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Research Highlight

Telehealth Can Help Improve Antibiotic Prescribing for Veterans

During World War II, 21 pharmaceutical companies in the United States worked together to mass produce a new drug that had been isolated from the Penicillium mold and had the unique ability to kill bacteria. The use of this “miracle drug,” known as penicillin, saved the lives of countless soldiers who would have otherwise died from infections.

The discovery of penicillin marked the beginning of the modern era of medicine. Thanks to penicillin and other antibiotics discovered in the years after the war, doctors could now treat a wide range of bacteria that infected their patients. Survival for bacterial pneumonia quadrupled while infections that were once universally fatal (e.g., bacterial meningitis) were typically cured. Antibiotics also paved the way for other ground-breaking medical advances, such as organ transplantation and aggressive chemotherapy to treat cancer.

Unfortunately, the widespread use of antibiotics in healthcare settings as well as in animals and agriculture has contributed to the spread of antibiotic resistance. Antibiotic resistance happens when bacteria acquire the ability to grow even in the presence of drugs designed to kill them. Infections due to antibiotic-resistant bacteria lead to longer hospital stays, increased medical costs, and higher mortality. Antibiotic resistance is now considered one of the greatest threats to global public health. Addressing this crisis will require not only discovering new antibiotics but also finding ways to prescribe currently available antibiotics in a more judicious manner. These efforts to improve antibiotic prescribing are broadly referred to as antibiotic stewardship.

Programs to promote antibiotic stewardship have been shown to safely reduce unnecessary antibiotic use and reduce the emergence of antibiotic resistance. In 2014, the Veterans Health Administration (VHA) required all its facilities to develop and maintain an antibiotic stewardship program. These programs are now mandated for all accredited hospitals, nursing homes, and outpatient centers both within and outside VHA.

However, a major barrier to antibiotic stewardship in any setting is the limited availability of physicians and pharmacists formally trained in infectious diseases (ID), also known as ID specialists. Based on a 2020 VHA survey, one out of every five inpatient VHA facilities lacks access to an on-site ID specialist. Access to ID expertise is also a problem outside of VHA, where at least a quarter of all hospitals and virtually all nursing homes lack on-site ID expertise. Our team’s 2016 analysis of antibiotic use across VHA found that patients at hospitals with an on-site ID specialist received antibiotics in a manner more consistent with antibiotic stewardship principles than patients at hospitals without an ID specialist.¹ These findings confirm other studies that have highlighted the importance of ID specialists to effective stewardship implementation.

Limited access to ID expertise is not only an obstacle to antibiotic stewardship but it also means patients with complicated infections cannot benefit from the direct care of an ID physician. ID physician consultation has been shown to improve outcomes for several infections commonly seen among hospitalized patients, such as bloodstream infections and infections due to multidrug-resistant bacteria.

To address these access barriers, telehealth tools can be leveraged. When telehealth has been used for remote ID physician consultation, patient outcomes have been comparable to in-person consultation. Telehealth can also be used to support local antibiotic stewardship activities remotely, independent of direct patient care.

To evaluate the benefit of telehealth-supported activities, our team conducted a one-year pilot trial in 2021 across three rural VHA facilities, all of which had both an acute care unit and a Community Living Center (CLC).² The intervention involved an off-site ID physician meeting virtually via Microsoft Teams with a local stewardship pharmacist three times per week to review hospitalized patients on antibiotics and to provide real-time feedback to clinicians about how to improve their antibiotic prescribing. Over the course of twelve months, the program reviewed 502 unique patients and made 681 recommendations to 24 clinicians. Three out of every four recommendations were accepted by the frontline clinicians. The most common recommendations were to stop unnecessary antibiotic therapy or to shorten the duration of therapy. Once the program went into effect, antibiotic use in CLCs decreased by 30 percent without any evidence of harm.

Based on interviews conducted after the pilot trial ended, clinicians generally appreciated the feedback they received and the opportunity to participate in collaborative discussions about patient care. One of the hospitalists commented, “Having an ID consultant give some recommendations on the length of therapy and scaling up or down therapy is very helpful.” At a different site, a hospitalist acknowledged how much she had learned over the past year: “I think they [the stewardship program] taught us a lot. We are definitely over-prescribing some antibiotics.”

While our approach to ID telehealth proved to be effective and well-received, other models for delivering this same service have been described. In 2022, we convened a panel of ID specialists with telehealth expertise to identify best practices for implementing an ID telehealth program. In our published implementation roadmap, we describe how a telehealth program can be implemented to provide remote ID specialist support for patient consultation and/or antibiotic stewardship.³ Our step-by-step guide is based on the QUERI Roadmap and is organized into three broad phases: pre-implementation, implementation, and sustainment. To increase the likelihood of success, we recommend actively involving local leadership and other stakeholders in all aspects of developing, implementing, measuring, and refining programmatic activities.

References

1. Livorsi DJ, Nair R, Lund BC, et al. “Antibiotic Stewardship Implementation and Antibiotic Use at Hospitals With and Without On-site Infectious Disease Specialists,” Clinical Infectious Diseases 2021;72:1810-7.
2. Livorsi DJ, Sherlock SH, Goedken CC, et al. “The Use of Telehealth-supported Stewardship Activities in Acute-care and Long-term Care Settings: An Implementation Effectiveness Trial,” Infection Control & Hospital Epidemiology 2023 Jun 14:1-8 (online ahead of print).
3. Livorsi DJ, Abdel-Massih R, Crnich CJ, et al. “An Implementation Roadmap for Establishing Remote Infectious Disease Specialist Support for Consultation and Antibiotic Stewardship in Resource-Limited Settings,” Open Forum Infectious Diseases 2022;9:ofac588.