Primary Care Telemedicine vs In-Person Antibiotic Prescribing for Pediatric Respiratory Tract Infections.

Importance: Acute respiratory tract infections (ARTIs) are among the most common reasons for pediatric primary care visits and antibiotic receipt. Telemedicine outside of primary care settings has been associated with overuse of antibiotics for ARTIs in children. The quality of telemedicine when integrated within primary care for children is not clear. Objective: To compare antibiotic management during primary care visits conducted through telemedicine vs in-person. Design, Setting, and Participants: This retrospective, cross-sectional study analyzed visits for ARTIs in children younger than 18 years between January 1 and December 31, 2023, at 694 US primary care practices (including community health organizations, independent pediatric practices, and practice networks affiliated with large health systems). Analyses were performed between October 1, 2024, and February 12, 2026. Exposure: Primary care telemedicine vs primary care in-person index visits. Main outcomes and measures: The primary outcomes were percentage of index visits with antibiotics prescribed and percentage with antibiotic management concordant with guidelines for visit diagnosis. Secondary outcomes included index visit diagnosis, follow-up visits within 14 days, and antibiotic prescription within 14 days. Weighted analyses were conducted using a propensity score model to estimate the probability of an ARTI index visit being conducted via telemedicine and estimated the average treatment effect associated with telemedicine. Results: This study included 438 148 in-person and 11 482 telemedicine index ARTI visits at primary care practices by 302 817 children (mean [SD] age: 6.6 [4.7] years; 51.4% male). Antibiotic prescription occurred during 46.8% (95% CI, 45.1%-48.4%) of primary care in-person visits vs 34.6% (95% CI, 27.0%-42.3%) of primary care telemedicine visits in the propensity score-weighted model, with a difference of -12.1 (95% CI, -19.3 to -5.0) percentage points. Antibiotic management was guideline concordant for 86.2% (95% CI, 85.1%-87.3%) of primary care in-person visits vs 85.5% (95% CI, 80.5%-90.4%) of primary care telemedicine visits, with a difference of -0.7 (95% CI, -5.3 to 3.8) percentage points. The proportion of follow-up visits and antibiotic prescription within 14 days after initial visit did not vary significantly by index visit modality. Conclusions and Relevance: In this cross-sectional study of primary care practices caring for children, telemedicine integrated within primary care was associated with judicious antibiotic prescribing without increased follow-up visits or subsequent antibiotics prescribed. Supporting primary care practices in offering telemedicine for acute concerns may be a strategy to limit unnecessary antibiotic receipt.