ADEQUATE Advanced Diagnostics for Enhanced Quality of Antibiotic Prescription (ADEQUATE)

ADEQUATE Advanced Diagnostics for Enhanced QUality of Antibiotic Prescription in Respiratory Tract Infections in Emergency Rooms

To assess the impact of rapid diagnostic testing of patients with Acute Respiratory Tract Infection (ARTI) at the emergency department, on (1) hospital admission rates and (2) antimicrobial prescriptions (days of treatment) and (3) the non-inferiority in terms of clinical outcome. Geographical and seasonal variation will be assessed on a real time basis including pathogens of public health interest. The impact will be stratified within age groups and risk factors in order to determine the long-term clinical, public health and economic determinants for the integration of diagnostics in a global and sustainable perspective.

Study Overview

• Status: Terminated
• Conditions: Respiratory Tract Infections
• Intervention / Treatment: Diagnostic test: BioFire

Detailed Description

Objective: To assess the impact of rapid diagnostic testing of patients with Acute Respiratory Tract Infection (ARTI) at the emergency department, on (1) hospital admission rates and (2) antibiotic prescriptions (days of treatment) and (3) the non-inferiority in terms of clinical outcome. Geographical and seasonal variation will be assessed on a real time basis including pathogens of public health interest. The impact will be stratified within age groups and risk factors in order to determine the long-term clinical, public health and economic determinants for the integration of diagnostics in a global and sustainable perspective.

Study design: Prospective, multi-center, individually randomised, controlled trial.

Study population: Adults (≥18 years old) consulting in selected participating sites with CA-ARTI.

Study Intervention: The diagnostic intervention is rapid syndromic testing with:

• BioFire FilmArray Pneumonia Panel plus (PP): Sputum (and/or ETA or BAL sample)
• BioFire FilmArray Respiratory Panel 2.1 plus (RP2.1plus): Nasopharyngeal swab

Main study parameters/endpoints:

• Days alive out of hospital (superiority endpoint), within 14 days
• Days on Therapy (DOT) with antibiotics (superiority endpoint), within 14 days

• Adverse outcome (non-inferiority safety endpoint)

  • For initially non-admitted patients: any admission or death within 30 days
  • For initially hospitalised patients: i) any readmission, ii) ICU admission ≥ 24 hours after hospitalisation, or iii) death within 30 days Nature and extent of the burden and risks associated with participation, benefit and group relatedness: Participation in the study involves collection of data that can be obtained from medical charts and follow up questionnaires and interviews. Respiratory samples (e.g. nasopharyngeal swab, sputum) will be obtained as standard of care and diagnostic intervention (Biofire FilmArray) will be used only for participants randomised to the intervention,Based on the results of diagnostic testing (BioFire FilmArray) antibiotics may be withheld when deemed unnecessary, or a different antibiotic class may be selected when certain bacterial pathogens are detected. The risks and benefits of management decisions, complemented with adequate training, are subject to the current investigation.

• Study Type: Interventional
• Enrollment (Actual): 185
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Belgium
  • Gent, Belgium
    • University Hospital Gent
• Hungary
  • Pecs, Hungary
    • University Hospital Pecs
• Serbia
  • Belgrade, Serbia
    • Clinical Center of Serbia
  • Kragujevac, Serbia
    • General Hospital Kragujevac

Participation Criteria

Eligibility Criteria

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

Description

Inclusion Criteria:

1. Adults (≥18 years old) presenting to the Emergency Room with an acute illness (present for 14 days or less) with cough, and with at least 1 other lower respiratory tract symptom or clinical sign at physical examination:

   • Sputum production,
   • Breathlessness,
   • Chest discomfort or chest pain,
   • Wheeze,
   • Crackles,
   • Self-reported dystermia or documented fever;

   • Documented hypoxemia (adjusting definition for chronic oxygen therapy users, method of measurement) and no alternative explanation (infection, such as sinusitis; other, such as asthma).

     2. Managing medical team considers:

     1. to treat patient with antibiotics and/or to hospitalize patient

        AND

     2. that the rapid syndromic diagnostic test result can be awaited up to a maximum of 4 hours before the decision to discharge the patient or to initiate antibiotic therapy.

