Heeding Key “4 Moments” to Reduce Inappropriate Antibiotic Therapy

Moment 2: Have I ordered appropriate cultures before starting antibiotics? What empiric antibiotic therapy should I initiate?

“Lack of appropriate cultures can lead to prolonged antibiotic therapy when no bacterial process exists or continuation of broad-spectrum antibiotics when narrower-spectrum agents with a more favorable adverse event profile could be used,” as stated in the paper. Moment 2 prompts prescribers to “think carefully about specific patient risk factors and severity of illness in association with the likely source of infection.” They point to cases of intra-abdominal infections, community-acquired pneumonia, and nonpurulent cellulitis, which do not present a high risk for methicillin-resistant Staphylococcus aureus in most patients. “To ensure that appropriate knowledge is available to enact moment 2, local antibiotic guidelines should be developed and available at the point of care for common inpatient infectious conditions.”

Moment 3: What duration of antibiotic therapy is needed for this patient’s diagnosis?

In many cases in which antibiotic therapy is initiated, providers may not consider whether changes are needed or whether it is necessary to continue treatment after more data become available. This step is a reminder to perform a daily “time-out” for each patient being treated with antibiotics; this may involve completion of a form or daily verbal discussions during rounds. All details of the resulting decisions should be documented in progress notes. Among other benefits, such record keeping facilitates tracking of the effectiveness of antibiotic time-outs and may inform future policy changes regarding antibiotic stewardship.

Moment 4: A day or more has passed. Can I stop antibiotics? Can I narrow therapy? Can I change from intravenous to oral therapy?

A growing body of research indicates that urinary tract infections, intra-abdominal infections, community-acquired and ventilator-associated pneumonia, cellulitis, and gram-negative bacteria — which collectively account for more than 50% of antibiotic use in inpatient settings — respond to shorter durations of antibiotic therapy than previously recommended.5 Decisions about treatment duration should be based on the literature and on an evaluation of the patient’s response to therapy.

“The benefit of an approach like the 4 Moments of Antibiotic Decision Making is that it reminds clinicians to think through each time point at which the need for antibiotics should be considered,” said Dr Tamma. “We think the 4 Moments are best used when reviewed as a group during patient rounds so that all healthcare workers participating in a patient’s care may have the opportunity to weigh in.”

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According to senior author Sara E. Cosgrove, MD, professor of medicine and associate hospital epidemiologist at Johns Hopkins, “The 4 Moments are intended to refocus the responsibility of optimizing antibiotic therapy to the prescriber through use of a consistent framework that can be used on a daily basis for all patients receiving antibiotics.” She told Pulmonology Advisor that ASPs “should be considered content experts for education and implementation of approaches to improve antibiotics use, but the frontline prescribers must operationalize consistent excellence in antibiotic decision-making that benefits the patient and the public health.”


  1. Centers for Disease Control and Prevention (CDC). Core elements of hospital antibiotic stewardship programs. Last reviewed May 7, 2015. Accessed February 18, 2019.
  2. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873.
  3. Dekker ARJ, Verheij TJM, van der Velden AW. Inappropriate antibiotic prescription for respiratory tract indications: most prominent in adult patients. Fam Pract. 2015;32(4):401-407.
  4. Alshammari TM, Larrat EP, Morrill HJ, Caffrey AR, Quilliam BJ, Laplante KL. Risk of hepatotoxicity associated with fluoroquinolones: a national case-control safety study. Am J Health Sys Pharm. 2014;71(1):37-43.
  5. Tamma PD, Miller MA, Cosgrove SE. Rethinking how antibiotics are prescribed: incorporating the 4 moments of antibiotic decision making into clinical practice. JAMA. 2019;321(2):139-140.6.
  6. Agency for Healthcare Research and Quality (AHRQ). The AHRQ safety program for improving antibiotic use. Last reviewed September 2017. Accessed February 18, 2019.