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Health Serv Insights
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SAGE Publications Sage UK: London, England

10.1177/11786329241280812
10.1177_11786329241280812
Original Research
The Use of Antibiotics at the End of Life: A Cross-Sectional Study
Miranda-Chavez Brayan 12
Fuentes-Yufra Andre 12
Hueda-Zavaleta Miguel 1
https://orcid.org/0000-0002-3497-0158
Copaja-Corzo Cesar 34
Flores-Cohaila Javier A. 25
https://orcid.org/0000-0001-7317-9177
Rivarola-Hidalgo Marco 12
1 Facultad de Ciencias de la Salud, Universidad Privada de Tacna, Tacna, Peru
2 Centro de Estudios e Investigación en Educación Médica y Bioética. Universidad Privada de Tacna. Tacna, Perú
3 Unidad de investigación para la generación y síntesis de evidencias en salud, Universidad San Ignacio de Loyola, Lima, Perú
4 Servicio de Infectología, Hospital Nacional Edgardo Rebagliati Martins, EsSalud, Lima, Perú
5 Carrera de Medicina Humana, Universidad Científica del Sur, Lima, Perú
Cesar Copaja-Corzo, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Av. La Fontana 550, Lima 23004, Perú. Email: Csarcopaja@gmail.com
Brayan Miranda-Chavez is also affiliated to Servicio de Geriatría. Hospital Guillermo Almenara Irigoyen. Lima, Perú

Javier A. Flores-Cohaila is also affiliated to Hospital Victor Larco Herrera. Lima, Perú

15 9 2024
2024
17 1178632924128081225 6 2024
19 8 2024
© The Author(s) 2024
2024
SAGE Publications Ltd unless otherwise noted. Manuscript content on this site is licensed under Creative Commons Licenses
https://creativecommons.org/licenses/by-nc/4.0/ This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Objective:

To identify and analyze antibiotics’ prescription patterns and associated factors among terminally ill patients at a hospital in southern Peru.

Methodology:

A cross-sectional analytical study was conducted on adult patients who died in Hospital III Daniel Alcides Carrion in Tacna, Peru, 2023. Data were collected from electronic medical records, focusing on antibiotic use during the last hospitalization. Univariate, bivariate, and multivariate analyses were performed using Poisson regression to adjust for potential confounders.

Results:

The study included 239 patients with an average age of 76. Antibiotics were administered to 93.72% of patients, with 42.46% lacking an identified infectious focus. Ceftriaxone, Meropenem, and Vancomycin were the most used antibiotics. A lower use of antibiotics within 72 hours prior to death was associated with hospitalizations longer than 18 days and having 2 or more comorbidities.

Conclusion:

The high prevalence of antibiotic use at the end of life, often without an infectious focus, suggests a need for better guidelines and education on palliative care to avoid inappropriate antibiotic prescribing. Improved communication between healthcare providers, patients, and families is essential for optimizing end-of-life care.

Antibiotics
palliative care
hospitalization
comorbidities
infections (Source: MeSH)
cover-dateJanuary-December 2024
typesetterts1
==== Body
pmcIntroduction

Although the effectiveness of antibiotic therapy at the end of life is often questioned, it continues to be a mainstay practice in hospital care.1-3 This indication aims to alleviate patient’s symptoms derived from infectious diseases. However, terminally ill patients derive little to no benefit from these interventions. 4 Since infections may not be the primary cause of health deterioration in this phase, the focus should be palliative care and pain relief rather than futile treatments.

Moreover, inappropriate antibiotic use at this stage can lead to further complications. 4 Antibiotic resistance is an escalating global concern, and the excessive prescription of antibiotics to patients who derive no benefit from them can exacerbate this issue. 5 Additionally, side effects such as allergic reactions, gastrointestinal issues, and potential interactions with other palliative medications can worsen patients’ conditions, making their final days less comfortable.

Understanding antibiotic prescribing patterns is essential for enhancing medical practices and care for terminally ill patients. Previous studies indicate that antibiotic prescriptions are prevalent among these patients. A systematic review and meta-analysis that included observational studies from 2000 to 2019 found that terminally ill patients who did not receive palliative care were 50% more likely to be prescribed antibiotics. 6 There is a lack of consensus regarding the benefits of antibiotics in this stage of life. While some physicians routinely prescribe antibiotics, others are more selective, resulting in a variability in clinical practice that requires further investigation and standardization. 7 This variability highlights the need for a deeper evaluation to determine when and how antibiotics should be used in palliative care.

