Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE)

Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness: Randomized Controlled Trial

The World Health Organization, U.S. Centers for Disease Control and Prevention, Association of Medical Microbiology and Infectious Diseases (AMMI) Canada, and Health Canada have all declared antimicrobial resistance a global threat to health, based on rapidly increasing resistance rates and declining new drug development. Up to 30-50% of antibiotic use is inappropriate, and excessive durations of treatment are the greatest contributor to inappropriate use. Shorter duration treatment (≤7 days) has been shown in meta-analyses to be as effective as longer antibiotic treatment for a range of mild to moderate infections. A landmark trial in critically ill patients with ventilator-associated pneumonia showed that mortality and relapse rates were non-inferior in patients who received 8 vs 15 days of treatment. Similar adequately powered randomized trial evidence is lacking for the treatment of patients with bloodstream infections caused by a wide spectrum of organisms.

Study Overview

• Status: Completed
• Conditions: Sepsis; Mortality; Bacteremia; Critically Ill; Intensive Care; Antimicrobial
• Intervention / Treatment: Other: 7 days of adequate antibiotic treatment; Other: 14 days of adequate antibiotic treatment.

Detailed Description

Bloodstream infections are a common and serious problem, increasing length of hospital stay by 2-3 weeks, adding $25,000-40,000 in excess hospital costs, and tripling the risk of death. At the same time, antibiotic overuse is also a common and serious problem, in that 30-50% of antibiotic use is unnecessary or inappropriate, and results in avoidable drug side effects such as kidney failure, Clostridioides difficile infection, increased costs, and spiralling antibiotic resistance rates. The greatest contributor to antibiotic overuse is excessive durations of treatment.

Extensive research has demonstrated that shorter duration antibiotic treatment (less or equal to 7 days) is as effective as longer duration treatment for a variety of infectious diseases, but this question has not been directly studied in the setting of bloodstream infection. BALANCE team's systematic review of the medical literature, national survey of Canadian infectious diseases and critical care physicians, multicentre retrospective study and BALANCE pilot RCT, all support the need for a randomized controlled trial comparing shorter (7 days) versus longer (14 days) antibiotic therapy for bloodstream infections. Prior to performing the main trial, Investigators completed a pilot trial in ICU patients to establish the feasibility of the research design, and to optimize the definitive trial. Investigators also completed a pilot trial of non-ICUs patients to test the feasibility, compare the patient population in two settings and to assess the reasonableness of expanding the main BALANCE Trial to non-ICU wards. The overall recruitment rate of the non-ICU ward pilot RCT exceeded the recruitment rate in the BALANCE ICU pilot RCT with a protocol adherence of 90%. The results of this pilot were used to estimate the necessary sample size recalculation, after merging the BALANCE ward trial with the BALANCE main trial, with the principle of maintaining an equal to smaller non-inferiority margin by the trial's completion. With the completion of this pilot RCT, the eligibility criteria for the BALANCE trial are also modified to broaden the inclusion of all bacteremic patients admitted to hospital. By defining the duration of treatment for bloodstream infections, BALANCE research program will help maximize the clinical cure of individual patients, while minimizing their risk of drug side effects, C. difficile, and antibiotic resistance. Since this intervention would require no new technology, and would reduce (rather than increase) health care costs, it would offer immediate benefits to patients and the healthcare system.

The BALANCE RCT will randomize hospitalized patients with bloodstream infection to 7 versus 14 days of adequate antibiotic treatment; the antibiotic drugs, doses, routes and interval will be left to the discretion of the treating team. Although placebo controls are not feasible, prolonged allocation concealment to day 7 will be used to mitigate selection bias. The primary analysis will assess whether 7 days is associated with non-inferior 90 day survival as compared to 14 days of treatment. Participants from the vanguard BALANCE pilot RCTs will be included in the BALANCE main RCT, and participating Canadian sites will continue to enrol patients. BALANCE international collaborators include New Zealand, Australia, Saudi Arabia, the United States, Israel and Switzerland.

