***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: 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 From 1998 to 2000 , 13 rural Alaskan villages ( population , 3326 ) were surveyed annually by nasopharyngeal cultures for Streptococcus pneumoniae carriage . Data regarding antibiotic use for the entire population was abstract ed from clinic records . In 1999 , education of medical providers and the community about appropriate antibiotic use began in 4 villages ; this program was exp and ed to include all villages in 2000 .  Antibiotic courses per person decreased by 31 % in the initial intervention villages and by 35 % in the remaining villages after education ( P<.01 for each ) . Sample s were obtained for culture from a mean of 31 % of the population each year ; 31 % carried pneumococcus . No sustained decrease in carriage of penicillin-nonsusceptible strains was observed . When linear regression was used , serotype accounted for 81 % of the variance in pneumococcal minimum inhibitory concentrations after the intervention , compared with 7 % for antibiotic use . This suggests that reducing the carriage of serotypes associated with antibiotic resistance by use of pneumococcal conjugate vaccines may have a greater short-term impact than does decreasing antibiotic use 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 There is increasing evidence that antibiotics have limited value for many respiratory illnesses . This study investigates changes in overall antibiotic prescribing rates , and rates for specific conditions , by Australian general practitioners ( GPs ) between 1990 - 91 and 2002 - 03 . This is a comparative study of two cross-sectional surveys of general practice activity , the Australian Morbidity and Treatment Survey ( AMTS ) 1990 - 91 and Bettering Evaluation and Care of Health ( BEACH ) 2002 - 03 . Both studies used r and om sample s of GPs , each providing data about a cluster of patient encounters . Outcome measures are the  antibiotic prescribing rate per 100 encounters or per 100 selected problems managed . Between 1990 - 91 and 2002 - 03 , the overall antibiotic prescribing rate decreased 24.3 % from 18.9 prescriptions per 100 encounters to 14.3 ( P<0.001 ) . For children , the decrease for acute upper respiratory tract infection ( URTI ) was from 39.0 per 100 URTI problems to 24.4 ( P<0.001 ) , while the antibiotic prescribing rate increased for acute otitis media , decreased for bronchitis/bronchiolitis , and remained unchanged for other respiratory problems analysed . For adults the antibiotic prescribing rate for URTI decreased from 58.2 per 100 URTI problems to 40.0 ( P<0.001 ) , increased significantly for sinusitis and remained unchanged for all other respiratory problems .  Antibiotic prescribing decreased significantly between 1990 - 91 and 2002 - 03 but the decrease was selective . The decline has been more pronounced among children than adults , and particularly for URTI . While the message of educators may be achieving its goal for URTI , other approaches targeting specific respiratory problems may be required to reduce antibiotic prescribing in these areas OBJECTIVES Infections with group A streptococcus ( GAS ) occur in 10 % to 20 % of patients with sore throats , whereas antibiotics are prescribed 50 % of the time . Clinical scoring rules can more accurately predict the likelihood of GAS infection , but whether family physicians will adopt such approaches is unclear . This study sought to determine whether repeated clinical prompts to use a scoring approach could help family physicians lower antibiotic use in patients with a sore throat . STUDY DESIGN R and omized trial in which physicians were assigned to use either ( 1 ) chart stickers that prompted them to calculate a score based on clinical findings and provided management recommendations linked to score totals or ( 2 ) a clinical checklist . POPULATION Ninety-seven family physicians in Ontario , Canada , assessed 621 children and adults with sore throat and obtained a throat swab for culture . OUTCOMES MEASURED ( 1 ) Unnecessary antibiotic prescriptions given to patients with a negative throat culture and ( 2 ) overall antibiotic use . RESULTS There were no differences between the control and intervention group in unnecessary antibiotic prescriptions ( 16.1 % vs 20.4 % , respectively , P = .29 ) or overall antibiotic use ( 27.9 % vs 28.1 % , P = .97 ) . However , a number of physicians dropped out of the study ; as a result , the characteristics of the physicians in the 2 groups were dissimilar in factors related to prescribing . After adjusting for these differences and patient clustering by physician , the odds ratio for the effect of the intervention on unnecessary antibiotic prescriptions was 0.76 ( 95 % confidence interval [ CI ] = 0.42 , 1.40 ) and 0.57 for overall antibiotic use ( 95 % CI = 0.27 , 1.17 ) . CONCLUSIONS Chart prompts during clinical encounters to use a clinical score in the assessment of patients with a sore throat did not reduce unnecessary antibiotic prescribing by family physicians . The problems encountered in conducting this community-based intervention trial are discussed in relation to the negative result Systematic review s provide the best evidence on the effectiveness of healthcare interventions including quality improvement strategies . The methods of systematic review of individual patient r and omised trials of healthcare interventions are well developed . We discuss method ological and practice issues that need to be considered when undertaking systematic review s of quality improvement strategies including developing a review protocol , identifying and screening evidence sources , quality assessment and data abstract ion , analytical methods , reporting systematic review s , and appraising systematic review s. This paper builds on our experiences within the Cochrane Effective Practice and Organisation of Care ( EPOC ) review group The intervention level of epidemiology is useful for study ing effects in health systems research . Due to practical and ethical reasons , it is often difficult to apply experimental methods such as classical r and omized clinical trials in the field . However with alternative approaches such as ' r and omization by group ' some of these problems can be overcome . Drug information has since long been considered as an instrument to influence physicians , however evaluation of its effects is a new field of research . In the present study the impact of drug information on prescribing behaviour was evaluated in an outpatient setting in Sri Lanka . The study included 15 state health institutions ( 45 prescribers ) with a common drug formulary . Groups of prescribers were r and omized into two interventions ; newsletters and newsletters reinforced by a group seminar , and one control group . The target topic was ' rational prescribing of antibiotics ' . Some 18,766 r and omly selected outpatient drug prescriptions were studied . Antibiotics ( and sulphonamides ) were prescribed to 33.2 % of the patients . An overall trend towards a decrease in proportion of patients prescribed antibiotics in the two intervention groups was seen , although the difference was not significant ( p greater than 0.05 ) compared to the control group . This is similar to the effect of written information on prescribing in other studies . A mean difference of -7.4 % in written , -7.3 % in written + seminar and -0.4 % in the control group was shown . The general antibiotic prescribing pattern did not change in any of the three groups . Penicillin was the most commonly prescribed antibiotic and tetracycline was only rarely prescribed to children . This experiment indicates the feasibility of drug information intervention studies in developing countries . ( ABSTRACT TRUNCATED AT 250 WORDS CONTEXT The impact of clinical decision support systems ( CDSS ) on antimicrobial prescribing in ambulatory setting s has not previously been evaluated . OBJECTIVE To measure the added value of CDSS when coupled with a community intervention to reduce inappropriate prescribing of antimicrobial drugs for acute respiratory tract infections . DESIGN , PARTICIPANTS AND SETTING Cluster r and omized trial that included 407,460 inhabitants and 334 primary care clinicians in 12 rural communities in Utah and Idaho ( 6 with 1 shared characteristic and 6 with another ) , and a third group of 6 communities that served as non study controls 
    Output:
    
Compared with studies targeting specific conditions or patient population s , broad-based interventions extrapolated to larger community-level impacts on total antibiotic use , with savings of 17–117 prescriptions per 1000 person-years .
Conclusions : QI efforts are effective at reducing antibiotic use in ambulatory setting s , although much room for improvement remains .
Strategies using active clinician education and targeting management of all ARIs ( rather than single conditions in single age groups ) may yield larger reductions in community-level antibiotic use