Background The COVID-19 pandemic has led to an ongoing increase in the use of remote consultations in general practice in England. Though the evidence is limited, there are concerns that the increase in remote consultations could lead to more antibiotic prescribing. Methods We used patient-level primary care data from the Clinical Practice Research Datalink to estimate the association between consultation mode (remote vs face-to-face) and antibiotic prescribing in England for acute respiratory infections (ARI) between April 2021 - March 2022. We used targeted maximum likelihood estimation, a causal machine learning method with adjustment for patient-, clinician- and practice-level factors. Findings There were 45,997 ARI consultations (34,555 unique patients), of which 28,127 were remote and 17,870 face-to-face. For children, 48% of consultations were remote whereas for adults 66% were remote. For children, 42% of remote and 43% face-to-face consultations led to an antibiotic prescription; the equivalent in adults was 52% of remote and 42% face-to-face. Adults with a remote consultation had 23% (Odds Ratio (OR) 1.23 95% Confidence Interval (CI): 1.18-1.29) higher chance of being prescribed antibiotics compared to if they had been seen face-to-face. We found no significant association between consultation mode and antibiotic prescribing in children (OR 1.04 95% CI 0.98-1.11). Interpretation This study uses rich patient-level data and robust statistical methods and represents an important contribution to the evidence base on antibiotic prescribing in post-COVID primary care. The higher rates of antibiotic prescribing in remote consultations for adults are cause for concern. We see no significant difference in antibiotic prescribing between consultation mode for children. These findings should inform antimicrobial stewardship activities for health care professionals and policy makers. Future research should examine differences in guideline-compliance between remote and face-to-face consultations to understand the factors driving antibiotic prescribing in different consultation modes. Funding No external funding. Keywords general practice; England; antibiotics; remote consultations; telehealth; telemedicine; TMLE; causal inference; machine learning; acute respiratory infections; antimicrobial resistance; covid; ARTI; ARI; antibiotic prescribing; primary care

The authors have declared no competing interest.

No external funding was received for this work.

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CPRD has ethics approval from the Health Research Authority to support research using anonymised patient data. Requests by researchers to access the data are reviewed via the CPRD Research Data Governance (RDG) and the protocol number for this study is : 21_000357. The RDG process is to ensure that the proposed research is of benefit to patients and public health. The data used in this study were obtained from practices that had consented to participate in CPRD research, and all data were handled in accordance with CPRD guidelines for data management and confidentiality.

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We used deidentified primary care data from the Clinical Practice Research Datalink (CPRD). For more information, please visit: https://www.cprd.com/Data-access, and enquiries can be emailed to enquiries@cprd.gov.uk. Scientific approval for this study was given by the CPRD Independent Scientific Advisory Committee (ISAC). The study was approved by the ISAC for CPRD research (20_143). The data are provided by patients and collected by the NHS as part of their care and support. The primary care data can be requested via application to the Clinical Practice Research Datalink.