Despite the high frequency of antibiotic prescriptions at the end of life, there is a lack of specific data on this practice in hospitals in less-studied regions, such as in low- and middle-income countries. Additionally, the factors associated with these prescriptions are not well-documented in this context. Lacking a clear understanding of the patterns and factors influencing antibiotic prescriptions, it is difficult to establish appropriate guidelines to optimize their use in terminally ill patients. Thus, this study aims to identify and analyze the prescription patterns and associated factors for antibiotics among terminally ill patients at a hospital in southern Peru.

Methods and Materials

Study design and population

A cross-sectional analytical study was conducted by collecting data from adult patients (over 18 years old) who died while hospitalized in Hospital III Daniel Alcides Carrión in Tacna, Peru, during the year 2023. This hospital is a third-level referral center for the three primary care centers that make up the city of Tacna. It also has 110 hospitalization beds and 28 beds in the Intensive Care Unit.

Cases were eligible if: (1) The patient died during the year 2023, (2) They were hospitalized in the services of Internal Medicine, Surgery, Gynecology, Intensive Care Unit, or Emergency. Cases with incomplete medical records were excluded from the analysis.

Procedure

After receiving authorization from the institutional research ethics committee of the Faculty of Health Sciences at the Private University of Tacna, the principal investigator (BMC) requested the death records for the year 2023 from the hospital’s epidemiology section. Once access to the electronic medical record system was obtained through the EsSalud Intelligent Health Service (ESSI), two researchers (BMC and AFY) independently extracted the study variables into a Microsoft Excel file (v.2017). Each extraction was then compared to ensure there were no errors in data transcription. Any discrepancies were resolved with the intervention of a third researcher (MHZ), who specializes in Infectious Medicine and tropical diseases.

Variables

The dependent variable was antibiotic use within 72 hours before death (yes/no). Antibiotic use was considered from the first administration regardless of the duration (one or more days) during the last hospitalization before the patient’s death. This methodology was similar to that of Cruellas et al. 8 The decision to use this cutoff point was made by consensus among the authors.

Independent variables were selected based on the researchers’ experience and after a comprehensive literature review. These were: (1) Age, coded as a continuous variable and then categorized into tertiles. This categorization of age into tertiles was made to reduce variability in the sample; (2) Gender; (3) Duration of the last hospitalization in days; (4) Acute resuscitation plan, which includes maneuvers such as cardiopulmonary resuscitation and the use of vasopressor medications (adrenaline, noradrenaline, dopamine) in response to significant clinical deterioration; (5) Comorbidities, classified as none, one, or two or more, as well as the type of comorbidities: Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease, and Malignancy; (6) If the patient had previously received palliative care, which was categorized as yes/no, information verified in the medical history upon admission, and reviewed during all consultations during their last hospital stay; (7) The variable “infectious focus” was also collected, identifying whether it was urinary, pulmonary, skin and soft tissue, abdominal, or if there was no evidence of an infectious focus. The definition of an infectious focus was determined retrospectively by reviewing the patient’s medical records and followed the following considerations: signs and symptoms suggestive of infection, elevated acute-phase reactants (C-reactive protein, leukocytosis, procalcitonin), and imaging studies suggesting an infectious focus (X-ray, CT scan, or MRI). 9 Additionally, it was evaluated whether there was any microbiological isolation (urine culture, blood culture, secretion culture). This analysis was conducted by a specialist in infectious diseases.

Other variables included were instability upon admission evidenced using vasopressors, the cause of hospitalization, the department of origin, the timing of death (before or after 48 hours from admission), and the number of hospitalizations during the last year before the current admission.

Statistical analysis

In the univariate analysis, categorical variables were presented as absolute numbers and their frequencies. Depending on their distribution, numerical variables were described using measures of central tendency (median) and dispersion (interquartile range). In the multivariate analysis, Poisson regression with robust variance was used to adjust for potential confounders and explore the variables that influenced the dependent variable of interest, “use of antibiotics within 72 hours before death (yes/no).” Variables with a P < .05 in the crude model were included in the adjusted model. All analyses were performed using Stata V17 software.

