191 Discussion 7 A study in the United Kingdom has shown that an influenza point-of-care (POC) test is feasible in primary care (24). A Dutch study concluded that an influenza POC test might contribute to a more precise diagnosis of RTIs (25). Two primary care cohort studies showed that the number of antimicrobial prescriptions is lower if patients with influenzalike symptoms are tested for influenza (26, 27). A randomized clinical trial has been suggested as a way to determine whether influenza POC tests are effective in lowering antimicrobial prescriptions for RTIs which is currently underway (28). An important finding of this thesis, described in chapter 6, was that approximately 40% of antimicrobial prescriptions for an RTI can be considered inappropriate, a proportion similar to other Dutch studies (29, 30). While at first glance there appears to be room for a 40% improvement, there are valid reasons to prescribe an antimicrobial despite guideline recommendations. For example, GP familiarity with their patients and their medical history, as previous similar infections may have had an unexpectedly severe course that required antimicrobial treatment. Another factor when deciding to prescribe an antimicrobial is diagnostic uncertainty regarding RTIs, a problem that will persist as long as reliable tests are unavailable. One strategy to lower diagnostic uncertainty could be the use of prediction models, although these are still based on signs and symptoms, themselves subject to diagnostic uncertainty. Adding CRP testing may make a modest contribution to reducing uncertainty (31). However, we can conclude that reducing presumed inappropriate antimicrobial prescribing for RTIs will be a significant challenge. In addition to the decision concerning whether to prescribe antimicrobials, we applied two approaches to examine factors influencing the choice between various antimicrobials: antibiotic allergy registrations, as discussed in chapter 5, and a simpler dosing scheme, as discussed in chapter 6. Registration of antibiotic allergies may lead to avoidable prescribing of broadspectrum antimicrobials, as discussed in detail in the introduction (32-38). GPs play a pivotal role in registering allergies and assessing antibiotic allergy registrations as part of their role as gatekeeper in the healthcare system. As described in chapter 5, many aspects of antibiotic allergy registration could be improved. All registrations lacked additional contextual information essential to determining the accuracy of registrations, such as the symptoms of an allergic reaction. Adding this information could theoretically lead to a reduction of up to 90% in antimicrobial antibiotic allergy registrations. For instance, one reported intervention in a hospital removed 50% of antibiotic allergy registrations simply by taking a medical history (39). A similar reduction of redundant allergy registrations in primary care is likely to be possible.
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