Antimicrobials in serious illness and end-of-life care: lifting the veil of silence

Abstract

Global rates of antimicrobial consumption increased by 65% between 2000 and 2015, by 16% between 2016 and 2023, and are estimated to increase by an additional 52% by 2030. Antimicrobial use and misuse remains high among people with serious illness and at end of life, despite scarce evidence of benefit. In addition, the overuse and misuse of antimicrobials at end of life further exacerbate antimicrobial resistance, which is a substantial public and global health concern. This Personal View synthesises global interprofessional and multidisciplinary perspectives on antimicrobial use, stewardship, and resistance at end of life and implications at patient and population levels. Guidelines have been summarised from multiple countries, some of which offer guidance for antimicrobial use at end of life. Countries at different income levels are included (ie, Chile, Colombia, Germany, India, Malaysia, Nigeria, Rwanda, and Sudan) to show how practice norms and standards vary internationally. These examples are combined with a case of non-beneficial end-of-life antimicrobial use and clinical guidance for patient and family communication regarding antimicrobial treatment. This Personal View also provides recommendations to improve antimicrobial stewardship with the goal of engaging multidisciplinary stakeholders and decreasing inappropriate antimicrobial use at end of life.