Antimicrobial use at the end of life: a scoping review

Abstract

ObjectiveTo 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.DesignScoping reviewData sourcesAn 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 selectionStudies reporting antibiotic use in patients approaching end of life in any setting and clinicians’ attitudes and behaviour in relation to antibiotic prescribing in this populationData extractionTwo 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.ResultsEighty-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.ConclusionsUse 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.

Trends of antibiotic use at the end-of-life of cancer and non-cancer decedents: a nationwide population-based longitudinal study (2006–2018)

“…14 Another retrospective study from a tertiary medical center during 2019-2021 reported that 96% of cancer patients received antibiotics, 76.5% received antibiotic combinations during EOL care, and 81.1% received antibiotics until death. 15 Regarding the factors of antibiotic use in patients nearing the EOL, literature reviews by Fairweather et al 16 and Macedo et al 17 reveal inconsistencies and challenges in antibiotic decision-making for EOL patients, driven by ethical and legal uncertainties. The unpredictability of death, even during EOL care, may raise concerns about the potential for reversing infectious diseases in terminally ill patients, and the complex nature of these patients' conditions often makes the diagnosis of infections difficult, if not impossible.…”

Antibiotic stewardship in Indian palliative care: a single-center retrospective study

“…A 2020 scoping review suggests that antibiotics do provide a limited survival benefit to some patients nearing the end of life and may also mitigate symptoms associated with certain infections such as urinary tract infections; however, these benefits may come at the cost of prolonging the dying process, compounding adverse effects, and promoting antibiotic resistance. 22 Existing stewardship guidelines including AOF guidelinesdo not typically reflect the challenges surrounding prescription decisions at the end of life, ultimately limiting their use among terminally ill patients. Therefore, a focus for future stewardship efforts may be to develop guidance to help providers navigate discussions surrounding antibiotic use at the end of life.…”

The Trial to Reduce Antimicrobial Use in Nursing Home Residents With Alzheimer Disease and Other Dementias (TRAIN-AD)

“…Multicomponent nursing home interventions that have been tested in randomized clinical trials (RCTs) and have been shown to reduce antimicrobial use have not been adopted into practice. Despite the need to align antimicrobial use at the end-of-life with goals of care, efforts to improve infection management in nursing homes have not integrated infectious disease and palliative care principles nor have they focused on residents with advanced dementia.…”