Redefining Antibiotic Use in Palliative Care: Insights From End-of-Life Prescribing Patterns

Dear Editor,

I am writing regarding the article by Miranda-Chavez et al titled “The Use of Antibiotics at the End of Life: A Cross-Sectional Study.” ¹ The study is well-conceived, addressing an important and often overlooked issue in palliative care: the clinical and ethical considerations surrounding end-of-life antibiotic use. By assessing antibiotic prescribing patterns and the frequency of antibiotic administration without confirmed infection, this article contributes meaningfully to the literature on palliative care practices and antibiotic stewardship. The authors conducted a cross-sectional study examining antibiotic use patterns among terminally ill patients in a Peruvian hospital. The finding that 93.7% of patients received antibiotics, with 42.3% lacking an identified infectious focus, raises significant concerns about antimicrobial stewardship. However, certain methodological and analytical aspects warrant further discussion.

The strengths of this study:

1.  The study addresses a crucial knowledge gap regarding antibiotic prescribing patterns in low- and middle-income countries, particularly in end-of-life care.

2.  The methodology for data collection appears robust, with independent extraction by 2 researchers and validation by a third specialist.

3.  The statistical analysis appropriately used Poisson regression with robust variance for the multivariate analysis.

Methodological Concerns

First, the study’s sample size determination should have been explicitly discussed. While the authors conducted a census of all deaths in 2023, a power analysis would have strengthened the study design and helped readers understand if the sample could detect meaningful associations. Noordzij et al noted that sample size calculations are crucial even in observational studies to ensure reliable conclusions. ²

Second, the definitions of “terminally ill” patients were not operationalised. This raises questions about the population studied and potential selection bias. The World Health Organization emphasises the importance of clear definitions in palliative care research to ensure comparability across studies.

Third, while the authors collected data on previous palliative care exposure, the meagre rate (2.1%) suggests potential underreporting or classification bias. This finding deserves more attention, as it might significantly influence antibiotic prescribing patterns.

Reporting Considerations

The STROBE checklist recommends several elements that were inadequately addressed:

1.  The authors did not discuss potential sources of bias in detail. Selection bias might have occurred since only hospital deaths were included, potentially missing patients who died at home or were transferred to other facilities.

2.  The handling of missing data should have been explicitly described. While the authors mentioned excluding cases with incomplete medical records, the number of excluded cases and their characteristics were not reported.

3.  The external validity of the findings deserves more careful consideration. The single-centre design in a tertiary hospital limits generalizability, particularly given the diverse healthcare settings in Peru.

Clinical Implications

The high rate of antibiotic use without identified infectious foci (42.3%) is particularly concerning. This finding aligns with recent systematic reviews showing widespread inappropriate antibiotic use in end-of-life care. ³ However, the authors could have strengthened their discussion by:

1.  Providing more context about local antibiotic prescribing guidelines and resistance patterns

2.  Discussing the economic implications of potentially unnecessary antibiotic use

3.  Offering specific recommendations for improving antimicrobial stewardship in end-of-life care

Future Research Directions

This study highlights several areas requiring further investigation:

1.  Qualitative research exploring physician decision-making regarding antibiotic prescribing in end-of-life care

2.  Multi-centre studies, including different levels of healthcare facilities

3.  Intervention studies testing antimicrobial stewardship programs designed explicitly for palliative care settings

The Use of Antibiotics at the End of Life is a compelling study that contributes valuable insights into an area of palliative care practice that demands ongoing evaluation and improvement. The study highlights the need for standardised guidelines to help physicians make evidence-based decisions about antibiotic use in terminal patients, balancing patient comfort with the imperative to combat antibiotic resistance. While methodological refinements, such as more apparent sample size justification and expanded statistical analysis, would strengthen the study, the authors’ efforts to illuminate this critical issue are commendable. Future studies could build on these findings by exploring longitudinal data or incorporating qualitative analyses to capture the nuanced decision-making processes behind end-of-life care.

Helan Rajan
Department of Otorhinolaryngology and Head & Neck Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India

S. Johnson
Department of Community Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India

Bhagyashree Sharma
Department of Pharmacology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India