55 Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers 3 broad overview of all determinants by domain and can be used, after validation, to design interventions intended to reduce inappropriate prescriptions in primary care. For example, the framework shows that clinical judgement differs between GPs due to different interpretations of the severity of the symptoms (24,26,30). A career longer than 10 years was associated with more inappropriate antibiotic prescription with a possible cause being that they are less familiar with guidelines and rely more on their clinical experience (29,31,34). This illustrates that a more objective tool for judgement of severity is needed. A possible solution could be using C-reactive protein (CRP) and other point of care tests for patients with RTIs. CRP-guided treatment has been proven effective in reducing inappropriate antibiotic prescription for patients with RTIs (44). More examples of effective interventions per determinant are presented in Table 1. Only determinants associated with inappropriate antibiotic prescriptions that can be influenced by effective interventions were included (Table 1). Studies on effective interventions for reducing antibiotic prescriptions in primary care show that multifaceted interventions thus covering more determinants seem to be more effective in reducing antibiotic prescribing (44–48). The focus and interpretation of the framework, and hence the needed interventions, differ by country. For example, patient expectations of an antibiotic may stem from local beliefs and attitudes and be more common in cultures placing an emphasis on masculinity as antibiotic prescription tends to be higher in such societies (49). A priority in a masculine society is an early return to work and antibiotics are seen as an important facilitator therefore (50). In societies in which this effect is smaller, illness is considered a legitimate reason for absence from work. Ireland, Spain and the UK have much higher masculinity scores than The Netherlands (51), and antibiotic prescription rates are indeed higher in those three countries as compared with The Netherlands (3). Interventions should focus on informing patients about the mild natural course of most infectious diseases and the low value of antibiotic use. Strength and limitations The strengths of our study include that our review summarises determinants covering many domains, thus providing a broad overview. Additionally, the Morgan et al. framework was specifically designed to reduce overuse in primary care (17), making it particularly useful when designing and/or implementing interventions to reduce inappropriate antibiotic prescription. Only studies from developed countries where GPs act as gatekeepers were included as both influence the level of appropriate antibiotic prescriptions in a country (52). This choice reduced the number of eligible studies and may have concurrently reduced the number of detected determinants.
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