Antimicrobial therapy in palliative care: an overview

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.

Utilization of medical interventions in hospitalized Mexican adults with cancer at the end of life in a referral hospital: The importance of early palliative care

OBJECTIVES

To investigate the impact of early vs. late palliative care (PC) on the frequency of admissions to acute hospital settings and the utilization of end-of-life (EoL) interventions in cancer decedents.

METHODS

In this single-center, cross-sectional study, we examined the frequency of intensive care unit (ICU) and emergency department (ED) admissions among adult cancer decedents between 2018 and 2022 in a referral hospital in México. Additionally, we assessed EoL medical interventions, categorizing patients into 3 groups: those who received early PC (EPC), late PC (LPC), and those who did not receive PC (NPC).

RESULTS

We analyzed data from 1762 patients, averaging 56 ± 16.3 years old, with a predominant representation of women (56.8%). PC was administered to 45.2% of patients, but EPC was limited to only 12.3%. The median time from the initiation of PC to death was 5 days (interquartile range: 2.0-31.5). Hematological malignancies were the most prevalent, affecting 21.5% of patients. EPC recipients demonstrated notable reductions in ICU and ED admissions, as well as diminished utilization of chemotherapy, radiotherapy (RT), antibiotics, blood transfusions, and surgery when compared to both LPC and NPC groups. EPC also exhibited fewer medical interventions in the last 14 days of life, except for RT.

SIGNIFICANCE OF RESULTS

The findings of this study indicate that a significant proportion of EoL cancer patients receive PC; however, few receive EPC, emphasizing the need to improve accessibility to these services. Moreover, the results underscore the importance of thoughtful deliberation regarding the application of EoL medical interventions in cancer patients.

Factors Associated with Antimicrobial Use at the End-Of-Life Among Hospitalized Cancer Patients

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.

Effectiveness of Subcutaneous Administration of Antibiotics to Control Infections in Elder Palliative Patients: A Systematic Review

Background: Infections are common in patients with advanced illnesses for whom the intravenous or oral route is not possible. The subcutaneous administration of antibiotics is a promising alternative, but there is not enough theoretical support for its use. This study aims to explore the effectiveness and safety of subcutaneous antibiotic therapy in the context of palliative care in elderly patients. Methods: A systematic review was conducted using PubMed and Embase, without time or language limits. Seven articles were selected on the effectiveness of subcutaneous antibiotic therapy in adult patients with chronic progressive diseases. The quality of the articles was assessed with the Newcastle Ottawa Scale and relevant data was extracted using a selection capture file. Results: Seven quasi-experimental studies evaluated 865 elderly patients with advanced diseases, comorbidities, and infections (ie, urinary tract, respiratory system, and bone joint) who received subcutaneous antibiotic therapy (ie, Ceftriaxone, Ertapenem, and Teicoplanin). The pooled success rate of subcutaneous antibiotics for the 7 studies was 71%, the therapy failure rate was 22%, its withdrawal mean was 8%, and the mean mortality rate was 7%. The studies were of low quality and were heterogeneous in the types of infections, types of antibiotics, time of follow-up, and outcomes assessed. Conclusions: Pilot studies have found a limited number of antibiotics that can be safely used to treat specific infections. Nevertheless, the data isn´t robust enough to recommend their use.

Profile of Antimicrobial Consumption in Patients Assisted by a Palliative Care Team During the COVID-19 Pandemic in Brazil

BACKGROUND

This study aimed to evaluate the profile of antimicrobial consumption in patients assisted by a palliative care (PC) team during the COVID-19 pandemic.

METHODS

A retrospective observational study was conducted in a quaternary hospital. Patients assisted by the PC team in 2020 were selected. The clinical and demographic characteristics, as well as the outcomes, were assessed using electronic records.

RESULTS

A total of 181 patients were included in the study, of whom 93.4% had used antimicrobials and 24.3% had had COVID-19. COVID-19 patients were more likely to receive at least one course of antimicrobial therapy. Patients who received polytherapy in the first course of treatment were more likely to die and to be still receiving antimicrobials at death. There was no significant difference in the length of hospital stay, new hospitalization in 12 months, nor the time to death among patients who received monotherapy or polytherapy during the first course of antimicrobial therapy.

CONCLUSIONS

There was a large amount of PC patients receiving antimicrobial therapy during the COVID-19 pandemic. SARS-CoV-2-positive patients were more likely to receive antimicrobial therapy.

