192 Chapter 7 However, retrieving additional contextual information that should accompany any allergy registration will be a challenge and will often be impractical due to lack of GP time. Removal of incorrect interpretations of allergy registrations would help considerably in improving the quality of antimicrobial prescriptions, as 1st choice and/ or narrow-spectrum antibiotics will be prescribed relatively more often. Another finding from chapter 5 was that GPs need a better understanding of antimicrobial allergies in order to be able to accurately assess possible allergic reactions and verify existing antibiotic allergy registrations. This could be initially promoted through education of primary care teams involved in registration, thus increasing knowledge and awareness. Verifying existing antibiotic allergy registrations can be effective in lowering the number of antibiotic allergy registrations. Another observed problem was difficulty in entering or removing an antibiotic allergy registration in an EMR. Removing registrations is particularly difficult, as due to technical communication issues between different EMRs deleted registrations tend to reappear if not completely removed. When an allergic reaction is entered into any EMR in any domain, registrations in The Netherlands are centralized in a national hub [“landelijk schakelpunt” (LSP)] and subsequently communicated to other EMRs. Removal of the original allergy registration is required to achieve removal of the LSP registration and subsequent removal from other EMRs. A substantial proportion of macrolides are prescribed to patients despite being neither the first nor second choice in guidelines, as described in chapter 6. This finding is corroborated by another Dutch study (40) and should be considered serious overprescription of macrolides to patients. A hypothesized explanation is the simpler dosing scheme of macrolides compared with many first or second choice antimicrobials. Some macrolides need only be taken once a day for only three days, whereas penicillin, for example, must be taken 3 to 4 times a day for 5 or more days. GPs assume that a lower burden for the patient may improve compliance. Indeed, as discussed in chapter 6, most macrolides were prescribed for children under the age of 5 years, for whom compliance can be a problem. However, there are no studies confirming our hypothesis. In addition, children in that age group have virtually no contraindications for the use of penicillins. Other explanations might be availability or deliverability, or may relate to the presumed causative microorganisms that justify macrolide treatment. This relative overprescription of macrolides should nevertheless be discouraged, as macrolides generally have a broader antibacterial spectrum compared to penicillin and consequently increase the risk of AMR. One can reasonably argue that a substantial proportion of these prescriptions could be avoided.
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