Original Study Does Adherence to the Loeb Minimum Criteria Reduce Antibiotic Prescribing Rates in Nursing Homes? Lauren E.W. Olsho PhD a, *, Rosanna M. Bertrand PhD a , Alrick S. Edwards MPH a , Louise S. Hadden a , G. Brant Morefield PhD a , Donna Hurd MSN a , C. Madeline Mitchell MURP b , Philip D. Sloane MD, MPH b, c , Sheryl Zimmerman PhD b, d a US Health Division, Abt Associates Inc, Cambridge, MA b Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC c Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC d School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC Keywords: Antibiotics prescribing infections Loeb minimum criteria nursing homes abstract Objectives: The Loeb minimum criteria (LMC), developed by a 2001 consensus conference, are minimum standards for initiation of antibiotics in long term care settings, intended to reduce inappropriate prescribing. This study examined the relationship between nursing home prescriber adherence to the LMC and antibiotic prescribing rates, overall and for each of three specific conditions (urinary tract infections, respiratory infections, and skin and soft tissue infections). Design: We performed a cross-sectional analysis at the resident-day level. We estimated multivariate models adjusting for nursing home characteristics via multilevel Poisson regression, with robust stan- dard errors to account for clustering of prescriptions within residents within nursing homes. Setting: Data were collected through medical record abstraction in 12 North Carolina nursing homes between March and May 2011. Participants: In total, we identified 3381 antibiotic prescriptions across the 3-month observation period, representing 110,810 nursing home resident-days. In addition, we performed chart audits for a random sample of 653 prescriptions for urinary tract, respiratory, and skin and soft tissue infections to create measures of LMC adherence. Measurements: The primary outcome was a count of prescriptions per resident per day, and the key explanatory variable was a nursing home-level estimate of the proportion of antibiotic prescriptions that adhered to the LMC. Results: Only 12.7% of prescriptions were classified as LMC adherent, although there was substantial variation across study nursing homes (range: 4.8% to 22.0%) and by infection type (1.9% adherence for respiratory infections, 10.2% for urinary tract infections, and 42.7% for skin and soft tissue infections). We found no statistically significant relationship between adherence to the LMC and total prescribing rates (IRR 1.00, 95% CI 0.98e1.03; P ¼ .84). Similarly, there was no significant relationship between LMC adherence and prescribing rates for treating urinary tract infections (IRR 0.99, 95% CI 0.96e1.02; P ¼ .49), respiratory infections (IRR 0.91, 95% CI 0.76e1.08; P ¼ .28), or skin and soft tissue infections (IRR 0.99, 95% CI 0.98e1.01; P ¼ .39) considered alone. Conclusion: We found little evidence that prescribers in study nursing homes considered the LMC when making prescribing decisions. Further, we found no evidence that greater adherence to the LMC was associated with lower rates of antibiotic prescribing. Evidence-based guidelines for antibiotic initiation must be adopted more widely before any substantial gains from adherence are likely to be recognized. Copyright Ó 2013 - American Medical Directors Association, Inc. Antibiotic resistance among common bacterial pathogens is an important and growing public health problem. In the 60 years since the discovery of penicillin, health care providers have struggled to stay a step ahead of bacterial adaptation, and multidrug-resistant strains of bacteria have become increasingly common. 1,2 Inappro- priate prescribing by primary care clinicians is believed to be a major This research was conducted by Abt Associates Inc. under contract to the Agency for Healthcare Research and Quality Contract No. HHSA 290 2006 00011I,Task Order #11, Rockville, MD. The authors of this article are responsible for its content. No statement may be construed as the official position of the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services. * Address correspondence to Lauren E.W. Olsho, PhD, Abt Associates Inc, 55 Wheeler Street, Cambridge, MA 02138. E-mail address: lauren_olsho@abtassoc.com (L.E.W. Olsho). JAMDA journal homepage: www.jamda.com 1525-8610/$ - see front matter Copyright Ó 2013 - American Medical Directors Association, Inc. http://dx.doi.org/10.1016/j.jamda.2013.01.002 JAMDA 14 (2013) 309.e1e309.e7