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Maldonado N, Rosso-Fernández CM, Portillo-Calderón I, Borreguero Borreguero I, Tristán-Clavijo E, Palacios-Baena ZR, Salamanca E, Fernández-Cuenca F, De-Cueto M, Stolz-Larrieu E, Rodriguez-Baño J, López-Cortés LE. Randomised, open-label, non-inferiority clinical trial on the efficacy and safety of a 7-day vs 14-day course of antibiotic treatment for uncomplicated enterococcal bacteraemia: the INTENSE trial protocol. BMJ Open 2023; 13:e075699. [PMID: 37673453 PMCID: PMC10496718 DOI: 10.1136/bmjopen-2023-075699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023] Open
Abstract
INTRODUCTION Enterococcus spp is responsible for 8%-15% of total bacteraemias with an associated global mortality around 23%-30%. Regarding the clinical management of enterococcal bacteraemia, the evidence on the duration of antibiotic treatment is scarce and the studies do not discriminate between complicated and uncomplicated bacteraemia. METHODS The INTENSE study is a multicentre, open-label, randomised, pragmatic, phase-IV clinical trial to demonstrate the non-inferiority of a 7-day vs 14-day course for the treatment of uncomplicated enterococcal bacteraemia and incorporating the early switching to oral antibiotics when feasible. The primary efficacy endpoint is the clinical cure at day 30±2 after the end of the treatment. Secondary endpoints will include the rate of relapse or infective endocarditis, length of stay, duration of intravenous therapy, Clostridioides difficile infection and the evaluation of the safety of both treatment arms through the recording and analysis of adverse events. For a 6% non-inferiority margin and considering a 5% withdrawal rate, 284 patients will be included. ANALYSIS The difference in proportions with one-sided 95% CIs will be calculated for the clinical cure rate using the control group as reference. For secondary categorical endpoints, a similar analysis will be performed and Mann-Whitney U-test will be used to compare median values of quantitative variables. A superiority analysis applying the response adjusted for days of antibiotic risk will be performed if there were incidents in recruitment; will allow obtaining results with 194 patients recruited. ETHICS AND DISSEMINATION The study has obtained the authorisation from the Spanish Regulatory Authority, the approval of the ethics committee and the agreement of the directors of each centre. Data will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05394298.
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Affiliation(s)
- Natalia Maldonado
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; CIBERINFEC, Sevilla, Spain
| | - Clara M Rosso-Fernández
- Unidad de Investigación Clínica y Ensayos Clínicos (CTU-UICEC-HUVR-HUVM), Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Inés Portillo-Calderón
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; CIBERINFEC, Sevilla, Spain
| | - Irene Borreguero Borreguero
- Unidad de Investigación Clínica y Ensayos Clínicos (CTU-UICEC-HUVR-HUVM), Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Enriqueta Tristán-Clavijo
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; CIBERINFEC, Sevilla, Spain
| | - Zaira R Palacios-Baena
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; CIBERINFEC, Sevilla, Spain
| | - Elena Salamanca
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; CIBERINFEC, Sevilla, Spain
| | - Felipe Fernández-Cuenca
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; CIBERINFEC, Sevilla, Spain
| | - Marina De-Cueto
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; CIBERINFEC, Sevilla, Spain
| | - Emilio Stolz-Larrieu
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; CIBERINFEC, Sevilla, Spain
| | - Jesús Rodriguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; CIBERINFEC, Sevilla, Spain
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; CIBERINFEC, Sevilla, Spain
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2
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Ong SWX, Petersiel N, Loewenthal MR, Daneman N, Tong SYC, Davis JS. Unlocking the DOOR - how to design, apply, analyse, and interpret desirability of outcome ranking (DOOR) endpoints in infectious diseases clinical trials. Clin Microbiol Infect 2023:S1198-743X(23)00206-9. [PMID: 37179006 DOI: 10.1016/j.cmi.2023.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Desirability of outcome ranking (DOOR) outcomes, with or without response adjusted for antibiotic risk (RADAR), are increasingly used in infectious diseases randomized clinical trials (RCTs), with the advantage of being able to combine multiple clinical outcomes and antibiotic duration in a single metric. However, it remains poorly understood, and there is considerable heterogeneity in its use. OBJECTIVES In this scoping review, we explain how to design, use, and analyse a DOOR endpoint, and highlight several pitfalls and potential improvements that can be made to DOOR/RADAR. SOURCES The Ovid MEDLINE database was searched for terms related to DOOR in English-language papers published up to 31 December 2022. Papers discussing DOOR methodology and/or reporting clinical trial analyses (as either primary, secondary, or post-hoc analysis) using a DOOR outcome were included. CONTENT 17 papers were included in the final review, of which 9 reported DOOR analyses of 12 RCTs. 8 papers discussed DOOR methodology. We synthesised information from these papers and discuss (a) How to develop a DOOR scale, (b) How to conduct a DOOR/RADAR analysis, (c) Use in clinical trials, (d) Use of alternative tiebreakers apart from RADAR, (e) Partial credit analyses, and (f) Criticisms and pitfalls of DOOR/RADAR. IMPLICATIONS DOOR is an important innovation for RCTs in infectious diseases. We highlight potential areas of methodological improvement for future research. There remains considerable heterogeneity in its implementation, and further collaborative efforts, with a more diverse range of perspectives, should be made to develop consensus scales for use in prospective studies.
