Antimicrobial Use in Patients on a Comfort Care Protocol: A Retrospective Cohort Study.

BACKGROUND

Antimicrobials are commonly used in patients near the end of life, but the percentage and predictors of patients prescribed antibiotics while hospitalized on a comfort care protocol are unknown.

OBJECTIVE

To determine how often patients in the acute care setting are continued on antimicrobials when they are transitioned to comfort-focused care and to describe patient characteristics correlated with antimicrobial use.

DESIGN

Retrospective cohort study conducted from June 2012 to August 2014.

SETTING

Two interrelated academic medical centers.

PATIENTS

Inpatients >18 years old transitioned to a comfort care protocol.

MEASUREMENTS

Administration of antimicrobials to patients on the comfort care protocol.

ANALYSIS

We generated descriptive statistics and used a modified Poisson regression to estimate unadjusted and adjusted associations along with 95% confidence intervals (CIs) and p-values.

RESULTS

There were 1881 patients included in the study; 77% of patients ultimately transitioned to a comfort care protocol received antimicrobials during their admission and 82% died in hospital. Of the 711 alive at ≥24 hours after comfort care orders, 111 (15.6%) were still on antimicrobials. After adjusting for age, a documented infection was positively associated with being on antibiotics (adjusted relative risk [ARR] = 1.46, 95% CI: 1.00-2.12, p = 0.05). Patients in the medical and surgical intensive care units (ICUs) were less likely than those on medicine to receive antimicrobials (MICU ARR = 0.32, 95% CI: 0.14-0.72, p = 0.01; SICU/Neuro ARR = 0.32, 95% CI: 0.12-0.85, p = 0.02).

CONCLUSIONS

Antimicrobial use is relatively high in hospitalized patients near the end of life, even when the goal is comfort.