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Tobramycin Nebulization to Prevent Multidrug-Resistant Ventilator-Associated Pneumonia (TOP-MDRVAP)

Tobramycin Nebulization to Prevent Multidrug-Resistant Ventilator-Associated Pneumonia: A Prospective, Multicenter, Double-Blind, Randomized Controlled Trial

The TOP-MDRVAP trial will test whether inhaled tobramycin can safely prevent pneumonia caused by multidrug-resistant bacteria in adults who need a breathing machine. Tobramycin is an antibiotic. Multidrug-resistant bacteria are bacteria that resist treatment with several types of antibiotics. Pneumonia that develops in patients receiving breathing support through a breathing tube is called ventilator-associated pneumonia (VAP). This study will evaluate tobramycin as a preventive treatment, rather than as treatment for existing VAP.

The study plans to enroll 574 adults aged 18 years or older in intensive care units (ICUs) at several hospitals. Participants must have received breathing support through a tube for 72 to 96 hours and be expected to need this support for at least another 72 hours. They must have at least one risk factor for infection with multidrug-resistant bacteria and must not have suspected or confirmed VAP when entering the study.

Participants will be assigned by chance to one of two groups, with an equal chance of entering either group. One group will receive tobramycin inhalation solution, 300 mg in 5 mL, twice daily for 3 consecutive days. The other group will receive 5 mL of 0.9% saline, a saltwater solution containing no antibiotic, on the same schedule. A nebulizer will turn the solution into a fine mist delivered through the breathing tube.

Both groups will receive standard measures to prevent VAP. Participants, their representatives, the healthcare professionals providing their direct care, and the researchers assessing outcomes will not know which study treatment each participant receives.

The main question is whether fewer participants develop VAP caused by multidrug-resistant bacteria within 28 days after assignment to a study group. Researchers will also compare the occurrence of VAP from any cause, antibiotic use, time receiving breathing support, time spent in the ICU and hospital, and deaths within 28 and 90 days.

Participants will be monitored for possible side effects, including kidney problems, narrowing of the airways, and complications involving the breathing tube or equipment. Samples will be tested for bacteria and antibiotic resistance. Follow-up will continue for up to 90 days after assignment, using hospital records or telephone contact to assess survival and recovery milestones, including discharge and the end of breathing support.

Aperçu de l'étude

Statut

Pas encore de recrutement

Les conditions

Intervention / Traitement

Type d'étude

Interventionnel

Inscription (Estimé)

574

Phase

  • Phase 4

Contacts et emplacements

Cette section fournit les coordonnées de ceux qui mènent l'étude et des informations sur le lieu où cette étude est menée.

Coordonnées de l'étude

Sauvegarde des contacts de l'étude

Lieux d'étude

    • Zhejiang
      • Hangzhou, Zhejiang, Chine, 310000
        • Second Affiliated Hospital of Zhejiang University School of Medicine
        • Contact:

Critères de participation

Les chercheurs recherchent des personnes qui correspondent à une certaine description, appelée critères d'éligibilité. Certains exemples de ces critères sont l'état de santé général d'une personne ou des traitements antérieurs.

Critère d'éligibilité

Âges éligibles pour étudier

18 ans et plus (Adulte, Adulte plus âgé)

Accepte les volontaires sains

Non

Sexes éligibles pour l'étude

Tout

La description

Inclusion Criteria:

  1. Age ≥18 years at enrollment.

  2. Invasive mechanical ventilation through an endotracheal tube for ≥72 hours and ≤96 hours, measured from the time of intubation, with an anticipated requirement for at least another 72 hours of invasive mechanical ventilation, as assessed by the attending physician.

  3. At least one of the following risk factors for multidrug-resistant (MDR) bacterial infection:

    3.1 Exposure to systemic antibiotics for ≥24 hours within the 30 days before enrollment.

    3.2 Current hospitalization for at least 120 hours before randomization. 3.3 Septic shock requiring vasoactive medication to maintain a mean arterial pressure ≥65 mmHg, with a blood lactate level >2 mmol/L.

    3.4 Moderate-to-severe acute respiratory distress syndrome (ARDS), according to the Berlin definition, with a PaO2/FiO2 ratio ≤200 mmHg and positive end-expiratory pressure (PEEP) ≥5 cm H2O.

