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

Abstract

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.

Aspectos éticos frente al inicio o la suspensión de terapia antibiótica en pacientes al final de la vida

“…Dentro de las opciones para lograr el adecuado control sintomático, se ha planteado el uso de antibióticos como una alternativa y algunos estudios han encontrado que entre el 64 y el 84 % de los pacientes con cáncer avanzado hospitalizados reciben manejo con antibiótico durante la última semana de vida (Goghari et al 2020), esto debido a la alta prevalencia de infecciones en este periodo que pueden relacionarse con las complicaciones propias de la enfermedad (necrosis tumoral, úlceras tumorales, aumento de secreciones bronquiales, entre otras) y con otras condiciones relacionadas como la desnutrición, la polifarmacia, la inmunosupresión, el inmovilismo crónico, la presencia de catéteres y dispositivos externos, entre otros (López 2021); pero también, porque se ha reportado que el inicio de manejo antibiótico contribuye a un mejor control de algunos síntomas emergentes dentro de los que se encuentran la fiebre, el dolor, la alteración de la esfera mental y la disnea, por lo que cerca del 50 % de los pacientes que son tratados con antibióticos al final de la vida lo reciben de forma empírica (Rosenberg et al 2013).…”

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

“…[11][12][13] To our knowledge, there is no high-level evidence to support antimicrobial use for relief of distressing symptoms, with the exception of pain secondary to urinary tract infection at EOL (prescriptive use poorly defined). 3,4,[14][15][16] Furthermore, when a patient's prognosis is estimated as weeks-to-months, there is little data to support survival benefits, 5,17 and conversely, continued use for those imminently dying may hasten death. 16 Frequent and long-term use of broad-spectrum antimicrobials at the EOL can cause adverse drug events (e.g., diarrhea, endorgan toxic effects, venous access complications, infection control consequences).…”

“…22 Antimicrobials can also increase the administration of unnecessary invasive testing, such as blood cultures or radiological imaging. 4,23,24 EOL antimicrobial use is associated with longer hospital length of stays, barriers to accessing communitybased or hospice services, and myriad other clinician and financial costs to patients and health organizations. 4,[24][25][26][27] The absence of consistent guidelines for antimicrobial stewardship in cancer patients at EOL leads to prescriber variation.…”

“…4,23,24 EOL antimicrobial use is associated with longer hospital length of stays, barriers to accessing communitybased or hospice services, and myriad other clinician and financial costs to patients and health organizations. 4,[24][25][26][27] The absence of consistent guidelines for antimicrobial stewardship in cancer patients at EOL leads to prescriber variation. Examining the covariates of EOL antimicrobial use may support the development of training and clinical interventions to promote evidence-based practice, prevent avoidable harm, and reduce unnecessary spending while enhancing goal-concordant EOL care.…”

“…The majority of patients with cancer receive antimicrobials during terminal admissions, in palliative care units, and at the time surrounding death-even in the absence of infection. [1][2][3][4][5][6][7][8] In fact, one systematic review reported that more than 50% of patients with advanced cancer at the end of life (EOL) received antimicrobials (n = 15 studies). 2 Prophylactic and empiric antimicrobial use is common in cancer patients due to immunocompromised states and resultant non-specific signs of infection.…”