Ethical considerations

This study aligned with the international standards set forth by the Declaration of Helsinki. It was authorized by the institutional research ethics committee of the Faculty of Health Sciences at the Private University of Tacna on January 15, 2024, under the identification code FACSA-CEI/XXX-2024. The confidentiality of the extracted data was maintained. Due to the observational and retrospective nature of the study, informed consent was not requested.

Results

Table 1 describes the general characteristics of the patients. The median age of the participants was 76 years (IQR [Interquartile Range] from 66 to 84). There were 131 male patients, representing 54.8%. The median hospitalization time was 9 days (IQR from 4 to 17), and 65 patients (27.2%) underwent an acute resuscitation plan. It was observed that 58.2% of the patients had 2 or more comorbidities, with hypertension (34.3%), chronic kidney disease (27.6%), and neoplasms (31.8%) being the most common. Only 5 patients (2.1%) had received palliative care before hospitalization.

Table 1. Sociodemographic characteristics in the studied population (n = 239).

Variable	n (%)	
Age a	76 (66-84)	
Age in tertiles (y)	
 31-70	86 (36.0)	
 71-82	77 (32.2)	
 83-98	76 (31.8)	
Sex	
 Female	108 (45.2)	
 Male	131 (54.8)	
Length of hospital stay (d) a	9 (4-17)	
Acute resuscitation plan	
 Yes	65 (27.2)	
 No	174 (72.8)	
Number of comorbidities	
 None	19 (8.0)	
 One	81 (33.9)	
 Two or more	139 (58.2)	
Comorbilidities	
 Hypertension	82 (34.3)	
 Diabetes Mellitus type 2	55 (23.1)	
 Chronic kidney disease	66 (27.6)	
 Cerebrovascular disease	33 (13.8)	
 Chronic Obstructive Pulmonary Disease	21 (8.8)	
 Diffuse Interstitial Lung Disease	32 (13.4)	
 Malignancy	76 (31.8)	
 Arthropathy	22 (9.2)	
 Hepatopathy	29 (12.1)	
 Cardiopathy	32 (13.4)	
Received palliative care previously	
 Yes	5 (2.1)	
 No	234 (7.9)	
a Median (Interquartile Range).

Table 2 shows the clinical characteristics of the patients. The most common infectious focus was pulmonary (n = 83, 34.7%), followed by gastrointestinal (n = 26, 10.9%) and urinary (n = 18, 7.5%). However, most (n = 101, 42.3%) did not present any infectious focus. Almost all patients (n = 224, 93.7%) received at least one antibiotic. The main cause of hospitalization was the decompensation of a previous illness (n = 113, 47.5%), followed by sepsis (n = 81, 34.0%). As for the history of hospitalizations, most patients (n = 151, 63.2%) had no hospitalizations in the last year.

Table 2. Clinical variables of the studied population (n = 239).

Variable	N (%)	
Infectious focus	
 Urinary	18 (7.5)	
 Pulmonary	83 (34.7)	
 Skin	11 (4.6)	
 Gastrointestinal	26 (10.9)	
 There was no infectious focus	101 (42.3)	
Use of antibiotics	
 Yes	224 (93.7)	
 No	15 (6.3)	
Hemodynamic instability upon admission	
 Yes	56 (23.6)	
 No	181 (76.4)	
Cause of hospitalization	
 Sepsis	81 (34.0)	
 Decompensation of a previous illness	113 (47.5)	
 Evaluation or initiation of treatment	2 (0.8)	
 Added illness	42 (17.7)	
Service of origin	
 Internal Medicine	8 (3.4)	
 Surgery	16 (6.7)	
 Emergency	213 (89.5)	
 Gynecology and Obstetrics	1 (0.4)	
Time of death	
 <48 h after admission	17 (7.1)	
 >48 h after admission	221 (92.9)	
Number of hospitalizations during the last year	
 None	151 (63.2)	
 One hospitalization	67 (28.0)	
 Two or more hospitalizations	21 (8.8)	

Table 3 describes the characteristics of the antibiotics administered to the patients. Within the cephalosporin group, the most used antibiotic was Ceftriaxone (61.5%), with significant use across all infectious focus. Cefepime was second and most used in patients with a pulmonary focus. Meropenem was the most prescribed carbapenem used in 62.8% of the patients. Piperacillin/tazobactam was particularly used in patients with a pulmonary focus, representing 46% of its use. Ciprofloxacin was most frequently used in patients with a pulmonary focus, accounting for 39.1% of its total use. Other heavily used antibiotics were vancomycin (55.2%) and metronidazole (13.0%).

