Management of Infections in Palliative and Terminal Cancer Care

Česká verzia

Authors: M. Sochor
Authors place of work: Komplexní onkologické centrum, KN Liberec a. s.
Published in the journal: Klin Onkol 2013; 26(5): 323-330
Category: Přehled

Summary

Background:
Patients with cancer are highly susceptible to infections. There is a lack of evidence‑based guidelines or protocols for their management in palliative and end‑of‑life care.

Purpose:
To define an optimal diagnostic approach and therapeutic management of infections in patients with palliative and terminal cancer care. Along with thromboembolic disease and cancer progression, infections are the most frequent causes of death in oncology. Besides the impact on mortality, they are accompanied with a myriad of symptoms decreasing the quality of life. High incidence of infectons is due to a malignancy itself, the oncolgical therapy and host factors. There is a lack of evidence‑based guidelines and protocols for the therapy of infections in palliative and terminal cancer care. Most of available studies are retrospective in nature, with diverse methods and cohorts. Incidence of infections in these patient oscillates between 16– 55% in specialized palliative units, and rises up to 83% in acute care hospitals. From the epidemiologic viewpoint, urinary (39– 42%) and respiratory infections (22– 36%) are the most frequent cases, followed by soft tissue and skin infections (6– 12%) and bacteremias (5– 14%). At present, the antibiotic treatment does not seem to have a positive impact on the survival rate. Symptom control antibiotic therapy as a means of symptom control still remains controversial, since it meets this purpose only in a few percents of studies. The most successful is the symtom control in urinary tract infections (60– 79%), in contrast to other sites of infection (30– 43%). In the last week of life there the symptom control is achieved only in 10% of patient. One should always consider the prognosis, actual preformance status and patient‘s preferences when it comes to the management of diagnostics and therapy of infections. If the prognosis counts in weeks or months the diagnostics and therapy should not differ from the approach to any other oncological patient. In terminal cancer care the antibiotics should be spared strictly for the purpose of symptom control and with a palliative intent. This article reviews current knowledge of diagnostics and therapy of infections in palliative cancer care and includes an algorithm for their management.

Key words:
palliative care – supportive care – terminally ill cancer – infection – diagnosis and therapy – blood cultures – antibiotics – fever

The author declare he has no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.

Submitted:
28. 4. 2013

Accepted:
26. 5. 2013

Zdroje

1. Viscoli C, EORTC International Antimicrobial Theray Group. Management of infection in cancer patients. Studies of the EORTC International Antimicrobial Therapy Group (IATG). Eur J Cancer 2002; 38 (Suppl 4): S82– S87.

2. Homsi J, Walsh D, Panta R et al. Infectious complications of advanced cancer. Support Care Cancer 2000; 8(6): 487– 492.

3. Vitetta L, Kenner D, Sali A. Bacterial infections in terminally ill hospice patients. J Pain Symptom Manage 2000; 20(5): 326– 334.

4. Asai N, Aoshima M, Ohkuni Y et al. Should blood cultures be performed in terminally ill cancer patients? Indian J Palliat Care 2012; 18(1): 40– 44.

5. Johnson G, Abraham C. The WHO objectives for palliative care: to what extent are we achieving them? Palliative Med 1995; 9(2): 123– 137.

6. Nagy‑ Agren S, Haley H. Management of infections in palliative care patients with advanced cancer. J Pain Symptom Manage 2002; 24(1): 64– 70.

7. White PH, Kuhlenschmidt HL, Vancura BG et al. Antimicrobial use in patients with advanced cancer receiving hospice care. J Pain Symptom Manage 2003; 25(5): 438– 443.

8. Reinbolt RE, Shenk AM, White PH et al. Symptomatic treatment of infections in patients with advanced cancer receiving hospice care. J Pain Symptom Manage 2005; 30(2): 175– 182.

9. Pereira J, Watanabe S, Wolch G. A retrospective review of the frequency of infections and patterns of antibiotic utilization on a palliative care unit. J Pain Symptom Manage 1998; 16(6): 374– 381.

