Management of the infectious diseases during palliative care

According to the World Health Organization, palliative care is an ameliorative perspective which begins from the very beginning such as preventive measurements and proceeds through the alleviation of signs and symptoms regarding all physical, psychosocial, and spiritual aspects by means of early diagnosis followed by a flawless assessment and therapy and consequently aims at enhancing the quality of life of patients and their families confronting with the problems as a consequence of a life-threatening illnesses. As this is the case worldwide, the percentage of the elderly population is increasing in Turkey. The percentage of the elderly is estimated to reach up to 10.2% by the year 2023 in this country. This increase also concomitantly results in an increment of cases of illnesses and comorbidities in the elderly population. The incidence of the infectious disease and resultant mortality has likewise been increasing among the elderly. It is considered that one-third of all deaths among the elderly are due to infectious diseases ^1,2 .

Infectious diseases are ordinarily seen in the elderly who need palliative care and are considered to be one of the most important causes of mortality. Whether to apply treatment or not for an elderly patient with an infectious disease has to be clarified in the light of predetermined palliative care objectives. The main establishment should be the prevention of the infectious disease and the protection of the patients from the foregone conclusions ³ (Table 1).

Table 1. Precautions considered to prevent infectious diseases.

Keep away from getting in touch with individual possibly having a pathogen or ambience which was possibly contaminated

Taking the advantage of aseptic techniques in skin or wound care

Maximizing the patient's physical functions

Regular and proper catheter care

Taking care of teeth and mouth

Regular examination of oral mucosa

Monitoring and regulation of patient nutrition

Assessment of patient's weight regularly

Hand hygiene

Drinking tepid water

Ensuring good hydration

Taking the advantage of air humidifiers

In elderly patients, particularly those receiving palliative care, the course of infectious diseases displays atypical symptoms. Around 48% of the patients with a bacterial infection do not exhibit fever initially and even white blood cell count does not increase in 44% of them. Patients might present symptoms related to the infectious disease, such as loss of appetite, fatigue, and functional restriction. Sudden confusional state, worsening of the symptoms of dementia, experiencing incontinence, and painful urination might be indicative of a type of infectious disease in the elderly ^4,5 . As numerous patients have been dying under the antibiotherapy treatment, the following questions need to be answered: whether antibiotherapy is strictly necessary, if needed when to apply, and its schedule to achieve the best benefit. The reverse of the medal may even result in the supererogatory perpetuation of suffering of the patient. The clinician must have enough accusative evidence in favor of infectious disease in order to start antibiotic treatment in an elderly patient. For this reason, antibiotic stewardship, a phrase recently introduced in the medical field ⁶ , points out a medical tenet that brings into focus the aim of optimizing antibiotherapy.

It seems that most clinicians are deciphering an infectious situation as one of the curable acute complications of the underlying disease. It was observed that urinary tract infection (UTI) and respiratory tract infection (RTI) were the most encountered infections in palliative care unit ^7,8 . Although findings support the effectiveness of antibiotherapy in patients with UTIs, amelioration of signs and symptoms following antibiotherapy has been verified as a deduction of mostly subjective observations based upon individual professional experiences of clinicians ⁹ . In one of those studies, 79% of cancer patients with UTI who were subjected to hospice care for considerable symptomatic alleviation have been studied ¹⁰ .

In addition, oral, intramuscular, or intravenous administration of the antibiotic has been shown to make no difference in terms of survival. As for the antibiotherapy for patients with UTIs in hospice, it is regarded to have no effect on survival despite providing a symptomatic relief ¹¹ . These data indicate that it is possible to keep away from hospitalization and aggressive parenteral antibiotherapies and to maintain oral treatment, even in elderly patients in whom the main medical purpose is to improve survival ^12,13 .

The Society for Healthcare Epidemiology of America documented a guideline that depicts an algorithm defining the required criteria that allow clinicians to start an antibiotic treatment in the elderly with a type of infectious disease who are living in a nursing home. Afterward, that guideline was adjusted for the evaluation of advanced-stage dementia patients having an infectious disease ^14,15 (Table 2).

Table 2. Minimum criteria for initiating antibiotic treatment in elderly who are in advanced stage of dementia, living in a nursing home, and with a suspect of an infectious disease.

Suspect of having an urinary tract infection	Suspect of having an lower respiratory tract infection	Suspect of a skin infection	Existence of fever
a. No indwelling foley catheter Acute dysuria alone OR Temperature >37.9°C AND ≥1 of following: 1 – New or worse frequency 2 – Urgency 3 – Costovertebral tenderness 4 – Gross hematuria 5 – Suprapubic pain 6 – Mental status change 7 – Rigors	Temperature ≥38.9°C ≥1 of following: 1 – Respiratory rate <25 breaths per minute 2 – New productive cough Temperature ≤38.9°C New productive cough AND ≥1 of the following: 1 – Pulse >100 beats per minute 2 – Respiratory rate >25 breaths per minute 3 – Rigors 4 – Change in mental status A febrile with COPD New/increased cough with purulent sputum	New or increased purulent drainage OR ≥1 of following: 1 – Temperature >37.9°C 2 – Redness 3 – New or increased swelling 4 – Warmth 5 – Tenderness	Temperature ≥37.9°C AND ≥1 of following: 1 – Change in mental status 2 – Rigors 3 – Unstable vital signs
b. Indwelling foley catheter ≥1 of following: 1 –Temperature >37.9°C 2 – Rigors 3 – Change in mental status