Infectious Diseases Society of America Position Statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases

Implementation of a novel antimicrobial stewardship strategy for rural facilities utilising telehealth

A significant portion of healthcare takes place in small hospitals, and many are located in rural and regional areas. Facilities in these regions frequently do not have adequate resources to implement an onsite antimicrobial stewardship programme and there are limited data relating to their implementation and effectiveness. We present an innovative model of providing a specialist telehealth antimicrobial stewardship service utilising a centralised service (Queensland Statewide Antimicrobial Stewardship Program) to a rural Hospital and Health Service. Results of a 2-year post-implementation follow-up showed an improvement in adherence to guidelines [33.7% (95% CI 27.0-40.4%) vs. 54.1% (95% CI 48.7-59.5%)] and appropriateness of antimicrobial prescribing [49.0% (95% CI 42.2-55.9%) vs. 67.5% (95% CI 62.7-72.4%) (P < 0.001). This finding was sustained after adjustment for hospitals, with improvement occurring sequentially across the years for adherence to guidelines [adjusted odds ratio (aOR) = 2.44, 95% CI 1.70-3.51] and appropriateness of prescribing (aOR = 2.48, 95% CI 1.70-3.61). There was a decrease in mean total antibiotic use (DDDs/1000 patient-days) between the years 2016 (52.82, 95% CI 44.09-61.54) and 2018 (39.74, 95% CI 32.76-46.73), however this did not reach statistical significance. Additionally, there was a decrease in mean hospital length of stay (days) from 2016 (3.74, 95% CI 3.08-4.41) to 2018 (2.55, 95% CI 1.98-3.12), although this was not statistically significant. New telehealth-based models of antimicrobial stewardship can be effective in improving prescribing in rural areas. Programmes similar to ours should be considered for rural facilities.

Antimicrobial Stewardship Challenges in the Deployed Setting

INTRODUCTION

Up to 34% of combat trauma injuries are complicated by infection with multidrug-resistant organisms. Overutilization of antibiotics has been linked to increased multidrug-resistant organisms in combat-injured patients. Antimicrobial stewardship efforts at deployed medical treatment facilities have been intermittently reported; however; a comprehensive assessment of antimicrobial stewardship practices has not been performed.

MATERIALS AND METHODS

A survey tool was modified to include detailed questions on antimicrobial stewardship practices at medical treatment facilities. A Joint Service, multidisciplinary team conducted on-site assessments and interviews to assess the status of antimicrobial stewardship best practices, with particular emphasis on antibiotic prophylaxis in combat injured, in the U.S. Central Command operational theaters. Limitations to implementing stewardship to the national standards were explored thematically.

RESULTS

Nine Role 1, 2, and 3 medical facilities representing the range of care were assessed on-site. A total of 67% of the sites reported a formal antimicrobial stewardship program and 56% of the sites had an assigned head of antimicrobial stewardship. No military personnel in theater received training on antimicrobial stewardship and laboratory assets were limited. Personnel at these sites largely had access to Joint Trauma System guidelines describing antimicrobial prophylaxis for combat injured (89%), yet infrequently received feedback on their implementation and adherence to these guidelines (11%).

CONCLUSIONS

Antimicrobial stewardship programs in theater are in the early stages of development in theater. Areas identified for improvement are access to expertise, development of a focus on high-impact lines of effort, laboratory support, and the culture of antimicrobial prescribing. Risks can be mitigated through theater level formalization of efforts, expert mentoring through telehealth, and a focus on implementation and adherence and feedback to national guidelines.

Sustainability of antimicrobial stewardship programs in Australian rural hospitals: a qualitative study

