The Use of Antibiotics in Hospice and Palliative Care Settings

Is the use of antibiotic stewardship measures in the context of specialized outpatient palliative care sensible and feasible? An interview-based study

BACKGROUND

Specialized outpatient palliative care (SAPV) is a component of palliative care in Germany, which assists approximately 10% of palliative patients. The majority of these patients have a malignant disease and are at increased risk of complications or severe infection. Antibiotic stewardship (ABS) measures are implemented to optimize antibiotic administration; however, there is little data available in this area, particularly for SAPV. Therefore, we examined the extent to which ABS measures can be meaningfully used or implemented in SAPV.

METHODS

After establishing a corresponding interview guide, 15 experts from specialized areas were interviewed on this subject by the Institute for Market Research in Healthcare Munich (IMIG) through audio-registered individual interviews. The interviews were analyzed using the qualitative content analysis method according to Mayring.

RESULTS

All 15 experts participated. The primary benefits cited were greater safety in the prescription and decision-making process for antibiotics in the areas of SAPV and improved quality of life. The implementation of continuous ABS measures for SAPV was considered difficult in some cases and linked to certain prerequisites, such as supportive advice from existing systems. The possibility of further training for SAPV members in the area of ABS was considered particularly advantageous.

CONCLUSIONS

The implementation of ABS measures in SAPV is feasible in principle; however, it is difficult to implement under the current conditions. Close cooperation with an existing external ABS expert/team will be helpful. This will provide more security for a small, but relevant proportion of SAPV patients, and for the SAPV team treating them.

Prophylactic antibiotics and corticosteroid prescribing in palliative medicine: retrospective study

OBJECTIVES

To investigate whether patients under the care of the community specialist palliative care team receiving steroids are at increased risk of infection.To identify other risk factors that predispose community palliative care patients to infection.

METHODS

A retrospective chart review of all patients referred to a community specialist palliative care service.

RESULTS

177 adult patients were referred to the community specialist palliative care service. Corticosteroids were significantly associated with infection. 39% of patients who received an oral steroid had infection compared with 22% of those who did not receive steroids (OR 2.6 (95% CI 1.07 to 3), RR 1.78 (95% CI 1.08 to 2.9), p=0.02). Regular opioids were significantly associated with infection. 33% of patients receiving a regular opioid had an infection compared with 15% of those not receiving a regular opioid (OR 2.69 (95% CI 1.26 to 5.7), RR 2.06 (95% CI 1.2 to 3.8), p=0.008). Male gender, lung disease, diabetes and immunosuppressive therapies were associated with an increased rate of infection but were not statistically significant.

CONCLUSIONS

Oral corticosteroids were associated with a significantly increased infection rate in a community palliative care population. These patients could potentially benefit from antibiotic prophylaxis while receiving corticosteroids.

Ethical and Practical Issues with the Use of Antimicrobial Agents during the End of Life

The use of antimicrobials in patients receiving end-of-life (EOL) care, which is generally defined as supportive care provided to patients anticipated to live less than 1 year, has been actively debated in the realm of palliative care medicine due to the nebulous nature of the topic. In this article, we explore the use of antimicrobial use near EOL as it relates to both the ethical and practical issues that face physicians. We also discuss the reasons underlying the scarcity of prospective studies on this topic.

Utilization of Antibiotics for the Treatment of Urinary Tract Infections in End-of-Life Patients

PURPOSE

The use of antibiotics for end-of-life patients is controversial; currently there is limited guidance on the use of antibiotics in hospice patients. The threat of antibiotic resistance, risk of adverse events, variable efficacy, and time to benefit in hospice patients makes their use divisive. Patients' potential care needs are estimated using the palliative performance scale (PPS) with lower scores indicating more care is required. The purpose of this project is to examine the utilization of antibiotics for urinary tract infections (UTIs) in hospice patients.

METHODS

This multi-center retrospective observational cohort study evaluated the prescribing of antibiotics in symptomatic vs asymptomatic hospice patients being treated for UTIs and assessed antibiotic initiation based on PPS of ≥30% or <30%. Patients included in this study were adults initiated on oral antibiotics for UTI. Exclusion criteria included antibiotics initiated prior to admission, prophylactic antibiotics, non-oral antibiotics, or if the patient revoked election of hospice.

RESULTS

A total of 56 patients were prescribed antibiotics for UTIs during the 1-year study period. Half of the antibiotics were prescribed appropriately based on documented symptoms when starting the antibiotics. There was not a statistically significant difference between appropriate utilization based on PPS ≥30% or <30% using the Mann-Whitney U test (P = 0.255).

CONCLUSION

The prescribing of antibiotics in end-of-life patients is not always appropriate regardless of the PPS. This may indicate that antibiotics are initiated in asymptomatic hospice patients, and the utilization of unnecessary medications presents the risk of adverse effects.

Improving shared decision-making around antimicrobial-prescribing during the end-of-life period: a qualitative study of Veterans, their support caregivers and their providers

Objective

Antimicrobials are frequently used for palliation during end-of-life care, but adverse effects, such as antimicrobial resistance, are a concern. Shared decision-making is beneficial in end-of-life care conversations to help align antimicrobial-prescribing with patient preferences. However, there is limited data regarding optimal incorporation of antimicrobial-prescribing discussions into shared decision-making conversations. We explored healthcare provider, patient, and support caregiver (eg, family member/friend) perceptions of barriers and facilitators to discussing antimicrobial-prescribing during the end-of-life period.

Design

Qualitative study.

Participants

Healthcare providers; palliative care/hospice care patients/caregivers.

Methods

We conducted semi-structured interviews on shared attitudes/beliefs about antimicrobial-prescribing during end-of-life patient care at one acute-care and one long-term-care facility. Interviews were analyzed for thematic content.

Results

Fifteen providers and 13 patients/caregivers completed interviews. Providers recognized the potential benefit of leveraging shared decision-making to guide antimicrobial-prescribing decisions. Barriers included limited face-to-face time with the patient and uncertainty of end-of-life prognosis. Patients/caregivers cited trust, comprehension, and feeling heard as important characteristics which act as facilitators in fostering effective shared decision-making around antimicrobial use. Communication in which providers ensure patients are involved in shared decision-making discussions could be increased to ensure patients and their providers develop a mutually agreeable care plan.

Conclusions

Shared decision-making is a practice that can guide antimicrobial-prescribing decisions during end-of-life care, thus potentially minimizing antimicrobial-related adverse effects. Our findings highlight opportunities for increased shared decision-making around antimicrobial use during end-of-life care. Interventions designed to address the identified barriers to shared decision-making have the potential to improve antimicrobial-prescribing practices at end-of-life.