Summary: Why is Antibiotic Overuse a Problem and How Can Telemedicine Reduce Antibiotic Resistance?

  • Antibiotic resistance is a significant global public health issue. Overprescribing and misuse of antibiotics are key drivers of antibiotic resistance.
  • Telemedicine Can Reduce Antibiotic Resistance. By utilizing clinical support tools, focusing on patient education, and improving documentation, virtual clinicians can decrease their rates of inappropriate antibiotic prescribing. 
  • Clinical decision support tools help healthcare providers avoid overusing antibiotics. Examples include evidence-based templates, real-time alerts, at-home testing for bacterial infections, and clinical calculators.  
  • Telemedicine offers a unique opportunity to educate patients about antibiotics. Virtual visits allow ample time for clinicians to help patients understand how antibiotics work and the importance of avoiding antibiotic overuse.  
  • Telehealth platforms that prioritize good antibiotic stewardship have been shown to decrease antibiotic overuse.
  • Prescribing appropriate antibiotics remains a challenge for telehealth care. Lack of thorough physical exams, fear of missed diagnoses, and non-adherence to sound antibiotic stewardship principles are ongoing challenges. 

Introduction

Antibiotic resistance is one of the most significant public health threats worldwide, according to the  World Health Organization. Antibiotic resistance occurs when bacteria mutate to evade the antibiotic’s killing power, rendering the antibiotic ineffective. 

One of the primary drivers of this resistance is the overuse and misuse of antibiotics. The Centers for Disease Control (CDC) estimates that around 30% of all antibiotic prescriptions in the US are unnecessary.

Simply stated, antibiotics become less effective the more they are used. 

In 2019, antibiotic resistance was directly responsible for 1.27 million deaths worldwide and contributed to 4.95 deaths.  Experts predict that worsening antibiotic resistance will result in an additional $1 trillion in direct healthcare costs by 2050. 

Telemedicine can help reduce antibiotic resistance by limiting the overuse of antibiotics, especially in hospital settings. A systematic review, published earlier this year in the journal PLOS One, found that telemedicine outperforms traditional care models in terms of effective antibiotic stewardship (defined as prescribing the correct antibiotic only when necessary for the appropriate length of time). 

As a family medicine doctor, I know firsthand the importance of good antibiotic stewardship to public health. When I first started working in telehealth, I was fortunate to partner with Amwell, an exemplary telehealth company that focuses on quality healthcare. Part of their commitment to quality care is a robust antibiotic stewardship program that helps providers follow appropriate guidelines and limit unnecessary antibiotic prescriptions. I applied what I learned from their program to my traditional brick-and-mortar clinic. 

It’s clear that telemedicine plays a crucial role in reducing the inappropriate use of antibiotics. By facilitating better triage protocols, enhancing documentation, integrating clinical decision support systems, and providing patient education, telemedicine is a gatekeeper against antibiotic overuse. 

Why is antibiotic overuse problematic?

Antibiotics, which are effective only against bacterial infections, are often prescribed inappropriately for viral illnesses. Inappropriate antibiotic prescribing usually occurs when a doctor is uncertain about the diagnosis, when the patient expects or demands an antibiotic, and when time constraints are present.

Common settings where overuse occurs include urgent care sites, primary care offices, emergency departments, and hospitals. Studies show that twenty-eight percent of all outpatient antibiotics are unnecessary; thirty percent of antibiotics given in hospitals are inappropriate; and around half of the antibiotics prescribed at hospital discharge aren’t needed.

The consequences of antibiotic overuse are far-reaching.

  • The development of resistance means that the antibiotics we have are no longer effective in treating common illnesses, leading to an increase in hospitalizations and deaths.
  • Adverse events, such as life-threatening allergic reactions, kidney failure, and gastrointestinal side effects, are more common. Twenty percent of hospitalized patients on antibiotics have at least one adverse event.
  • Secondary infections, such as Clostridium difficile and yeast infections, often occur.
  • The overuse of antibiotics has been linked to asthma, obesity, and autoimmune diseases, especially in children.
  • Healthcare costs increase due to high drug costs, management of complications, and prolonged hospital stays. 

How does telemedicine function as a gatekeeper for antibiotic prescribing?

Telemedicine offers an ideal solution for enhancing antibiotic stewardship. Telehealth-based antibiotic stewardship programs have proven to be effective in reducing the overuse and misuse of antibiotics. By utilizing clinical decision support tools, improving documentation through preset visit templates, and educating both healthcare providers and patients on the importance of antibiotic stewardship, telemedicine can help decrease the rate of antibiotic resistance. 