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Affiliation(s)
- Sean W X Ong
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia; Sunnybrook Health Sciences Centre, Toronto, Canada; National Centre for Infectious Diseases, Singapore
| | - Neta Petersiel
- Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Mark R Loewenthal
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia; Department of Immunology and Infectious Diseases, John Hunter Hospital, Newcastle, Australia
| | - Nick Daneman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Steven Y C Tong
- Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia; Department of Immunology and Infectious Diseases, John Hunter Hospital, Newcastle, Australia; Global and Tropical Health Division, Menzies School of Health and Research, Darwin, Australia.
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3
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Rodríguez-Baño J, Gutiérrez-Gutiérrez B. Opening a DOOR for Pivotal Studies: An Example for Complicated Urinary Tract Infections. Clin Infect Dis 2023; 76:e1166-e1167. [PMID: 36125087 DOI: 10.1093/cid/ciac778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/17/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Belén Gutiérrez-Gutiérrez
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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4
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Chammas M, Pust GD, Hatton G, Pedroza C, Kao L, Rattan R, Namias N, Yeh DD. Outcomes of Restricted versus Liberal Post-Operative Antibiotic Use in Patients Undergoing Appendectomy: A DOOR/RADAR Post Hoc Analysis of the EAST Appendicitis MUSTANG Study. Surg Infect (Larchmt) 2022; 23:489-494. [PMID: 35647893 DOI: 10.1089/sur.2021.287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: There is no consensus on the duration of antibiotic use after appendectomy. We hypothesized that restricted antibiotic use is associated with better clinical outcomes. Patients and Methods: We performed a post hoc analysis of the Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America-Acute, Perforated, and Gangrenous (MUSTANG) study using the desirability of outcome ranking/response adjusted for duration of antibiotic risk (DOOR/RADAR) framework. Three separate datasets were analyzed based on restricted versus liberal post-operative antibiotic groups: simple appendicitis (no vs. yes); complicated appendicitis, only four days (≤24 hours vs. 4 days); and complicated appendicitis, four or more days (≤24 hours vs. ≥4 days). Patients were assigned to one of seven mutually exclusive DOOR categories RADAR ranked within each category. DOOR/RADAR score pairwise comparisons were performed between all patients. Each patient was assigned either 1, 0, or -1 if they had better, same, or worse outcomes than the other patient in the pair, respectively. The sum of these numbers (cumulative comparison score) was calculated for each patient and the group medians of individual sums were compared by Wilcoxon rank sum. Results: For simple appendicitis, the restricted group had higher median sums than the liberal group (552 [552,552] vs. -1,353 [-1,353, -1,353], p < 0.001). For both complicated appendicitis analyses, the restricted group had higher median sums than the liberal: only 4 (196 [23,196] vs. -121 [-121, -121], p < 0.02) and 4 or more (660 [484,660] vs -169 [-444,181], p < 0.001). Conclusions: Restricted post-operative antibiotic use in patients after appendectomy is a dominant strategy when considering treatment effectiveness and antibiotic exposure.
