190 Chapter 7 (practice location, size and GP decision making) and how these factors influence decisions such as antimicrobial treatment (16). The authors of this review concluded that context has a profound impact on the decision to prescribe an antimicrobial and that this is not a “simple” decision. Another important behavioural aspect is the ability of a GP to communicate, explain and negotiate effectively concerning antimicrobials and disease course (chapter 3). This was illustrated in a Danish study which explored the effect of empathy on the rate of antimicrobial prescription (17). GPs showing high empathy prescribed less penicillins compared to GPs showing less empathy. According to the authors, high empathy GPs may prescribe less penicillin because they take more time to explain and meet the patient’s fears and expectations, as well as evaluating antimicrobial choices in their community with reference to local resistance patterns. High empathy GPs may be better at identifying patient’s concerns and expectations and may be better able to contextualize the patient’s infection in the community (17). This thesis and previous studies have shown that antimicrobial prescribing in primary care is not always based on clinical aspects alone, but also involves nonclinical determinants such as practice size and an ability to communicate effectively. Patients, as well as a GP’s practice context, influence GP behaviour up to a point, but the GP ultimately decides whether to prescribe an antibiotic. This is suggested in a Dutch report, which showed large variation in the number of antimicrobial prescriptions per primary care practice (18). This variation was partly due to differences in encountered infections per practice, patient populations, and factors such as comorbidity, patient age and practice size (19-21), but these differences did not fully explain variance between practices. Practice variation is therefore likely due to differences in style of work, which in turn influences a GP’s decision to prescribe an antimicrobial. Room for improvement in antimicrobial prescribing We found significantly higher antimicrobial prescription rates during influenza infections compared to during SARS-CoV-2 infections (chapter 4), which was remarkable considering the very similar RTI caused by the two viruses. Both virus types cause a generally selflimiting disease, although both carry a risk of bacterial superinfection and a severe course, potentially leading to hospital admission or even death (22, 23). As previously described, an explanation for differences in prescription rates may have been the influence of SARS-CoV-2 diagnostic testing on decision making. One could therefore reasonably argue that testing for influenza will reduce antimicrobial prescriptions.
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