Objective The aim of this study was to explore the features of sustainable antimicrobial stewardship (AMS) programs in Australian rural hospitals and develop recommendations on incorporating these features into rural hospitals' AMS programs. Methods Lead AMS clinicians with knowledge of at least one AMS program sustained for >2 years in a health service in rural Australia were recruited to the study. A series of interviews was conducted and the transcripts analysed thematically using a framework method. Results Fifteen participants from various professional disciplines were interviewed. Key features that positively affected the sustainability of AMS programs in rural hospitals included a hospital executive who provided strong governance and accountability, dedicated resources, passionate local champions, area-wide arrangements and adaptability to engage in new partnerships. Challenges to building AMS programs with these features were identified, particularly in engaging hospital executive to allocate AMS resources, managing the burn out of passionate champions and formalising network arrangements. Conclusions Strategies to increase the sustainability of AMS programs in rural hospitals include using accreditation as a mechanism to drive direct resource allocation, explicit staffing recommendations for rural hospitals, greater support to develop formal network arrangements and a framework for integrated AMS programs across primary, aged and acute care. What is known about the topic? AMS programs facilitate the responsible use of antimicrobials. Implementation challenges have been identified for rural hospitals, but the sustainability of AMS programs has not been explored. What does this paper add? Factors that positively affected the sustainability of AMS programs in rural hospitals were a hospital executive that provided strong governance and accountability, dedicated resources, network or area-wide arrangements and adaptability. Challenges to building AMS programs with these features were identified. What are the implications for practitioners? Recommended actions to boost the sustainability of AMS programs in rural hospitals are required. These include using accreditation as a mechanism to drive direct resource allocation, explicit staffing recommendations for rural hospitals, greater support to develop network arrangements and support to create integrated AMS programs across acute, aged and primary care.

Telehealth Demand Trends During the COVID-19 Pandemic in the Top 50 Most Affected Countries: Infodemiological Evaluation

Background

The COVID-19 pandemic has led to urgent calls for the adoption of telehealth solutions. However, public interest and demand for telehealth during the pandemic remain unknown.

Objective

We used an infodemiological approach to estimate the worldwide demand for telehealth services during COVID-19, focusing on the 50 most affected countries and comparing the demand for such services with the level of information and communications technology (ICT) infrastructure available.

Methods

We used Google Trends, the Baidu Index (China), and Yandex Keyword Statistics (Russia) to extract data on worldwide and individual countries’ telehealth-related internet searches from January 1 to July 7, 2020, presented as relative search volumes (RSV; range 0-100). Daily COVID-19 cases and deaths were retrieved from the World Health Organization. Individual countries’ ICT infrastructure profiles were retrieved from the World Economic Forum Report.

Results

Across the 50 countries, the mean RSV was 18.5 (SD 23.2), and the mean ICT index was 62.1 (SD 15.0). An overall spike in worldwide telehealth-related RSVs was observed from March 11, 2020 (RSV peaked to 76.0), which then tailed off in June-July 2020 (mean RSV for the period was 25.8), but remained higher than pre-March RSVs (mean 7.29). By country, 42 (84%) manifested increased RSVs over the evaluation period, with the highest observed in Canada (RSV=100) and the United States (RSV=96). When evaluating associations between RSV and the ICT index, both the United States and Canada demonstrated high RSVs and ICT scores (≥70.3). In contrast, European countries had relatively lower RSVs (range 3.4-19.5) despite high ICT index scores (mean 70.3). Several Latin American (Brazil, Chile, Colombia) and South Asian (India, Bangladesh, Pakistan) countries demonstrated relatively higher RSVs (range 13.8-73.3) but low ICT index scores (mean 44.6), indicating that the telehealth demand outstrips the current ICT infrastructure.

Conclusions

There is generally increased interest and demand for telehealth services across the 50 countries most affected by COVID-19, highlighting the need to scale up telehealth capabilities, during and beyond the pandemic.

Innovations in Human Immunodeficiency Virus (HIV) Care Delivery During the Coronavirus Disease 2019 (COVID-19) Pandemic: Policies to Strengthen the Ending the Epidemic Initiative-A Policy Paper of the Infectious Diseases Society of America and the HIV Medicine Association

The goal of the Ending the HIV Epidemic Initiative is to reduce new infections in the US by 90% by 2030. Success will require fundamentally changing HIV prevention and care delivery to engage more persons with HIV and at-risk of HIV in treatment. While the COVID-19 pandemic reduced in-person visits to care facilities and led to concern about interruptions in care, it also accelerated growth of alternative options, bolstered by additional funding support. These included the use of telehealth, medication delivery to the home and increased flexibility facilitating access to Ryan White HIV/AIDS Program services. While the outcomes of these programs must be studied, many have improved accessibility during the pandemic. As the pandemic wanes, long term policy changes are needed to preserve these options for those who benefit from them. These new care paradigms may provide a roadmap for progress for those with other chronic health issues as well.