Knowledge gaps, attitudes, and practices regarding end-of-life medical care among physicians in an academic medical center

<b>Introduction:</b> End-of-life medical care (ELMC) plans and do-not-resuscitate (DNR) decision-making are usually affected by multiple factors compared to other medical care decisions.<b> </b>ELMC and DNR policy implementation are still diversified and heterogeneous, especially in Saudi Arabia, because policymakers have adopted no guidelines. Thus, this study investigated physicians’ knowledge, attitude, and practice regarding ELMC and DNR.<br /> <b>Methods:</b> A cross-sectional study design was adopted. Three hundred physicians working at King Fahad Hospital of the University, Khobar, Saudi Arabia, were randomly selected and administered an anonymous self-administered questionnaire using the Likert scale. Data analysis was carried out using SPSS 23.0.<br /> <b>Results: </b>Of 300 distributed questionnaires, 264 (88%) were completed and analysed. Knowledge gaps and negative attitudes were observed, a quarter of the participants were opposed to issuing a DNR order, and 29.0% considered DNR as equal to euthanasia as they practice. The participants’ patient age and religious factors were the most critical factors in the ELMC plan and DNR decision. The physician’s level of acceptance regarding a set of ELMC interventions and DNR decisions showed heterogenicity and uncertainty among participants.<br /> <b>Conclusions:</b> The ELMC plan and DNR decision-making should be appropriately addressed in the medical residents’ training programs to bridge the knowledge gap and the physicians’ negative attitudes during their practice. Additionally, there is a need to update and unify the DNR policies at the national level, considering the patient’s right to be informed and involved actively during the decision process making. Finally, more prospective research is needed for the global standardization of ELMC.

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.

Association of entry into hospice or palliative care consultation during acute care hospitalization with subsequent antibiotic utilization

OBJECTIVE

We aimed to estimate antibiotic use during the last 6 months of life for hospitalized patients under hospice or palliative care and identify potential targets (i.e. time points) for antibiotic stewardship during the end-of-life period.

METHODS

We conducted a retrospective cohort study of nationwide Veterans Affairs (VA) patients who died between January 1, 2014 and December 31, 2019 and who had been hospitalized within 6 months prior to death. Data from the VA's integrated electronic medical record were collected, including demographics, comorbid conditions, and duration of inpatient antibiotics administered, along with outpatient antibiotics dispensed. A propensity score-matched cohort analysis was conducted to compare antibiotic use between hospitalized patients placed into palliative care or hospice matched to hospitalized patients not receiving palliative care or hospice.

RESULTS

There were 9808 and 40 796 propensity score-matched patient pairs in the hospice and palliative care groups, respectively. Within 14 days of placement or consultation, 41% (4040/9808) of hospice patients and 48% (19 735/40 796) of palliative care patients received at least one antibiotic, while 25% (2420/9808) matched nonhospice and 27% (10 991/40 796) matched nonpalliative care patients received antibiotics. Entry into hospice was independently associated with a 12% absolute increase in antibiotic prescribing, and entry into palliative care was associated with a 17% absolute increase during the 14 days post-entry vs. pre-entry period.

DISCUSSION

We observed that patients receiving end-of-life care had high levels of antibiotic exposure across this VA population, particularly during admissions when they received hospice or palliative care consultation.

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.

Factors That Influence the Prescription of Antibiotic Therapy at the End-of-Life: Construction and Validation of a Scale

INTRODUCTION

End-of-life care is frequently discussed in clinical practice. Non-beneficial treatments and the need for decision-making regarding therapeutic institutions are increasingly addressed. There are no guidelines regarding prescribing or de-prescribing antibiotic therapy at the end of life, which depends on clinical decisions. In this study, we developed a scale to assess the factors influencing clinicians' decisions when prescribing antimicrobial agents.

METHODS

This is a quantitative, exploratory, and descriptive study. After the literature review, the scale was constructed with an analysis of internal consistency and temporal stability. It was applied online together with a sociodemographic and clinical questionnaire. Statistical analysis of the scale, its construction, and final validation were performed.

RESULTS

A total of 196 physicians participated in this study (76.5% female, 78.6% aged <40 years), 60.2% specialists, and 35.7% without palliative care training. Almost all of the participants (89.9%) reported having end-of-life care concerns with a high frequency. In this study, a scale was developed to assess factors associated with the prescription of antibiotic therapy in end-of-life patients. This scale revealed the presence of 3 factors: infection, patient/illness, and symptoms. Together, the three factors explain 57.4% of the clinician's decisions. The factors associated with symptoms were the most predominant in decision-making compared to those associated with infection.

CONCLUSIONS

Among the multiple factors that may influence the institution of antibiotic therapy at the end of life, symptomatic control is the most important factor.

[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.

Do Perceptions about Palliative Care Affect Emergency Decisions of Health Personnel for Patients with Advanced Dementia?