Telehealth infectious disease specialists are also a vital part of the solution to antibiotic overuse. These specialists can help primary care clinicians in selecting the most suitable treatment option for bacterial infections, whether in a hospital setting or an outpatient clinic. Consultation is just a video chat away, even in remote locations. 

What clinical decision support tools help decrease antibiotic overuse?

Clinical decision support tools enable telehealth providers to make evidence-based decisions about the most effective treatment for each patient’s illness. Various tools can help improve antibiotic stewardship, and many of the most popular telehealth platforms have adopted these tools.

Integrated prescribing guidelines

Several telehealth platforms have integrated antibiotic prescribing guidelines directly into their electronic health records, enabling providers to ensure they select the most appropriate antibiotic. The CDC has developed core elements for prescribing antibiotics via telemedicine to decrease overuse, and many platforms have adopted these principles. Other platforms adhere to the IDSA (Infectious Disease Society of America) prescribing principles. 

An example of an integrated prescribing guideline is the Centor score, which is used for diagnosing strep throat. The Centor score helps clinicians calculate the likelihood that a patient’s sore throat is due to a bacterial strep infection rather than a viral infection.

Real-time alerts

Some platforms incorporate provider alerts if an inappropriate antibiotic is selected, if the treatment duration is too long, or if an antibiotic is not indicated based on the patient’s medical history. This function prompts healthcare providers to make more informed prescribing decisions and reduce the overuse or misuse of antibiotics.

At-home tests for bacterial infections

Physicians can diagnose many bacterial infections through readily available at-home tests. The incorporation of tools such as at-home strep tests, UTI tests, and COVID-19 tests helps improve diagnosis and limit unnecessary antibiotic use.

Several different types of over-the-counter test kits are available at chain drug stores, such as CVS or Walgreens. Many telemedicine platforms also offer test kits that can be mailed directly to the patient. Lab orders, such as a urine culture order, can also be emailed to patients, who can then be tested at their local laboratory. 

These tests help telehealth providers make the correct diagnosis and prescribe the best treatment to help patients feel better without overprescribing antibiotics.

Oversight by infectious disease specialists

Some telemedicine platforms, such as Amwell, utilize remote infectious disease physicians to provide oversight for antibiotic stewardship programs. These specialists are also available for consultation with the clinician if any questions arise. 

Hospital physicians can also consult telehealth infectious disease experts for advice on appropriate antibiotic treatment. Expert consultation helps to minimize inappropriate prescribing in an inpatient setting. 

Telehealth Platforms with Antibiotic Stewardship Programs (ASPs)

PlatformsASP FeaturesFocus AreasWebsite
Teladoc HealthEvidence-based guidelines, decision support tools, and data analytics Focusing on stewardship for conditions such as sore throats and UTIs.
teladoc.com
Amwell (American Well)Clinical decision support tools, educational support for clinicians, and infectious disease specialist oversightReducing overprescribing, promoting evidence-based guidelines, and education
amwell.com
DoctorOnDemandUtilizes clinical guidelines, provides education on the risk of misuse, and offers decision support toolsReducing unnecessary antibiotic prescriptions for viral illnesses
doctorondemand.com
MDLiveIntegrates decision support tools and adheres to AAFP antibiotic guidelinesGuideline-based antibiotic prescribing
mdlive.com
MeMDProtocols for appropriate antibiotic prescribing, diagnostic testing, and integrated support based on CDC guidelinesPreventing overprescribing and encouraging testing
memd.com
PlushCareClinical decision support for proper antibiotic use, adherence to national stewardship guidelines, patient education on antibiotic risksClinical decision support for proper antibiotic use, adherence to national stewardship guidelines, and patient education on antibiotic risks
plushcare.com

HealthTap		Uses clinical decision support to reduce unnecessary antibiotic prescriptions, integrates CDC guidelines and provides real-time feedback
Minimizing the overuse of antibiotics, focusing on correct diagnoses, and non-antibiotic treatments.
healthtap.com

How does improved documentation and close follow-up lead to better antibiotic stewardship?

Telehealth can efficiently assess symptoms from the very start of the visit, before the patient connects with a healthcare provider. Most platforms utilize virtual assistants that guide patients through a series of pertinent questions before the start of the visit. These questions help filter out non-bacterial conditions, such as viral colds, influenza, or COVID-19. 

