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Original Research: CRITICAL CARE MEDICINE |

End-of-Life Treatment and Bacterial Antibiotic Resistance: A Potential Association

Phillip D. Levin, MB, BChir; Andrew E. Simor, MD; Allon E. Moses, MD; Charles L. Sprung, MD, FCCP
Author and Funding Information

From the Department of Anesthesiology and Critical Care Medicine (Drs Levin and Sprung), and the Department of Clinical Microbiology and Infectious Diseases (Dr Moses), Hadassah Hebrew University Medical Center, Jerusalem, Israel; and the Department of Microbiology (Dr Simor), Sunnybrook Health Sciences Center and Division of Infectious Diseases, University of Toronto, Toronto, ON, Canada.

Correspondence to: Phillip Levin, MB, BChir, Department of Anesthesiology and Critical Care Medicine, POB 12000, Jerusalem 91120, Israel; e-mail: phillipl@hadassah.org.il


Presented in part at The Society of Critical Care Medicine 38th Critical Care Congress, Nashville, Tennessee, February 2009.

Funding/Support: This study was funded in part by an internal Hadassah Medical Organization research grant.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(3):588-594. doi:10.1378/chest.09-2757
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Background:  Great variability exists in the occurrence of 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 h and who grew a resistant bacteria in any culture during ICU admission were compared with those without resistant organisms across a 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 = .026), were more frequently admitted from another ICU (17/82, 21% vs 33/341, 10%; P = .005), received more antibiotics in the ICU (19 ± 17 vs 14 ± 14 days; P = .005), and had more ventilator (10 ± 10 vs 7 ± 8; P = .031) and central line days (10 ± 8 vs 7 ± 8; P < .001). These patients had a lower incidence of limitation-of-therapy orders (9/82, 11% vs 78/341, 23%; P = .015). Only the absence of a limitation-of-therapy order (odds ratio, 2.62; 95% CI, 1.21-5.68; P = .014) was independently associated with the acquisition of resistant organisms. Further, among ICU fatalities, 5/45 (11%) patients acquired a resistant organism prior to withdrawal vs 17/44 (39%) nonwithdrawal fatalities (P = .003). Nonwithdrawal fatalities received significantly more third-line antibiotics (7 ± 14 vs 2 ± 4; P = .031) despite similar ICU lengths of stay (15 ± 21 days for nonwithdrawal fatalities vs 10 ± 11 for withdraw fatalities; P = .210)

Conclusions:  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.


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