Decision analysis regarding emergency medical treatment in patients with advanced dementia has seldom been investigated. We aimed to examine the preferred medical treatment in emergency situations for patients with advanced dementia and its association with perceptions of palliative care. We conducted a survey of 159 physicians and 156 nurses from medical and surgical wards in two tertiary hospitals. The questionnaire included two case scenarios of patients with advanced dementia presenting gastrointestinal bleeding (scenario I) or pneumonia (scenario II) with a list of possible interventions and 11 items probing perceptions towards palliative care. Low burden interventions such as laboratory tests and intravenous administration of antibiotics/blood were preferred. Palliative measures such as analgesia/sedation were chosen by about half of the participants and invasive intervention by 41.6% (gastroscopy in scenario I) and 37.1% (intubation/mechanical ventilation in scenario II). Medical ward staff had a more palliative approach than surgical ward staff in scenario I, and senior staff had a more palliative approach than junior staff in scenario II. Most participants (90.4%) agreed that palliative care was appropriate for patients with advanced dementia. Stress in caring for patients with advanced dementia was reported by 24.5% of participants; 33.1% admitted fear of lawsuit, 33.8% were concerned about senior-level responses, and 69.7% were apprehensive of family members' reaction to palliative care. Perceptions of health care workers towards palliative care were associated with preferred treatment choice for patients with advanced dementia, mainly in scenario II. Attitudes and apprehensions regarding palliative care in these situations may explain the gap between positive attitudes towards palliative care and the chosen treatment approach. Acquainting emergency care practitioners with the benefits of palliative care may impact their decisions when treating this population.

Parameters affecting prognosis after hemodialysis withdrawal: experience from a single center

INTRODUCTION

Withdrawal from maintenance hemodialysis is unavoidable in some patients due to their poor general condition; however, their survival days vary depending on their health status. The factors associated with life prognosis in the terminal phase in patients undergoing hemodialysis remain unclear.

METHODS

Patients who died after withdrawal from hemodialysis between 2011 and 2021 at Nagasaki Renal Center were included. Patient background data were collected, and the association between the patients' clinical features and survival duration was analyzed.

RESULTS

The withdrawal group included 174 patients (79.8 ± 10.8 years old; 50.6% male; median dialysis vintage, 3.6 years). The most common reason for withdrawal (95%) was that hemodialysis was more harmful than beneficial because of the patient's poor general condition. The median time from withdrawal to death was 4 days (interquartile range, 3-10 days). Multivariable Cox proportional regression analysis showed that oral nutrition (hazard ratio (HR), 1.98; 95% confidence interval (CI), 1.12-3.50; P = 0.03), hypoxemia (HR, 2.32; 95% CI, 1.55-3.47; P < 0.01), ventilator use (HR, 0.26; 95% CI, 0.11-0.58; P < 0.01), and pleural effusion (HR, 1.54; CI, 1.01-2.37; P = 0.04) were associated with increased survival duration. In contrast, antibiotics and vasopressor administration were not associated with the survival duration.

CONCLUSION

In this study, we explored the parameters affecting the survival of patients who withdrew from hemodialysis. Physicians could use our results to establish more accurate predictions, which may help the patient and their family to emotionally accept and implement the desired care plan.

Antibiotic Therapy in Integrated Oncology and Palliative Cancer Care: An Observational Study

Simple Summary

Approximately one-quarter of the patients with advanced cancer acutely admitted to the Palliative Care Unit at St. Olav’s University Hospital received intravenous antibiotics. We observed that physiological variables and paraclinical findings in patients with and without infections differed at admission but observed no differences in patient-reported outcome measures. Patients admitted for infection had no shorter life expectancy than patients without infections. We did not observe any difference in the prescription of antibiotics to patients with ongoing anti-cancer therapy (integrated pathway) compared to patients with no ongoing cancer therapy (palliative care pathway). This information increases the knowledge about the use of antibiotic therapy in palliative cancer care.

Abstract

Decision-making for antibiotic therapy in palliative cancer care implies avoiding futile interventions and to identify patients who benefit from treatment. We evaluated patient-reported outcome-measures (PROMs), physiological findings, and survival in palliative cancer care patients hospitalized with an infection. All acute admissions during one year, directly to a University Hospital unit that provided integrated services, were included. Serious infection was defined as a need to start intravenous antibiotics. PROMs, clinical and paraclinical variables, and survival were obtained. Sixty-two of 257 patients received intravenous antibiotic treatment. PROMs were generally similar in the infection group and the non-infection group, both in respect to intensities at admission and improvements during the stay. There were more physiological and paraclinical deviations at admission in patients in the infection group. These deviations improved during the stay. Survival was not poorer in the infection group compared to the non-infection group. Patients in integrated cancer care were as likely to be put on intravenous antibiotics but had longer survival. In integrated oncology and palliative cancer services, patients with an infection had similar outcomes as those without an infection. This argues that the use of intravenous antibiotics is appropriate in many patients admitted to palliative care.

