The Qure study: Q fever fatigue syndrome--response to treatment; a randomized placebo-controlled trial

Stephan P Keijmel, Corine E Delsing, Tom Sprong, Gijs Bleijenberg, Jos W M van der Meer, Hans Knoop, Chantal P Bleeker-Rovers, Stephan P Keijmel, Corine E Delsing, Tom Sprong, Gijs Bleijenberg, Jos W M van der Meer, Hans Knoop, Chantal P Bleeker-Rovers

Abstract

Background: Q fever is a zoonosis that is present in many countries. Q fever fatigue syndrome (QFS) is one of the most frequent sequelae after an acute Q fever infection. QFS is characterized by persistent fatigue following an acute Q fever infection, leading to substantial morbidity and a high socio-economic burden. The occurrence of QFS is well-documented, and has been described in many countries over the past decades. However, a treatment with proven efficacy is not available. Only a few uncontrolled studies have tested the efficacy of treatment with antibiotics on QFS. These studies suggest a positive effect of long-term treatment with a tetracycline on performance state; however, no randomized controlled trials have been performed. Cognitive behavioral therapy (CBT) has been proven to be an effective treatment modality for chronic fatigue in other diseases, but has not yet been tested in QFS. Therefore, we designed a trial to assess the efficacy of long-term treatment with the tetracycline doxycycline and CBT in patients with QFS.

Methods/design: A randomized placebo-controlled trial will be conducted. One-hundred-eighty adult patients diagnosed with QFS will be recruited and randomized between one of three groups: CBT, long-term doxycycline or placebo. First, participants will be randomized between CBT and medication (ratio 1:2). A second double-blinded randomization between doxycycline and placebo (ratio 1:1) will be performed in the medication condition. Each group will be treated for six months. Outcome measures will be assessed at baseline and post intervention. The primary outcome measure is fatigue severity. Secondary outcome measures are functional impairment, level of psychological distress, and Coxiella burnetii PCR and serology.

Discussion: The Qure study is the first randomized placebo-controlled trial, which evaluates the efficacy of long-term doxycycline and of cognitive behavioral therapy in patients with QFS. The results of this study will provide knowledge about evidence-based treatment options for adult patients with QFS.

Trial registration: ClinicalTrials.gov: NCT01318356, and Netherlands Trial Register: NTR2797.

Figures

Figure 1
Figure 1
Flowchart of trial design. * According to the Dutch guideline Q fever fatigue syndrome [14]. Including questionnaires: general questionnaire, CIS, SIP total score. ** General questionnaire, PARS, SES28, IMQ, CBRSQ, JFCS, CAL, and SCL90. # Questionnaires used for mediation analysis: PARS, SES28, IMQ, CBRSQ, and CIS. ¥ Exclusion criteria: pregnancy; serious adverse events; AST/ALT > 5 times normal value; AF > 3 times normal value; > 10 days use of quinolon, co-trimoxazol, macroliden or tetracycline; or discontinuation of study medication > 7 consecutive days. ^ CIS, PARS, IMQ, JFCS, SIP, SES28, CBRSQ, and SCL90. Abbreviations: CIS = Checklist Individual Strength, SIP = Sickness Impact Profile, ECCF = Expert Centre for Chronic Fatigue, PARS = Physical Activity Rating, SES28 = Self Efficacy Scale, IMQ = Symptom focusing of the illness Management Questionnaire, CBRSQ = Cognitive and Behavioral Responses to Symptoms Questionnaire, JFCS = Jacobson Fatigue Catastrophising Scale, CAL = Causal Attribution List, SCL90 = Symptom Checklist 90, CBT = cognitive behavioral therapy, AST = aspartate aminotransferase, ALT = alanine aminotransferase, AF = alkaline phosphatase.

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