Antimicrobial therapy in palliative care: an overview

Macedo, Filipa; Nunes, Catarina; Ladeira, Kátia; Pinho, Filipa; Saraiva, N.; Bonito, Nuno; Pinto, Luísa; Gonçalves, F.

doi:10.1007/s00520-018-4090-8

Cited by 42 publications

(56 citation statements)

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“…Moreover, the treatment of overt infections or fever in neutropenic and other severe immune-compromised patients require the use of broad spectrum antimicrobials early on, before the identification of the etiological agent, and often in combination, higher doses, and longer time as compared with the immune competent patient for the very same clinical disease presentation (98)(99)(100)(101)(102)(103)(104)(105)(106)(107)(108)(109)(110)(111)(112)(113). Cure of severe infections and sepsis with antimicrobial drugs in terminal immune compromised patients is virtually unachievable (114)(115)(116). Finally, in poor income populations, malnutrition may act synergistically with circumstantial factors, such as lack of sewerage, drinkable water, and protection to environmental aggression, to compromise fitness and functionality of the immune system, decreasing the efficiency of antimicrobial drugs (117,118).…”

Section: Discussionmentioning

confidence: 99%

Immune Response Resetting in Ongoing Sepsis

Nowill

Fornazin

Spago

et al. 2019

The Journal of Immunology

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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.

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Section: Discussionmentioning

confidence: 99%

Immune Response Resetting in Ongoing Sepsis

Nowill

Fornazin

Spago

et al. 2019

The Journal of Immunology

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“…The use of antibiotics in the last week of life was high in all countries, from one in ten in Belgium to four in ten in Poland. There is an ongoing debate on the indications for antibiotics at the end of life (47,48) and guidelines on antimicrobial stewardship in palliative care do not yet exist (48). While some researchers consider antibiotic treatment in the last days of life to be pointless (49)(50)(51), others consider it part of symptom control (52).…”

Section: What This Paper Addsmentioning

confidence: 99%

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

Honinx

Block

Piers

et al. 2021

Journal of Pain and Symptom Management

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ContextCertain 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. ObjectivesTo 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. MethodsA 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. ResultsWe included 1,384 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%). ConclusionAlthough 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 2 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.

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“…These studies did not have control groups and their methodology was heterogeneous. 3 Ethical dilemmas 12 -15 and challenges with study design may be barriers to randomized studies looking into outcomes for antimicrobial prescribing for this population. 3 Although lacking strong evidence, other studies have suggested that, excluding UTIs, treatment of infections (known or suspected) rarely improves symptoms for hospice patients.…”

Section: Introductionmentioning

confidence: 99%

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

Lopez

Vyas

Malhotra

et al. 2020

Am J Hosp Palliat Care

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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.

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Antimicrobial therapy in palliative care: an overview

Cited by 42 publications

References 50 publications

Immune Response Resetting in Ongoing Sepsis

Immune Response Resetting in Ongoing Sepsis

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

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

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