***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: Purpose The use of surgical antibiotic prophylaxis ( SAP ) in children is poorly characterized . Our aim was to evaluate the effectiveness of a quality improvement ( QI ) intervention targeting  SAP in children , by means of a multicenter prospect i ve intervention study , with a before and after design . Methods We prospect ively investigated elective surgical procedures performed in children < 18 years , prior to the QI intervention  , after the intervention and at 9-month follow-up . The primary outcomes were adherence to SAP indications and SAP appropriateness , defined considering antibiotic choice , timing of first dose and duration of administration . We compared SAP adherence and appropriateness prior the QI intervention , to the post-intervention and the follow-up . We considered patient and procedure characteristics as covariates in two logistic regression models to assess the effect of the QI intervention on SAP adherence and appropriateness . Results We collected information on 2383 procedures ( pre-intervention : 784 ; post-intervention : 790 ; follow-up : 809 ) . The QI intervention had a significant impact on the adherence to SAP indications ( 86.6 % in the post-intervention , compared to 82.0 % prior to the intervention ; p < 0.05 ) , and on its appropriateness ( 35.7 % compared to 19.9 % ; p < 0.01 ) . The impact of the intervention on SAP appropriateness was maintained at follow-up ( 38.3 % ; p < 0.01 compared to pre-intervention ) . All components of SAP appropriateness significantly improved after the intervention and at follow-up . The logistic regression analyses confirmed the effect of intervention in improving adherence to SAP indications and appropriateness . Conclusions Following the QI intervention , there was a significant improvement in quality of SAP in pediatric surgery , though more efforts are needed to increase SAP appropriateness Objective To establish whether an interactive booklet on  respiratory tract infections in children reduces reconsultation for the same illness episode , reduces antibiotic use , and affects future consulting intentions , while maintaining parental satisfaction with care . Design Pragmatic cluster r and omised controlled trial . Setting 61 general practice s in Wales and Engl and . Participants 558 children ( 6 months to 14 years ) presenting to primary care with an acute respiratory tract infection ( 7 days or less ) . Children with suspected pneumonia , asthma or a serious concomitant illness , or needing immediate hospital admission were excluded . Three withdrew and 27 were lost to follow-up , leaving 528 ( 94.6 % ) with main outcome data . Interventions Clinicians in the intervention group were trained in the use of an interactive booklet on respiratory tract infections and asked to use the booklet during consultations with recruited patients ( and provide it as a take home re source ) . Clinicians in the control group conducted their consultations as usual . Main outcome measures The proportion of children who attended a face-to-face consultation about the same illness during the two week follow-up period . Secondary outcomes included antibiotic prescribing , antibiotic consumption , future consulting intentions , and parental satisfaction , reassurance , and enablement . Results Reconsultation occurred in 12.9 % of children in the intervention group and 16.2 % in the control group ( absolute risk reduction 3.3 % , 95 % confidence interval −2.7 % to 9.3 % , P=0.29 ) . Using multilevel modelling ( at the practice and individual level ) to account for clustering , no significant difference in reconsulting was noted ( odds ratio 0.75 ; 0.41 to 1.38 ) . Antibiotics were prescribed at the index consultation to 19.5 % of children in the intervention group and 40.8 % of children in the control group ( absolute risk reduction 21.3 % , 95 % confidence interval 13.7 to 28.9 ) , P<0.001 ) . A significant difference was still present after adjusting for clustering ( odds ratio 0.29 ; 0.14 to 0.60 ) . There was also a significant difference in the proportion of parents who said they would consult in the future if their child developed a similar illness ( odds ratio 0.34 ; 0.20 to 0.57 ) . Satisfaction , reassurance , and parental enablement scores were not significantly different between the two groups . Conclusions Use of a booklet on respiratory tract infections in children within primary care consultations led to important reductions in antibiotic prescribing and reduced intention to consult without reducing satisfaction with care . Trial registration Current Controlled Trials IS RCT Background Antibiotics are overused in children and adolescents with lower respiratory tract infection ( LRTI ) .  