Does Adherence to the Loeb Minimum Criteria Reduce Antibiotic Prescribing Rates in Nursing Homes?

Olsho, Lauren; Bertrand, Rosanna M.; Edwards, Alrick S.; Hadden, Louise; Morefield, G. Brant; Hurd, Donna; Mitchell, C. Madeline; Sloane, Philip D.; Zimmerman, Sheryl

doi:10.1016/j.jamda.2013.01.002

Cited by 39 publications

(28 citation statements)

References 26 publications

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“…25 Studies have used these criteria to evaluate antimicrobial use in NHs. 14,15,33 We determined whether these criteria were present for treated suspected urinary tract, respiratory tract, and skin infections, and febrile episodes of unclear source (eAppendix in the Supplement). 24,34 …”

Section: Methodsmentioning

confidence: 99%

Infection Management and Multidrug-Resistant Organisms in Nursing Home Residents With Advanced Dementia

et al. 2014

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management in advanced dementia has important implications for (1) providing high-quality care to patients near the end of life and (2) minimizing the public health threat posed by the emergence of multidrug-resistant organisms (MDROs). DESIGN, SETTING, AND PARTICIPANTSProspective cohort study of 362 residents with advanced dementia and their health care proxies in 35 Boston area nursing homes for up to 12 months. MAIN OUTCOMES AND MEASURES Data were collected to characterize suspected infections, use of antimicrobial agents (antimicrobials), clinician counseling of proxies about antimicrobials, proxy preference for the goals of care, and colonization with MDROs (methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and multidrug-resistant gram-negative bacteria). Main outcomes were (1) proportion of suspected infections treated with antimicrobials that met minimum clinical criteria to initiate antimicrobial treatment based on consensus guidelines and (2) cumulative incidence of MDRO acquisition among noncolonized residents at baseline. RESULTSThe cohort experienced 496 suspected infections; 72.4% were treated with antimicrobials, most commonly quinolones (39.8%) and third-or fourth-generation cephalosporins (20.6%). At baseline, 94.8% of proxies stated that comfort was the primary goal of care, and 37.8% received counseling from clinicians about antimicrobial use. Minimum clinical criteria supporting antimicrobial treatment initiation were present for 44.0% of treated episodes and were more likely when proxies were counseled about antimicrobial use (adjusted odds ratio, 1.42; 95% CI, 1.08-1.86) and when the infection source was not the urinary tract (referent). Among noncolonized residents at baseline, the cumulative incidence of MDRO acquisition at 1 year was 48%. Acquisition was associated with exposure (>1 day) to quinolones (adjusted hazard ratio [AHR], 1.89; 95% CI, 1.28-2.81) and third-or fourth-generation cephalosporins (AHR, 1.57; 95% CI, 1.04-2.40).CONCLUSIONS AND RELEVANCE Antimicrobials are prescribed for most suspected infections in advanced dementia but often in the absence of minimum clinical criteria to support their use. Colonization with MDROs is extensive in nursing homes and is associated with exposure to quinolones and third-and fourth-generation cephalosporins. A more judicious approach to infection management may reduce unnecessary treatment in these frail patients, who most often have comfort as their primary goal of care, and the public health threat of MDRO emergence.

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Section: Methodsmentioning

confidence: 99%

Infection Management and Multidrug-Resistant Organisms in Nursing Home Residents With Advanced Dementia

et al. 2014

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“…2,33,34 A recent study of 12 nursing homes in North Carolina found an overall low adherence to the Loeb criteria (0%–38.9%, mean 10.2%) when deciding on whether to institute antibiotic therapy for suspected UTI. 34 Furthermore, they did not find a significant association between adherence to the Loeb criteria and prescribing rates of antibiotics for UTI.…”

Section: Diagnosis Of Uti In Long-term Care Facilitiesmentioning

confidence: 99%

Diagnosis and Management of Urinary Tract Infection in Older Adults

Rowe

Juthani‐Mehta

2014

Infectious Disease Clinics of North America

238

174

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“…Clarifying this would be useful for NH clinicians, because an updated definition of fever that labeled fewer serious illnesses as afebrile might help clinicians more confidently include or exclude the need for antibiotics. Given the call to reduce inappropriate antibiotics in this population, a lower fever threshold, if more valid in determining the need for antibiotics than the current threshold, might help clinicians avoid the potentially disastrous consequences of failure to treat a serious infection such as bacteremia.…”

Section: Discussionmentioning

confidence: 99%

“…Antimicrobial use is so common in this setting that, at any given time, more than 10% of NH residents are taking systemic antibiotics . Many feel that this rate of antibiotic use is unjustified clinically—experts have estimated that between 21% and 87% of antibiotic prescriptions do not meet clinical guidelines for prescribing appropriateness . However, NH clinicians face many challenges in determining whether and when a NH resident is progressing from bacterial colonization to invasive infection, and the price of delaying treatment can be bacteremia and sepsis.…”

mentioning

confidence: 99%

Role of Body Temperature in Diagnosing Bacterial Infection in Nursing Home Residents

Sloane

Kistler

Mitchell

et al. 2014

J American Geriatrics Society

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Does Adherence to the Loeb Minimum Criteria Reduce Antibiotic Prescribing Rates in Nursing Homes?

Cited by 39 publications

References 26 publications

Infection Management and Multidrug-Resistant Organisms in Nursing Home Residents With Advanced Dementia

Infection Management and Multidrug-Resistant Organisms in Nursing Home Residents With Advanced Dementia

Diagnosis and Management of Urinary Tract Infection in Older Adults

Role of Body Temperature in Diagnosing Bacterial Infection in Nursing Home Residents

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