Ethical dilemmas in antibiotic treatment: focus on the elderly

Maximal antibiotic treatment for all patients suspected of harbouring a bacterial infection is non-viable, because it will rapidly induce resistance and exhaust this finite resource. This raises two ethical dilemmas: the question of whether we are justified in increasing the danger to a present, named, patient so as to benefit future, unknown, patients; and whether we are allowed to do so without asking the present patient for consent. Although the considerations for healthy elderly patients are similar to younger adults, the answers are complex when addressing patients with dementia, severely reduced quality of life and at end of life. We argue that a public debate on the balance between benefit to a present patient versus harm to future patients should be conducted. Such a debate should include examinations of scenarios in which antibiotic treatment does not gain any benefit in a patient with infection: at the end of life; in situations in which resistance is such that empirical antibiotic treatment seldom matches the susceptibilities of the pathogen; and in patients with no quality of life. An explicit cost-benefit model, incorporating quality of life and risk of resistance, in computerized decision support might obviate a clinician's need to deal with these difficult issues at bedside.