days in the last 30 days of life.

Results

Among 1295 eligible decedents with ≥1 inpatient-day during the last 30 days of life, 318 (24.6%) completed a POLST form. Of 318, 120 (37.7%) were completed ≥30 days before death, 35/120 (29.2%) specified limited antimicrobials, 55/120 (45.8%) specified full antimicrobial use, and 30/120 (25%) omitted antimicrobial preference. Eighty-three percent (1070/1295) received ≥1 inpatient antimicrobial. The median total and intravenous (IV) antimicrobial DOT/1000 inpatient-days were 1077 and 667. Patients specifying limited antimicrobials had significantly lower total antimicrobial DOT (adjusted incidence rate ratio [IRR], 0.68; 95% CI, 0.49-0.95; P = .02) and IV antimicrobial DOT (IRR, 0.57; 95% CI, 0.38-0.86; P = .008) compared with those without a POLST.

Conclusions

Indicating a preference for limited antimicrobials on a POLST form ≥30 days before death may lead to less inpatient antimicrobial use in the last 30 days of life.

The Role of Gut Microbiota in Overcoming Resistance to Checkpoint Inhibitors in Cancer Patients: Mechanisms and Challenges

The introduction of immune checkpoint inhibitors has constituted a major revolution in the treatment of patients with cancer. In contrast with the traditional cytotoxic therapies that directly kill tumor cells, this treatment modality enhances the ability of the host’s immune system to recognize and target cancerous cells. While immune checkpoint inhibitors have been effective across multiple cancer types, overcoming resistance remains a key area of ongoing research. The gut microbiota and its role in cancer immunosurveillance have recently become a major field of study. Gut microbiota has been shown to have direct and systemic effects on cancer pathogenesis and hosts anti-tumor immune response. Many studies have also shown that the host microbiota profile plays an essential role in the response to immunotherapy, especially immune checkpoint inhibitors. As such, modulating this microbial environment has offered a potential path to overcome the resistance to immune checkpoint inhibitors. In this review, we will talk about the role of microbiota in cancer pathogenesis and immune-system activity. We will also discuss preclinical and clinical studies that have increased our understanding about the roles and the mechanisms through which microbiota influences the response to treatment with immune checkpoint inhibitors.

Education needed to improve antimicrobial use during end-of-life care of older adults with advanced cancer: A cross-sectional survey

BACKGROUND

Antimicrobial use during end-of-life care of older adults with advanced cancer is prevalent. Factors influencing the decision to prescribe antimicrobials during end-of-life care are not well defined.

AIM

To evaluate factors influencing medicine subspecialists to prescribe intravenous and oral antimicrobials during end-of-life care of older adults with advanced cancer to guide an educational intervention.

DESIGN

18-item single-center cross-sectional survey.

SETTING/PARTICIPANTS

Inpatient medicine subspecialists in 2018.

RESULTS

Of 186 subspecialists surveyed, 67 (36%) responded. Most considered withholding antimicrobials at the time of clinical deterioration during hospitalization (n = 54/67, 81%), viewed the initiation of additional intravenous antimicrobials as escalation of care (n = 44/67, 66%), and believed decision-making should involve patients or surrogates and providers (n = 64/67, 96%). Fifty-one percent (n = 30/59) of respondents who conducted advance care planning did not discuss antimicrobials. Barriers to discussing end-of-life antimicrobials included the potential to overwhelm patients or families, challenges of withdrawing antimicrobials, and insufficient training.

CONCLUSIONS

Although the initiation of additional intravenous antimicrobials was viewed as escalation of care, antimicrobials were not routinely discussed during advance care planning. Educational interventions that promote recognition of antimicrobial-associated adverse events, incorporate antimicrobial use into advance care plans, and offer communication simulation training around the role of antimicrobials during end-of-life care are warranted.

Antimicrobial use at the end of life: a scoping review

OBJECTIVE

To examine antibiotic use in patients approaching end of life, in terms of frequency of prescription, aim of treatment, beneficial and adverse effects and contribution to the development of antimicrobial resistance.