Table 3. Characteristics of antibiotics used in the studied population (n = 239).

Variable	Use of antibiotics according to infectious focus (N %) a	
Urinary	Pulmonary	Dermic	Gastrointestinal	There was no infectious focus	
Cephalosporins	
 Cefepime	1 (11.1)	4 (44.4)			4 (44.4)	
 Ceftriaxone	12 (8.2)	61 (41.5)	6 (4.0)	17 (11.6)	51 (34.7)	
 Ceftazidime		1 (16.7)	1 (16.7)	1 (16.7)	3 (50.0)	
Carbapenems	
 Meropenem	13 (8.7)	60 (40.0)	10 (6.7)	22 (14.7)	45 (30.0)	
 Ertapenem	3 (37.5)	1 (12.5)		1 (12.5)	3 (37.5)	
 Imipenem/Cilastatin		2 (100)				
Beta-lactamase inhibitors	
 Piperacilin/Tazobactam	4 (8.0)	23 (46.0)	1 (2.0)	6 (12.0)	16 (32.0)	
 Amoxicilin/Clavulanic Acid					1 (100)	
 Ampicilin/Sulbactam		1 (20.0)		1 (20.0)	3 (60.0)	
Quinolones	
 Ciprofloxacin	1 (4.4)	9 (39.1)	2 (8.7)	2 (8.7)	9 (39.1)	
 Levofloxacin		1 (25.0)		1 (25.0)	2 (50.0)	
Others	
 Vancomycin	10 (7.6)	58 (43.9)	11 (8.3)	18 (13.6)	35 (26.5)	
 Metronidazole	2 (6.45)	3 (9.7)	1 (3.2)	12 (38.7)	13 (41.9)	
Use of antibiotics upon admission	
 Yes	17 (9.7)	68 (38.9)	9 (5.1)	25 (14.29)	56 (32.0)	
 No	1 (1.9)	14 (25.9)	2 (3.7)	1 (1.85)	36 (66.7)	
a Some patients used more than 1 antimicrobial.

Table 4 describes the duration of antibiotic use in the population. The median duration of antibiotic use was 7 days (IQR from 3 to 15 days). It was observed that 96.5% of patients continued antibiotics until their demise, while only 3.5% discontinued antibiotics 3 days before death.

Table 4. Duration of antibiotic use in the studied population (n = 224).

Variable	N (%)	
Duration of antibiotic use during hospitalization in days a	7 (3-15)	
Invasive procedure for treatment administration	
 Yes	221 (98.7)	
 No	3 (1.3)	
Duration of antibiotic discontinuation before death	
 >3 d	8 (3.5)	
 3 d or <24 h	27 (12.1)	
 Not discontinued	189 (84.4)	
a Median (Interquartile Range).

Table 5 shows the factors associated with receiving antibiotics within 72 hours before death. Patients with 18 or more days of hospitalization were less likely to receive antibiotics 72 hours before death compared to those with 1 to 7 days (PR: 0.91; 95% CI: 0.85-0.98). Regarding comorbidities, having two or more comorbidities was associated with a lower use of antibiotics 72 hours prior to death compared to having no comorbidities (PR: 0.93; 95% CI: 0.85-0.98).

Table 5. Factors associated with the use of antibiotics within 72 hours before death (n = 224).

