188 Chapter 7 The high proportion of ASI generated in primary care highlights the central role of primary care in increasing AMR. The unexpectedly low proportion of penicillins and relatively high proportion of inappropriately prescribed macrolides show that antimicrobial prescribing in primary care is not confined to relatively harmless antimicrobials. These results underline the need to include primary care in nationwide AMS programs, and a better appreciation of the impact on AMR will raise awareness among GPs, whose knowledge and awareness will be crucial to the successful implementation of AMS interventions in primary care. Quality of antimicrobial prescribing in primary care Role of the patient Patients play a crucial role in the decision to prescribe antimicrobials, as outlined in chapters 3 to 6. The systematic literature review in chapter 3 identified several patient-related factors, including past experiences leading to expectations of antimicrobial prescription, high expectations of antimicrobial effectiveness, and requests for antimicrobial drugs without justification. Previous literature found an important interaction between patient and GP: the often unverified GP assumption that a patient’s wish for an antimicrobial prescription was the reason for their visit (6-9). In fact, patients may visit their GP for a variety of other reasons, such as reassurance (10-12). In chapter 6 we describe how patients with a Turkish, Surinamese and Dutch-Caribbean migration background were more often prescribed antimicrobial medications considered inappropriate compared to patients with a Dutch or Moroccan background. We assume these patterns are due to cultural differences and/or GP expectations regarding a patient’s wish for an antimicrobial prescription. For these groups, it is therefore important to establish whether GPs have unverified expectations regarding a patient’s wish for an antimicrobial prescription. Several studies have explored the reasons underlying antimicrobial overprescribing for RTIs, which we found in chapter 6. The studies examined the beliefs, needs and perspectives of patients receiving antimicrobials for RTIs. A Dutch study by Duijn et al. compared patient and GP perspectives on RTIs through questionnaires. Patients placed more emphasis on the seriousness of symptoms, the need to consult a GP, the need to prescribe antimicrobials and the assumption that antimicrobials hasten recovery. By contrast, GPs place more emphasis on the self-limiting character of respiratory tract symptoms and on the side effects of antimicrobials (13). Another Dutch study based on an online questionnaire among 1,248 patients showed that 48% believed antimicrobials are effective in treating a viral infection (14). Encouragingly, around 92%
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