Tamma, et al. Rethinking How Antibiotics Are Prescribed: Incorporating the 4 Moments of Antibiotic Decision Making Into Clinical Practice. JAMA. 2018 Dec 27. doi: 10.1001/jama.2018.19509. [Epub ahead of print]
BOTTOM LINE: Providers should be asking themselves: “What is the likelihood my patient has an infection and that it requires antibiotic therapy?”
Those who know me, know my passion for medicine can occasionally turn into a status rant-icus type soliloquy on the failures of modern medicine (I feel one of those coming on me like a seizure…). One of these high horses I like to ride is on a term that has come to have as much meaning and futility as “military intelligence” or “President Trump”…that term is antibiotic stewardship.
I think its easy to know to whom I am referring. For instance, if you have ever in one breath prescribed “a zpack, prednisone, and albuterol” then I am referring to you; if you reflexively say flouroquinolone when you hear words that start with Sinu-, bronch-, or cyst- and end in -itis, then I’m referrering to you; if you have ever used the words “just to be safe” as your clinical decision aid to give antibiotics, then I’m referring to you; if you use the terms “strong” and “weak” to describe antibiotics, then I am referring to you; and lastly if anyone has ever asked you “so what infection are you actually treating?!” Then I am definitely referring to you. (By the way I think a great use of machine learning would be to develop a wristband that shocks providers who type keystrokes recognized as -itis and then Rx an antibiotic.)
Thus much like music to my ears or more appropriately propofol to my seizure I came upon the opinion paper in JAMA entitled “Rethinking How Antibiotics Are Prescribed: Incorporating the 4 Moments of Antibiotic Decision Making Into Clinical Practice”….Ahh had they only incorporated the word zen into the title then I might have been able to sleep more between these night shifts. I think this is a must read!
The article delineates a 4 step process (much shorter than 12) to thoughtfully redirect the thinking of antibiotic prescriptions.
(Zen) Moment #1: (an antibiotic “TIMEOUT”)
This is the most important step! “Does this patient have an infection that requires antibiotics?
Yes, there are cases in severe infections where early antibiotics makes sense, but that does not translate down to an otitis media, or worse a fever! Just as all the glitters isn’t gold…all that has a temp is not an infection. Let’s go back to considering a differential (inflammation, medication, etc) and seeing if there is an alternate reason for the fever. Conversely, some causes of fever are viral and don’t need antibiotics. In fact, there is much literature currently on asymptomatic bacturia and I question giving antibiotics to all urinalyses… So ask yourself “what is the likelihood of an infection that requires antibiotic therapy.
(Zen) Moment #2:
Have I ordered appropriate cultures before starting antibiotics? What empiric antibioitcs should be started? Although not all patients need cultures we should culture appropriately. The authors state that most patients with community acquired pneumonia, abdominal, and no purple tissue cellulitis are NOT high risk for MRSA and may not need vancomycin (I am definitely guilty of not using enough empiric nafcillin/ancef)
(Zen) Moment #3:
A day or more has passed, can I stop antibiotics or narrow the therapy? Can I change from IV to oral therapy? There is much literature on physicians continuing therapy despite culture data to the opposite.
(Zen) Moment #4:
What duration of antibiotic therapy for this patients diagnosis is needed? Remember the timelines we use are have minimal evidence behind them. Some will say that most bacterimia is cleared after 2-3 doses of IV abx. We should be using patient response to therapy rather than opinion based guidelines.
I love this article and think everyone should read it as a reminder. The more we remind ourselves of the literature the better we will do with decreasing unnecessary antibiotic use.
Maybe the authors should have changed the name of the article to “An Antibiotic Timeout”. There more I think about this concept the more I like it.
I better go check my EEG…