12 Chapter 1 can be de-escalated during treatment based on the clinical course and the outcome of cultures, aiming for an antimicrobial with the narrowest spectrum possible. One health approach The One health approach is often used in the context of AMR. The One health approach recognizes that the health of humans, domestic and wild animals, plants, and the wider environment (including ecosystems) are closely linked and interdependent, sharing not only the same environment but also many infectious diseases (14, 15). Although the interdependence of humans, animals and nature has been acknowledged for centuries, the relatively new One health approach goes further by encompassing the health of the environment, humans and animals. It promotes the idea that, with ever-increasing human population growth, accompanied by climate change, pollution and depletion of the earth's resources, health disciplines and other fields must collaborate to ensure the future health and well-being of humans, animals and the environment (15, 16). Antimicrobial selection pressure is an essential factor in the development of AMR and is defined as the extent to which the use of antimicrobials enhances the selective process, increasing the prevalence of resistant microorganisms (17). When applying the One health approach to antimicrobial selection pressure, antimicrobial use in all domains (hospital care, veterinary care, primary care or industrial use) contributes to overall antimicrobial selection pressure, regardless of the specific domain where the antimicrobial was used. It is still unclear to what extent each domain contributes to overall antimicrobial selection pressure. Although various aspects of antimicrobial prescribing differ between primary and hospital care, both domains contribute to the risk of AMR through antimicrobial prescription. It could be argued that the impact of primary care on AMR is lower compared to hospital care, one element of which is the general view that antimicrobial prescriptions in primary care are mainly short-term, narrow-spectrum penicillins. Another is that even if a patient is a carrier of resistant bacteria, the risk of contaminating other patients is low outside of hospital. By contrast, in hospital care antimicrobial prescriptions are more often broad-spectrum antimicrobials, sometimes used for long periods. Resistant bacteria from admitted patients are more easily transferred to other patients. Nonetheless, around 80-90% of antimicrobial prescriptions for human use are estimated to originate from primary care in European countries (18). While this likely has a substantial effect on antimicrobial selection
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