Questions over use of antibiotics in 'end of life' care

Antibiotics appear to be frequently prescribed to individuals with advanced dementia in nursing homes, especially in the two weeks before death, according to a report in the February 25 issue of Archives of Internal Medicine.

More than 5 million Americans have dementia, according to background information in the article. About 70 percent of them will live in nursing homes at the end of their lives. Recurrent infections and fever are common among these patients, who may receive antibiotics to treat these conditions.

Erika D'Agata, M.D., M.P.H., of Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, and colleagues studied 214 residents (average age 85.2) with advanced dementia living in 21 area nursing homes. The participants underwent an initial assessment between 2003 and 2006 and then were examined every three months for a maximum of 18 months. At each evaluation, the number of courses of antibiotic therapy prescribed since the prior visit was obtained from facility records.

During an average of 322 days of follow-up, 142 (66.4 percent) participants received at least one course of antibiotics and the overall average was four courses. Of the 99 (46.3 percent) residents who died, 42 (42.4 percent) received antibiotics during the two weeks before their death. “The proportion of residents taking antimicrobials was seven times greater in the last two weeks of life compared with six to eight weeks before death,” the authors write. Thirty of the 72 courses (41.7 percent) in the last two weeks of life were administered intravenously rather than by mouth, a method that may be uncomfortable for patients with advanced dementia.

“This extensive use of antimicrobials and pattern of antimicrobial management in advanced dementia raises concerns not only with respect to individual treatment burden near the end of life but also with respect to the development and spread of antimicrobial resistance in the nursing home setting,” the authors write. The results support “the development of programs and guidelines designed to reduce the use of antimicrobial agents in advanced dementia.”

Editor's Note: This study was supported by a grant from the National Institute on Aging, National Institutes of Health. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Antibiotics Raise Ethical Dilemmas That Must Be Solved Individually

“The findings in this study require the medical community to ask whether the extensive use of antibiotics in this particular patient population is appropriate, taking two factors into consideration: the benefit to the patient treated and the risk imposed on other patients,” write Mitchell J. Schwaber, M.D., M.Sc., and Yehuda Carmeli, M.D., M.P.H., of the Tel Aviv Medical Center, Israel, in an accompanying editorial.

“The solution is not to categorically deny antibiotics to the severely demented elderly, or even to impose limits on their use or their spectrum as a matter of policy,” they continue. “We must, however, begin to consider every decision to use antibiotics in this population as we would decisions regarding other treatment modalities, including resuscitation and major surgery. That is, we must ask whether the interests of the patient are being served by using antibiotics. We must further ask whether the use of antibiotics in each specific patient justifies the risk placed on others by their use.”

“All such decisions must ultimately be made individually, based on the medical situation and the expressed wishes of the patient and family, as well as on the physician's judgment of the benefits and risks entailed in treating vs. not treating,” they conclude.

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