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Ciani O, Manyara AM, Davies P, Stewart D, Weir CJ, Young AE, Blazeby J, Butcher NJ, Bujkiewicz S, Chan AW, Dawoud D, Offringa M, Ouwens M, Hróbjartssson A, Amstutz A, Bertolaccini L, Bruno VD, Devane D, Faria CD, Gilbert PB, Harris R, Lassere M, Marinelli L, Markham S, Powers JH, Rezaei Y, Richert L, Schwendicke F, Tereshchenko LG, Thoma A, Turan A, Worrall A, Christensen R, Collins GS, Ross JS, Taylor RS. A framework for the definition and interpretation of the use of surrogate endpoints in interventional trials. EClinicalMedicine 2023; 65:102283. [PMID: 37877001 PMCID: PMC10590868 DOI: 10.1016/j.eclinm.2023.102283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 10/26/2023] Open
Abstract
Background Interventional trials that evaluate treatment effects using surrogate endpoints have become increasingly common. This paper describes four linked empirical studies and the development of a framework for defining, interpreting and reporting surrogate endpoints in trials. Methods As part of developing the CONSORT (Consolidated Standards of Reporting Trials) and SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) extensions for randomised trials reporting surrogate endpoints, we undertook a scoping review, e-Delphi study, consensus meeting, and a web survey to examine current definitions and stakeholder (including clinicians, trial investigators, patients and public partners, journal editors, and health technology experts) interpretations of surrogate endpoints as primary outcome measures in trials. Findings Current surrogate endpoint definitional frameworks are inconsistent and unclear. Surrogate endpoints are used in trials as a substitute of the treatment effects of an intervention on the target outcome(s) of ultimate interest, events measuring how patients feel, function, or survive. Traditionally the consideration of surrogate endpoints in trials has focused on biomarkers (e.g., HDL cholesterol, blood pressure, tumour response), especially in the medical product regulatory setting. Nevertheless, the concept of surrogacy in trials is potentially broader. Intermediate outcomes that include a measure of function or symptoms (e.g., angina frequency, exercise tolerance) can also be used as substitute for target outcomes (e.g., all-cause mortality)-thereby acting as surrogate endpoints. However, we found a lack of consensus among stakeholders on accepting and interpreting intermediate outcomes in trials as surrogate endpoints or target outcomes. In our assessment, patients and health technology assessment experts appeared more likely to consider intermediate outcomes to be surrogate endpoints than clinicians and regulators. Interpretation There is an urgent need for better understanding and reporting on the use of surrogate endpoints, especially in the setting of interventional trials. We provide a framework for the definition of surrogate endpoints (biomarkers and intermediate outcomes) and target outcomes in trials to improve future reporting and aid stakeholders' interpretation and use of trial surrogate endpoint evidence. Funding SPIRIT-SURROGATE/CONSORT-SURROGATE project is Medical Research Council Better Research Better Health (MR/V038400/1) funded.
