102 Chapter 4 different symptoms and diseases, which makes them difficult to compare directly. The prescription of antibiotics was less common during the SARS-CoV-2 pandemic in The Netherlands compared with the rates recorded for RTIs pre-SARS-CoV-2. The proportion of antibiotic prescriptions per contact for COVID-19 during the first wave (9.6%) was comparable with antibiotic prescribing in the management of RTI symptoms in Dutch primary care reported in a study of van der Velden et al. during the SARS-CoV-2 pandemic (7.1%) (18). In the present study, the total sum of antibiotic prescriptions during SARS-CoV-2 did not differ much between the first and second waves. This, in spite of the burden of the SARS-CoV-2 pandemic being higher during the second compared with the first wave, reflected by the higher number of hospital admissions for COVID-19 patients in The Netherlands (19). The relatively higher frequency of antibiotic prescriptions during the first wave may partly be owing to registration bias, as not all COVID-19 patients during the first wave were registered. Another reason for the less frequent prescription of antibiotics during the second wave may be the increasing knowledge on disease course and risk factors for severe deterioration of COVID-19. Further, there were fewer nonCOVID RTIs during the SARS-CoV-2 pandemic (20). The high probability of a SARS-CoV-2 infection combined with accessible PCR testing aids the GP with diagnostic accuracy and likely decreases antibiotic prescription. Strengths and limitations A strength of the study is the comparison of antibiotic prescriptions during influenza seasons with those during the SARS-Cov-2 pandemic. Influenza was already a major seasonal cause of viral RTIs and antibiotic prescriptions, and now SARS-CoV-2, at least initially, may have the same effect on GPs' prescribing behaviour in primary health care. Influenza patients and patients with COVID-19 present with similar symptoms. Therefore, the initial assessment does not differ between the two diseases. However, the study revealed increasing differences in antibiotic prescriptions, which may reflect increasing experience among physicians in judging disease severity, or better estimates of potential adverse disease course development. The results of the study may be hindered by registration bias as not all COVID19 patients were registered (correctly) before 1 June 2020. The gold standard for diagnosing COVID-19 patients is a positive PCR test from a nasal and throat swab (10). Until 1 June 2020, there was a lack of PCR-testing capacity in The Netherlands. As a consequence, only patients with COVID-19 symptoms assessed at an emergency
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