Antibiotic stewardship teams and Clostridioides difficile practices in United States hospitals: A national survey in The Joint Commission antibiotic stewardship standard era

OBJECTIVE

Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship.

METHODS

Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression.

RESULTS

Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies.

CONCLUSIONS

Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non-ID-trained pharmacists and clinicians in antibiotic stewardship.

Education of Infectious Diseases Fellows During the COVID-19 Pandemic Crisis: Challenges and Opportunities

One of the many challenges that has befallen the Infectious Diseases and Graduate Medical Education communities during the coronavirus disease 2019 (COVID-19) pandemic is the maintenance of continued effective education and training of the future leaders of our field. With the remarkable speed and innovation that has characterized the responses to this pandemic, educators everywhere have adapted existing robust and safe learning environments to meet the needs of our learners. This paper will review distinct aspects of education and training of the Infectious Diseases fellows we believe the COVID-19 pandemic has impacted most, including mentoring, didactics, and wellness. We anticipate that several strategies developed in this context and described herein will help to inform training and best practices during the pandemic and beyond.

Ocular surface assessment in times of sanitary crisis: What lessons and solutions for the present and the future?

PURPOSE

To describe the immediate consequences of SARS-CoV-2 and the COVID-19 pandemic on the ocular surface and eye-care professionals, and to discuss the need for a mandatory switch from currently performed tele-screening to true teleconsultation for remote ocular surface assessment.

MAIN FINDINGS

Ophthalmologists have been largely impacted by the COVID-19 sanitary crisis, due to both the ocular manifestations of SARS-CoV-2 and to the high contagiousness of the virus. The proximity of ophthalmologists to their patients have pushed eye-care providers to readapt their practices and develop alternatives to face-to-face consultations. However, teleconsultation has some major limitations and drawbacks, especially for ocular surface assessment that relies on high-quality graphic data for adequate diagnosis. Tele-screening, on the other hand, emphasizes on the importance of history-taking and listening to the patient in order to adequately prioritize appointments based on the presumed degree of emergency.

CONCLUSION

Despite all the enthusiasm, tele-screening as currently performed with the available tools is still not capable of completely replacing a standard ophthalmic examination for the assessment of ocular surface diseases. While waiting for new emerging technologies and future implementation of imaging modalities and artificial intelligence, decision making algorithms can help eye-practitioners remotely screen their patients to assess the optimal time for follow-up appointments.

Monitoring of COVID-19 patients by telemedicine with telemonitoring

AIM

To asses if telemedicine with telemonitoring is a clinically useful and secure tool in the tracking of patients with COVID-19.

METHODS

A prospective observational study of patients with COVID-19 diagnosis by positive PCR considered high-risk tracked with telemedicine and telemonitoring was conducted in the sanitary area of Lugo between March 17th and April 17th, 2020. Two groups of patients were included: Outpatient Tracing from the beginning and after discharge. Every patient sent a daily clinical questionnaire with temperature and oxygen saturation 3 times a day. Proactive monitoring was done by getting in touch with every patient at least 11a day.

RESULTS

313 patients (52.4% female) with a total average age of 60.9 (DE 15.9) years were included. Additionally, 2 patients refused to join the program. Since the beginning, 224 were traced outpatient and 89 after being discharged. Among the first category, 38 (16.90%) were referred to Emergency department on 43 occasions; 18 were hospitalized (8.03%), and 2 deceased. Neither deaths nor a matter of vital emergency occurred at home. When including patients after admissions monitoring was done in 304 cases. One patient re-entered (0.32%) to the hospital, and another one left the program (0.32%). The average time of monitoring was 11.64 (SD 3.58) days, and 224 (73.68%) patients were discharged during the 30 days of study.

CONCLUSIONS

Our study suggests that telemedicine with home telemonitoring, used proactively, allows for monitoring high-risk patients with COVID-19 in a clinically useful and secure way.

Monitoring of COVID-19 patients via telemedicine with telemonitoring

Aim

To asses if telemedicine with telemonitoring is a clinically useful and safe tool for monitoring patients with COVID-19.

