Antimicrobial prescribing in patients with advanced-stage illness in the antimicrobial stewardship era

2018 ◽  
Vol 39 (9) ◽  
pp. 1023-1029 ◽  
Author(s):  
Yasuaki Tagashira ◽  
Kanae Kawahara ◽  
Akane Takamatsu ◽  
Hitoshi Honda
Keyword(s):  
End Of Life ◽  
Antimicrobial Stewardship ◽  
Symptom Relief ◽  
Terminally Ill ◽  
Study Cohort ◽  
Antimicrobial Use ◽  
Advanced Stage ◽  
Factors Associated ◽  
Terminally Ill Patients ◽  
Days Of Therapy

AbstractObjectiveAntimicrobials are frequently administered to patients with an advanced-stage illness. Understanding the current practice of antimicrobial use at the end of life and the factors influencing physicians’ prescribing behavior is necessary to develop an effective antimicrobial stewardship program and to provide optimal end-of-life care for terminally ill patients.DesignA 1-year retrospective cohort study.SettingA public tertiary-care center.PatientsThe study included 260 adult patients who were hospitalized and later died at the study institution with an advanced-stage illness.ResultsOf 260 patients in our study cohort, 192 (73.8%) had an advanced-stage malignancy and 136 (52.3%) received antimicrobial therapy in the last 14 days of their life; of the latter, 60 (44.1%) received antimicrobials for symptom relief. Overall antimicrobial use in the last 14 days of life was 421.9 days of therapy per 1,000 patient days. Factors associated with antimicrobial use in this period included a history of antimicrobial use prior to the last 14 days of life during index hospitalization (adjusted odds ratio [aOR], 4.86; 95% confidence interval [CI], 2.67–8.84) and antipyretic use in the last 14 days of life (aOR, 4.19; 95% CI, 2.01–8.71).ConclusionApproximately half of the patients hospitalized with an advanced-stage illness received antimicrobials in the last 14 days of life. The factors associated with antimicrobial use at the end of life in this study are likely to explain physicians’ prescribing behaviors. In the current era of antimicrobial stewardship, reconsidering antimicrobial use in terminally ill patients is necessary.

Aggressive End-of-Life Care and Symptom Relief Treatments in Terminally Ill Patients Who Had Discussed Withdrawal of Mechanical Ventilation: A Hospital-Based Observational Study

2020 ◽  
Vol 37 (11) ◽  
pp. 897-903
Author(s):  
Hsiao-Ting Chang ◽  
Ming-Hwai Lin ◽  
Chun-Ku Chen ◽  
Tzeng-Ji Chen ◽  
Shinn-Jang Hwang
Keyword(s):  
Mechanical Ventilation ◽  
Observational Study ◽  
End Of Life ◽  
End Of Life Care ◽  
Symptom Relief ◽  
Terminally Ill ◽  
Shared Care ◽  
Life Care ◽  
Terminally Ill Patients ◽  
The Status

Objective: The aim of this study was to explore the status of aggressive end-of-life care and symptom relief treatments in terminally ill patients who had discussed the withdrawal of mechanical ventilation. Methods: This research is a retrospective observational study based on a chart review. Terminal patients aged ≥20 years, who were intubated with mechanical ventilation support, who underwent hospice-shared care, and who personally, or whose close relatives, had discussed the withdrawal of mechanical ventilation with hospice-shared care team members in a tertiary hospital in Taiwan during 2012 to 2015 were included. Demographics, medical conditions, and aggressive end-of-life care, including hospitalization, use of vasopressors, artificial nutrition, tube feeding, antibiotics, and symptom relief treatments including the use of opioids, steroids, and sedatives, were identified. The modes of care and treatments of patients by the status of withdrawal of mechanical ventilation were compared. Results: A total of 141 patients had discussed the withdrawal of mechanical ventilation, and 111 (78.7%) had been withdrawn. Aggressive end-of-life care was noted in all patients regardless of mechanical ventilation status. There were no significant differences in the number and pattern of aggressive end-of-life care measures between patients who had or had not been withdrawn. There were significantly higher rates of symptom relief treatments used in patients who had been withdrawn. Conclusions: Aggressive end-of-life care is common for patients who have discussed the withdrawal of mechanical ventilation. There are significantly higher rates of symptom relief medications administered in patients who have been withdrawn from mechanical ventilation.

