16 Chapter 1 and to which extent the quality of antimicrobial prescribing can be improved. With this approach we hope to find starting points from which to restrain currently increasing AMR. Quality of antimicrobial prescribing is defined by two elements in this thesis: 1. an antimicrobial is only prescribed when effective in treating symptoms and preventing complications, morbidity or mortality 2. an appropriate antimicrobial is prescribed for the type, location and severity of the infection, with the narrowest spectrum possible. Outline of the thesis Five different studies, described in chapters 2-6, address the aims of this thesis, with each study examining a distinct dimension of AMR in primary care. The impact of antimicrobial prescriptions originating in primary care on antimicrobial selection pressure and consequent AMR was examined in chapter 2. This opensource data study used publicly available data from the European Centre of Disease Prevention and Control (ECDC) and inventoried types and volumes of antimicrobials prescribed by primary care physicians in European countries. Antimicrobial pressure was calculated using a proxy indicator, the Antibiotic Spectrum Index (ASI), which we correlated with a country’s AMR. Different elements of antimicrobial prescribing in primary care were examined in chapter 3. The goal of this systematic literature review was to provide a framework of determinants of inappropriate antimicrobial prescribing in primary care in developed countries where GPs acts as a gatekeeper. Our observational cohort study in chapter 4 explored the influence of SARSCoV-2 infections on the numbers of antimicrobial prescriptions in primary care. The proportion of antimicrobial prescriptions for patients during a COVID-19 infection was compared with the proportion of antimicrobial prescriptions for patients during an influenza or influenza-like infection in other years. The association between antimicrobial prescriptions and risk factors for an adverse course of a SARS-CoV-2 infections was examined. In a mixed method study that included semi-structured interviews and a file analysis (chapter 5), we explored the details of incorrect antibiotic allergy registrations and what might be improved in the registration of antimicrobial allergies. The results show
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