The Use of Antibiotics in Hospice and Palliative Care Settings

Antibiotics are commonly prescribed medications in the hospice and palliative care setting, as well as in many other healthcare settings. The overuse or negligent use of antibiotics is associated with the harmful consequence of fostering the development of antibiotic-resistant pathogens. Thus, there is an urgent need to critically examine and audit antibiotic use in all aspects of healthcare. In the status quo, there is a lack of consistent standards and guidelines surrounding the use of antibiotics in hospice and palliative care settings, leading to significant variations in how antibiotics are prescribed and administered in end-of-life care. It is apparent that greater thought needs to go into antibiotic decisions for patients receiving hospice or palliative care, especially considering the harmful consequences of the overprescription of antibiotics. The literature suggests that many clinicians prescribe antibiotics inappropriately for patients who would not benefit from their use or prescribe them without adequate documentation. Clinicians should be deliberate about when they prescribe antibiotics and adhere to the appropriate documentation standards and procedures within their institution or community. Future research should seek to generate generalizable knowledge about which patients will benefit most from antibiotic therapy during end-of-life care.

The Differences and Perspectives Between Elderly Individuals and Their Surrogates Regarding End-of-Life Care: A Mixed Methods Study

Background: Family members often take the place of decision-making for elderly individuals. Previous studies showed that family members could not predict elderly individuals' thoughts about end-of-life care. Objectives: The aims are to understand the differences and perspectives between elderly individuals and surrogates regarding end-of-life care. Design: A mixed methods study comprising a cross-sectional survey and field notes analysis. Setting: Two geriatric wards in a veterans hospital located in northern Taiwan. Subjects: Fifty-five pairs of elderly individuals and their surrogates. Measurements: Life support preferences questionnaire and field notes. Results: The quantitative data showed that the elderly individuals and their surrogates had proper consistency in cardiopulmonary resuscitation and surgery. However, their consistency was poor in antibiotics and nasogastric tube feeding. Four themes were identified in qualitative data: recognizing old age, struggling with hope and peace, worries and concerns, and control of life. Recognizing old age for both elderly individuals and their surrogates was critical. Elderly individuals and their surrogates may seek a ray of hope among aggressive treatments and struggle with hope and peace. A lot of worries and concerns were mentioned, including contextual concerns. Elderly individuals need to depend on their ability to control their life. Conclusions: The study highlights elderly individuals' and their surrogates' considerations for antibiotics and nasogastric tube feeding. Furthermore, elderly individuals expressed that it is different for making decisions for themselves or others; thus, future studies can further explore whether elderly individuals allow their surrogates leeway from their wishes.

Characterization of Antibiotic Use, Documented Infection and Prevalence of Multidrug-Resistant Organisms in Palliative Care Patients Admitted to a Private Hospital in Brazil: A Retrospective, Cohort Study

Objectives:

Antibiotic use in palliative care patients is a frequent dilemma. The benefits of their use in terms of quality of end-of-life care or survival improvement are not clear and the potential harm and futility of this practice not well established. Our aim was to characterise the prevalence of antibiotic use, documented infection and multidrug-resistant organisms (MDROs) colonisation among palliative care patients admitted to a private hospital in Brazil.

Materials and Methods:

Retrospective analysis of all palliative care patients admitted to our hospital during 1 year, including demographic characteristics, diagnosis of infectious disease at admission, antibiotic use during hospital stay, infectious agents isolated in cultures, documented MDRO colonisation and hospital mortality.

Results:

A total of 114 patients were included in the analysis. Forty-five (39%) were male and the median age was 83 years. About 78% of the patients had an infectious diagnosis at hospital admission and 80% of the patients not admitted with an infectious diagnosis used antibiotics during their stay, out of which a great proportion of large spectrum antibiotics. Previous MDRO colonisation and hospital mortality were similar between patients admitted with or without an infectious diagnosis.

Conclusion:

Infection is the leading cause of hospital admission in palliative care patients. However, antibiotics prescription is also very prevalent during hospital stay of patients not admitted with an infectious condition. Mortality is very high regardless of the initial reason for hospital admission. Therefore, the impact of multiple large spectrum antibiotics prescription and consequent significant cost burden should be urgently confronted with the real benefit to these patients.

