The Pattern of Antimicrobial Use for

Palliative Care In-Patients During

the Last Week of Life
Mohammed Abduh Al-Shaqi, MBBS, DCH, ABFM, PallCM
1
,
Ahmad Hasan Alami, Rph
2
, Ali Saeed Al- Zahrani, MD, PhD
2
,
Batlah Al-Marshad
2
, Abdulrahman Bin- Muammar
2
, and
Al-Shahri MZ, MBChB, ABFM, FFCM, ABHPM
2
Abstract
Background: In terminally ill cancer patients approaching the dying phase, liberal use of antimicrobials is often viewed by
palliative care experts as irrational. No previous reports have reviewed current antimicrobial use in palliative care settings in
Saudi Arabia. Objective: The objective of this study was to explore the pattern of antimicrobial use in a tertiary palliative
care unit (TPCU) during the last week of patients life. Methods: Medical records of all patients who died in the TPCU over
a 14-month period were reviewed for demographics as well as the frequency and rationale of antimicrobial use during the
patients last week of life. Information on antimicrobial use was obtained from a computerized pharmacy database.
Results: Of 138 patients who died with advanced cancer in the TPCU, 87 (63%) were on one or more antimicrobials during their
last week of life. Antibiotics were more frequently used as compared to antifungal and antiviral agents, 64 (46.4%); 45 (32.6%); and
2 (1.5%), respectively. About one third (31.3%) of patients who received antibiotics during their last week of life were prescribed
more than one antibiotic. Antimicrobials were mostly given systemically (79%) rather than topically (21%). The most common
rationales for antimicrobial prescribing were oral thrush in 36 patients (25.4%), wound care in 29 patients (20.4%), and on empiri-
cal basis in 29 patients (20.4%). Conclusions: The current practice of antimicrobial prescribing, especially for patients who are
eminently dying, may need to be reviewed. Initiation of antimicrobial treatment in this group of patients should be based on clear
treatment goals and desired outcomes, considering views of patients and families.
Keywords
terminal-ill cancer, antimicobials, palliative care, last week, patient, family
Introduction
Traditionally, antimicrobial therapy has generally been
considered non-aggressive. More recently, however, this view
is becoming debatable in view of the rising cost of newer anti-
microbial agents and the long list of potential side effects. The
argument against nonaggressiveness of antimicrobial therapy
may even be more valid when such agents are prescribed to
terminally ill patients approaching the active dying phase.
1,2
The 10-bedded Tertiary Palliative Care Unit (TPCU) in King
Faisal Specialist Hospital and Research Center (KFSHRC),
Riyadh, Saudi Arabia, is the one and only of its kind in the
country. The patients admitted to this unit are essentially
patients with cancer who are not for cardiopulmonary resusci-
tation and for whom no disease-modifying therapy is possible.
3
There are several other palliative care programs in the country
that are planning to establish similar specialized tertiary units
in the foreseeable future. The authors felt that situational
analysis research at this stage is important and may help all
palliative care programs in the country to understand the
current practice and look for opportunities to improve. We
were under the impression that antimicrobials are probably
being used more liberally than should be in our TPCU even
when patients are approaching the dying phase. The objective
of this study was to explore the pattern of antimicrobial use
in our TPCU during the patients last week of life.
Methods
We retrospectively reviewed medical records of all patients
who died in the TPCU between June 2007 and July 2008,
inclusive. Data on patients characteristics, cancer diagnoses,
length of hospital stay, and rationale for antimicrobial use was
obtained from the medical records. A pharmacist
1
Riyadh Military Hospital, Riyadh, Saudi Arabia
2
King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
Corresponding Author:
Mohammed Abduh Al-Shaqi, Section of Palliative Care Medicine, Oncology
Department, Riyadh Military Hospital, Riyadh 11159, Saudi Arabia
Email: malshaqi@rmh.med.sa
American Journal of Hospice
& Palliative Medicine