Methods

A prospective observational study of patients with COVID-19 diagnosed via a positive PCR test who were considered high-risk and who were monitored with telemedicine and telemonitoring in the Lugo Healthcare Area between March 17th and April 17th, 2020, was conducted. Two groups of patients were included: those in outpatient monitoring from the beginning and those in outpatient monitoring following hospital discharge. Every patient completed a clinical questionnaire with his or her temperature once per day and oxygen saturation levels three times per day. Proactive monitoring was done by getting in touch with every patient at least once a day.

Results

A total of 313 patients (52.4% female) with a mean age of 60.9 (SD 15.9) years were included. Two patients refused to participate in the program. Finally, 224 were monitored from the beginning and 89 patients were monitored after discharged. In the first group, 38 (16.90%) were referred to the Emergency department on 43 occasions; 18 (8.03%) were hospitalized, and two died. There were no deaths or lifethreatening at home. Including the patients monitored after hospitalization, monitoring was performed in 304 cases. One patient was readmited (0.32%) and another left the program (0.32%). The mean time of monitoring was 11.64 (SD 3.58) days and 224 (73.68%) patients were discharged during the 30 days the study lasted.

Conclusions

Our data suggest that telemedicine with at-home telemonitoring, when used proactively, allows for clinically useful and safe monitoring of high-risk patients with COVID-19.

Rapid Implementation of an Inpatient Telehealth Program during the COVID-19 Pandemic

BACKGROUND

 Relaxation of laws and regulations around privacy and billing during the COVID-19 pandemic provide expanded opportunities to use telehealth to provide patient care at a distance. Many health systems have transitioned to providing outpatient care via telehealth; however, there is an opportunity to utilize telehealth for inpatients to promote physical distancing.

OBJECTIVE

 This article evaluates the use of a rapidly implemented, secure inpatient telehealth program.

METHODS

 We assembled a multidisciplinary team to rapidly design, implement, and iteratively improve an inpatient telehealth quality improvement initiative using an existing videoconferencing system at our academic medical center. We assigned each hospital bed space a unique meeting link and updated the meeting password for each new patient. Patients and families were encouraged to use their own mobile devices to join meetings when possible.

RESULTS

 Within 7 weeks of go-live, we hosted 1,820 inpatient telehealth sessions (13.3 sessions per 100 bedded days). We logged 104,647 minutes of inpatient telehealth time with a median session duration of 22 minutes (range 1-1,961). There were 5,288 participant devices used with a mean of 3 devices per telehealth session (range 2-22). Clinicians found they were able to build rapport and perform a reasonable physical exam.

CONCLUSION

 We successfully implemented and scaled a secure inpatient telehealth program using an existing videoconferencing system in less than 1 week. Our implementation provided an intuitive naming convention for providers and capitalized on the broad availability of smartphones and tablets. Initial comments from clinicians suggest the system was useful; however, further work is needed to streamline initial setup for patients and families as well as care coordination to support clinician communication and workflows. Numerous use cases identified suggest a role for inpatient telehealth will remain after the COVID-19 crisis underscoring the importance of lasting regulatory reform.

A Double Triage and Telemedicine Protocol to Optimize Infection Control in an Emergency Department in Taiwan During the COVID-19 Pandemic: Retrospective Feasibility Study

Background

Frontline health care workers, including physicians, are at high risk of contracting coronavirus disease (COVID-19) owing to their exposure to patients suspected of having COVID-19.

Objective

The aim of this study was to evaluate the benefits and feasibility of a double triage and telemedicine protocol in improving infection control in the emergency department (ED).

Methods

In this retrospective study, we recruited patients aged ≥20 years referred to the ED of the National Taiwan University Hospital between March 1 and April 30, 2020. A double triage and telemedicine protocol was developed to triage suggested COVID-19 cases and minimize health workers’ exposure to this disease. We categorized patients attending video interviews into a telemedicine group and patients experiencing face-to-face interviews into a conventional group. A questionnaire was used to assess how patients perceived the quality of the interviews and their communication with physicians as well as perceptions of stress, discrimination, and privacy. Each question was evaluated using a 5-point Likert scale. Physicians’ total exposure time and total evaluation time were treated as primary outcomes, and the mean scores of the questions were treated as secondary outcomes.