End-of-life use of antibiotics: a survey on how doctors decide

OBJECTIVES

Infections are the main complications in terminal diseases. Many patients die using antibiotics, which raises questions about their real usefulness and role in unnecessary prolongation of suffering. This survey evaluated how doctors use antibiotics in palliative care.

METHODS

From June to August of 2016, an online survey was conducted with 224 doctors who provide palliative care. They had to decide whether to initiate antibiotics in fictitious scenarios involving patients with suspected infections (urinary tract infection, pneumonia, sepsis) in end-of-life (from cancer, dementia, malignant stroke with sequelae, advanced COPD, multiple organ failure). Then, they had to decide whether to stop, maintain, or extend antibiotics after non-response in 72 hours.

RESULTS

88-100% of doctors decided to initiate antibiotics in all situations, except in advanced dementia (55%), and most of them decided to maintain/extend antibiotics inadequately. Factors associated with maintaining/extending antibiotics inadequately were: longer time since graduation (over 13 years; significant in all 7 clinical situations; OR range: 2.45-10.11), and not having formal specialization in palliative care (statistically significant in 3 of 7 situations).

CONCLUSIONS

Most palliative care physicians in this study decided to initiate and maintain/extend antibiotics at the end-of-life.

The Role of Regional and State Initiatives in Nursing Home Advance Care Planning Policies

OBJECTIVE

Antibiotic use at the end of life (EoL) may introduce physiological as well as psychological stress and be incongruent with patients' goals of care. Advance care planning (ACP) related to antibiotic use at the EoL helps improve goal-concordant care. Many nursing home (NH) residents are seriously ill. Therefore, we aimed to examine whether state and regional ACP initiatives play a role in the presence of "do not administer antibiotics" orders for NH residents at the EoL.

METHODS

We surveyed a random, representative national sample of 810 U.S. NHs (weighted n = 13,983). The NH survey included items on "do not administer antibiotics" orders in place and participation in infection prevention collaboratives. The survey was linked to state Physician Orders for Life-Sustaining Treatment (POLST) adoption status and resident, facility, and county characteristics data. We conducted multivariable regression models with state fixed effects, stratified by state POLST designation.

RESULTS

NHs in mature POLST states reported higher rates of "do not administer antibiotics" orders compared to developing POLST states (10.1% vs. 4.6%, respectively, p = 0.004). In mature POLST states, participation in regional collaboratives and smaller NH facilities (<100 beds) were associated with having "do not administer antibiotics" orders for seriously ill residents (β = 0.11, p = 0.006 and β = 0.12, p = 0.003, respectively).

DISCUSSION

NHs in states with mature POLST adoption that participated in infection control collaboratives were more likely to have "do not administer antibiotics" orders. State ACP initiatives combined with regional antibiotic stewardship initiatives may improve inappropriate antibiotic use at the EoL for NH residents.

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.

Evaluation of Antibiotic Initiation Tools in End-of-Life Care

BACKGROUND

Hospice patients are frequently confronted with potentially infectious complications necessitating antibiotic consideration. Information regarding the appropriate use of antibiotics and their impact on symptom management in hospice patients are unknown.

OBJECTIVES

This study aimed to evaluate and describe the use of an antibiotic initiation tool in patients admitted to outpatient hospice services. The primary outcome assessed the percentage of antibiotics that were appropriately initiated based on Loeb's Minimum Criteria (LMC) for Antibiotic Initiation Tool. Secondary outcomes included the number of patients with documented symptom resolution following antibiotic completion, the number of antibiotic courses that were successfully completed, and treatment-related adverse events.

METHODS

This was a retrospective, multisite, descriptive analysis of hospice patients treated with antibiotics between April 2019 and September 2020.

RESULTS

Two hundred and thirty patients were assessed for inclusion, with 172 meeting eligibility criteria and receiving a total of 201 antibiotic courses. Based on LMC, 84 of the 201 (42%) antibiotics ordered were appropriate, with 60% of these LMC-approved courses resulting in symptom resolution. Out of 201 total courses, 99 (49%) resulted in symptom resolution. Overall, 160 (80%) antibiotic courses were successfully completed.

CONCLUSION

In this study, antibiotic initiation in hospice patients frequently did not meet LMC. Less than half of the antibiotics prescribed led to symptom resolution despite antibiotic course completion in most patients. There is no consensus or guidelines directing appropriate antibiotic decision-making in hospice patients. The appropriate use of antibiotics in terminally ill patients warrants additional research.

Potentially Inappropriate Treatments at the End of Life in Nursing Home Residents: Findings From the PACE Cross-Sectional Study in Six European Countries

CONTEXT

Certain treatments are potentially inappropriate when administered to nursing homes residents at the end of life and should be carefully considered. An international comparison of potentially inappropriate treatments allows insight into common issues and country-specific challenges of end-of-life care in nursing homes and helps direct health-care policy in this area.

