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| Antibiotics May Be Overused Near the End of Life | | medpagetoday.com Hace 8 años (26/02/2008 16:57:26) |  |
By John Gever, Staff Writer, MedPage Today
Published: February 25, 2008
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.
BOSTON, Feb. 25 -- Antimicrobial therapy in elderly patients with advanced dementia is common and increases as they near death, raising questions of overuse, researchers here said.
Two-thirds of nursing home residents with advanced dementia received at least one course of antibiotics during a mean of 322 days of follow-up, reported Erika D'Agata, M.D., M.P.H., of Beth Israel Deaconess Medical Center, and Susan L. Mitchell, M.D., M.P.H., of the Hebrew Senior Life Institute for Aging Research, in the Feb. 26 issue of Archives of Internal Medicine.
The researchers also found that the likelihood of receiving antibiotics, the number prescribed, and the duration of therapy increased during patients' last weeks of life.
"This extensive use of antimicrobials and pattern of antimicrobial management in advanced dementia raises concerns not only with respect to individual treatment burden near the end of life but also with respect to the development and spread of antimicrobial resistance in the nursing home setting," the researchers wrote.
They added, "We believe that the widespread use of antibiotics in advanced dementia may pose a potential public health risk through the emergence of antibiotic resistance."
Their findings came from an ongoing, prospective study of Boston-area nursing home residents with advanced dementia, called Choices, Attitudes and Strategies for Care of Advanced Dementia at the End-of-Life (CASCADE). The current study reported data from the first 214 evaluable participants.
Patients were recruited if they had a Cognitive Performance Scale score of 5 or 6 in their most recent Minimum Data Set assessment and a Global Deterioration Scale score of 7. These values indicate very severe cognitive decline, minimal to no verbal communication, dependence for eating and toileting, urinary and fecal incontinence, and inability to walk.
Enrollment took place from February 2003 through September 2006. Patients were examined every three months for up to 18 months.
Mean age of participants was 85.2 (SD 7.9) and 99 of them (46.3%) died during the follow-up period.
Drs. D'Agata and Mitchell found a mean of four courses of antibiotic therapy per patient during the study, with 66.4% of patients receiving at least one course. Mean duration of treatment per 1,000 resident-days was 53.0 days.
Quinolones, third-generation cephalosporins, and first-generation cephalosporins accounted for about 65% of all prescribed treatment.
Among the patients who died, 42.4% received antibiotics during their final two weeks of life.
Duration of antibiotic treatment in the two weeks before death reached 171.9 days per 1,000 resident-days, more than triple the rate seen in the entire cohort.
These values were significantly more (P<0.001) than were seen in the same patients six to eight weeks before death.
Types of infections prompting treatment during the final eight weeks of life were respiratory (80 courses, 63.5% of all infections), urogenital (22, 17.5%), skin (21, 16.7%), and gastrointestinal tract (three, 2.4%).
Respiratory tract illness increased significantly as the indication for antimicrobial treatment as patients approached death (P=0.01), the researchers said.
In an interview, Dr. D'Agata stressed that the individual decisions to treat these patients were not necessarily faulty.
She and Dr. Mitchell pointed out that it's difficult to know how much distress infections may cause in the severely demented. Some research has indicated that pneumonia causes discomfort and antibiotic therapy may improve symptoms, they said.
On the other hand, they said, there is little evidence that most antimicrobial treatment improves outcomes in patients with advanced dementia.
Moreover, they said, an earlier study found that up to one-third of antimicrobial prescriptions in nursing homes are for asymptomatic conditions that do not require treatment.
They also noted that antibiotic resistance is a major public health concern, with the elderly being a major reservoir for drug-resistant organisms.
"These observations and the extensive use of antibiotics found in this study raise the serious concern that nursing home residents with advanced dementia may be contributing to the emergence and spread of antimicrobial-resistant bacteria, posing health risks that extend beyond the individual being treated," they said.
They noted that their cohort did not include a control group, which means that the study could not determine how widespread antibiotic use is among all residents of nursing homes, not just those with dementia.
Nor did the study determine the presence of antibiotic-resistant bacteria or the effectiveness of antibiotic therapy in eliminating infections or reducing symptoms in the patients who were treated.
Despite these limitations, an accompanying editorial by Mitchell J. Schwaber, M.D., and Yehuda Carmeli, M.D., M.P.H., of Tel Aviv Medical Center in Israel, echoed the Boston group's conclusions.
"The data provided by D'Agata and Mitchell require us to consider whether we are overusing antibiotics in the severely demented elderly population, especially at the end of life, without paying adequate attention to the ramifications of their use," Drs. Schwaber and Carmeli wrote.
They also pointed out a possible institutional pressure that may contribute to aggressive treatment of infections in patients with advanced dementia.
"If the physician … treats the patient empirically with an antibiotic known to provide adequate coverage of the presumed pathogen, his clinical judgment is unlikely to be questioned," they wrote.
"If, on the other hand, he decides not to use antibiotics, based solely on the underlying status of the patient, he may be considered to have taken a decision with ethical ramifications, one that may require the approval of the institutional administration."
Drs. Schwaber and Carmeli argued that the decision to prescribe antibiotics in this setting should require as much ethical deliberation as a decision to withhold them.
The study was funded by the National Institute on Aging.
The authors and editorialists reported no potential conflicts of interest.
From: www.medpagetoday.com
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