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Affiliation(s)
- Oriana Ciani
- Centre for Research on Health and Social Care Management, SDA Bocconi School of Management, Milan, Italy
| | - Anthony M. Manyara
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Philippa Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Christopher J. Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Jane Blazeby
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nancy J. Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - An-Wen Chan
- Women's College Research Institute, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Dalia Dawoud
- Science, Evidence and Analytics Directorate, Science Policy and Research Programme, National Institute for Health and Care Excellence, London, UK
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | | | - Asbjørn Hróbjartssson
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Alain Amstutz
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Luca Bertolaccini
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Vito Domenico Bruno
- Department of Minimally Invasive Cardiac Surgery, IRCCS Galeazzi – Sant’Ambrogio Hospital, Milan, Italy
| | - Declan Devane
- University of Galway, Galway, Ireland
- Health Research Board-Trials Methodology Research Network, University of Galway, Galway, Ireland
| | - Christina D.C.M. Faria
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Ray Harris
- Patient and Public Involvement Partner, UK
| | - Marissa Lassere
- St George Hospital and School of Population Health, The University of New South Wales, Sydney, Australia
| | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sarah Markham
- Department of Biostatistics, King's College London, London, UK
| | - John H. Powers
- George Washington University School of Medicine, Washington, USA
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Ardabil University of Medical Sciences, Ardabil, Iran
- Behyan Clinic, Pardis New Town, Tehran, Iran
| | - Laura Richert
- University Bordeaux, INSERM, Institut Bergonié, CHU Bordeaux, BPH U1219, CIC-EC 1401, RECaP and Euclid/F-CRIN, Bordeaux, France
| | | | - Larisa G. Tereshchenko
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, OH, USA
| | | | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen & Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Gary S. Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joseph S. Ross
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rod S. Taylor
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Futier E, Jaber S, Garot M, Vignaud M, Panis Y, Slim K, Lucet JC, Lebuffe G, Ouattara A, El Amine Y, Couderc P, Dupré A, De Jong A, Lasocki S, Leone M, Pottecher J, Pereira B, Paugam-Burtz C. Effect of oral antimicrobial prophylaxis on surgical site infection after elective colorectal surgery: multicentre, randomised, double blind, placebo controlled trial. BMJ 2022; 379:e071476. [PMID: 36328372 PMCID: PMC9631300 DOI: 10.1136/bmj-2022-071476] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate whether oral antimicrobial prophylaxis as an adjunct to intravenous antibiotic prophylaxis reduces surgical site infections after elective colorectal surgery. DESIGN Multicentre, randomised, double blind, placebo controlled trial. SETTING 11 university and non-university hospitals in France between 25 May 2016 and 8 August 2019. PARTICIPANTS 926 adults scheduled for elective colorectal surgery. INTERVENTION Patients were randomised to receive either a single 1 g dose of ornidazole (n=463) or placebo (n=463) orally 12 hours before surgery, in addition to intravenous antimicrobial prophylaxis before surgical incision. MAIN OUTCOME MEASURES The primary outcome was the proportion of patients with surgical site infection within 30 days after surgery. Secondary outcomes included individual types of surgical site infections and major postoperative complications (Clavien-Dindo classification grade 3 or higher) within 30 days after surgery. RESULTS Of the 960 patients who were enrolled, 926 (96%) were included in the analysis. The mean age of participants was 63 years and 554 (60%) were men. Surgical site infection within 30 days after surgery occurred in 60 of 463 patients (13%) in the oral prophylaxis group and 100 of 463 (22%) in the placebo group (absolute difference -8.6%, 95% confidence interval -13.5% to -3.8%; relative risk 0.60, 95% confidence interval 0.45 to 0.80). The proportion of patients with deep infections was 4.8% in the oral prophylaxis group and 8.0% in the placebo group (absolute difference -3.2%, 95% confidence interval -6.4% to -0.1%). The proportion of patients with organ space infections was 5.0% in the oral prophylaxis group and 8.4% in the placebo group (absolute difference -3.4%, -6.7% to -0.2%). Major postoperative complications occurred in 9.1% patients in the oral prophylaxis group and 13.6% in the placebo group (absolute difference -4.5%, -8.6% to -0.5%). CONCLUSION Among adults undergoing elective colorectal surgery, the addition of a single 1 g dose of ornidazole compared with placebo before surgery significantly reduced surgical site infections. TRIAL REGISTRATION ClinicalTrials.gov NCT02618720.
