Charlotte Woods-Hill, MD, MSHP
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
Disclosure information not submitted.
Erica Addesa, CRNP
Nurse Practitioner
Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Hannah Stinson, MD
Assistant Professor
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Wynne Morrison, MD, MBE,FCCM
Director of the Justin Michael Ingerman Center for Palliative Care
Childrens Hospital of Philadelphia
Cherry Hill, New Jersey, United States
Disclosure information not submitted.
Kathleen Chiotos, MD, MSCE
Assistant Professor
Childrens Hospital of Philadelphia, United States
Disclosure information not submitted.
Title: Antibiotic Use at the End of Life in Critically Ill Children
INTRODUCTION/HYPOTHESIS:
Antibiotics are commonly prescribed to patients receiving hospice care, but few studies have characterized patterns of antibiotic use in patients at the end of life in the pediatric intensive care unit (PICU). We hypothesized that most patients would receive antibiotics within 7 days of death, including patients without evidence of a bacterial infection.
Methods:
We conducted a single-center, retrospective cohort study including a sample of children 0-18 years of age who died between January 2014 and February 2019 in a quaternary care PICU. Children who died within 48 hours of PICU admission were excluded. Antibiotic exposures, presence of an infection, and clinical variables were assessed within 7 days of death. Patients were classified as having definite infection, probable infection, possible infection, definitely no infection, undergoing an evaluation for infection, or receiving antibiotics for prophylaxis/non-infectious conditions only using standardized definitions. Patients with multiple infections were classified as the infection diagnosed most definitively.
Results:
186 patients were included, of which 151 (83%) received at least one antibiotic within 7 days of death. Definite infections were present in 35 (22%), probable infections in 21 (13%), possible infections in 38 (24%), no infection in 11 (7%); 35 (22%) and 16 (10%) received antibiotics for empiric therapy or for prophylaxis/non-infectious conditions only, respectively. All patients with possible, probable, or definite infections were treated with antibiotics. Most patients had active do not attempt resuscitation (DNAR) orders (100 patients, 67%) and over a third had palliative care consults (58 patients, 39%). Infectious disease was consulted in 79 (53%), including 18 (37%) of patients with possible or no infection. Bacterial infection was the primary cause of death in 18 children (11%) and a possible contributing cause in 82 (55%).
Conclusions:
Antibiotics are frequently prescribed within 7 days of death in critically ill children, and over a third lacked a definite or probable infection. Future studies related to the role of antibiotics in symptom management and the feasibility of deprescribing antibiotics at the end of life are needed.