Abstract
The global antibiotic resistance crisis necessitates optimized stewardship programs, with telemedicine emerging as a promising delivery strategy. This systematic review evaluated the effectiveness of telemedicine interventions in improving antibiotic stewardship across clinical settings. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched seven databases from January 2010 to July 2024. Two independent reviewers assessed studies using Risk of Bias in Non-randomized Studies (ROBINS-I) and Cochrane Risk of Bias 2.0 tools, with evidence certainty evaluated using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Twenty-one studies met inclusion criteria (10 observational, 8 quasi-experimental, 2 Randomized Controlled Trials [RCTs], 1 mixed-methods), predominantly from the United States (57.0%, n = 12). Among studies reporting antibiotic use outcomes (52.4%, n = 11), 90.9% demonstrated significant reductions ranging from 5.3% to 62.7%, with the highest-quality evidence showing a 28% reduction (95% Confidence Interval [CI]: 22-34%). Guideline adherence studies (57.1%, n = 12) showed acceptance rates of 67.7% to 98%, with comparable effectiveness between telemedicine and in-person consultation (79.1% vs 80.4%, p = 0.36). Prescribing rate outcomes (38.1%, n = 8) revealed setting-dependent variations: inpatient implementations demonstrated significant reductions (Relative Risk [RR] 0.68; 95% CI: 0.63-0.75), while outpatient findings showed mixed results. Quality assessment revealed predominantly low risk of bias [ROB] (66.7%, n = 14). These findings suggest that telemedicine effectively improves antibiotic stewardship compared to traditional care models, particularly in hospital settings, while outpatient applications demonstrated variable effectiveness. This review was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023454663).