Antibiotics in Palliative Care

The issue comes up a lot lately on Stewardship rounds regarding antibiotics in palliative/”comfort-only” care. Often we see orders like “discontinue all medications, except IV antibiotics”. This is often a difficult and controversial topic with very little evidence behind it. There main arguments in favour of keeping antibiotics are for non life-threatining infections, where the infection will not shorten lifespan, but treating will help as a symptom management. This argument is backed, for example, by this paper: Antibiotic Treatment in End-of-Life Cancer Patients—A Retrospective Observational Study at a Palliative Care Center in Sweden (cancers, 2016). Here they found that antibiotics helped symptoms in 37% of patients, and had minimal adverse events. The discussion section of the paper also has an excellent literature review showing many papers that agree and ones that disagree.

This paper is a bit older, and looks more at longer term palliation. Survival and Comfort After Treatment of Pneumonia in Advanced Dementia (JAMA, 2010). In this patient population, when treating pneumonia, comfort scores decreased as intensity of therapy increased (i.e., no therapy -> PO antibiotics -> Parenteral Antibiotics). The reasons behind the decrease in comfort could not be validated (dementia patients), but were thought to be due to ADRs and the invaseness of injectable formulations.

Overall, nothing conclusive enough to sway the decision in either direction. Unfortunately, the papers in favour of palliative Abx do not look at the situation from a Stewardship mindset; yes, the individual patients did not experience many adverse events, but there may be overall impact on hospital antibiogram and resistance patterns for other patients. In practice, the biggest factor we find in decision making tends to be the patient’s family looking for one last shred of hope… meaning that most of the pros and cons discussed in these papers tend to be irrelevant anyway.