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Affiliation(s)
- Majid Chammas
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Gerd Daniel Pust
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Gabrielle Hatton
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA.,McGovern Medical School at UTHealth, Center for Clinical Research and Evidence-Based Medicine, Houston, Texas, USA
| | - Claudia Pedroza
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA.,McGovern Medical School at UTHealth, Center for Clinical Research and Evidence-Based Medicine, Houston, Texas, USA
| | - Lillian Kao
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA.,McGovern Medical School at UTHealth, Center for Clinical Research and Evidence-Based Medicine, Houston, Texas, USA
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - D Dante Yeh
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
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5
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Weiss E, Zahar JR, Alder J, Asehnoune K, Bassetti M, Bonten MJM, Chastre J, De Waele J, Dimopoulos G, Eggimann P, Engelhardt M, Ewig S, Kollef M, Lipman J, Luna C, Martin-Loeches I, Pagani L, Palmer LB, Papazian L, Poulakou G, Prokocimer P, Rello J, Rex JH, Shorr AF, Talbot GH, Thamlikitkul V, Torres A, Wunderink RG, Timsit JF. Elaboration of Consensus Clinical Endpoints to Evaluate Antimicrobial Treatment Efficacy in Future Hospital-acquired/Ventilator-associated Bacterial Pneumonia Clinical Trials. Clin Infect Dis 2020; 69:1912-1918. [PMID: 30722013 DOI: 10.1093/cid/ciz093] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/26/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Randomized clinical trials (RCTs) in hospital-acquired and ventilator-associated bacterial pneumonia (HABP and VABP, respectively) are important for the evaluation of new antimicrobials. However, the heterogeneity in endpoints used in RCTs evaluating treatment of HABP/VABP may puzzle clinicians. The aim of this work was to reach a consensus on clinical endpoints to consider in future clinical trials evaluating antimicrobial treatment efficacy for HABP/VABP. METHODS Twenty-six international experts from intensive care, infectious diseases, and the pharmaceutical industry were polled using the Delphi method. RESULTS The panel recommended a hierarchical composite endpoint including, by priority order, (1) survival at day 28, (2) mechanical ventilation-free days through day 28, and (3) clinical cure between study days 7 and 10 for VABP; and (1) survival (day 28) and (2) clinical cure (days 7-10) for HABP. Clinical cure was defined as the combination of resolution of signs and symptoms present at enrollment and improvement or lack of progression of radiological signs. More than 70% of the experts agreed to assess survival and mechanical ventilation-free days though day 28, and clinical cure between day 7 and day 10 after treatment initiation. Finally, the hierarchical order of endpoint components was reached after 3 Delphi rounds (72% agreement). CONCLUSIONS We provide a multinational expert consensus on separate hierarchical composite endpoints for VABP and HABP, and on a definition of clinical cure that could be considered for use in future HABP/VABP clinical trials.
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Affiliation(s)
- Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Assistance Publique-Hôpitaux de Paris (AP-HP), Beaujon Hospital, Clichy.,Unité Mixte de Recherche (UMR) 1149, Centre for Research on Inflammation, Institut national de la santé et de la recherche médicale (INSERM)/Université Paris Diderot, Paris
| | - Jean-Ralph Zahar
- Department of Clinical Microbiology and Infection Control Unit, Avicennes Hospital, AP-HP, Bobigny.,Infection, Antibiotics, Modelisation, Epidemiology (IAME), UMR 1137, Université Paris 13, Sorbonne Paris Cité, France
| | | | - Karim Asehnoune
- University Hospital of Nantes, Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu, Nantes, France
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Santa Maria Misericordia University Hospital, Italy
| | - Marc J M Bonten
- Department of Medical Microbiology and Julius Center for Health Science and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Jean Chastre
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Belgium
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, National and Kapodistrian University of Athens, Greece
| | - Philippe Eggimann
- Department of Critical Care, Centre Hospitalier Universitaire Vaudois, Lausanne
| | | | - Santiago Ewig
- Department of Respiratory Medicine and Infectious Diseases, Evangelic Hospital in Herne and Augusta Hospital, Bochum, Germany
