205 English summary E more easily assume drug-resistant microorganisms are at play when treating bacterial infections. This relatively uncontrolled spiral of ever increasing prescription of more and broader spectrum antimicrobials will eventually reach a tipping point beyond which few antimicrobials remain suitable for empirical use. This process may ultimately lead to a post-antimicrobial era, in which few or no currently available antimicrobials remain effective, and infections once again become a major cause of morbidity and mortality. In the Netherlands, AMR rates for relevant microorganisms is relatively low compared to other countries, which can be attributed to the limited use of antimicrobials compared to most European countries. However, the Netherlands is also experiencing an increase in AMR. The only way to slow down this increase is to optimise antimicrobial use. GPs in the Netherlands prescribe approximately 80-90% of all antimicrobials in the Dutch healthcare system. This significant proportion highlights the importance of the primary care practice as a crucial starting point for implementing interventions that enhance the appropriate use of antimicrobials. The aim of the studies brought together in this thesis was to quantify the contribution to antimicrobial selection pressure by primary care practices, examine the quality of antimicrobial prescribing in primary care practices and explore opportunities for improvement. For this purpose, 5 studies were conducted, which are described in chapters 2 to 6. The results of the studies are summarised and discussed in chapter 7. The impact of antimicrobial prescribing in primary care practices It was unclear from the literature to what extent antimicrobial prescribing in primary care practice contributes to antimicrobial selection pressure. It could reasonably be argued that primary care practices contribute less, compared to hospitals, as they mainly prescribe narrow-spectrum antimicrobials for a short period of time. In hospital care, broad-spectrum antimicrobials are in general prescribed more frequently and for a longer period and even without confirmed infection. If a patient becomes a carrier of a resistant bacterial strain, the risk of infecting other patients is very low as long as carriers in general are not admitted to a hospital. Resistant bacteria who are carried by hospitalised patients can more easily be transmitted to other, often vulnerable, hospitalized patients. We quantified the contribution of antimicrobial prescriptions by primary care practices on antimicrobial selection pressure in chapter 2. This study with open-source data from the European Centre for Disease Prevention and Control (ECDC) inventories and compares the types and quantities of antimicrobials prescribed in primary care
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