Retrospective analysis of antibiotic use and survival in advanced cancer patients with infections

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.

End-of-Life Infections and the Dilemma of Emerging Antimicrobial Resistance: A Scoping Review

The goals of antimicrobial treatment of end-of-life (EOL) infections are variously defined, raising complex questions about the management futility, ethical aspects, psychosocial burden, and the risk of emerging antimicrobial resistance. The author searched PubMed, Scopus, and Web of Science databases to retrieve relevant articles published from May 1, 2000, to April 30, 2024, on EOL infections and emerging multidrug-resistant organisms. The titles and abstracts of retrieved articles were screened, duplicate records were excluded, and the eligibility of selected papers was assessed. Sixty-one articles were included; the prevalence of EOL infections and antimicrobial therapy were calculated, the common sites and characteristics of EOL infections were identified, and the extent of emerging multidrug-resistant organisms among EOL patients, especially the "superbugs" ones, were estimated. The review indicates that infections are common in terminally ill patients, the prevalence of irrational antimicrobial prescriptions is high globally, with antimicrobials frequently administered until death. Limited data regarding antimicrobial resistance are available, and they cover short periods, while many of those patients survive longer with modern healthcare and become an essential reservoir for emerging multidrug-resistant organisms. This underscores the importance of antimicrobial stewardship programs and the urgent need for further research in this often-overlooked study area.

Current trends in antimicrobial use and the role of antimicrobial stewardship in palliative oncology: a narrative review

BACKGROUND

The overuse of antimicrobials is prevalent in palliative oncology care, with up to 86.9% of terminal cancer patients receiving these agents during end-of-life care. This overutilization stems from recurrent infections due to immunosuppression, malnutrition, and frequent hospitalizations, as well as difficulty differentiating infection-related symptoms from cancer-related complications.

DISCUSSION

Antimicrobial use in palliative cancer care offers limited symptomatic relief while posing significant risks, including Clostridioides difficile infections, multidrug resistance, and patient dissatisfaction. The lack of clear survival benefit highlights the need for judicious antimicrobial use, particularly in terminally ill patients. Effective antimicrobial stewardship strategies, such as integrating infection management into goals-of-care discussions, early referrals to specialized palliative care teams, and implementing early intravenous-to-oral antimicrobial switches, are critical for balancing patient comfort and minimizing unnecessary antibiotic exposure.

CONCLUSION

Optimizing antimicrobial use in palliative oncology care requires a multidisciplinary approach that prioritizes patient-centered goals, minimizes harm, and addresses misconceptions about antibiotic efficacy in end-of-life care. Antimicrobial stewardship programs, when tailored to palliative settings, play a vital role in reducing overuse and improving care quality in this vulnerable patient population.

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.

[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.

Infections in hospitalised patients affected by end-stage diseases: a narrative overview

AIM

To analyse the presence and treatment of infections in hospitalised terminal patients by identifying potential risk factors.

METHODS

We conducted a retrospective study using health data from 229 terminally ill patients (evaluated by our hospital palliative care team (HPCT) hospitalised from January to December 2018.

RESULTS

A total of two types of infections were identified: blood flow infection (through blood cultures) and pneumonia (through radiological examinations), while the other cases of infection remained unknown. The most frequently identified microorganism was Staphylococcus spp. The prevalence of infections was higher in patients with non-oncological diseases (n=47, 36.7%; p value 0.009). The potential risk factors identified for infections were the presence of: Parkinson's disease (n=15, 11.7%; p value 0.005), dysphagia (n=49, 38.3%; p value 0.007), bedding (n=15, 11.7%; p value 0.048), pressure ulcers (n=31, 24. 2%); p value 0.018), oxygen therapy (n=60, 46.9%; p value 0.050), urinary catheters (n=95, 74.2%; p value 0.038) and polypathology (2.3 vs 1.7; p value 0.022). Parkinson's disease (OR=5.973; 95% CI=1.292-27.608), dysphagia (OR=2.090; 95% CI=1.080-4.046) and polypathology (OR=1.220; 95% CI=1.015-1.466) were confirmed by a corrected logistic regression analysis.