Morphine prescription to terminally ill patients with lung cancer and dyspnea: French physicians’ attitudes

2005 ◽  
Vol 1 (1) ◽  
pp. 25 ◽  
Author(s):  
Marc K. Bendiane, MSC ◽  
Patrick Peretti-Watel, PhD ◽  
Herve Pegliasco, MD ◽  
Roger Favre, PhD ◽  
Anne Galinier, MD ◽  
...  
Keyword(s):  
Lung Cancer ◽  
End Of Life ◽  
End Of Life Care ◽  
Terminally Ill ◽  
Life Care ◽  
Factors Associated ◽  
Terminally Ill Patients ◽  
Line Therapy ◽  
Back Ground ◽  
Analgesic Use

This study aimed to investigate factors associated with analgesic use of morphine in end-of-life care. French general practitioners (GPs) and oncologists (N = 719) were asked whether they would prescribe morphine asfirst-line therapy to patients with terminal lung cancer suffering from dyspnea associated with cough and great anxiety. Overall, 54 percent of oncologists and 40percent of GPs stated that they would prescribe morphine in the presented case. This prescriptive attitude correlated with physicians’ age, professional back-ground, communication skills, and attitude toward terminally ill patients. The findings of this study indicate that improving analgesic use of opioids in end-of-life care is not only a matter of enhancing technical skills acquired through training or experience but also a matter of improving communication and empathy between physicians and patients.

scholarly journals 139. association of Physician Orders for Life-sustaining Treatment (POLST) with Antimicrobial Use at End of Life in Cancer Patients: An Antimicrobial Stewardship Opportunity

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S199-S200
Author(s):  
Olivia Kates ◽  
Elizabeth M Krantz ◽  
Juhye Lee ◽  
John Klaassen ◽  
Jessica Morris ◽  
...  
Keyword(s):  
End Of Life ◽  
Cancer Patients ◽  
Symptom Management ◽  
Research Study ◽  
Antibiotic Use ◽  
Antimicrobial Use ◽  
Study Investigator ◽  
Days Of Therapy ◽  
Life Sustaining Treatment ◽  
Rate Ratios

Abstract Background IDSA/SHEA guidelines recommend that antimicrobial stewardship programs support providers in antibiotic decisions for end of life care. Washington State Physician Orders for Life-Sustaining Treatment (POLST) forms allow patients to indicate antimicrobial use preferences. We sought to characterize antimicrobial use in the last 30 days of life for cancer patients by presence of a POLST and antimicrobial use preferences. Methods We performed a single-center, retrospective cohort study of cancer patient deaths from January 1, 2016 - June 30, 3018. Patient demographics, clinical characteristics, POLST, and antimicrobial use within 30 days before death were extracted from electronic records. To test for an association between POLST completed at least 30 days before death and inpatient antimicrobial days of therapy (DOT) in the 30 days before death, we used negative binomial models adjusted for age, sex, race, and service line (hematologic versus solid malignancy); model estimates are presented as incidence rate ratios (IRR) with 95% confidence intervals (CI) Results Of 1796 patients, 406 (23%) had a POLST. 177/406 (44%) were completed less than 30 days before death, and 58/177 (32.8%) specified limited antibiotic use; 40/177 (23%) did not specify any antimicrobial use preference (Fig 1). Of 1295 patients with at least 1 inpatient day in the 30 days before death, 1070 (83%) received at least 1 inpatient antimicrobial with median DOT of 1077 per 1000 inpatient days (Tab 1). There was no difference in DOT among patients with and without a POLST > /= 30 days before death (IRR 0.92, CI 0.77, 1.10). Patients with a POLST specifying limited antibiotic use had significantly lower inpatient IV antimicrobial DOT compared to those without a POLST (IRR 0.64, CI 0.42–0.97) (Fig 2). Figure 1. Classification of Patients by Presence of POLST, Timing, and Antimicrobial Preference Content of POLST. Numbers shown represent the number of patients (percentage). Full antibiotic use refers to the selection “Use antibiotics for prolongation of life.” Limited antibiotic use refers to the selection “Do not use antibiotics except when needed for symptom management.” Table 1: Antimicrobial use for all patients and by advance directive group Figure 2. Forest plot of model estimates, represented as incidence rate ratios (IRR) with 95% confidence intervals (CI), for associations between POLST antimicrobial specifications completed at least 30 days before death and inpatient antibiotic days of therapy (DOT) in the 30 days before death. Estimates represent comparisons between each POLST category and no POLST completed at least 30 days before death. Dots represent the IRR and brackets extend to the lower and upper limit of the 95% CI. Blue estimates are for the inpatient antibiotic DOT outcome and red estimates are for the inpatient IV antibiotic DOT outcome. Conclusion POLST completion is rare > /= 30 days before death, with few POLSTs specifying antimicrobial use. Compared to those with no POLST in this time frame, patients who indicated that antibiotics should be used only for symptom management received significantly fewer inpatient IV antimicrobials. Early discussion of advance directives including POLST with specification of antimicrobial use preferences may promote more thoughtful use of antimicrobials near the end of life in a compassionate, patient-centered way. Disclosures Steven A. Pergam, MD, MPH, Chimerix, Inc (Scientific Research Study Investigator)Global Life Technologies, Inc. (Research Grant or Support)Merck & Co. (Scientific Research Study Investigator)Sanofi-Aventis (Other Financial or Material Support, Participate in clinical trial sponsored by NIAID (U01-AI132004); vaccines for this trial are provided by Sanofi-Aventis)

