A randomized controlled trial of cefiderocol versus standard therapy for Gram-negative bacterial bloodstream infections: Benefit and risk assessment using DOOR and generalized pairwise comparisons

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ID: 328020
2026
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Ranked #550 of 550 articles by views in Clinical infectious diseases : an official publication of the Infectious Diseases Society of America

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Abstract
BACKGROUND: Gram-negative bacterial bloodstream infections (BSI) cause substantial mortality and morbidity. The GAME CHANGER trial compared cefiderocol with standard of care (SOC) for Gram-negative BSI, with 14-day all-cause mortality (ACM) as the primary endpoint. We evaluated cefiderocol versus SOC integrating efficacy and safety outcomes using desirability of outcome ranking (DOOR) and generalized pairwise comparisons (GPC). METHODS: Composite endpoints were prespecified prior to data review. The DOOR endpoint included treatment failure, infectious complications, serious adverse events (SAEs) and 90-day ACM, with functional improvement as a tiebreaker. The GPC approach included ACM at 30-days, clinical failure, SAEs, functional improvement and hospitalization duration. Analyses were conducted in the main population and carbapenem-resistant subset. RESULTS: The DOOR composite in the main population resulted in a probability of a more desirable outcome with cefiderocol of 50.4% (95% CI 45.6, 55.1). The analysis with GPC resulted in a win ratio and win odds of 1.04 (95% CI: 0.85, 1.28) and net treatment benefit (NTB) of 2.1% (95% CI: -8.0%, 12.2%). In the carbapenem-resistant subset, the DOOR probability with cefiderocol was 46.8% (95% CI 37.4%, 56.1%). The analysis with GPC resulted in a win ratio and win odds of 0.90 (95% CI: 0.60, 1.34) and NTB of -5.4% (95% CI: -25.3%, 14.5%). CONCLUSIONS: In adults with Gram-negative bacterial BSI, cefiderocol was not superior to SOC based on DOOR or GPC analyses in both the main population and carbapenem-resistant subset. Integrating efficacy, safety and functional outcomes using these approaches provides a more comprehensive assessment than mortality alone.
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Authors Melissa J. Hardy, Patrick N. A. Harris, Yin Mo, Mark D. Chatfield, Helmi Sulaiman, Po‐Yu Liu, Mesut Yılmaz, Zeti Norfidiyati Salmuna Ayub, Mohd Zulfakar Mazlan, Siriluck Anunnatsiri, Rujipas Sirijatuphat, Darunee Chotiprasitsakul, David C Lye, Jyoti Somani, Shirin Kalimuddin, Abdullah T Aslan, Visanu Thamlikitkul, Yi‐Tzu Lee, Ya-Sung Yang, Yi‐Tsung Lin, Ong Hang Cheng, Chien-Hao Tseng, Sophia Archuleta, Yvonne Fu Zi Chan, Clinton Colaco, David L. Paterson
Journal Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
Year 2026
DOI
10.1093/cid/ciag538
URL
https://doi.org/10.1093/cid/ciag538
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