4d Antibiotics in palliative care

Is it clinically appropriate to either start or withhold antibiotic therapy? The physician needs to weigh the benefits of antibiotics against the risk of prolonging dying

Which antibiotic will be the most effective while minimizing any burden to the patient?

The commonest site for bacterial infection seems to vary between chest and urinary tract in different studies. Soft tissue infections are less common

Antibiotics seem, at best, to offer small improvements in symptom control, with urinary symptoms the most likely to improve

They will not deal with the ethics of commencing, withdrawing or withholding treatment

They will not discuss the difficulties of making a diagnosis of infection in the palliative population

To limit the number of antibiotics that need to be stocked

To reduce the risk of the emergence of multiresistant organisms

To allow audit

Symptom control (pyrexia, pain, bleeding, delirium, dyspnoea, reduce odour)

Advanced disease

Steroids

Immunosuppression from disease or treatment

ECOG status 3 and 4

Evidence of organ dysfunction, e.g. biochemical derangement, delirium

Clinical findings of infection severity, e.g. rigors, peripheral hypoperfusion

Change in vital observations, e.g. hypotension

Anatomical distortion in the affected organ system, e.g. chronic obstructive pulmonary disease, bladder tumour

Cultures and swabs should always be taken prior to starting antibiotics

There is no point in taking samples for microbiological culture and leaving them sitting at room temprature overnight for a morning collection. This will increase the chance of having false-positive and false-negative results

Swabs and urine samples can be stored overnight at 4°C. Investing in a fridge for this purpose seems most appropriate

Blood cultures must be kept at body temperature

Swabs will pick up commensals as well as pathogens so only treat a positive swab result if symptomatic

Bacteriuria is common so a positive MSU/CSU should only be treated if symptomatic

Positive blood cultures should be treated unless there is a good reason not to. Discussion with the microbiology department would help to assess clinical significance

Antibiotic courses can be assumed to be for 5 days unless specifically stated

If the infection is severe then the first 24 hours of antibiotics should be given intravenously (IV)

Parenteral antibiotics IV or IM may need to be used for a prolonged course if the patient cannot swallow tablets or absorb them from the gastrointestinal tract. In this case the reason should be clearly documented in the medical notes

After 48 hours, if the patient’s condition has not improved discuss with microbiology regarding changing antibiotics

Direct antibiotic therapy once culture results are known

Cross-reaction in 15–20% of people between penicillin and the cephalosporins, carbapenems and monobactam.

Remember to consider boosting steroids if necessary

If in doubt—liaise with the local microbiology service