DESIGN

Scoping review DATA SOURCES: An information scientist searched Ovid MEDLINE, Ovid EMBASE, The Cochrane library, PubMed Clinical Queries, NHS Evidence, Epistemonikos, SIGN, NICE, Google Scholar from inception to February 2019 for any study design including, but not limited to, randomised clinical trials, prospective interventional or observational studies, retrospective studies and qualitative studies. The search of Ovid MEDLINE was updated on the 10 June 2020.

STUDY SELECTION

Studies reporting antibiotic use in patients approaching end of life in any setting and clinicians' attitudes and behaviour in relation to antibiotic prescribing in this population DATA EXTRACTION: Two reviewers screened studies for eligibility; two reviewers extracted data from included studies. Data were analysed to describe antibiotic prescribing patterns across different patient populations, the benefits and adverse effects (for individual patients and wider society), the rationale for decision making and clinicians behaviours and attitudes to treatment with antibiotics in this patient group.

RESULTS

Eighty-eight studies were included. Definition of the end of life is highly variable as is use of antibiotics in patients approaching end of life. Prescribing decisions are influenced by patient age, primary diagnosis, care setting and therapy goals, although patients' preferences are not always documented or adhered to. Urinary and lower respiratory tract infections are the most commonly reported indications with outcomes in terms of symptom control and survival variably reported. Small numbers of studies reported on adverse events and antimicrobial resistance. Clinicians sometimes feel uncomfortable discussing antibiotic treatment at end of life and would benefit from guidelines to direct care.

CONCLUSIONS

Use of antibiotics in patients approaching the end of life is common although there is significant variation in practice. There are a myriad of intertwined biological, ethical, social, medicolegal and clinical issues associated with the topic.

Antibiotic use during end-of-life care: A systematic literature review and meta-analysis

BACKGROUND

We performed a systematic literature review and meta-analysis measuring the burden of antibiotic use during end-of-life (EOL) care.

METHODS

We searched PubMed, CINAHL (EBSCO platform), and Embase (Elsevier platform), through July 2019 for studies with the following inclusion criteria in the initial analysis: antibiotic use in the EOL care patients (advanced dementia, cancer, organ failure, frailty or multi-morbidity). If the number of patients in palliative care consultation (PCC) was available, antibiotic use data were pooled to compare the proportion of patients who received antibiotics under PCC compared to those not receiving PCC. Random-effect models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 value.

RESULTS

Overall, 72 studies met the inclusion criteria and were included in the final review: 22 EOL studies included only patients with cancer; 17 studies included only patients with advanced dementia; and 33 studies included "mixed populations" of EOL patients. Although few studies reported antibiotic using standard metrics (eg, days of therapy), 48 of 72 studies (66.7%) reported antibiotic use in >50% of all patients. When the 3 studies that evaluated antibiotic use in PCC were pooled together, patients under PCC was more likely to receive antibiotics compared to patients not under PCC (pooled odds ratio, 1.73; 95% CI, 1.02-2.93).

CONCLUSIONS

Future studies are needed to evaluate the benefits and harms of using antibiotics for patients during EOL care in diverse patient populations.

Determinants of doctors' antibiotic prescriptions for patients over 75 years old in the terminal stage of palliative care

INTRODUCTION

Notwithstanding high prevalence of presumably bacterial infections in elderly persons (EP) in palliative care (PC), there exists no recommendation on the role of antibiotic therapy (ABP) in this type of situation.

OBJECTIVE

To describe the determinants of antibiotic prescription by general practitioners (GP) and by doctors practicing in institutions (DPI) for patients>75 years, in end-of-life situations in PC.

METHOD

Descriptive investigation by anonymous self-administered questionnaire disseminated in France by e-mail.

RESULTS

A total of 301 questionnaires analyzed: 113 GP, 188 DPIs. The latter were mainly geriatricians (69, 36.6%) and infectologists/internists (41, 21.8%). Sixty-three (55,75%) GPs and 144 (78.7%) DPIs stated that they had prescribed antibiotics. Practice in "EHPAD" retirement homes or intensive care was often associated with non-prescription of antibiotics. Age, PC training and number of patients monitored bore no influence. Family involvement in decision-making was more frequent for GPs than for DPIs. The main purpose of antibiotic therapy was to relieve different symptoms (fever, respiratory congestion, functional urinary signs). Most of the doctors (81%) had previously encountered complications (allergy, adverse effect), which represented the main causes of treatment discontinuation.

