Antimicrobial use in patients with end-of-life status in intensive care units: A systematic review and meta-analysis

Objectives: Advances in critical care have increased antimicrobial use in intensive care units (ICUs), often extending to end-of-life patients without clear clinical benefit. This systematic review and meta-analysis investigated antimicrobial use in critically ill ICU patients with end-of-life care status. Methods: A comprehensive search of Medline (PubMed) and Embase identified articles published from January 2000 through August 2023. Interventional and observational studies focusing on antimicrobial use for critically ill ICU patients with end-of-life status were included. Study types, demographics, clinical characteristics, and antimicrobial use (i.e., continuation or discontinuation) were extracted. A meta-analysis was conducted to estimate the proportion of antimicrobial use, with subgroup analyses by region and national income status. Results: From 13,542 publications, 26 studies met the inclusion criteria; no randomized or prospective studies were identified. Thirteen studies (50.0%) reported antimicrobial use and were included in the quantitative synthesis. The pooled proportion of antimicrobial prescriptions was 0.35 (95% CI, 0.18–0.54) with significant heterogeneity (I2=99.7%, P<0.01). Subgroup analysis revealed regional differences: 0.50 (95% CI, 0.11–0.89) in North America, 0.40 (95% CI, 0.10–0.76) in Europe, and 0.24 (95% CI, 0.10–0.76) in the Asia-Pacific region. Conclusions: Despite increasing emphasis on judicious antimicrobial use, studies comprehensively assessing antimicrobial prescribing in ICU patients with end-of-life care status remain scarce. Based on the limited available evidence, approximately one-third of such patients received antimicrobials. Regional differences in prescribing patterns were also observed, potentially influencing overall antimicrobial consumption in ICUs.