OBJECTIVES

To estimate the prevalence of potentially inappropriate treatments in the last week of life in nursing home residents and analyze the differences in prevalence between countries.

METHODS

A cross-sectional study of deceased residents in nursing homes (2015) in six European countries: Belgium (Flanders), England, Finland, Italy, The Netherlands, and Poland. Potentially inappropriate treatments included enteral administration of nutrition, parental administration of nutrition, artificial fluids, resuscitation, artificial ventilation, blood transfusion, chemotherapy/radiotherapy, dialysis, surgery, antibiotics, statins, antidiabetics, new oral anticoagulants. Nurses were questioned about whether these treatments were administered in the last week of life.

RESULTS

We included 1384 deceased residents from 322 nursing homes. In most countries, potentially inappropriate treatments were rarely used, with a maximum of 18.3% of residents receiving at least one treatment in Poland. Exceptions were antibiotics in all countries (between 11.3% in Belgium and 45% in Poland), artificial nutrition and hydration in Poland (54.3%) and Italy (41%) and antidiabetics in Poland (19.7%).

CONCLUSION

Although the prevalence of potentially inappropriate treatments in the last week of life was generally low, antibiotics were frequently prescribed in all countries. In Poland and Italy, the prevalence of artificial administration of food/fluids in the last week of life was high, possibly reflecting country differences in legislation, care organization and culture, and the palliative care competences of staff.

Determinants of Physicians' Attitudes Toward the Management of Infectious Diseases in Terminally Ill Patients With Cancer

OBJECTIVES

Antimicrobials are frequently prescribed to terminally ill patients with cancer; however, physicians' practice patterns regarding antimicrobial use vary widely. This study aimed to systematically identify factors that determine physicians' attitudes toward the management of infectious diseases in terminally ill patients with cancer.

METHODS

A nationwide cross-sectional survey involving 600 oncologists, 600 infectious diseases physicians, 600 palliative care physicians, and 220 home care physicians was conducted between November 2017 and January 2018. The primary endpoint was physicians' attitudes toward the management of infectious diseases in terminally ill patients with cancer with a few weeks of prognosis. Physicians' beliefs regarding management of infectious diseases as well as physician-perceived "good death" were also assessed (1 = strongly disagree to 6 = strongly agree).

RESULTS

There were 895 (44.3%) analyzable response, and average scores of physicians' attitudes ranged between 2.69 and 4.32. In total, 241 (27%; 95% CI = 24-30) to 691 (78%; 95% CI = 75-81) respondents showed proactive attitudes toward various infectious diseases management. In linear regression analysis, determinants of proactive attitudes included the following: physicians' belief that examination and treatment will improve quality of life and prognosis and reduce suffering (β = 0.32, t = 9.99, P = 0.00); greater physician-perceived importance on receiving enough treatment (β = 0.09, t = 2.88, P = 0.00) and less importance on dying a natural death (β = -0.07, t = -2.14, P = 0.03) for a "good death"; working at a tertiary care hospital (β = 0.16, t = 4.40, P = 0.00); and not being a home care physician (β = -0.20, t = -5.51, P = 0.00) or palliative care physician (β = -0.12, t = -3.64, P = 0.00).

CONCLUSIONS

Physicians have divergent attitudes toward the management of infectious diseases in terminally ill patients with cancer. Reflection by physicians on their own beliefs and perceptions regarding infectious disease management and a "good death" may help provide the best end-of-life care.

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.

Status and cost analysis of antimicrobial treatment of terminally ill patients with hematological malignancy in an acute hospital

OBJECTIVE

Terminally ill patients with hematological malignancy tend to be treated aggressively. We aimed to clarify the status and costs of antimicrobial treatment of patients dying with hematological malignancies.

METHODS

This retrospective study was conducted in a Japanese acute hospital between September 2010 and August 2015. A total of 141 patients who stayed for 14 days or longer and died in the hospital were investigated.

RESULTS

The median patient age was 67 years (range, 22-93). Most patients were treated with antibacterial, antifungal, and antiviral agents (98%, 75%, and 27% of the patients, respectively) in the last 14 days of their lives. The frequency of antibiotics used in the last 7 days did not differ from that of the week before. The median cost of antimicrobials was 245,000 JPY (2227 USD), which reflected 16% of the total medical costs spent over the last 14 days. A subgroup analysis of the patients according to care policy (aggressive care policy (A) and palliative care policy (P), respectively) showed that the total medical cost in group P in the last 7 days decreased from that of the preceding week; however, the cost of antimicrobials did not lessen even in the last 7 days.