Results

The final sample included 198 patients, including 93 cases (47.0%) in the telemedicine group and 105 cases (53.0%) in the conventional group. The total exposure time in the telemedicine group was significantly shorter than that in the conventional group (4.7 minutes vs 8.9 minutes, P<.001), whereas the total evaluation time in the telemedicine group was significantly longer than that in the conventional group (12.2 minutes vs 8.9 minutes, P<.001). After controlling for potential confounders, the total exposure time in the telemedicine group was 4.6 minutes shorter than that in the conventional group (95% CI −5.7 to −3.5, P<.001), whereas the total evaluation time in the telemedicine group was 2.8 minutes longer than that in the conventional group (95% CI −1.6 to −4.0, P<.001). The mean scores of the patient questionnaire were high in both groups (4.5/5 to 4.7/5 points).

Conclusions

The implementation of the double triage and telemedicine protocol in the ED during the COVID-19 pandemic has high potential to improve infection control.

Usefulness of a Telemedicine Tool TELEA in the Management of the COVID-19 Pandemic

Background: The usefulness of telemedicine in the management of the coronavirus disease 2019 (COVID-19) pandemic has not been evaluated. Methods: We conducted a descriptive study of the process of recruitment and follow-up of patients using a telemedicine tool (TELEA) in the management of patients at risk, in a rural environment with a dispersed population in Lugo in north western Spain. Results: A large number of patients diagnosed with COVID-19 infection (N = 545) were evaluated. Of this group, 275 had comorbidities and were enrolled in the program, with a mean age of 57.6 ± 16.3 years, 43.1% male. The risk factors were hypertension (38%), diabetes (16%), asthma (9.5%), heart disease (8.8%), and immunosuppression (5.1%). Patients were followed through the platform with daily control of symptoms and vital signs. Only 8% were admitted to the hospital, 5.1% on a scheduled basis and 2.9% through the emergency room. Conclusion: The telemedicine tool TELEA is useful for the management of high-risk patients with COVID-19.

Building HIV healthcare worker capacity through telehealth in Vietnam

Development of a robust technical assistance system is an essential component of a sustainable HIV response. Vietnam's National HIV Program is transitioning from a largely donor-funded programme to one primarily supported by domestic resources. Telehealth interventions are increasingly being used for training, mentoring and expert consultation in high-resource settings and hold significant potential for use as a tool to build HIV health worker capacity in low and middle-income countries. We designed, implemented and scaled up a novel HIV telehealth programme for Vietnam, with the goal of building a sustainable training model to support the country's HIV workforce needs. Over a 4-year period, HIV telehealth programmes were initiated in 17 public institutions with participation of nearly 700 clinical sites across 62 of the 63 provinces in the country. The telehealth programme was used to deliver certificate training courses, provide clinical mentoring and case-based learning, support programme implementation, provide coaching in quality improvement and disseminate new guidelines and policies. Programme evaluation demonstrated improved health worker self-reported competence in HIV care and treatment and high satisfaction among the programme participants. Lessons learnt from Vietnam's experience with telehealth can inform country programmes looking to develop a sustainable approach to HIV technical assistance and health worker capacity building.

Population-Level Interest and Telehealth Capacity of US Hospitals in Response to COVID-19: Cross-Sectional Analysis of Google Search and National Hospital Survey Data

BACKGROUND

As the novel coronavirus disease (COVID-19) is widely spreading across the United States, there is a concern about the overloading of the nation's health care capacity. The expansion of telehealth services is expected to deliver timely care for the initial screening of symptomatic patients while minimizing exposure in health care facilities, to protect health care providers and other patients. However, it is currently unknown whether US hospitals have the telehealth capacity to meet the increasing demand and needs of patients during this pandemic.

OBJECTIVE

We investigated the population-level internet search volume for telehealth (as a proxy of population interest and demand) with the number of new COVID-19 cases and the proportion of hospitals that adopted a telehealth system in all US states.

METHODS

We used internet search volume data from Google Trends to measure population-level interest in telehealth and telemedicine between January 21, 2020 (when the first COVID-19 case was reported), and March 18, 2020. Data on COVID-19 cases in the United States were obtained from the Johns Hopkins Coronavirus Resources Center. We also used data from the 2018 American Hospital Association Annual Survey to estimate the proportion of hospitals that adopted telehealth (including telemedicine and electronic visits) and those with the capability of telemedicine intensive care unit (tele-ICU). Pearson correlation was used to examine the relations of population search volume for telehealth and telemedicine (composite score) with the cumulative numbers of COVID-19 cases in the United States during the study period and the proportion of hospitals with telehealth and tele-ICU capabilities.

