209 English summary E prescribing in primary care practice. A second question was to determine the extent to which antimicrobial prescribing could be improved and the extent to which the factors mentioned above were associated with appropriate antimicrobial prescribing. It was possible to combine two large registries, GP data from the extramural Leiden Academic network (ELAN) and data from Statistics Netherlands (SN), at the individual patient level. This allowed us to examine the associations of various determinants that are not recorded in an HER with various endpoints such appropriate antibiotic prescribing, Our study showed that 17.8% of all antimicrobial prescriptions were not in accordance with guidelines, and 39.6% of antimicrobial prescriptions for respiratory infections not following guidelines. The rate of overprescription of antimicrobials for respiratory infections was consistent with previous Dutch studies. Studies in other countries also showed similar rates and with regularly higher rates. In addition, 77.1% of macrolide prescriptions were not first and second choices according to guidelines. A previous Dutch study found a similar percentage of macrolide overprescribing. We found several patient determinants associated with overprescription of antimicrobials: female gender, age 5 years and older and a migration background (Turkish, Surinamese, Dutch Caribbean). Female gender and age have been identified as important determinants in several earlier studies. Migration background is a newly identified determinant associated with overprescription of antimicrobials. A previously unidentified practice determinant in the Netherlands was found to be associated with excessive antibiotic prescribing: larger practice size. Previous studies from the UK and Canada presented conflicting results on this. The UK study found an association, while the Canadian study did not. The context and location (urban or rural) of the practice may have been a contributing factor to the difference in these studies. We cautiously interpreted the undeniable difference we found as an argument for creating "more time and continuity for the patient" Conclusion and recommendations An important overarching finding of the studies in this thesis, is that antimicrobial prescriptions from primary care practices are a much larger contributor to the development of AMR than previously thought, and that the European data (including the Netherlands) show that the amount of antibiotic prescribing correlates with the development of resistance.
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