160 - A Pre- and Post-intervention Study to Implement a Successful Antimicrobial Stewardship Program in Palliative Care

Background: In patients receiving palliative care, medical interventions are transitioned away from aggressive and curative attempts to less invasive and more comfort measures. Antimicrobial usage remains a challenging subject in palliative care decisions, where many physicians focus interventions on reduction of patient pain and discomfort, without consideration for adverse effects such as the development of antimicrobial resistance or patient-specific adverse drug events. With limited data on the comfort benefit, we aimed to assess antimicrobial use in patients at the end of life in our institution as well as the success of targeted stewardship interventions in palliative care patients.

Methods: Patients who expired between November 2018 and August 2019 were assessed retrospectively for antimicrobial use during their last 14 days of life. In January 2020, a prospective stewardship initiative began in collaboration with our institution’s palliative care team to focus antimicrobial interventions on patients involved in goals of care discussions.

Results: In our retrospective review of 200 patients, 139 (69.5%) of patients received antimicrobials in their last two weeks of life, with 50% having formal palliative care consultations. The most commonly used antimicrobials were piperacillin-tazobactam (64.7%) and vancomycin (60.4%), with primary indications being pneumonia (34.5%) and empiric coverage/sepsis (24.5%). Of note, 46% of antimicrobial regimens were eligible for optimization through stewardship initiatives. 
 
From January through February 2020, sixteen stewardship interventions were made on thirteen palliative care patients, with an 81.3% acceptance rate. Duration of therapy based on indication and discontinuation of antibiotics following transition to comfort measures only were the most frequent interventions made.Table 1. Baseline Characteristics
Table 2. Antimicrobial Usage - Pre-intervention
Table 3. Prospective Intervention Data


Conclusion: Close of half of patients receiving antimicrobials at the end of life are eligible for interventions to improve antibiotic regimens. These patients are often overlooked in antimicrobial stewardship, and, despite small sample size, our study shows the benefit of targeted stewardship in palliative care populations with an intervention acceptance rate of over 80%.