Antimicrobial use at the end of life: a retrospective cohort study

Introduction: Antibiotic resistance poses a global threat. Antibiotics are administered to 80-90% of terminally ill patients but evidence of their effectiveness in improving survival or symptom relief at the end of life (EOL) is scarce. Aim: To determine the proportion of deceased patients that continue antibiotic treatment after documented EOL discussion and the decision to prioritise symptom relief over active treatment. Secondarily compare the groups with and without antibiotics after EOL discussion in terms of differences in demographics, type of infection, mean survival time after EOL discussion and if fluid therapy followed the same trend as antibiotic use. Method: This was a retrospective cohort study including 100 patients aged 18 years or older who died with continued or discontinued antibiotics after EOL discussion, at Blekinge Hospital from January 2022 to February 2024. Patients were excluded if they received curative intended treatment until death, did not receive antibiotics during hospitalisation, or the antibiotic treatment was ended before EOL discussion. Medical record data were compared, using chi-2- , Fisher’s exact- and t-tests, between patients who continued antibiotics or not after EOL discussion, in terms of demographics, focus of infection and survival time after EOL discussion. Ethical approval was granted by the Swedish Ethical Review Authority on 2023-12-14 (Dnr: 2023-07647-01). Results: A total 36% (36/100) patients continued antibiotic treatment after EOL discussion. The most prescribed antibiotics were piperacillin-tazobactam (37%) and cefotaxime (32%) and the most common site of infection was pneumonia (45%). There was no statistical significance in survival time after EOL discussion between patients with antibiotics after EOL discussion or not (mean 2.7 days (range 0-11); IQR 1-3 vs 1.9 days (range 0-10); IQR 0.75-3; 95% CI 0.46-1.05; p=0.082). Patients who continued antibiotics were also significantly more likely to continue with intravenous fluids (11/36 (31%) vs 3/64 (5%); between-group difference of 26%; 95% CI 0.10-0.42; p=0.001). Conclusion: After EOL discussion more than one-third of inpatients continued antibiotics despite a shift to symptom relief, reflecting ongoing challenges in antimicrobial stewardship in palliative care.