• Study Type: Interventional
• Enrollment (Actual): 3622
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Australia
  • New South Wales
    • Bankstown, New South Wales, Australia
      • Bankstown Hospital
    • Darlinghurst, New South Wales, Australia
      • St Vincent's Hospital
    • Kogarah, New South Wales, Australia
      • St. George Hospital
    • New Lambton Heights, New South Wales, Australia
      • John Hunter Hospital
    • Westmead, New South Wales, Australia
      • Westmead Hospital
    • Wollongong, New South Wales, Australia
      • Wollongong Hospital ICU
  • Queensland
    • Birtinya, Queensland, Australia
      • Sunshine Coast University Hospital
  • Victoria
    • Ballarat, Victoria, Australia
      • Ballarat Hospital
    • Bendigo, Victoria, Australia
      • Bendigo Hospital
    • Berwick, Victoria, Australia
      • Casey Hospital
    • Clayton, Victoria, Australia
      • Monash Medical Centre
    • Dandenong, Victoria, Australia
      • Dandenong Hospital- Monash Health
    • Frankston, Victoria, Australia
      • Frankston Hospital
    • Langwarrin, Victoria, Australia
      • Peninsula Private Hospital
    • Malvern, Victoria, Australia
      • Cabrini Health
  • Western Australia
    • Murdoch, Western Australia, Australia
      • Fiona Stanley Hospital
    • Subiaco, Western Australia, Australia
      • St John of God Hospital
• Canada
  • Quebec, Canada
    • Centre hospitalier affilié universitaire de Québec
  • Alberta
    • Calgary, Alberta, Canada
      • Foothills Hospital
    • Calgary, Alberta, Canada
      • Peter Lougheed Centre
    • Edmonton, Alberta, Canada
      • University of Alberta Hospital
  • British Columbia
    • Vancouver, British Columbia, Canada
      • Vancouver General Hospital
    • Vancouver, British Columbia, Canada
      • St. Paul's Hospital
    • Vancouver, British Columbia, Canada
      • Royal Columbian Hospital
    • Vancouver, British Columbia, Canada
      • Lions Gate Hospital
    • Victoria, British Columbia, Canada
      • Vancouver Island Health
  • Manitoba
    • Winnipeg, Manitoba, Canada
      • University of Manitoba
  • Newfoundland and Labrador
    • Saint John's, Newfoundland and Labrador, Canada
      • Eastern Regional Health Authority
  • Nova Scotia
    • Halifax, Nova Scotia, Canada
      • Queen Elizabeth II Hospital
  • Ontario
    • Brampton, Ontario, Canada
      • William Osler Health System
    • Hamilton, Ontario, Canada
      • St. Joseph's Healthcare
    • Hamilton, Ontario, Canada
      • Hamilton General Hospital
    • Hamilton, Ontario, Canada
      • Brantford General Hospital
    • Kingston, Ontario, Canada
      • Kingston General Hospital
    • London, Ontario, Canada
      • London Health Sciences Centre
    • Mississauga, Ontario, Canada
      • Trillium Health Partners
    • Ottawa, Ontario, Canada
      • The Ottawa Hospital
    • St. Catharines, Ontario, Canada
      • Niagara Health System
    • Sudbury, Ontario, Canada
      • Health Sciences North
    • Toronto, Ontario, Canada, M4N3M5
      • Sunnybrook Health Sciences Centre
    • Toronto, Ontario, Canada
      • Mount Sinai Hospital
    • Toronto, Ontario, Canada
      • St. Michael's Hospital
    • Toronto, Ontario, Canada
      • Toronto General Hospital
    • Toronto, Ontario, Canada
      • Toronto Western Hospital
    • Toronto, Ontario, Canada
      • St. Joseph's Health Centre
    • Toronto, Ontario, Canada
      • North York General Hospital
    • Toronto, Ontario, Canada
      • Michael Garron Hospital
  • Quebec
    • Montreal, Quebec, Canada
      • Centre Hospitalier de l'Universite de Montreal (CHUM)
    • Montreal, Quebec, Canada
      • Hospital Maisonneuve-Rosemont
    • Montreal, Quebec, Canada
      • Montreal General Hospital
    • Montreal, Quebec, Canada
      • Hospitalier Régional de Trois-Rivières
    • Québec, Quebec, Canada
      • Institut Universitaire de cardiologie et de pneumologie de Quebec
    • Québec, Quebec, Canada
      • Royal Victoria Hospital
    • Sherbrooke, Quebec, Canada
      • Université de Sherbrooke
• Israel
  • Tel Aviv
    • Petah Tikva, Tel Aviv, Israel
      • Rabin Medical Center
    • Tel HaShomer, Tel Aviv, Israel
      • Sheba Medical Center
• New Zealand
  • Auckland, New Zealand
    • Auckland City Hospital
  • Auckland, New Zealand
    • Middlemore Hospital
  • Christchurch, New Zealand
    • Christchurch Hospital
  • Hamilton, New Zealand
    • Waikato Hospital
  • New Plymouth, New Zealand
    • Taranaki Hospital
  • Rotorua, New Zealand
    • Rotorua Hospital
  • Wellington, New Zealand
    • Wellington Hospital
• Saudi Arabia
  • Jeddah, Saudi Arabia
    • King Faisal Specialist Hospital & Research Centre
  • Riyadh, Saudi Arabia
    • King Abdulaziz Medical City
• Switzerland
  • Bern, Switzerland
    • University Hospital Bern
• United States
  • New York
    • New York, New York, United States, 10016
      • NYU School of Medicine
  • Ohio
    • Cleveland, Ohio, United States, 44195
      • Cleveland Clinic

