Antibiotic overuse at end of life: A cautionary tale

March 23rd, 2018

Antibiotics are a powerful tool that, when used appropriately, can cure infections and save lives. But when used without an indication of infection, or in patients with limited life expectancy, they can do more harm than good.

Dr. Timothy Sullivan, infectious disease specialist at Mt. Sinai hospital, knows what can happen when antibiotics are used unnecessarily. His recent blog in Health Affairs highlights the harms of antibiotic overuse at the end of life, a type of overuse that’s rarely talked about but all too common. 

He describes the case of a patient with terminal cancer who developed an infection due to a tumor and was given powerful antibiotics in the hospital. Even though her care team thought it would be too risky to give her chemotherapy or surgery, they kept giving her antibiotics for the infection.

“Antibiotics are a good choice if there’s a finite course, but if the source of the infection is still there, there’s no way to stop the treatment,” said Sullivan. In this case, the patient developed an anti-biotic resistant infection, and was in the hospital for a total of six weeks before deciding to go to hospice care. 

For patients with advanced cancer, almost 90% receive antibiotics in their last week of life.

When exposed to antibiotics, bacteria in the body can quickly develop mutations that make them resistant, Sullivan explains. If some bacteria transfer genes to nearby organisms, a patient can become infected with multiple resistant species. Even scarier, drug-resistant bacteria can easily spread to others within the hospital through contaminated surfaces or skin to skin contact.

This case isn’t exceptional. For patients with advanced cancer, almost 90% receive antibiotics in their last week of life. “You wonder what the benefit would be for giving antibiotics at that point,” said Sullivan.

“We should think of antibiotics as an invasive treatment.”

Why are patients given more and more antibiotics despite the potential for harm and lack of an endpoint for treatment? Unfortunately, doctors often don’t include antibiotic treatment in their conversations with patients about treatment at the end of life. Antibiotics are commonly used in the hospital and not thought of as risky as other kinds of treatment.

“We think of chemotherapy and surgery in terms of risks and benefits, but we don’t apply same type of thinking to antibiotics at the end of life,” said Sullivan, “We should think of antibiotics as an invasive treatment.”

This means discussing the potential benefits and harms of antibiotic treatment with patients that have advanced illness early in their hospitalization. “Some patients will still want to receive aggressive treatment, and we shouldn’t limit that,” said Sullivan, “But either way there needs to be a conversation.”

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