Exclusion Criteria:

1. Development of ARTI more than 48 hours after hospital admission (hospital acquired);
2. Patients with cystic fibrosis;
3. Less than 14 days since the last episode of respiratory tract infection;
4. Pregnancy (confirmed by pregnancy test) and breastfeeding;
5. Any clinically significant abnormality identified at the time of screening that in the judgment of the Investigator would preclude safe completion of the study or constrain endpoints assessment such as major systemic diseases or patients with short life expectancy;

6. Inability to obtain informed consent from a competent patient.

   Based on standard of care microbiological diagnosis and thoracic imaging (when indicated):

7. Radiologically confirmed acute lobar pneumonia;
8. Known or suspected Pneumocystis jirovecii pneumonia or active tuberculosis;
9. Alternative noninfectious diagnosis that explains clinical symptoms (pulmonary embolism, alveolar hemorrhage, acute heart failure, lung cancer).

Study Plan

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention; Diagnostic intervention	Diagnostic test: BioFire; A molecular rapid syndromic testing platform, using the following panels: BioFire FilmArray Respiratory Panel 2.1 plus (RP2.1plus); BioFire FilmArray Pneumonia Panel plus (PP)
No Intervention: Standard of Care; Standard of care testing

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Days Alive Out of Hospital (Superiority Endpoint)	Days alive out of hospital (superiority endpoint), within 14 days after study enrolment	Day 1 - Day 14
Days on Therapy (DOT) With Antibiotics (Superiority Endpoint)	Days on Therapy (DOT) with antibiotics (superiority endpoint), within 14 days after study enrolment	Day 1 - Day 14
Adverse Outcome (Non-inferiority Safety Endpoint)	For initially non-admitted patients: any admission or death; For initially hospitalized patients: any readmission, ICU admission >= 24 hours after hospitalization, or death	Day 1 - Day 30

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Direct Costs and Indirect Costs Within 30 Days After Enrolment.	Cost of healthcare within 30 days after enrolment, including hospital and ICU days, utilisation of non-hospital services and cost of anti-infective and concomitant medication; Cost of workdays lost within 30 days, including days for childcare	Day 1 - Day 30
Microbiological Results Obtained as Standard of Care and With the Diagnostic Intervention	Proportion of participants with an identified respiratory pathogen in both study groups on randomisation day samples. Data refers to the number of participants so in case more than one microorganism is detected in the same sample (co-detection) or same result in more than one sample, it is still counted as one participant.	Day 1
Empirical Antibiotics Based on Antimicrobial Agent Categories	Proportion of participants on non-first-line anti-infective regimens (as defined by local guidelines). For this report, results are defined as non first-line if the choice includes a third or fourth generation cephalosporin or a carbapenem but analysis needs to be adjusted to baseline risk factors, comorbidities, local guidelines and time to de escalation.	Day 1 - Day 14
Antibiotic Type Switches and De-escalation Based on Antimicrobial Agent Categories	For this report is presented the number of patients where the antimicrobial was switched to narrower spectrum.	Day 1 - Day 14
Detection of Antimicrobial Resistance (Carriage or Infection) Related to the Diagnostic Intervention Results Compared to Standard of Care and Impact on Antimicrobial Stewardship Guidelines and Prevention of Hospital Acquired Infections.	Proportion of hospitalised participants with detection of cephalosporin-, carbapenem- or chinolone-resistant Enterobacteriaceae on any standard of care samples >7 days after randomisation comparing diagnostic intervention arm and standard of care arm.	>7 days after randomisation
Impact on Decisions Regarding Isolation Measures Related to Test Result.	Hours in individual or cohort isolation in hospitalised participants comparing the 2 groups	Day 1 - Day 30

Collaborators and Investigators

• Sponsor: UMC Utrecht
• Collaborators: BioMérieux
• Investigators: Principal Investigator: Marc Bonten, MD, UMC Utrecht

Study record dates

Study Major Dates

• Study Start (Actual): October 25, 2021
• Primary Completion (Actual): May 21, 2022
• Study Completion (Actual): May 21, 2022

Study Registration Dates

• First Submitted: September 7, 2020
• First Submitted That Met QC Criteria: September 7, 2020
• First Posted (Actual): September 14, 2020

Study Record Updates

• Last Update Posted (Actual): October 15, 2024
• Last Update Submitted That Met QC Criteria: October 10, 2024
• Last Verified: October 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Respiratory Tract Diseases; Infections; Respiratory Tract Infections
• Other Study ID Numbers: WP4b - adults

Drug and device information, study documents

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