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey Lipman
- Royal Brisbane and Womens Hospital, Australia.,University of the Witwatersrand, Johannesburg, South Africa
| | - Carlos Luna
- Department of Medicine, Pulmonary Diseases Division, Hospital de Clínicas, Universidad de Buenos Aires, Argentina
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, Multidisciplinary Intensive Care Research Organization, St James's Hospital, Trinity Centre for Health Sciences, Dublin, Ireland
| | | | - Lucy B Palmer
- Pulmonary, Critical Care and Sleep Division, State University of New York at Stony Brook, France
| | - Laurent Papazian
- Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, France
| | - Garyphallia Poulakou
- Third Department of Medicine, Sotiria General Hospital, Greece.,Medical School, National and Kapodistrian University of Athens, Greece
| | | | - Jordi Rello
- Centro Investigacion Biomedica En Red de Enfermedades Respiratorias (CIBERES), Vall d'Hebron Barcelona Hospital Campus, Spain
| | | | - Andrew F Shorr
- Medstar Washington Hospital Center, Washington, District of Columbia
| | | | - Visanu Thamlikitkul
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Antoni Torres
- Servei de Pneumologia, Hospital Clinic, Universitat de Barcelona, Institut De Investigacio Biomedica Agusti Pi i Sunyer, CIBERES, Spain
| | | | - Jean-François Timsit
- AP-HP, Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, Paris.,UMR 1137 IAME, INSERM, Université Paris Diderot, France
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6
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Abstract
PURPOSE OF REVIEW Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. Clinical trials should help guide and improve the management of cIAIs. However, inappropriate selection or measurement of outcomes in cIAIs clinical trials can lead to misleading results on the effectiveness of interventions. This review aims to describe how outcomes are reported in randomized controlled trials evaluating antibiotic treatment for cIAIs and discuss how outcome reporting may be improved. RECENT FINDINGS Commonly used primary outcomes are treatment success or failure, and these outcomes are endorsed by regulatory bodies. However, a consensus objective definition of either is not available and current measures are prone to bias. Variation exists in timing of outcome evaluation and analysis populations, which can lead to further bias. Use of core outcome sets can help standardize outcome reporting. SUMMARY Inconsistency in outcome selection and reporting can lead to misleading results and impedes meta-analysis of data. Further progress, engaging clinical trialists, regulatory authorities, clinicians and patients is required to achieve consensus on which outcomes should be reported and how and when to measure them.
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7
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de Kraker MEA, Sommer H, de Velde F, Gravestock I, Weiss E, McAleenan A, Nikolakopoulos S, Amit O, Ashton T, Beyersmann J, Held L, Lovering AM, MacGowan AP, Mouton JW, Timsit JF, Wilson D, Wolkewitz M, Bettiol E, Dane A, Harbarth S. Optimizing the Design and Analysis of Clinical Trials for Antibacterials Against Multidrug-resistant Organisms: A White Paper From COMBACTE's STAT-Net. Clin Infect Dis 2019; 67:1922-1931. [PMID: 30107400 PMCID: PMC6260160 DOI: 10.1093/cid/ciy516] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/15/2018] [Indexed: 01/08/2023] Open
Abstract
Innovations are urgently required for clinical development of antibacterials against multidrug-resistant organisms. Therefore, a European, public-private working group (STAT-Net; part of Combatting Bacterial Resistance in Europe [COMBACTE]), has reviewed and tested several innovative trials designs and analytical methods for randomized clinical trials, which has resulted in 8 recommendations. The first 3 focus on pharmacokinetic and pharmacodynamic modeling, emphasizing the pertinence of population-based pharmacokinetic models, regulatory procedures for the reassessment of old antibiotics, and rigorous quality improvement. Recommendations 4 and 5 address the need for more sensitive primary end points through the use of rank-based or time-dependent composite end points. Recommendation 6 relates to the applicability of hierarchical nested-trial designs, and the last 2 recommendations propose the incorporation of historical or concomitant trial data through Bayesian methods and/or platform trials. Although not all of these recommendations are directly applicable, they provide a solid, evidence-based approach to develop new, and established, antibacterials and address this public health challenge.