CONCLUSION

Antibiotic use in end-of-life EPs in PC seems frequent. In accordance with the principle of beneficence, its goal of often symptom-related; that said, in the absence of scientific data, antibiotic prescription in end-of-life situations should be individualized in view of observing the other ethical caregiving principles (beneficence, non-maleficence, justice, patient autonomy) and re-evaluated daily.

Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients

Introduction

Early initiation of end-of-life (EOL) care in terminally ill patients can reduce the administration of unnecessary medications, minimize laboratory and radiological investigations, and avoid procedures that can provoke untoward complications without substantial benefits. This retrospective observational study was performed to compare early vs late initiation of EOL care in terminally ill ICU patients after the recognition of treatment futility.

Materials and methods

The medical records of all patients who were considered to be terminally ill any time after ICU admission between January 2014 and December 2018 were extracted from the ICU database. The patients who were recognized for treatment futility were eligible for inclusion. The patients who were already on EOL care prior to the ICU admission or whose diagnosis was unconfirmed were excluded from the study. The treatment futility was a subjective decision jointly undertaken by the primary physician and the intensivist based upon the disease stage and the available therapeutic options. The commencement of EOL care after recognition of treatment futility was divided into (a) early group (EG)—within 48 hours of decision of treatment futility and (b) late group (LG)—after 48 hours of recognition of treatment futility. Both the groups were compared for (a) ICU mortality, (b) length of ICU stay, (c) number of antibiotic-free days, (d) number of ventilator-free days, (e) number of medical and/or surgical interventions (insertion of central lines, drains, IABP, etc.), (f) number of blood and radiological investigations, and (g) satisfaction level of family members.

Results

Out of 107 terminally ill patients with diagnosis of treatment futility, 64 patients (59.8%) underwent early initiation of EOL against delayed initiation in 43 (40.2%) patients (1.3 ± 0.4 days vs 5.1 ± 1.6 days; p = 0.01). The patients in the late initiation group were younger in age (49 ± 3.6 years vs 66 ± 5.3 years; p = 0.03). The number of antibiotic-free days was higher in the early initiation group (12 ± 5.2 days vs 6 ± 7.5; p = 0.02). The number of medical and surgical interventions was lesser in the early initiation group (3.0 ± 0.7 episodes vs 12 ± 3.9 episodes; p = 0.007). The late initiation of EOL was caused by prognostic dilemma (30.2%), reluctance of the family members (44.1%), ambivalence of the primary physician (18.6%), and hesitancy of the intensivist (6.9%). The satisfaction level of the family members was similar in both the groups.

Conclusion

We conclude that delayed initiation of EOL care in terminally ill ICU patients after recognition of treatment futility can increase the antibiotic usage and medical and/or surgical interventions with no effect on the satisfaction level of the family members.

How to cite this article

Choudhuri AH, Sharma A, Uppal R. Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients. Indian J Crit Care Med 2020;24(6):404–408.

Prospective Evaluation of Intensity of Symptoms, Therapeutic Procedures and Treatment in Palliative Care Patients in Nursing Homes

The aim of the study is to evaluate the intensity of symptoms, and any treatment and therapeutic procedures received by advanced chronic patients in nursing homes. A multi-centre prospective study was conducted in six nursing homes for five months. A nurse trainer selected palliative care patients from whom the sample was randomly selected for inclusion. The Edmonton Symptoms Assessment Scale, therapeutic procedures, and treatment were evaluated. Parametric and non-parametric tests were used to evaluate month-to-month differences and differences between those who died and those who did not. A total of 107 residents were evaluated. At the end of the follow-up, 39 had (34.6%) died. All symptoms (p < 0.050) increased in intensity in the last week of life. Symptoms were more intense in those who had died at follow-up (p < 0.05). The use of aerosol sprays (p = 0.008), oxygen therapy (p < 0.001), opioids (p < 0.001), antibiotics (p = 0.004), and bronchodilators (p = 0.003) increased in the last week of life. Peripheral venous catheters (p = 0.022), corticoids (p = 0.007), antiemetics (p < 0.001), and antidepressants (p < 0.05) were used more in the patients who died. In conclusion, the use of therapeutic procedures (such as urinary catheters, peripheral venous catheter placement, and enteral feeding) and drugs (such as antibiotics, anxiolytics, and new antidepressant prescriptions) should be carefully considered in this clinical setting.

