***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: Resistance to amikacin , gentamicin , and tobramycin was surveyed prospect ively during controlled aminoglycoside usage in 14 hospitals . Following an initial baseline period ( minimum , three months ) during which gentamicin use predominated , gentamicin and tobramycin were placed on restrictive control , establishing amikacin as the aminoglycoside of general use ( 86 percent of total aminoglycoside usage ) . During an average of 35 months ' restriction of gentamicin and tobramycin , significant reductions in gram-negative resistance to gentamicin ( 8.4 to 7.0 percent , p less than 0.001 ) and tobramycin ( 6.0 to 5.3 percent , p less than 0.01 ) were observed . The most significant decreases in resistance to gentamicin and tobramycin ( p less than 0.001 ) were found for Pseudomonas aeruginosa , Klebsiella species , Serratia species , and Proteus species . Amikacin resistance among gram-negative bacilli was observed to increase marginally from 1.4 to 1.7 percent ( p less than 0.05 ) during the surveillance period , primarily due to a significant increase in resistance among P. aeruginosa ( 3.0 to 3.9 percent , p = 0.05 ) . These data were compared with data from a similar surveillance program at the 700-bed Minneapolis Veterans Administration Medical Center . Over a period of 54 months , both gentamicin and tobramycin resistance decreased significantly when amikacin was used ( p less than 0.001 ) , then increased with re introduction of gentamicin ( p less than 0.05 ) , and decreased significantly with re introduction of amikacin ( p less than 0.001 ) . Despite predominant amikacin use for a total of 38 months , amikacin resistance did not increase and actually decreased significantly ( p less than 0.05 ) in the last 12 months BACKGROUND Reduced duration of antibiotic treatment might contain the emergence of multidrug-resistant bacteria in intensive care units . We aim ed to establish the effectiveness of an algorithm based on the biomarker procalcitonin to reduce antibiotic exposure in this setting . METHODS In this multicentre , prospect i ve , parallel-group , open-label trial , we used an independent , computer-generated r and omisation sequence to r and omly assign patients in a 1:1 ratio to procalcitonin ( n=311 patients ) or control ( n=319 ) groups ; investigators were masked to assignment before , but not after , r and omisation . For the procalcitonin group , antibiotics were started or stopped based on predefined cut-off ranges of procalcitonin concentrations ; the control group received antibiotics according to present guidelines . Drug selection and the final decision to start or stop antibiotics were at the discretion of the physician . Patients were expected to stay in the intensive care unit for more than 3 days , had suspected bacterial infections , and were aged 18 years or older . Primary endpoints were mortality at days 28 and 60 ( non-inferiority analysis ) , and number of days without antibiotics by day 28 ( superiority analysis ) . Analyses were by intention to treat . The margin of non-inferiority was 10 % . This trial is registered with Clinical Trials.gov , number NCT00472667 . FINDINGS Nine patients were excluded from the study ; 307 patients in the procalcitonin group and 314 in the control group were included in analyses .  Mortality of patients in the procalcitonin group seemed to be non-inferior to those in the control group at day 28 ( 21.2 % [ 65/307 ] vs 20.4 % [ 64/314 ] ; absolute difference 0.8 % , 90 % CI -4.6 to 6.2 ) and day 60 ( 30.0 % [ 92/307 ] vs 26.1 % [ 82/314 ] ; 3.8 % , -2.1 to 9.7 ) . Patients in the procalcitonin group had significantly more days without antibiotics than did those in the control group ( 14.3 days [ SD 9.1 ] vs 11.6 days [ SD 8.2 ] ; absolute difference 2.7 days , 95 % CI 1.4 to 4.1 , p<0.0001 ) . INTERPRETATION A procalcitonin-guided strategy to treat suspected bacterial infections in non-surgical patients in intensive care units could reduce antibiotic exposure and selective pressure with no apparent adverse outcomes . FUNDING Assistance Publique-Hôpitaux de Paris , France , and Brahms , Germany The timing of surgical antimicrobial prophylaxis  was determined before and after an intervention programme of education of surgeons , anaesthetists and nurses on the subject of antimicrobial drug prophylaxis , and the subsequent implementation of new protocol s of single dose prophylaxis administered within one hour before incision . This prospect i ve study was performed in three surgical departments of a university hospital . For comparison , the timing of prophylaxis was also determined in an operating department of a community hospital . The timing improved considerably in the departments of the university hospital where the intervention was carried out : administration of the first dose within one hour before incision increased from 39 % to 69 % in department A and from 64 % to 80 % in department B. Before the intervention , seven out of 16 prophylactic doses were given after inflation of the tourniquet . After the intervention all doses of prophylactic antibiotics were administered before inflation of the tourniquet . Initially , the intervals of multidose prophylaxis varied widely . In the second review , single-dose prophylaxis increased from 21 % to 78 % in department A and from 31 % to 85 % in department B. We conclude that the intervention succeeded in improving the quality of surgical prophylaxis BACKGROUND We investigated the possible association between fluoroquinolone use and the rate of methicillin-resistant Staphylococcus aureus ( MRSA ) recovery  from consecutive hospitalized patients . METHODS We conducted a nonr and omized , prospect i ve , controlled interventional " fluoroquinolone-free "  study at 4 large teaching hospitals in northwest France , catering to a total of 5,882,600 persons . During the intervention period ( January through December 2001 ) , fluoroquinolone use was prohibited at 1 of the 4 hospitals ( Caen Hospital ) , unless no effective alternative was available . Three university hospitals were used as controls because they had similar preintervention rates of MRSA . RESULTS During the intervention period ( 2001 ) , the annual rate of fluoroquinolone use decreased from 54 to 5 defined daily doses per 1000 patients per day at Caen Hospital and remained stable in the control hospitals . At the end of the intervention , the rate of MRSA isolation was significantly lower at Caen Hospital than at the control hospitals ( 353 [ 32.3 % ] of 1093 S. aureus isolates were MRSA , compared with 2495 [ 36.8 % ] of 6787 isolates ; odds ratio , 0.82 ; 95 % confidence interval , 0.69 - 0.99 ; P=.036 ) , as determined on the basis of a marginal model that took into account within-hospital clustering . In a before-after time series analysis , compared with forecasted rates , there was a significant downward trend in observed monthly rates of MRSA isolation at Caen Hospital at the end of the intervention . CONCLUSION This quasi experimental study confirms the association between fluoroquinolone use and MRSA isolation among hospitalized patients OBJECTIVES Antibiotic stewardship is important , but the ideal strategy for providing stewardship in a hospital setting is unknown . A practical , sustainable and transferable strategy is needed . This study evaluates the impact of a novel computerized antimicrobial approval system on antibiotic-prescribing behaviour in a hospital . Effects on drug consumption , antibiotic resistance patterns of local bacteria and patient outcomes were monitored . METHODS The study was conducted at a tertiary referral teaching hospital in Melbourne , Australia . The system was deployed in January 2005 and guided the use of 28 restricted antimicrobials .  Data were collected over 7 years : 5 years before and 2 years after deployment . Uptake of the system was evaluated using an in-built audit trail . Drug utilization was prospect ively monitored using pharmacy data ( as defined daily doses per 1000 bed-days ) and analysed via time-series analysis with segmental linear regression . Antibiograms of local bacteria were prospect ively evaluated . In-hospital mortality and length of stay for patients with Gram-negative bacteraemia were also reported . RESULTS Between 250 and 300 approvals were registered per month during 2006 . The gradients in the use of third- and fourth-generation cephalosporins ( + 0.52 , -0.05 , -0.39 ; P < 0.01 ) , glycopeptides ( + 0.27 , -0.53 ; P = 0.09 ) , carbapenems ( + 0.12 , -0.24 ; P = 0.21 ) , aminoglycosides ( + 0.15 , -0.27 ; P < 0.01 ) and quinolones ( + 0.76 , + 0.11 ; P = 0.08 ) all fell after deployment , while extended-spectrum penicillin use increased . Trends in increased susceptibility of Staphylococcus aureus to methicillin and improved susceptibility of Pseudomonas spp . to many antibiotics were observed . No increase in adverse outcomes for patients with Gram-negative bacteraemia was observed . CONCLUSIONS The system was successfully adopted and significant changes in antimicrobial usage were demonstrated BACKGROUND Ventilator-associated pneumonia is the most frequently observed nosocomial infection in intensive care units , and it is associated with high morbidity and mortality . Early microbiological diagnosis and the initial administration of appropriate antimicrobial therapy are associated with decreased mortality and potentially reduced costs . Our study evaluates the clinical and financial impact of performing rapid antimicrobial susceptibility tests directly on sample s obtained from the lower respiratory tract . METHODS A prospect i ve , r and omized study was performed over a 2-year period . Patients who had a lower respiratory tract infection that was acquired during mechanical ventilation and for whom sample s obtained from the respiratory tract were sent for culture were r and omized to 1 of 2 groups . Sample s were cultured for the control group , and results were reported using st and ard procedures . Sample s were also cultured for the test subject group using st and ard procedures , but in addition , a rapid antibiogram was immediately performed by placing E-test antibiotic strips ( AB Biodisk ) directly on respiratory tract sample s. Patients in the E-test group received a preliminary laboratory report when it became available . The 2 patient groups were compared according to the following variables : type and severity of underlying conditions , total days of antimicrobial use , number of defined daily doses , cost of acquisition of the antimicrobial agent per episode , days of fever , days receiving mechanical ventilation , days in the intensive care unit , incidence of Clostridium difficile-associated diarrhea , and mortality . RESULTS Reporting a rapid E-test was associated with fewer days of fever , fewer days of antibiotic administration until resolution of the episode of ventilator-associated pneumonia , decreased antibiotic consumption , less C. difficile-associated diarrhea , lower costs of antimicrobial agents , and fewer days receiving mechanical ventilation . CONCLUSIONS A rapid E-test of respiratory tract sample s improves antimicrobial use in cases of ventilator-associated pneumonia Improving health care quality depends on having valid ways to measure quality . Unfortunately , there are few vali date d quality outcome measurements , because valid and feasible case-mix adjustors are lacking and patients are difficult to follow over time for clinical ly important outcomes , such as death . Processes of care are easier to identify and measure , but some of these measures will be proven invalid or inappropriate because their scientific rationale was flawed from the start , unanticipated consequences emerge after implementation , or later studies undermine them . We review how these issues played out in the measure of time to first antibiotic dose ( TFAD ) , also called door-to-needle time , for patients presenting to the hospital with community-acquired pneumonia ( CAP ) . We also propose lessons that can be learned from the experience . TFAD as a Quality Measure Community-acquired pneumonia is one of the most common admitting diagnoses in U.S. hospitals , accounting for more than 1 million hospitalizations yearly ( 1 ) , with short-term mortality rates ranging from 0.5 % to 27.1 % ( 2 ) . Given its risk , frequency , and perceived outcome variations , CAP was an obvious c and i date for quality measurement and improvement initiatives . Because outcome measurement in CAP was problematic for the usual reasons ( data collection burden , case-mix adjustment , and need for posthospital follow-up ) , investigators sought process measures associated with higher quality . During the 1990s , the notion of time-based quality measures gained favor because evidence emerged that rapid treatment of myocardial infa rct ion , and later trauma , stroke , and sepsis , improved outcomes ( 37 ) . Naturally , investigators began to examine whether rapid administration of antibiotics might improve CAP outcomes . In 1997 , a retrospective study of 
    Output:
    
Interventions intended to decrease excessive prescribing were associated with reduction in Clostridium difficile infections and colonization or infection with aminoglycoside- or cephalosporin-resistant gram-negative bacteria , methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis .
The results show that interventions to reduce excessive antibiotic prescribing to hospital in patients can reduce antimicrobial resistance or hospital-acquired infections , and interventions to increase effective prescribing can improve clinical outcome .
This up date provides more evidence about unintended clinical consequences of interventions and about the effect of interventions to reduce exposure of patients to antibiotics .