Ciprofloxacin for Prevention of BK Infection

Ciprofloxacin for Prevention of BK Infection in Renal Transplant Recipients

BK infection is an important cause of graft dysfunction and graft loss after renal transplantation. It has been widely accepted that emergence of BK virus correlates with the more potent immunosuppressive agents used to lower acute rejection rates. In contrast to other opportunistic infections after transplantation, for which routine prophylactic agents are administered, there is no effective agent for the prevention of BK infection. Some data, however, suggests that quinolone antibiotics such as ciprofloxacin may have activity against BK virus. This has led us to investigate whether routine, short-term ciprofloxacin administration post-transplant can lower the incidence of BK infection.

Study Overview

• Status: Completed
• Conditions: BK Virus Infection
• Intervention / Treatment: Drug: Ciprofloxacin; Drug: placebo

Detailed Description

BK virus is a member of the virus family polyomaviridae ("polyoma"). The virus, which can manifest as a viral nephritis, was first described in a renal transplant recipient in 1971, however it was not until the past decade that infection with BK virus became known as an important contributor to graft dysfunction and graft loss after renal transplantation. It has been widely accepted that emergence of BK virus correlates with the more potent immunosuppressive agents currently used to lower acute rejection rates. In contrast to other opportunistic infections after transplantation, for which routine prophylactic agents are administered, there is no effective agent for the prevention of BK infection, nor is there an effective agent for treating BK infection once it occurs.

Ciprofloxacin is a well known anti-infective agent in the fluoroquinolone class of antibiotics. It is most active against gram-negative enteric pathogens, and is commonly used for a variety of infectious indications.

Though classified as antibacterial agents, fluoroquinolones have been suggested to exhibit anti-BK viral effects by interfering with helicase activity of the BK virus large T antigen. Ciprofloxacin has been shown in previous studies to reduce urine BK viral load, and BK-associated hemorrhagic cystitis in the stem cell transplant population. Ciprofloxacin has also been associated with a lower incidence of BK viremia in one retrospective study in kidney transplant recipients. Based on these reports, the investigators hope to find a reduction BK viremia and BK nephropathy using a prospective, randomized study design.

• Study Type: Interventional
• Enrollment (Actual): 200
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • Texas
    • Houston, Texas, United States, 77030
      • Houston Methodist Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Male or female subjects over the age of 18 years
• Recipients of a primary or repeat renal allograft either alone (from a deceased or living donor) or as a dual-kidney transplant
• Signed informed consent form prior to any research assessment

Exclusion Criteria:

• Patients with known severe allergy to ciprofloxacin
• History of tendon rupture or tendinitis
• Use of antiarrythmic drugs known to prolong the QT interval such as class IA antiarrhythmic drugs (e.g. quinidine, procainamide, disopyramide), class III antiarrhythmic drugs (e.g. amiodarone, sotalol)
• Patients with history of previous non-renal transplantation
• Recipients administered rituximab within one year prior to transplantation, or recipients expected to receive rituximab as part of desensitization strategy or for the presence of historical donor specific antibodies
• QTc interval interval of greater than 500 msec on admission or post-operative EKG
• BK nephropathy with previous transplant
• BK viremia on admission
• Any condition present during the initial transplant hospitalization that in the investigator's judgment would increase the risk associated with participation in the study

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Ciprofloxacin; Ciprofloxacin will be administered as two-250 mg capsules, administered once daily for 3 months post-transplant	Drug: Ciprofloxacin; Patients will be randomized 2:1 active comparator, Cipro, to placebo comparator.; Other Names: Cipro
Placebo Comparator: Placebo; Matching placebo will be administered as two-capsules given once daily for 3 months post-transplant	Drug: placebo; Patients will be randomized 2:1 placebo comparator to active comparator, Cipro.; Other Names: inactive drug; innocuous medication

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Patients Developing BK Infection at 6 Months Post-transplant	Number of patients (followed by proportion) developing BK infection at 6 months post-transplant. BK infection is defined as the presence of a detectable BK viral load in plasma by polymerase chain reaction (PCR), or the presence of BK viral inclusions on kidney biopsy specimens.	6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Patients With Gram Negative Urinary Tract Infections at 6 Months	Number of patients with gram negative urinary tract infections as defined by a midstream urine sample containing 10^4 or more colony-forming units per mL	6 months
Number of Patients With Bacteremia at 6 Months	Number of patients with bacteremic infection at 6 months. Bacteremia defined by a single positive blood culture that was not thought to be contaminated.	6 months
Number of Patients With Quinolone-resistant Infection at 6 Months	Number of patients with quinolone-resistant gram negative bacterial infections, among those with a gram-negative infection	6 months
Clostridium Difficile at 6 Months	Clostridium difficile infection at 6 months	6 months
Serious Adverse Events	Serious adverse events collected for up to 4 months (3 months on study drug plus 1 additional month)	4 months
Time to BK Infection	Median time to initial BK viremia episode, days	12 months
BK Viremia at 1 Year	Proportion of patients developing BK viremia at 1 year	12 months
First Plasma Viral Loads	First BK plasma viral loads	12 months
Acute Rejection at 1 Year	Number of patients with biopsy-proven acute rejection of the allograft at 1 year, based on Banff classification	12 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Graft Loss at 1 Year	kidney failure within first 1 year of transplant	12 months
Death at 1 Year	Patient death at 1 year	12 months

