- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03782454
Quantification of Bacterial DNA in Sepsis
Quantification of Bacterial DNA in Septic Intensive Care Patients in Relation to Concentration of Antibiotics and Clinical Outcome: A Prospective Observation Study
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Septic syndrome caused by bloodstream infections represents a major healthcare problem worldwide and is the leading cause of mortality in the non-cardiac intensive care unit (ICU). Despite ongoing research efforts in sepsis, the mortality remains as high as 12-30%.
In severe sepsis, the time to adequate antibiotic therapy has been clearly linked to survival. However, in the emergency room, it is challenging to identify the cause behind the clinical presentation and identify patients who would benefit the most from antibiotic treatment. An indiscriminate use of antibiotics inevitably leads to bacterial resistance and unacceptable adverse events. Thus, there is a great and unmet medical need to develop novel diagnostic instruments that could inform the clinician about who would need antibiotics and who would not benefit from it. Furthermore, early identification of the causal microorganism and the inflammatory status of the patients would improve decisions about treatments and reduce administration of antibiotics.
Today the gold standard for diagnosis of bloodstream infections (BSI) is blood culture followed by identification of species and resistance pattern by standard laboratory procedures. This procedure is associated with a high specificity but also with a low sensitivity. Probable reasons for a negative blood culture despite a strong clinical suspicion could be insufficient blood volume in the culture bottles or antibiotic treatment prior to blood sampling with a subsequent failure of the bacteria to grow in the bottles.
In recent years Polymerase Chain reaction (PCR) has been proposed as a method to determine bacterial DNA based on amplification of specific subunits (16S and 18S) of bacterial ribosomal RNA. PCR require very small amount of DNA. Another advantage is the possibility to determine bacterial species from non-viable bacteria by multiplex PCRs. However most of those multiplex PCRs have shown a limited sensitivity even though they also found clinical relevant pathogens that were not detected with blood cultures. Another limitation is that multiplex-PCR only detects at maximum 95% of all sepsis causing pathogens. In a recent published study the author concluded that a tested multiplex PCR "on whole blood specimens" in adjunct to current culture-based methods provided a clinical add-on value. The future role of PCR and other molecular techniques in the clinical setting needs further evaluation.
A new method that could improve the diagnostics of sepsis and also have the possibility to follow the bacterial DNA load during antibiotic treatment is Droplet Digital PCR (ddPCR). This technique enables an absolute quantification of the sepsis causing pathogen targeting either a species specific gene or the 16S ribosomal DNA (rDNA) gene, present in several copies per bacteria. In ddPCR, the sample is divided into about 20.000 water-in-oil droplets, and in all of them the PCR-reaction occurs. Following PCR, each droplet is analyzed to determine the fraction of PCR-positive droplets giving the amount of bacterial DNA in the original sample. The absolute target DNA template concentration can then be calculated, since the size of the droplets is known, and by using Poisson distribution statistics for the correction of more than one positive reaction in the same droplet.
To identify the sepsis causing pathogen sequencing of the 16S rDNA gene or a shotgun metagenomics approach could be used. In the latter, all DNA in a sample is sequenced using Next Generation Sequencing (NGS) and the sepsis causing pathogen can be both detected and aims to be quantified through bioinformatics data analysis.
During the septic course the patient go from vasodilation to vascular leakage and finally a hypotension. This together with added intravenous fluid treatment will increase the distribution volume with an altered pharmacokinetic state for added antibiotics. Furthermore, decreased kidney function is common in ICU patients and augmented creatinine clearance during the acute phase of sepsis is described with increasing frequency. Therefore, it is difficult to anticipate the optimal antibiotic dose for the septic patient. Indeed, it is shown that in a considerable portion of ICU patients an adequate antibiotic exposure is not achieved and this is associated with negative clinical outcome.
A dysregulated host response is a cornerstone of the current understanding of sepsis pathophysiology. Initially during the sepsis course a proinflammatory response is induced by early activation genes, including cytokines associated with inflammation: tumor necrosis factor (TNF), Interleukin-1(IL-1), IL-12 and IL-18. Simultaneously an immune suppression is induced by anti-inflammatory cytokines i.e IL-10 and transforming growth factor. A disrupted homeostasis of the pro- and anti-inflammatory response is suggested to be part of the dysregulated host response in sepsis although clinically available biomarkers for its identification are lacking. Furthermore, the regulatory mediators involved in this process and the association to bacterial clearance during sepsis needs further investigation.
The gastrointestinal tract may be a source of bacteria and a worsening of the septic inflammation in ICU patients, if the epithelial barrier is disrupted. Thus intact gastrointestinal function is critical in severely diseased patients. There are no clinically available biomarkers of gastrointestinal function; however the recently described acute gastrointestinal injury (AGI) score has been shown to correlate with adverse outcome in ICU-patients.
The aim of the study is to investigate whether bacterial DNA in whole blood measured with ddPCR can be used for assessment of bacterial clearance in septic intensive care patients. To do so the investigators will search for a potential association between bacterial DNA clearance and clearance of bacteremia detected by blood cultures.
