189 Discussion 7 of patients felt that decisions regarding antimicrobial prescription are the physician’s responsibility and that AMR can develop with use of antimicrobials. A German study with a similar design found that, among the 1,076 responders, circa 30% thought that antimicrobials help in case of a cold or flu and 25% thought that antimicrobials are effective against a virus (15). Although most patients with RTI symptoms visit their GP for reassurance and/or physical examination and not for an antimicrobial prescription (10-12), this belief may nonetheless lead to more antibiotic prescription. The results of our studies as described in this thesis, as well as studies by van Duijn et al., Cals et al. and Faber et al., emphasize the importance of effective communication directed to the needs and beliefs of patients (13-15). Role of general practitioners A GP’s decision to prescribe an antimicrobial should be primarily based on clinical aspects such as severity, type and location of infection as well as expected course and risk of complications. However, the decision is as well influenced by non-clinical determinants such as diagnostic uncertainty, larger practice size, GPs’ unverified assumptions regarding patient wishes for an antimicrobial prescription, or an inability to effectively negotiate or explain antimicrobial use. These factors were all observed in the studies described in chapters 3 to 6. Diagnostic uncertainty was identified as an important determinant in chapters 4 and 6. Up to 40% of antimicrobial prescriptions for an RTI were not in accordance with primary care guidelines (chapter 6). This overprescribing may be partly due to diagnostic uncertainty, as the diagnosis, severity and individual patient risk for a severe RTI course are often uncertain in daily practice. This means that it is not always clear beforehand which patients with an RTI will benefit from an antimicrobial prescription. As shown in chapter 4, reducing diagnostic uncertainty may lead to fewer antimicrobial prescriptions. This was illustrated by the reduction in antimicrobial prescriptions for COVID-19 infections compared with influenza-like infections, which was most likely attributable to active testing for SARS-CoV-2 during the COVID-19 pandemic, while testing for influenza virus during influenza seasons is generally lacking. In cases of SARS-CoV-2 infection it was usually obvious to both the patient and the GP that a virus caused the symptoms and an antimicrobial prescription was unnecessary. Our results showed that the context in which GPs work influences antimicrobial prescribing. A larger practice size was related to relatively more inappropriate antimicrobial prescribing in chapters 3 and 6. A scoping review published by Al-Azzawi et al. has examined antimicrobial prescribing in primary care, with a focus on context
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