Examining Antibiotic Use During End of Life

Striking the right balance between addressing patient needs who have infections and addressing antimicrobial stewardship can be challenging for providers caring for patients at the end of life (EOL) phase. Without the benefit of a specified treatment protocol for EOL, practitioners are left to use their own judgement to decide how to proceed.

Certainly, practitioners want to keep their patients’ best interests in mind, especially comfort as a priority. In 1 survey, an overwhelming majority of practitioners said they prescribed their patients’ medicines in almost all EOL situations. And in fact, 88-100% of physicians started EOL patients on antibiotics in all situations, except for when the patients exhibited advanced dementia (45%).¹

A group of investigators decided to examine the estimated antibiotic use during the last 6 months of life for patients under hospice or palliative care. The investigators wanted to identify potential targets (time points) during the EOL period where antimicrobial stewardship interventions could be targeted for maximal benefit. This large retrospective national cohort study of Veterans Affairs (VA) patients was done over a 5 year period (2014-2019) with those who had been hospitalized within 6 months prior to death.

The investigators used electronic medical records data collecting demographics, comorbid conditions, and duration of inpatient antibiotics administered, as well as outpatient antibiotics dispensed. They used a propensity-score matched-cohort analysis to compare antibiotic use between patients placed into palliative care or hospice matched to patients not receiving palliative care or hospice. Repeated measures ANOVA and repeated measures linear regression methods were used to analyze difference in difference (D-I-D) of Days of Therapy (DOT) between the two cohorts.

“Overall, 77% (18,296/23,746) of hospice patients, and 80% (71,812/89,768) of palliative care patients received at least one antibiotic, while 69% (95,167/138,308) of those not placed in hospice or not receiving palliative care received antibiotics,” the investigators reported.

And in addition, in the cohort analysis they compared patients placed into hospice or palliative care to propensity-score matched controls. Those in palliative care were associated with a 11% absolute increase in prescribing antibiotics and those in hospice were associated with a 4% absolute increase during the 7-14 days post-entry vs pre-entry period.

“We observed that patients receiving EOL care have high levels of antibiotic exposure across VA population particularly on entry to hospice or during admissions when they receive palliative care consultation,” the investigators concluded.

The study, “Antibiotic use in end-of-life care patients: a nationwide Veterans Health Administration cohort study,” was presented on April 12 during the Society for Healthcare Epidemiology of America Conference 2022 (SHEA).

Reference

Crispim DH, da Silva IO, de Carvalho RT, Levin AS. End-of-life use of antibiotics: a survey on how doctors decide. Int J Infect Dis. 2022;114:219-225. doi:10.1016/j.ijid.2021.10.026