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Affiliation(s)
- Marlieke E A de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Harriet Sommer
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Germany
| | - Femke de Velde
- Department of Medical Microbiology and Infectious Diseases, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Isaac Gravestock
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Emmanuel Weiss
- Université Paris Diderot, Paris, France.,APHP Anesthesiology and Critical Care Department, Beaujon Hospital, Paris, France
| | - Alexandra McAleenan
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Stavros Nikolakopoulos
- Department of Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Ohad Amit
- GlaxoSmithKline, Collegeville, Pennsylvania
| | | | | | - Leonhard Held
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Andrew M Lovering
- Bristol Centre for Antibiotic Research and Evaluation, Infection Sciences, North Bristol NHS Trust, Southmead Hospital, United Kingdom
| | - Alasdair P MacGowan
- Bristol Centre for Antibiotic Research and Evaluation, Infection Sciences, North Bristol NHS Trust, Southmead Hospital, United Kingdom
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Rotterdam, The Netherlands
| | - Jean-François Timsit
- UMR 1137 IAME Inserm/Université Paris Diderot.,APHP Medical and Infectious Diseases ICU, Bichat Hospital, Paris, France
| | | | - Martin Wolkewitz
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Germany
| | - Esther Bettiol
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Aaron Dane
- DaneStat Consulting Limited, Macclesfield, United Kingdom
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Switzerland
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8
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Schweitzer VA, van Werkhoven CH, Rodríguez Baño J, Bielicki J, Harbarth S, Hulscher M, Huttner B, Islam J, Little P, Pulcini C, Savoldi A, Tacconelli E, Timsit JF, van Smeden M, Wolkewitz M, Bonten MJM, Walker AS, Llewelyn MJ. Optimizing design of research to evaluate antibiotic stewardship interventions: consensus recommendations of a multinational working group. Clin Microbiol Infect 2019; 26:41-50. [PMID: 31493472 DOI: 10.1016/j.cmi.2019.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antimicrobial stewardship interventions and programmes aim to ensure effective treatment while minimizing antimicrobial-associated harms including resistance. Practice in this vital area is undermined by the poor quality of research addressing both what specific antimicrobial use interventions are effective and how antimicrobial use improvement strategies can be implemented into practice. In 2016 we established a working party to identify the key design features that limit translation of existing research into practice and then to make recommendations for how future studies in this field should be optimally designed. The first part of this work has been published as a systematic review. Here we present the working group's final recommendations. METHODS An international working group for design of antimicrobial stewardship intervention evaluations was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). The group comprised clinical and academic specialists in antimicrobial stewardship and clinical trial design from six European countries. Group members completed a structured questionnaire to establish the scope of work and key issues to develop ahead of a first face-to-face meeting that (a) identified the need for a comprehensive systematic review of study designs in the literature and (b) prioritized key areas where research design considerations restrict translation of findings into practice. The working group's initial outputs were reviewed by independent advisors and additional expertise was sought in specific clinical areas. At a second face-to-face meeting the working group developed a theoretical framework and specific recommendations to support optimal study design. These were finalized by the working group co-ordinators and agreed by all working group members. RESULTS We propose a theoretical framework in which consideration of the intervention rationale the intervention setting, intervention features and the intervention aims inform selection and prioritization of outcome measures, whether the research sets out to determine superiority or non-inferiority of the intervention measured by its primary outcome(s), the most appropriate study design (e.g. experimental or quasi- experimental) and the detailed design features. We make 18 specific recommendation in three domains: outcomes, objectives and study design. CONCLUSIONS Researchers, funders and practitioners will be able to draw on our recommendations to most efficiently evaluate antimicrobial stewardship interventions.
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Affiliation(s)
- V A Schweitzer
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - C H van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - J Rodríguez Baño
- Unit of Infectious Diseases, Clinical Microbiology and Preventive Medicine, Department of Medicine, Hospital Universitario Virgen Macarena, Universidad de Sevilla and Biomedicine Institute of Sevilla (IBiS), Seville, Spain
| | - J Bielicki
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - S Harbarth
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - M Hulscher
- Scientific Centre for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B Huttner
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - J Islam
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - P Little
- Department of Primary Care Research, University of Southampton, Southampton, UK
| | - C Pulcini
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, APEMAC, Université de Lorraine, Nancy, France
| | - A Savoldi
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - E Tacconelli
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - J-F Timsit
- Medical and Infectious Diseases ICU, Bichat University Hospital, AP-HP, Paris, France; UMR 1137, Infection Antimicrobials Modelling Evolution, Paris Diderot University, Paris, France
| | - M van Smeden
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Wolkewitz
- Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - A S Walker
- MRC Clinical Trials Unit, University College London, London, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M J Llewelyn
- Department of Primary Care Research, University of Southampton, Southampton, UK.
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