Treatment of Positive Urine Cultures at End-of-Life and the Effect on Terminal Delirium Management

Abstract

Background: The decision to initiate antibiotics in hospice patients that are very near end-of-life is a complex ethical and stewardship decision. Antibiotics may be ordered to improve urinary tract infection–related symptoms, such as delirium. However, infection symptoms may be managed using antipsychotics, antipyretics, antispasmodics, and analgesics instead. Currently, there are no studies that compare symptom management between those who receive antibiotics and those who do not. Methods: A retrospective chart review was conducted for patients admitted to a hospice inpatient unit. Charts were included if the patient was admitted for delirium and had a Palliative Performance Scale score ≤40%, the urine culture was positive for organism growth, and the patient died while in the HIU. Clinical and demographic data was collected. Medication use was tallied for the 5 days prior to the date of death. Results: Sixty-one charts met the inclusion criteria. Thirty-five patients received antibiotics (ABX+) and 26 did not (ABX−). There was no difference in any medication consumption between groups during the 5 days prior to death. The ABX+ group died 8.2 days after obtaining the urine sample vs 6 days ( P =0.046). The ABX+ group had more documented urinary tract–specific infection symptoms (66% vs 38%, P =0.042). More than half of antibiotic courses were discontinued prematurely. Conclusion: The results of this study do not show a difference in overall medication consumption between groups, which suggests that antibiotics may not help improve terminal delirium symptoms in those with a suspected urinary tract infection at end-of-life.

Comment on “Treatment of Positive Urine Cultures at End-of-Life and the Effect on Terminal Delirium Management”

“…The issue raised by Latuga et al in their last article is vital regarding the seek for the best approach in patients with terminal delirium. 1…”

“…The issue raised by Latuga et al in their last article is vital regarding the seek for the best approach in patients with terminal delirium. 1 Main conclusion is that treatment of a suspected urinary tract infection may not improve delirium in hospice patients that are very near end-of-life, because it doesn't decrease the need of benzodiazepines and antipsychotics. As this is the first study that compares symptoms in an antibiotic treated group to a non-treated group, this work should be analysed with great attention.…”

“…If we look carefully at Latuga et al study, around half of empiric regimens were ordered as a short 2 or 3-day course. 1 This discussion raises the question if it is licit to make use of antibiotics as a short "therapeutic trial" and then to evaluate the change in the patient's behaviour.…”

Author Reply to Comment on “Treatment of Positive Urine Cultures at End-of-Life and the Effect on Terminal Delirium Management”

“…We appreciate the feedback on our recent article 1 examining antibiotic use in patients experiencing terminal delirium. Both infections and delirium are frequent burdensome symptoms to patients at end-of-life that often overlap in presentation.…”

Urinary tract infections in palliative care

“…Jednak ze względu na wysoki odsetek bezobjawowej bakteriurii u pacjentów w wieku podeszłym, w diagnostyce różnicowej należy rozwa- żyć inne przyczyny powyższych stanów, zwłaszcza jeśli w wywiadzie i badaniu fizykalnym brak współistniejących objawów ze strony układu moczowego i ogólnoustrojowych objawów infekcji. Nie wykazano, aby leczenie bezobjawowej bakteriurii miało istotny wpływ na ustąpienie delirium u osób starszych [64,65]. Gdy w przebiegu ZUM dojdzie do urosepsy, mogą wystąpić: tachykardia, tachypnoe, nudności i wymioty, bolesność i napięcie brzucha, wstrząs.…”