Use of antibiotics among end-of-life hospitalized patients with advanced directives: Status examination and association with infectious disease consultation and physician burnout

BACKGROUND

Overuse of antibiotics in end-of-life patients with advanced directives increases bacterial resistance and causes morbidity and mortality. Consultations with infectious disease (ID) physicians and burnout, which can affect antibiotic days of therapy (DOT) prescribed by physicians, have not been examined so far.

OBJECTIVES

To assess antibiotic use by physicians in end-of-life (EOL) patients with advanced directives and to investigate the association between ID consultations, physician burnout, and antibiotic DOT in those patients.

DESIGN

A descriptive correlational study.

SETTING

Acute-care and post-acute-care hospitals.

PARTICIPANTS

The study included 213 physicians and 932 their hospitalized patients in the last 2 weeks of life.

METHODS

We distributed questionnaires and analyzed the data collected regarding ID consultation, EOL antibiotics prescription with and without an advanced directive, and physician burnout to 278 physicians, and 213 were completed (response rate 76%).

RESULTS

Of the 932 deaths, 435 of 664 (>50%) were EOL patients with advanced directives. Of these patients, 74% received antibiotics, 29.9% had bacterial resistance cultures, and antibiotics were discontinued in only 5%. Half of the physicians lacked knowledge concerning antibiotics use issues and had significantly fewer consultations with ID physicians in EOL patients with advanced directives (mean rate, 0.27) than those without advanced directives (mean rate, 0.47). ID physicians reported significantly higher emotional exhaustion levels (mean rate, 29) than other medical specialties (mean rate, 19.2). Antibiotic DOT was significantly higher when patients had ID consultations (mean rate, 21.6) than in patients who did not (mean rate, 16.2). In post-acute-care hospitals and/or geriatric wards, antibiotic DOT was significantly higher than in other types of hospitals and/or wards. Depersonalization level was negatively related to antibiotic DOT (P < .05).

CONCLUSIONS

Antibiotics are overused in EOL patients with advanced directives. ID physician burnout and impact of ID consultation should be further assessed.

Implementation of Antimicrobial Stewardship Programs in End-of-Life Care

Many terminal patients at the end-of-life have been receiving antimicrobial therapy despite concerns including futile use, potential lack of efficacy, increased patient burden, excess costs, high risk of adverse effects, and increased antimicrobial resistance. Thus, the implementation of antimicrobial stewardship programs (ASPs) in end-of-life care needs to be discussed. But, the topics of antimicrobial therapy and ASPs have not been addressed in the Life-Sustaining Treatment Decision Act enacted in the Korea in February 2016. Antimicrobial therapy should be included in the decision-making framework for end-of-life care similar to other life-sustaining treatment decisions. If the antimicrobial therapy is legally considered as a life-sustaining treatment which can be withdrawn or withheld in patients at the end-of-life, the feasibility of implementing ASPs among this patient population may improve. Various researches on antimicrobial therapy for patients at the end-of-life need to be conducted and collaborations are required between ASPs professionals and many other concerned parties involved in the legislative process of the Life-Sustaining Treatment Decision Act. This review aims to summarize previous studies on the use of antimicrobials for end-of-life care and reveal important aspects for applying ASPs to this population in Korea.

Increased Length of Stay Associated With Antibiotic Use in Older Adults With Advanced Cancer Transitioned to Comfort Measures

BACKGROUND

Antibiotic use may increase hospital length of stay (LOS) among older patients with advanced cancer who are transitioned to comfort measures.

METHODS

We studied a cohort of patients with advanced cancer aged ≥65 years who were transitioned to comfort measures during admission from July 1, 2014, through November 30, 2016. We evaluated the association between antibiotic exposure and LOS using a Poisson regression model adjusted for age, gender, cancer type, comorbidities, infection, and intensive care unit admission.

