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Review
. 2025 Jul;25(7):e416-e431.
doi: 10.1016/S1473-3099(24)00832-6. Epub 2025 Mar 3.

Antimicrobials in serious illness and end-of-life care: lifting the veil of silence

William E Rosa  1 , Shila Pandey  2 , Renee Wisniewski  2 , Craig Blinderman  2 , Mark Wing Loong Cheong  3 , Juan Esteban Correa-Morales  4 , Diego Alejandro Cubides-Diaz  5 , Sharif Folorunso  6 , Nahla Gafer  7 , Mohja Marhoom  7 , Tiffanny Newman  8 , Christian Ntizimira  9 , Temitope Oyewole Obadare  10 , Cihan Papan  11 , Pedro Emilio Pérez-Cruz  12 , Lukas Radbruch  13 , Giri Shan Rajahram  14 , Tomás Alejandro Reyes-Barros  15 , Naveen Salins  16 , Kavitha Saravu  17 , Donald R Sullivan  18 , Edward Christopher Dee  19
Affiliations
Review

Antimicrobials in serious illness and end-of-life care: lifting the veil of silence

William E Rosa et al. Lancet Infect Dis. 2025 Jul.

Abstract

Global rates of antimicrobial consumption increased by 65% between 2000 and 2015, by 16% between 2016 and 2023, and are estimated to increase by an additional 52% by 2030. Antimicrobial use and misuse remains high among people with serious illness and at end of life, despite scarce evidence of benefit. In addition, the overuse and misuse of antimicrobials at end of life further exacerbate antimicrobial resistance, which is a substantial public and global health concern. This Personal View synthesises global interprofessional and multidisciplinary perspectives on antimicrobial use, stewardship, and resistance at end of life and implications at patient and population levels. Guidelines have been summarised from multiple countries, some of which offer guidance for antimicrobial use at end of life. Countries at different income levels are included (ie, Chile, Colombia, Germany, India, Malaysia, Nigeria, Rwanda, and Sudan) to show how practice norms and standards vary internationally. These examples are combined with a case of non-beneficial end-of-life antimicrobial use and clinical guidance for patient and family communication regarding antimicrobial treatment. This Personal View also provides recommendations to improve antimicrobial stewardship with the goal of engaging multidisciplinary stakeholders and decreasing inappropriate antimicrobial use at end of life.

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Conflict of interest statement

Declaration of interests CB has received royalties from UpToDate for editorial and reviewer contributions and participates on Tuesday Health's clinical advisory board. LR holds a position as the Chair of Board of Directors for the International Association for Hospice and Palliative Care. KS is a Deputy Treasurer for the Clinical Infectious Diseases Society, India and has received malaria rapid diagnostic tests and Haemozoin test equipment for research purposes from Hemex Health. All other authors declare no competing interests.

Figures

Figure 1:
Figure 1:. Communication strategies and skills for antimicrobial treatment discussions at end of life
QOL=quality of life. AND=allow for natural death. DNR=do not resuscitate. Adapted from Coyle and colleagues.
Figure 2:
Figure 2:. Patient and caregiver concerns with potential clinician responses and additional communication skills
Adapted from Brown and Bylund and Arnold and colleagues.
Figure 3:
Figure 3:. Diverse stakeholder recommendations to improve antimicrobial stewardship at end of life
AMR=antimicrobial resistance. ASP=antimicrobial stewardship programme. GOC=goals of care.
See this image and copyright information in PMC

References

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