    3.5 Current renal replacement therapy, including continuous renal replacement therapy or intermittent hemodialysis.

    3.6 A history of MDR bacterial colonization or infection within the previous 12 months, documented by clinical culture.

  4. Written informed consent obtained from the patient or the patient's legally authorized representative.

Exclusion Criteria:

  1. Suspected or confirmed ventilator-associated pneumonia (VAP) on the day of enrollment, based on the attending physician's clinical judgment.
  2. Continuous invasive mechanical ventilation for more than 96 hours before enrollment.
  3. Planned extubation within the next 24 hours.
  4. Previous tracheostomy.
  5. A history of allergy to tobramycin or any other aminoglycoside antibiotic.
  6. Use of tobramycin within the 7 days before enrollment; ongoing treatment with any aminoglycoside antibiotic at enrollment; or a clinical indication for intravenous treatment with any aminoglycoside antibiotic at enrollment.
  7. Chronic kidney disease (stages 4-5) with a baseline estimated glomerular filtration rate (eGFR) ≤30 mL/min/1.73 m², or acute kidney injury meeting the protocol-specified Kidney Disease: Improving Global Outcomes (KDIGO) stage 3 criteria: serum creatinine increased to three times baseline, serum creatinine >353.6 μmol/L, urine output <0.3 mL/kg/hour for more than 24 hours, or anuria for more than 12 hours. Patients currently receiving renal replacement therapy are exempt from this renal exclusion criterion.
  8. Expected survival of no more than 48 hours, as assessed by the attending physician.
  9. Pregnancy, indicated by a positive serum or urine human chorionic gonadotropin (hCG) test, or breastfeeding.
  10. Concurrent participation in another interventional clinical study involving nebulized antibiotics or other ventilator-associated pneumonia prevention interventions.

Plan d'étude

Cette section fournit des détails sur le plan d'étude, y compris la façon dont l'étude est conçue et ce que l'étude mesure.

Comment l'étude est-elle conçue ?

Détails de conception

  • Objectif principal: La prévention
  • Répartition: Randomisé
  • Modèle interventionnel: Affectation parallèle
  • Masquage: Quadruple

Armes et Interventions

Groupe de participants / Bras
Intervention / Traitement
Expérimental: Nebulized Tobramycin

Participants receive tobramycin inhalation solution, 300 mg in 5 mL per dose, administered through the endotracheal tube using a vibrating mesh nebulizer twice daily for 3 consecutive days (6 planned doses). The intervention is administered to prevent multidrug-resistant ventilator-associated pneumonia (MDR-VAP). Participants also receive standard ventilator-associated pneumonia (VAP) prevention measures.

Tobramycin inhalation solution (300 mg/5 mL) is administered at a dose of 300 mg (5 mL) twice daily for 3 consecutive days, for a total of 6 planned doses. The ready-to-use solution is administered without additional dilution through the endotracheal tube using a vibrating mesh nebulizer connected to the ventilator circuit. Each nebulization continues until the nebulizer reservoir is empty. The intervention is administered to prevent multidrug-resistant ventilator-associated pneumonia (MDR-VAP), in addition to standard VAP prevention measures.

Comparateur placebo: Nebulized 0.9% Sodium Chloride Placebo

Participants receive 5 mL of 0.9% sodium chloride solution (normal saline) as a placebo, administered through the endotracheal tube using a vibrating mesh nebulizer twice daily for 3 consecutive days (6 planned doses). Participants also receive standard ventilator-associated pneumonia (VAP) prevention measures.

A 5 mL dose of 0.9% sodium chloride solution (normal saline) is administered as a placebo twice daily for 3 consecutive days, for a total of 6 planned doses. The solution is delivered through the endotracheal tube using the same type of vibrating mesh nebulizer, administration schedule, and nebulization procedure as the tobramycin intervention. Each nebulization continues until the nebulizer reservoir is empty. Participants also receive standard VAP prevention measures.

Que mesure l'étude ?

Principaux critères de jugement

Mesure des résultats
Description de la mesure
Délai
28-Day Cumulative Incidence of Multidrug-Resistant Ventilator-Associated Pneumonia
Délai: From randomization through Day 28.

Percentage of randomized participants with a first episode of multidrug-resistant ventilator-associated pneumonia (MDR-VAP), adjudicated by an independent blinded endpoint adjudication committee. VAP develops after 48 hours of mechanical ventilation, including within 48 hours after weaning or extubation. Diagnosis requires new or progressive infiltrates, consolidation, or ground-glass opacities on chest X-ray or CT plus at least two of: temperature >38°C, purulent airway secretions, and white blood cell count >10 x 10^9/L or <4 x 10^9/L. MDR-VAP additionally requires a positive quantitative lower respiratory tract culture (tracheal aspirate ≥10^5 CFU/mL; bronchoalveolar lavage ≥10^4 CFU/mL; protected specimen brush ≥10^3 CFU/mL) with a causative bacterium resistant to at least three antimicrobial classes.

From randomization through Day 28.

Mesures de résultats secondaires

Mesure des résultats
Description de la mesure
Délai
Incidence Density of Multidrug-Resistant Ventilator-Associated Pneumonia
Délai: From randomization through Day 28.

