27 Trends in antibiotic selection pressure generated in primary care and their association with sentinel antibiotic resistance patterns in Europe 2 The contribution of primary care to the cumulative combined ASI (primary and hospital care) ranged from 80.4% (Finland) to 91.1% (Spain) (Figure 4). Association of ASP and AMR in a country The combined volumes of antibiotic prescribing in primary and hospital care, expressed both as DDD and the combined cumulative ASI, are shown plotted against the prevalence of the three SDRMs in Figure 5, and the standardized coefficients of association (beta) are presented in S4. The betas representing associations between SDRMs and combined cumulative ASI were all higher than those representing associations between SDRMs and combined total DDD. Discussion We studied the trends in volume of antibiotic prescribing in primary care, the prevalences of SDRMs, and the ASP using proxy indicators ASI and DDD in European countries where GPs act as gatekeepers. The volumes of antibiotic prescriptions in primary care and the prevalences of SDRMs varied significantly between countries. DDD and ASI were associated with SDRM prevalence. Primary care was a larger contributor to ASP than hospital care. Total number of antibiotic prescriptions We found a large variation in volume of antibiotic prescriptions between countries in primary care. This may be due to cultural effects on the prescription of antibiotics. Borg and Camilleri showed a high association between a high degree of uncertainty avoidance and the prescribing of more broad-spectrum antibiotics (18), and FletcherLartey et al. showed uncertainty avoidance to be associated with inappropriate antibiotic prescribing (5). Italy, Poland and Spain had high uncertainty avoidance scores (19). In 2020, the volume of antibiotic prescriptions in primary care was lower in all countries than in preceding years. This is likely due to the trend of decreasing antibiotic prescriptions and the severe acute respiratory syndrome coronavirus-2 pandemic. During the pandemic, there were fewer non-coronaviral disease respiratory tract infections (20), leading subsequently to fewer antibiotic prescriptions.
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