Considering Inpatient Antibiotic Use at End of Life for Children With Cancer

IF 3.2 2区医学 Q2 CLINICAL NEUROLOGY

Journal of pain and symptom management Pub Date : 2025-04-10 DOI:10.1016/j.jpainsymman.2025.02.066

Holly Spraker-Perlman MD, Gabriela Maron MD MS, Elizabeth Swift MSN CPNP-AC, Cynthia Marrero Sepulveda MD MS, Deena Levine MD FAAHPM

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Though nuanced, communication surrounding use of antibiotics at end of life is critical.</div></div><div><h3>Abstract</h3><div>Despite efforts to enhance end-of-life (EOL) care for cancer patients through decreased utilization of aggressive medical treatments and hospital-based services (1,2) including curbing antibiotics at EOL to promote stewardship (3,4), 87% of hospitalized adult cancer patients studied received antibiotics in the last week of life, while < 50% had a documented infection.(5) Many children with advanced cancer die in the inpatient setting, and despite best efforts to provide goal-concordant care, antibiotic use might not be addressed due to population-based routine use of antibiotics for prophylaxis and empiric treatment, healthcare practitioners beliefs and/or discomfort with EOL communication to facilitate shared decision-making. Better understanding of antibiotic prescription practices for children with cancer nearing EOL is essential to inform guidelines for best practices.</div></div><div><h3>Objectives</h3><div>To improve communication and documentation around antibiotic use at EOL to promote goal-concordant care, we aim to describe antibiotic use in children nearing EOL at an academic children's cancer center.</div></div><div><h3>Methods</h3><div>Through retrospective chart review, data was abstracted for children with malignancy experiencing inpatient death to determine the incidence of antibiotic, antiviral, and antifungal use in the last 2 weeks of life. Prescription and microbiological data were correlated to determine presence of infection. Progress notes were reviewed to determine if discussion surrounding antibiotic utilization was documented either by the Palliative Care (PC) or Infectious Disease (ID) teams. Patient demographics, disease and EOL variables were also compiled.</div></div><div><h3>Results</h3><div>Over a 10-year period 303 children died inpatient with 73.6% (n=223) receiving antibiotics at EOL. Most antibiotics were given without evidence of infection (65.9% with negative ID testing). Patients concurrently received 1-5 antibiotics at time of death. Seventy-nine patients (26%) had documented discussions regarding changing or discontinuing antimicrobials.</div></div><div><h3>Conclusion</h3><div>The use of antibiotics at the EOL for children with cancer is prevalent. Standardized processes may facilitate anticipatory guidance for goal-concordant care.</div></div><div><h3>References</h3><div>1. Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S. Identifying Potential Indicators of the Quality of End-of-Life Cancer Care From Administrative Data. J Clin Oncol. 2003;21(6):1133-1138. 2. Hassett MJ, McNiff KK, Dicker AP, et al. High-Priority Topics for Cancer Quality Measure Development: Results of the 2012 American Society of Clinical Oncology Collaborative . Cancer Measure Summit. J Oncol Pract. 2014;10(3):e160-e166. 3. Macedo F, Nunes C, Ladeira K, et al. Antimicrobial therapy in palliative care: an overview. Support Care Cancer. 2018;26(5):1361-1367. 4. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51-e77. 5. Thompson AJ, Silveira MJ, Vitale CA, Malani PN. Antimicrobial Use at the End of Life Among Hospitalized Patients With Advanced Cancer. Am J Hosp Palliat Med. 2012;29(8):599-603. 6. Ananth P, Mun S, Reffat N, et al. A Stakeholder-Driven Qualitative Study to Define High Quality End-of-Life Care for Children With Cancer. 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引用次数: 0

Outcomes

1. Recognize the prevalence of antibiotic use for children with cancer at end of life.

2. Understand the importance of re-addressing treatment choices, including antibiotic use, to reduce suffering and improve goal concordant care for children dying from cancer.

Key Message

Children with cancer who die from their disease, or its complications often die in the inpatient setting, frequently receiving antibiotics at end of life. In some cases, antibiotics may prolong the dying process or contribute to suffering and may not be consistent with goal-concordant care. Though nuanced, communication surrounding use of antibiotics at end of life is critical.

Abstract

Despite efforts to enhance end-of-life (EOL) care for cancer patients through decreased utilization of aggressive medical treatments and hospital-based services (1,2) including curbing antibiotics at EOL to promote stewardship (3,4), 87% of hospitalized adult cancer patients studied received antibiotics in the last week of life, while < 50% had a documented infection.(5) Many children with advanced cancer die in the inpatient setting, and despite best efforts to provide goal-concordant care, antibiotic use might not be addressed due to population-based routine use of antibiotics for prophylaxis and empiric treatment, healthcare practitioners beliefs and/or discomfort with EOL communication to facilitate shared decision-making. Better understanding of antibiotic prescription practices for children with cancer nearing EOL is essential to inform guidelines for best practices.

Objectives

To improve communication and documentation around antibiotic use at EOL to promote goal-concordant care, we aim to describe antibiotic use in children nearing EOL at an academic children's cancer center.

Methods

Through retrospective chart review, data was abstracted for children with malignancy experiencing inpatient death to determine the incidence of antibiotic, antiviral, and antifungal use in the last 2 weeks of life. Prescription and microbiological data were correlated to determine presence of infection. Progress notes were reviewed to determine if discussion surrounding antibiotic utilization was documented either by the Palliative Care (PC) or Infectious Disease (ID) teams. Patient demographics, disease and EOL variables were also compiled.

