The use of antibiotics is an ongoing ethical debate in hospice care as it can be perceived to be less aggressive/invasive than other curative/life-prolonging interventions (e.g., intubation, dialysis, chemotherapy, etc.).  Hospice patients are especially vulnerable to infections and have high rates of resistant bacteria due to long-term chronic illness.  However, there are no guidelines directing appropriate antibiotic decision-making in hospice patients.  Therefore, hospice-related infectious disease studies seek to determine if antibiotics provide symptom relief and/or prolong survival in our patient population.

 

Risks Associated with Antibiotic Treatment:

  • Adverse outcomes of drug administration (pill burden, drug interactions, side effects, cost)
  • Secondary infections (Clostridium difficile, Candida)
  • Multi-drug resistant organisms (MDRO)
  • Prolonged survival may result in prolonged suffering

 

Factors That May Influence the Decision Not to Treat:

  • Dysphagia (patient is unable to swallow)
  • The patient has a severe infection and aggressive treatment is not a goal of care (intravenous antibiotics are recommended and oral antibiotics may have little effect on overall outcome)
  • Expected prognosis is less than the recommended duration of the antimicrobial course
  • Patient/family goal is purely palliative (e.g., morphine, antipyretics)

 

Areas of Potential Antibiotic Misuse:

  • Prophylactic antibiotic for urinary tract infection (UTI)
  • Empiric prescribing without microbiological investigation
  • Treatment of asymptomatic bacteriuria
  • Widespread prescribing for upper RTIs or acute bronchitis
  • Prolonged duration of antibiotic treatment
  • Widespread prescribing of quinolones as empiric treatment for UTIs
  • Broad-spectrum or parenteral antibiotic treatment for elderly individuals with advanced dementia or end-stage illness

 

What Does the Literature Say?

Consider two important studies assessing whether antibiotics prolong survival.  Volicer, et al. first determined that survival rate increased for less severe infections, but there was no difference in survival outcome for severe infections.  A follow-up study by Givens, et. al. determined that patients treated with antibiotics (PO, IM, & IV) had greater survival rate, but experienced less comfort.

Additionally, a meta-analysis performed by Rosenberg, et. al. identified eight studies measuring symptom response following antimicrobial therapy.  The primary findings included that the methods of symptom assessment were highly variable making it difficult to draw conclusions.  Also, symptom improvement varies by indication. UTIs (in two studies) appeared to experience the greatest improvement following antimicrobial therapy.

 

An Important Infection to Remember:

Asymptomatic bacteriuria (ASB) is defined as the presence of 1+ species of bacteria growing in the urine at specified quantitative counts (≥105 colony-forming units [CFU]/mL or ≥108 CFU/L), regardless of the presence of pyuria, in the absence of signs or symptoms attributable to UTI.

 

Signs/Symptoms of UTI:

  • Pain: suprapubic pain, flank pain
  • Urinary-specific: frequency, urgency, hematuria, dysuria
  • Systemic: fever, chills, marked fatigue or malaise beyond baseline

If any of the above signs/symptoms present, then perform a urinalysis (UA).

Please note that foul-smelling or cloudy urine, or mental status changes alone does not indicate a UTI.

Furthermore, in older patients with functional and/or cognitive impairment with bacteriuria and delirium (e.g., acute mental status change, confusion) and without local genitourinary symptoms or other systemic signs of infection (e.g., fever or hemodynamic), it is recommended to assess for other causes with careful observation, (e.g. recent fall) rather than immediately initiate antimicrobial treatment.

If you suspect that your patient may have an infection, please reach out to a hospice clinical pharmacist or alternatively, the patient’s physician, to discuss whether treatment would be appropriate, based on the patient and their presenting symptoms.

 

Written by: Shaun Gutstein, PharmD

References:

  1. Albrecht JS, McGregor JC, Fromme EK, et. al. A nationwide analysis of antibiotic use in hospice care in the final week of life. J Pain Symptom Manage. 2013; 46(4):483-490.
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