CONCLUSIONS

Infections and, consequently, antibiotic therapies, have a high prevalence in hospitalised patients with terminal disease. Potential risk factors for infections in these patients could be polypathology, dysphagia and Parkinson's disease. Patients with these conditions could benefit from prevention programmes.

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.

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.

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.

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.

A Multicenter Cohort Study to Explore Differentiating Factors between Tumor Fever and Infection among Advanced Cancer Patients

Background: Tumor fever and infection are common febrile etiologies among advanced cancer patients. To date, only few studies have been conducted to differentiate between tumor fever and infections. Objective: This study aimed to identify discriminating factors that provide rapid results and are feasible and minimally invasive for discriminating between tumor fever and infection in advanced cancer patients. Methods: This is a retrospective cohort study. Advanced cancer patients with clinically diagnosed tumor fever or infection, who received medical treatment from palliative care specialists in 10 nationwide Japanese hospitals, were consecutively identified during August 2012 and November 2014. The symptoms, physical findings, blood test results at baseline and during fever, imaging findings, and sociodemographic factors of these patients were retrospectively extracted. Results: Thirty-three patients with tumor fever and 72 patients with infection were identified. Their mean age was 68.8 years, 68 (64.8%) were men, and the median palliative performance status (PPS) was 50. Statistically significant factors predicting tumor fever by logistic regression analysis were as follows: deterioration of PPS (odds ratio, 0.078), shaking chills during fever (0.067), and change from baseline data of neutrophil/lymphocyte ratio of ≥5 (0.14). Conclusions: Shaking chills during fever, and changes from baseline of performance status and white blood cell differentiation can be useful to differentiate between tumor fever and infection among advanced cancer patients. Further confirmatory studies are needed.

Variations in Physician Orders for Life-Sustaining Treatment Program across the Nation: Environmental Scan

Background: Physician Orders for Life-Sustaining Treatment (POLST) is an advance care planning tool that is designed to document end-of-life (EoL) care wishes of those living with limited life expectancies. Although positive impacts of POLST program has been studied, variations in state-specific POLST programs across the nation remain unknown. Objective: Identify state variations in POLST forms and determine if variations are associated with program maturity status. Design: Environmental scan. Measurements: Using the national POLST website, state-specific POLST program characteristics were examined. With available sample POLST forms, EoL care options were abstracted. Results: Of all 51 states (50 United States states and Washington, D.C examined), the majority (n = 48, 98%) were actively participating in POLST; 3 states (5.9%) had Mature status, 19 states and District of Columbia (39.2%) were Endorsed, 24 states were in the developing phase (47.1%), and 4 states (7.8%) were nonconforming. Forty-five states (88.2%) had forms available for review. Antibiotic and intravenous fluid options were identified in 32 (71.1%), and 33 (73.3%) POLST forms, respectively. Hospital transfer and use of oxygen were mentioned in all forms. Use of respiratory devices (i.e., continuous positive airway pressure and bi-level positive airway pressure) were mentioned on 27 (60%) forms, whereas ventilator or intubation use were mentioned in 36 POLST forms (80%). No associations were found between POLST maturity status and provision of treatment options. Conclusions: Variations in integration of infection and symptom management options were identified. Further research is needed to determine if there are regional factors associated with provision of treatment options on POLST forms and if there are differences in actual rates of infection or symptoms reported.

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 Use in Patients on a Comfort Care Protocol: A Retrospective Cohort Study

BACKGROUND

Antimicrobials are commonly used in patients near the end of life, but the percentage and predictors of patients prescribed antibiotics while hospitalized on a comfort care protocol are unknown.

OBJECTIVE

To determine how often patients in the acute care setting are continued on antimicrobials when they are transitioned to comfort-focused care and to describe patient characteristics correlated with antimicrobial use.

DESIGN

Retrospective cohort study conducted from June 2012 to August 2014.

SETTING

Two interrelated academic medical centers.

PATIENTS

Inpatients >18 years old transitioned to a comfort care protocol.

MEASUREMENTS

Administration of antimicrobials to patients on the comfort care protocol.

