***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: BACKGROUND This study was undertaken to determine the temporal relationship between implementation of different interventions in an intensive care unit ( ICU ) and control of endemic nosocomial acquisition of extended-spectrum β-lactamase Enterobacteriaceae ( ESBLE ) . METHODS This was a prospect i ve observational study with time-series analysis of the monthly incidence of ESBLE and its predictors . In November 2007 , after a 14-month baseline period , an intervention consisting of restriction of third-generation cephalosporins ( 3 GC ) and increased use of alcohol-based h and rubs was implemented . In January 2008 , an increased health care worker (HCW):patient ratio was also implemented . In March 2010 , the ICU was closed , and patients were moved to a clean ICU . RESULTS The first intervention result ed in global reduction in 3 GC and increased use of alcohol-based h and rub . A significant change in ESBLE incidence was observed in a full segmented univariate regression analysis ( mean change in level , -0.91 ± 0.19 ; P < .0001 ) . After ICU closure , there was a dramatic reduction in ESBLE acquisition . According to the multivariate model , the ICU closure was the main protective factor . Before ICU closure , an increase in the HCW : patient ratio of 0.1 point tended to be associated with a decreased risk of ESBLE acquisition ( relative risk , 0.28 ; 95 % confidence interval , 0.06 - 1.25 ; P = .09 ) . CONCLUSIONS This study shows that ICU closure was associated with , but not necessarily the reason for , control of ESBLE cross-transmission in a nonoutbreak setting . Environmental ESBE sources may play a role in cross-transmission ABSTRACT Beginning in 1992 , a sustained outbreak of multiresistantAcinetobacter baumannii infections was noted in our 1,000-bed hospital in Barcelona , Spain , result ing in considerable overuse of imipenem , to which the organisms were uniformly susceptible . In January 1997 , carbapenem-resistant (CR)A. baumannii strains emerged and rapidly disseminated in the intensive care units ( ICUs ) , prompting us to conduct a prospect i ve investigation . It was an 18-month longitudinal intervention study aim ed at the identification of the clinical and microbiological epidemiology of the outbreak and its response to a multicomponent infection control strategy . From January 1997 to June 1998 , clinical sample s from 153 ( 8 % ) of 1,836 consecutive ICU patients were found to contain CR A. baumannii . Isolates were verified to be A. baumannii by restriction analysis of the 16S-23S ribosomal genes and the intergenic spacer region . Molecular typing by repetitive extragenic palindromic sequence-based PCR and pulsed-field gel electrophoresis showed that the emergence of carbapenem resistance was not by the selection of resistant mutants but was by the introduction of two new epidemic clones that were different from those responsible for the endemic . Multivariate regression analysis selected those patients with previous carriage of CR A. baumannii(relative risk [ RR ] , 35.3 ; 95 % confidence interval [ CI ] , 7.2 to 173.1 ) , those patients who had previously received therapy with carbapenems ( RR , 4.6 ; 95 % CI , 1.3 to 15.6 ) , or those who were admitted into a ward with a high density of patients infected with CR A. baumannii ( RR , 1.7 ; 95 % CI , 1.2 to 2.5 ) to be at a significantly greater risk for the development of clinical colonization or infection with CR A. baumannii strains . In accordance , a combined infection control strategy was design ed and implemented , including the sequential closure of all ICUs for decontamination , strict compliance with cross-transmission prevention protocol s , and a program that restricted the use of carbapenem . Subsequently , a sharp reduction in the incidence rates of infection or colonization with A. baumannii , whether resistant or susceptible to carbapenems , was shown , although an alarming dominance of the carbapenem-resistant clones was shown at the end of the study Purpose Antibiotic de-escalation is promoted to limit prolonged exposure to broad-spectrum antibiotics , but proof that it prevents the emergence of resistance is lacking . We evaluated determinants of antibiotic de-escalation in an attempt to assess whether the latter is associated with a lower emergence of antimicrobial resistance . Methods Antibiotic treatments , starting with empirical beta-lactam prescriptions , were prospect ively documented during 2013 and 2014 in a tertiary intensive care unit ( ICU ) and categorized as continuation , de-escalation or escalation of the empirical antimicrobial treatment . Determinants of the de-escalation or escalation treatments were identified by multivariate logistic regression ; the continuation category was used as the reference group . Using systematic ally collected diagnostic and surveillance cultures , we estimated the cumulative incidence of antimicrobial resistance following de-escalation or continuation of therapy , with adjustment for ICU discharge and death as competing risks . Results Of 478 anti-pseudomonal antibiotic prescriptions , 42 ( 9 % ) were classified as escalation of the antimicrobial treatment and 121 ( 25 % ) were classified as de-escalation , mainly through replacement of the originally prescribed antibiotics with those having a narrower spectrum . In multivariate analysis , de-escalation was associated with the identification of etiologic pathogens ( p < 0.001 ) . The duration of the antibiotic course in the ICU in de-escalated versus continued prescriptions was 8 ( range 6–10 ) versus 5 ( range 4–7 ) days , respectively ( p < 0.001 ) . Mortality did not differ between patients in the de-escalation and continuation categories . The cumulative incidence estimates of the emergence of resistance to the initial beta-lactam antibiotic on day 14 were 30.6 and 23.5 % for de-escalation and continuation , respectively ( p = 0.22 ) . For the selection of multi-drug resistant pathogens , these values were 23.5 ( de-escalation ) and 18.6 % ( continuation ) respectively ( p = 0.35 ) . Conclusion The emergence of antibiotic-resistant bacteria after exposure to anti-pseudomonal beta-lactam antibiotics was not lower following de-escalation Introduction Although early use