In a resident receiving comfort‑measures‑only care for osteomyelitis (including methicillin‑resistant Staphylococcus aureus, Pseudomonas aeruginosa, and anaerobes), should systemic antibiotics be continued?

Discontinue Systemic Antibiotics in Comfort-Measures-Only Care for Osteomyelitis

In a resident receiving comfort-measures-only care for osteomyelitis, systemic antibiotics should generally be discontinued unless they are specifically needed for symptom palliation or the patient/family explicitly requests continuation after informed discussion of benefits and harms. 1

Rationale for Discontinuation

The primary goal of comfort-measures-only care is symptom relief and quality of life, not infection eradication. 1 Osteomyelitis requires prolonged antibiotic therapy (≥4–6 weeks) combined with surgical debridement for cure, which is incompatible with comfort-focused goals. 2, 3 Without surgical resection of infected bone, antibiotics alone cannot achieve remission and must be continued indefinitely. 2

Continuing antibiotics in this setting exposes the patient to unnecessary harms without meaningful benefit:

• Adverse effects: IV access complications, drug toxicity, Clostridioides difficile infection, and antimicrobial resistance. 1, 4
• Medicalization of dying: Prolonging interventions that do not improve comfort or quality of life. 1, 4
• False hope: Antibiotics may create unrealistic expectations of recovery when the focus should be on comfort. 1

When to Consider Continuation

Two specific scenarios may justify continuing antibiotics in comfort care:

1. Symptom Palliation

If the patient has fever, pain, or purulent drainage that is clearly distressing and antibiotics demonstrably improve these symptoms, a short course (3–7 days) may be appropriate. 1 However, osteomyelitis symptoms typically require weeks to months of therapy for meaningful improvement, making true palliation unlikely in the comfort-care timeframe. 2, 3

2. Patient/Family Preference After Informed Discussion

If the patient or family requests antibiotics after understanding that they will not cure the infection or prolong meaningful life, continuation may align with patient-centered care. 1, 4 Document this discussion clearly, including:

• Antibiotics will not cure osteomyelitis without surgery. 2
• Expected survival is measured in hours to days, not weeks. 1, 4
• Risks include IV line complications, drug side effects, and potential discomfort. 1, 4
• The primary goal remains comfort, not infection control. 1

Evidence from Clinical Practice

In a retrospective study of 711 hospitalized patients alive ≥24 hours after comfort-care orders, only 15.6% remained on antimicrobials. 4 Among those who continued antibiotics, only 26% had documented patient/family preference and 26% had documented symptom palliation as the rationale. 1 This suggests that most clinicians appropriately discontinue antibiotics when transitioning to comfort care. 1, 4

Another study found that 41% of providers "sometimes" or "often" continued antimicrobials during the transition to comfort-measures-only, with patient/family preference and symptom palliation being the most common cited factors. 1 However, there is limited evidence that antibiotics provide meaningful palliative benefit in the short timeframe of comfort care. 1

Practical Algorithm for Decision-Making

Step 1: Confirm the goals of care are truly comfort-focused (no curative intent, no surgical intervention planned). 1, 4

Step 2: Assess whether antibiotics are providing symptom relief:

• Is the patient febrile, and does fever cause distress? 1
• Is there purulent drainage causing discomfort? 1
• Have symptoms improved since starting antibiotics? 1

Step 3: If antibiotics are NOT providing clear symptom relief, discontinue them. 1, 4

Step 4: If the patient/family requests continuation despite lack of palliative benefit:

• Explain that osteomyelitis requires 4–6 weeks of antibiotics PLUS surgery for cure. 2, 3
• Clarify that antibiotics will not extend meaningful life in comfort care. 1, 4
• Discuss risks: IV line complications, drug toxicity, and potential discomfort. 1, 4
• If they still request continuation, honor this preference and document the discussion. 1

Step 5: If antibiotics are continued, reassess daily and discontinue if no benefit or if the patient becomes unable to tolerate IV access. 1, 4

Critical Pitfalls to Avoid

• Do not continue antibiotics by default without reassessing goals of care and symptom burden. 1, 4
• Do not assume antibiotics provide comfort without clear evidence of symptom improvement. 1
• Do not continue IV antibiotics if the patient is distressed by IV access or if access becomes difficult. 1, 4
• Do not use antibiotics to avoid difficult conversations with patients/families about prognosis and goals of care. 1

Special Considerations for This Case

This resident has polymicrobial osteomyelitis (MRSA, Pseudomonas aeruginosa, anaerobes), which typically requires broad-spectrum IV antibiotics (e.g., vancomycin + cefepime + metronidazole) for 6–8 weeks PLUS surgical debridement for any chance of cure. 5, 6, 2 In comfort-measures-only care, this aggressive regimen is neither feasible nor aligned with the patient's goals. 1, 4

The most appropriate course is to discontinue antibiotics unless the patient has distressing symptoms (fever, pain, purulent drainage) that clearly improve with antimicrobial therapy, or unless the patient/family explicitly requests continuation after informed discussion. 1, 4