RESULTS

Among 461 patients with advanced cancer, median age was 74 years (range: 65-99), 49.0% (n = 226) were female, and 20.6% (n = 95) had liquid tumors. Overall, 82.9% (n = 382) received ≥1 antibiotic and 64.6% (n = 298) had ≥1 infection diagnosis during hospitalization. Infection diagnoses commonly included sepsis (35%, n = 161/461), pneumonia (25%, n = 117/461), and urinary tract infection (14%, n = 66/461). Among those receiving antibiotics, the most common choices included vancomycin (79%, n = 300/382), cephalosporins (63%, n = 241/382), and penicillins (45%, n = 172/382). In a multivariable Poisson regression model, LOS was 34% longer (count ratio = 1.34, [95% confidence interval: 1.20-1.51]) among those exposed versus unexposed to antibiotics.

CONCLUSIONS

Antibiotic use among patients with advanced cancer who are transitioned to comfort measures is associated with longer LOS. These data illustrate the importance of tradeoffs associated with antibiotic use, such as unintended increased LOS, when striving for goal-concordant care near the end of life.

Does Recognition of the Dying Phase Have an Effect on the Use of Medical Interventions?

During the dying phase, patients often receive interventions that are not aimed at promoting their comfort. We investigated how recognition of the dying phase affects the use of interventions by comparing patients for whom the dying phase had been recognized with patients for whom it had not been recognized. We included 489 of 613 patients (80%) who died either in a hospital, nursing home, or primary care setting between November 2003 and February 2006. After the death of patients, nurses filled in questionnaires, and patient records were searched for information about therapeutic and diagnostic interventions applied during the dying phase. Caregivers had recognized the dying phase of 380 patients (78%). The number of patients who had received diagnostic interventions during the last three days of life was significantly lower when the dying phase had been recognized (39% vs. 57%) (p=0.00). Therapeutic interventions were used in similar frequencies in both groups. We conclude that recognition of the dying phase reduces the number of undesirable diagnostic interventions.

Design and analysis of longitudinal trials of antimicrobial use at the end of life: to give or not to give?

This perspective review considers analytic features of the design of a longitudinal trial regarding antimicrobial therapy in older terminal cancer patients receiving palliative care. We first overview antimicrobial use at the end of life; both the potential hazards and benefits. Antimicrobial prescribing should consider both initiation as well as cessation of medications when analyzing the burden of medications. Approaches to decision making regarding antimicrobial use are presented and the importance of health literacy in these decision processes. We next present aspects of both feasibility and comparative trial design with a health literacy intervention to reduce antimicrobial use in older terminal cancer patients receiving palliative care. Considerations to clustered randomization and given that infections can reoccur over a trial period, we share suggestions of longitudinal modeling of clustered randomized trial data.

Antimicrobial use in patients at the end of life in an Australian hospital

BACKGROUND

Antimicrobial resistance is increasing and there is an urgent international imperative to optimise use within hospitals. Antibiotic use at the end of life is frequent in the hospital setting, but data on use in Australian hospitals in this context is limited, and optimisation is complicated by clinical/diagnostic, ethical and humanistic considerations. As yet there is little data available on baseline use in hospital end of life settings, an empirical gap we sought to begin to fill here.

METHODS

A retrospective review of antibiotic use in patients who died in a Queensland hospital between January 2015 and July 2015.

RESULTS

One hundred and thirty-seven patients were included, of which 73 were male (53.3%) and the median age was 81 years. Of these patients, 86 received antibiotics at the end of life. The most common antibiotic prescribed was piperacillin/tazobactam (41.9%). The most common site of infection was pulmonary (32.8%). Of 86 patients prescribed antibiotics, 29 patients (33.7%) received antibiotics after futility was documented. 83 patients (96.5%) were administered their antibiotics intravenously.

CONCLUSION

Antimicrobial use at the end of life is frequent, with greater than one third of the patients who died in hospital having their antibiotics continued after discussion of futility. Antimicrobial use in this setting is complex with significant clinical, social and ethical considerations which need to be addressed if antibiotic optimization in this area (and more broadly in the hospital) is to be achieved.

