***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: Summary Background Unnecessary antibiotic prescribing contributes to antimicrobial resistance . In this trial , we aim ed to reduce unnecessary prescriptions of antibiotics by general practitioners ( GPs ) in Engl and . Methods In this r and omised , 2 × 2 factorial trial , publicly available data bases were used to identify GP practice s whose prescribing rate for antibiotics was in the top 20 % for their National Health Service ( NHS ) Local Area Team . Eligible practice s were r and omly assigned ( 1:1 ) into two groups by computer-generated allocation sequence , stratified by NHS Local Area Team . Participants , but not investigators , were blinded to group assignment . On Sept 29 , 2014 , every GP in the  feedback intervention group was sent a letter from Engl and 's Chief Medical Officer and a leaflet on antibiotics for use with patients . The letter stated that the practice was prescribing antibiotics at a higher rate than 80 % of practice s in its NHS Local Area Team . GPs in the control group received no communication . The sample was re-r and omised into two groups , and in December , 2014 , GP practice s were either sent patient-focused information that promoted reduced use of antibiotics or received no communication . The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population , controlling for past prescribing . Analysis was by intention to treat . This trial is registered with the IS RCT N registry , number IS RCT N32349954 , and has been completed . Findings Between Sept 8 and Sept 26 , 2014 , we recruited and assigned 1581 GP practice s to feedback intervention ( n=791 ) or control ( n=790 ) groups . Letters were sent to 3227 GPs in the intervention group . Between October , 2014 , and March , 2015 , the rate of antibiotic items dispensed per 1000 population was 126·98 ( 95 % CI 125·68–128·27 ) in the feedback intervention group and 131·25 ( 130·33–132·16 ) in the control group , a difference of 4·27 ( 3·3 % ; incidence rate ratio [ IRR ] 0·967 [ 95 % CI 0·957–0·977 ] ; p<0·0001 ) , representing an estimated 73 406 fewer antibiotic items dispensed . In December , 2014 , GP practice s were re-assigned to patient-focused intervention ( n=777 ) or control ( n=804 ) groups . The patient-focused intervention did not significantly affect the primary outcome measure between December , 2014 , and March , 2015 ( antibiotic items dispensed per 1000 population : 135·00 [ 95 % CI 133·77–136·22 ] in the patient-focused intervention group and 133·98 [ 133·06–134·90 ] in the control group ; IRR for difference between groups 1·01 , 95 % CI 1·00–1·02 ; p=0·105 ) . Interpretation Social norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale ; this outcome makes it a worthwhile addition to antimicrobial stewardship programmes . Funding Public Health Engl and Background Asymptomatic bacteriuria in the elderly commonly results in antibiotic administration and , in turn , contributes to antimicrobial resistance , adverse drug events , and increased costs . This is a major problem in the long-term care facility ( LTCF ) setting , where residents frequently transition to and from the acute-care setting , often transporting drug-resistant organisms across the continuum of care . The goal of this study was to assess the feasibility and efficacy of antimicrobial stewardship programs ( ASPs ) targeting urinary tract infections ( UTIs ) at community LTCFs . Methods This was a quasi-experimental study targeting antibiotic prescriptions for UTI using time-series analysis with 6-month retrospective pre-intervention and 6-month intervention period at three community LTCFs . The ASP team ( infectious diseases ( ID ) pharmacist and ID physician ) performed weekly prospect i ve audit and feedback of consecutive prescriptions for UTI . Loeb clinical consensus criteria were used to assess appropriateness of antibiotics ; recommendations were communicated to the primary treating provider by the ID pharmacist . Resident outcomes were recorded at subsequent visits . Generalized estimating equations using segmented regression were used to evaluate the impact of the ASP intervention on rates of antibiotic prescribing and antibiotic resistance . Results One-hundred and four antibiotic prescriptions for UTI were evaluated during the intervention , and recommendations were made for change in therapy in 40 ( 38 % ) , out of which 10 ( 25 % ) were implemented . Only eight ( 8 % ) residents started on antibiotics for UTI met clinical criteria for antibiotic initiation . An immediate 26 % decrease in antibiotic prescriptions for UTI during the ASP was identified with a 6 % reduction continuing through the intervention period ( 95 % Confidence Interval ( [ CI ) ] for the difference : −8 to −3 % ) . Similarly , a 25 % immediate decrease in all antibiotic prescriptions was noted after introduction of the ASP with a 5 % reduction continuing throughout the intervention period ( 95 % CI : −8 to −2 % ) . No significant effect was noted on resistant organisms or Clostridium difficile . Conclusion Weekly prospect i ve audit and feedback ASP in three community LTCFs over 6 months result ed in antibiotic utilization decreases but many lost opportunities for intervention BACKGROUND There is a paucity of literature describing the implementation of antimicrobial stewardship programs ( ASPs ) in long-term care ( LTC ) facilities . The current study evaluated the impact of an ASP that was implemented across a geriatric facility , which included an inpatient specialty hospital and an LTC facility . The program included prospect i ve audits with feedback , multidisciplinary education , information technology interventions , and guideline development . OBJECTIVE To investigate the impact of the ASP on physicians ' prescribing practice s in this geriatric facility . METHODS Utilization data for antibiotics commonly used to treat urinary tract infections were retrieved for the period September 1 , 2011 , to August 31 , 2013 . The study examined whether there were significant changes in overall antibiotic use , ciprofloxacin use , and physician prescribing behaviour after program implementation in September 2012 . RESULTS There was no significant change in the total number of antibiotic prescriptions for urinary tract infections in the hospital or the LTC facility after ASP implementation . Significant reductions were seen in the average days of therapy initially prescribed and the actual days of therapy after ASP implementation in the LTC facility but not the hospital . Across both facilities , significant reductions were seen in the number of ciprofloxacin prescriptions . CONCLUSIONS The current study showed that an ASP can affect physicians ' antibiotic prescribing behaviour and antibiotic usage in an LTC environment Before-after study