Antibiotic use common at the end of life

By Joanna Lyford, Senior medwireNews Reporter

More than one-quarter of hospice patients receive antibiotics in their last week of life, despite the absence of documented infection in most cases, US researchers report.

The findings raise concerns about antibiotic use in this population and also point to an underuse of potentially palliative treatments, say Jon Furuno (Oregon State University, Portland) and co-authors.

Furuno's team analyzed data from the 2007 National Home and Hospice Care Survey, a nationally representative sample of US hospice agencies. They included information on 3884 patients who died before discharge; the mean age was 78 years and 55% were female.

Writing in the Journal of Pain and Symptom Management, Furono et al report that patients received a mean of 10 different medications in the last 7 days of life, and 1.5% of the cohort received 25 different medications.

In all, 1028 (27%) patients received an antibiotic, with macrolide derivatives and fluoroquinolones being most frequently prescribed. Among patients given antibiotics, the mean number of antibiotic drugs was 1.3, the maximum number was six, and 1.3% of patients received three or more antibiotics.

Patients who received antibiotics differed from those who did not, being younger (mean age 76 vs 78 years) and with a longer duration of hospice stay (60 vs 48 days).

Antibiotic use also varied significantly by current primary diagnosis. For instance, patients with a current primary diagnosis of chronic obstructive pulmonary disease were more likely to receive antibiotics (34%) than were those with cancer, heart failure, or cardiovascular disease (16%), dementia (18%), cerebrovascular disease (6%), renal or liver diseases (11%), or other diseases (24%).

Of note, just 129 (15%) of the patients who received antibiotics had a documented infectious disease. The most frequent infectious diagnoses were pneumonia (7%), urinary tract infections (4%), and skin and soft tissue infections including pressure ulcers (3%).

Furuno et al note that there is an ongoing debate regarding the appropriateness of antibiotic use in hospice patients. "Concerns regarding antibiotic use in this patient population include potential lack of efficacy in reducing symptoms, increased patient burden, excess costs and risk of adverse effects, and increased antibiotic selective pressure and subsequent resistance," they write.

They conclude: "The increasing utilization of hospice care and lack of clear guidelines regarding antibiotic use may lead to a growing number of patients receiving potentially unnecessary treatment for infection or not receiving potentially palliative treatments; thus, further research is needed to guide antibiotic use in hospice care."

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