Perceptions and Reality of Antimicrobial Prescribing During the Transition to Comfort Measures Only at an Academic Medical Center

Abstract

Background Little is known about antimicrobial prescribing when patient care is transitioned to CMO. We used a multi-disciplinary survey and retrospective cohort study to gain insight into antimicrobial prescribing in this population at an academic medical center to inform future antimicrobial stewardship interventions. Methods A survey focusing on antimicrobial prescribing during the transition to CMO was electronically distributed to providers in medical subspecialities and responses were compared across specialties. A retrospective chart review was performed of patients admitted to an academic medical center in 2020 who were on antimicrobials in the 48 hours prior to CMO. We investigated the percentage of patients who remained on antimicrobials after the transition to CMO and rationale for continuing antimicrobials. Results We received 113 survey responses (35% response rate). 41% of respondents indicated that they “sometimes” or “often” continued antimicrobials during the transition to CMO. Patient/family preference and symptom palliation were the most common factors cited by respondents when deciding whether to continue antimicrobials in this population. Of the 546 patient charts reviewed, 140 (26%) patients were alive 48 hours after CMO order, and 19 (14%) of those patients remained on antimicrobials. 5/19 (26%) patients had documentation that antimicrobials were continued due to patient/family preference and 5/19 (26%) patients had documentation that antimicrobials were continued for palliation of symptoms. Discussion Patient/family preference and symptom palliation are important factors in prescribing antimicrobials when patient care is transitioned to CMO. More evidence is needed regarding palliative benefits of antibiotics to inform provider discussions of benefits and harms of antimicrobial use in this setting.

When Should Patients at the End of Life Get Antimicrobials?

“…6,10 In addition, antimicrobial use at the EOL can be influenced by the desire to palliate symptoms, as well as by patient or family preferences. 11,12,13…”

How Should Focus Be Shifted From Individual Preference to Collective Wisdom for Patients at the End of Life With Antimicrobial-Resistant Infections?

“…5,16 Recent research on antimicrobial use at the end of life has focused on prescribing patterns and factors contributing to them rather than generating evidence-based interventions. 6,7,10,17,18,19 Antimicrobial drug overuse and misuse often result from clinicians' inadequate education about antimicrobial drug stewardship, 20 tendencies to…”

“…treat symptoms rather than identified microorganisms, 21 and yielding to patients' and families' non-evidence-based desires for treatment. 18,22 Antimicrobial treatments at the end of life persist despite the fact that they are often ineffective, do not alleviate symptoms, 7,8 and do not result in a significant increase in the quality or length of life. 23 It is imperative to implement systems to overcome these challenges.…”