***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: BACKGROUND Therapy with antibiotics influences recovery only in selected cases of COPD exacerbations . We evaluated the efficacy and safety of procalcitonin guidance compared to st and ard therapy with antibiotic prescriptions in patients experiencing exacerbations of COPD . METHODS A total of 208 consecutive patients requiring hospitalization for COPD exacerbation were r and omized at the index exacerbation to procalcitonin-guided or st and ard antibiotic therapy . Patients receiving procalcitonin-guided therapy were treated with antibiotics according to serum procalcitonin levels ; st and ard-therapy patients received antibiotics according to the attending physician . The primary outcome was the antibiotic exposure at the index exacerbation and the subsequent antibiotic requirement for COPD exacerbation within 6 months . Secondary outcomes were clinical recovery , symptom scores , length of hospitalization , ICU stay , death , lung function , exacerbation rate , and time to next exacerbation . RESULTS At the index exacerbation , procalcitonin guidance reduced antibiotic prescription ( 40 % vs 72 % , respectively ; p < 0.0001 ) and antibiotic exposure ( relative risk [ RR ] , 0.56 ; 95 % confidence interval [ CI ] , 0.43 to 0.73 ; p < 0.0001 ) compared to st and ard therapy . Moreover , procalcitonin guidance at the index exacerbation allowed a significant sustained reduction in total antibiotic exposure for up to 6 months ( RR , 0.76 ; 95 % CI , 0.64 to 0.92 ; p = 0.004 ) . Clinical outcome and improvement in FEV(1 ) at 14 days and 6 months did not differ between groups . Within 6 months , the exacerbation rate ( 0.62 vs 0.64 , respectively ) , the rehospitalization rate ( 0.21 vs 0.24 , respectively ) , and mean ( + /- SD ) time to the next exacerbation ( 70.0 + /- 46.1 vs 70.4 + /- 51.9 days , respectively ; p = 0.523 ) were similar in both groups . CONCLUSIONS Procalcitonin guidance for exacerbations of COPD offers a sustained advantage over st and ard therapy in reducing antibiotic use for up to 6 months with a number-needed-to-treat of 3 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 OBJECTIVES To improve antimicrobial use in patients receiving long-term care ( LTC ) . DESIGN Prospect i ve , quasi-experimental before-after assessment of the effects of physician education and guideline implementation . SETTING Public LTC and acute care hospital . PARTICIPANTS Twenty salaried internists who provided most of the medical care to LTC patients . INTERVENTION National guidelines , hospital resistance data , and physician feedback were incorporated into a series of four teaching sessions presented over 18 months and into booklets detailing institutional guidelines on the optimal management of common LTC infection syndromes . MEASUREMENTS One hundred r and omly selected LTC patients treated with antimicrobials were review ed before these interventions were implemented and 100 after , and measures of the quality of care were compared . The effect of the interventions on antimicrobial days and starts were also assessed using interrupted time series analysis . RESULTS Charted clinical abnormalities met guideline diagnostic criteria ( 62 % vs 38 % , P=.006 ) , and initial therapy agreed with guideline recommendations ( 39 % vs 11 % , P<.001 ) , more often in the post- than in the preintervention cohort . Mean census-adjusted monthly LTC antimicrobial days fell 29.7 % , and antimicrobial starts fell 25.9 % during the intervention period ; both decreases were sustained during the 2-year postintervention period . CONCLUSION The teaching and guideline intervention improved the quality and reduced the quantity of antimicrobial use in LTC patients BACKGROUND Piperacillin/tazobactam , imipenem , and meropenem were inappropriately used in 50 % of hospitalized patients at Siriraj Hospital . Siriraj Hospital administrators implemented drug use evaluation ( DUE ) and antibiotic authorization for the aforementioned antibiotics beginning in August 2007 . The objective of the study was to determine the effectiveness of antibiotic authorization on patients ' clinical outcomes , antibiotic consumption , and antibiotic expenditures . METHODS Hospitalized patients who were prescribed piperacillin/tazobactam , imipenem , or meropenem from August to November 2007 were r and omly allocated to antibiotic authorization group and no-authorization group . The data on clinical outcomes , antibiotic consumption , and antibiotic expenditures of the patients who received and who did not receive antibiotic authorization were compared . RESULTS The patients who received antibiotic authorization ( 512 prescriptions ) had more favorable clinical outcomes ( 68.9 % vs 60.5 % , respectively , P < .01 ) , shorter duration of target antibiotics ( 7.5 days vs 9.3 days , respectively , P < .01 ) , shorter duration of all antibiotics ( 12.7 days vs 16.4 days , respectively , P < .01 ) , and lower mortality because of infections ( 29.4 % vs 35.4 % , respectively , P=.05 ) than those who did not receive antibiotic authorization ( 516 prescriptions ) . The costs of target antibiotics and all antibiotics in the authorization group were much less than those in the no-authorization group . The annual antibiotic cost savings from DUE and antibiotic authorization requirement could be extrapolated to US $ 862,704 . CONCLUSION DUE and antibiotic authorization are effective strategies in reducing antibiotic consumption and antibiotic expenditures without compromising the patients ' clinical outcomes 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 CONTEXT In previous smaller trials , a procalcitonin ( PCT ) algorithm reduced antibiotic use in patients with lower respiratory tract infections ( LRTIs ) . OBJECTIVE To examine whether a PCT algorithm can reduce antibiotic exposure without increasing the risk for serious adverse outcomes . DESIGN , SETTING , AND PATIENTS A multicenter , noninferiority , r and omized controlled trial in emergency departments of 6 tertiary care hospitals in Switzerl and with an open intervention of 1359 patients with mostly severe LRTIs r and omized between October 2006 and March 2008 . INTERVENTION Patients were r and omized to administration of antibiotics based on a PCT algorithm with predefined cutoff ranges for initiating or stopping antibiotics ( PCT group ) or according to st and ard guidelines ( control group ) . Serum PCT  was measured locally in each hospital and instructions were Web-based . MAIN OUTCOME MEASURES Noninferiority of the composite adverse outcomes of death , intensive care unit admission , disease-specific complications , or recurrent infection requiring antibiotic treatment within 30 days , with a predefined noninferiority boundary of 7.5 % ; and antibiotic exposure and adverse effects from antibiotics . RESULTS The rate of overall adverse outcomes was similar in the PCT and control groups ( 15.4 % [ n = 103 ] vs 18.9 % [ n = 130 ] ; difference , -3.5 % ; 95 % CI , -7.6 % to 0.4 % ) . The mean duration of antibiotics exposure in the PCT vs control groups was lower in all patients ( 5.7 vs 8.7 days ; relative change , -34.8 % ; 95 % CI , -40.3 % to -28.7 % ) and in the subgroups of patients with community-acquired pneumonia ( n = 925 , 7.2 vs 10.7 days ; -32.4 % ; 95 % CI , -37.6 % to -26.9 % ) , exacerbation of chronic obstructive pulmonary disease ( n = 228 , 2.5 vs 5.1 days ; -50.4 % ; 95 % CI , -64.0 % to -34.0 % ) , and acute bronchitis ( n = 151 , 1.0 vs 2.8 days ; -65.0 % ; 95 % CI , -84.7 % to -37.5 % ) . Antibiotic-associated adverse effects were less frequent in the PCT group ( 19.8 % [ n = 133 ] vs 28.1 % [ n = 193 ] ; difference , -8.2 % ; 95 % CI , -12.7 % to -3.7 % ) . CONCLUSION 
    Output:
    
One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams ( low-certainty evidence ) .Both enablement and restriction were independently associated with increased compliance with antibiotic policies , and enablement enhanced the effect of restrictive interventions ( high-certainty evidence ) .
There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use .
Enablement and restriction were independently associated with a larger effect size ( high-certainty evidence ) .
We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment .
Lower use of antibiotics probably does not increase mortality and likely reduces length of stay .
Enablement consistently increased the effect of interventions , including those with a restrictive component .
Although feedback further increased intervention effect , it was used in only a minority of enabling interventions .
Interventions were successful in safely reducing unnecessary antibiotic use in hospitals , despite the fact that the majority did not use the most effective behaviour change techniques .
Consequently , effective dissemination of our findings could have considerable health service and policy impact .