Supportive Care in Cancer

, Volume 26, Issue 5, pp 1361–1367 | Cite as

Antimicrobial therapy in palliative care: an overview

  • Filipa Macedo
  • Catarina Nunes
  • Katia Ladeira
  • Filipa Pinho
  • Nadine Saraiva
  • Nuno Bonito
  • Luísa Pinto
  • Francisco Gonçalves
Review Article


In the advanced stages of illness, patients often face challenging decisions regarding their treatment and overall medical care. Terminal ill patients are commonly affected by infections. However, in palliative care, the use of antimicrobials can be an ethical dilemma. Deciding whether to treat, withhold, or withdraw the antimicrobial treatment for an infection can be difficult. Antimicrobial administration can lead to adverse outcomes but the two main benefits, longer survival and symptom relief, are the main reasons why physicians prescribe antimicrobial when treating terminally ill patients. For the patient who has an irreversible advanced heart or lung disease, or an advanced dementia, or a metastatic cancer, it is easier the decision of withholding mechanical ventilation, tube feeding, and dialysis than antibiotherapy. To characterize infections, agents, and their treatments in palliative care, we conducted a review of the literature. We also included some tips to help health professionals to guide their clinical approach.


Palliative care End of life Antimicrobians Antibiotics Infections Survival 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    World Health Organization (2002). National cancer control programmes: policies and managerial guidelines. Accessed 13 April 2016
  2. 2.
    DeVita V, Hellman S, Rosenberg S (2001). Cancer principles and practice of oncology, Sixth edition. Lippincott, Williams.Google Scholar
  3. 3.
    Zimmermann C, Swami N, Krzyzanowska M, Hannon B, Leighl N, Oza A, Moore M, Rydall A, Rodin G, Tannock I, Donner A, Lo C (2014) Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 383:1721–1730CrossRefPubMedGoogle Scholar
  4. 4.
    Gaertner J, Weingärtner V, Wolf J, Voltz R (2013) Early palliative care for patients with advanced cancer: how to make it work? Curr Opin Oncol 25:342–352PubMedGoogle Scholar
  5. 5.
    Chochinov H (2002) Dignity-conserving care a new model for palliative care: helping the patient feel valued. JAMA 287:2253–2260CrossRefPubMedGoogle Scholar
  6. 6.
    Schofield P, Carey M, Love A, Nehill C, Wein S (2006) ‘Would you like to talk about your future treatment options?’ discussing the transition from curative cancer treatment to palliative care. Palliat Med 20(4):397–406CrossRefPubMedGoogle Scholar
  7. 7.
    Juthani-Mehta M, Malani P, Mitchell S (2015) Antimicrobials at the end of life: an opportunity to improve palliative care and infection management. JAMA 314(19):2017–2018CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Ahronheim J, Morrison R, Baskin S, Morris J, Meier DE (1996) Treatment of the dying in the acute care hospital. Arch Intern Med 156:2094–2100CrossRefPubMedGoogle Scholar
  9. 9.
    Goodlin S, Winzeberg G, Teno J et al (1998) Death in the hospital. Arch Intern Med 158:1570–1572CrossRefPubMedGoogle Scholar
  10. 10.
    Pereira J, Watanabe S, Wolch G (1998) A retrospective review of the frequency of infections and patterns of antibiotic utilization on a palliative care unit. J Pain Symptom Manag 16(6):374–381CrossRefGoogle Scholar
  11. 11.
    Lagman R, Panta R, Walsh D (1996) Infectious complications in advanced cancer. Support Care Cancer 4:226Google Scholar
  12. 12.
    Nagy-Agren S, Haley H (2002) Management of infections in palliative care patients with advanced cancer. J Pain Symptom Manag 24(1):64–70CrossRefGoogle Scholar
  13. 13.
    Glauser M, Zinner S (1982) Mechanisms of acquisition and development of bacterial infections in cancer patients. Raven Press, New York, pp 13–24Google Scholar
  14. 14.
    Vitetta L, Kenner D, Sali A (2000) Bacterial infections in terminally ill hospice patients. J Pain Symptom Manag 20(5):326–334CrossRefGoogle Scholar
  15. 15.
    Marcus E, Clarfield A, Moses A (2001) Ethical issues relating to the use of antimicrobial therapy in older adults. Clin Infect Dis 33(10):1697–1705CrossRefPubMedGoogle Scholar