Antimicrobial prescribing in patients with advanced-stage illness in the antimicrobial stewardship era

OBJECTIVE

Antimicrobials are frequently administered to patients with an advanced-stage illness. Understanding the current practice of antimicrobial use at the end of life and the factors influencing physicians' prescribing behavior is necessary to develop an effective antimicrobial stewardship program and to provide optimal end-of-life care for terminally ill patients.

DESIGN

A 1-year retrospective cohort study.

SETTING

A public tertiary-care center.PatientsThe study included 260 adult patients who were hospitalized and later died at the study institution with an advanced-stage illness.

RESULTS

Of 260 patients in our study cohort, 192 (73.8%) had an advanced-stage malignancy and 136 (52.3%) received antimicrobial therapy in the last 14 days of their life; of the latter, 60 (44.1%) received antimicrobials for symptom relief. Overall antimicrobial use in the last 14 days of life was 421.9 days of therapy per 1,000 patient days. Factors associated with antimicrobial use in this period included a history of antimicrobial use prior to the last 14 days of life during index hospitalization (adjusted odds ratio [aOR], 4.86; 95% confidence interval [CI], 2.67-8.84) and antipyretic use in the last 14 days of life (aOR, 4.19; 95% CI, 2.01-8.71).

CONCLUSION

Approximately half of the patients hospitalized with an advanced-stage illness received antimicrobials in the last 14 days of life. The factors associated with antimicrobial use at the end of life in this study are likely to explain physicians' prescribing behaviors. In the current era of antimicrobial stewardship, reconsidering antimicrobial use in terminally ill patients is necessary.

Antimicrobial Use at the End of Life

At least one-third of patients at the end of life (EOL) receive interventions that are without benefit, and a similar proportion of patients die in the intensive care unit. Here, the authors discuss the role of antimicrobials in patients at the EOL, including the patient populations and scenarios in which antimicrobials may or may not have benefit. They also review adverse outcomes associated with antimicrobial use at the EOL, including societal harms. Finally, an algorithm to aid management of suspected infections at the EOL is proposed.

Long-Acting Lipoglycopeptides for Gram-Positive Bacteremia at the End of Life to Facilitate Hospice Care: A Report of 3 Cases

Administering and monitoring intravenous antimicrobials may cause discomfort in patients at the end of life and delay transition to hospice. We describe 3 patients with terminal cancer with methicillin-resistant Staphylococcus aureus, Streptococcus gallolyticus, and Granulicatella adiacens bacteremia who were managed with the long-acting lipoglycopeptide oritavancin to facilitate discharge to hospice.

Burden and Management of Multidrug-Resistant Organisms in Palliative Care

Palliative care includes comprehensive strategies to optimize quality of life for patients and families confronting terminal illness. Infections are a common complication in terminal illness, and infections due to multidrug-resistant organisms (MDROs) are particularly challenging to manage in palliative care. Limited data suggest that palliative care patients often harbor MDRO. When MDROs are present, distinguishing colonization from infection is challenging due to cognitive impairment or metastatic disease limiting symptom assessment and the lack of common signs of infection. Multidrug-resistant organisms also add psychological burden through infection prevention measures including patient isolation and contact precautions which conflict with the goals of palliation. Moreover, if antimicrobial therapy is indicated per goals of care discussions, available treatment options are often limited, invasive, expensive, or associated with adverse effects that burden patients and families. These issues raise important ethical considerations for managing and containing MDROs in the palliative care setting.

Antibiotic Treatment in End-of-Life Cancer Patients-A Retrospective Observational Study at a Palliative Care Center in Sweden

Background: The aim of this study was to elucidate whether palliative cancer patients benefit from antibiotic treatment in the last two weeks of life when an infection is suspected. Method: We reviewed medical records from 160 deceased palliative cancer patients that had been included in previous studies on vitamin D and infections. Patients treated with antibiotics during the last two weeks of life were identified and net effects of treatment (symptom relief) and possible adverse events were extracted from medical records. Results: Seventy-nine patients (49%) had been treated with antibiotics during the last two weeks in life. In 37% (n = 29), the treatment resulted in evident symptom relief and among these 50% had a positive bacterial culture, 43% had a negative culture and in 7% no culture was taken. Among the patients with no or unknown effect of antibiotics, 50% had a positive culture. When the indication for antibiotic treatment was to avoid or treat sepsis, symptom relief was achieved in 50% of the patients (n = 19). Only 4% (n = 3) of the patients experienced adverse events of the treatment (diarrhea, nausea). Conclusions: Treating infections with antibiotics in the last weeks of life may improve the quality of life for palliative cancer patients, especially if sepsis is suspected or confirmed. According to our results, the beneficial effects outweigh the potentially negative outcomes.

