Dissemination of a facilitation strategy to de-implement unnecessary post-operative antibiotics at children's hospitals: The Optimizing Perioperative Antibiotic in Children (OPerAtiC) trial 2.0

Background: Excessive postoperative antibiotic use in pediatric surgical patients contributes to antibiotic resistance and increases the risk of Clostridioides difficile infection. Despite established guidelines recommending limited postoperative antibiotic duration, many hospitals struggle with de-implementation. This study aims to disseminate and evaluate the impact of a combined strategy to reduce unnecessary postoperative antibiotic use which combines enhanced antimicrobial stewardship program facilitation, defined as a set of actions to enable implementation, combined with order set review and modification. This multi-center study builds on an initial stepped wedge cluster randomized trial involving nine children’s hospitals, where facilitation training improved implementation of surgical prophylaxis guidelines and improved post-operative antibiotic use. Methods: The current study expands the strategy to a diverse set of hospitals caring for children in the US. Antimicrobial stewardship teams and surgeons from any hospital providing pediatric surgical care will be eligible to participate in facilitation training either as a single session webinar or as asynchronous modules. Based on the integrated Promoting Action on Research Implementation in Health Services (iPARiHS), the facilitation training includes didactic presentations and activities that focus on current evidence related to surgical prophylaxis, evaluation of context, interpersonal relationships, and structured processes to foster change. We will use a quasi-experimental time-series design collecting data from clinicians using a structured interview guide every six months on implementation of prophylaxis guideline congruent order sets as the primary implementation outcome. We will also evaluate trends in at least 20 hospitals collecting quality improvement data through the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) on postoperative antibiotic use, surgical site infections, and Clostridioides difficile infections from 2022–2027. Discussion: By scaling up this intervention, the study aims to provide a robust evaluation of its effectiveness across diverse hospital settings. If successful, this approach could inform future antimicrobial stewardship efforts in pediatric and adult surgical populations, offering a scalable model for reducing inappropriate antibiotic use while maintaining patient safety.