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Affiliation(s)
- Emmanuel Futier
- Département Anesthésie et Réanimation, Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
- Inserm U-1103, CNRS UMR 6293, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Samir Jaber
- Département Anesthésie et Réanimation B, Centre Hospitalier Universitaire de Montpellier, Hôpital Saint-Eloi, Montpellier, France
- Inserm U-1046, Université Montpellier, Montpellier, France
| | - Matthias Garot
- Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire de Lille, Hôpital Claude Huriez, Lille, France
| | - Marie Vignaud
- Département Anesthésie et Réanimation, Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
| | - Yves Panis
- Département de Chirurgie Colorectale, Assistance publique-Hôpitaux de Paris, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, Clichy, France
| | - Karem Slim
- Service de Chirurgie Digestive et Hépatobiliaire, Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
| | - Jean-Christophe Lucet
- Unité d'Hygiène et de Lutte Contre les Infections Nosocomiales, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
- IAME, Université Paris Sorbonne Nord, UMR 1137 Inserm, Paris, France
| | - Gilles Lebuffe
- Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire de Lille, Hôpital Claude Huriez, Lille, France
| | - Alexandre Ouattara
- Service Anesthésie et Réanimation, Centre Medico-chirurgical Magellan, Centre Hospitalier Universitaire de Bordeaux, Pessac, France
- Biologie des Maladies Cardiovasculaires, Université de Bordeaux, UMR 1034 Inserm, Pessac, France
| | - Younes El Amine
- Département Anesthésie et Réanimation, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Philippe Couderc
- Service de Chirurgie Viscérale et Digestive, Centre Hospitalier de Pau, Pau, France
| | - Aurélien Dupré
- Département de chirurgie oncologique, Centre Léon Bérard, Lyon, France
- Inserm, LabTAU, Université Claude Bernard Lyon 1, Lyon, France
| | - Audrey De Jong
- Département Anesthésie et Réanimation B, Centre Hospitalier Universitaire de Montpellier, Hôpital Saint-Eloi, Montpellier, France
| | - Sigismond Lasocki
- Département Anesthésie et Réanimation, Centre Hospitalier Universitaire de Angers, Angers, France
| | - Marc Leone
- Service Anesthésie et Réanimation, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Hôpital Nord, Marseille, France
| | - Julien Pottecher
- Service d'Anesthésie Réanimation et Médecine Périopératoire, Hôpitaux Universitaires de Strasbourg, Hôpital Hautepierre, Strasbourg, France
| | - Bruno Pereira
- Direction de la Recherche Clinique, Centre Hospitalier Universitaire de Clermont-Ferrand, Biostatistics Unit, Clermont-Ferrand, France
| | - Catherine Paugam-Burtz
- Département Anesthésie Réanimation, Assistance publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Nord Val de Seine, Hôpital Beaujon, Clichy, France
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Gómez Sánchez J, Forneiro Pérez R, Zurita Saavedra M, de Castro Monedero P, González Puga C, Garde Lecumberri C, Mirón Pozo B. Oncologic colorectal surgical site infection: oral or not oral antibiotic preparation, that is the question. Int J Colorectal Dis 2022; 37:373-379. [PMID: 34854980 DOI: 10.1007/s00384-021-04074-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical wound infection is the most frequent postoperative complication in abdominal surgery, especially at the colorectal level. The aim of this study is analysing the results of mechanical colon preparation combined with oral antibiotic versus mechanical colon preparation without antibiotic therapy in patients with colorectal cancer undergoing elective surgery. METHODS This retrospective cohort study had been developed from November 2017 to February 2020. We have included a total of 281 consecutive patients undergoing elective colon and rectal oncological surgeries by the same surgical group using laparoscopic and open approaches. Transanal minimally invasive surgery (TAMIS) and transanal total mesorectal excision (TaTME) approaches were excluded. Exposed patients undergoing colon and rectal cancer surgery received mechanical bowel preparation and oral antibiotics with three doses of neomycin 1 g and erythromycin 500 mg the day before surgery. RESULTS The primary outcome was reduction in surgical wound infection rates before and after starting the oral antibiotic therapy from 17 to 6% (p < 0.05). As a secondary analysis, we evaluated the anastomotic dehiscence rate, corresponding with a decrease from 12 to 3% (p < 0.05). CONCLUSION Mechanical bowel preparation combined with oral antibiotic therapy is still not unanimously carried out in all the medical hospitals. In this report, we show that mechanical bowel preparation in combination with oral antibiotic reduces the risk of surgical wound infection and anastomotic leakage in patients undergoing colon and rectal cancer surgery.
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Affiliation(s)
- Javier Gómez Sánchez
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Rocio Forneiro Pérez
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Marisol Zurita Saavedra
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Paola de Castro Monedero
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Cristina González Puga
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Carlos Garde Lecumberri
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Benito Mirón Pozo
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
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