13 Introduction 1 pressure, the relative impact of each domain on antimicrobial selection pressure or the size of their role under a “One health” approach has been insufficiently studied. Decisions regarding antimicrobial prescribing in primary care The decision to prescribe an antimicrobial is or should be primarily based on the expected effectiveness of an antimicrobial drug in curing the patient with a particular infection, caused by a particular micro organism or group of micro organisms. In other words, use of an antimicrobial drug will prevent morbidity and mortality by changing the course of the infection. However, during our daily work in primary care many general practitioners (GPs), including myself, experience situations that are often not so clear and straightforward. Uncertainty about the diagnosis or severity of the disease, the expected course of disease and the risk of complications are daily challenges in primary care. In this context, reliance on antimicrobial medication might not be effective in reducing symptoms and preventing morbidity and/or mortality. Determinants from several interacting domains (e.g., society, primary care practice, physician, patient) influence the decision to prescribe antimicrobial medication, an example of which is the presence of a comorbidity. Physicians tend to prescribe an antimicrobial more often if comorbidity is present, even though this is not a guideline recommendation for many infections. Physicians assume that a comorbidity will increase the risk of complications and that antimicrobial treatment will lower this risk. Indeed, many of the determinants that influence prescription behaviour have already been identified (19). However, information regarding associations between social-economic and primary care practice determinants is still lacking. A better understanding of socialeconomic determinants (such as those associated with immigrant groups),primary care practice determinants and as well as how these factors interact, is needed to understand and improve antimicrobial prescribing in primary care. Once the decision has been taken to prescribe an antibiotic, the next step is to choose the specific antimicrobial drug. This choice is based primarily on the site and severity of the infection, expected causative bacteria, presence of comorbidities and contraindications such as antibiotic allergies. Based on these criteria, recommendations in international guidelines advise a first choice antimicrobial, which generally has a narrow spectrum and few side effects (20-22). A second choice antimicrobial is recommended if the first choice antimicrobial conflicts with a registered antibiotic allergy or in case of treatment failure. To effectively treat unexpected causative or resistant bacteria the second choice antimicrobial has a broader spectrum, which can
RkJQdWJsaXNoZXIy MTk4NDMw