197 Discussion 7 background on antimicrobial prescribing in primary care. Qualitative research, such as focus groups or interviews, is needed to further explore and explain these findings. Another future challenge is the expected increasing AMR prevalence. More treatment failure with small spectrum antimicrobials will probably occur, leading to more broad spectrum antimicrobials prescriptions. This cascade requires up-to-date and more proactive surveillance of antimicrobial use and resistance in primary care. In addition, this surveillance can be part of the pandemic preparedness as shown in chapter 4. If there is an increase in antimicrobial use, specifically broad-spectrum, or an increase in resistant bacteria groups, intervention aimed at these developments can be implemented immediately. For example, through adjustments in national guidelines, messages in newsletters of national organisations or by pharmacotherapy education. Artificial Intelligence (AI) or Big Data can contribute to this surveillance. Chapter 6 showed that Big Data is applicable for analysis of antibiotic use. By use of these resources new relevant associations between antibiotic prescriptions and migrant groups were discovered. The use of AI in surveillance not only in the analysis of antimicrobial prescribing behaviour, but also in the support of prescribing process itself, is the next step to be investigated in this regard. Conclusion The aim of this thesis was to examine the impact and different elements of antimicrobial prescribing in primary care, and to define the extent to which the quality of antimicrobial prescribing can be improved. These goals were selected in light of our ultimate aim, which is to prevent a further increase in the prevalence of AMR. This can be achieved by, among others, improving the quality of antimicrobial prescribing in primary care. As antimicrobial prescribing in primary care is influenced by numerous varied factors this thesis took a multi-dimensional approach, with each study addressing a different dimension of AMR in primary care. A important finding was that primary care may have a much larger impact on the development of AMR than previously assumed. Important determinants of this impact were diagnostic uncertainty, inability to effectively negotiate or explain antimicrobial use, as well as the assumption that patients expect an antimicrobial. Considerable improvements in antimicrobial prescribing in primary care can be achieved for RTIs, macrolide prescription and for patients with a specific migrant or cultural background (Turkish, Dutch-Caribbean, Surinamese). The registration of antimicrobial allergies could be improved through better education of GPs to increase
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