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Saskia v. Popescu, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist with Phoenix Children's Hospital. During her work as an infection preventionist she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She is currently a PhD candidate in Biodefense at George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control.

Telemedicine Antibiotic Prescribing: A Gap in Stewardship Efforts?

APR 19, 2019 | SASKIA V. POPESCU
One of the more impressive medical advances in recent years has been the development of telemedicine, which allows a medical provider to interact remotely with patients. Using video equipment to allow providers and patients to maintain face-to-face consultations, telemedicine allows people to get a medical consultation if they don’t have immediate access to a health care facility or provider or just need a quick consult.

Imagine you've got a fever and cold but are traveling and may not be able to go to a doctor.

Skyping your primary care physician who could evaluate your symptoms, and provide a face-to-face consult would be helpful, right?

Even in medical facilities, telemedicine has allowed specialty practitioners to consult on cases and provide an extra layer of care if a specialized provider isn't available. While there are inherent limitations in what can be done via telemedicine, especially if the patient is not in a medical facility, a new article in Pediatrics is calling to light some worrying antimicrobial prescribing practices. 

For many parents, telemedicine has been a great way to avoid an office visit with a sick child, especially if they are suffering from the all-too-common upper respiratory infection. In fact, direct-to-consumer telemedicine has been increasingly used for acute respiratory infections. The authors wondered though, as concerns for antimicrobial resistance grow and the focus on stewardship becomes a main topic of conversation, where does that leave telemedicine? 

The authors evaluated 2 years of claims data from a national commercial health plan for children between less than 1 year to 17 years of age and the antibiotic prescribing practices for those children needing medical attention for acute respiratory infections. The patients and the prescribing habits of their providers were studied across 3 health care settings: direct-to-patient telemedicine, urgent care, and the primary care provider office. The investigators sorted the visits by age, sex, chronic medical complexity, state, rurality, health plan type, and the diagnostic category for acute respiratory infection.

Impressively, there were 4604 direct-to-consumer visits, 38,408 urgent care visits, and 485,201 to the primary care physician within this matched sample. What was startling though, is that for telemedicine, antibiotic prescribing was higher at 52%, while it was 42% at urgent cares, and 31% at primary care physicians’ offices. These findings were statistically significant.

Beyond the number of antibiotics prescribed, the investigators also found that guideline-concordant antibiotic management was lower at the telemedicine visits, indicating that stewardship practices were followed less. Primary care physician office visits had the highest in terms of guideline-concordant antibiotic management at 78%, while urgent cares were 67%, and telemedicine was 59%. These results were again, statistically significant. 

Ultimately, the findings of this study shed light on an area that antimicrobial stewardship efforts may not have been addressing - telemedicine and especially direct-to-consumer. It is concerning that these pediatric patients were more likely to receive antibiotics, especially if unnecessary or the wrong kind for the infection, in this environment compared to urgent cares and primary care physician offices. It is critical that we include this niche form of care in the talks on antimicrobial stewardship and ensures resources are provided to reduce unnecessary or improper prescribing. 
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Big advances in treatment can't make up for an inability to stop new infections, which number 5,000 per day worldwide.
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