Heeding Key “4 Moments” to Reduce Inappropriate Antibiotic Therapy

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The “4 Moments of Antibiotic Decision Making” provides simple, structured guidelines on antibiotic prescribing, similar to previous models pertaining to hand hygiene, central line insertion, and other practices.

In acute care hospitals in the United States, an estimated 20% to 50% of all antibiotic prescriptions are inappropriate or unnecessary,1 including 50% of those prescribed for acute respiratory conditions such as bronchitis and bronchiolitis, asthma and allergy, viral and nonviral pneumonia, sinusitis, suppurative and nonsuppurative otitis media, pharyngitis, viral upper respiratory tract infection, and influenza.2 In primary care settings, where the majority of antibiotics are prescribed, research has demonstrated that overprescribing of these therapies is generally highest in adult patients with lower respiratory infections.3

These types of misuse have fueled the antibiotic resistance crisis that has been linked to approximately 23,000 deaths each year in the United States.1 In addition, antibiotic use is associated with adverse effects such as Clostridium difficile infection1 and hepatoxicity,4 further underscoring the need to avoid unnecessary prescription of these drugs.

Antibiotic stewardship programs (ASPs) represent a critical component of efforts toward that goal. Evidence thus far shows that ASPs can help clinicians improve patient safety and quality of care “through increased infection cure rates, reduced treatment failures, and increased frequency of correct prescribing for therapy and prophylaxis…. [and they] …significantly reduce hospital rates of [C difficile infection] and antibiotic resistance,” according to the Centers for Disease Control and Prevention.1

Nevertheless, because some of the practices commonly used in ASPs — including audit and feedback strategies — rely on external motivators, their “ability to influence how clinicians will prescribe antibiotics in the absence of an antibiotic stewardship program-driven intervention is questionable,” wrote the authors of a recent paper published in JAMA.5

To that end, they recommended that clinicians apply the “4 Moments of Antibiotic Decision Making” each time antibiotic therapy is considered. This is a core feature of the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use,6 which was created in collaboration with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality and NORC at the University of Chicago. The 4 Moments framework provides a simple, structured approach to guide antibiotic prescribing, similar to previous models pertaining to hand hygiene, central line insertion, and other practices.

“Very often when clinicians prescribe antibiotics, they may be more focused on other aspects of the patient’s care and forget to readdress the continued need for antibiotic therapy,” said coauthor Pranita D. Tamma, associate professor of pediatrics and director of the Pediatric Antimicrobial Stewardship Program at Johns Hopkins University School of Medicine. “This is partially a consequence of the notion that antibiotics are not very harmful — as in, they might help but won’t hurt. However, the body of evidence indicating that antibiotics are not benign and could cause harm is growing,” she told Pulmonology Advisor.

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Questions that clinicians should consider at each time point in the antibiotic decision-making process are highlighted below.

Moment 1: Does this patient have an infection that requires antibiotics?

Moment 1 can help limit antibiotic prescription as a habitual response to a clinical change or abnormal vital sign, such as delirium in an elderly patient or isolated fever. This step reminds prescribers to consider the possibility of a noninfectious condition (eg, aspiration pneumonitis, congestive heart failure, or pulmonary embolism in a patient with dyspnea and chest imaging changes). The authors noted that antibiotics are typically not indicated for patients with asymptomatic bacteriuria, and antibiotic treatment in these cases has been shown to increase the risk for antibiotic-resistant urinary tract infections.