Variables	Receives antibiotics more than 72 h before death (%)	Receives antibiotics within 72 h before death (%)	Crude PR (95% CI) a	Adjusted PR (95% CI) b	
Age a	83 (72-86)	75 (66-84)	0.99 (0.99-1.00)		
Age in tertiles	
 31-71 y	2 (2.5)	79 (97.5)	REF		
 72-81 y	2 (2.8)	70 (97.2)	0.99 (0.95-1.05)		
 82-98 y	4 (5.6)	67 (94.4)	0.97 (0.91-1.03)		
Sex					
 Female	5 (5.2)	92 (94.8)	REF		
 Male	3 (2.4)	124 (97.6)	1.03 (0.98-1.09)		
Length of hospital in tertiles	
 1-7 d	0 (0)	71 (100)	REF	REF	
 8-17 d	2 (2.6)	76 (97.4)	0.97 (0.94-1.01)	0.98 (0.94-1.01)	
 Greater than or equal to 18 d	6 (8)	69 (92)	0.92 (0.86-0.98)	0.91 (0.85-0.98)	
Acute resuscitation plan	
 Yes	1 (1.7)	59 (98.3)	REF		
 No	7 (4.3)	157 (95.7)	0.97 (0.93-1.02)		
Number of comorbidities	
 None	0 (0)	16 (100)	REF		
 One	5 (6.5)	72 (93.5)	0.94 (0.88-0.99)	0.92 (0.86-0.98)	
 Two or more	3 (2.3)	128 (97.7)	0.98 (0.95-1.00)	0.93 (0.86-0.99)	
Arterial hypertension	
 Yes	0 (0)	77 (100)	REF	REF	
 No	8 (5.4)	139 (94.6)	0.95 (0.91-0.98)	0.94 (0.90-0.99)	
Diabetes Mellitus Type 2	
 Yes	0 (0)	50 (100)	REF	REF	
 No	8 (4.6)	166 (95.4)	0.95 (0.92-0.99)	0.96 (0.93-0.99)	
Malignancy	
 Yes	6 (8.2)	67 (91.8)	REF		
 No	10 (6.2)	149 (93.7)	1.03 (0.97-1.09)		
Chronic kidney disease	
 Yes	2 (3.2)	59 (96.7)	REF		
 No	6 (3.7)	157 (96.3)	0.99 (0.94-1.05)		
Hemodynamic instability upon admission	
 Yes	2 (3.8)	51 (96.2)	REF		
 No	6 (3.5)	165 (96.5)	1.00 (0.94-1.07)		
Admission to the intensive care unit	
 Yes	4 (2.6)	148 (97.4)	REF		
 No	4 (5.9)	64 (94.1)	0.98 (0.95-1.02)		
a Simple Poisson regression with robust variance.

b Multiple Poisson regression with robust variance, a model was generated with the variables hospitalization time in tertiles, number of comorbidities, hypertension, and diabetes mellitus type 2.

Discussion

Summary of findings

We conducted a cross-sectional analytical study on 239 patients who died in 2023 to examine antibiotic use patterns. Our main findings are as follows: (1) 93.7% of the patients received antibiotics during their final hospitalization before dying. (2) No infectious focus was confirmed in 42.5% of these cases. (3) Ceftriaxone, Meropenem, and Vancomycin were the most frequently used antibiotics. (4) Having 18 or more days of hospitalization, having a comorbidity, as well as not having hypertension or type 2 diabetes mellitus, were associated with a lower probability of receiving antibiotics within 72 hours before death.

Interpretation of findings

Our study reveals a significant prevalence of antibiotic use among terminally ill patients, with 93.7% receiving at least one antibiotic during their hospital stay. In 81.5% of the cases, antibiotic treatment continued until the patient’s death. Additionally, it is concerning that in 42.3% of the cases, no infectious focus was identified to justify their use. Similar results have been reported in various studies conducted between 2015 and 2019. The first study, conducted in Australia on 137 deceased patients, showed that 63.0% received antibiotics until their death, and in 37.2% of the cases, no infectious focus was detected. 10 The second study, conducted on 101 oncology patients, found that 6 out of 10 patients received antibiotics upon admission, 92% received them during their last 7 days of life, and no clear infectious focus was identified in 49.0% of cases. 8

Despite differences in healthcare systems and the availability of diagnostic and therapeutic resources in other countries, our findings reveal an alarmingly similar pattern. A study conducted in Brazil in 2016 also reported that a longer time since a physician’s graduation is associated with the inappropriate continuation of antibiotic therapy. 11 This suggests a global trend in inappropriate antibiotic prescribing practices during the final days of patients’ lives. Several factors could influence this trend, including the pressure to “do something” for the patient and their families, the preventive use of antibiotics against opportunistic infections in immunocompromised patients, an aversion to risk to avoid adverse outcomes, and insufficient training in palliative care. 7 These findings indicate that physician experience and ongoing education may also be critical factors.

