Over the weekend one of our hospice patients had been brought to the Emergency Department when his temperature was 101.  His work-up had revealed WBC’s in his urine and he had been admitted for a possible UTI.  He had even spent a couple of days in the ICU when his BP was “low”; in the 90”s. Now a week later, after developing delirium, an early stage decubitus ulcer, bruises on his arms from blood draws and IV’s and becoming considerable weaker, we were preparing to readmit him to our home hospice program.

As we talked about this among ourselves we found that this was not an uncommon story.  Frequently, we had fielded calls about signs and symptoms of infections. Sometimes we had been able to evaluate the situation and when it seemed appropriate prescribe antibiotics to be used at home.  At night and on the weekend’s families often became alarmed and brought their loved one to the hospital.  As one daughter told me, “I know granddad is dying from his lung cancer; but won’t he feel better if this bladder infection is treated?”

After discussing this issue we decided to add a few capsules of the antibiotic ciprofloxacin to our home hospice emergency kit (HEK), or a substitute, if there was an allergy or contraindication. Subsequently, we studied the use of HEK’s in our patient population.  While the most common medication used in the kit was the liquid morphine the antibiotic was  used 1 in 6 times the kit was opened and a third of families thought the emergency medications had help them keep their family member at home.

Appropriate antibiotic use is important as the key to preventing the development of drug- resistant bacteria.  JAMA recently published a paper outlining “Incorporating the 4 Moments of Antibiotic Decision Making into Clinical Practice.” For the most part this framework would be appropriate for home hospice patients. However, clinical wisdom would suggest that very sick people at home will need to have empiric treatment of infections more often and that obtaining cultures before treatment will often not be practical.  More research is needed to help balance the public health needs for antibiotic stewardship and the needs of the seriously ill who would like to remain in their homes at the end-of-life.

JAMA: Rethinking How Antibiotics Are Prescribed. Incorporating the 4 Moments of Antibiotic Decision Making Into Clinical Practice  By Pranita D. Tamma, MD, Miller, M. Cosgrove. S.   December 27, 2018

https://jamanetwork.com/journals/jama/fullarticle/2719862