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Four Steps to Manage Antibiotics in Acute Care Settings

Hospital Safety Insider, January 31, 2019

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By Christopher Cheney, Healthleaders

A four-phase approach to prescribing and managing antibiotics focuses on critical time points to achieve effective antibiotics stewardship, a recent article in JAMA says.

Appropriate prescribing of antibiotics by healthcare providers is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.

The lead author of the JAMA article, Pranita Tamma, MD, MHS, of Johns Hopkins University School of Medicine, is a co-creator of the 4 Moments of Antibiotic Decision-Making concept.

“The 4 Moments concept is a simple construct that clinicians can incorporate into their daily decision making to decide whether antibiotics are needed in the first place; and if they are needed, making sure the right antibiotic for that particular patient is being administered and for only as long as necessary,” Tamma told Healthleaders recently.

In the acute care setting, the 4 Moments approach creates a simple framework for comprehensive administration of antibiotics, she said.

“Our hope would be that the Four Moments are discussed on a daily basis— depending on the moment relevant to the particular patient—during clinical rounds with team care involving nursing, pharmacy, and clinicians to ensure the best possible outcomes for patients.”

Moment 1

At the first step of care, Moment 1 is when prescribers should decide deliberately on whether a noninfectious process is at play. In dyspnea patients, several noninfectious conditions could be an underlying cause such as aspiration pneumonitis, atelectasis, congestive heart failure, and pulmonary embolism.

At Moment 1, clinicians should assess relevant patient information to gauge the likelihood of an infection and advisability of prescribing antibiotics.

Moment 2

There are a pair of considerations at Moment 2.

First, cultures should be obtained when advisable before antibiotics are administered. Second, after antibiotics have been ordered the care team should administer the medication promptly.

To facilitate Moment 2 decision making, there should be hospital treatment guidelines for common inpatient infections.

Moment 3

A day or two after antibiotics have been administered, clinicians should consider whether to continue the medication, narrow the therapy, or change from intravenous to oral antibiotics. Review of a patient’s antibiotics treatment should be conducted daily and documented in progress notes, including indications to continue antibiotics, plans to narrow therapy, and anticipated therapy duration.

Moment 4

Therapy duration is the focus of Moment 4.

Studies indicate that therapy duration should be shorter than previously practiced for many of the infections treated in the acute care setting such as community-acquired pneumonia, ventilator-associated pneumonia, intra-abdominal infections, and urinary tract infections.

Adopting best practices

Part of good antibiotics stewardship is breaking bad habits, Tamma said.

“Very often as clinicians, it becomes practice to start antibiotics as a reflex. For example, if a hospitalized patient has a fever, antibiotics are administered. If the same patient was at home, we would probably suggest he or she monitor symptoms for some time before considering antibiotics,” she said.

Monitoring the administration of antibiotics in the inpatient setting is crucial, Tamma said.

“After antibiotics are started for a hospitalized patient, clinicians often get consumed with other aspects of the patient’s medical care and sometimes forget that antibiotics are still onboard or forget to review whether the antibiotics can be changed to less toxic agents or switched from intravenous to oral antibiotics.”

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