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End-of-life treatment and bacterial antibiotic resistance - a potential association.
Chest. 2010 May 14;
Authors: Levin PD, Simor AE, Moses AE, Sprung CL
Abstract: BACKGROUND: Great variability exists in the occurrence of multi-antibiotic resistant bacteria in ICUs around the world. The contribution of specific ICU care variables to these geographic variations is unknown. METHODS: ICU patients from two ICUs (in Jerusalem and Toronto) who were admitted for >48 hours and who grew a resistant bacteria in any culture during ICU admission were compared to those without resistant organisms across a wide range of demographic and ICU care interventions. Significant variables were investigated with logistic regression to identify factors predictive of infection/colonization with a resistant organism. RESULTS: Resistant organisms were acquired by 82/423 (19%) patients. Patients acquiring a resistant organism had a higher incidence of diabetes mellitus (21/82, 26% vs 52/341, 15%, p=0.026), were more frequently admitted from another ICU (17/82, 21% vs 33/341, 10%, p=0.005), received more antibiotics in ICU (19+/-17 vs 14+/-14 days, p=0.005), and had more ventilator (10+/-10 vs 7+/-8, p=0.031) and central line days (10+/-8 vs 7+/-8, p<0.001). These patients had a lower incidence of limitation of therapy orders (9/82, 11% vs 78/341, 23 %, p=0.015). Only absence of a limitation of therapy order (OR 2.62, 95%CI 1.21 - 5.68, p=0.014) was independently associated with acquisition of resistant organisms. Further, amongst ICU fatalities, 5/45 (11%) patients dying after withdrawal acquired resistant bacteria vs 17/44 (39%) non-withdrawal fatalities (p=0.003). Non-withdrawal fatalities received significantly more third line antibiotics (7+/-14 vs 2+/-4, p=0.031) despite similar ICU lengths of stay (15+/-21 days for non withdrawal fatalities vs 10+/-11 for withdraw fatalities, p=0.210) CONCLUSION: End-of-life treatment is independently associated with acquisition of resistant bacteria. Patients dying without withdraw orders receive more antibiotics, and develop more resistant organisms. These patients may represent a reservoir of resistant bacteria in the ICU.
PMID: 20472860 [PubMed - as supplied by publisher]