Results

Over a 10-year period 303 children died inpatient with 73.6% (n=223) receiving antibiotics at EOL. Most antibiotics were given without evidence of infection (65.9% with negative ID testing). Patients concurrently received 1-5 antibiotics at time of death. Seventy-nine patients (26%) had documented discussions regarding changing or discontinuing antimicrobials.

Conclusion

The use of antibiotics at the EOL for children with cancer is prevalent. Standardized processes may facilitate anticipatory guidance for goal-concordant care.

References

1. Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S. Identifying Potential Indicators of the Quality of End-of-Life Cancer Care From Administrative Data. J Clin Oncol. 2003;21(6):1133-1138. 2. Hassett MJ, McNiff KK, Dicker AP, et al. High-Priority Topics for Cancer Quality Measure Development: Results of the 2012 American Society of Clinical Oncology Collaborative . Cancer Measure Summit. J Oncol Pract. 2014;10(3):e160-e166. 3. Macedo F, Nunes C, Ladeira K, et al. Antimicrobial therapy in palliative care: an overview. Support Care Cancer. 2018;26(5):1361-1367. 4. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51-e77. 5. Thompson AJ, Silveira MJ, Vitale CA, Malani PN. Antimicrobial Use at the End of Life Among Hospitalized Patients With Advanced Cancer. Am J Hosp Palliat Med. 2012;29(8):599-603. 6. Ananth P, Mun S, Reffat N, et al. A Stakeholder-Driven Qualitative Study to Define High Quality End-of-Life Care for Children With Cancer. J Pain Symptom Manage. 2021;62(3):492-502.

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考虑癌症儿童生命末期住院抗生素的使用

Outcomes1。认识到患有癌症的儿童在生命末期使用抗生素的普遍情况。了解重新处理治疗选择的重要性，包括抗生素的使用，以减少癌症死亡儿童的痛苦和改善目标和谐护理。死于癌症或其并发症的癌症儿童往往死于住院环境，往往在生命结束时接受抗生素治疗。在某些情况下，抗生素可能延长死亡过程或增加痛苦，可能与目标一致的护理不一致。尽管有细微差别，但围绕生命末期抗生素使用的沟通至关重要。尽管通过减少积极的药物治疗和医院服务的使用（1,2）来加强癌症患者的临终关怀（EOL），包括在EOL中限制抗生素以促进管理（3,4），87%的住院成年癌症患者在生命的最后一周接受抗生素治疗，而<；(5)许多患有晚期癌症的儿童死于住院环境，尽管尽了最大努力提供目标一致的护理，抗生素的使用可能无法解决，因为基于人群的常规使用抗生素进行预防和经验治疗，医疗从业人员的信念和/或不适的EOL沟通，以促进共同决策。更好地了解癌症接近生存期儿童的抗生素处方做法，对于制定最佳做法指南至关重要。目的：为了改善EOL期抗生素使用的沟通和记录，以促进目标一致的护理，我们旨在描述一家学术儿童癌症中心接近EOL期儿童的抗生素使用情况。方法通过回顾性图表分析，抽取住院死亡的恶性肿瘤患儿的资料，确定其生命最后2周内抗生素、抗病毒药物和抗真菌药物的使用情况。处方和微生物数据相互关联以确定是否存在感染。审查了进度记录，以确定姑息治疗（PC）或传染病（ID）团队是否记录了围绕抗生素使用的讨论。还编制了患者人口统计、疾病和EOL变量。结果10年间住院患儿死亡303例，其中73.6%（223例）在EOL接受抗生素治疗。大多数抗生素使用无感染证据（65.9%为阴性）。患者在死亡时同时接受1-5种抗生素治疗。79名患者（26%）有关于改变或停止使用抗菌素的讨论记录。结论肿瘤儿童门诊抗生素的使用较为普遍。标准化过程可促进对目标一致性护理的预期指导。李建军，李建军，李建军，李建军。基于数据的癌症临终关怀质量评估。中华临床医学杂志，2003;21(6):1133-1138。2. Hassett MJ, McNiff KK, Dicker AP，等。癌症质量测量发展的高优先级主题：2012年美国临床肿瘤合作协会的结果。癌症措施峰会。中华肿瘤学杂志，2014;10(3):e160-e166。3. 马塞多F， Nunes C, Ladeira K，等。姑息治疗中的抗菌治疗：综述。癌症护理，2018;26(5):1361-1367。4. Barlam TF, Cosgrove SE, Abbo LM，等。实施抗生素管理计划：美国传染病学会和美国卫生保健流行病学学会的指南。临床感染杂志，2016;62(10):e51-e77。5. Thompson AJ, Silveira MJ, Vitale CA, Malani PN。晚期癌症住院患者生命末期抗菌药物的使用中华内科杂志，2012;29(8):599-603。6. Ananth P, Mun S, Reffat N，等。一项利益相关者驱动的定性研究：定义癌症儿童的高质量临终关怀。中华口腔医学杂志，2011;32(3):492- 492。

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来源期刊

Journal of pain and symptom management 医学-临床神经学

CiteScore

8.90

自引率

6.40%

发文量

821

审稿时长

26 days

期刊介绍： The Journal of Pain and Symptom Management is an internationally respected, peer-reviewed journal and serves an interdisciplinary audience of professionals by providing a forum for the publication of the latest clinical research and best practices related to the relief of illness burden among patients afflicted with serious or life-threatening illness.