***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To assess the quality of antibiotic prescribing by Victorian general practitioners , and the effectiveness of educational intervention techniques in improving prescribing . DESIGN A r and omised , controlled , parallel group trial . SETTING AND PARTICIPANTS In rural and metropolitan Victoria , 182 general practitioners ( 78 control , 104 intervention ) began and 103 ( 41 control , 62 intervention ) completed the study . INTERVENTION Participants recorded their  antibiotic prescribing for tonsillitis .  The intervention group received an educational mailing campaign . A project pharmacist visited each doctor to discuss campaign messages . MAIN OUTCOME MEASURE The percentages of prescriptions of antibiotics for tonsillitis complying with those recommended in Antibiotic guidelines . RESULTS In the intervention group , prescriptions consistent with recommendations in the guidelines increased from 60.5 % before the campaign to 87.7 % afterwards . Improvement also occurred in the control group , from 52.9 % to 71.7 % of prescriptions . The improvement within the intervention group was significantly greater than that within the control group . CONCLUSIONS The educational campaign significantly improved the prescribing of appropriate antibiotics for tonsillitis by general practitioners CONTEXT The emergence and spread of antibiotic-resistant Streptococcus pneumoniae in US communities is due , in part , to the excessive use of antibiotics for acute respiratory tract infections . OBJECTIVE To decrease total antibiotic use for uncomplicated acute bronchitis in adults . DESIGN Prospect i ve , nonr and omized controlled trial , including baseline ( November 1996-February 1997 ) and study ( November 1997-February 1998 ) periods . SETTING Four selected primary care practice s belonging to a group-model health maintenance organization in the Denver , Colo , metropolitan area . PARTICIPANTS Consecutive adults diagnosed as having uncomplicated acute bronchitis . A total of 2462 adults were included at baseline and 2027 adults were included in the study . Clinicians included 56 physicians , 28 physician assistants or nurse practitioners , and 9 registered nurses . INTERVENTION The full intervention site received household and office-based patient educational material s , as well as a clinician intervention consisting of education , practice -profiling , and academic detailing . A limited intervention site received only office-based educational material s , and control sites provided usual care . MAIN OUTCOME MEASURE Antibiotic prescriptions for uncomplicated acute bronchitis during baseline and study periods . RESULTS Antibiotic prescription rates for uncomplicated acute bronchitis were similar at all 4 sites during the baseline period . During the study period , there was a substantial decline in antibiotic prescription rates at the full intervention site ( from 74 % to 48 % [ P = .003 ] ) , but not at the control and limited intervention sites ( 78 % to 76 % [ P = .81 ] and 82 % to 77 % [ P = .68 ] , respectively ) . Compared with control sites , changes in nonantibiotic prescriptions ( inhaled bronchodilators , cough suppressants , and analgesics ) were not significantly different for intervention sites . Return office visits ( within 30 days of the incident visit ) for bronchitis or pneumonia did not change significantly for any of the sites . CONCLUSIONS Antibiotic treatment of adults diagnosed as having uncomplicated acute bronchitis can be safely reduced using a combination of patient and clinician interventions OBJECTIVE In this study , clinical practice guidelines were developed by a multidisciplinary team for patients with infections admitted to a surgical intensive care unit ( ICU ) . DESIGN A 51-day baseline audit period ( Phase I ) in a 20-bed ( private rooms ) surgical ICU was compared with a 34-day period in the same unit after implementation of the guidelines ( Phase II ) . PATIENTS Phase I included 182 patients ( 670 patient days ) , and Phase II included 139 patients ( 427 patient days ) . RESULTS There was no significant difference between patients in the Phase I and Phase II groups regarding age ( 65.4/19 - 95 vs. 64.8/18 - 90 yrs ) , gender ( 56 % male vs. 55 % male ) ,  severity of illness ( mean Acute Physiology and Chronic Health Evaluation III , 38 vs. 39.1 ) , total infections  ( respiratory , 8 % vs. 4 % ; urinary tract , 