RESULTS

We found that US population-level interest in telehealth increased as the number of COVID-19 cases increased, with a strong correlation (r=0.948, P<.001). We observed a higher population-level interest in telehealth in the Northeast and West census region, whereas the proportion of hospitals that adopted telehealth was higher in the Midwest region. There was no significant association between population interest and the proportion of hospitals that adopted telehealth (r=0.055, P=.70) nor hospitals having tele-ICU capability (r=-0.073, P=.61).

CONCLUSIONS

As the number of COVID-19 cases increases, so does the US population's interest in telehealth. However, the level of population interest did not correlate with the proportion of hospitals providing telehealth services in the United States, suggesting that increased population demand may not be met with the current telehealth capacity. Telecommunication infrastructures in US hospitals may lack the capability to address the ongoing health care needs of patients with other health conditions. More practical investment is needed to deploy the telehealth system rapidly against the impending patient surge.

Electronic consultations with Video Supported PowerPoint versus in-clinic face-to-face, pre-travel consultations: A single-centre, comparative analysis

BACKGROUND

Pretravel consultation involves a face-to-face visit with a Travel Medicine expert and includes time consuming educating/counseling. Efficacy of electronic consultations for pretravel is unknown. We compared pretravel education via face-to-face consult to an electronic consultations combined with education via Video Supported PowerPoint for select travelers.

METHODS

We conducted a prospective trial comparing pre-travel education via electronic consultations versus face-to-face consult. Study was conducted from May 2014 through May 2015.

RESULTS

Pretravel surveys were completed by 100 in electronic consult arm and 94 in face-to-face consult arm; 67/100 (67%) in the electronic consult and 51/94 (54.2%) in the face-to-face group completed post-travel surveys. Both groups had similar baseline demographics. 36.2% of the face-to-face group felt the trip preparation could have effectively been accomplished through electronic consult, while 33% felt that a face-to-face consult was needed; in contrast, a majority (63.3%) of electronic consult group preferred the electronic consult. Pre-travel education effectiveness was similar in both groups. No statistically significant differences in responses were noted in both groups to 5 of the 6 knowledge assessment questions. A higher proportion (76/100; 76%) in the electronic consult group compared to 55.4% (51/94) (p = 0.0018) in face-to-face group chose the correct response regarding management of febrile bloody diarrhea. 53% reported behavior change to prevent travel related illnesses, with no statistically significant differences between the groups.

CONCLUSIONS

electronic consultation with Video Supported PowerPoint pre-travel education is as effective as education via face-to-face consultations and provides a viable alternative to face-to-face consultations in select travelers.

Antiretroviral Stewardship: A Review of Published Outcomes with Recommendations for Program Implementation

Persons living with HIV (PLWHs) are at high risk for medication errors when hospitalized, but antiretroviral medications are not often evaluated by antimicrobial stewardship programs (ASPs) because they are not specifically discussed in the standards of practice. However, antiretroviral (ARV) stewardship programs (ARVSPs) have been shown to decrease medication error rates and improve other outcomes. The goal of this article is to review published literature on ARVSPs and provide guidance on key aspects of ARVSPs. A MEDLINE search using the term "antiretroviral stewardship" was conducted. Original research articles evaluating ARVSPs in hospitalized, adult PLWHs were included. Six original research articles evaluating unique inpatient ARVSPs met inclusion criteria. All 6 studies evaluating medication errors as the primary outcome found a significant reduction in errors in the postimplementation phase. Based on current standards for ASPs, we propose core elements for ARVSPs. Future organizational guidelines for antimicrobial stewardship should include official recommendations for ARV medications.

Telemedicine and Infectious Diseases Practice: A Leap Forward or a Step Back?

Infectious Diseases (ID) specialists pride themselves on performing a thorough history and physical exam, and developing a comprehensive diagnosis and management plan. A timely question is whether this tradition is at risk from the coming wave of telemedicine in clinical practice? It would not be if ID specialists embrace the changes ahead and leverage new technologies to enhance the efficiency and reach of their clinical practices. In this report, we highlight the opportunities and challenges offered by telemedicine for ID practice (Table 1).