- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT05443854
Impact of Aminoglycosides-based Antibiotics Combination and Protective Isolation on Outcomes in Critically-ill Neutropenic Patients With Sepsis: (Combination-Lock01)
Impact of Aminoglycosides-based Antibiotics Combination and Protective Isolation on Outcomes in Critically-ill Neutropenic Patients With Sepsis: A Randomized 2 by 2 Factorial Design Randomized Pragmatic Trial.
Sepsis remains the leading cause of ICU admission in neutropenic patients. This condition remains associated with a high morbidity and mortality, with hospital mortality of 60% when vasopressors are required.
Full protective isolation (including geographic isolation, technical isolation, high-efficiency air filtration, and digestive decontamination) proved to be efficient in patients with profound and prolonged neutropenia with regard to infection rate. However, these studies are biased and were performed up to 40 years ago. More recent studies, performed in patients with less profound neutropenia, or performed without digestive decontamination or with partial protective isolation led however to negative results. More importantly, isolation has been demonstrated to limit access to patients' room and to be associated with suboptimal monitoring, with increased rate of severe and avoidable adverse events. This may explain the uneven use of protective isolation in hematology ward and expert's suggestion to appraise protective isolation benefits using large well conducted RCT.
In neutropenic patients with suspected sepsis, urgent broad antibiotic therapy is mandatory and failure to initiate adequate antibiotic therapy within 1 hour has been associated with a 10 fold increase in adjusted mortality. Current IDSA guidelines recommend using preferentially large anti-pseudomonas beta-lactam therapy. Routine antibiotic combination using aminoglycosides is controversial and not recommended. On one hand, meta-analyses suggested not-only a lack of benefit from this association but also increased rate of renal failure and a trend towards a higher mortality rate with aminoglycosides use. On the other hand, subgroup analysis and low-level evidences studies suggest however a benefit from aminoglycosides in critically-ill patients, patients with severe sepsis, or those with documented gram negative infection. Along this line, both the recent Cochran systematic review and the recent French guidelines focusing on neutropenia management in critically-ill patients advocated additional trials in this field focusing in the sickest patients.
The current study aims to assess benefits of protective isolation and systematic use of aminoglycosides combination antibiotic therapy in critically-ill patients with cancer-related neutropenia and sepsis or septic shock. To do so, the investigators intend to perform a 2x2 factorial design randomized pragmatic trial comparing on one hand benefits of protective isolation (versus no protective isolation) and in the other hand benefits of systematic aminoglycosides antibiotics combination (versus no systematic combination).
Study Overview
Status
Study Type
Enrollment (Anticipated)
Phase
- Phase 3
Contacts and Locations
Study Contact
- Name: Michael Darmon
- Phone Number: 01 42 49 94 19
- Email: michael.darmon@aphp.fr
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Age ≥ 18 years
- Sepsis or septic shock as defined by SEPSIS3 definition
- Underlying tumor, allogeneic stem cell transplantation or hematological malignancy
- Neutropenia (defined by either absolute neutrophil count <500/mm3 or leucocytes <1000/mm3) related to an underlying malignancy or its treatment
- Informed or deferred consent
Exclusion Criteria:
- Pregnancy and breastfeeding
- Moribund patients (death expected within 48 hours by attending physician)
- Previous participation to this study
- No affiliation to social security
- Patients under legal protection according to French Law
- Patient having received more than 1 injection of aminoglycosides in the 3 days preceding ICU admission
Contraindication to aminoglycosides as mentioned in SpC section 4.3:
- Hypersensitivity to amikacin, to other antibiotics from the aminoglycoside family, or to any excipient from the amikacin used.
- Patients with documented allergy to aminoglycosides
- Myasthenia gravis
- Concomitant administration of intravenous Polymyxin- Delay between admission for a new sepsis and inclusion>24 hours or (in patients previously admitted in the ICU for another reason) delay between new sepsis in study inclusion >24h
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Factorial Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Aminoglycosides intervention
Systematic aminoglycoside therapy using Amikacin at a dose of 25 to 30 mg/Kg per dose, at a rate of a maximum of 1 infusion per day will be delivered. Recommended duration will be of three days or until microbiological documentation. |
Antibiotic therapy and prophylaxis will be in line with more recent IDSA and ESCMID guidelines [3, 28, 50]. Systematic aminoglycoside therapy using Amikacin at a dose of 25 to 30 mg/Kg per dose, at a rate of a maximum of 1 infusion per day will be delivered. Recommended duration will be of three days or until microbiological documentation. |
Experimental: Lack of protective isolation intervention
Protective isolation will be avoided until ICU discharge is deemed possible.