10. Oh DY, Kim JH, Kim DW et al. Antibiotic use during the last days of life in cancer patients. Eur J Cancer Care 2006; 15(1): 74– 79.

11. Abduh Al‑ Shaqi M, Alami AH, Zahrani AS et al. The pattern of antimicrobial use for palliative care in‑patients during the last week of life. Am J Hosp Palliat Care 2012; 29(1): 60– 63.

12. 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(2): 325– 333.

13. Clayton J, Fardell B, Hutton‑ Potts J et al. Parenteral antibiotics in a palliative care unit-prospective analysis of current practice. Palliat Med 2003; 17(1): 44– 48.

14. Mirhosseini M, Oneschuk D, Hunter B et al. The role of antibiotics in the management of infection‑related symptoms in advanced cancer patients. J Palliat Care 2006; 22(2): 69– 74.

15. Nakagawa S, Toya Y, Okamoto Y et al. Can anti‑infective drugs improve the infection‑related symptoms of patients with cancer during the terminal stages of their lives? J Palliat Med 2010; 13(5): 535– 540.

16. Chen LK, Chou YC, Hsu PS et al. Antibiotic prescription for fever episodes in hospice patients. Support Care Cancer 2002; 10(7): 538– 541.

17. Girmenia C, Moleti ML, Cartoni C et al. Management of infective complications in patients with advanced haematological malignancies in home care. Leukemia 1997; 11(11): 1807– 1812.

18. Hallenbeck J (ed.). Palliative care perspective. New York: Oxford University Press 2003.

19. Ford PJ, Fraser TG, Davis MP et al. Anti‑infective therapy at end of life: ethical decision‑ making in hospice eligible patients. Bioethics 2005; 19(4): 379– 392.

20. Council on Ethical and Judicial Affairs, American Medical Association. Decision near the end of life. JAMA 1992; 267(16): 2229– 2233.

21. Radbruch L, Nauck F, Fuchs M et al. Whar is palliative care in Germany? Results from a representative survey. J Pain Symptom Manage 2002; 23(6): 471– 483.

22. Marin PP, Bayer AJ, Tomlinson A et al. Attitudes of hospital doctors in Wales to use of intravenous fluids and antibiotics in terminally ill. Postgrad Med J 1989; 65(767): 650– 652.

23. Oh DY, Kim JE, Lee CH et al. Discrepancies among patients, family members, and physicians in Korea in terms of value regarding the withholding of treatment from patients with terminal malignancies. Cancer 2004; 100(9): 1961– 1966.

24. Lam PT, Chan KS, Tse CY et al. Retrospective analysis of antibiotic use and survival in advanced cancer patients with infections. J Pain Symptom Manage 2005; 30(6): 175– 182.

25. Oneschuk D, Fainsinger R, Demoissac D et al. Antibiotic use in the last week of life in three different palliative care settings. J Palliat Care 2002; 18(1): 25– 28.

26. Green K, Webster H, Watanabe S et al. Management of nosocomial respiratory tract infections in terminally ill cancer patients. J Palliat Care 1994; 10(4): 31– 34.

27. Chun ED, Rodgers PE, Vitale CA et al. Antimicrobial use among patients receiving palliative care consultation. Am J Hosp Palliat Med 2010; 27(4): 261– 265.

28. Campbell SG, Marrie TJ, Anstey R et al. The contribution of blood cultures in clinical management of adult patients admitted to the hospital with community‑ acquired pneumonia: A prospective observational study. Chest 2003; 123(4): 1142– 1150.

29. Penel N, Fournier C, Clisant S et al. Causes of fever and value of C‑ reactive protein and procalcitonin in differentiating infections from paraneoplastic fever. Support Care Cancer 2004; 12(8): 593– 598.

30. Hickman S, Nelson CA, Moss AH et al. Use of the physician orders for life sustaining treatment (POLST) paradigm program in the hospice setting. J Palliat Med 2009; 12(2):133– 141.