The most common antibiotics prescribed in our study were ceftriaxone, meropenem, and vancomycin. These findings contrast with those reported in other studies. The first, conducted in Spain in 2019, found higher prescriptions of amoxicillin-clavulanic acid, piperacillin-tazobactam, ceftriaxone, and levofloxacin. 8 Two studies conducted in the United States at different hospitals in 2004 and 2007 highlighted different prescribing patterns. The first study noted a higher use of fluoroquinolones and macrolides, 12 and the other study reported a higher use of vancomycin and piperacillin/tazobactam. 13 Finally, a study conducted in Germany in 2015 identified piperacillin-tazobactam and ceftriaxone as the most commonly used antibiotics. 10 The variability in antibiotic prescribing patterns could be associated with differences in patient’s clinical conditions and the specific practices of each hospital or country. However, it is important to highlight that both ceftriaxone and vancomycin are consistently mentioned as frequently prescribed antibiotics in various studies. This is in accordance with a systematic review conducted in Africa, citing studies from 2010 to 2020, which reported that ceftriaxone was inappropriately indicated in more than 50% of cases. 14 Additionally, the widespread use of vancomycin is especially notable given the significant efforts to restrict its misuse and combat bacterial resistance in pathogens such as Enterococcus and Staphylococcus aureus. 15

Albeit beyond the primary question, one striking and concerning finding was that only 2.1% of the patients who died had previously received palliative care. This low prevalence of palliative care utilization suggests a limited medical culture regarding the early implementation of these specialized care services. 11 It could further explain the high prevalence rate of antibiotic prescriptions. Therefore, it is essential to identify patients who could benefit from palliative care early to avoid prolonging life at the expense of poor quality of life and increased healthcare costs.

Regarding associated factors, our study found that a hospitalization of more than 18 days, as well as having 2 or more comorbidities, were linked to a lower probability of receiving antibiotics within 72 hours before death. Up to the time of conducting this work, we have not found studies that have associated these variables with the use of antibiotics at the end of life. However, we can infer that our results could be due to the fact that a prolonged hospitalization might have completed various cycles of antibiotics, eliminating the need to continue them. Regarding patients with 2 or more comorbidities and their relation to the lower use of antibiotics, this scenario could be due to the limitation of therapeutic efforts because of the complexity of their pathological condition. We believe that a good ethical question to investigate would be at what point the treatment becomes futile and an unnecessary expense, rather than attempting to achieve the medical objective that we might aim to reach in a human being. In contrast to our results, a study in Portugal in 2017, when associating other variables, identified a significant association with the presence of fever and elevated C-reactive protein levels. 16 It is important to note that few studies have investigated how the patient’s functional status affects antibiotic prescribing, generally because it is considered that the patient’s general condition and sociodemographic characteristics do not directly influence these medical decisions. Additionally, a controversial study indicated that withholding antibiotics from patients in poorer general conditions did not affect their survival rates compared to those who received antibiotics. 17

Limitations

The study presents several important limitations. First, the results may not represent other regions because they include only patients from a specific hospital in southern Peru, limiting their generalizability. Secondly, the retrospective nature of the study may introduce selection and information biases, which could limit the analysis performed on the “infectious focus” variable, as it was defined solely based on information recorded in the medical records. Third, the low prevalence of prior palliative care may influence the decision to prescribe antibiotics, and the variability in clinical practice among physicians is not fully explored. Fourth, is the lack of a statistical power analysis. Although a census sample was conducted, which theoretically covers the entire target population and could be considered exhaustive, this analysis was not performed. It is essential to determine if the sample size is adequate to identify statistically significant effects, an omission that could impact the ability to generalize the results.

Conclusions

In conclusion, the use of antibiotics in end-of-life patients presents significant ethical and clinical challenges. Our findings indicate that nearly half of the deceased patients who received antibiotics had no identifiable infection source. Additionally, prolonged hospitalization (more than 18 days), as well as not having type 2 diabetes mellitus or hypertension, was associated with a lower probability of receiving antibiotics within 72 hours before death. It is important to address these issues since the misuse of antibiotics leads to increased healthcare costs and contributes to the broader problem of bacterial resistance.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was self-funded by the authors.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Contributions: Conceptualization: Brayan Miranda-Chavez, Andre Fuentes-Yufra and Miguel Hueda Zavaleta. Data collection: Brayan Miranda-Chavez, and Miguel Hueda Zavaleta. Data analysis: Brayan Miranda-Chavez, Andre Fuentes-Yufra, and Javier A. Flores-Cohaila. Drafting the manuscript: Brayan Miranda-Chavez, Andre Fuentes-Yufra and Cesar Copaja-Corzo. Writing the final manuscript: All authors. Critical revision of the manuscript: Cesar Copaja-Corzo, Javier A. Flores- Cohaila and Marco Rivarola-Hidalgo. Approval of the final version: All authors.

