Four Moments of Antibiotic Decision Making
The Four Moments of Antibiotic Decision Making are the critical time periods of antibiotic decision making. Clinicians are encouraged to use the Four Moments framework for all patients receiving antibiotics and whenever the need for antibiotics is being considered.
Four Moments Questions
Before initiating antibiotics it is important to pause and review all relevant clinical and laboratory data and then weigh the potential benefit versus harm of initiating antibiotic therapy.
After the decision to initiate antibiotics is made, ensure appropriate cultures are collected. Cultures obtained before antibiotics are initiated are the most useful for making clinical decisions about de-escalating or stopping antibiotic therapy after the results are available. Next, decide on the appropriate empiric antibiotic treatment regimen based on what you think the source of infection is and relevant patient factors such as severity of illness, immunocompromised status, history of drug-resistant infections, and presence of a severe penicillin allergy. Use local antibiotic treatment guidelines whenever they are available.
After more clinical and microbiological data are available and the patient’s clinical trajectory becomes more apparent, the need for continued antibiotic therapy should be assessed. This can occur as early as after the first day the patient is on antibiotics; thus, the Moment 3 questions should be asked every day that a patient is on antibiotics, ideally at a prespecified time such as during rounds. If there is no evidence of a bacterial infection, stop antibiotics. If an organism was recovered, use the narrowest spectrum agent expected to be effective. If clinical improvement is observed and oral antibiotic therapy can be tolerated and is appropriate for the type of infection diagnosed, transition from intravenous to oral therapy.
Moment 4 should occur when the patient’s diagnosis becomes clear. Always use the shortest effective antibiotic duration for the infectious process you are treating. Specific recommendations can be found throughout the AHRQ Safety Program toolkit. It is important to document the planned duration and stop date in the medical record.
Implementation of the Four Moments
Several actions can be taken to integrate the Four Moments into regular practice. Local guidelines should be developed using the Four Moments framework. All “Best Practices” presentations in the AHRQ Safety Program Toolkit incorporate the Four Moments framework and most have One Page Document templates to assist with guideline development.