What is the role of antibiotics in a patient at the end of life (EOL) and what is the optimal duration of antibiotic therapy in this setting?

From the Guidelines

The use of antibiotics in patients at the end of life should be limited to symptom management, with a focus on improving comfort and quality of life, rather than extending survival. When considering antibiotics in this setting, healthcare providers should prioritize goals-of-care discussions with patients and families, focusing on whether the infection is causing distressing symptoms that antibiotics might relieve 1. The optimal duration of antibiotic therapy in end-of-life care is typically shorter than standard courses, often ranging from 3-7 days, as prolonged treatment may not provide significant benefits and can increase the risk of adverse effects and antibiotic resistance 1. Key considerations in the decision to use antibiotics include:

• The potential for symptom relief
• The risk of adverse effects, such as Clostridioides difficile infection (CDI)
• The burden of treatment, including invasive administration and disruption of peaceful dying
• The public health risks associated with antibiotic resistance In general, oral antibiotics are preferred when possible, with common choices including amoxicillin, doxycycline, or trimethoprim-sulfamethoxazole for respiratory or urinary infections 1. Discontinuation of antibiotics is appropriate if there's no symptomatic improvement within 48-72 hours, and regular reassessment of treatment response and goals is essential to ensure care remains aligned with the patient's wishes and best interests 1. It's also important to note that infections are often part of the natural dying process, and aggressive treatment may prolong suffering without meaningful benefit, therefore, a more conservative approach to antibiotic use is recommended, as suggested by the most recent and highest quality study 1.

From the Research

Role of Antibiotics in End-of-Life Care

• Antibiotics are frequently prescribed at the end of life, although the benefits and harms are not well understood 2.
• The use of antibiotics in end-of-life care is impactful, and efforts to educate patients and providers will be invaluable in optimizing care 2.
• Antibiotics can improve symptoms when used for specific diseases, but they can also have negative consequences such as drug reactions, resistant organisms, and delayed discharge 2.

Optimal Duration of Antibiotic Therapy

• There is limited guidance on the optimal duration of antibiotic therapy in end-of-life care, leading to variable practice and potential overuse of antibiotics 3, 4.
• Good practice recommendations have been developed, focusing on shared decision-making, clear goals and limits of therapy, and regular review of antibiotic prescribing decisions 3.
• The use of antibiotics at the end of life should be guided by the type of infection, clinical course, patient's primary disease and prognosis, and patient preferences 4.

Factors Influencing Antibiotic Use

• Physicians' over-estimation of patient preference for antibiotics and the increased probability of misdiagnosis can increase antibiotic prescription rates 2.
• Factors associated with maintaining or extending antibiotics inadequately include longer time since graduation and lack of formal specialization in palliative care 5.
• Discussing and documenting antibiotic preferences during the care planning process can help optimize antibiotic use 4.

Specific Considerations for Urinary Tract Infections

• The use of antibiotics for urinary tract infections in end-of-life patients is controversial, with limited guidance and potential risks such as antibiotic resistance and adverse events 6.
• A study found that half of antibiotics prescribed for urinary tract infections in hospice patients were initiated appropriately based on documented symptoms, but there was no significant difference in appropriate utilization based on palliative performance scale scores 6.