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

Area of Science:

• Healthcare Management
• Infectious Diseases
• Clinical Pharmacy

Background:

• Unnecessary postoperative antibiotic use is a widespread issue in healthcare settings.
• This study investigates interventions to curb prolonged antibiotic administration post-surgery.

Purpose of the Study:

• To evaluate the effectiveness of modifying electronic health record order sets combined with facilitation workshops by antimicrobial stewardship teams in reducing inappropriate postoperative antibiotic duration.
• To compare this combined approach against modifying order sets alone.

Main Methods:

• A stepped-wedge cluster randomized trial was conducted across 9 US children's hospitals from November 2020 to October 2023.
• The primary outcome measured was the rate of inappropriate postoperative antibiotic duration exceeding 24 hours post-incision closure.
• Secondary outcomes included any postoperative antibiotic use, surgical site infections (SSI), and Clostridioides difficile infections (CDI), analyzed using generalized estimating equations (GEEs).

Main Results:

• The study included 18,267 patients; the experimental group (order set modification plus facilitation) showed a slightly lower rate of prolonged antibiotic use (10.05%) compared to the control group (11.02%), though this was not statistically significant in GEE analysis (P=.74).
• No significant differences were observed between groups for any postoperative antibiotic use (45.1% vs 44.7%), SSI rates (1.96% vs 2.03%), or CDI rates (0.15% vs 0.06%).

Conclusions:

• Facilitation training, when added to order set modification, did not lead to a significant reduction in inappropriate postoperative antibiotic duration.
• Understanding the influence of hospital context on the success of change strategies is crucial for future antimicrobial stewardship interventions.