206 English summary practices and in hospitals in 12 European countries where the GP can be considered a ‘gatekeeper’ in the healthcare system. Antimicrobial selection pressure was quantified with a proxy indicator, the antibiotic spectrum index (ASI). The ASI includes both the number of antimicrobials used and the activity against microorganisms. The ASI expresses this in an index number representing the spectrum of micro-organisms susceptible to that drug. It assigns numerical values to an antimicrobial effective against 1 or more of 13 categories of bacteria, with lower values indicating narrowspectrum agents and higher values indicating broader-spectrum agents. Our analysis of antimicrobial prescriptions reveals that the proportion of penicillin prescriptions finding its origin in primary care varies between 29% and 65% across the 12 European countries. Between 80-90% of cumulative ASI comes from these antimicrobial prescriptions in primary care practices. This proportion is much higher than previously assumed and an important finding, as previous studies showed that GPs tend to be under the assumption that antimicrobial prescribing in primary care practice does not substantially contribute to the development of AMR. This relatively large contribution to antimicrobial selection pressure from primary care seems to be related to a shift towards prescribing relatively more broad-spectrum antimicrobials. Determinants of antimicrobial prescribing Numerous studies have demonstrated that various factors impact the decision to prescribe antimicrobials in primary care practice. However, a comprehensive overview of these determinants and their interrelationships was previously unavailable. To enhance understanding and improve antimicrobial prescribing in primary care practice, a systematic literature review was conducted and is included in Chapter 3. Important patient-related determinants were that patients sometimes expect an antimicrobial prescription because of previous experiences, have high expectations of the effect of antimicrobials, or explicitly ask for it. An important patient-general practitioner interaction found was that GPs assumed that patients wanted an antimicrobial prescription as the reason for their visit but did not verify this assumption. The decision of a GP to prescribe an antimicrobial should be based primarily on a clinical working diagnosis and aspects such as patient characteristics and the severity, type and location of the infection and the expected course and risk of complications. However, the decision was also found to be based on non-clinical determinants. These include determinants such as a larger practice size or the lack of possibilities to effectively negotiate or explain the use of antimicrobials. Our study results showed that
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