53 Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers 3 Determinants of inappropriate antibiotic prescription in primary care Comorbidity was the most frequently found determinant of inappropriate antibiotic prescription (25–27,29,35,37,40). However, it is not clear to what extent prescribing an antibiotic for a patient with one or more comorbidities is inappropriate. The guidelines for appropriate antibiotic use are largely based on studies of patients without comorbidities. Consideration of antibiotic prescription is also advised by guidelines in cases of comorbidity (5,9). GPs may quickly choose to prescribe an antibiotic to be on the safe side with regard to complications, leading to more antibiotic prescriptions for patients presumably at risk for complications. Another important determinant was the GPs perception of a patient’s expectation of getting antibiotics (24–26,30). GPs may assume the reason for a patient’s visit is an antibiotic prescription, but may not verify this with the patient. Thus, more effort focused towards verifying the specific reason for the encounter may represent a typical primary care approach to further reducing inappropriate antibiotic prescriptions. Inability to effectively negotiate or explain antibiotic use also leads to more inappropriate prescriptions (32). Both determinants illustrate the benefits of the availability of time to communicate with patients and efficient communication skills. This was confirmed by a recent review of communication training aimed at reduction of antibiotic prescriptions for RTIs (41). Remarkably, some GPs did not consider themselves responsible for antibiotic resistance (32). In their opinion, their prescribing at an individual level did not contribute to AMR. Rather, they believe AMR is mainly driven by antibiotic prescriptions in hospitals or those in veterinary use. This notion was confirmed by a study performed by the European Centre for Disease Control (42). In reality, up to 90% of antibiotic prescriptions find their origin in primary care (3,4). Furthermore, according to the one health concept, antibiotic prescriptions from all sectors contribute to antibiotic selection pressure (43). Additionally, more (inappropriate) antibiotic prescription is the cause of a vicious cycle of increasing AMR which leads to prescribing of second choice, mostly broad-spectrum antibiotics leading to increasing AMR. This points to the need for continuous education which emphasises that inappropriate antibiotic prescriptions give unnecessary antibiotic selection pressure and thus lead to more AMR. There were conflicting results on some determinants. A study by Eggermont et al. specifically designed to investigate gender differences in inappropriate antibiotic prescriptions failed to detect any such association with gender (27). However, there were three studies reporting a gender association. Therefore, we included female
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