Facilitation as an effective strategy to reduce excessive antibiotic prophylaxis in Children’s hospitals: A stepped-wedge cluster randomized controlled trial

Background Excessive use of postoperative prophylactic antibiotics in children’s hospitals is a significant public health concern, leading to increased risks of infections like Clostridioides difficile , multidrug-resistant organisms, and unnecessary healthcare costs. Antibiotic stewardship programs (ASPs) are designed to optimize antibiotic use, but ideal strategies for implementing evidence-based guidelines remain unclear. We tested facilitation, a dynamic process where trained individuals support healthcare personnel in bridging evidence-practice gaps, as a promising strategy for the de-implementation of unnecessary postoperative antibiotics in healthcare. Methods The OPerAtiC trial employed a stepped-wedge cluster randomized controlled design across nine hospitals to compare the effectiveness of two ASP-led strategies, specifically order set changes to align with antibiotic guidelines (baseline arm) and facilitation training (intervention arm). Facilitation workshops were informed by the i-PARIHS framework, emphasizing context analysis, evidence application, and recipient engagement; and were conducted remotely. Data were collected from 2019 to 2024, involving interviews with stewardship team members every two months. Data collected included proximal implementation outcomes of each ASP team member (acceptability, feasibility, appropriateness), intermediate outcomes (facilitation skill use) reported by the ASP team, and order set change completion rates. Results Proximal implementation outcomes for both strategies were rated high across all study phases, indicating strong baseline enthusiasm among participants (N = 30). Key facilitation skills—effective communication, conflict resolution, and data presentation—were pivotal for successful implementation. Most order set changes (76%) were completed post-facilitation, targeting various specialties and achieving reductions or eliminations in antibiotic use. Facilitation was associated with significantly more completed order sets targeting antibiotic reduction (p = 0.01), thereby increasing the appropriateness of antibiotic use. Conclusions Facilitation is a valuable approach in refining ASP efforts, contributing to the successful reduction and de-implementation of unnecessary antibiotic use in children's hospitals. The study underscores the need for ongoing training and support for ASP teams to enhance their effectiveness in promoting appropriate antibiotic-prescribing practices. Future research should explore the long-term impacts of facilitation on antibiotic stewardship and patient outcomes Trial Registration information ClinicalTrials.gov ID NCT04366440, https://clinicaltrials.gov/study/NCT04366440?term=OPERATIC&rank=1&tab=history, registered on 04/27/2020.