***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: Abstract Objective : To determine the effect of antibiotic treatment for acute otitis media in children between 6 months and 2 years of age . Design : Practice based , double blind , r and omised , placebo controlled trial . Setting : 53 general practice s in the Netherl and s. Subjects : 240 children aged 6 months to 2 years with the diagnosis of acute otitis media . Intervention : Amoxicillin 40 mg/kg/day in three doses . Main outcome measures : Persistent symptoms at day four and duration of fever and pain or crying , or both . Otoscopy at days four and 11 , tympanometry at six weeks , and use of analgesic . Results : Persistent symptoms at day four were less common in the amoxicillin group ( risk difference 13 % ; 95 % confidence interval 1 % to 25 % ) . The median duration of fever was two days in the amoxicillin group versus three in the placebo group ( P=0.004 ) . No significant difference was observed in duration of pain or crying , but analgesic consumption was higher in the placebo group during the first 10 days ( 4.1 v 2.3 doses , P=0.004 ) . In addition , no otoscopic differences were observed at days four and 11 , and tympanometric findings at six weeks were similar in both groups . Conclusions : Seven to eight children aged 6 to 24 months with acute otitis media needed to be treated with antibiotics to improve symptomatic outcome at day four in one child . This modest effect does not justify prescription of antibiotics at the first visit , provided close surveillance can be guaranteed 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 Overuse of antibiotics for children 's upper respiratory infections is widespread and contributes to the emergence of antibiotic-resistant bacteria . OBJECTIVE To assess changes in knowledge and awareness regarding antibiotic resistance and appropriate antibiotic use after community-wide educational interventions to reduce inappropriate antibiotic use . DESIGN Baseline survey conducted during June through July 1997 and postintervention survey of baseline participants during June through August 1998 . SETTING Communities in northern Wisconsin . PARTICIPANTS Parents of 729 r and omly selected children < 4 years of age were called until 215 in each of the intervention and control areas were reached . Of the 430 baseline participants , 365 ( 85 % ) participated in the postintervention survey . INTERVENTION Parent-oriented activities included distribution of material s and presentations . Physician-oriented activities included formal presentations and small group meetings . OUTCOME MEASURE Change in awareness about antibiotic resistance and knowledge about antibiotic indications . RESULTS A higher proportion of parents in the intervention area ( 53 % ) were exposed to 2 or more local educational messages , compared with the control area ( 23 % ) . From the baseline to the postintervention survey , the percentage of parents with a high degree of antibiotic resistance awareness increased more in the intervention area ( 58 % to 73 % ) than in the control area ( 60 % to 65 % ) . In the intervention area , there was also a larger increase in knowledge regarding appropriate indications for antibiotic use , compared with the control area . The proportion of parents who expected an antibiotic for their child and did not receive one declined in the intervention area ( 14 % to 9 % ) , while it increased in the control area ( 7 % to 10 % ) . In addition , the percentage of parents in the intervention area who brought their child to another physician because they did not receive an antibiotic decreased ( 5 % to 2 % ) , while it increased in the control area ( 2 % to 4 % ) . CONCLUSION Parental knowledge and awareness about antibiotic indications and antibiotic resistance can be changed with educational interventions directed at parents and clinicians Abstract Objective : To assess three prescribing strategies for sore throat .  Design : R and omised follow up study . Setting : 11 general practice s in the South and West region . Subjects : 716 patients aged 4 years and over with sore throat and an abnormal physical sign in the throat ; 84 % had tonsillitis or pharyngitis . Patients were r and omised to three groups : prescription for antibiotics for 10 days ( group 1 , 246 patients ) ; no prescription ( group 2 , 230 patients ) ; or prescription for antibiotics if symptoms were not starting to settle after three days ( group 3 ; 238 patients ) . Main outcome measures : Duration of symptoms ; satisfaction and compliance with and perceived efficacy of antibiotics ; time off school or work . Outcomes were documented in 582 subjects ( 81 % ) . Results : Median duration of antibiotic use differed significantly in the three groups ( 10 v 0 v 0 days , P<0.001 ) ; 69 % of patients in group 3 did not use their prescription . The proportion of patients better by day 3 did not differ significantly ( 37 % v 35 % v 30 % , P=0.28 ) , nor did the duration of illness ( median 4 v 5 v 5 days , P=0.39 ) , days off work or school ( median 2 v 2 v 1 , P=0.13 ) , or proportion of patients satisfied ( 96 % v 90 % v 93 % , P=0.09 ) , although group 1 had fewer days of fever ( median 1 v 2 v 2 days , P=0.04 ) . More patients in group 1 thought the antibiotics were effective ( 87 % v 55 % v 60 % , P<0.001 ) and intended coming to the doctor in future attacks ( 79 % v 54 % v 57 % , P<0.001 ) . “ Legitimation ” of illness — to explain to work or