A study of patients at the end of life in South Korea found high rates of exposure to broad-spectrum antibiotics, particularly among those with cancer, researchers reported today in Antimicrobial Stewardship & Healthcare Epidemiology.

Using data from the Korean National Health Insurance Database, researchers from Seoul National University analyzed antibiotic consumption during the final month, 6 months, and year of life in patients with and without cancer from 2006 to 2018. 

Although smaller studies have found that antibiotic use during end-of-life (EOL) care is common, especially in cancer patients who are at risk for infection, the evidence supporting its use is limited. The study authors note that since cancer is the second-leading cause of death in most Organization for Economic Cooperation and Development countries, antibiotic use among terminal cancer patients is an important target for antimicrobial stewardship.

Increased use of broad-spectrum antibiotics

Of the more than 3.4 million decedents in the study population, 28.1% had cancer. Overall antibiotic consumption rates decreased slightly among decedents in their final month, with a less pronounced annual decrease rate among cancer decedents compared with non-cancer controls (0.4% vs 2.3%). 

But over the study period, while narrow-spectrum antibiotics were used less, use and prescription of broad-spectrum antibiotics (beta-lactam/beta-lactamase inhibitor combinations, carbapenems, and polymyxins) steadily increased, and prescription rates were higher in cancer decedents than in non-cancer controls. 

Specifically, carbapenem prescription rates increased from 5.6% to 18.5% (rate ratio [RR], 1.087; 95% confidence interval [CI], 1.085 to 1.088) in cancer decedents and from 2.9% to 13.2% (RR, 1.115; 95% CI, 1.113 to 1.116) in non-cancer decedents.

"Our findings suggest that patients at EOL, particularly those with cancer, are increasingly and heavily exposed to broad-spectrum antibiotics, which, although likely a consequence of increased AMR [antimicrobial resistance] over time, poses a great threat for further AMR emergence and spread," the study authors wrote. "There is a need to critically assess the tangible benefits of antibiotic use in EOL care and reconsider the perceptions of its noninvasive nature."

The Global Coalition on Aging (GCOA) last week issued a report calling on G7 countries to commit to funding pull incentives and making other investments in antibiotic innovation.

The report, which summarizes a GCOA-convened April meeting that included experts and government officials from Japan, the United States, Canada, the United Kingdom, Italy, and the European Union, asserts that the lack of new antibiotics and rising resistance to current antibiotics is having a severe impact on those most at risk of infection and that the current antibiotic pipeline is inadequate and must be prioritized.

Therefore, the experts concluded, incentive structures to develop new antibiotics, such as the subscription-based model adopted in the United Kingdom, must be supported, and other countries in the G7 must "rise to the challenge" and complement the UK model with their own incentives. To date, the United Kingdom is the only country to follow up on pledges to incentivize new antibiotic research and development made at the 2022 G7 meeting. 

Call for 'fair share' contributions

Noting that the current healthcare burden of antimicrobial resistance (AMR) is estimated at $1 trillion globally, the experts agreed that if all G7 countries contributed their "fair share" to a $4.5 billion pull incentive to fund a single new antibiotic, the return on investment would be 5:1.

The report urged G7 countries to use the opportunity presented by the upcoming United Nations High-Level Meeting on AMR and demonstrate their commitment to solving the problem.

"There will never be more political momentum on AMR than this year," the report states. "All countries must take this opportunity to address AMR through collaborative multi-stakeholder action and commitments to invest a fair share in our most vital healthcare infrastructure."

Scotland's government last week reported a classical bovine spongiform encephalopathy (BSE) case involving a cow that died on a farm in Ayrshire, its fifth such case since 2014.

In a statement, officials said the fallen cow was tested as part of its BSE surveillance program and did not enter the food chain. The animal died after showing clinical signs consistent with BSE. The cow had been used for breeding. Ayrshire is in southwest Scotland.

A notification today from the World Organization for Animal Health (WOAH) said the cow was 7-and-a-half-years old and was close to calving. Over a 2-week period, the indigenous cow displayed illness symptoms and was recumbent and aggressive before it died. There are 206 cows on the breeding farm.

BSE is not contagious and comes in two forms, classical and atypical. Classical BSE is associated with the outbreak in the United Kingdom in the 1980s and Creutzfeldt-Jakob disease (mad cow disease). 

Precautionary culling for cow's farm cohorts

Restrictions remain in place for the cow's cohorts and offspring as a precaution, and those born in the last 2 years have been identified, will be humanely culled, and will be tested for BSE.

The United Kingdom's Animal and Plant Health Agency has launched an epidemiological investigation to determine the cause of the case.

BSE is a fatal neurogenerative disease that is part of a group of prion-related illnesses that includes chronic wasting disease (CWD), which affects deer and other cervids.

A higher proportion of people who trekked through at least one country with endemic malaria on their way to three southern US border cities arrived with cases of the mosquito-borne illness—nearly a third of them with severe disease—in 2023 than in 2022, finds a study published in Morbidity and Mortality Weekly Report.

Researchers from the Centers for Disease Control and Prevention (CDC) and local health departments conducted enhanced imported malaria case investigations from January to December 2023.

People born outside the United States who arrived in the three cities within the past 6 months were classified as newly arrived refugees officially admitted through the US Refugee Admissions Program, other new arrivals such as asylum seekers, or people of unknown immigration status.

72% of cases in other newly arrived migrants

Sixty-eight imported malaria cases were identified in Pima, Arizona (18 cases); San Diego, California (27); and El Paso, Texas (23), compared with 28 cases in 2022 in Pima (3), San Diego (12), and El Paso (13). Of the 68 cases in 2023, 22% occurred in US residents, 3% among newly arrived refugees, 72% in other newly arrived migrants, and 3% in travelers of unknown immigration status. 

Outreach and education about malaria directed to local health care professionals and to new arrivals with recent travel in areas with endemic malaria are crucial.

US residents and refugees had traveled directly from another country with endemic malaria. Of the 49 other newly arrived migrants, 94% had traveled through at least one endemic country, including the country of origin. 

The median length of travel was 29 days, and 73% of travelers said they had crossed land borders. Thirty-one percent of malaria patients were severely ill, and severe disease was more common in other newly arrived migrants (37%) than in US residents (7%). A total of 91% were hospitalized; none died.

"Outreach and education about malaria directed to local health care professionals and to new arrivals with recent travel in areas with endemic malaria are crucial because prompt care seeking, diagnosis, and treatment of malaria will reduce morbidity in this population," the researchers concluded.