RESUMO
BACKGROUND: Antimicrobial use during end-of-life care of older adults with advanced cancer is prevalent. Factors influencing the decision to prescribe antimicrobials during end-of-life care are not well defined. AIM: To evaluate factors influencing medicine subspecialists to prescribe intravenous and oral antimicrobials during end-of-life care of older adults with advanced cancer to guide an educational intervention. DESIGN: 18-item single-center cross-sectional survey. SETTING/PARTICIPANTS: Inpatient medicine subspecialists in 2018. RESULTS: Of 186 subspecialists surveyed, 67 (36%) responded. Most considered withholding antimicrobials at the time of clinical deterioration during hospitalization (n = 54/67, 81%), viewed the initiation of additional intravenous antimicrobials as escalation of care (n = 44/67, 66%), and believed decision-making should involve patients or surrogates and providers (n = 64/67, 96%). Fifty-one percent (n = 30/59) of respondents who conducted advance care planning did not discuss antimicrobials. Barriers to discussing end-of-life antimicrobials included the potential to overwhelm patients or families, challenges of withdrawing antimicrobials, and insufficient training. CONCLUSIONS: Although the initiation of additional intravenous antimicrobials was viewed as escalation of care, antimicrobials were not routinely discussed during advance care planning. Educational interventions that promote recognition of antimicrobial-associated adverse events, incorporate antimicrobial use into advance care plans, and offer communication simulation training around the role of antimicrobials during end-of-life care are warranted.
Assuntos
Planejamento Antecipado de Cuidados , Anti-Infecciosos , Neoplasias , Assistência Terminal , Idoso , Estudos Transversais , Humanos , Neoplasias/tratamento farmacológicoRESUMO
Among 300 advanced cancer patients with potential urinary tract infection (UTI), 19 had symptomatic UTI. Among remaining patients (n = 281), 21% had asymptomatic bacteriuria or candiduria, and 14% received inappropriate therapy for 279 antimicrobial days. Bacteriuria or candiduria predicted antimicrobial therapy. At 10,000 to <100,000 CFU/mL, the incidence rate ratio [IRR] was 16.9 (95% confidence interval [CI], 6.0-47.2), and at ≥100,000 CFU/mL, the IRR was 27.9 (95% CI, 10.9-71.2).
Assuntos
Antibacterianos/uso terapêutico , Prescrição Inadequada/estatística & dados numéricos , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/microbiologia , Idoso , Idoso de 80 Anos ou mais , Bacteriúria/complicações , Bacteriúria/tratamento farmacológico , Candidíase/complicações , Candidíase/tratamento farmacológico , Estudos de Coortes , Connecticut , Feminino , Hospitais Universitários , Humanos , Masculino , Neoplasias/complicações , Assistência Terminal , Infecções Urinárias/complicaçõesRESUMO
BACKGROUND: Serratia marcescens is an opportunistic gram-negative rod which typically infects compromised hosts. OBJECTIVES: To identify risk factors, signs, and outcomes associated with non-epidemic S marcescens bacteremia in a neonatal intensive care unit (NICU). METHODS: The records of infants with S marcescens bacteremia while in the Yale-New Haven Hospital NICU from 1980-2004 were reviewed. A matched case-control study was performed by comparing each case of S marcescens to 2 uninfected controls and 2 cases of Escherichia coli bacteremia. RESULTS: Twenty-five sporadic cases of S marcescens bacteremia were identified. Eleven available isolates were determined to be different strains by pulse field gel electrophoresis. Infants with S marcescens bacteremia had median gestational age and birth weight of 28 weeks and 1235 grams, respectively. Compared to matched, uninfected controls, infants with S marcescens bacteremia were more likely to have had a central vascular catheter (OR = 4.33; 95% CI (1.41 to 13.36)) and surgery (OR = 5.67; 95% CI (1.81 to 17.37)), and had a higher overall mortality (44% vs 2%; OR = 38.50; 95% CI (4.57 to 324.47)). Compared to E coli matched controls, infants with S marcescens bacteremia had later onset of infection (median of 33 days of life vs 10; p<0.001), prolonged intubation (OR = 5.76; 95% CI (1.80 to 18.42)), and a higher rate of CVC (OR = 7.77; 95% CI (2.48 to 24.31)) use at the time of infection. A higher rate of meningitis (24% vs 7%; OR = 3.98; 95% CI (1.09 to 14.50)) was observed with S marcescens bacteremia compared to E coli. CONCLUSIONS: S marcescens bacteremia occurs sporadically in the NICU, primarily in premature infants requiring support apparatus late in their hospital course. Associated meningitis is common and mortality high.