Are we enrolling the right patients? A scoping review of external validity and generalizability of clinical trials in bloodstream infections

Reporting of sociodemographic characteristics of trial participants in infectious diseases clinical trials-a systematic review

BACKGROUND

Reporting of demographic characteristics in randomized clinical trials (RCTs) is recommended to facilitate assessment of generalizability to other populations. However, there is a lack of consensus as to what variables should be reported, and there are limited data describing current research practice.

OBJECTIVES

We aimed to evaluate reporting of sociodemographic characteristics of participants in infectious diseases RCTs and identify gaps in current practice.

METHODS

We conducted a systematic review of all infectious diseases-related RCTs published between January 2014 and August 2023 in ten selected high-impact journals by searching the Ovid MEDLINE database. Outcomes of interest were the reporting of five patient-level sociodemographic characteristics, as recommended by the CONSORT-Equity 2017 extension to the CONSORT (Consolidated Standards of Reporting Trials) reporting guidelines: (a) ethnicity, (b) sex and/or gender, (c) education level, (d) socioeconomic status (SES), and (e) rurality. We summarized descriptive results for the reporting of each characteristic overall, by trial type (health equity-related vs. non-health equity-related), subject area, and year of publication. We fitted multivariable logistic regression models to identify trial characteristics associated with the reporting of each characteristic. Risk of bias of trials was not assessed as our objective was to assess trial reporting and not results.

RESULTS

We screened 4234 articles and included 1343. Almost all trials (1201/1233, 97.4%) reported sex and/or gender. In contrast, less than half (654/1326, 49.3%) reported ethnicity, and only a minority reported education level (113/1252, 9.0%), SES (120/1340, 9.0%), and rurality (45/1269, 3.9%). There was no improvement in reporting of each characteristic over the 10-year period. Subject area, funding source, whether a trial was health equity-related, use of a medical writer, and trial setting (high vs. low/middle-income country) were significantly associated with the reporting of ethnicity, education level, and SES.

CONCLUSIONS

Reporting of sociodemographic characteristics in infectious diseases RCTs is inconsistent and has not improved over time.

Association of Daily Body Temperature, White Blood Cell Count, and C-reactive Protein With Mortality and Persistent Bacteremia in Patients With Staphylococcus Aureus Bacteremia: A Post Hoc Analysis of the CAMERA2 Randomized Clinical Trial

Introduction

Classification of patients with Staphylococcus aureus bacteremia as complicated versus uncomplicated is based on a combination of clinical and microbiologic variables. Whether daily body temperature and common laboratory tests such as C-reactive protein (CRP) and white blood cell (WBC) can improve risk stratification algorithms is unclear.

Methods

We conducted a post hoc secondary analysis of the CAMERA2 trial, which enrolled hospitalized adult patients with methicillin-resistant S aureus bacteremia and prospectively collected daily body temperature and peripheral blood WBC and CRP. We evaluated the prognostic relevance of each parameter by calculating crude and adjusted odds ratios for 90-day all-cause mortality comparing patients with the abnormal parameter of interest versus those with normal parameters on each day of illness.

Results

A total of 345 patients were included in this analysis, of whom 63 (18.3%) died within 90 days. Fever (body temperature ≥38.0 °C) was associated with increased odds of 90-day mortality from day 4 and onwards. Fever later in the illness course was associated with higher adjusted odds of mortality (8.78; 95% confidence interval, 2.78-27.7 on day 7 vs adjusted odds ratio 3.70; 95% CI, 1.58-8.67 on day 4). In contrast, CRP and abnormal WBC count did not demonstrate a consistent or temporal association with mortality.

Conclusions

Persistent fever after 72 hours is associated with increased mortality in patients with methicillin-resistant S aureus bacteremia, supporting recommendations that this should be kept as a criterion for classifying patients as either "high-risk" or "complicated." Within this dataset, there was limited additional predictive value in WBC or CRP.

The value of decentralized clinical trials: Inclusion, accessibility, and innovation

In this Review, we explore the transformative potential of decentralized clinical trials (DCTs) in addressing the limitations of traditional randomized controlled trials (RCTs). We highlight the merits of DCTs fostering greater inclusivity, efficiency, and adaptability. We emphasize the challenges of RCTs, including limited participant diversity and logistical barriers, geographical constraints, and mistrust in research institutions, showing how DCTs are preferred in addressing these challenges by utilizing remote digital technologies and community providers to enable broader, more inclusive participation. Furthermore, we underscore the potential of DCTs for democratizing clinical research. We also stress the importance of addressing unresolved challenges, including data security and privacy, remote patient monitoring, and regulatory variations. Research is needed to devise standardized protocols to streamline DCT processes, explore its long-term impacts on patient outcomes, and overcome challenges through equitable stakeholder engagement.

Five steps to high quality antimicrobial stewardship research

The escalating threat of antimicrobial resistance (AMR) necessitates impactful, reproducible, and scalable antimicrobial stewardship strategies. This review addresses the critical need to enhance the quality of antimicrobial stewardship intervention research. We propose five considerations for authors planning and evaluating antimicrobial stewardship initiatives. Antimicrobial stewards should consider the following mnemonic ABCDE: (A) plan Ahead using implementation science; (B) Be clear and thoroughly describe the intervention by using the TidIER checklist; (C) Use a Checklist to comprehensively report study components; (D) Select a study Design carefully; and (E) Assess Effectiveness and implementation by selecting meaningful outcomes. Incorporating these recommendations will help strengthen the evidence base of antimicrobial stewardship literature and support optimal implementation of strategies to mitigate AMR.

Evaluating the impact of a SIMPlified LaYered consent process on recruitment of potential participants to the Staphylococcus aureus Network Adaptive Platform trial: study protocol for a multicentre pragmatic nested randomised clinical trial (SIMPLY-SNAP trial)

INTRODUCTION

Informed consent forms (ICFs) for randomised clinical trials (RCTs) can be onerous and lengthy. The process has the potential to overwhelm patients with information, leading them to miss elements of the study that are critical for an informed decision. Specifically, overly long and complicated ICFs have the potential to increase barriers to trial participation for patients with mild cognitive impairment, those who do not speak English as a first language or among those with lower medical literacy. In turn, this can influence trial recruitment, completion and external validity.

METHODS AND ANALYSIS

SIMPLY-SNAP is a pragmatic, multicentre, open-label, two-arm parallel-group superiority RCT, nested within a larger trial, the Staphylococcus aureus Network Adaptive Platform (SNAP) trial. We will randomise potentially eligible participants of the SNAP trial 1:1 to a full-length ICF or a SIMPlified LaYered (SIMPLY) consent process where basic information is summarised with embedded hyperlinks to supplemental information and videos. The primary outcome is recruitment into the SNAP trial. Secondary outcomes include patient understanding of the clinical trial, patient and research staff satisfaction with the consent process, and time taken for consent. As an exploratory outcome, we will also compare measures of diversity (eg, gender, ethnicity), according to the consent process randomised to. The planned sample size will be 346 participants.

ETHICS AND DISSEMINATION

The study has been approved by the ethics review board (Sunnybrook Health Sciences Research Ethics Board) at sites in Ontario. We will disseminate study results via the SNAP trial group and other collaborating clinical trial networks.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT06168474; www.

CLINICALTRIALS

gov).