  16. 16.
    Thompson A, Silveira M, Vitale C, Malani P (2012) Antimicrobial use at the end of life among hospitalized patients with advanced cancer. Am J Hosp Palliat Care 29(8):599–603CrossRefPubMedGoogle Scholar
  17. 17.
    Albrecht J, McGregor J, Fromme E et al (2013) A nationwide analysis of antibiotic use in hospice care in the final week of life. J Pain Symptom Manag 46(4):483–490CrossRefGoogle Scholar
  18. 18.
    Evers M, Purohit D, Perl D et al (2002) Palliative and aggressive end-of-life care for patients with dementia. Psychiatr Serv 53(5):609–613CrossRefPubMedGoogle Scholar
  19. 19.
    Yao C, Hsieh M, Chiu T et al (2015) Wishes of patients with terminal cancer and influencing factors toward the use of antibiotics in Taiwan. Am J Hosp Palliat Care 32(5):537–543CrossRefPubMedGoogle Scholar
  20. 20.
    White P, Kuhlenschmidt H, Vancura B, Navari R (2003) Antimicrobial use in patients with advanced cancer receiving hospice care. J Pain Symptom Manag 25(5):438–443CrossRefGoogle Scholar
  21. 21.
    Stiel S, Krumm N, Pestinger M, Lindena G, Nauck F, Ostgathe C, Radbruch L, Elsner F (2012) Antibiotics in palliative medicine-results from a prospective epidemiological investigation from the HOPE survey. Support Care Cancer 20(2):325–333CrossRefPubMedGoogle Scholar
  22. 22.
    Clayton J, Fardell B, Hutton-Potts J, Webb D, Chye R (2003) Parenteral antibiotics in a palliative care unit: prospective analysis of current practice. Palliat Med 17(1):44–48CrossRefPubMedGoogle Scholar
  23. 23.
    Reinbolt R, Shenk A, White P, Navari R (2005) Symptomatic treatment of infections in patients with advanced cancer receiving hospice care. J Pain Symptom Manag 30(2):175–182CrossRefGoogle Scholar
  24. 24.
    Brown N, Thompson D (1979) Nontreatment of fever in extended-care facilities. N Engl J Med 300:1246–1250CrossRefPubMedGoogle Scholar
  25. 25.
    Fabiszewski K, Volicer B, Volicer L (1990) Effect of antibiotic treatment on outcome of fevers in institutionalized Alzheimer patients. JAMA 263:3168–3172CrossRefPubMedGoogle Scholar
  26. 26.
    Chen L, Chou Y, Hsu P et al (2002) Antibiotic prescription for fever episodes in hospice patients. Support Care Cancer 10(7):538–541CrossRefPubMedGoogle Scholar
  27. 27.
    Robinson G, Tegtmeier B, Zaia J (1984) Brief report: nosocomial infection rates in a cancer treatment center. Infect Control 5:289–294CrossRefPubMedGoogle Scholar
  28. 28.
    Kuehn N, MacEachern T, Miller M, Spachynski K (1992) Nosocomial infections (NI) on a palliative care unit (PCU): a prospective comparison study. In: Poster for 9th international congress on Care of the Terminally ill. Canada, MontrealGoogle Scholar
  29. 29.
    Homsi J, Walsh D, Panta R et al (2000) Infectious complications of advanced cancer. Support Care Cancer 8(6):487–492PubMedGoogle Scholar
  30. 30.
    Beckers M, Ruven H, Seldenrijk C et al (2010) Risk of thrombosis and infections of central venous catheters and totally implanted access ports in patients treated for cancer. Thromb Res 125(4):318–321CrossRefPubMedGoogle Scholar
  31. 31.
    Narducci F, Jean-Laurent M, Boulanger L et al (2011) Totally implantable venous access port systems and risk factors for complications: a one-year prospective study in a cancer centre. Eur J Surg Oncol 37(10):913–918CrossRefPubMedGoogle Scholar
  32. 32.
    Becton D, Kletzel M, Golladay E et al (1988) An experience with an implanted port system in 66 children with cancer. Cancer 61(2):376–378CrossRefPubMedGoogle Scholar
  33. 33.
    Winters V, Peters B, Coilá S, Jones L (1990) A trial with a new peripheral implanted vascular access device. Oncol Nurs Forum 17(6):891–896PubMedGoogle Scholar
  34. 34.
    McNelis J, Zarcone J, Marini C, Jurkiewicz A (2002) Outcome of subcutaneously implanted catheters in a teaching hospital. Am J Med Qual 17(5):185–188CrossRefPubMedGoogle Scholar
  35. 35.
    Rotstein C, Cummings K, Nicolaou A et al (1988) Nosocomial infection rates at an oncology center. Infect Control Hosp Epidemiol 9(1):13–19CrossRefPubMedGoogle Scholar
  36. 36.
    Bentley D, Bradley S, High K et al (2001) Practice guideline for evaluation of fever and infection in long-term care facilities. J Am Geriatr Soc 49(2):210–222CrossRefPubMedGoogle Scholar