15 % vs. 4 % ; wound , 4 % vs. 3 % ; skin/soft tissue , 3 % vs. 7 % ; sepsis , 5 % vs. 3 % ; intra-abdominal , 9 % vs. 17 % ) , and no infection ( 64 % vs. 67 % ) . Clinical outcomes of patients with infections in the Phase I group compared with those in the Phase II group were as follows : clinical improvement or cure , 64 % vs. 76 % ; persistent infection , 17 % vs. 11 % ; clinical failure , 0 vs. 2 % ; and death , 18 % vs. 7 % ( p = NS ) . When patients with infections were compared , death rates were 20 % in the Phase I group and 5.6 % in the Phase II group ( p = .02 ) . After implementation of the clinical pathways , antibiotic costs were reduced from $ 676.54 per patient to $ 157.88 per patient ( p = .001 ) . Length of stay in the ICU was 3.7 days in the Phase I trial and a mean of 3 days in the Phase II trial ( p = NS ) . Specimens of Escherichia coli demonstrated a trend toward a decreased resistance to all antibiotics and Pseudomonas aeruginosa to ciprofloxacin and aminoglycosides ( p = NS ) . CONCLUSIONS In this study , the use of clinical practice guidelines for patients who were admitted to the surgical ICU was shown to reduce costs , without adversely affecting patients ' outcomes . This study has important implication s for the use of clinical practice guidelines for the management of patients with infections who are admitted to surgical ICUs BACKGROUND Antibiotics are a medication class for which inappropriate prescribing is frequently described . We sought to assess the effectiveness of a mailed intervention combining confidential prescribing feedback with targeted educational bulletins in increasing the use of less expensive , first-line antibiotics by practising physicians . METHODS The participants were 251 r and omly selected primary care physicians from southern Ontario who consented to participate ( 135 in the feedback group and 116 in the control group ) . Prescribing data were obtained from the cl aims data base of the Ontario Drug Benefit program , which covers all Ontarians over age 65 years for drugs selected from a minimally restrictive formulary . Confidentially prepared profiles of antibiotic prescriptions coupled with guidelines -based educational bulletins were mailed to the intervention group every 2 months for 6 months . The control group received no intervention until after completion of the study . The main outcome measures were change from baseline in physician 's median antibiotic cost and proportion of episodes of care in which a prespecified first-line antibiotic was used first . RESULTS The median prescription cost of about $ 11 remained constant in the feedback group but rose in the control group ( change of $ 0.05 v. $ 3.37 , p < 0.002 ) . First-line drug use increased in the feedback group but decreased in the control group ( change of 2.6 % v. -1.7 % , p < 0.01 ) . In a mailed survey of 100 feedback recipients ( response rate 76 % ) , 82 % indicated that they would participate readily in another , similar program . INTERPRETATION A simple program of confidential feedback and educational material s blunted cost increases , increased the use of first-line antibiotics and was highly acceptable to Ontario primary care physicians The efficacy of single-dose therapy with trimethoprim-sulfamethoxazole ( TMP-SMZ ) and the cost-effectiveness of routine urinalyses and cultures were studied in a prospect i ve r and omized trial of 200 women who presented with symptoms of acute lower urinary tract infection . Without the physician 's knowledge of the results of urinalysis or culture , the patients were r and omly assigned to receive either a single dose or a 10-day multiple-dose course of TMP-SMZ and were followed up for 6 months . Of the 136 patients with positive urine cultures , 68 received single-dose therapy with TMP-SMZ--10 of whom had relapses-- and 68 received multiple-dose therapy with TMP-SMZ -- only 2 of whom had relapses ( P less than 0.02 ) . Fifteen patients in each treatment group experienced reinfection . Side effects of rash and vaginitis were more common in patients who received multiple-dose therapy , but they were mild and well tolerated . Of the 51 patients with urethral syndrome , 48 became asymptomatic after therapy . None of the following tests predicted treatment outcome : pretreatment urinalysis , urine culture or susceptibility testing , antibody-coated bacteria testing , or routine follow-up urinalyses or urine cultures . Empiric therapy with TMP-SMZ in selected women with symptoms of acute uncomplicated urinary tract infection seems practical , safe , and cost-efficient . Considerable savings can be achieved by reserving urinalyses and urine cultures for patients with persistent or recurrent symptoms . Higher cure rates can be expected in patients who receive a st and ard 10-day course of therapy with TMP-SMZ compared with those who receive single-dose therapy with TMP-SMZ To assess the effects of implementing a st and ardized order form on the prescribing and monitoring of gentamicin sulfate at a nonteaching Veterans Affairs Medical Center , we prospect ively evaluated the prescribing and monitoring of gentamicin for 14 months after the use of such a form was implemented . The data collected included dosing , initial serum gentamicin concentrations , and serum creatinine measurements . These data were compared with similar data obtained during a period of 6 months before the order form was used . A total of 76 patient records were review ed , 39 before the use of the order form and 47 after the order form was implemented .  Gentamicin peak concentrations were statistically higher in the group treated after the order form was implemented . No differences were seen in gentamicin trough concentrations . The timely measurement of serum gentamicin concentrations and serum creatinine levels was improved in the group for whom the order form was used . The order form was completed satisfactorily in 44 patients ( 94 % ) . We conclude that implementing a st and ardized order form improved the use of gentamicin The project goal was to decrease excessive vancomycin use . Interventions included an educational chart note the first day of therapy , followed by pharmacists discussing the need for continued therapy with patients ' physicians .  Empirical vancomycin use improved from 20 % to 90 % compliance with guidelines within 6 months of the intervention CONTEXT Large variations exist among hospitals in the use of treatment re sources for community-acquired pneumonia ( CAP ) . Lack of a common approach to the diagnosis and treatment of CAP has been cited as an explanation for these variations . OBJECTIVE To determine if use of a critical pathway improves the efficiency of treatment for CAP without compromising the well-being of patients . DESIGN Multicenter controlled clinical trial with cluster r and omization and up to 6 weeks of follow-up . SETTING Nineteen teaching and community hospitals in Canada . PATIENTS A total of 1743 patients with CAP presenting to the emergency department at 1 of the participating institutions between January 1 and July 31 , 1998 . INTERVENTION Hospitals were assigned to continue conventional management ( n = 10 ) or implement the critical pathway ( n = 9 ) , which consisted of a clinical prediction rule to guide the admission decision , levofloxacin therapy , and practice guidelines . MAIN OUTCOME MEASURES Effectiveness of the critical pathway , as measured by health-related quality of life on the Short-Form 36 Physical Component Summary ( SF-36 PCS ) scale at 6 weeks ; and re source utilization , as measured by the number of bed days per patient managed ( BDPM ) . RESULTS Quality of life and the occurrence of complications , readmission , and mortality were not different for the 2 strategies ; the 1-sided 95 % confidence limit of the between-group difference in the SF-36 PCS change score was 2.4 points , which was within a predefined 3-point boundary for equivalence . Pathway use was associated with a 1.7-day reduction in BDPM ( 4.4 vs 6.1 days ; P = .04 ) and an 18 % decrease in the admission of low-risk patients ( 31 % vs 49 % ; P = .01 ) . Although in patients at critical pathway hospitals had more severe disease , they required 1.7 fewer days of intravenous therapy ( 4.6 vs 6.3 days ; P = .01 ) and were more likely to receive treatment with a single class of antibiotic ( 64 % vs 27 % ; P<.001 ) . CONCLUSION In this study , implementation of a critical pathway reduced the use of institutional re sources without causing adverse effects on the well-being of patients BACKGROUND The extent of use of antibiotics to treat upper respiratory infections in general practice is an area for concern due to the increasing problem of bacterial resistance . Effective educational strategies 
    Output:
    
The available evidence showed that multifaceted implementation methods were most successful .