ANALYSIS

We generated descriptive statistics and used a modified Poisson regression to estimate unadjusted and adjusted associations along with 95% confidence intervals (CIs) and p-values.

RESULTS

There were 1881 patients included in the study; 77% of patients ultimately transitioned to a comfort care protocol received antimicrobials during their admission and 82% died in hospital. Of the 711 alive at ≥24 hours after comfort care orders, 111 (15.6%) were still on antimicrobials. After adjusting for age, a documented infection was positively associated with being on antibiotics (adjusted relative risk [ARR] = 1.46, 95% CI: 1.00-2.12, p = 0.05). Patients in the medical and surgical intensive care units (ICUs) were less likely than those on medicine to receive antimicrobials (MICU ARR = 0.32, 95% CI: 0.14-0.72, p = 0.01; SICU/Neuro ARR = 0.32, 95% CI: 0.12-0.85, p = 0.02).

CONCLUSIONS

Antimicrobial use is relatively high in hospitalized patients near the end of life, even when the goal is comfort.

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.

Antimicrobial use at the end of life among hospitalized patients with advanced cancer

BACKGROUND

We sought to evaluate antimicrobial use among patients with advanced cancer.

METHODS

Retrospective review of patients experiencing cancer-related death while hospitalized.

RESULTS

Among 145 patients, 126 (86.9%) received antimicrobials for a mean of 12.5 ± 12.9 days. 88 (69.8%) of 126 had clinical findings suggestive of infection. Sixty-one patients (48.4%) had positive cultures, the remaining were treated empirically. "Comfort care" was ultimately pursued in 99 (78.5%) of 126; 35 (35.4%) of 99 continued to receive antimicrobials after a transition to comfort care for an average of 1.6 ± 1.1 days. On average, antimicrobials were discontinued <1day prior to death.

CONCLUSION

Antimicrobial use was common among patients with advanced cancer. Even after transition to comfort care, more than one third of patients remained on antimicrobials. The risks and burdens of antimicrobials should be carefully examined when comfort is the stated goal.

The Pattern of Antimicrobial Use for Palliative Care In-Patients During the Last Week of Life

Background: In terminally ill cancer patients approaching the dying phase, liberal use of antimicrobials is often viewed by palliative care experts as irrational. No previous reports have reviewed current antimicrobial use in palliative care settings in Saudi Arabia. Objective: The objective of this study was to explore the pattern of antimicrobial use in a tertiary palliative care unit (TPCU) during the last week of patients’ life. Methods: Medical records of all patients who died in the TPCU over a 14-month period were reviewed for demographics as well as the frequency and rationale of antimicrobial use during the patients’ last week of life. Information on antimicrobial use was obtained from a computerized pharmacy database. Results: Of 138 patients who died with advanced cancer in the TPCU, 87 (63%) were on one or more antimicrobials during their last week of life. Antibiotics were more frequently used as compared to antifungal and antiviral agents, 64 (46.4%); 45 (32.6%); and 2 (1.5%), respectively. About one third (31.3%) of patients who received antibiotics during their last week of life were prescribed more than one antibiotic. Antimicrobials were mostly given systemically (79%) rather than topically (21%). The most common rationales for antimicrobial prescribing were oral thrush in 36 patients (25.4%), wound care in 29 patients (20.4%), and on empirical basis in 29 patients (20.4%). Conclusions: The current practice of antimicrobial prescribing, especially for patients who are eminently dying, may need to be reviewed. Initiation of antimicrobial treatment in this group of patients should be based on clear treatment goals and desired outcomes, considering views of patients and families.

Antimicrobial use among patients receiving palliative care consultation

BACKGROUND

We sought to characterize antimicrobial use among patients receiving palliative care consultation.

METHODS

Retrospective review of patients seen by the Palliative Care Service at the University of Michigan Health System from January 2008 to May 2008.