Ethical Considerations: This study aligned with the international standards set forth by the Declaration of Helsinki. It was authorized by the institutional research ethics committee of the Faculty of Health Sciences at the Private University of Tacna on January 15, 2024, under the identification code FACSA-CEI/023-01-2024. The confidentiality of the extracted data was maintained. Due to the observational and retrospective nature of the study, informed consent was not requested.

Data Availability Statement: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

ORCID iDs: Cesar Copaja-Corzo https://orcid.org/0000-0002-3497-0158

Marco Rivarola-Hidalgo https://orcid.org/0000-0001-7317-9177
==== Refs
References

1 Stiel S Krumm N Pestinger M , et al . Antibiotics in palliative medicine—results from a prospective epidemiological investigation from the HOPE survey. Support Care Cancer. 2012;20 :325-333.21274577
2 Dagli O Tasdemir E Ulutasdemir N. Palliative care infections and antibiotic cost: a vicious circle. Aging Male. 2020;23 :98-105.30821574
3 Seaton RA Cooper L Fairweather J , et al . Antibiotic use towards the end of life: development of good practice recommendations. BMJ Support Palliat Care [Internet]. 2021 [citado 26 de diciembre de 2023]; Disponible en: https://spcare.bmj.com/content/early/2021/09/26/bmjspcare-2020-002732
4 Karlin D Pham C Furukawa D , et al . Executive summary: state-of-the-art review: use of antimicrobials at the end of life. Clin Infect Dis. 2024;78 :493-495.38301074
5 Macedo F Nunes C Ladeira K , et al . Antimicrobial therapy in palliative care: an overview. Support Care Cancer. 2018;26 :1361-1367.29435712
6 Marra AR Puig-Asensio M Balkenende E , et al . Antibiotic use during end-of-life care: a systematic literature review and meta-analysis. Infect Control Hosp Epidemiol. 2021;42 :523-529.33172507
7 Hojman M Basombrío A Líbero E , et al . Antibioticoterapia en estadios finales de la vida. Actualizaciones en Sida e Infectología [Internet]. 1 de octubre de 2020 [citado 21 de abril de 2024]; Disponible en: https://revista.infectologia.info/index.php/revista/article/view/33
8 Cruellas M Gascón Ruiz M Alonso Marin N , et al . Estudio retrospectivo del uso de antimicrobianos en pacientes que fallecen en un servicio de oncología. j.medipa. 2021; Disponible en: http://gestormedpal.inspiranetwork.com/fichaArticulo.aspx?iarf=685769746232-410275197169
9 IDSA Practice Guidelines [Internet]. [citado 29 de julio de 2024]. Disponible en: https://www.idsociety.org/practice-guideline/practice-guidelines/
10 Dyer J Vaux L Broom A Broom J. Antimicrobial use in patients at the end of life in an Australian hospital. Infect Dis Health. 2019;24 :92-97.30655096
11 Crispim DH da Silva IO de Carvalho RT Levin AS. End-of-life use of antibiotics: a survey on how doctors decide. Int J Infect Dis. 2022;114 :219-225.34670142
12 Albrecht JS McGregor JC Fromme EK Bearden DT Furuno JP. A nationwide analysis of antibiotic use in hospice care in the final week of life. J Pain Symptom Manag. 2013;46 :483-490.
13 Thompson AJ Silveira MJ Vitale CA Malani PN. Antimicrobial use at the end of life among hospitalized patients with advanced cancer. Am J Hosp Palliat Care. 2012;29 :599-603.22218916
14 Bishaw B Tegegne G Berha A . Appropriate use of ceftriaxone in Sub-Saharan Africa: a systematic review. Infection and drug resistance [Internet]. 28 de agosto de 2021 [citado 1 de junio de 2024]; Disponible en: https://www.tandfonline.com/doi/abs/10.2147/IDR.S329996
15 Aslam W Mathew NE Shaver C , et al . Impact of inappropriate antibiotic therapy in vancomycin-resistant Enterococcus bacteremia. Am J Ther. 2021;28 :e388-e396.
16 Campoa E Teixeira J Luz P Magalhaes J. End-of-life antibiotherapy: factors associated with prescription. Cureus. 2022;14 :e31634.
17 White PH Kuhlenschmidt HL Vancura BG Navari RM. Antimicrobial use in patients with advanced cancer receiving hospice care. J Pain Symptom Manag. 2003;25 :438-443.
