Antibiotic Stewardship in Outpatient Telemedicine


The expansion of outpatient telemedicine has transformed how patients receive health care and has created new opportunities to optimize antibiotic use during telemedicine visits. CDC published guidance describing how health systems and direct-to-consumer telemedicine companies can enhance the implementation and impact of antibiotic stewardship in outpatient telemedicine. This guidance describes how the Core Elements of Outpatient Antibiotic Stewardship can be used as a framework for improving antibiotic use in outpatient telemedicine.*


Telehealth: A broad term to describe the delivery of health care, health education, and health information services via remote technologies.

Telemedicine: The use of technology and telecommunication systems to administer health care to patients who are geographically separated from healthcare providers, including the facilitation of remote diagnoses and treatment of patients.

Synchronous visit: Healthcare services provided using real-time communication, such as virtual visits provided through video, phone, or online chat.

Asynchronous visit: Communication that does not occur in real time (i.e., “store and forward”), such as a virtual visit facilitated using a messaging service or online portal.

E-visit: An asynchronous encounter where a patient fills out an intake form, later reviewed by a healthcare provider, to determine the plan of care.

Telemedicine-Specific Considerations for Antibiotic Stewardship

Health systems and direct-to-consumer telemedicine companies can adapt antibiotic stewardship interventions supported by implementation research and expert opinion to help improve antibiotic use in outpatient telemedicine. The following healthcare delivery strategies can support the implementation of stewardship interventions in outpatient telemedicine1:

  • Establish standards for telediagnosis.

Telemedicine healthcare service delivery may occasionally require a physical examination or laboratory testing to establish a clinical diagnosis. The availability of additional services to overcome these shortcomings vary. It can be important to provide clear guidance to clinicians regarding when it may be acceptable to use telemedicine to establish a clinical diagnosis and when it may be ideal for patients to receive in-person health care.

  • Establish standards for antibiotic prescribing during virtual visits.

Organizational adaptation and promotion of practice guidelines for antibiotic prescribing during virtual visits for conditions which commonly result in an antibiotic prescription is essential for establishing clear expectations for appropriate antibiotic prescribing. Health systems and direct-to-consumer telemedicine companies can establish these standards through adapting national clinical practice guidelines or developing local- or system-specific guidelines for common conditions.

  • Use the highest level of audio/visual technology available during virtual visits.

When practical, prioritize live video for virtual visits to optimize information gathering, diagnostic accuracy, and treatment planning. When available technology does not allow for sufficient information to establish a diagnosis, clinicians can redirect the virtual visit to healthcare services which can appropriately diagnose and manage the condition.

  • Use triage systems to redirect conditions requiring additional support beyond a virtual visit to an alternative care site.

If a virtual encounter or the virtual care platform is unable to meet the needs of a patient encounter, and access to partner services is not available, clinicians should refer patients to an alternative healthcare site. Some health systems-based telemedicine programs further reduce barriers to appropriate prescribing by waiving or minimizing fees for visits requiring a higher level of care.

  • Identify populations at risk of being underserved or excluded by antibiotic stewardship efforts.

Clinicians should proactively identify populations who may be unintentionally or systematically disadvantaged by antibiotic stewardship efforts in virtual settings. Possible actions to reduce this effect include provision of health equity training for clinicians, consideration of health equity impact during telemedicine workflows, and equitable messaging and promotion of outpatient telemedicine services and digital health advocacy efforts.

Outpatient Telemedicine Implementation of the Core Elements

The Core Elements of Outpatient Antibiotic Stewardship provide a framework for antibiotic stewardship for health systems and direct-to-consumer telemedicine companies that routinely provide antibiotic treatment in outpatient telemedicine.

4 Core Elements of Outpatient Antibiotic Stewardship


*Final publication is available from Mary Ann Liebert, Inc.:

  1. Sanchez GV, Kabbani S, Tsay SV, et al. Antibiotic Stewardship in Outpatient Telemedicine: Adapting Centers for Disease Control and Prevention Core Elements to Optimize Antibiotic Use. Telemed J E Health 2023, doi:10.1089/tmj.2023.0229
  2. Drees M, Fischer K, Consiglio-Ward L, et al. Statewide Antibiotic Stewardship: : An eBrightHealth Choosing Wisely Initiative. Dela J Public Health 2019;5(2):50-58, doi:10.32481/djph.2019.05.009
  3. El Feghaly RE, Burns A, Goldman J, et al. 126. Implementation of the core elements of an outpatient antimicrobial stewardship program in pediatric emergency departments and urgent care clinics. Open Forum Infectious Diseases 2020;7(Supplement_1):S76-S76, doi:10.1093/OFID/OFAA439.171
  4. Gross AE, Hanna D, Rowan SA, et al. Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice. Open Forum Infectious Diseases 2019;6(3):ofz067, doi:10.1093/ofid/ofz067
  5. Laude JD, Kramer HP, Lewis M, et al. Implementing Antibiotic Stewardship in a Network of Urgent Care Centers. The Joint Commission Journal on Quality and Patient Safety 2020;46(12):682-690, doi:10.1016/J.JCJQ.2020.09.001
  6. CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. Available at
  7. Madaras-Kelly K, Hostler C, Townsend M, et al. Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship Within Veterans Health Administration Emergency Departments and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes. 2021;73(5), doi:10.1093/CID/CIAA1831
  8. Yadav K, Meeker D, Mistry RD, et al. A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings. Academic Emergency Medicine 2019;26(7):719-731, doi:10.1111/acem.13690
  9. Meeker D, Knight TK, Friedberg MW, et al. Nudging Guideline-Concordant Antibiotic Prescribing. JAMA Internal Medicine 2014;174(3):425, doi:10.1001/jamainternmed.2013.14191
  10. Rittmann B, Stevens MP. Clinical Decision Support Systems and Their Role in Antibiotic Stewardship: a Systematic Review. Current Infectious Disease Reports 2019;21(8), doi:10.1007/s11908-019-0683-8
  11. Meeker D, Linder JA, Fox CR, et al. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. Jama 2016;315(6):562-70, doi:10.1001/jama.2016.0275
  12. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recommendations and Reports 2016;65(6):1-12, doi:10.15585/mmwr.rr6506a1
  13. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013;131(3):e964-99, doi:10.1542/peds.2012-3488
  14. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngology–Head and Neck Surgery 2015;152(2_suppl):S1-S39, doi:10.1177/0194599815572097
  15. Frost HM, Monti JD, Andersen LM, et al. Improving Delayed Antibiotic Prescribing for Acute Otitis Media. Pediatrics 2021;147(6), doi:10.1542/peds.2020-026062
  16. Hersh AL, Stenehjem E, Daines W. RE: Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics 2019;144(2), doi:10.1542/peds.2019-1786B
  17. King LM, Fleming-Dutra KE, Hicks LA. Advances in optimizing antibiotic prescribing in outpatient settings. BMJ (Clinical research ed) 2018;363(k3047-k3047, doi:10.1136/BMJ.K3047
  18. Kronman MP, Gerber JS, Grundmeier RW, et al. Reducing antibiotic prescribing in primary care for respiratory illness. Pediatrics 2020;146(3):e20200038-e20200038, doi:10.1542/PEDS.2020-0038
  19. Ray KN, Martin JM, Wolfson D, et al. Antibiotic Prescribing for Acute Respiratory Tract Infections During Telemedicine Visits Within a Pediatric Primary Care Network. Academic Pediatrics 2021;21(7):1239-1243, doi:
  20. Du Yan L, Dean K, Park D, et al. Education vs Clinician Feedback on Antibiotic Prescriptions for Acute Respiratory Infections in Telemedicine: a Randomized Controlled Trial. Journal of General Internal Medicine 2021;36(2):305-312, doi:10.1007/s11606-020-06134-0
  21. Pedrotti CHS, Accorsi TAD, De Amicis Lima K, et al. Antibiotic stewardship in direct-to-consumer telemedicine consultations leads to high adherence to best practice guidelines and a low prescription rate. International Journal of Infectious Diseases 2021;105(130-134, doi:10.1016/j.ijid.2021.02.020
  22. Wasylyshyn AI, Kaye KS, Chen J, et al. Improving antibiotic use for sinusitis and upper respiratory tract infections: A virtual-visit antibiotic stewardship initiative. Infection Control and Hospital Epidemiology 2022;1-4, doi:10.1017/ice.2022.19
  23. Balinskaite V, Johnson AP, Holmes A, Aylin P. The Impact of a National Antimicrobial Stewardship Program on Antibiotic Prescribing in Primary Care: An Interrupted Time Series Analysis. Clinical Infectious Diseases 2019;69(2):227-232, doi:10.1093/cid/ciy902
  24. Ellegård LM, Dietrichson J, Anell A. Can pay-for-performance to primary care providers stimulate appropriate use of antibiotics? Health Economics 2018;27(1):e39-e54, doi:10.1002/hec.3535
  25. McIsaac W, Kukan S, Huszti E, et al. A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada. BMC Family Practice 2021;22(1), doi:10.1186/s12875-021-01536-3
  26. Sanchez GV, Roberts RM, Albert AP, et al. Effects of Knowledge, Attitudes, and Practices of Primary Care Providers on Antibiotic Selection, United States. Emerging Infectious Diseases 2014;20(12):2041-2047, doi:10.3201/eid2012.140331
  27. Rose J, Crosbie M, Stewart A. A qualitative literature review exploring the drivers influencing antibiotic over-prescribing by GPs in primary care and recommendations to reduce unnecessary prescribing. Perspect Public Health 2021;141(1):19-27, doi:10.1177/1757913919879183
  28. Avorn J. Academic Detailing. JAMA 2017;317(4):361, doi:10.1001/jama.2016.16036
  29. O’Brien MA, Rogers S, Jamtvedt G, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2007, doi:10.1002/14651858.cd000409.pub2
  30. Roberts RM, Albert AP, Johnson DD, Hicks LA. Can Improving Knowledge of Antibiotic-Associated Adverse Drug Events Reduce Parent and Patient Demand for Antibiotics? Health Services Research and Managerial Epidemiology 2015;2(0):233339281456834, doi:10.1177/2333392814568345