O2203: Flipping the Script: Antibiotic Stewardship Success in a Low-Prescribing Direct-to-Consumer Telehealth Model

Background: The rise of direct-to-consumer (DTC) pediatric telehealth has created unique challenges in clinical decision-making. Compared to traditional in-person visits, DTC telehealth encounters are more likely to result in antibiotic prescribing, increasing the risk of inappropriate antibiotic use and antimicrobial resistance. A 2024 study by Wittman et al. found that children seen via DTC telehealth were more than twice as likely to receive antibiotics as those seen via primary care telemedicine (61% vs. 29%), highlighting the importance of stewardship interventions in DTC contexts. Integrating stewardship strategies into virtual care is critical but requires improved access to objective clinical information during encounters.

Blueberry Pediatrics, a subscription-based pediatric DTC model operating in 29 states, integrates stewardship strategies with novel at-home diagnostics, closing diagnostic gaps and aligning prescribing practices with Centers for Disease Control and Prevention (CDC) stewardship guidelines and Healthcare Effectiveness Data and Information Set (HEDIS) quality benchmarks.

Methods: We retrospectively evaluated 119,287 de-identified pediatric telehealth encounters for common pediatric complaints between July 2024 and March 2025 (Table 1). Outcomes included condition-specific and overall antibiotic prescribing rates, use of home diagnostic tools, and prescribing appropriateness per CDC guidelines.

Results: Overall, 26.8% (N= 31,887) of visits resulted in antibiotic prescription. Oral antibiotics were prescribed in only 17.0% (N= 20,287), with 98.6% guideline adherence. The prescribing rate for presumed viral conditions (N=46,293)—including viral upper respiratory infections, asthma, bronchiolitis, fever without source, and gastrointestinal illness—was just 0.16% (Table 2).

Respiratory illnesses treated with antibiotics included strep pharyngitis, acute otitis media, and bacterial sinusitis. Pharyngitis (N=6,914) had a 33.8% prescribing rate, with positive home strep testing in 97.7% of treated cases. Visits for otalgia (N=26,336), diagnosed as acute otitis media had a 45.0% prescribing rate, with 99.7% confirmed via video otoscopy. Sinusitis (N=3,615), based on clinical history alone, had a 90.0% prescribing rate. The majority of suspected pneumonia cases (N=971) assessed via video examination were referred for in-person evaluation (92.74%), and 7.74% were treated with antibiotics.

Skin and soft tissue infections (N=4,443), were informed by asynchronous photo or video examinations. Of these, 85.7% received antibiotics (33.2% oral only, 48.7% topical only, and 18.1% both).

Patients with dysuria (N=2464) were offered outpatient urinalysis and urine culture. Only 3.94% (N=97) received empiric antibiotics prior to specimen collection, yielding an appropriate prescribing rate of over 98%.

Conclusion: Antibiotic stewardship can be successfully integrated into pediatric DTC telehealth when supported by home diagnostic tools. This model enables appropriate antibiotic prescribing grounded in well-informed clinical decision-making. Compared to the high prescribing rates observed in prior studies of DTC platforms, our findings challenge assumptions that DTC care inherently undermines stewardship and demonstrate that high-quality, guideline-concordant prescribing is achievable through an evidence-based virtual care approach.