Once a diagnosis is made and the clinician decides the patient should be treated with a course of antibiotics, preset templates on telemedicine platforms help ensure the appropriate documentation of the diagnosis and the reason for antibiotics. This specific documentation helps quality assurance teams analyze the data and confirm that the provider made a suitable choice.

By using preset templates for documentation, clinicians can easily access previous visits the patient may have had, which helps reduce the need for repeated antibiotic prescriptions. For patients not prescribed an antibiotic for respiratory symptoms, a follow-up appointment can be scheduled to monitor symptom progression. This ease of access to the clinician helps limit the overuse of antibiotics.

Patients can also utilize asynchronous messaging if they have concerns about worsening respiratory symptoms. The healthcare provider can review messages regarding new or worsening symptoms without a knee-jerk response of immediately prescribing potentially unnecessary medication. 

How can telemedicine enhance patient and provider education about antibiotic overuse?

Telemedicine offers a unique opportunity for healthcare providers to explain to patients why antibiotics may not be necessary and the potential health risks associated with overprescribing them. Acute care office visits in a primary care, urgent care, or ER setting are often rushed; telemedicine visits are generally focused on a single problem, with plenty of time allowed for the provider to educate the patient.

Healthcare providers can also email or message patients with educational visuals, links to helpful websites, and provide written summaries of care to reinforce understanding of the importance of good antibiotic stewardship.

Clinicians often prescribe antibiotics to patients even when they suspect a viral infection in response to patient demands. Patients often have treatment expectations that are based on past illnesses. Healthcare providers who are pressed for time sometimes find it easier to “just give in” rather than face confrontation with a patient. 

A study published this year in The Journal of Medical Internet Research found that patient pressure or demand for antibiotics is decreased when face-to-face dynamics are removed. This study shows that physicians are less likely to prescribe antibiotics via telehealth compared to in-person visits.

Many telehealth companies offer their healthcare providers ongoing education about good antibiotic stewardship. These platforms emphasize the importance of antibiotic stewardship programs through ongoing quality assurance audits. 

What are the challenges telehealth platforms face when committing to good antibiotic stewardship?

When good antibiotic stewardship practices are followed, there is always a risk of under-treatment or missed bacterial infections. Missed bacterial infections can lead to worsening of the condition, increased rates of hospitalization, and poor patient outcomes.

Virtual providers are limited in conducting physical exams, such as examining the ears with an otoscope or listening to the heart and lungs with a stethoscope. This limitation can also lead to underdiagnosis of bacterial infections.

To prevent missed bacterial infections, virtual healthcare providers need to be highly trained, and telehealth platforms need to be held to high-quality standards. The availability of clinical support decision tools helps minimize the possibility of misdiagnosis. 

Not all telehealth platforms adhere to sound antibiotic stewardship programs, leading to an increase in inappropriate antibiotic prescribing. To prevent antibiotic overuse, all telehealth platforms should incorporate standard principles of antibiotic stewardship.

In the future, expanding remote diagnostics and AI-powered clinical decision tools will help virtual healthcare providers ensure antibiotics are not overused or misused. 

Frequently Asked Questions:

Can I get a prescription for antibiotics through telemedicine?

Yes, antibiotics can be prescribed through telemedicine if the healthcare provider diagnoses you with a bacterial infection.

How do doctors know if I need antibiotics without seeing me in person?

Telehealth providers take a thorough history and conduct a virtual physical examination to diagnose your illness. If they determine a bacterial infection is causing your illness,  antibiotics can be prescribed. Your telehealth provider can utilize diagnostic tools, such as at-home urine tests or Centor scores for strep, to ensure the antibiotic treatment is appropriate. 

Is it safe to take antibiotics prescribed via telemedicine?

It is just as safe to take antibiotics prescribed via telehealth as it is to take antibiotics that an in-person doctor prescribes. Telehealth providers rely on taking a thorough medical history, including any drug allergies, to ensure it’s safe for you to take antibiotics. The provider will also review any potential side effects with you and then send the antibiotic prescription to your local pharmacy.

What conditions can be treated with antibiotics through telemedicine?

Virtual providers can treat UTIs, sinus infections, strep throat, some instances of cellulitis, and other bacterial infections through telemedicine.

How quickly can I get antibiotics after a telemedicine appointment?

Medications are typically prescribed at the end of your telehealth visit. If your pharmacy hasn’t received the prescription within a couple of hours, reach out to your telehealth provider to ensure they have the correct pharmacy information. 

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