Viewpoint: 4 moments to change how antibiotics are prescribed

Four moments in the antibiotic decision-making process can make all the difference in curbing antibiotic resistance, three physicians write in a JAMA commentary.

The Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use aims to improve antibiotic prescribing practices by training clinicians to incorporate these four moments when prescribing antibiotics:

1. Does this patient have an infection that requires antibiotics? Providers often prescribe antibiotics to hospitalized patients in response to an abnormal vital sign, but they should stop and consider whether the patient has an infection that needs an antibiotic or a viral infection that will not benefit from antibiotic treatment.

2. Have I ordered appropriate cultures before starting antibiotics? What empiric therapy should I initiate? Lack of appropriate cultures can lead to prolonged antibiotic therapy, the authors said. Providers must ensure timely administration of appropriate empirical antibiotic therapy. "[This moment] reminds the prescriber to think carefully about specific patient risk factors and severity of illness in association with the likely source of infection," the authors said.

3. A day or more has passed. Can I stop antibiotics? Can I narrow therapy? Can I change from intravenous to oral therapy? "Too often, the decision to continue antibiotic therapy is not revisited as more clinical and microbiological data become available," the authors said. Prescribers should perform a daily antibiotic timeout for every patient receiving antibiotics, which may include the clinical team having a discussion or completing a written form during daily patient rounds.

4. What duration of antibiotic therapy is needed for this patient's diagnosis? A growing number of studies support shorter durations of antibiotic therapy than previously administered for infections, the authors said. "The duration of therapy should be based on the literature and an assessment of whether patients have had appropriate clinical responses."

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