193 Discussion 7 Antimicrobial stewardship interventions in primary care Earlier sections described determinants that affect the quality of antimicrobial prescribing and what might be improved in primary care. This section is dedicated to how these results might be integrated into existing AMS interventions to improve the quality of antimicrobial prescribing. When implementing (more) effective AMS interventions, several aspects have to be considered: combined AMS interventions are more effective than a single intervention (41), active rather than passive implementation is most effective (42), and multilevel barriers and facilitators of AMS uptake should be identified before implementation of an AMS intervention (43). Improving the patient experience As described earlier, patients often have more diverse needs and beliefs about RTIs than GPs assume. Effective interventions should incorporate these needs and beliefs. Patients sometimes express the wish for an antimicrobial prescription without a medical reason. This wish or need can nevertheless be fulfilled through delayed antimicrobial prescribing, a scenario in which a GP prescribes an antimicrobial but persuades the patient to postpone its use until symptoms worsen or become too prolonged. Studies have found that patients with an RTI or UTI may be willing to postpone antimicrobial use (44, 45). For a variety of RTIs this delayed antimicrobial prescribing strategy was found to be safe compared to direct antimicrobial prescribing (46), and no difference in patient satisfaction was found between the two strategies. A meta-analysis has shown that delayed antimicrobial prescribing is safe for most patients, even in a higher risk group (47), and no difference was seen in RTI complication rates or patient satisfaction. Delayed prescribing may reduce consultation rates compared to no antimicrobial prescribing, and postponing an antimicrobial prescription for UTIs reduced antimicrobial prescriptions by 63% (48). However, postponing an antimicrobial prescription for a UTI was associated with higher risk of incomplete recovery (OR 3.0 95% CI: 1.65 - 5.47) or a complicated UTI (OR 5.63 95% CI: 2.29-13.87) (48). Both can still be treated effectively and no urosepsis cases were reported in the review. Patients often consult a GP for a physical examination or seek reassurance when nothing is seriously wrong (10-12). The actual need of the patient at that moment is reassurance, which can be fulfilled via other communication channels such as eHealth (e-mail and online consults). During the COVID-19 pandemic, the telehealth approach used for RTI consults satisfied patients (49, 50). Patients need easy access to reliable
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