***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 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 Viral respiratory infections are common worldwide and range from completely benign disease to life-threatening illness . Symptoms can be unspecific , and an etiologic diagnosis is rarely established because of a lack of suitable diagnostic tools . Improper use of antibiotics is common in this setting , which is detrimental in light of the development of bacterial resistance . It has been suggested that the use of diagnostic tests could reduce antibiotic prescription rates . The objective of this study was to evaluate whether access to a multiplex polymerase chain reaction ( PCR ) assay panel for etiologic diagnosis of acute respiratory tract infections ( ARTIs ) would have an impact on antibiotic prescription rate in primary care clinical setting s. Methods Adult patients with symptoms of ARTI were prospect ively included . Nasopharyngeal and throat swabs were analysed by using a multiplex real-time PCR method targeting thirteen viruses and two bacteria . Patients were recruited at 12 outpatient units from October 2006 through April 2009 , and sample s were collected on the day of inclusion ( initial visit ) and after 10 days ( follow-up visit ) . Patients were r and omised in an open-label treatment protocol to receive a rapid or delayed result ( on the following day or after eight to twelve days ) . The primary outcome measure was the antibiotic prescription rate at the initial visit , and the secondary outcome was the total antibiotic prescription rate during the study period . Results A total sample of 447 patients was r and omised . Forty-one were excluded , leaving 406 patients for analysis . In the group of patients r and omised for a rapid result , 4.5 % ( 9 of 202 ) of patients received  antibiotics  at the initial visit , compared to 12.3 % ( 25 of 204 ) ( P = 0.005 ) of patients in the delayed result group . At follow-up , there was no significant difference between the groups : 13.9 % ( 28 of 202 ) in the rapid result group and 17.2 % ( 35 of 204 ) in the delayed result group ( P = 0.359 ) , respectively . Conclusions Access to a rapid method for etiologic diagnosis of ARTIs may reduce antibiotic prescription rates at the initial visit in an outpatient setting . To sustain this effect , however , it seems necessary to better define how to follow and manage the patient according to the result of the test , which warrants further investigation . Trial registration Clinical Trials.gov identifier : NCT01133782 Background : Few interventions have proven effective in reducing the overuse of antibiotics for acute respiratory infections . We evaluated the effect of DECISION+2 , a shared decision-making training program , on the percentage of patients who decided to take  antibiotics  after consultation with a physician or resident . Methods : We performed a r and omized trial , clustered at the level of family practice teaching unit , with 2 study arms : DECISION+2 and control . The DECISION+2 training program included a 2-hour online tutorial followed by a 2-hour interactive seminar about shared decision-making . The primary outcome was the proportion of patients who decided to use antibiotics immediately after consultation . We also recorded patients ’ perception that shared decision-making had occurred . Two weeks after the initial consultation , we assessed patients ’ adherence to the decision , repeat consultation , decisional regret and quality of life . Results : We compared outcomes among 181 patients who consulted 77 physicians in 5 family practice teaching units in the DECISION+2 group , and 178 patients who consulted 72 physicians in 4 family practice teaching units in the control group . The percentage of patients who decided to use antibiotics after consultation was 52.2 % in the control group and 27.2 % in the DECISION+2 group ( absolute difference 25.0 % , adjusted relative risk 0.48 , 95 % confidence interval 0.34–0.68 ) . DECISION+2 was associated with patients taking a more active role in decision-making ( Z = 3.9 , p < 0.001 ) . Patient outcomes 2 weeks after consultation were similar in both groups . Interpretation : The shared decision-making program DECISION+2 enhanced patient participation in decision-making and led to fewer patients deciding to use antibiotics for acute respiratory infections . This reduction did not have a negative effect on patient outcomes 2 weeks after consultation . Clinical Trials.gov trial register no. NCT01116076 OBJECTIVE To examine whether the Acute Respiratory Infection ( ARI )  Quality Dashboard , an electronic health record (EHR)-based feedback system , changed antibiotic prescribing . STUDY DESIGN Cluster r and omized , controlled trial . METHODS We r and omly assigned 27 primary care practice s to receive the ARI Quality Dashboard or usual care .  