Say your 90-year-old severely demented grandmother in a nursing home has pneumonia. She has a fever and she could die. Should the doctor prescribe antibiotics, at least to control her coughing and laboured breathing? Most laymen would say Yes instantly. But a study in the most recent issue of the Archives of Internal Medicine urges caution. Antibiotics could be unwise for both the patient and for the rest of us. First of all, argue Erika D’Agata and Susan L. Mitchell, the antibiotics may not prolong life, it may be possible to control the symptoms with other methods, and elderly patients can react badly to antibiotics in some cases.

But the main reason they advance has little to do with the welfare of the individual patient. It is that antibiotic overuse is leading to the development of resistant strains of bacteria. Nursing homes can house superbugs and patients admitted to hospital can spread them elsewhere. "Nursing home residents with advanced dementia may be contributing to the emergence and spread of antimicrobial-resistant bacteria, posing health risks that extend beyond the individual being treated," they say. However, they admit that this is just an interesting hypothesis.

In an accompanying editorial, Drs Mitchell J. Schwaber and Yuhuda Carmeli, of Tel Aviv Medical Center treat the hypothesis as a fact and cautiously suggest that the wisest course of action is to withhold antibiotics from the demented elderly. "The ethical question of treatment of bacterial infection must encompass not just the deliberation over whether to withhold or withdraw treatment, but the decision to initiate it as well."

The on-going debate over this issue may not be about patient care or a superbug epidemic, but about "futile care", or whether it is worthwhile to treat a patient who has a very quality of life. As Dr Mitchell told AP, "advanced dementia is a terminal illness. If we substituted ‘end-stage cancer’ for ‘advanced dementia’, I don’t think people would have any problem understanding this." ~ AP, Feb 25; Archives of Internal Medicine, Feb 25