CONCLUSIONS

Most patients dying with hematological malignancy were treated with a broad spectrum of antimicrobials. It appeared to be difficult to reduce, let alone discontinue antimicrobial treatment even in patients treated according to the palliative care policy. The optimal use of antibiotics for hematological patients in their end-of-life should be discussed.

A Retrospective Study Analyzing the Lack of Symptom Benefit With Antimicrobials at the End of Life

BACKGROUND

Infections are common in terminally ill patients (pts), and although antibiotics are frequently prescribed, their benefit for symptom relief is not clear. Antimicrobials at the end of life (EOL) may increase the risk of antimicrobial resistance and Clostrioides difficile infection. Our aim was to determine the frequency of symptom occurrence at the EOL when comparing pts who did or did not receive antibiotics (AB+ or AB-).

METHODS

We reviewed electronic medical records of pts admitted to a palliative care unit of a quarternary care hospital between 01/09/2017 and 07/16/2017 and assessed antimicrobial use in the last 14 days of life. Differences in demographics and symptom control between AB+ and AB- pts were analyzed using chi-square analyses; p-values were computed using Mann-Whitney tests.

RESULTS

Of a total of 133 pts included, 90 (68%) received antimicrobials (AB+). The indication for antibiotics was documented in only 12% of pts. The AB+ and AB- groups were similar with respect to demographics, including sex, and Charleston Comorbidity Index except for age (p = 0.01) and race (p = 0.03). Documented infections were similar between AB+ and AB- groups, except urinary tract infections. No statistically significant differences were noted in documented symptoms including pain, dyspnea, fever, lethargy, and alteration of mental state or length of stay.

CONCLUSION

Our study did not show differences in frequencies of documented symptoms with use of antimicrobials at EOL. Antimicrobial stewardship programs and further research can help with developing EOL care antimicrobial guidelines supporting patients and providers through shared decision-making.

Antimicrobial use and misuse at the end of life: a retrospective analysis of a treatment escalation/limitation plan

BACKGROUND

Antimicrobial treatment is common at end of life. A treatment escalation/limitation plan (TELP) offers the opportunity to avoid non-beneficial treatment in critically ill patients. Our aim was to evaluate antimicrobial prescribing in terminally ill patients, and assess whether it was modified using a TELP.

METHODS

Appropriateness of antimicrobial treatment was audited using a priori criteria in 94 consecutive hospital deaths. Prescribing in patients whose death was expected/unexpected, and who had a TELP with/without a 'ceiling' for antimicrobials, were compared.

RESULTS

Twenty three of 94 patients (24.5%) were receiving antimicrobials at time of death. This was not influenced by evidence of infection or whether death was expected. The use of a TELP (n = 81) with an antimicrobial 'ceiling' (28 with, 53 without) was associated with a significant reduction in antimicrobials administered (28.6% vs 81.1%; p < 0.0005).

CONCLUSIONS

Many complex factors contribute to antimicrobial misuse at end of life. An appropriately constructed TELP reduces inappropriate prescribing.

Palliative care infections and antibiotic cost: a vicious circle

Aim: In this study our aim was to evaluate the nosocomial infections and to understand factors affecting the cost of used antibiotics in palliative care unit.Materials and methods: Between 2016 and 2017, 113 patients were included in the study in palliative care unit of University of Health Sciences Bursa Yuksek Ihtisas Research and Training Hospital. Patients medical records were analyzed retrospectively for nosocomial infections, chronic diseases, presence of decubitis ulcers, opioid use, enteral, parenteral feedings, mortality and antibiotic cost.Results: Nosocomial infections were observed in 74.3% of the cases and 92.0% of patients used antibiotics. The mean duration of antibiotic use was 23.13 ± 18.06 days; and the average antibiotic cost was 2009.72 ± 2153.37 TL. Length of stay, male sex, presence of decubitus ulcers, tracheostomy, enteral and parenteral nutrition significantly increased antibiotic cost. Antibiotic cost and mortality were not related statistically.Conclusions: A vicious circle in palliative care involves the following order: length of stay, increased rate of infection, use of antibiotics, infection with resistant microorganisms, use of broad spectrum antibiotics, increased length of stay; all affecting each other. Therefore, using antibiotics for aggressive treatment of infections in palliative care is contraindicated as it opposes to real philosophy of palliative care.

Palliative care and infection management at end of life in nursing homes: A descriptive survey

BACKGROUND

Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics.

AIM

The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation.

DESIGN

This is a cross-sectional survey of nationally representative US nursing homes.

SETTING/PARTICIPANTS

Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation.