The primary outcome was the intent-to-intervene antibiotic prescribing rate for ARI visits . We also compared antibiotic prescribing between ARI Quality Dashboard users and nonusers . RESULTS During the 9-month intervention , there was no difference between intervention and control practice s in antibiotic prescribing for all ARI visits ( 47 % vs 47 % ; P = .87 ) , antibiotic-appropriate ARI visits ( 65 % vs 64 % ; P = .68 ) , or non – antibiotic-appropriate ARI visits ( 38 % vs 40 % ; P = .70 ) . Among the 258 intervention clinicians , 72 ( 28 % ) used the ARI Quality Dashboard at least once . These clinicians had a lower overall ARI antibiotic prescribing rate ( 42 % vs 50 % for nonusers ; P = .02 ) . This difference was due to less antibiotic prescribing for non-antibiotic-appropriate ARIs ( 32 % vs 43 % ; P = .004 ) , including nonstreptococcal pharyngitis ( 31 % vs 41 % ; P = .01 ) and nonspecific upper respiratory infections ( 19 % vs 34 % ; P = .01 ) . CONCLUSIONS The ARI Quality Dashboard was not associated with an overall change in antibiotic prescribing for ARIs , although when used , it was associated with improved antibiotic prescribing . EHR-based quality reporting , as part of " meaningful use , " may not improve care in the absence of other changes to primary care practice IMPORTANCE Antimicrobial stewardship programs have been effective for in patients , often through prescribing audit and feedback . However , most antimicrobial use occurs in out patients with acute respiratory tract infections ( ARTIs ) . OBJECTIVE To evaluate the effect of an antimicrobial stewardship intervention on antibiotic prescribing for pediatric out patients . DESIGN Cluster r and omized trial of outpatient antimicrobial stewardship comparing prescribing between intervention and control practice s using a common electronic health record . After excluding children with chronic medical conditions , antibiotic allergies , and prior antibiotic use , we estimated prescribing rates for targeted ARTIs st and ardized for age , sex , race , and insurance from 20 months before the intervention to 12 months afterward ( October 2008-June 2011 ) . SETTING AND PARTICIPANTS A network of 25 pediatric primary care practice s in Pennsylvania and New Jersey ; 18 practice s ( 162 clinicians ) participated . INTERVENTIONS One 1-hour on-site clinician education session ( June 2010 ) followed by 1 year of personalized , quarterly audit and feedback of prescribing for bacterial and viral ARTIs or usual practice . MAIN OUTCOMES AND MEASURES Rates of broad-spectrum ( off- guideline ) antibiotic prescribing for bacterial ARTIs and antibiotics for viral ARTIs for 1 year after the intervention . RESULTS Broad-spectrum antibiotic prescribing decreased from 26.8 % to 14.3 % ( absolute difference , 12.5 % ) among intervention practice s vs from 28.4 % to 22.6 % ( absolute difference , 5.8 % ) in controls ( difference of differences [ DOD ] , 6.7 % ; P = .01 for differences in trajectories ) . Off- guideline prescribing for children with pneumonia decreased from 15.7 % to 4.2 % among intervention practice s compared with 17.1 % to 16.3 % in controls ( DOD , 10.7 % ; P < .001 ) and for acute sinusitis from 38.9 % to 18.8 % in intervention practice s and from 40.0 % to 33.9 % in controls ( DOD , 14.0 % ; P = .12 ) . Off- guideline prescribing was uncommon at baseline and changed little for streptococcal pharyngitis ( intervention , from 4.4 % to 3.4 % ; control , from 5.6 % to 3.5 % ; DOD , -1.1 % ; P = .82 ) and for viral infections ( intervention , from 7.9 % to 7.7 % ; control , from 6.4 % to 4.5 % ; DOD , -1.7 % ; P = .93 ) . CONCLUSIONS AND RELEVANCE In this large pediatric primary care network , clinician education coupled with audit and feedback , compared with usual practice , improved adherence to prescribing guidelines for common bacterial ARTIs , and the intervention did not affect antibiotic prescribing for viral infections . Future studies should examine the drivers of these effects , as well as the generalizability , sustainability , and clinical outcomes of outpatient antimicrobial stewardship . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01806103 PURPOSE The purpose of the study was to assess the long-term effect of family physicians ’ use of C-reactive protein ( CRP ) point-of-care testing and /or physician training in enhanced communication skills on office visit rates and antibiotic prescriptions for patients with respiratory tract infections . METHODS We conducted a 3.5-year follow-up of a pragmatic , factorial , cluster-r and omized controlled trial ; 379 patients ( 20 family practice s in the Netherl and s ) who visited their family physician for acute cough were enrolled in the trial and had follow-up data available ( 88 % of original trial cohort ) . Main outcome measures were the average number of episodes of respiratory tract infections for which patients visited their family physician per patient per year ( PPPY ) , and the percentage of the episodes for which patients were treated with antibiotics during follow-up . RESULTS The mean number of episodes of respiratory tract infections during follow-up was 0.40 PPPY in the CRP test group and 0.56 PPPY in the no CRP test group ( P = . 
    Output:
    
We found medium-strength evidence that stewardship programs incorporating communication skills training and laboratory testing are associated with reductions in antimicrobial use , and low-strength evidence that other stewardship interventions are associated with improved prescribing .
Patient-centered outcomes , which were infrequently reported , were not adversely affected .
Medication costs were generally lower with stewardship interventions , but overall program costs were rarely reported .
Low- to moderate-strength evidence suggests that antimicrobial stewardship programs in outpatient setting s improve antimicrobial prescribing without adversely effecting patient outcomes .
Effectiveness depends on program type .