of broad-spectrum antimicrobials in critically ill patients may increase antimicrobial adequacy , uncontrolled use of these agents may select for more-resistant organisms . This study investigated the effects of early use of broad-spectrum antimicrobials in critically ill patients with hospital-acquired pneumonia . Methods We compared the early use of broad-spectrum antimicrobials plus subsequent de-escalation ( DE ) with conventional antimicrobial treatment ( non-de-escalation , NDE ) in critically ill patients with hospital-acquired pneumonia ( HAP ) . This open-label , r and omized clinical trial was performed in patients in a tertiary-care center medical intensive care unit ( MICU ) in Korea . Patients ( n = 54 ) r and omized to the DE group received initial imipenem/cilastatin plus vancomycin with subsequent de-escalation according to culture results , whereas patients r and omized to the NDE group ( n = 55 ) received noncarbapenem , nonvancomycin empiric antimicrobials . Results Between November 2004 and October 2006 , 109 MICU patients with HAP were enrolled .  Initial antimicrobial adequacy was significantly higher in the DE than in the NDE group for Gram-positive organisms ( 100 % versus 14.3 % ; P < 0.001 ) , but not for Gram-negative organisms ( 64.3 % versus 85.7 % ; P = 0.190 ) . Mean intensive care unit ( ICU ) stay , and 14-day , 28-day , and overall mortality rates did not differ in the two groups . Among culture-positive patients , mortality from methicillin-resistant Staphylococcus aureus ( MRSA ) pneumonia was higher in the DE group , even after early administration of vancomycin . Multidrug-resistant organisms , especially MRSA , were more likely to emerge in the DE group ( adjusted hazard ratio for emergence of MRSA , 3.84 ; 95 % confidence interval , 1.06 to 13.91 ) . Conclusions The therapeutic advantage of early administration of broad-spectrum antimicrobials , especially with vancomycin , was not evident in this study Background We determined the effects of two antibiotic policies ( predominance of either β-lactam antibiotics or fluroquinolones ) on acquisition with third-generation cephalosporin-resistant Enterobacteriaceae ( CRE ) and fluoroquinolone-resistant CRE ( FCRE ) in two ICUs , with monitoring of other variables that may influence acquisition . Methods After an 8-month baseline period , units were r and omized to a  predominant β-lactam antibiotic regimen ( weekly cycling of ceftriaxone , amoxicillin – clavulanic acid and fluroquinolones ) or a fluoroquinolone regimen for 3 months , with cross-over for another 3 months . Acquisition of CRE and FCRE was determined by microbiological surveillance . Results During baseline , acquisition rates for CRE and FCRE were 14/1,000 and 2/1,000 patient days at risk , respectively . Cross-transmission of CRE accounted for ≤25 % of acquisitions , and CRE acquisition was associated with the use of β-lactam antibiotics ( amoxicillin – clavulanic acid in particular ) . As compared to baseline , β-lactam antibiotic use [ in defined daily dose (DDD)/1,000 patient days ] was reduced from 854 to 526 ( −39 % ) and 555 ( −35 % ) during both intervention periods . Fluoroquinolone use was increased from 150 and 129 DDD/1,000 patient days in baseline and the β-lactam period to 514 DDD/1,000 patient days ( + 243 % ) in the fluoroquinolone period . Reductions in β-lactam use were not associated with reduced CRE acquisition [ adjusted HRs were 1.0 ( 95 % CR : 0.5–2.2 ) and 1.1 ( 95 % CI : 0.5–2.5 ) during both periods , respectively ] . Increased use of fluoroquinolones was associated with increased acquisition of FCRE [ adjusted HR 4.1 ( 95 % CI : 1.4–11.9 ; p < 0.01 ] . Infection control variables remained comparable during all periods . Conclusion A 35–39 % reduction of β-lactam exposure was not associated with reduced acquisition of CRE , whereas a 243 % increase of fluoroquinolone use increased acquisition of FCRE Mixed treatment comparison ( MTC ) meta- analysis is a generalization of st and ard pairwise meta- analysis for A vs B trials , to data structures that include , for example , A vs B , B vs C , and A vs C trials . There are two roles for MTC : one is to strengthen inference concerning the relative efficacy of two treatments , by including both ' direct ' and ' indirect ' comparisons . The other is to facilitate simultaneous inference regarding all treatments , in order for example to select the best treatment . In this paper , we present a range of Bayesian hierarchical models using the Markov chain Monte Carlo software WinBUGS . These are multivariate r and om effects models that allow for variation in true treatment effects across trials . We consider models where the between-trials variance is homogeneous across treatment comparisons as well as heterogeneous variance models . We also compare models with fixed ( unconstrained ) baseline study effects with models with r and om baselines drawn from a common distribution . These models are applied to an illustrative data set and posterior parameter distributions are compared . We discuss model critique and model selection , illustrating the role of Bayesian deviance analysis , and node-based model criticism . The assumptions underlying the MTC models and their parameterization are also discussed Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Objective To study the effect of selective digestive tract decontamination by erythromycin-base on the  incidence of carriage and infection with MREnterobacteriaceae producing an extended spectrum beta-lactamase ( ESB ) . Design After a 10-week prospect i ve survey to ascertain the baseline incidence in two bays ( 1 and 3 ) of the same ICU , bay 1 was compared with bay 3 during a further survey of 6 moths . The patients in bya 1 .  received erythromycin-base . Setting Two non-contiguous bays , 1 and 3 , of 4 beds , in the same polyvalent ICU of a university hospital . PatientConsecutive patients with unit stay longer than 2 days ; 34 patients were included during the control period , 43 in bay 1 ( decontamination ) and 46 in bay 3 ( control ) during the trial period . InterventionErythromycin-base , 1 g t.i.d . in powder form administered 
    Output:
    
Conclusions A 4-component strategy was the most effective intervention to prevent MDR-GNB acquisition .