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Desirability of Outcome Ranking for the Management of Antimicrobial Therapy (DOOR MAT): A Framework for Assessing Antibiotic Selection Strategies in the Presence of Drug Resistance.

ABSTRACT: The complexities of antibiotic resistance mean that successful stewardship must consider both the effectiveness of a given antibiotic and the spectrum of that therapy to minimize imposing further selective pressure. To meet this challenge, we propose the Desirability of Outcome Ranking approach for the Management of Antimicrobial Therapy (DOOR MAT), a flexible quantitative framework that evaluates the desirability of antibiotic selection. Herein, we describe the steps required to implement DOOR MAT and present examples to illustrate how the desirability of treatment selection can be evaluated using resistance information. While treatments and the scoring of treatment selections must be adapted to specific clinical settings, the principle of DOOR MAT remains constant: The most desirable antibiotic choice effectively treats the patient while exerting minimal pressure on future resistance.

SUBMITTER: Wilson BM

PROVIDER: S-EPMC8516503 | biostudies-literature | 2021 Jul

REPOSITORIES: biostudies-literature

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Desirability of Outcome Ranking for the Management of Antimicrobial Therapy (DOOR MAT): A Framework for Assessing Antibiotic Selection Strategies in the Presence of Drug Resistance.

Wilson Brigid M BM Jiang Yunyun Y Jump Robin L P RLP Viau Roberto A RA Perez Federico F Bonomo Robert A RA Evans Scott R SR

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 20210701 2

The complexities of antibiotic resistance mean that successful stewardship must consider both the effectiveness of a given antibiotic and the spectrum of that therapy to minimize imposing further selective pressure. To meet this challenge, we propose the Desirability of Outcome Ranking approach for the Management of Antimicrobial Therapy (DOOR MAT), a flexible quantitative framework that evaluates the desirability of antibiotic selection. Herein, we describe the steps required to implement DOOR ...[more]

PMID: 33245333

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Project description:As global trade of live animals expands, there is increasing need to assess the risks of invasive organisms, including pathogens, that can accompany these translocations. The movement and release of live baitfish by recreational anglers has been identified as a particularly high-risk pathway for the spread of aquatic diseases in the United States. To provide risk-based decision support for preventing and managing disease invasions from baitfish release, we developed a hazard identification and ranking tool to identify the pathogens that pose the highest risk to wild fish via this pathway. We created a screening protocol and semi-quantitative stochastic risk ranking framework, combining published data with expert elicitation (n = 25) and applied the framework to identify high-priority pathogens for the bait supply in Minnesota, USA. Normalized scores were developed for seven risk criteria (likelihood of transfer, prevalence in bait supply, likelihood of colonization, current distribution, economic impact if established, ecological impact if established and host species) to characterize a pathogen's ability to persist in the bait supply and cause impacts to wild fish species of concern. The generalist macroparasite Schizocotyle acheilognathi was identified as presenting highest overall threat, followed by the microsporidian Ovipleistophora ovariae, and viral haemorrhagic septicaemia virus. Our findings provide risk-based decision support for managers charged with maintaining both the recreational fishing industry and sustainable, healthy natural resources. Particularly, the identification of several high-risk but currently unregulated pathogens suggests that focusing risk management on pathogens of concern in all potential host species could reduce disease introduction risk. The ranking process, implemented here for a single state case study, provides a conceptual framework for integrating expert opinion and sparse available data that could be scaled up and applied across jurisdictions to inform risk-based management of the live baitfish pathway.

Project description:BackgroundIn randomized trials, 1 primary outcome is typically chosen to evaluate the consequences of an intervention, whereas other important outcomes are relegated to secondary outcomes. This issue is amplified for many obstetrical trials in which an intervention may have consequences for both the pregnant person and the child. In contrast, desirability of outcome ranking, a paradigm shift for the design and analysis of clinical trials based on patient-centric evaluation, allows multiple outcomes-including from >1 individual-to be considered concurrently.ObjectiveThis study aimed to describe desirability of outcome ranking methodology tailored to obstetrical trials and to apply the methodology to maternal-perinatal paired (dyadic) outcomes in which both individuals may be affected by an intervention but may experience discordant outcomes (eg, an obstetrical intervention may improve perinatal but worsen maternal outcomes).Study designThis secondary analysis applies the desirability of outcome ranking methodology to data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network ARRIVE trial. The original analysis found no substantial difference in the primary (perinatal composite) outcome, but a decreased risk of the secondary outcome of cesarean delivery with elective induction at 39 weeks. In the present desirability-of-outcome-ranking analysis, dyadic outcomes ranging from spontaneous vaginal delivery without severe neonatal complication (most desirable) to cesarean delivery with perinatal death (least desirable) were classified into 8 categories ranked by overall desirability by experienced investigators. Distributions of the desirability of outcome ranking were compared by estimating the probability of having a more desirable dyadic outcome with elective induction at 39 weeks of gestation than with expectant management. To account for various perspectives on these outcomes, a complementary analysis, called the partial credit strategy, was used to grade outcomes on a 100-point scale and estimate the difference in overall treatment scores between groups using a t test.ResultsAll 6096 participants from the trial were included. The probability of a better dyadic outcome for a randomly selected patient who was randomized to elective induction was 53% (95% confidence interval, 51-54), implying that elective induction led to a better overall outcome for the dyad when taking multiple outcomes into account concurrently. Furthermore, the desirability-of-outcome-ranking probability of averting cesarean delivery with elective induction was 52% (95% confidence interval, 51-53), which was not at the expense of an operative vaginal delivery or a poorer outcome for the perinate (ie, survival with a severe neonatal complication or perinatal death). Randomization to elective induction was also advantageous in most of the partial credit score scenarios.ConclusionDesirability-of-outcome-ranking methodology is a useful tool for obstetrical trials because it provides a concurrent view of the effect of an intervention on multiple dyadic outcomes, potentially allowing for better translation of data for decision-making and person-centered care.

Dataset Information

Desirability of Outcome Ranking for the Management of Antimicrobial Therapy (DOOR MAT): A Framework for Assessing Antibiotic Selection Strategies in the Presence of Drug Resistance.

Publications

Desirability of Outcome Ranking for the Management of Antimicrobial Therapy (DOOR MAT): A Framework for Assessing Antibiotic Selection Strategies in the Presence of Drug Resistance.

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