49 Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers 3 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, frequently inappropriate, of antibiotics (2). Worldwide efforts are now underway to decrease unnecessary antibiotic prescribing and consequently reduce the development of AMR (1). The most common prescribers of antibiotics in developed countries are general practitioners (GPs), accounting for between 80% and 90% of all antibiotic prescriptions (3,4). As such, GPs play an important role in reducing AMR. However, there is currently insufficient insight into which potentially changeable determinants are associated with inappropriate antibiotic prescription in this setting. GPs prescribe antibiotics for a variety of infectious diseases, ranging from respiratory tract infections (RTI) to cellulitis (5–10). However between 44% and 98% of the antibiotic prescriptions for RTIs are classified as inappropriate (11–14). The proportion of inappropriate antibiotic prescriptions for urinary tract infections is estimated at between 3% and 36.5% (15,16). Antibiotic prescriptions are generally considered inappropriate when, according to the guidelines, no or other antimicrobials should be used. The high proportion of inappropriate antibiotic prescriptions combined with the large quantity of antibiotics prescribed by GPs suggest that efforts to improve antibiotic prescribing in primary care may have a substantial effect on the development of AMR. Determinants across several domains affect the proportion of inappropriate antibiotic prescribing in primary care. These domains include patient–doctor interactions, the organisation of primary care, the national role of primary care and the nationwide healthcare system (17,18). Reducing inappropriate antibiotic prescribing is therefore complex. To increase effectiveness, each domain should be taken into account in any intervention. However, it is still unclear which determinants play a role in each specific domain and how the different determinants may interact. The aim of this review is to identify the determinants influencing inappropriate antibiotic prescribing by GPs, sort the determinants into a framework according to their domain and identify which determinants may be subject to antimicrobial stewardship interventions for reducing inappropriate antibiotic prescribing.
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