Further, the aim is to examine a possible relation between clearance of bacterial DNA, biomarkers of dysregulated host response, and clinical outcome in the septic patient. Outcome is measured as: mortality on ICU, mortality <28 days, days in the ICU, change in Sequential Organ Failure Assessment score(SOFA), time in assisted ventilation, lactate clearance, need of vasopressors, and severity of gastrointestinal injury. Further, the aim is to study the relationship between concentration of beta-lactam antibiotics i.e. the minimal inhibitory concentration for the bacteria (T>MIC) detected and the clearance of bacterial DNA. The material collected will also contribute to reveal the relationship between ddPCR and shot gun sequencing in detecting the sepsis causing bacteria.
Study Type
Enrollment (Anticipated)
Contacts and Locations
Study Contact
- Name: Johanna Savilampi, PhD
- Phone Number: +460196020266
- Email: johanna.savilampi@regionorebrolan.se
Study Contact Backup
- Name: Karolina Liljedahl Pryz, MD
- Phone Number: +460196020000
- Email: karolina.liljedahl.pryz@regionorebrolan.se
Study Locations
-
-
-
Örebro, Sweden, 701 85
- Recruiting
- University Hospital in Örebro
-
Contact:
- Johanna Savilampi, MD
- Phone Number: +46196020266
- Email: johanna.savilampi@orebroll.se
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Sampling Method
Study Population
Description
Inclusion Criteria:
- Adult patient at the emergency department with verified or suspected sepsis and who is in need of intensive care.
- Informed Consent by patient or legal representative.
- Indication for beta-lactam antibiotics
Exclusion Criteria:
- < 18 years
- Patients and/or relatives unable to understand study information.
- Anaphylactic allergy to beta-lactam antibiotics
- Patients already treated with antibiotics
Study Plan
How is the study designed?
Design Details
- Observational Models: Cohort
- Time Perspectives: Prospective
Cohorts and Interventions
Group / Cohort |
Intervention / Treatment |
---|---|
intensive care patients with sepsis
Adult patients with verified or suspected sepsis admitted to the intensive care department from the emergency department
|
Blood samples taken every third hour during the first 48 hours of intensive care
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Bacterial DNA measured by 16S ddPCR
Time Frame: 48 hours
|
copies/mL
|
48 hours
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Concentration of beta-lactam antibiotics
Time Frame: 48 hours
|
mg/mL
|
48 hours
|
Lactate clearance
Time Frame: 48 hours
|
mmol/L, clearance %
|
48 hours
|
SOFA
Time Frame: ICU stay up to 30 days
|
Sequential Organ Failure Assessment score, from 0(normal) to 24(highest organ dysfunction)
|
ICU stay up to 30 days
|
Time in assisted ventilation
Time Frame: ICU stay up to 30 days
|
hours
|
ICU stay up to 30 days
|
Need of vasopressors
Time Frame: ICU stay up to 30 days
|
mcg/kg/hour
|
ICU stay up to 30 days
|
Days in the ICU
Time Frame: ICU stay up to 30 days
|
Days
|
ICU stay up to 30 days
|
AGI score
Time Frame: ICU stay up to 30 days
|
Acute Gastrointestinal Injury Score 0(normal) to 4(life-threatening GI complications)
|
ICU stay up to 30 days
|
ICU mortality
Time Frame: ICU stay up to 30 days
|
Occurence of death during ICU stay
|
ICU stay up to 30 days
|
28-day mortality
Time Frame: 28 days
|
Occurence of death at day 28
|
28 days
|
Gastrointestinal complications
Time Frame: 28 days
|
Occurence of gastrointestinal complications including GI-bleeding, GI-ischemia, pancreatitis and ileus
|
28 days
|
Intestinal fatty acid binding protein (I-FABP)
Time Frame: 48 hours
|
picogram/mL, biomarker of gastrointestinal injury
|
48 hours
|
Citrulline
Time Frame: 48 hours
|
nmol/mL, biomarker of gastrointestinal injury
|
48 hours
|
Nuclear DNA
Time Frame: 48 hours
|
copies/mL
|
48 hours
|
Cytokines (Th1 and Th2 signature panel)
Time Frame: 48 hours
|
pg/ml
|
48 hours
|
Blood cell populations
Time Frame: 48 hours
|
Mean fluorescence intensity/ Antibodies/cell.
Monocytes, granulocytes, T-cells, and myeloid derived stem cells including surface markers such as PD-1(Programmed cell death protein 1),PD-L1 (Programmed death ligand 1), and HLA-DR (Human leukocyte Antigen - DR isotype)
|
48 hours
|
HLA-DR messenger RNA (mRNA)
Time Frame: 48 hours
|
ratio/reference gene
|
48 hours
|
Procalcitonin
Time Frame: 48 hours
|
mcg/L
|
48 hours
|
MicroRNA (miRNA)
Time Frame: 48 hours
|
Relative expression/ratio reference gene, transcriptomic and quantitative PCR based measurement
|
48 hours
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Jan Källman, PhD, Region Örebro County
- Principal Investigator: Hans Hjelmqvist, Phd, Region Örebro County
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Anticipated)
Study Completion (Anticipated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- JS008
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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