***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 
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    ***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 Inappropriate use and overuse of antibiotics is a serious concern in the treatment of  upper respiratory tract infections ( URTIs )  , especially in developing countries . In recent decades , information disclosure and public reporting ( PR ) has become an instrument for encouraging good practice in healthcare . This study evaluated the impact of PR on antibiotic prescribing for URTIs in a sample of primary care institutions in China . Methods A matched-pair cluster-r and omized trial was undertaken in QJ city , with 20 primary care institutions participating in the trial . Participating institutions were matched into pairs before being r and omly assigned into a control and an intervention group . Prescription statistics were disclosed to patients , health authorities , and health workers monthly within the intervention group , starting from October 2013 . Outpatient prescriptions for URTIs were collected from both groups before ( 1st March to 31st May , 2013 ) and after the intervention ( 1st March to 31st May , 2014 ) . A total of 34,815 URTI prescriptions were included in a difference-in-difference analysis using multivariate linear or logistic regression models , controlling for patient attributes as well as institutional characteristics . Results Overall , 90 % URTI prescriptions required antibiotics and 21 % required combined use of antibiotics . More than 77 % of URTI prescriptions required intravenous ( IV ) injection or infusion of drugs . PR result ed in a 9 percentage point ( 95 % CI -17 to -1 ) reduction in the use of oral antibiotics ( adjusted RR = 39 % , P = 0.027 ) , while the use of injectable antibiotics remained unchanged . PR led to a 7 percentage point reduction ( 95 % CI -14 to 0 ; adjusted RR = 36 % ) in combined use of antibiotics ( P = 0.049 ) , which was largely driven by a significant reduction in male patients ( -7.5 % , 95 % CI -14 to -1 , P = 0.03 ) . The intervention had little impact on the use of IV injections or infusions , or the total prescription expenditure . Conclusions The results suggest that PR could improve prescribing practice s in terms of reducing oral antibiotics and combined use of antibiotics ; however , the impacts were limited . We suggest that PR would probably be enhanced by provider payment reform , management and training for providers , and health education for patients Background Interventions to promote prudent antibiotic prescribing by general practitioners ( GPs ) have often only been developed for use in one country . We aim ed to develop an intervention which would be appropriate to implement in multiple European countries in order to offer greater benefit to practice whilst using fewer re sources . The INTRO ( INternet TRaining for antibiOtic use ) intervention needed to deliver training to GPs in the use of C-Reactive Protein ( CRP ) near patient tests to help diagnose acute cough and in communication skills to help explain prescribing decisions to patients . We explored GPs ’ views on the initial version of INTRO to test acceptability and potentially increase applicability for use in multiple countries before the start of a r and omised trial . Method 30 GPs from five countries ( Belgium , Engl and , the Netherl and s , Pol and and Spain ) , were interviewed using a “ think aloud ” approach . GPs were asked to work through the intervention and discuss their views on the content and format in relation to following the intervention in their own practice . GPs viewed the same intervention but versions were created in five language s. Data were coded using thematic analysis . Results GPs in all five countries reported the view that the intervention addressed an important topic , was broadly acceptable and feasible to use , and would be a useful tool to help improve clinical practice . However , GPs in the different countries identified aspects of the intervention that did not reflect their national culture or healthcare system . These included perceived differences in communication style used in the consultation , consultation length and the stage of illness at which patient typically presented . Conclusion An online intervention to support evidence -based use of antibiotics is acceptable and feasible to implement amongst GPs in multiple countries . However , tailoring of the intervention to suit national context s was necessary by adding local information and placing more emphasis on the fact that GPs could select the communication skills they wished to use in practice . Using think aloud methods to complement the development of interventions is a powerful method to identify regional context ual barriers to intervention implementation 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 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 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 A 
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Conclusions : A human factors engineering approach suggests that investigating the role of the clinic 's processes or physical layout or external pressures ' role in antibiotic prescribing may be a promising way to improve ambulatory AS