From the Guidelines
Palliation should be considered for patients with recurrent hospital-acquired infections (HAIs) when the focus shifts from curative therapy to symptom management and quality of life, particularly in those with poor prognosis, declining functional status, and significant treatment burden. This approach is supported by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines, which emphasize the importance of considering the impact of antibiotic therapy on symptom alleviation in patients with terminal conditions 1.
When deciding to consider palliation, it is essential to assess the patient's overall clinical context, including the presence of underlying terminal conditions, severe immunosuppression, or multiple comorbidities. The guidelines suggest that antibiotic therapy should be viewed as aggressive care in the end-of-life setting, with potential for adverse effects such as CDI and public health risks 1.
Key considerations for palliation in patients with recurrent HAIs include:
- Poor prognosis despite maximal therapy
- Declining functional status
- Significant impact of infections on quality of life without prospect of meaningful recovery
- Multiple treatment failures with appropriate antibiotics
- Underlying terminal conditions, severe immunosuppression, or multiple comorbidities
The decision to consider palliation should be made after a multidisciplinary discussion involving infectious disease specialists, the primary medical team, palliative care specialists, and the patient and family. This conversation should focus on reframing goals toward comfort rather than cure, and may involve continuing antimicrobial therapy, but with a focus on symptom management, such as pain control, antipyretics, and comfort measures 1.
Ultimately, the decision to consider palliation in patients with recurrent HAIs requires a careful balancing of the potential benefits and burdens of continued aggressive treatment, with a focus on prioritizing the patient's quality of life and overall wellbeing.
From the Research
Considerations for Palliation in Patients with Recurrent Hospital-Acquired Infections (HAIs)
- Palliation may be considered in patients with recurrent HAIs when the focus shifts from curative treatment to symptom management and quality of life improvement 2.
- The decision to consider palliation should take into account the patient's overall condition, including the severity of the infection, underlying health status, and the presence of any life-limiting illnesses 2.
- Hospital-acquired infections can result in significant increases in morbidity, mortality rates, and cost, making prevention and management crucial 3, 4, 5.
- In patients with recurrent HAIs, palliative care approaches can help address the physical, psychological, social, and spiritual dimensions of suffering, improving the quality of life for patients and their loved ones 2.
- The World Health Organization Pain Ladder can be used to systematically quantify, treat, and titrate pain, which is often the most common reason for critical care palliative consultation 2.
- While efforts to prevent HAIs are ongoing, and strategies such as therapeutic drug monitoring and continuous infusion of β-lactam antibiotics may be implemented to optimize antimicrobial therapy, the decision to consider palliation should be individualized and based on the patient's unique circumstances 6.