PIRATE project: point-of-care, informatics-based randomised controlled trial for decreasing overuse of antibiotic therapy in Gram-negative bacteraemia

Abstract

Introduction: Antibiotic overuse drives antibiotic resistance. The optimal duration of antibiotic therapy for Gram-negative bacteraemia (GNB), a common community and hospital-associated infection, remains unknown and unstudied via randomised controlled trials (RCTs).

Methods and analysis: This investigator-initiated, multicentre, non-inferiority, informatics-based point-of-care RCT will randomly assign adult hospitalised patients receiving microbiologically efficacious antibiotic(s) for GNB to (1) 14 days of antibiotic therapy, (2) 7 days of therapy or (3) an individualised duration determined by clinical response and 75% reduction in peak C reactive protein (CRP) values. The randomisation will occur in equal proportions (1:1:1) on day 5 (±1) of efficacious antibiotic therapy as determined by antibiogram; patients, their physicians and study investigators will be blind to treatment duration allocation until the day of antibiotic discontinuation. Immunosuppressed patients and those with GNB due to complicated infections (endocarditis, osteomyelitis, etc) and/or non-fermenting bacilli (Acinetobacter spp, Burkholderia spp, Pseudomonas spp) Brucella spp, Fusobacterium spp or polymicrobial growth with Gram-positive organisms will be ineligible. The primary outcome is incidence of clinical failure at day 30; secondary outcomes include clinical failure, all-cause mortality and incidence of Clostridiumdifficile infection in the 90-day study period. An interim safety analysis will be performed after the first 150 patients have been followed for ≤30 days. Given a chosen margin of 10%, the required sample size to determine non-inferiority is roughly 500 patients. Analyses will be performed on both intention-to-treat and per-protocol populations.

Ethics and dissemination: Ethics approval was obtained from the cantonal ethics committees of all three participating sites. Results of the main trial and each of the secondary endpoints will be submitted for publication in a peer-reviewed journal.

Trial registration number: This trial is registered at www.clinicaltrials.gov (NCT03101072; pre-results).

Keywords: Antibiotic Therapy; Bacteraemia; Duration; Gram-negative; Point-of-care Randomization.

Conflict of interest statement

Competing interests: None declared.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Figures

Figure 1

Trial sites: the HUG is the principal site; CHUV and KSSG are participating peripheral sites. CHUV, Centre Hospitalier Universitaire Vaudois; HUG, Geneva University Hospitals; KSSG, Catonal Hospital St Gallen.

Figure 2

Trial flow: day 1 is defined as the first day of microbiologically appropriate antibiotic therapy. Patients will be randomised on day 5 (±1) and followed until day 90.

Figure 3

Electronic-healthcare record workflow for patient identification, randomisation and follow-up in Geneva. The EHR workflow is outlined in red, the control (‘back-up’) workflow in grey. Grey arrows indicate safety valves; these cover all points at which the EHR workflow could malfunction. In this hypothetical case, the patient has been randomised to the control arm (antibiotic therapy duration of 14 days). EHR, electronic health record.