RESULTS

Of 131 patients seen in consultation, 70 received antimicrobials. We identified 92 infections among these 70 patients; therapy for 54 (58.7%) was empiric. Empiric therapy was most commonly prescribed for respiratory infection and urinary tract infection. Piperacillin/tazobactam (P/T) was the most frequently used agent, with 26 patients receiving P/T (37.1%); 22 of 26 received this agent empirically (84.6%, P = .005). Vancomycin was prescribed to 23 patients (32.9%). Sixteen patients (22.9%) died in hospital; another 31 were enrolled in hospice care.

CONCLUSIONS

Our results suggest significant use of empiric, broad-spectrum antimicrobial therapy among hospitalized patients near the end of life. We advocate for careful assessment of potential benefits and treatment burdens of antimicrobial therapy, especially when palliation is the goal.

[Bacterial infections in palliative care: antibiotics and therapeutic limitations]

The benefits of antibiotics treatments are not obvious at the end of life except for the symptomatic urinary infections. The numerous antibiotics prescribed raise economic and ecological problems in terms of bacterial resistances development and also in terms of quality of life. The control of symptoms has to be the main indication to prescribe antibiotics at the end of life. It is the general state, the prognostic of the patient, his wishes and those of his family, and his symptoms, controlled or not, that direct the decision to prescribe an antibiotic. Physicians must consider the objective of antibiotic treatment, the risk of side effects and the constraints related to this treatment before prescribing it for terminally ill people. They have to respect the bioethical principles, primarily the principles of beneficence, non-maleficience, and the respect to autonomy of the patient. In the event of decision of an antibiotic treatment at a patient at the end of the lifetime, the choice of this one must answer obviously the same requirements as in the other medical situations, within the framework of comprehensive and rigorous process.

HTLV-1 tax-induced NF-kappaB activation is synergistically enhanced by 12-O-tetradecanoylphorbol-13-acetate: mechanism and implications for Tax oncogenicity

Nuclear factor kappa B (NF-kappaB) factors regulate a wide range of physiological and oncogenic processes. Normally, these factors are transiently activated by specific external signals which induce their dissociation from inhibitors of kappaB (IkappaB) and subsequent translocation to the nucleus where p65 links to the cyclic adenosine monophosphate response element binding protein (CBP)-p300 and P/CAF coactivators that are essential for its transcriptional activity. The pathogenic potential of human T-cell leukemia virus type 1 (HTLV-1) Tax protein is partly ascribed to its capacity to constitutively activate NF-kappaB factors because constitutive activity of these factors play an important role in the pathophysiology of adult T-cell leukemia (ATL) and tropical spastic paraparesis-HTLV-1 associated myelopathy (TSP-HAM). In assessing the possibility of modulating Tax pathogenic potential by external factors, we focused here on 12-O -tetradecanoylphorbol-13-acetate (TPA) which is a potent protein kinase C (PKC) activator. There are conflicting reports regarding the effect of TPA and PKC on NF-kappaB. Therefore, we reassessed this issue and also investigated their influence on Tax-mediated activation of these factors. We found that TPA promoted NF-kappaB nuclear translocation and the DNA binding of p65 dimers through PKC activation. However, both TPA and ectopically expressed PKC had only a marginal effect on the transcriptional competence of these dimers, indicating that the DNA binding of such dimers is insufficient by itself for gene activation. Notably, however, both TPA and the ectopic PKC displayed strong synergistic enhancement of the Tax-induced activation of the NF-kappaB transcriptional function. In contrast, TPA and the ectopic PKC only slightly elevated the low activation of the NF-kappaB transcriptional capacity by cytoplasmic Tax mutants, indicating that the nuclear translocation of Tax was essential for this synergism. Subsequent experiments suggested that TPA contributed to this synergism by increasing the pool of free p65 which Tax could link to CBP and elevate, thereby, the amount of a p65-Tax-CBP ternary complex that could bind to NF-kappaB-responsive promoters and stimulate their expression. Finally, we demonstrated that this synergism operated also in HTLV-1-infected human T-cells. Earlier reports have shown a close linkage of pathological PKC-activating conditions (e.g., infectious and inflammatory diseases) to certain malignancies. On this ground, the present study suggests that such conditions may enhance the risk for ATL and TSP-HAM in HTLV-1 carriers by increasing the Tax-induced NF-kappaB activation.