23 Trends in antibiotic selection pressure generated in primary care and their association with sentinel antibiotic resistance patterns in Europe 2 Introduction Antimicrobial resistance (AMR) is increasing worldwide and represents a major threat to global healthcare (1). The major driver of the rise in AMR is the use of antibiotics (2). Worldwide, efforts are now being undertaken to decrease antibiotic prescribing and consequently reduce the rate of AMR development (1). Given that GPs are responsible for the majority of antibiotic prescriptions in a country, they potentially have an important role to play in reducing AMR (3). However, the extent to which antibiotic prescribing in primary care contributes to increasing AMR is still unclear (4). For varied reasons, not all GPs consider their antibiotic prescribing practices to be part of the process eventually leading to increasing AMR (5,6). Part of the process leading to AMR is referred to as ‘antibiotic selection pressure’ (ASP), defined as the extent to which the use of antibiotics enhances the selective process increasing the growth of resistant microorganisms (7). According to the One Health concept, all antibiotic prescriptions contribute to ASP (8). The relative contribution to the ASP of an antibiotic most likely depends on the dosage, duration of use, and type and spectrum of an antibiotic. The aim of this study was to inventory types and volumes of antibiotics prescribed by primary care practitioners in European countries where they act as gatekeepers. Importantly, this study investigates the correlation between a country’s AMR and the overall level of antibiotic prescribing, and resultant antibiotic pressure, in that country. Testing associations between prescription data and the AMR levels in a country provides insight into the role primary care has compared with hospital care in increasing AMR. Methods In this study, we collected and analysed open source data on the volume of antibiotic prescriptions and on the prevalence of three drug-resistant micro organisms. The volume of antibiotic prescriptions was used to calculate ASP. The volume of antibiotic prescriptions and ASP were then correlated to the prevalence of a sentinel drug-resistant micro organism (SDRM). The study was performed according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidance for reporting observational studies (9), and the STROBE-AMS recommendations for reporting epidemiological studies of AMR and informing improvement in antimicrobial stewardship (S1) (10)
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