Reduction in antimicrobial use among medical intensive care unit patients during a cluster randomized crossover trial of palliative care consultation

Abstract

To the Editor-Intensive care units (ICUs) are one of the largest consumers of antimicrobials, with >70% of patients of receiving antimicrobials on a given day. 1 With the continuing emergence of difficult to treat, costly, and deadly multidrug-resistant pathogens, antimicrobial stewardship strategies to reduce antimicrobial use are urgently needed. 2,3 Patients at the end of life are often cared for in ICUs and frequently receive antimicrobials 4 with uncertain benefits. 5 We recently conducted a cluster randomized crossover trial of early palliative care consultation in our medical ICUs, 6 with the goal of determining the impact of early palliative care interventions on outcomes of medical ICU patients. The purpose of the current investigation was to determine whether palliative-care consultation in our medical ICU resulted in reduced antimicrobial use at the end of life. MethodsThe details of the trial have recently been described. 6 Briefly, the trial was a single-center cluster randomized crossover trial (August 2017-May 2018) at Barnes-Jewish Hospital (1,250 beds). The study included a 6-week washout period halfway through the study, followed by crossing over to intervention or usual care of the 2 medical ICUs. The Washington University School of Medicine Human Studies Committee approved this investigation, and the need for informed consent was waived (Institutional Review Board no. 201707067; ClinicalTrials.gov Identifier: NCT03263143). All patients admitted on weekdays that were ≥18 years of age and at high risk for morbidity and mortality based on predetermined palliativecare screening criteria could be enrolled as long as they did not meet exclusion criteria. 6 Patients in the intervention arm received palliative-care consultation within 48 hours of ICU admission, and the control arm received standard of care with palliative-care consultation at the discretion of the treating physicians.Collected data included sociodemographic data; medical comorbidities; laboratory results; changes in resuscitation preferences; length of stay; duration and use of mechanical ventilation, vasopressors, and antimicrobials; place of discharge; mortality during the hospital stay; and antimicrobial prescriptions at discharge. Days of antimicrobial therapy were calculated by adding the total number of calendar days of each administered antimicrobial agent. Only antimicrobials with antibacterial properties were considered.The primary outcome of the current investigation was the proportion of patients receiving antimicrobial prescriptions at hospital discharge among those who did and did not change their resuscitation preference. Our secondary outcomes were total duration of inpatient and outpatient antimicrobials. We compared discharge on antimicrobials between groups using the χ 2 test and duration of inpatient antimicrobials using the Mann-Whitney U test. All statistical analyses were performed using SPSS version 25 software (IBM, Armonk, NY).

Antibiotic use during end-of-life care: A systematic literature review and meta-analysis

“…Overall, 33 studies documented patients in EOL care classified as a "mixed population" (Supplementary Table 3). Most studies were conducted at an academic medical center (19 studies) 54,56,57,[60][61][62]64,65,67,70,[73][74][75][76][77]80,81,84,86 or a hospice, home care, or nursing home (9 studies). 55,59,66,68,71,79,82,85 The EOL care period definition varied from the 12 hours prior to death in 1 study 80 to 6 months in 2 studies.…”

“…54 Most of the included studies were retrospective studies (27 studies), [54][55][56]58,59,61,62,[64][65][66][68][69][70][71][72][73][74][75][76][77][78]80,81,[83][84][85][86] prospective cohort studies (3 studies), 57,63,82 or cross-sectional studies (2 studies), 67,79 and 1 study was a randomized clinical trial. 60 In combination, these studies included 13,028 patients with different terminal illnesses. Also, 11 studies were restricted to cancer and other terminal illness (eg, COPD) 58,59,63,65,70,71,[73][74][75]78,86 and 10 studies were restricted to patients with cancer or advanced dementia or with other terminal illness (eg, heart failure or chronic renal failure).…”

“…54,55,57,62,64,67,69,77,79,83 Other studies included COPD patients (2 studies), 81,84 cystic fibrosis patients (2 studies), 76,80 patients with stroke (1 study), 56 patients with amyotrophic lateral sclerosis (1 study), 85 elderly patients (1 study), 71 elderly patients with and without dementia (1 study), 82 and 4 studies did not report underlying conditions. 60,61,66,68 In 24 studies for which data were available (72.7%), more than a half of patients (58.4%, 7,607) in the "mixed population" were referred to palliative care. 56,[59][60][61][62][63][64][65][66][67][68][69][70][71][73][74][75][76][80][81][82][83][84][85][86] In 21 studies, >50% of patients received antibiotics during their EOL per...…”

“…60,61,66,68 In 24 studies for which data were available (72.7%), more than a half of patients (58.4%, 7,607) in the "mixed population" were referred to palliative care. 56,[59][60][61][62][63][64][65][66][67][68][69][70][71][73][74][75][76][80][81][82][83][84][85][86] In 21 studies, >50% of patients received antibiotics during their EOL period. 54,56,57,[59][60][61][62][63][64][72][73][74][75][76] Also, 23 studies did not report the antibiotic route of administration, [55][56][57][58][60][61]…”

“…83 Microbiological cultures were requested before antibiotics were prescribed in 8 studies, 59,[62][63][64]67,83,84,86 and 25 of these studies did not report microbiological data. [54][55][56][57][58]60,61,65,66,[68][69][70][71][72][73][74][75][76][77][78][79][80][81][82]85 Only 6 studies examined whether the use of antibiotics was associated with beneficial outcomes (ie, comfort), 63,65,71,73,83,86 and 1 study evaluated survival and comfort as beneficial outcome due to antibiotic prescription. 59 Most of these studies (26 studies) did not report any outcome associated with antibiotic prescriptions.…”