Proportionate antimicrobial use in pediatric end-of-life care: a narrative review and practical framework

Antimicrobial prescribing in pediatric palliative care is frequent, emotionally charged, and clinically complex. In children approaching the end of life, antimicrobial therapy may offer symptom relief in selected circumstances, but it may also add procedural burden, adverse effects, and a risk of prolonging the dying process without improving comfort. The objective is to synthesize the limited pediatric evidence, distinguish it from adult palliative-care evidence and general stewardship guidance, and propose a practical operational framework for decision-making in pediatric end-of-life care. This study is a narrative review of the infectious-disease and palliative-care literature, with a targeted PubMed search and hand-searching of relevant reference lists and guidance documents. The review focused on symptom-oriented benefits, treatment-related burdens, the ethical principles of beneficence, distributive justice, and proportionality, antimicrobial stewardship, and the role of shared decision-making and clinical documentation in pediatric practice. The literature search was last updated in March 2026. For each major clinical proposition, we distinguished direct pediatric end-of-life evidence from adult palliative-care evidence, general pediatric infectious-disease or stewardship guidance, and the authors' reasoned recommendations. Available evidence suggests that antimicrobials may be proportionate when symptomatic benefit is plausible, perceptible, and aligned with the goals of care. However, benefits are inconsistent, pediatric evidence remains limited, and antimicrobial therapy is often prescribed empirically even when its palliative value is uncertain. Direct pediatric evidence is sparse and largely observational or descriptive. Across studies and guidelines, recurrent principles emerge: avoid automatic prescribing, define the goal of treatment, prefer the least burdensome option, document the rationale, and reassess within 48-72 h.

In pediatric end-of-life care, the key question is not simply whether an infection is present, but whether treating it is likely to meaningfully and proportionately improve the child's comfort. A structured framework that integrates ethics, antimicrobial stewardship, shared decision-making, and clear documentation may help clinicians move from reflexive prescribing to deliberate, proportionate decision-making in pediatric palliative care.

• Direct pediatric evidence on antimicrobial use at the end of life is sparse,largely descriptive, and provides limited information on patient-centered symptomatic benefit.

• This narrative review explicitly separates pediatric evidence from adult extrapolation and general stewardship guidance and proposes an authorderived practical framework linking comfort goals, proportionality, child participation, early reassessment, and documentation.