Palliative care patients are susceptible to infection due to their underlying condition and treatment. Studies have shown a prevalence of infection at the time of death in 47–63% of patients with advanced cancer, and large proportions of patients in specialist palliative care units receive antibiotics in the last week of life.
Antibiotics may be considered non-aggressive therapy and appropriate, even when other treatments such as intravenous fluids or chemotherapy are not. However, they carry significant risks including treatment related side effects, adverse drug reactions, drug interactions and Clostridium difficile infection. Moreover, there are concerns about inappropriate antibiotic use driving increasing antimicrobial resistance both for individual patients, healthcare institutions and society at large.
NHS England introduced antimicrobial stewardship in 2012 with the aim of optimising antibiotic use for individual patients, preventing the overuse and misuse of antibiotics and minimising the development of resistance at patient, organisation and community levels.
An audit in 2015 showed that 50% of hospice in-patients received at least one antibiotic course, many of which were used in empirically for a suspected chest or urinary infection during the last two weeks of life. Since this time, we have demonstrated a significant reduction in the use of antimicrobials within our hospice. Initiatives have included; the introduction of ‘Start Smart then Focus’ guidance, weekly antibiotic dashboards shared with clinical teams, and encouraging earlier discussions with patients and their families/carers. We have also provided education to improve documentation around goals of therapy, increase confidence in stopping antibiotic treatment when considered futile, and improve the use of microbiology specimen requests and results.
We continue to educate and support medical and nursing teams as well as patients and their families to view antibiotic use like other medicines and processes – that significant risks need to be weighed against the potential benefits.
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