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Patient is in ICU or non-ICU ward at the time the blood culture is drawn or reported as positive.
2. Patient has a positive blood culture with pathogenic bacteria.

Exclusion Criteria:

1. Patient already enrolled in the trial
2. Patient has severe immune system compromise, as defined by: absolute neutrophil count <0.5x109/L; or is receiving immunosuppressive treatment for solid organ or bone marrow or stem cell transplant
3. Patient has a prosthetic heart valve or synthetic endovascular graft (post major vessel repair with synthetic material) (note: coronary artery stents are not an exclusion)

4. Patient has documented or suspected syndrome with well-defined requirement for prolonged treatment:

   i) infective endocarditis; ii) osteomyelitis/septic arthritis; iii) undrainable/undrained abscess; iv) unremovable/unremoved prosthetic-associated infection (e.g. infected pacemaker, prosthetic joint infection, ventriculoperitoneal shunt infection etc.) (note: central venous catheters, including tunneled central intravenous catheter, and urinary catheters are not excluded unless the treating clinical team does not have equipoise for enrollment and randomization to either group)

5. Patient has a single positive blood culture with a common contaminant organism according to Clinical Laboratory & Standards Institute (CLSI) Guidelines: coagulase negative staphylococci; or Bacillus spp.; or Corynebacterium spp.; or Propionobacterium spp.; or Aerococcus spp.; or Micrococcus spp.
6. Patient has a positive blood culture with Staphylococcus aureus or Staphylococcus lugdunensis
7. Patient has a positive blood culture with Candida spp. or other fungal species.
8. Blood culture grows rare bacterial pathogens requiring prolonged treatment (e.g. Mycobacteria spp., Nocardia spp., Actinomyces spp., Brucella spp., Burkholderia pseudomallei)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Short duration (7 days); Patients in 7 day arm will receive adequate antibiotics until the end of day 7 only	Other: 7 days of adequate antibiotic treatment; The choice of treatment including type, dose, route and interval of antibiotic will be left at the discretion of treating team as long as it is appropriate for the bacteremia
Active Comparator: Long duration (14 days); Patients in 14 day arm will receive adequate antibiotics until the end of day 14 only	Other: 14 days of adequate antibiotic treatment.; The choice of treatment including type, dose, route and interval of antibiotic will be left at the discretion of treating team as long as it is appropriate for the bacteremia