Serum-procalcitonin ( PCT ) can be used to guide treatment when bacterial infection is suspected . Its role in pediatric LRTI is unclear . Methods Between 01/2009 and 02/2010 we r and omized previously healthy patients 1 month to 18 years old presenting with LRTI to the emergency departments of two pediatric hospitals in Switzerl and to receive antibiotics either according to a PCT guidance algorithm established for adult LRTI or st and ard care clinical guidelines . In intention-to-treat analyses , antibiotic prescribing rate , duration of antibiotic treatment , and number of days with impairment of daily activities within 14 days of r and omization were compared between the two groups . Results In total 337 children , mean age 3.8 years ( range 0.1–18 ) , were included .  Antibiotic prescribing rates were not significantly different in PCT guided patients compared to controls ( OR 1.26 ; 95 % CI 0.81 , 1.95 ) . Mean duration of antibiotic exposure was reduced from 6.3 to 4.5 days under PCT guidance ( −1.8 days ; 95 % CI −3.1 , −0.5 ; P = 0.039 ) for all LRTI and from 9.1 to 5.7 days for pneumonia ( −3.4 days 95 % CI −4.9 , −1.7 ; P<0.001 ) . There was no apparent difference in impairment of daily activities between PCT guided and control patients . Conclusion PCT guidance reduced antibiotic exposure by reducing the duration of antibiotic treatment , while not affecting the antibiotic prescribing rate . The latter may be explained by the low baseline prescribing rate in Switzerl and for pediatric LRTI and the choice of an inappropriately low PCT cut-off level for this population . Trial Registration Controlled-Trials.com IS RCT N17057980 IS RCT Significant overtreatment with antibiotics for suspected early onset sepsis ( EOS )  constitutes a persisting clinical problem , generating unnecessary risks , harms , and costs for many newborns . We aim ed to study feasibility and impact of a sepsis calculator to help guide antibiotic for suspected EOS in a European setting . In this single-center study , the sepsis calculator was implemented as an addition to and in accordance with existing protocol s. One thous and eight hundred seventy-seven newborns ≥ 35 weeks of gestational age were prospect ively evaluated ; an analogous retrospective control group ( n = 2076 ) was used for impact analysis . We found that empirical treatment with intravenous antibiotics for suspected EOS was reduced from 4.8 to 2.7 % after sepsis calculator implementation ( relative risk reduction 44 % ( 95 % confidence interval 21.4–59.5 % ) ) . No evidence for changes in time to treatment start , treatment duration , or proven sepsis rates was found . Adherence to sepsis calculator recommendation was 91 % . Conclusion : Pragmatic and feasible implementation of the sepsis calculator yields a 44 % reduction of empirical use of antibiotics for EOS , without signs of delay or prolongation of treatment . These findings warrant a multicenter , nation-wide , r and omized study evaluating systematic use of the sepsis calculator prediction model and its effects in clinical practice outside of the USA.What is known:• Significant overtreatment with antibiotics for suspected early-onset sepsis results in unnecessary costs , risks , and harms.• Implementation of the sepsis calculator in the USA has result ed in a significant decrease in empirical antibiotic treatment , without apparent adverse events . What is new:• Implementation of the sepsis calculator in daily clinical decision-making in a Dutch teaching hospital is feasible in conjunction with existing protocol s , with high adherence.• Antibiotic therapy for suspected early-onset sepsis was reduced by 44 % following implementation of the calculator Background A second-sign prospect i ve restriction of select broad-spectrum antimicrobials was fully implemented in January 2015 as a pediatric antimicrobial stewardship program ( ASP ) initiative to help ensure the most appropriate empiric use of ceftaroline , cefepime , fidaxomicin , linezolid , and vancomycin ( intravenous ) . The objective of this evaluation is to assess the effectiveness of a forced second-sign process in the electronic medical record as a pediatric ASP strategy . We anticipated that the second-sign process for antibiotics would increase the