Number of first episodes of multidrug-resistant ventilator-associated pneumonia per 1,000 invasive mechanical ventilation days accumulated during the assessment period.

From randomization through Day 28.
28-Day Incidence of Ventilator-Associated Pneumonia From Any Cause
Délai: From randomization through Day 28.

28-Day Incidence of Ventilator-Associated Pneumonia From Any Cause

From randomization through Day 28.
Systemic Antibiotic Use Expressed as Antibiotic-Days
Délai: From randomization through Day 28.

Cumulative systemic antibiotic use during the assessment period, expressed as antibiotic-days.

From randomization through Day 28.
Days of Exposure to Systemic Antibiotics
Délai: From randomization through Day 28.

Number of days on which a participant receives at least one systemic antibiotic during the assessment period. Each day with systemic antibiotic exposure is counted once, regardless of the number of antibiotics administered.

From randomization through Day 28.
Duration of Mechanical Ventilation
Délai: From randomization through Day 28.

Total duration of invasive and noninvasive mechanical ventilation, measured in days, during the assessment period.

From randomization through Day 28.
Intensive Care Unit Length of Stay
Délai: From randomization to ICU discharge, assessed up to Day 90.

Duration of intensive care unit stay, measured in days from randomization to ICU discharge, with follow-up through Day 90.

From randomization to ICU discharge, assessed up to Day 90.
Hospital Length of Stay
Délai: From randomization to hospital discharge, assessed up to Day 90.

Duration of hospital stay, measured in days from randomization to hospital discharge, with follow-up through Day 90.

From randomization to hospital discharge, assessed up to Day 90.
28-Day All-Cause Mortality
Délai: From randomization through Day 28.

Percentage of participants who die from any cause within 28 days after randomization.

From randomization through Day 28.
90-Day All-Cause Mortality
Délai: From randomization through Day 90.

Percentage of participants who die from any cause within 90 days after randomization. Survival status is obtained from hospital records or telephone follow-up.

From randomization through Day 90.
Incidence of Ventilator-Associated Pneumonia Caused by Tobramycin-Susceptible Gram-Negative Bacteria
Délai: From randomization through Day 28.

Percentage of participants who develop ventilator-associated pneumonia caused by gram-negative bacteria that are susceptible to tobramycin on in vitro antimicrobial susceptibility testing.

From randomization through Day 28.
Incidence of Ventilator-Associated Events
Délai: From randomization through Day 28.

Percentage of participants who develop a ventilator-associated event, assessed using the protocol-specified 2023 Centers for Disease Control and Prevention/National Healthcare Safety Network definitions. Assessments include ventilator-associated conditions, infection-related ventilator-associated complications, and possible ventilator-associated pneumonia.

From randomization through Day 28.
Incidence of New-Onset Acute Kidney Injury
Délai: From randomization through Day 28.

Percentage of participants without acute kidney injury at baseline who develop Kidney Disease: Improving Global Outcomes (KDIGO) stage 1 or higher acute kidney injury during the assessment period.

From randomization through Day 28.
Daily Trajectory of the Clinical Pulmonary Infection Score
Délai: Assessed daily from randomization until extubation or Day 28, whichever occurs first.

Daily Clinical Pulmonary Infection Score (CPIS) values and their longitudinal changes during the assessment period, calculated using available clinical data.

Assessed daily from randomization until extubation or Day 28, whichever occurs first.
Time to First Successful Spontaneous Breathing Trial
Délai: From randomization through Day 28.

Time, measured in days, from randomization to the first successful spontaneous breathing trial (SBT) during the assessment period.

From randomization through Day 28.
Detection Rate of Tobramycin-Resistant Bacteria
Délai: From randomization through Day 28.

Rate of isolation of tobramycin-resistant bacteria from respiratory specimens or blood cultures during the assessment period.

From randomization through Day 28.
Composite Incidence of Serious Nebulization-Related Adverse Effects
Délai: From randomization through Day 28.

Percentage of participants experiencing at least one serious adverse effect related to nebulization, including increased expiratory filter resistance, bronchospasm, or endotracheal tube obstruction.

From randomization through Day 28.

Autres mesures de résultats

Mesure des résultats
Description de la mesure
Délai
Longitudinal Changes in Respiratory Microbiome Alpha Diversity
Délai: Protocol-specified Days 1, 4, 7, and 14, with additional sampling at VAP onset.

Longitudinal changes in respiratory microbiome alpha diversity, assessed by 16S ribosomal RNA amplicon sequencing in participants enrolled in the microbiome substudy.

Protocol-specified Days 1, 4, 7, and 14, with additional sampling at VAP onset.
Longitudinal Changes in Respiratory Microbiome Beta Diversity
Délai: Protocol-specified Days 1, 4, 7, and 14, with additional sampling at VAP onset.