scholarly journals Effects of a Paediatric Antimicrobial Stewardship Program on Antimicrobial Use and Quality of Prescriptions in Patients with Appendix-Related Intraabdominal Infections

Antibiotics ◽  
2020 ◽  
Vol 10 (1) ◽  
pp. 5
Author(s):  
Sílvia Simó ◽  
Eneritz Velasco-Arnaiz ◽  
María Ríos-Barnés ◽  
María Goretti López-Ramos ◽  
Manuel Monsonís ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Broad Spectrum ◽  
Case Fatality ◽  
University Hospital ◽  
Antimicrobial Use ◽  
Stewardship Program ◽  
Days Of Therapy ◽  
Length Of Therapy ◽  
Intraabdominal Infections

The effectiveness of antimicrobial stewardship programs (ASP) in reducing antimicrobial use (AU) in children has been proved. Many interventions have been described suitable for different institution sizes, priorities, and patients, with surgical wards being one of the areas that may benefit the most. We aimed to describe the results on AU and length of stay (LOS) in a pre-post study during the three years before (2014–2016) and the three years after (2017–2019) implementation of an ASP based on postprescription review with feedback in children and adolescents admitted for appendix-related intraabdominal infections (AR-IAI) in a European Referral Paediatric University Hospital. In the postintervention period, the quality of prescriptions (QP) was also evaluated. Overall, 2021 AR-IAIs admissions were included. Global AU, measured both as days of therapy/100 patient days (DOT/100PD) and length of therapy (LOT), and global LOS remained unchanged in the postintervention period. Phlegmonous appendicitis LOS (p = 0.003) and LOT (p < 0.001) significantly decreased, but not those of other AR-IAI diagnoses. The use of piperacillin–tazobactam decreased by 96% (p = 0.044), with no rebound in the use of other Gram-negative broad-spectrum antimicrobials. A quasisignificant (p = 0.052) increase in QP was observed upon ASP implementation. Readmission and case fatality rates remained stable. ASP interventions were safe, and they reduced LOS and LOT of phlegmonous appendicitis and the use of selected broad-spectrum antimicrobials, while increasing QP in children with AR-IAI.

scholarly journals Facing Death: Attitudes toward Physician-Assisted End of Life among Physicians Working at a Tertiary-Care-Hospital in Israel

2021 ◽  
Vol 18 (12) ◽  
pp. 6396
Author(s):  
Keren Dopelt ◽  
Dganit Cohen ◽  
Einat Amar-Krispel ◽  
Nadav Davidovitch ◽  
Paul Barach
Keyword(s):  
End Of Life ◽  
Tertiary Care Hospital ◽  
Human Life ◽  
Tertiary Care ◽  
Terminally Ill ◽  
Background Information ◽  
Care Hospital ◽  
Medical Assistance In Dying ◽  
Terminally Ill Patients ◽  
The Right

