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Opportunity for collaboration: ASPs and palliative care providers
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A survey of antimicrobial stewardship programs in the United States revealed that about two-thirds monitor antimicrobial use in patients receiving end-of-life care, but most do not intervene on oral end-of-life antibiotics or provide guidance for patients receiving comfort care, according to researchers.
Respondents indicated that they favor more collaboration between antimicrobial stewardship programs (ASPs) and palliative care practitioners, the researchers reported.
The electronic survey was sent to ASPs included in the Society for Healthcare Epidemiology of America (SHEA) Research Network. Of the 94 eligible hospitals, 36 completed the survey for a final response rate of 38%. All had an ASP and 75% had one or more full-time equivalent physician dedicated to antibiotic stewardship.
According to the study, 64% of ASPs monitored antimicrobial use among patients receiving end-of-life care, but only 39% intervened on oral end-of-life antibiotics and just 14% had institutional end-of-life care guidelines that addressed antimicrobial use. Survey data suggested that antimicrobial approval was influenced by patient goals of care, including do not resuscitate/intubate, no escalation of care and comfort measures only, the researchers found.
An area of the survey that allowed free-text responses revealed four general ways ASPs should support clinicians: “discern antimicrobial-associated adverse effects,” “support palliative care providers,” “refine guidelines” and “educate clinicians.”
“Antibiotic stewardship programs may play an important role during end-of-life care,” Rupak Datta, MD, PhD, an infectious diseases fellow at the Yale School of Medicine, told Infectious Disease News. “There is an opportunity for antibiotic stewardship programs to collaborate with palliative care providers, offer feedback to clinicians regarding the potential burden of treatment (ie, dosing schedule, route of administration, drug interactions, adverse effects), and inform institutional end-of-life care guidelines with respect to antibiotic use.”
According to Datta and colleagues, in 86% of the surveyed programs, recommendations for IV antimicrobials were more common than recommendations for oral antibiotics. They suggested that programs should consider integrating antibiotics into institutional end-of-life care guidelines.
“Our data support implementation guidelines by [the Infectious Diseases Society of America] and SHEA to reduce antibiotic use in terminally ill patients. We contribute further by identifying potential areas for ASP intervention,” Datta said. “These include increased collaboration with palliative care providers, offering guidance to clinical teams considering the discontinuation of antimicrobial therapy and providing insight regarding optimal agents to facilitate discharge to home or hospice. ASPs may also discuss integrating antibiotics into institutional end-of-life care guidelines.” – by Marley Ghizzone
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Jason P. Burnham, MD
There is a lot of room for improvement in antimicrobial use at the end of life. Hospitals would likely benefit from an approach that includes education as well as audit and feedback in a collaborative relationship between antimicrobial stewards, intensivists and palliative care providers.
Guidelines would be useful as a template for testing a standardized approach to end-of-life antimicrobials and determining the impact of guideline adherence. These findings demonstrate the need for guidelines in the face of significant practice variation but do not provide guidance on the recommendations themselves.
Many studies have looked at the risks and benefits of antimicrobials at the end of life. Now what is required is an evidence synthesis to inform guideline development.
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