What is the role of antibiotics in a patient at the end of life, and what is the optimal duration of treatment?

From the Guidelines

The role of antibiotics in end-of-life care should be carefully considered on a case-by-case basis, with treatment duration typically limited to short courses of 3-7 days if used at all, as supported by the most recent guidelines 1. When considering the use of antibiotics in patients at the end of life, it is essential to weigh the potential benefits against the risks and burdens of treatment. The primary goal of care in this setting is to manage symptoms, improve comfort, and optimize quality of life, rather than to prolong survival.

Key Considerations

• Antibiotics may be appropriate when they can provide symptom relief and improve comfort, such as for urinary tract infections causing pain or respiratory infections causing distressing cough or breathlessness 1.
• Common regimens might include amoxicillin 500mg three times daily for respiratory infections or nitrofurantoin 100mg twice daily for urinary symptoms.
• However, antibiotics should generally be avoided when they primarily extend life without improving quality, especially in patients with advanced dementia or multiple organ failure 1.
• The decision to use antibiotics should align with the patient's goals of care and advance directives, involving discussions with the patient (if possible) and family members.

Treatment Duration

• The optimal duration of antibiotic treatment in end-of-life care is typically limited to short courses of 3-7 days, as longer courses may increase the risk of adverse effects and contribute to antibiotic resistance 1.
• Regular reassessment is essential, with willingness to discontinue antibiotics if they're not improving symptoms or if the patient's condition deteriorates despite treatment.

Patient-Centered Approach

• The patient's goals, values, and preferences should be respected and prioritized in decision-making about antibiotic use at the end of life 1.
• Discussions with the patient (if possible) and family members are crucial in determining the best course of action.
• A patient-centered approach focuses on comfort, dignity, and quality of life, rather than solely on prolonging the dying process.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Role of Antibiotics in End-of-Life Care

• The decision to initiate antibiotics in hospice patients near end-of-life is complex and involves ethical and stewardship considerations 2.
• Antibiotics may be ordered to improve symptoms related to urinary tract infections, such as delirium, but infection symptoms can also be managed using antipsychotics, antipyretics, antispasmodics, and analgesics 2.
• A survey of doctors found that 88-100% of them decided to initiate antibiotics in patients with suspected infections at end-of-life, except in cases of advanced dementia 3.

Optimal Duration of Antibiotic Treatment

• There is limited guidance on the optimal duration of antibiotic treatment in end-of-life patients, and the decision to stop or extend antibiotics is often based on clinical judgment 4.
• A study found that more than half of antibiotic courses were discontinued prematurely, suggesting that the optimal duration of treatment may be shorter than expected 2.
• The use of antibiotics in end-of-life patients is not always appropriate, and unnecessary medication can present a risk of adverse effects 4.

Factors Associated with Antibiotic Prescription

• The decision to prescribe antibiotics at end-of-life is related to clinical and analytical aspects suggestive of infection, such as fever and elevated C-reactive protein (CRP) values 5.
• Factors associated with maintaining or extending antibiotics inadequately include longer time since graduation and lack of formal specialization in palliative care 3.
• Effective communication with patients and their families, and making treatment decisions aligned with a patient's goals and priorities, are important considerations in antibiotic prescription at end-of-life 6.

Good Practice Recommendations

• Good practice recommendations for antibiotic use in end-of-life care include making shared decisions about future care, agreeing clear goals and limits of therapy, and reviewing all antibiotic prescribing decisions regularly 6.
• A patient version of these recommendations has been produced to support implementation and optimal care for patients towards the end of life 6.