By Stan Deresinski, MD, FACP, FIDSA

Clinical Professor of Medicine, Stanford University

Dr. Deresinski reports no financial relationships relevant to this field of study.

SYNOPSIS: Compared to in-person visits, virtual visits were associated with improved antibiotic prescribing practices for women with uncomplicated urinary tract infections.

SOURCE: Johnson KL, Dumkow LE, Salvati LA, et al. Comparison of diagnosis and prescribing practices between virtual visits and office visits for adults diagnosed with uncomplicated urinary tract infections within a primary care network. Infect Control Hosp Epidemiol 2020; Oct 29.:1-6. doi: 10.1017/ice.2020.1255. [Online ahead of print].

Johnson and colleagues retrospectively examined the appropriateness of outpatient treatment of uncomplicated urinary tract infections in women ages 18-65 years who were encountered either via virtual or actual visits between Jan. 1 and Dec. 31, 2018. After screening of records, a total of 350 cases (175 in each group) were selected using a random number generator.

Virtual visits to providers in this large primary care practice health system start with a patient entering information into an existing system. On electronic notification, the provider examines the information, including patient answers to a questionnaire, makes a diagnosis, and selects a treatment plan from a drop-down menu with antibiotic (dose and duration) and supportive care choices based on national recommendations.

Antibiotics were prescribed during 100% and 96.6% of virtual and in-person visits, respectively. Guideline-concordant antibiotic selection occurred significantly more frequently during virtual visits: 74.9% vs. 59.4% (P = 0.002). Nitrofurantoin was the most frequently prescribed antibiotic in both groups. The prescribed duration of antibiotic therapy was more likely to be guideline concordant for virtual visits (100% vs. 53.1%; P < 0.001).

A urinalysis was ordered during 97.1% of office visits and 0% of virtual visits, while urine cultures were ordered during 73.1% and 0%, respectively. The bacteria isolated in culture from the office visitors was susceptible to nitrofurantoin 94.8% of the time in those given this drug but was susceptible to the alternative agents administered to the others only 76.3% of the time (P = 0.011). An unplanned interval revisit in the following seven days occurred more frequently in those with an initial office visit: 18.9% vs. 5.1%; P < 0.001.

COMMENTARY

Increasing progress has been made in the implementation of effective antimicrobial stewardship in the outpatient setting. This has resulted in increased appropriate use of antibiotics during in-person patient visits. However, there has been a significant shift from in-person to virtual patient visits. Although the shift was, to some extent, already occurring, the emergence of the COVID-19 pandemic and the Centers for Medicare & Medicaid Services (CMS) waiver of its previously existing payment limitations has shifted telemedicine into high gear. Although the CMS waiver is planned to only be temporary, it seems clear that telemedicine will continue to be a significant part of clinical practice — and this raises the question of whether and how to implement antimicrobial stewardship practice into the management of patients during virtual visits. Now Johnson and colleagues have provided useful information in this regard.

These same investigators previously performed a very similar study in adults with acute sinusitis and found that virtual visits were associated with a significant greater likelihood of guideline-concordant diagnoses as well as a significant decrease in antibiotic prescriptions.1

The improved adherence to antibiotic prescribing guidelines during virtual visits may be the result of a number of factors, perhaps most importantly the use of a drop-down menu giving recommendations. Regarding the results in patients with sinusitis, it could also be speculated that it is easier for the provider to say “no” to a remote patient’s request for an antibiotic prescription than it is to say “no” to a patient sitting in front of that provider. At any rate, it would appear that telemedicine may prove to be an important element in the armamentarium of antimicrobial stewardship programs.

REFERENCE

  1. Johnson KM, Dumkow LE, Burns KW, et al. Comparison of diagnosis and prescribing practices between virtual visits and office visits for adults diagnosed with sinusitis within a primary care network. Open Forum Infect Dis 2019;6:ofz393.