Frequent Prescription of Antibiotics and High Burden of Antibiotic Resistance among Deceased Patients in General Medical Wards of Acute Care Hospitals in Korea

Background

Antibiotics are often administered to terminally ill patients until death, and antibiotic use contributes to the emergence of multidrug-resistant organisms (MDROs). We investigated antibiotic use and the isolation of MDROs among patients who died in general medical wards.

Methods

All adult patients who died in the general internal medicine wards at four acute care hospitals between January and June 2013 were enrolled. For comparison with these deceased patients, the same number of surviving, discharged patients was selected from the same divisions of internal medicine subspecialties during the same period.

Results

During the study period, 303 deceased patients were enrolled; among them, 265 (87.5%) had do-not-resuscitate (DNR) orders in their medical records. Antibiotic use was more common in patients who died than in those who survived (87.5% vs. 65.7%, P<0.001). Among deceased patients with DNR orders, antibiotic use was continued in 59.6% of patients after obtaining their DNR orders. Deceased patients received more antibiotic therapy courses (two [interquartile range (IQR) 1–3] vs. one [IQR 0–2], P<0.001). Antibiotics were used for longer durations in deceased patients than in surviving patients (13 [IQR 5–23] vs. seven days [IQR 0–18], P<0.001). MDROs were also more common in deceased patients than in surviving patients (25.7% vs. 10.6%, P<0.001).

Conclusions

Patients who died in the general medical wards of acute care hospitals were exposed to more antibiotics than patients who survived. In particular, antibiotic prescription was common even after obtaining DNR orders in patients who died. The isolation of MDROs during the hospital stay was more common in these patients who died. Strategies for judicious antibiotic use and appropriate infection control should be applied to these patient populations.

Acute symptomatic complications among patients with advanced cancer admitted to acute palliative care units: A prospective observational study

BACKGROUND

Limited information is available on the symptomatic complications that occur in the last days of life.

AIM

We documented the frequency, clinical course, and survival for 25 symptomatic complications among patients admitted to acute palliative care units.

DESIGN

Prospective longitudinal observational study.

MEASUREMENTS

Their attending physician completed a daily structured assessment of symptomatic complications from admission to discharge or death.

SETTING/PARTICIPANTS

We enrolled consecutive advanced cancer patients admitted to acute palliative care units at MD Anderson Cancer Center, USA, and Barretos Cancer Hospital, Brazil.

RESULTS

A total of 352 patients were enrolled (MD Anderson Cancer Center = 151, Barretos Cancer Hospital = 201). Delirium, pneumonia, and bowel obstruction were the most common complications, occurring in 43%, 20%, and 16% of patients on admission, and 70%, 46%, and 35% during the entire acute palliative care unit stay, respectively. Symptomatic improvement for delirium (36/246, 15%), pneumonia (52/161, 32%), and bowel obstruction (41/124, 33%) was low. Survival analysis revealed that delirium (p < 0.001), pneumonia (p = 0.003), peritonitis (p = 0.03), metabolic acidosis (p < 0.001), and upper gastrointestinal bleed (p = 0.03) were associated with worse survival. Greater number of symptomatic complications on admission was also associated with poorer survival (p < 0.001).

CONCLUSION

Symptomatic complications were common in cancer patients admitted to acute palliative care units, often do not resolve completely, and were associated with a poor prognosis despite active medical management.

Wishes of Patients With Terminal Cancer and Influencing Factors Toward the Use of Antibiotics in Taiwan

Context:

The use of antibiotics is a common ethical dilemma in palliative care, thus identifying the concerns of patients with terminal cancer and respecting their wishes are important in making an ethically justified decision.

Objectives:

The aim of this study was to understand wishes of patients with terminal cancer and determine influencing factors toward the use of antibiotics.

