Siegel, Leslie

Abstract Background At hospice enrollment, patients are asked preferences regarding antibiotic use. Limited evidence on how these medications impact survival makes it difficult for clinicians to offer clear guidance. To support decision-making and antimicrobial stewardship, we assessed the association between antibiotic use and survival in outpatient hospice patients. Methods The association between antibiotic use and survival was evaluated using a time-dependent Cox proportional hazards model, adjusted for age, sex, Charlson Comorbidity Index, and hospice-qualifying conditions (HQCs). The cohort included patients enrolled in a large health system’s outpatient hospice program between June 20, 2017, and January 1, 2023. Results Among 6169 patients with an HQC, 1233 received at least one antimicrobial prescription during the study period. The median time from hospice enrollment to first prescription was 16 days (IQR 3-83). Antimicrobial prescribing patterns varied by HQC category. In time-dependent Cox models, antibiotic use was associated with increased hazard of death (aHR 1.47; 95% confidence interval [CI], 1.37–1.57).Stratified analyses showed the strongest association with increased mortality in patients with cancer HQCs (aHR 1.67; 95% CI, 1.50–1.87) and a survival benefit in those with infectious HQCs (aHR 0.60; 95% CI, 0.40–0.89). Discussion Physicians, patients, and families often overestimate the benefits of antibiotics near the end of life. The observed increase in mortality shortly after antibiotic initiation suggests that symptoms prompting antibiotic use may reflect the dying process rather than treatable infection. Knowledge of the limited role of antibiotics in prolonging life in hospice settings may improve decision-making and enhance the quality of end-of-life care.

Background Antibiotics are frequently prescribed at the end of life, though the benefits and harms are not well understood. Methods We abstracted relevant findings from articles published in English in the past 25 years to answer questions generated by discussion among the authors and with stakeholders in Palliative Care and Infectious Diseases. Findings Prescribing practices vary based on individual situation and geographic location. Patients with cancer and those hospitalized receive more antibiotics than those enrolled in outpatient hospice. Urinary tract infections and pulmonary infections are the most common conditions treated with antibiotics at the end of life -most often with penicillin derivatives and vancomycin in the hospital, fluoroquinolones in outpatient, and cephalosporins in both settings. When asked, patients most often prefer limiting antibiotics to symptom management at the end of life. Physicians’ over-estimation of patient preference for antibiotics and the increased probability of misdiagnosis increases antibiotic prescription rates. Antibiotics can improve symptoms when used for specific diseases at the cost of drug reactions, resistant organisms, and delayed discharge. Antibiotic use has variable results on survival duration. Antimicrobial stewardship exists in hospital and long-term care facilities, but not outpatient hospice groups. Stewardship interventions could increase proper use of antibiotics, but more information is needed to apply these interventions to hospice groups. Conclusions Antibiotics at the end of life are impactful and efforts to educate patients and providers will be invaluable in optimizing care.