design s are effective research tools and in some cases , have changed practice . These design s , however , are inherently susceptible to bias ( ie , systematic errors ) that are sometimes subtle but can invali date their conclusions . This overview provides examples of before-after studies relevant to anesthesiologists to illustrate potential sources of bias , including selection /assignment , history , regression to the mean , test-retest , maturation , observer , retrospective , Hawthorne , instrumentation , attrition , and reporting/publication bias . Mitigating strategies include using a control group , blinding , matching before and after cohorts , minimizing the time lag between cohorts , using prospect i ve data collection with consistent measuring/reporting criteria , time series data collection , and /or alternative study design s , when possible . Improved reporting with enforcement of the Enhancing Quality and Transparency of Health Research ( EQUATOR ) checklists will serve to increase transparency and aid in interpretation . By highlighting the potential types of bias and strategies to improve transparency and mitigate flaws , this overview aims to better equip anesthesiologists in design ing and /or critically appraising before-after studies OBJECTIVES To assess the feasibility of a multifaceted strategy to translate evidence -based guidelines for treating nursing home-acquired pneumonia ( NHAP ) into practice using a small intervention trial . DESIGN Pre-posttest with untreated control group . SETTING Two Colorado State Veterans Homes ( SVHs ) during two influenza seasons . PARTICIPANTS Eighty-six residents with two or more signs of lower respiratory tract infection . INTERVENTION Multifaceted , including a formative phase to modify the intervention , institutional-level change emphasizing immunization , and availability of appropriate antibiotics ; interactive educational sessions for nurses ; and academic detailing . MEASUREMENTS Subjects ' SVH medical records were review ed for guideline compliance retrospectively for the influenza season before the intervention and prospect ively during the intervention . Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test . RESULTS At the intervention facility , compliance with five of the guidelines improved : influenza vaccination , timely physician response to illness onset , x-ray for patients not being hospitalized , use of appropriate antibiotics , and timely antibiotic initiation for unstable patients . Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year . CONCLUSION Multifaceted , evidence -based , NHAP guideline implementation improved care processes in a SVH . Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents Objective To elicit prescribers ' preferences for behavioural economics interventions design ed to reduce inappropriate antibiotic prescribing , and compare these to actual behaviour . Design Discrete choice experiment ( DCE ) . Setting 47 primary care centres in Boston and Los Angeles . Participants 234 primary care providers , with an average 20 years of practice . Main outcomes and measures Results of a behavioural economic intervention trial were compared to prescribers ' stated preferences for the same interventions relative to monetary and time rewards for improved prescribing outcomes . In the r and omised controlled trial ( RCT ) component , the 3 computerised prescription order entry-triggered interventions studied included : Suggested Alternatives ( SA ) , an alert that populated non-antibiotic treatment options if an inappropriate antibiotic was prescribed ; Accountable Justifications ( JA ) , which prompted the prescriber to enter a justification for an inappropriately prescribed antibiotic that would then be documented in the patient 's chart ; and Peer Comparison ( PC ) , an email periodically sent to each prescriber comparing his/her antibiotic prescribing rate with those who had the lowest rates of inappropriate antibiotic prescribing . A DCE study component was administered to determine whether prescribers felt  SA , JA , PC , pay-for-performance or additional clinic time  would most effectively reduce their inappropriate antibiotic prescribing . Willingness-to-pay ( WTP ) was calculated for each intervention . Results In the RCT , PC and JA were found to be the most effective interventions to reduce inappropriate antibiotic prescribing , whereas SA was not significantly different from controls . In the DCE however , regardless of treatment intervention received during the RCT , prescribers overwhelmingly preferred SA , followed by PC , then JA . WTP estimates indicated that each intervention would be significantly cheaper to implement than pay-for-performance incentives of $ 200/month . Conclusions Prescribing behaviour and stated preferences are not concordant , suggesting that relying on stated preferences alone to inform intervention design may eliminate effective interventions . Trial registration number NCT01454947 ; Results OBJECTIVES This article examines the views of nursing staff and administrators in long-term care facilities ( LTCFs ) regarding a clinical pathway for managing urinary tract infections ( UTIs ) in LTCF residents . DESIGN A qualitative ( case study ) design was used . SETTING Data were collected from 8 LTCFs in southern Ontario and 2 in Iowa enrolled in a larger r and omized controlled trial of clinical pathway for managing UTIs in LTCF residents , conducted between September 2001 and March 2003 . The clinical pathway , design ed to more effectively identify , diagnose , and treat UTIs , and reduce inappropriate antibiotics use for asymptomatic UTIs , introduced 2 decision tools to determine when to order a urine culture and initiate antibiotic treatment for suspected UTIs . PARTICIPANTS We conducted 19 individual interviews with administrators and 10 focus groups with 52 nurses . FINDINGS Nurses generally thought that the pathways were well developed and easy to use , and administrators believed they were an important educational re source . Barriers to their use varied by group-initial lack of buy-in from nurses ( medical directors ) , additional work ( directors of nursing ) , and the need to change the protocol to exclude certain residents based on prior health conditions and /or pressure from physicians or families ( nurses ) . CONCLUSIONS Both administrators and staff , once familiar with a new clinical protocol to improve UTI management in LTCFs , generally supported its use OBJECTIVES To assess the impact of a multifaceted educational intervention concerning treatment of  infections  in the nursing home setting . METHODS We used a cluster r and omized controlled trial . Fifty- 
    Output:
    
There is insufficient evidence that interventions employed to date are effective at improving antibiotic use in LTCFs .