15 Introduction 1 Antimicrobial resistance in The Netherlands In The Netherlands, the prevalence of AMR has increased only modestly over the past decade. Current prevalence is considered problematic but is not yet seen as a threat (33), as attributable mortality due to resistant infections is still limited in The Netherlands (34). However, vigilance is needed as many neighbouring European countries are already experiencing increasing and even problematic levels of AMR (35). Resistant pathogens can be easily transported to The Netherlands due to extensive travel by Dutch inhabitants and visitors. To prepare for this pandemic the Dutch government has set up a structure consisting of ten regional care networks, tasked with organizing and implementing AMS programs, which are coordinated and supported by the National Institute for Public Health and the Environment (RIVM). The Dutch Working Party on Antibiotic Policy (SWAB) has formulated several guidelines on AMS. The aim is to stop further spread of highly resistant micro organisms and to decrease AMR (36). The two main focus areas are hygiene measurements and prudent use of antimicrobials, while in primary care the focus is on improving the quality of antimicrobial prescribing. All major stakeholders (municipal health services, elderly care, primary care and hospital care) are involved in this network. Role of Dutch primary care The number of antimicrobial prescriptions originating from primary care in The Netherlands is much lower compared to other European countries (18). For example in 2022, GPs in Dutch primary care prescribed 9.1 defined daily doses (DDD) of antimicrobials per 1000 patients, compared with 21.9 prescribed by primary care physicians in Italy (18). Dutch GPs are, in general, cautious when prescribing antimicrobials and Dutch primary care guidelines have restraining recommendations for prescribing antimicrobials (21). Therefore, one could postulate that there is limited room for improvement in antimicrobial prescribing in the Netherlands. However, Dutch studies have found antimicrobial overprescribing rates of 40 to 50% for RTIs (37, 38), although information about potential improvements for other types of infections is limited at present. Aim This thesis focuses on the quality and quantity of antimicrobial drug prescription in primary care, exploring the background and determinants that influence it. The aim of this thesis was therefore to examine the impact and quality of antimicrobial prescribing
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