  37. 37.
    High K, Bradley S, Gravenstein S et al (2009) Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the infectious diseases society of America. Clin Infect Dis 48(2):149–171CrossRefPubMedGoogle Scholar
  38. 38.
    McGeer A, Campbell B, Emori T et al (1991) Definitions of infection for surveillance in long-term care facilities. Am J Infect Control 19:1–7CrossRefPubMedGoogle Scholar
  39. 39.
    Yoshikawa TT, Norman DC (1987) Diagnostic approach to infections. Igaku-Shoin, New York, pp 26–31Google Scholar
  40. 40.
    Wasserman M, Levinstein M, Keller E et al (1989) Utility of fever, white blood cells, and differential count in predicting bacterial infections in the elderly. J Am Geriatr Soc 37:537–543CrossRefPubMedGoogle Scholar
  41. 41.
    Nicolle LE (1993) Urinary tract infections in long-term care facilities. Infect Control Hosp Epidemiol 14:220–225CrossRefPubMedGoogle Scholar
  42. 42.
    Muder R, Brennen C, Wagener M, Goetz A (1992) Bacteremia in a long-term care facility: a five-year prospective study of 163 consecutive episodes. Clin Infect Dis 14:647–654CrossRefPubMedGoogle Scholar
  43. 43.
    Green K, Webster H, Watanabe S, Fainsinger R (1994) Management of nosocomial respiratory tract infections in terminally ill cancer patients. J Palliative Care 10(4):31–34Google Scholar
  44. 44.
    Bolayirli M, Turna H, Orhanoğlu T et al (2007) C-reactive protein as an acute phase protein in cancer patients. Med Oncol 24(3):338–344CrossRefPubMedGoogle Scholar
  45. 45.
    Sedef A, Kose F, Mertsoylu H, Ozyilkan O (2015) Procalcitonin as a biomarker for infection-related mortality in cancer patients. Curr Opin Support Palliat Care 9(2):168–173CrossRefPubMedGoogle Scholar
  46. 46.
    Shomali W, Hachem R, Chaftari A et al (2012) Can procalcitonin distinguish infectious fever from tumor-related fever in non-neutropenic cancer patients? Cancer 118(23):5823–5829CrossRefPubMedGoogle Scholar
  47. 47.
    Miller D (1994) Withholding antibiotics as a form of care: an ethical perspective. Springer, New York, pp 283–298Google Scholar
  48. 48.
    MacKey J, Birchall I, MacDonald N (1995) Occult infection as a cause of hip pain in a patient with metastatic breast cancer. J Pain Symptom Manag 10(7):569–572CrossRefGoogle Scholar
  49. 49.
    Reilly R, Teasdale T, McCullough L (1994) Projecting patients’ preferences from living wills: an invalid strategy for management of dementia with life-threatening illness. J Am Geriatr Soc 42:997–1003CrossRefPubMedGoogle Scholar
  50. 50.
    Schrijvers D, Cherny N (2014) ESMO clinical practice guidelines on palliative care: advanced care planning. Ann Oncol 25(suppl 3):iii138–iii142CrossRefPubMedGoogle Scholar
  51. 51.
    Hirsh J, Hoak J (1996) Management of deep vein thrombosis and pulmonary embolism. A statement for healthcare professionals. Council on thrombosis (in consultation with the council on cardiovascular radiology), American Heart Association. Circulation 93(12):2212–2245CrossRefPubMedGoogle Scholar
  52. 52.
    Kröger K, Weiland D, Ose C et al (2006) Risk factors for venous thromboembolic events in cancer patients. Ann Oncol 17(2):297–303CrossRefPubMedGoogle Scholar
  53. 53.
    Stein P, Willis P, DeMets D et al (1981) History and physical examination in acute pulmonary embolism in patients without preexisting cardiac or pulmonary disease. Am J Cardiol 47:218–223CrossRefPubMedGoogle Scholar
  54. 54.
    Stein P, Afzal A, Henry J, Villareal C (2000) Fever in acute pulmonary embolism. Chest 117(1):39–42CrossRefPubMedGoogle Scholar
  55. 55.
    Prigerson H, Bao Y, Shah M et al (2015) Chemotherapy use, performance status, and quality of life at the end of life. JAMA Oncol 1(6):778–784CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Filipa Macedo
    • 1
  • Catarina Nunes
    • 2
  • Katia Ladeira
    • 2
  • Filipa Pinho
    • 2
  • Nadine Saraiva
    • 1
  • Nuno Bonito
    • 1
  • Luísa Pinto
    • 2
  • Francisco Gonçalves
    • 2
  1. 1.Portuguese Oncology Institute of CoimbraCoimbraPortugal
  2. 2.Braga HospitalBragaPortugal

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