The demand for medical assistance in dying remains high and controversial with a large knowledge gap to support optimal patient care. The study aimed to explore physicians’ attitudes regarding euthanasia and examine the factors that related to these attitudes. We surveyed 135 physicians working at a tertiary-care hospital in Israel. The questionnaire was comprised of demographic and background information, DNR procedure information, encounters with terminally ill patients, familiarity with the law regarding end-of-life questions, and Attitudes toward Euthanasia. About 61% agreed that a person has the right to decide whether to expedite their own death, 54% agreed that euthanasia should be allowed, while 29% thought that physicians should preserve a patients’ life even when they expressed the wish to die. A negative statistically significant relationship was found between the level of religiosity and attitudes toward euthanasia. The physicians’ attitudes towards euthanasia are quite positive when compared to other countries. The data shows a conflict of values: the sacredness of human life versus the desire to alleviate patients’ suffering. The Coronavirus-19 outbreak reinforces the importance of supporting physicians’ efforts to provide ethical and empathic communication for terminally ill patients. Future studies should aim to improve our understanding and treatment of the specific types of suffering that lead to end-of-life requests.

Facing Death in Medical Training

2017 ◽  
Vol 80 (3) ◽  
pp. 340-354 ◽  
Author(s):  
Asunción Álvarez-del Río ◽  
Ma. Luisa Marván ◽  
Julieta Gómez Avalos
Keyword(s):  
Medical Students ◽  
End Of Life ◽  
Medical Training ◽  
Terminally Ill ◽  
Medical Attention ◽  
Objective Data ◽  
Educational Activities ◽  
Terminally Ill Patients ◽  
Student Views ◽  
Impending Death

This study explores how medical students feel about caring for terminally ill patients as well as how their medical courses prepare them for addressing end-of-life (EOL) issues with patients. Four hundred and five Mexican medical students were surveyed through the Student Views on Death questionnaire. The vast majority of students (94%) felt that physicians should inform patients of their impending death. Most students said they felt comfortable talking with (61%) or examining (76%) terminally ill patients. However, only half the students actually talked with patients about death. Participants in our study were interested in learning about EOL medical attention, yet most considered themselves poorly prepared to offer this type of care to terminally ill patients. The study provides objective data on a topic that has scarcely been explored in Mexico, data that will be useful in designing educational activities to improve EOL medical training.

scholarly journals Preferences for place of care and place of death: What, how, when and who to ask?

2019 ◽  
Author(s):  
Katrin Gerber ◽  
BARBARA HAYES ◽  
CHRISTINA BRYANT
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Final Stage ◽  
Terminally Ill ◽  
Healthcare Systems ◽  
Place Of Death ◽  
Preference Assessments ◽  
Terminally Ill Patients ◽  
Key Questions

As healthcare systems worldwide are confronted with increasing numbers of ageing and terminally ill patients, the topic of where people want to spend their last days has received considerable attention. However, the strategies that researchers and clinicians use to capture these end-of-life views vary greatly in four key questions. These include: what, how, when and who to ask about location preferences. We will argue that how researchers and clinicians choose to answer these questions directly influences their findings. Based on these considerations, we will highlight ways to improve future palliative care and empirical end-of-life studies by addressing the precision, methods, timing and sources of preference assessments. Only when we are able to accurately identify where people want to spend their last days, can we begin to meet the needs of patients as they approach the final stage of their lives.

scholarly journals 1081. Use of Antimicrobials at the End of Life (EOL): A Retrospective Cohort Study Analyzing Providers’ Reasons for Prescribing Antimicrobials at the EOL, Their Benefits and Adverse Effects

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S383-S384
Author(s):  
Pooja Vyas ◽  
Prashant Malhotra ◽  
Santiago Lopez ◽  
Bruce Hirsch ◽  
Kayla D Finuf
Keyword(s):  
End Of Life ◽  
Symptom Relief ◽  
Symptom Control ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Antimicrobial Use ◽  
Care Hospital ◽  
Chi Square ◽  
Potential Benefits ◽  
Tract Infections

Abstract Background Infections are common in terminally ill patients, and although antibiotics are frequently prescribed, their benefit for symptom relief is not clear. Antimicrobials at the end of life (EOL) increase the risk of antimicrobial resistance and Clostridium difficile infection. Very few studies have described the risks and benefits of antimicrobials in patients at EOL. Here, we describe a retrospective chart review of antimicrobial use at EOL. Methods We reviewed electronic medical records of patients admitted in a palliative care unit of a tertiary care hospital between 2017 and 2018 and assessed antimicrobial use in the last 14 days of life. The analysis excluded neutropenic patients. Differences in demographics and symptom control between patients who did or did not receive antibiotics (AB+ or AB−) were analyzed using chi-square analyses; P-values were computed using Mann–Whitney tests. Results Of a total of 133 patients included, 89 (67%) received antimicrobials (AB+); however, the role of antibiotics was documented in only 12% of patients. The AB− and AB+ groups were similar with respect to demographics, including sex, and Charleston Comorbidity Index except for age (table). Documented infections were similar between AB− and AB+ groups, except urinary tract infections. No statistically significant differences were noted in documented symptoms including pain, dyspnea, fever, lethargy, and alteration of mental state or length of stay (LOS). Conclusion Our study did not show differences in frequencies of documented symptoms with use of antimicrobials at EOL. These results indicate that the risks of antimicrobial use may outweigh potential benefits and their use should be a part of goals of care discussions at EOL. Disclosures All authors: No reported disclosures.

scholarly journals Application of an antibiotic spectrum index in the neonatal intensive care unit

2019 ◽  
Vol 40 (10) ◽  
pp. 1181-1183 ◽  
Author(s):  
Alexandra C. Lahart ◽  
Christopher C. McPherson ◽  
Jeffrey S. Gerber ◽  
Barbara B. Warner ◽  
Brian R. Lee ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Antimicrobial Stewardship ◽  
Neonatal Intensive Care ◽  
Very Low Birth Weight ◽  
Antimicrobial Use ◽  
Low Birth Weight Infants ◽  
Antimicrobial Spectrum ◽  
Days Of Therapy ◽  
The Impact

AbstractAntimicrobial stewardship programs typically use days of therapy to assess antimicrobial use. However, this metric does not account for the antimicrobial spectrum of activity. We applied an antibiotic spectrum index to a population of very-low-birth-weight infants to assess its utility to evaluate the impact of antimicrobial stewardship interventions.

scholarly journals Effects of a Remote Antimicrobial Stewardship Program on Antimicrobial Use in a Regional Hospital System

Pharmacy ◽  
2020 ◽  
Vol 8 (1) ◽  
pp. 41 ◽  
Author(s):  
Joshua Knight ◽  
Jessica Michal ◽  
Stephanie Milliken ◽  
Jenna Swindler
Keyword(s):  
Antimicrobial Stewardship ◽  
Antimicrobial Use ◽  
Hospital System ◽  
Physician Review ◽  
Stewardship Program ◽  
Time Period ◽  
Days Of Therapy ◽  
Before And After ◽  
Implementation Time ◽  
Acceptance Rates

While antimicrobial stewardship programs (ASPs) are well established at most large medical centers, small or rural facilities often do not have the same resources; therefore, different methods must be developed to start or expand ASPs for these hospitals. The purpose of this quality improvement study was to describe the implementation of a pharmacist-led remote ASP and assess the effect on antimicrobial use. Antimicrobial use in days of therapy per 1000 patient days (DOT/1000 PD) was compared between the six months before and after remote ASP implementation. Changes in system-wide, facility-specific, and target antimicrobial use were evaluated. Pharmacist interventions, acceptance rates, and number of times infectious disease (ID) physician assistance was sought were also tracked. System-wide antimicrobial use was 4.6% less in the post-implementation time period than in the pre-implementation time period, with vancomycin, piperacillin/tazobactam, and fluoroquinolones having the greatest reductions in use. Ninety-one percent of interventions made during the post-implementation period were accepted. ID physician review was requested 38 times, and direct ID physician intervention was required six times. Remote ASPs delivered from a central facility to serve a larger system may reduce antimicrobial use, especially against targeted agents, with minimal increase in ID physician workload.

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