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
90 day survival	Survival at 90-days recorded as alive or dead at day 90 following index positive blood culture	90 days from index blood culture

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hospital mortality	Recorded as alive or dead at hospital discharge following index positive blood culture	Expected average of 4 weeks assessed upto one year
ICU mortality	Recorded as alive or dead at ICU discharge following index positive blood culture	Expected average of 2 weeks assessed upto one year
Relapse rates of bacteremia with the same organism	Defined as the recurrence of bacteremia due to original infecting organism (same Genus and species) after documentation of negative blood cultures or clinical improvement and within 30 days after completing course of adequate antimicrobial therapy.	Upto 30 days after adequate antibiotic treatment
Antibiotic allergy and adverse events	Effect of medication on body that produces the allergic reaction to a medication like: Hives; Itching of the skin or eyes; Skin rash; Swelling of the lips, tongue, or face; Wheezing; Organ toxicity	Upto 30 days from start of antibiotic treatment
Rates of C. difficile infection in hospital	Defined as a positive PCR or ELISA test for Clostridium difficile toxin in the context of diarrhea within hospital of bacteremia diagnosis.	Upto 30 days after index blood culture collection date
Rates of secondary nosocomial infection/colonization with antimicrobial resistant organisms in hospital	Colonized or infected with at least one highly-resistant microorganism during their hospital stay	Upto 30 days after index blood culture collection date
ICU length of stay	Defined as the duration between index blood culture and discharge from the ICU for a consecutive 48-hour period	Expected for an average of 30 days assessed up to 1 year
Hospital length of stay	Defined as the duration between index blood culture and discharge date from hospital	Expected for an average of 30 days assessed up to 1 year
Mechanical ventilation duration	Defined as the number of consecutive days receiving invasive (via an endotracheal tube or tracheostomy), or non-invasive (via a facemask, nasal mask, or helmet) ventilation	Expected for an average of 30 days
Antibiotic free days	Defined as the number of days during the 28 days after the start of adequate antibiotics in which patients did not receive any antibiotics.	Upto 30 days after adequate antibiotic treatment

Collaborators and Investigators

• Sponsor: Sunnybrook Health Sciences Centre
• Investigators: Principal Investigator: Nick Daneman, MD, Sunnybrook Health Sciences Centre

Publications and helpful links

General Publications

• Daneman N, Rishu AH, Pinto RL, Arabi YM, Cook DJ, Hall R, McGuinness S, Muscedere J, Parke R, Reynolds S, Rogers B, Shehabi Y, Fowler RA; Canadian Critical Care Trials Group. Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE) randomised clinical trial: study protocol. BMJ Open. 2020 May 11;10(5):e038300. doi: 10.1136/bmjopen-2020-038300.

Helpful Links

• Related Info

Study record dates

Study Major Dates

• Study Start (Actual): February 24, 2017
• Primary Completion (Actual): May 5, 2023
• Study Completion (Actual): August 3, 2023

Study Registration Dates

• First Submitted: December 20, 2016
• First Submitted That Met QC Criteria: December 22, 2016
• First Posted (Estimated): December 29, 2016

Study Record Updates

• Last Update Posted (Actual): February 29, 2024
• Last Update Submitted That Met QC Criteria: February 28, 2024
• Last Verified: November 1, 2023

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Pathologic Processes; Infections; Systemic Inflammatory Response Syndrome; Inflammation; Disease Attributes; Bacterial Infections; Bacterial Infections and Mycoses; Sepsis; Bacteremia; Critical Illness; Anti-Infective Agents; Antitubercular Agents; Anti-Bacterial Agents; Antibiotics, Antitubercular
• Other Study ID Numbers: 0796

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No