186 Chapter 7 Aim The aim of this thesis was to examine the impact and quality of antimicrobial prescribing in primary care, and to determine the extent to which the quality of antimicrobial prescribing can be improved. This chapter discusses the main findings of this thesis per aim. A discussion of methodological considerations, recommendations concerning how to incorporate the main findings into AMS interventions, as well as future perspectives, is included in this chapter. Main findings of the research in this thesis An important finding, described in chapter 2, was that the impact of antimicrobial prescriptions originating in primary care may be much greater than previously assumed. The main determinants associated with inappropriateness of antimicrobial prescription, using the framework in chapter 3, were found to be 1) presence of comorbidity, 2) the view of many primary care physicians that their approach to antimicrobial prescribing is not responsible for AMR, 3) diagnostic uncertainty, and 4) the supposed expectations of patients regarding antimicrobial prescription. The studies in chapters 2 and 3 were conducted with international data and the studies in chapters 4 to 6 with data from The Netherlands . In chapter 4 we found that fewer antimicrobials were prescribed to patients during a SARS-CoV-2 episode compared to patients during influenza or influenza-like infection in four other influenza seasons. In chapter 5, rates for completeness and correctness of antibiotic allergy registrations were 0% and 29.3%, respectively. Perceived barriers to improved antibiotic allergy registration included insufficient knowledge, lack of priority, limitations of registration features in electronic medical records (EMR), fear of medical liability and patients interpreting side effects as allergies. In chapter 6 we describe the overprescribing of antimicrobials for RTIs and of macrolides. Factors associated with more appropriate antimicrobial prescribing were a Moroccan migration background of the patient and a smaller primary care practice size, which we consider a proxy for sufficient consultation time and continuity of care by the same GP.
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