appropriateness of empiric antibiotic use , as defined by preapproved criteria , clinical pathways , national guidelines , and pediatric-specific infectious diseases reference texts , while not causing significant delay in the initial administration of antibiotic therapy . Methods This was a retrospective before and after intervention chart review conducted from July 2014 to June 2015 . The study was conducted at a 187-bed , freest and ing teaching children 's hospital that included the following : level-1 pediatric trauma center , 18-bed pediatric intensive care unit , and 32-bed neonatal intensive care unit . Results A total of 1178 orders were identified , and 389 met inclusion criteria . The vast majority of second-sign orders were for vancomycin ( 92 % ) , 61 % were written for males , and the median age was 6 years old . Appropriateness of second-sign restricted antibiotic use significantly increased after second-sign implementation ( 84.5 % to 92.9 % , P = .01 ) . The secondary outcome of time from initial order entry to medication administration was not different between the before and after groups ( median time , 184.5 [ interquartile range , 110.25 - 280.75 ] vs 174 [ interquartile range , 104 - 228 ] minutes ; P = .342 ) . Conclusions The use of a second-sign approval process for antimicrobial restriction can lead to increased appropriateness of antibiotic use at a pediatric hospital , without causing a delay in administration Background Pediatric stewardship programs have been successful at reducing unnecessary antibiotic use . Data from nonfreest and ing children 's hospitals are currently limited . This study is an analysis of antibiotic use after implementation of an antimicrobial stewardship program at a community nonfreest and ing children 's hospital . Methods In April 2013 , an antimicrobial stewardship program that consisted of physician-group engagement and pharmacist prospect i ve auditing and feedback was initiated . We compared antibiotic use in the preintervention period ( April 2012 to March 2013 ) with that in the postintervention period ( April 2013 to March 2015 ) in all units except the neonatal intensive care unit and the emergency department . In addition , drug-acquisition costs , antibiotic-specific use , death , length of stay , and case-mix index were examined . Results Antibiotic use decreased by 16.8 % ( 95 % confidence interval , 18.0 % to -9.2 % ; P < .001 ) in the postintervention period . Vancomycin use decreased by 38 % ( P = .001 ) , whereas antipseudomonal β-lactam use was unaltered . Drug-acquisition cost savings were estimated to be $ 67 000/year over the 2-year postintervention period . Lengths of stay and mortality rates were unchanged in the postintervention period after adjusting for case-mix index . Conclusions Implementation of a simple stewardship initiative with limited re sources at a community nonfreest and ing children 's hospital effectively reduced antibiotic use without an overt negative impact on overall clinical outcomes . The results of this study suggest that nonfreest and ing children 's hospitals can achieve substantial reductions in antibiotic use despite limited re sources Introduction : The use of vancomycin is common among hospitalized children . We sought to evaluate the impact of prospect i ve audit with real-time feedback on  vancomycin use and pharmacy costs . Methods : Vancomycin use was evaluated at Monroe Carell Jr Children ’s Hospital at V and erbilt ( MCJCHV ) before and after the implementation of prospect i ve audit with intervention and feedback to providers in 2012 . Antibiotic use was compared to academic children ’s hospitals with established antimicrobial stewardship programs ( ASPs ) . Two similar pediatric academic institutions without an ASP were used as nonintervention controls . Analysis of monthly days of antibiotic therapy ( DoT ) per 1000 patient-days was performed by interrupted time series analysis . Results : Monthly vancomycin use decreased from 114 DoTs/1000 patient-days to 89 DoTs/1000 patient-days ( P < .0001 ) . We did not find significant differences in the slope of change in vancomycin use between MCJCHV and institutions with ASPs either before or after the intervention ( P = .86 and P = .71 , respectively ) . When compared to children ’ 
    Output:
    
Almost all the studies ( 79.6 % ) showed a significant reduction in inappropriate prescriptions .
Compliance after ASP implementation increased .
Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration .