scholarly journals Why is optimisation of antimicrobial use difficult at the end of life?

2019 ◽  
Vol 49 (2) ◽  
pp. 269-271 ◽  
Author(s):  
Jennifer Broom ◽  
Alex Broom ◽  
Phillip Good ◽  
Zarnie Lwin
Keyword(s):  
End Of Life ◽  
Antimicrobial Use

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 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.

Antimicrobial use in patients at the end of life in an Australian hospital

2019 ◽  
Vol 24 (2) ◽  
pp. 92-97 ◽  
Author(s):  
Jane Dyer ◽  
Lucinda Vaux ◽  
Alex Broom ◽  
Jennifer Broom
Keyword(s):  
End Of Life ◽  
Antimicrobial Use ◽  
Australian Hospital

Antimicrobial Use at the End of Life Among Hospitalized Patients With Advanced Cancer

2012 ◽  
Vol 29 (8) ◽  
pp. 599-603 ◽  
Author(s):  
Andrew J. Thompson ◽  
Maria J. Silveira ◽  
Caroline A. Vitale ◽  
Preeti N. Malani
Keyword(s):  
End Of Life ◽  
Advanced Cancer ◽  
Hospitalized Patients ◽  
Antimicrobial Use

Physician Perceptions Regarding Antimicrobial Use in End-of-Life Care

2018 ◽  
Vol 39 (4) ◽  
pp. 383-390 ◽  
Author(s):  
Christopher E. Gaw ◽  
Keith W. Hamilton ◽  
Jeffrey S. Gerber ◽  
Julia E. Szymczak
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Antimicrobial Stewardship ◽  
Patient Population ◽  
Improve Patient Care ◽  
Antimicrobial Treatment ◽  
Free Text ◽  
Antimicrobial Use ◽  
Physician Decision Making ◽  
Patient Pain

BACKGROUNDThe decision to utilize antimicrobials in end-of-life situations is complex. Understanding the reasons why physicians prescribe antimicrobials in this patient population is important for informing the design of antimicrobial stewardship interventions.METHODSA 51-item survey containing both closed and open-ended questions on end-of-life antimicrobial use was administered to physicians affiliated with the University of Pennsylvania and Children’s Hospital of Philadelphia from January through April 2017. A mixed-methods approach was used to analyze responses.RESULTSOf 637 physicians surveyed, 283 responses (44.4%) were received. Most (86.2%) physicians believed that respecting a patient’s wish to continue antimicrobials was important. Approximately half of physicians (49.8%) believed that antimicrobial use at the end of life contributes to resistance. A higher proportion of pediatricians would often or always continue antimicrobial treatment for active infections and for hospice patients whose death was imminent compared to adult physicians (P<.001). Analysis of free-text responses revealed additional reasons why physicians may continue antimicrobials at end of life, including meeting family expectations, wanting to avoid the perception of “giving up,” uncertainty about prognosis, and reducing patient pain or discomfort.CONCLUSIONSPhysician decision making concerning antimicrobial use in patients at the end of life is multifactorial. Clinicians may overweigh the benefits of antimicrobial therapy in end-of-life situations and view the importance of adhering to stewardship policies differently. Pediatric and adult clinicians have different approaches to this patient population. Better understanding of the complex decision making that occurs in the end-of-life patient population can help guide antimicrobial stewardship policies and improve patient care.Infect Control Hosp Epidemiol 2018;39:383–390

Education needed to improve antimicrobial use during end-of-life care of older adults with advanced cancer: A cross-sectional survey

2020 ◽  
pp. 026921632095681
Author(s):  
Rupak Datta ◽  
Jeffrey Topal ◽  
Dayna McManus ◽  
Tara Sanft ◽  
Louise Marie Dembry ◽  
...  
Keyword(s):  
Older Adults ◽  
End Of Life ◽  
Advanced Cancer ◽  
End Of Life Care ◽  
Antimicrobial Use ◽  
Life Care ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Factors Influencing ◽  
Advance Care

Background: Antimicrobial use during end-of-life care of older adults with advanced cancer is prevalent. Factors influencing the decision to prescribe antimicrobials during end-of-life care are not well defined. Aim: To evaluate factors influencing medicine subspecialists to prescribe intravenous and oral antimicrobials during end-of-life care of older adults with advanced cancer to guide an educational intervention. Design: 18-item single-center cross-sectional survey. Setting/participants: Inpatient medicine subspecialists in 2018. Results: Of 186 subspecialists surveyed, 67 (36%) responded. Most considered withholding antimicrobials at the time of clinical deterioration during hospitalization ( n = 54/67, 81%), viewed the initiation of additional intravenous antimicrobials as escalation of care ( n = 44/67, 66%), and believed decision-making should involve patients or surrogates and providers ( n = 64/67, 96%). Fifty-one percent ( n = 30/59) of respondents who conducted advance care planning did not discuss antimicrobials. Barriers to discussing end-of-life antimicrobials included the potential to overwhelm patients or families, challenges of withdrawing antimicrobials, and insufficient training. Conclusions: Although the initiation of additional intravenous antimicrobials was viewed as escalation of care, antimicrobials were not routinely discussed during advance care planning. Educational interventions that promote recognition of antimicrobial-associated adverse events, incorporate antimicrobial use into advance care plans, and offer communication simulation training around the role of antimicrobials during end-of-life care are warranted.

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.

Sign in / Sign up

Export Citation Format

Share Document