Collaborators and Investigators

• Sponsor: The Methodist Hospital Research Institute
• Investigators: Study Chair: Samir J Patel, Pharm.D., Clinical Pharmacist; Principal Investigator: Ahmed O Gaber, MD, Director, Houston Methodist Transplant Center

Publications and helpful links

General Publications

• Brennan DC, Agha I, Bohl DL, Schnitzler MA, Hardinger KL, Lockwood M, Torrence S, Schuessler R, Roby T, Gaudreault-Keener M, Storch GA. Incidence of BK with tacrolimus versus cyclosporine and impact of preemptive immunosuppression reduction. Am J Transplant. 2005 Mar;5(3):582-94. doi: 10.1111/j.1600-6143.2005.00742.x. Erratum In: Am J Transplant. 2005 Apr;5(4 Pt 1):839.
• Ali SH, Chandraker A, DeCaprio JA. Inhibition of Simian virus 40 large T antigen helicase activity by fluoroquinolones. Antivir Ther. 2007;12(1):1-6.
• Leung AY, Chan MT, Yuen KY, Cheng VC, Chan KH, Wong CL, Liang R, Lie AK, Kwong YL. Ciprofloxacin decreased polyoma BK virus load in patients who underwent allogeneic hematopoietic stem cell transplantation. Clin Infect Dis. 2005 Feb 15;40(4):528-37. doi: 10.1086/427291. Epub 2005 Jan 21.
• Miller AN, Glode A, Hogan KR, Schaub C, Kramer C, Stuart RK, Costa LJ. Efficacy and safety of ciprofloxacin for prophylaxis of polyomavirus BK virus-associated hemorrhagic cystitis in allogeneic hematopoietic stem cell transplantation recipients. Biol Blood Marrow Transplant. 2011 Aug;17(8):1176-81. doi: 10.1016/j.bbmt.2010.12.700. Epub 2010 Dec 23.
• Gabardi S, Waikar SS, Martin S, Roberts K, Chen J, Borgi L, Sheashaa H, Dyer C, Malek SK, Tullius SG, Vadivel N, Grafals M, Abdi R, Najafian N, Milford E, Chandraker A. Evaluation of fluoroquinolones for the prevention of BK viremia after renal transplantation. Clin J Am Soc Nephrol. 2010 Jul;5(7):1298-304. doi: 10.2215/CJN.08261109. Epub 2010 May 27.
• Patel SJ, Knight RJ, Kuten SA, Graviss EA, Nguyen DT, Moore LW, Musick WL, Gaber AO. Ciprofloxacin for BK viremia prophylaxis in kidney transplant recipients: Results of a prospective, double-blind, randomized, placebo-controlled trial. Am J Transplant. 2019 Jun;19(6):1831-1837. doi: 10.1111/ajt.15328. Epub 2019 Apr 4.

Study record dates

Study Major Dates

• Study Start (Actual): January 1, 2013
• Primary Completion (Actual): April 1, 2017
• Study Completion (Actual): October 1, 2017

Study Registration Dates

• First Submitted: February 7, 2013
• First Submitted That Met QC Criteria: February 11, 2013
• First Posted (Estimate): February 12, 2013

Study Record Updates

• Last Update Posted (Actual): November 13, 2019
• Last Update Submitted That Met QC Criteria: October 25, 2019
• Last Verified: October 1, 2019

More Information

Terms related to this study

• Keywords: fluoroquinolone; ciprofloxacin; BK infection; BK viremia; BK nephropathy; polyomavirus
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Infections; Communicable Diseases; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Enzyme Inhibitors; Antineoplastic Agents; Topoisomerase II Inhibitors; Topoisomerase Inhibitors; Anti-Bacterial Agents; Cytochrome P-450 Enzyme Inhibitors; Cytochrome P-450 CYP1A2 Inhibitors; Ciprofloxacin
• Other Study ID Numbers: Pro00007510; IRB0612-0114 (Other Identifier: HMRI IRB)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Undecided

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No