The Fight Against Resistance Begins With 4 Moments

As antibiotic resistance is now considered an urgent public health threat, antimicrobial stewardship programs are on the rise in hospitals across the United States and the world.

But as a new report in JAMA points out, these programs frequently rely on external interventions, such as requiring approval prior to prescribing antibiotics or conducting conversations with clinicians to determine continued need for an antibiotic.

Despite the success of antibiotic stewardship programs, relying on external interventions can create a dependency, rather than inspiring a prescribing behavior change in clinicians. In order to stray from external intervention and induce a change in prescriber habits, the authors from Johns Hopkins University and the Agency for Healthcare Research and Quality, introduce the “4 moments of antibiotic decision making.”

“A structured approach emphasizing the 4 critical time points of antibiotic prescribing may improve antibiotic decision making by clinicians and communication surrounding antibiotic decisions among health care practitioners,” the authors write in the report.

The framework was created as a tool to train clinicians to be thoughtful about their prescribing actions in an easy-to-remember way that can be incorporated during real-time decision making in acute care facilities.

Moment 1

The first moment asks the provider to consider if the patient has an infection that requires antibiotics. By pausing to consider if it is possible that the patient does not need to be treated with antibiotics, the clinician can reduce the occurrence of inappropriate prescriptions for abnormal vital signs or isolated clinical change observations.

The authors indicate that an example of an infection that does not require antibiotics, but for which patients are sometimes still issued a prescription, is asymptomatic bacteriuria. In fact, several studies have shown that treating the asymptomatic bacteriuria can increase the risk of urinary tract infections that are drug resistant.

Moment 2

The second moment requires the clinician to consider if appropriate cultures have been ordered prior to introducing antibiotics, as well as what empirical antibiotic should be introduced. This step is critical to the selection of appropriate antibiotics that are administered in a timely manner.

By ordering appropriate cultures, clinicians can mitigate the risk of prolonging antibiotics in the absence of bacterial process, as well as the continuation of broad-spectrum antibiotics associated with more adverse event risks when narrower spectrum agents with a more favorable adverse event profile could be used.

The authors provide the example that most patients with community-acquired pneumonia and intra-abdominal infections, urinary tract infections, and nonpurulent cellulitis are not at a risk for methicillin-resistant Staphylococcus aureus and do not benefit from empirical vancomycin.

Additionally, the authors indicate that local antibiotic guidelines should be available for the most common inpatient infectious conditions to ensure that appropriate information is available to carry out this step.

Moment 3

The third moment advises clinicians to evaluate if antibiotics can be stopped, therapy can be narrowed, and patients can switch from an intravenous to an oral therapy. This step encourages prescribers to revisit decisions when more data become available, which the authors refer to as an “antibiotic time-out.”

For this particular moment, nurses and pharmacists can prompt the physician to discuss the overall plan for antibiotics and document decisions including the indication for therapy, plans to narrow or switch the method of administration, and the expected duration of the course of therapy. This step emphasizes the support of other clinicians and encouragement for addressing changes to long-standing practices.

Moment 4

The fourth and final moment advises the clinician to assess the total duration of therapy that is required to treat the infection. Several studies have demonstrated support for shorter courses of therapy. When determining a course of therapy, clinicians should rely on the available literature and clinical responses.

According to the authors, implementing the 4 moments of antibiotic decision making into each antibiotic therapy decision could be helpful. If this practice is used frequently, antibiotic stewardship programs can shift focus to ensuring that clinicians have access to required information to make informed decisions for their patients.