Acute respiratory tract infections (ARTIs) account for about 20% of pediatric health care visits and drive the bulk of outpatient antibiotic prescriptions for children.1
Despite this, previous research indicates that 25% to 50% of antibiotics prescribed for these respiratory issues are unnecessary. Telemedicine used outside of traditional primary care environments has specifically been associated with this pattern of overprescribing antibiotics.1
In a recent retrospective cross-sectional analysis, investigators sought to understand differences in antibiotic management for pediatric ARTIs between in-person and telemedicine primary care visits.
Kristin N. Ray, MD, MS, Associate Professor of Pediatrics and Director of Health Systems Improvement at the University of Pittsburgh and lead author of the study, said the findings from the analysis differ from those of prior studies evaluating direct-to-consumer and virtual-only telemedicine platforms, which are non-primary care settings.
“The surprise is that these results are in the opposite direction of findings looking at direct-to-consumer or virtual-only telemedicine vendors, where antibiotic prescribing during telemedicine visits is higher than in-person visits,” Dr. Ray said. “That shows that telemedicine does not have an inherently positive or negative effect on prescribing but instead that telemedicine can enable programs that increase or decrease prescribing.”
The analysis included 694 practices in 45 US states and the District of Columbia. Investigators defined episodes of ARTI care as index visits preceded by a 21-day period without any ARTI diagnoses. The study focused on primary outcomes, including the total frequency of systemic antibiotic prescriptions and the receipt of guideline-concordant antibiotic prescriptions based on visit diagnosis. Secondary outcomes included follow-up visits and further ARTI-related antibiotic use within 14 days of the index visit.1
For the study, 449,630 ARTI index visits were evaluated, among 302,817 children (mean [SD] age, 6.6 [4.7] years; 48.6% female; 51.4% male). Of those, 46.8% (95% CI, 45.1%-48.4%) of the ARTI index visits completed in person were prescribed antibiotics, compared with 34.6% (95% CI, 27.0%-42.3%) of primary care telemedicine visits receiving antibiotics.1 Guideline-concordant antibiotic management was achieved in 86.2% (95% CI, 85.1%-87.3%) of in-person primary care visits, comparable to the 85.5% (95% CI, 80.5%-90.4%) observed in telemedicine visits.1
Additionally, telemedicine visits were associated with viral diagnoses in 66.9% (95% CI, 59.8%-74.1%), while in-person visits received viral diagnoses in 55.6% (95% CI, 54.0%-57.2%) of cases. Compared with in-person encounters, telemedicine was associated with a lower frequency of acute otitis media diagnoses and a higher frequency of sinusitis diagnoses.1
“The difference in antibiotic prescribing was primarily driven by the difference in diagnoses between the two modalities, with in-person visits more likely to be bacterial ARTIs warranting antibiotics,” said Samuel R. Wittman, MS, Research Data Analyst at the University of Pittsburgh, and coauthor of the study. “It makes sense that both parental decision-making and provider triaging would direct the more severe bacterial cases to in-person rather than telemedicine visits, if possible.”
Investigators found the proportion of follow-up primary care ARTI visits and the subsequent antibiotic prescriptions—both within 14 days—did not differ significantly by visit modality.1 The researchers examined this to account for the possibility that lower antibiotic prescriptions in telemedicine may have been because of missed diagnoses.
One shortcoming of the study was that urgent care and emergency department follow-up data were not available, so it is unknown whether some patients seen with telemedicine who were not prescribed antibiotics did receive them at such a facility shortly thereafter because the diagnosis was initially missed.
Wittman said the findings may have broader implications for antibiotic stewardship by encouraging primary care-based telemedicine over virtual-only models, which could “divert children from less judicious sites to more judicious sites for ARTI antibiotic management.”
Additionally, Dr. Ray said, the findings underscore the importance of integrating telemedicine into primary care appropriately.
“We should focus on factors that support judicious prescribing through telemedicine—and the factor we identified in this study is the use of telemedicine by primary care physicians who are also providing in-person primary care visits to the same panel of patients as their telemedicine visits,” she said.
References
1. Ray KN, Wittman SR, Kelly MK, et al. Primary care telemedicine vs in-person antibiotic prescribing for pediatric respiratory tract infections. JAMA Netw Open. 2026;9(5):e2610062. doi:10.1001/jamanetworkopen.2026.10062
