Antimicrobial Use for Symptom Management in Patients Receiving Hospice and Palliative Care: A Systematic Review

Abstract

Background: Patients receiving hospice or palliative care often receive antimicrobial therapy; however the effectiveness of antimicrobial therapy for symptom management in these patients is unknown. Objective: The study's objective was to systematically review and summarize existing data on the prevalence and effectiveness of antimicrobial therapy to improve symptom burden among hospice or palliative care patients. Design: Systematic review of articles on microbial use in hospice and palliative care patients published from January 1, 2001 through June 30, 2011. Measurements: We extracted data on patients' underlying chronic condition and health care setting, study design, prevalence of antimicrobial use, whether symptom response following antimicrobial use was measured, and the method for measuring symptom response. Results: Eleven studies met our inclusion criteria in which prevalence of antimicrobial use ranged from 4% to 84%. Eight studies measured symptom response following antimicrobial therapy. Methods of symptom assessment were highly variable and ranged from clinical assessment from patients' charts to the Edmonton Symptom Assessment Scale. Symptom improvement varied by indication, and patients with urinary tract infections (two studies) appeared to experience the greatest improvement following antimicrobial therapy (range 67% to 92%). Conclusion: Limited data are available on the use of antimicrobial therapy for symptom management among patients receiving palliative or hospice care. Future studies should systematically measure symptom response and control for important confounders to provide useful data to guide antimicrobial use in this population.

Should we refrain from antibiotic use in hospice patients?

“…Other studies have reported a prevalence of antibiotic use exceeding 50% with higher prevalence estimates occurring in dedicated palliative care units within hospitals where patients are receiving entirely or primarily supportive care. [14] In the study by Reinbolt et al described above, 92% (633/685) of diagnosed infections were treated with antimicrobial therapy. [13] …”

“…However, as our systematic review of studies published between 2000 and 2010 on antimicrobial use in hospice and palliative care settings concluded there are limited data on the effectiveness of antimicrobial therapy to improve symptoms. [14] The strongest data suggest that antimicrobial therapy is most effective among patients with UTIs. [9,13,15] However, we also concluded that the methods used to assess symptom burden varied between studies and often deferred to subjective clinical assessment of improvement, sometimes supplemented with patient and caregiver assessment rather than validated measures.…”

“…[9,13,15] However, we also concluded that the methods used to assess symptom burden varied between studies and often deferred to subjective clinical assessment of improvement, sometimes supplemented with patient and caregiver assessment rather than validated measures. [14][15][16] Only one study included in our review used a validated symptom assessment measure, the Edmonton Symptom Assessment Scale.…”

Frequency of Outpatient Antibiotic Prescription on Discharge to Hospice Care

“…The use of antibiotics is also common in hospice care with a national study suggesting that approximately 27% of U.S. hospice patients received antibiotics in the final week of life (5). However, there is limited evidence that antibiotic use benefits hospice patients by reducing symptom burden, prolonging survival, or improving quality of life (6,7). Additional concerns with antibiotic use in hospice care include potential medication side effects and adverse events, increased risk of subsequent opportunistic infections, and prolonging the dying process (6,8).…”

“…However, there is limited evidence that antibiotic use benefits hospice patients by reducing symptom burden, prolonging survival, or improving quality of life (6,7). Additional concerns with antibiotic use in hospice care include potential medication side effects and adverse events, increased risk of subsequent opportunistic infections, and prolonging the dying process (6,8). Furthermore, antimicrobial therapy increases selective pressure for antimicrobial-resistant organisms.…”