RESULTS

Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics.

CONCLUSION

The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.

Immune Response Resetting in Ongoing Sepsis

Cure of severe infections, sepsis, and septic shock with antimicrobial drugs is a challenge because morbidity and mortality in these conditions are essentially caused by improper immune response. We have tested the hypothesis that repeated reactivation of established memory to pathogens may reset unfavorable immune responses. We have chosen for this purpose a highly stringent mouse model of polymicrobial sepsis by cecum ligation and puncture. Five weeks after priming with a diverse Ag pool, high-grade sepsis was induced in C57BL/6j mice that was lethal in 24 h if left untreated. Antimicrobial drug (imipenem) alone rescued 9.7% of the animals from death, but >5-fold higher cure rate could be achieved by combining imipenem and two rechallenges with the Ag pool (p < 0.0001). Antigenic stimulation fine-tuned the immune response in sepsis by contracting the total CD3⁺ T cell compartment in the spleen and disengaging the hyperactivation state in the memory T subsets, most notably CD8⁺ T cells, while preserving the recovery of naive subsets. Quantitative proteomics/lipidomics analyses revealed that the combined treatment reverted the molecular signature of sepsis for cytokine storm, and deregulated inflammatory reaction and proapoptotic environment, as well as the lysophosphatidylcholine/phosphatidylcholine ratio. Our results showed the feasibility of resetting uncontrolled hyperinflammatory reactions into ordered hypoinflammatory responses by memory reactivation, thereby reducing morbidity and mortality in antibiotic-treated sepsis. This beneficial effect was not dependent on the generation of a pathogen-driven immune response itself but rather on the reactivation of memory to a diverse Ag pool that modulates the ongoing response.

Drug Management in End-of-Life Hospitalized Palliative Care Cancer Patients: The RHESO Cohort Study

OBJECTIVE

Little data about the management of drugs in terminally ill palliative care cancer patients is available. The present study aimed at describing the evolution of anticancer and non-anticancer treatments (NACTs) in cancer patients in palliative care units. The second objective was to identify factors leading to the medical decision to withdraw or not NACTs.

METHODS

Data from 1,091 cancer patients hospitalized in palliative care units were prospectively collected in 2010-2011, through a multicenter, observational French cohort.

RESULTS

The median overall survival after admittance in palliative care units was 15 days. Specific anticancer treatments were systematically stopped in the first 24 h in palliative care units, but for 4.5% of patients. Regarding NACTs, patients were heavily treated with strong opioids (74%), corticosteroids (51%), and antidepressants (21.8%) until death. Antiulcer agents (63.4%), antibiotics (25.7%), thrombosis prevention (21.8%), antidiabetics (7.6%), and transfusions (4%) were often also continuously prescribed. In multivariate analysis, ECOG PS 4 was an independent predictor of continuous prescription of morphine and an independent predictor of discontinuation of corticosteroids, proton-pump inhibitors, antidiabetics, and preventive anticoagulant therapy. Infection symptoms independently predicted continuous prescription of paracetamol. Paralysis and cancer palpable mass independently predicted corticosteroid withdrawal. Brain metastases independently predicted antiulcer withdrawal. Hemorrhage independently predicted preventive anticoagulant withdrawal. Availability to a venous access independently predicted paracetamol and antiulcer continuous prescriptions. Co-prescriptions independently predicted continuous prescriptions (antibiotics with antiulcer, antifungals with antibiotics) or withdrawal (preventive anticoagulant with antiplatelets and antifungals).

CONCLUSIONS

NACT prescription remained commonplace in terminally ill palliative cancer patients, although their benefit is questionable.

Current opinion about antimicrobial therapy in palliative care: an update

PURPOSE OF REVIEW

The review englobes the latest studies published regarding the problem of antimicrobial usage with palliative intent.

RECENT FINDINGS

In the advanced stages of illness like cancer, dementia, or neurodegenerative diseases, important decisions have to be made concerning the global treatment plan. Infections are very common among this kind of patients as they typically have multiple comorbidities and are incapacitated. These infections, in a majority of the cases, will be treated with antimicrobial therapy because this is a standard medical procedure. For a health professional, the decision of whether to treat, withhold, or withdraw a treatment can be difficult. In fact, in palliative care, the challenge is to balance compassionate care for people suffering from end-of-life diseases with the need for responsible antibiotic usage. Antimicrobial treatment could alleviate symptoms from an infection and make patients more comfortable, on the other hand, its overuse of it could bring a broader public health risk.

SUMMARY

On the contrary, in 18 months there are few studies about this problem, what reveals no concern about the use of antimicrobians in end-of-life patients.