29(1) 60-63
The Author(s) 2012
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1049909111406900
http://ajhpm.sagepub.com
coinvestigator retrieved data on antimicrobial use from the
computerized database of our in-patient pharmacy. The last
week of life was determined to be 7 days preceding the time
of death as documented in the medical records. For patient to
be considered on antimicrobials during the last week of life,
they should have been on at least 1 antibiotic, antifungal, or
antiviral agent regardless of whether or not the agent was
stopped before death. Data was analyzed using the Statistical
Package for the Social Sciences. Descriptive statistics included
frequencies, means, medians, ranges, and percentages. Analy-
tic statistics included chi-square tests and unpaired Student t-
test. P value of <.05 was considered statistically significant.
Results
A total of 138 patients, of whom 78 (56.5%) were females, died
in the TPCU during the study period. The mean (SD) age was
48.4 (17.8) years and the mean (SD) length of hospital stay was
25.1 (39.5) days. All patients had a cancer diagnosis with the
most common primary cancers being gastrointestinal (29%),
breast (13.8%), head and neck (12.3%), bone (11.6%), gyneco-
logical (9.4%), and hematological (7.2%). Table 1 shows the
details of patient characteristics.
In all, 87 patients, constituting 63%of the study population,
were on one or more antimicrobials during their last week of
life; 64 patients (46.4%) were on antibiotics, 45 (32.6%) on
antifungal agents, and 2 (1.5%) on antiviral agents. About one
third of patients on antibiotics 20 (31.3%) have received more
than one antibacterial agent, either simultaneously or sepa-
rately, during their last week of life. Antimicrobials were
mostly given intravenously (42%) or enterally (37%) rather
than topically (21%), as shown in Table 2.
The most common rationales for antimicrobial prescribing
were oral thrush in 36 patients (25.4%), wound care in 29
(20.4%), and empirically in 29 (20.4%), see Table 3. Metroni-
dazole was the most commonly prescribed antibiotic, received
by 28 patients, followed by ceftriaxone (18 patients) and piper-
acillin/tazobactam (12 patients). Of the 45 patients who were
on antifungal agents, 34 (75.6%) received nystatin. Table 4
illustrates the antimicrobials used and their respective frequen-
cies. The common organisms reported included Pseudomonas
aeruginosa 12 (24.5%), Escherichia coli 8 (16%), and staphy-
lococcus species 8 (16%) as shown in Table 5. No statistically
significant association was found between the use of antimicro-
bials and the patients age, sex, or cancer diagnosis.
Discussion
Palliative care approach focuses on interventions that are sup-
posed to improve the quality of life and relieve suffering of
patients and families facing problems associated with life-
threatening conditions.
4
Ideally, toward the end of life when
comfort becomes the main goal of care, health care approach
shall adopt the least aggressive interventions with maximum
comforting potential. Experts in palliative care usually per-
ceive antimicrobial use in the last week of life as an aggressive
intervention that is often futile and cost-ineffective.
1,5,6
The use
of antibiotics may improve symptoms in a majority of patients
with urinary tract infections.
7
However, observational studies
suggest that antibiotic treatment may bring modest
Table 1. Patient Characteristics (n 138)
Frequency Percentage
Sex
Male 60 43.5
Female 78 56.5
Age (years)
Mean 48.4
Standard deviation 17.8
Median 50.5
Range 3-93
Length of hospital stay (days)
Mean 25.1
Standard deviation 39.5
Median 15.5
Range 1-372
Primary cancer sites Frequency Percentage
Gastrointestinal 40 29
Breast 19 13.8
Head and neck 17 12.3
Bone 16 11.6
Gynecological 13 9.4
Hematological 10 7.2
Lung 7 5.1
Genitourinary 6 4.3
Unknown 6 4.3
Nervous system 4 2.9
Table 2. The Frequency and Route of Administration of Various
Antimicrobials
Frequency Percentage
Patients on 1 antimicrobial 87 63
Patients on antibiotics 64 46.4
Received 1 antibiotic 44
Received >1 antibiotic 20
Patients on antifungal agents 45 32.6
Patients on antiviral agents 2 1.5
Route of administration
Parenteral 50 42
Enteral 45 37
Topical 25 21
Table 3. Rationale for Antimicrobial Use
Rationale Frequency Percentage
Oral thrush 36 25.4
Empirical 29 20.4
Wound care 29 20.4
Positive urine culture 22 15.5
Chest infection 12 8.5
Positive blood culture 8 5.6
Others 6 4.2
Al-Shaqi et al 61
symptomatic relief in only about 15% to 48% of terminally ill
cancer patients, with no survival benefits.
8,9
A previous report from Canada has suggested that
antibiotic treatment for terminally ill cancer patients is more
predominant in an acute care hospital and a TPCU than in
hospice setting.
6
Reports from Canada, Hong Kong, and
South Korea have shown higher prevalence of antibiotic use
among terminally ill cancer patients compared to our find-
ings.
6,8,10
Nonetheless, we believe that the use of antimicro-
bials in our TPCU is a fairly common practice even when
patients are in their final days of life. Indeed, close to one
third of patients who received antibiotics in our sample
were on more than one antibiotic during their last week of
life. Our study shows also that, similar to other researchers
findings, antimicrobials are not uncommonly prescribed on
empirical basis rather than to treat specific infections based
on proven antibiotic susceptibility.
10
In a hospice setting in the United States of America, the major-
ity of patients chose either touse antimicrobials onlyfor symptom
control or not at all.
7
It is difficult to predict with certainty what
would our patients choices might be if they were asked similar
questions uponadmissiontoour TPCU. However, we suspect that
a significant proportion of patients and families might prefer
using antimicrobials even when the disease is far advanced and
the desirable outcomes of antimicrobial use are minimal. We base
our assumption on the impression that antimicrobials are still
commonly perceived by the community as nonaggressive treat-
ment options. Obviously, this assumption calls for substantiation
through research.
A recent study from Germany has shown that initiation
of antibiotic therapy in patients with advanced cancer is
usually initiated by physicians, while the more difficult
decision on withdrawal of the treatment is reached based
on discussion with members of the interdisciplinary team.
11
In our setup, initiating and discontinuing antimicrobial ther-
apy is solely a physicians decision. A general discussion
with the patient and the family about the concept of pallia-
tive care and its emphasis on quality of life takes place rou-
tinely before admitting patients to our palliative care
program. However, no detailed discussions with patients
and families are usually held to clarify the issue of antimi-
crobial use prior (or upon admission) to the TPCU.
Conclusion
The use of antimicrobials in patients with advanced cancer
approaching their dying phase is a common practice in our
TPCU. Due to the significant cost, long list of potential adverse
effects, and the risk of antimicrobial resistance in view of
paucity of novel antimicrobials in the pipeline, the use of
antimicrobials in terminally ill cancer patients shall be
rationalized and robustly justified.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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Antimicrobial Frequency
Antibiotics
Metronidazole 28
Topical 15
Systemic 13
Ceftriaxone 18
Piperacillin/tazobactam 12
Meropenum 4
Others 15
Antifungal agents
Nystatin 34
Clotrimazole 5
Fluconazole 3
Itraconazole 1
Ketoconazole 1
Caspofungin 1
Antiviral agents
Acyclovir 2
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Organism Frequency Percentage
Pseudomonas aeruginosa 12 24.5
Escherichia coli 8 16.3
Staphylococcus species 8 16.3
Klebsiella pneumoniae 5 10.2
Streptococcus species 5 10.2
Others 11 22.5
62 American Journal of Hospice & Palliative Medicine

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Al-Shaqi et al 63