Longitudinal changes in respiratory microbiome beta diversity, assessed by 16S ribosomal RNA amplicon sequencing in participants enrolled in the microbiome substudy.

Protocol-specified Days 1, 4, 7, and 14, with additional sampling at VAP onset.
Longitudinal Changes in Antibiotic Resistance Gene Abundance
Délai: Protocol-specified Days 1, 4, 7, and 14, with additional sampling at VAP onset.

Longitudinal changes in antibiotic resistance gene abundance in respiratory samples, assessed by metagenomic next-generation sequencing.

Protocol-specified Days 1, 4, 7, and 14, with additional sampling at VAP onset.
Longitudinal Changes in Antibiotic Resistance Gene Diversity
Délai: Protocol-specified Days 1, 4, 7, and 14, with additional sampling at VAP onset.

Longitudinal changes in antibiotic resistance gene diversity in respiratory samples, assessed by metagenomic next-generation sequencing.

Protocol-specified Days 1, 4, 7, and 14, with additional sampling at VAP onset.
Tobramycin Concentration-Time Profile in Epithelial Lining Fluid
Délai: During the 3-day study treatment period.

Tobramycin concentrations in epithelial lining fluid over time in participants enrolled in the pharmacokinetic substudy.

During the 3-day study treatment period.
Plasma Tobramycin Concentration-Time Profile
Délai: During the 3-day study treatment period.

Plasma tobramycin concentrations over time in participants enrolled in the pharmacokinetic substudy.

During the 3-day study treatment period.

Collaborateurs et enquêteurs

C'est ici que vous trouverez les personnes et les organisations impliquées dans cette étude.

Dates d'enregistrement des études

Ces dates suivent la progression des dossiers d'étude et des soumissions de résultats sommaires à ClinicalTrials.gov. Les dossiers d'étude et les résultats rapportés sont examinés par la Bibliothèque nationale de médecine (NLM) pour s'assurer qu'ils répondent à des normes de contrôle de qualité spécifiques avant d'être publiés sur le site Web public.

Dates principales de l'étude

Début de l'étude (Estimé)

7 octobre 2026

Achèvement primaire (Estimé)

31 octobre 2028

Achèvement de l'étude (Estimé)

29 janvier 2029

Dates d'inscription aux études

Première soumission

23 septembre 2026

Première soumission répondant aux critères de contrôle qualité

23 septembre 2026

Première publication (Réel)

2 octobre 2026

Mises à jour des dossiers d'étude

Dernière mise à jour publiée (Réel)

2 octobre 2026

Dernière mise à jour soumise répondant aux critères de contrôle qualité

23 septembre 2026

Dernière vérification

1 septembre 2026

Plus d'information

Termes liés à cette étude

Autres numéros d'identification d'étude

  • 2026-0634

Plan pour les données individuelles des participants (IPD)

Prévoyez-vous de partager les données individuelles des participants (DPI) ?

OUI

Description du régime IPD

De-identified individual participant data underlying the results reported in the primary publication of the TOP-MDRVAP trial will be shared, together with a data dictionary. The dataset will include baseline characteristics, treatment allocation, and data supporting the reported efficacy and safety outcomes. Direct identifiers and the participant identification linkage file will not be shared. Data will be made available through controlled access for approved research proposals, subject to participant consent, institutional and ethics requirements, and applicable data-protection regulations.

Délai de partage IPD

Data and supporting documents will be available beginning 6 months after publication of the primary trial results and ending 5 years after that publication.

Critères d'accès au partage IPD

Access will be available to qualified researchers who submit a methodologically sound proposal for secondary analyses or individual participant data meta-analyses. Requests should be submitted to the principal investigator through the study contact listed in the trial registry. The principal investigator and the study Executive Committee will review the scientific merit, feasibility, and data-protection safeguards of each request. Approved applicants must sign a data use agreement limiting use to the approved research, prohibiting participant re-identification and unauthorized onward sharing, and requiring secure data storage. Data will be provided by secure electronic transfer after any required institutional, ethics, or regulatory approvals have been obtained.

Type d'informations de prise en charge du partage d'IPD

  • PROTOCOLE D'ÉTUDE
  • SÈVE

Informations sur les médicaments et les dispositifs, documents d'étude

Étudie un produit pharmaceutique réglementé par la FDA américaine

Non

Étudie un produit d'appareil réglementé par la FDA américaine

Non

Ces informations ont été extraites directement du site Web clinicaltrials.gov sans aucune modification. Si vous avez des demandes de modification, de suppression ou de mise à jour des détails de votre étude, veuillez contacter register@clinicaltrials.gov. Dès qu'un changement est mis en œuvre sur clinicaltrials.gov, il sera également mis à jour automatiquement sur notre site Web .