Specific measures regarding nutrition (including avoidance of food consider at risk of fungal contamination) and water protection will be maintained.
|
Protective isolation will be avoided until ICU discharge is deemed possible. Specific measures regarding nutrition (including avoidance of food consider at risk of fungal contamination) and water protection will be maintained. Extended universal hygiene measures will be maintained and use of mask will be advocated during viral epidemic periods. A high degree of compliance as regard to antifungal prophylaxis guidelines and local standard hygiene procedures will be advocated |
Other: No systematic aminoglycosides intervention
Antibiotic therapy and prophylaxis will be in line with more recent IDSA and ESCMID guidelines - standard arm
|
Antibiotic therapy and prophylaxis will be in line with more recent IDSA and ESCMID guidelines [3, 28, 50]. No systematic aminoglycoside therapy will be provided except in presence of predefined specific organ infection (such intra-vascular infection such endocarditis for example) or drug-resistant infection requiring aminoglycosides. |
Other: Protective isolation intervention
Protective isolation will be provided systematically as currently practiced in participating centers - standard arm
|
Protective isolation will be provided systematically as currently practiced in participating centers. Modality will be in line with recent SRLF guidelines, we will recommend for the patients to receive an isolation the maximal available isolation with the aim to provide:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Mortality
Time Frame: at day 90
|
Overall death
|
at day 90
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Mortality
Time Frame: at Day-28
|
Overall death
|
at Day-28
|
Hospital mortality
Time Frame: at hospital discharge within 3 months
|
Mortality at hospital discharge
|
at hospital discharge within 3 months
|
Incidence of acute kidney injury
Time Frame: within 3 months
|
Acute kidney injury (AKI) will be defined according to KDIGO criteria
|
within 3 months
|
Severity of acute kidney injury
Time Frame: within 3 months
|
Acute kidney injury (AKI) will be defined according to KDIGO criteria
|
within 3 months
|
Duration of acute kidney injury
Time Frame: within 3 months
|
Acute kidney injury (AKI) will be defined according to KDIGO criteria
|
within 3 months
|
Major Adverse Kidney Events
Time Frame: at day-28
|
at day-28
|
|
Major Adverse Kidney Events
Time Frame: at day 90
|
at day 90
|
|
Incidence of clinically apparent loss of hearing
Time Frame: at ICU discharge
|
at ICU discharge
|
|
Incidence of clinically apparent loss of hearing
Time Frame: at dat 90
|
at dat 90
|
|
Rate of adherence of hand hygiene
Time Frame: at 24 hours
|
hand hygiene will be assessed by external observer
|
at 24 hours
|
Incidence density of selected serious adverse events
Time Frame: within 3 months
|
within 3 months
|
|
Incidence density of new bacterial episodes
Time Frame: within 3 months
|
within 3 months
|
|
Incidence density of new viral infection episodes
Time Frame: within 3 months
|
within 3 months
|
|
Incidence density of new fungal episodes
Time Frame: within 3 months
|
within 3 months
|
|
Number of days free from organ support therapy (mechanical ventilation, vasopressors or RRT)
Time Frame: at day 28
|
at day 28
|
|
Rate of clinical cure
Time Frame: within 3 months
|
within 3 months
|
|
Frequency of initial antibiotic therapy inadequate as regard to microbiological documentation.
Time Frame: at inclusion
|
at inclusion
|
|
Number of day free of antibiotic therapy
Time Frame: at day-28
|
at day-28
|
|
Duration of aminoglycoside therapy
Time Frame: within 3 months
|
within 3 months
|
|
Rate of aminoglycoside overdosage according to residual concentration
Time Frame: within 3 months
|
within 3 months
|
|
Rate of overuse when compared to experts recommendations
Time Frame: within 3 months
|
within 3 months
|
Collaborators and Investigators
Study record dates
Study Major Dates
Study Start (Anticipated)
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
Additional Relevant MeSH Terms
Other Study ID Numbers
- APHP180690
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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