Audit of the prescription of antimicrobials using the four moments of decision tool in a university hospital

Antimicrob Resist Infect Control https://doi.org/10.1186/s13756-026-01761-4 Article in Press Audit of the prescription of antimicrobials using the four moments of decision tool in a university hospital Amanda Magalhães Vilas Boas Cambiais, Vanusa Barbosa Pinto, Andréa Cassia Pereira Sforsin, Luiz Marcelo Sa Malbouisson, Arnaldo Lichtenstein, Nelson Luccia, Aleia Faustina Campos, Ícaro Boszczowski, Silvia Figueiredo Costa & Thaís Guimarães Received: 23 September 2025 Accepted: 2 May 2026 Cite this article as: Cambiais A.M.V.B., Pinto V.B., Sforsin A.C.P. et al. Audit of the prescription of antimicrobials using the four moments of decision tool in a university hospital. Antimicrob Resist Infect Control (2026). https://doi. org/10.1186/s13756-026-01761-4 A S S We are providing an unedited version of this manuscript to give early access to its findings. Before final publication, the manuscript will undergo further editing. Please note there may be errors present which affect the content, and all legal disclaimers apply. IN E R P If this paper is publishing under a Transparent Peer Review model then Peer Review reports will publish with the final article. I T R E L C © The Author(s) 2026. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. ACCEPTED ARTICLEMANUSCRIPT IN PRESS Audit of the prescription of antimicrobials using the four moments of decision tool in a university hospital. (1) Amanda Magalhães Vilas Boas Cambiais; Division of Pharmacy, Instituto Central, Hospital das Clínicas, São Paulo, Brazil (2) Vanusa Barbosa Pinto; Division of Pharmacy, Instituto Central, Hospital das Clínicas, São Paulo, Brazil (3) Andréa Cassia Pereira Sforsin; Division of Pharmacy, Instituto Central, Hospital das Clínicas, São Paulo, Brazil S S E R P (4) Luiz Marcelo Sa Malbouisson; Intensive Care Unit, Instituto Central, Hospital das Clínicas, São Paulo, Brazil E L C IN (5) Arnaldo Lichtenstein; Clinical Medicine Department, Instituto Central, Hospital das I T AR Clínicas, São Paulo, Brazil (6) Nelson De Luccia; Vascular Surgery Department, Instituto Central, Hospital das Clínicas, São Paulo, Brazil (7) Aleia Faustina Campos; Infection Control Department, Instituto Central, Hospital das Clínicas, São Paulo, Brazil (8) Ícaro Boszczowski; Infection Control Department, Instituto Central, Hospital das Clínicas, São Paulo, Brazil (9) Silvia Figueiredo Costa; Infection Control Department, Instituto Central, Hospital das Clínicas, São Paulo, Brazil ACCEPTED ARTICLEMANUSCRIPT IN PRESS (10) Thaís Guimarães; Infection Control Department, Instituto Central, Hospital das Clínicas, São Paulo, Brazil Correspondent author: Thaís Guimarães, MD, PhD Av. dos Eucaliptos, 155 apto. 121 – São Paulo – São Paulo – Brazil Zip Code: 04517-050 E-mail: E L C IN S S E R P I T AR Structured Abstract Background: Antimicrobial resistance is a growing global threat driven by inappropriate antimicrobial use. The Four Moments of Antibiotic Decision Making is a stewardship framework that promotes rational antibiotic use. This study applied this framework to audit antimicrobial prescribing, assess adherence, and measure antimicrobial use. ACCEPTED ARTICLEMANUSCRIPT IN PRESS Methods: We conducted a retrospective, cross-sectional audit of patients who received systemic antimicrobials between October and November 2023. The four audited moments included: (1) indication, suspected site, and clinical evidence of infection; (2) antimicrobial selection and culture collection; (3) reassessment between days 3 and 5 based on clinical response and culture results; and (4) treatment duration. Antimicrobial consumption was measured using days of therapy (DOT), length of therapy (LOT) and the WHO AWaRe classification. Results: A total of 228 patients (53.5% male; mean age 57 years) received 304 S S E R P antimicrobial treatments, including 129 intensive care units (ICU) admissions. 75.0% IN were fully adherent to all Four Moments. Adherence rates across moments 1 to 4 were E L C 97%, 88.8%, 89.3%, and 87.1%, respectively. In moment 2, cultures were indicated in I T AR 201 treatments but not requested in 15% of cases. Vancomycin was the most prolonged treatment, followed by ceftriaxone, piperacillin-tazobactam, and meropenem. Antimicrobial use was higher in ICUs, with DOT and LOT reaching 739 and 706 per 1,000 patient-days, respectively, compared with 496 and 319 in the wards. Most antimicrobial consumption corresponded to WHO AWaRe Watch antibiotics. Conclusions: Adherence to stewardship principles was high, although opportunities for improvement remain, particularly regarding culture collection and treatment duration optimization. ACCEPTED ARTICLEMANUSCRIPT IN PRESS Keywords: Antimicrobial stewardship; antibiotic prescribing; infection control; antimicrobial resistance; hospital audit. Disclosures The authors declare no conflicts of interest relevant to this study. Funding S S E R P This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. E L C Ethical Approval IN I T AR The study was approved by the Institutional Ethics Committee of HC-FMUSP (approval number 6.234.289), and all patient data were anonymized prior to analysis. Introduction Antimicrobial resistance (AMR) is a critical global public health threat, driven by inappropriate use of broad-spectrum antimicrobials in clinical settings 1. According to UK economist Jim O’Neill in the report Tackling Drug-Resistant Infections Globally: Final Report and Recommendations, AMR could become the leading cause of death ACCEPTED ARTICLEMANUSCRIPT IN PRESS worldwide by 2050, potentially resulting in 10 million deaths annually if no effective measures are implemented 2. The 2019 Centers for Disease Control and Prevention (CDC) Antibiotic Resistance Threats Report estimated that more than 2.8 million antibiotic-resistant infections occur annually in the United States, resulting in over 35,000 deaths. Globally, AMR was directly responsible for at least 1.27 million deaths and associated with nearly 5 million deaths in 2019 3. One of the main strategies to optimize antimicrobial use (...truncated)