school ( 60 % ) or family or friends (37%)–was an important reason for consultation . Patients who were more satisfied got better more quickly , and satisfaction related strongly to how well the doctor dealt with patient 's concerns . Conclusion : Prescribing antibiotics for sore throat only marginally affects the resolution of symptoms but enhances belief in antibiotics and intention to consult in future when compared with the acceptable strategies of no prescription or delayed prescription . Psychosocial factors are important in the decision to see a general practitioner and in predicting the duration of illness . Key messages Sore throat is one of the commonest presentations of upper respiratory illness to general practitioners , and attendance is increasing Prescribing antibiotics for sore throat does not reduce the extent and duration of symptoms Prescribing antibiotics enhances belief in antibiotics and intention to consult Legitimation of illness is an important reason for attending the doctor Satisfaction predicts duration of illness and closely relates to how well concerns are dealt with — unless patients are very ill , general practitioners should consider exploring concerns and should avoid or delay prescribing OBJECTIVES To identify which children with acute otitis media are at risk of poor outcome and to assess benefit from antibiotics in these children . DESIGN Secondary analysis of r and omised controlled trial cohort . SETTING Primary care . PARTICIPANTS 315 children aged 6 months to 10 years . INTERVENTION Immediate or delayed ( taken after 72 hours if necessary ) antibiotics . MAIN OUTCOME MEASURE Predictors of short term outcome : an episode of distress or night disturbance three days after child saw doctor . RESULTS Distress by day three was more likely in children with high temperature ( adjusted odds ratio 4.5 , 95 % confidence interval 2.3 to 9.0 ) , vomiting ( 2.6,1.3 to 5.0 ) , and cough ( 2.0 , 1.1 to 3.8 ) on day one . Night disturbance by day three was more likely with high temperature 2.4 ( 1.2 to 4.8 ) , vomiting ( 2.1,1.1 to 4.0 ) , cough ( 2.3,1.3 to 4.2 ) , and ear discharge ( 2.1 , 1.2 to 3.9 ) . Among the children with high temperature or vomiting , distress by day three was less likely with immediate antibiotics ( 32 % for immediate v 53 % for delayed , chi2=4.0 ; P=0.045 , number needed to treat 5 ) as was night disturbance ( 26 % v 59 % , chi2=9.3 ; P=0.002 ; number needed to treat 3 ) . In children without higher temperature or vomiting , immediate antibiotics made little difference to distress by day three ( 15 % v 19 % , chi2=0.74 ; P=0.39 ) or night disturbance ( 20 % v 27 % , chi2=1.6 ; P=0.20 ) . Addition of cough did not significantly improve prediction of benefit . CONCLUSION In children with otitis media but without fever and vomiting antibiotic treatment has little benefit and a poor outcome is unlikely Abstract Objective : To assess the medicalising effect of prescribing antibiotics for sore throat . Setting : 11 general practice s in Engl and . Design : R and omised trial of three approaches to sore throat : a 10 day prescription of antibiotics , no antibiotics , or a delayed prescription if the sore throat had not started to settle after three days . Patients : 716 patients aged 4 and over with sore throat and an abnormal physical sign : 84 % had tonsillitis or pharyngitis . Outcome measures : Number and rate of patients making a first return with sore throat , pharyngitis , or tonsillitis . Early returns ( within two weeks ) and complications ( otitis media , sinusitis , quinsy ) . Outcomes were documented in 675 subjects ( 94 % ) . Results : Mean follow up time was similar ( antibiotic group 1.07 years , other two groups 1.03 years ) . More of those initially prescribed antibiotics initially returned to the surgery with sore throat ( 38 % v 27 % , adjusted hazard ratio for return 1.39 , 95 % confidence interval 1.03 to 1.89 ) . Antibiotics prescribed for sore throat during the previous year had an additional effect ( hazard ratio 1.69 , 1.20 to 2.37 ) . Longer duration of illness ( > 5 days ) was associated with increased return within six weeks ( hazard ratio 2.90 , 1.70 to 4.92 ) . Prior attendance with upper respiratory conditions was also associated with increased reattendance . There was no difference between groups in early return ( 13/238 ( 5.5 % ) v 27/437 ( 6 % ) ) , or complications ( 2/236 ( 0.8 % ) v3/434 ( 0.7 % ) ) . Conclusions : Complications and early return result ing from no or delayed prescribing of antibiotics for sore throat are rare . Both current and previous prescribing for sore throat increase reattendance . To avoid medicalising a self limiting illness doctors should avoid antibiotics or offer a delayed prescription for most patients with sore throat . Key messages Sore throat is one of the commonest presentations of upper respiratory illness in primary care and attendence is increasing Complications are rare with no , or delayed , antibiotic prescription Prescribing antibiotics increases reattendance for future episodes Unless patients are very ill general practitioners should consider exploring concerns , explain the natural history , and avoid or delay prescribing Abstract Objective 
    Output:
    
CONCLUSION The consistent reduction in antibiotic usage in the five controlled trials included in this review suggests that delayed prescription is an effective means of reducing antibiotic usage for acute respiratory infections .