Methods:

Two hundred and one patients with terminal cancer, admitted to a palliative care unit in Taiwan, completed a structured questionnaire interview, including demographic characteristics, knowledge and attitudes on antibiotics, the health locus of control, subjective norms, and the wishes to use antibiotics.

Results:

The most common misconception was “Antibiotics use is helpful to all terminal patients with infection,” which only 13.4% respondents disagreed. Of the 201patients, 92 (45.8%) expressed their wishes to use antibiotics even in the very terminal stage, and around one-fourth (26.4%) of patients wished not to use antibiotics, the remaining 27.8% were unclear. The most influential persons were medical professionals. The results of logistic regression analysis that showed familiarity with antibiotics, subjective norms, and the attitude toward burdens of antibiotics were the most significant predicting variables for those wishing to use antibiotics (odds ratio [OR] = 4.133, 95% confidence interval [CI] = 1.012-16.880; OR = 1.890, 95% CI = 1.077-3.317; and OR = 1.255, 95% CI = 1.047-1.503).

Conclusion:

This study indicated the responsibility of medical professionals to convey burdens of using antibiotics to patients and family. Otherwise, by enhancing professional training and performing effective communication with patients, we can reach a more appropriate decision in the use of antibiotics.

Antimicrobial use for symptom management in patients receiving hospice and palliative care: a systematic review

BACKGROUND

Patients receiving hospice or palliative care often receive antimicrobial therapy; however the effectiveness of antimicrobial therapy for symptom management in these patients is unknown.

OBJECTIVE

The study's objective was to systematically review and summarize existing data on the prevalence and effectiveness of antimicrobial therapy to improve symptom burden among hospice or palliative care patients.

DESIGN

Systematic review of articles on microbial use in hospice and palliative care patients published from January 1, 2001 through June 30, 2011.

MEASUREMENTS

We extracted data on patients' underlying chronic condition and health care setting, study design, prevalence of antimicrobial use, whether symptom response following antimicrobial use was measured, and the method for measuring symptom response.

RESULTS

Eleven studies met our inclusion criteria in which prevalence of antimicrobial use ranged from 4% to 84%. Eight studies measured symptom response following antimicrobial therapy. Methods of symptom assessment were highly variable and ranged from clinical assessment from patients' charts to the Edmonton Symptom Assessment Scale. Symptom improvement varied by indication, and patients with urinary tract infections (two studies) appeared to experience the greatest improvement following antimicrobial therapy (range 67% to 92%).

CONCLUSION

Limited data are available on the use of antimicrobial therapy for symptom management among patients receiving palliative or hospice care. Future studies should systematically measure symptom response and control for important confounders to provide useful data to guide antimicrobial use in this population.

A nationwide analysis of antibiotic use in hospice care in the final week of life

CONTEXT

Antibiotic prescription in hospice patients is complicated by the focus on palliative rather than curative care and concerns regarding increasing antibiotic resistance.

OBJECTIVES

To estimate the antibiotic use in a national sample of hospice patients and identify facility and patient characteristics associated with antibiotic use in this population.

METHODS

This was an analysis of data from the 2007 National Home and Hospice Care Survey, a nationally representative sample of U.S. hospice agencies. We included data from 3884 patients who died in hospice care. The primary outcome measure was prevalence of antibiotic use in the last seven days of life. Diagnoses, including potential infectious indications for antibiotic use, were defined using International Classification of Diseases, Ninth Revision (ICD-9) codes. Chi-squared tests and t-tests were used to quantify associations of patient and facility characteristics with antibiotic use.

RESULTS

During the last seven days of life, 27% (95% CI: 24%-30%) of patients received at least one antibiotic and 1.3% (95% CI: 0.7%-2.0%) received three or more antibiotics. Among patients who received at least one antibiotic, 15% (95% CI: 10%-20%) had a documented infectious diagnosis compared with 9% (95% CI: 7%-11%), who had an infectious diagnosis but received no antibiotics.

CONCLUSION

In this nationally representative sample, 27% of hospice patients received an antibiotic during the last seven days of life, most without a documented infectious diagnosis. Further research is needed to elucidate the role of antibiotics in this patient population to maintain palliative care goals while reducing unnecessary antibiotic use.