Eliminating Inappropriate Postoperative Antibiotics: A Stepped-Wedge Cluster Randomized Trial

BACKGROUND: Unnecessary postoperative antibiotic use is common. This study evaluated whether modifying electronic health record order sets plus participation in a facilitation workshop by the antimicrobial stewardship team reduced inappropriate postoperative antibiotic duration more than modifying order sets alone. METHODS: A stepped-wedge cluster randomized trial compared order set modification (active control) vs order set modification plus facilitation (experimental) from November 1, 2020, to October 31, 2023, at 9 US children's hospitals. The primary outcome was the rate of inappropriate postoperative antibiotic duration of greater than 24 hours after incision closure. Secondary outcomes included inappropriate postoperative antibiotics, defined as any antibiotic use and the rate of surgical site infections (SSI) or Clostridioides difficile infections (CDI). Generalized estimating equations (GEEs) accounting for clustering at the step and hospital level were utilized to compare 2 groups. RESULTS: A total of 18 267 patients (5910 control, 12 357 experimental) were included, with a median age of 9.2 years (IQR 2-14), 50.6% of the female gender, and 58% with public insurance/self-pay. The primary outcome was lower in the experimental group (10.05%, (95% CI: 9.53-10.59) than the control (11.02%, 95% CI: 10.23-11.84, P = .05), but this difference was not apparent in the GEE analysis (P = .74). The secondary outcomes demonstrated no difference between control and experimental groups for any postoperative antibiotic use (45.1% vs 44.7%, P = .98), SSI (1.96% vs 2.03%, P = .70), and CDI (0.15% vs 0.06%, P = .85). CONCLUSIONS: Facilitation training did not reduce inappropriate postoperative antibiotic duration compared with order set modification; better understanding of how hospital context informs change strategies is needed.