52 Chapter 3 Results The literature search identified 2257 studies. Following screening of titles and abstracts, 285 studies were retained for full-text review, of which 17 were ultimately included in the review as they specified determinants of inappropriate antibiotic prescription (Figure 1) (24–40). Characteristics of the selected studies are presented in the supplemental materials S6a and S6b. The studies were conducted in six countries: Australia, Canada, Ireland, The Netherlands, Spain and the UK. Four studies (25,32,33,38) had a qualitative design (one explorative qualitative design, one crosssectional survey, one focus group and one questionnaire), while 13 studies had a quantitative design (all observational in nature). The methodologies of the included studies as assessed by the NHLI or CASP tool all had a low risk of bias. Quality assessment tables are presented in the supplemental materials S7; S8. Framework determinants of inappropriate prescriptions In total, 54 determinants were identified from 17 studies. Seven determinants were directly not included in the framework as they showed no association with inappropriate antibiotic prescribing, either positive or negative (online supplemental materials S6b). Forty-five determinants were included and are presented in a framework (Figure 2). There were five determinants with conflicting results from the included studies and three determinants with a positive impact on inappropriate antibiotic prescribing. Three determinants showed similarity and were combined with each other to one determinant (34). Silverman et al. compared careers of between 11 and 24 years with careers shorter than 11 years and careers longer than 25 years with careers less than 11 years (34). These outcomes were combined to form one determinant, a career longer than 10 years. Discussion We systematically reviewed the determinants of inappropriate antibiotic prescription in developed countries in which GPs act as the gatekeepers. Comorbidity and GPs’ perceptions of a patient’s expectation for antibiotics were consistently identified as main factors that drive inappropriate prescription of antibiotics in primary care. There were no restrictions on the design of the study for the inclusion as our aim was to include as many determinants as possible.
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