이 페이지는 자동 번역되었으며 번역의 정확성을 보장하지 않습니다. 참조하십시오 영문판 원본 텍스트의 경우.

그람 음성 혈류 감염에 대한 플랫폼 시험 (BALANCE+)

2026년 11월 5일 업데이트: Dr. Nick Daneman, Sunnybrook Health Sciences Centre

BALANCE+: 그람 음성 혈류 감염에 대한 플랫폼 시험

BALANCE+ is a perpetual multiple domain randomized controlled platform trial to evaluate various treatment strategies for Gram-negative bloodstream infections (GN BSIs). Each domain addresses critical questions in the management of GN BSIs, aiming to refine treatment strategies, enhance patient outcomes, and reduce antimicrobial resistance.

The initial vanguard pilot RCT (NCT05893147) started on 29 August 2023 and has successfully completed the pilot phase on 24-Apr-2024. All patients enrolled in the vanguard phase are part of the main platform trial.

연구 개요

상태

모병

정황

개입 / 치료

상세 설명

BALANCE+ is an adaptive platform trial evaluating multiple treatment options in patients admitted to the hospital due to Gram negative bloodstream infections (BSIs). It focuses on both cross-cutting and subgroup-specific questions, using an open-label, pragmatic design embedded in routine care.

BALANCE+ addresses the significant health concern of BSIs, which have high morbidity and mortality rates, exacerbated by the global public health threat of antimicrobial resistance (AMR). With rising resistance rates and limited new drug development, effective treatment strategies for BSIs remain under-researched.

BALANCE+ follows the BALANCE trial, which evaluated duration of antibiotic treatment, and aims to further investigate critical questions in managing Gram-negative BSIs. This platform trial will explore various aspects of BSI treatment, including antibiotic de-escalation, oral antibiotic choices, central line management, treatment of specific pathogens, and the necessity of follow-up blood cultures.

BALANCE+ is using Bayesian methods without a fixed sample size. Interim analyses will occur after every 1000th patient in each domain, and then for every 200th patient thereafter. The trial will stop if futility or superiority thresholds are met, or if a domain reaches its ceiling sample size (2500 patients for most domains and 4000 for the beta-lactam versus non-beta-lactam domain) without meeting a stopping threshold.

A vanguard pilot trial involving over 150 patients at 9 hospitals across Canada confirmed the feasibility of the BALANCE+ trial. The main trial will include patients from the vanguard pilot phase since there has been no major change in the overall study design and domains. The adaptive design allows for interim analyses and adjustments by adding or removing domains as per the statistical analysis plan, enhancing the trial's efficiency and relevance.

연구 유형

중재적

등록 (추정된)

2500

단계

  • 해당 없음

연락처 및 위치

이 섹션에서는 연구를 수행하는 사람들의 연락처 정보와 이 연구가 수행되는 장소에 대한 정보를 제공합니다.

연구 연락처

연구 연락처 백업

연구 장소

    • Auckland
      • Auckland, Auckland, 뉴질랜드, 2025
        • 모병
        • Middlemore Hospital
        • 연락하다:
        • 연락하다:
        • 수석 연구원:
          • Susan Morpeth, Clinical Microbiologist
        • 부수사관:
          • Michael Trent Herdman, Specialist Registrar
      • Takapuna, Auckland, 뉴질랜드, 0622
    • Wellington Region
      • Newtown, Wellington Region, 뉴질랜드, 6021
        • 모병
        • Wellington Hospital
        • 연락하다:
        • 수석 연구원:
          • Maxim Bloomfield
        • 부수사관:
          • Paul Young
    • Tel Aviv
      • Ramat Gan, Tel Aviv, 이스라엘
        • 모병
        • Sheba Medical Center
        • 수석 연구원:
          • Dafna Yahav
        • 연락하다:
    • Alberta
      • Calgary, Alberta, 캐나다
      • Calgary, Alberta, 캐나다
        • 모병
        • Peter Lougheed Centre
        • 수석 연구원:
          • Ranjani Somayaji
        • 연락하다:
      • Calgary, Alberta, 캐나다
        • 모병
        • South Health Campus
        • 수석 연구원:
          • Ranjani Somayaji
        • 연락하다:
      • Calgary, Alberta, 캐나다
        • 모병
        • Foothills Hospital
        • 연락하다:
          • Ranjani Somayaji, MD
      • Edmonton, Alberta, 캐나다
        • 모병
        • University of Alberta
        • 연락하다:
        • 수석 연구원:
          • Wendy Sligl
    • British Columbia
      • Surrey, British Columbia, 캐나다
        • 모병
        • Surrey Memorial Hospital
        • 수석 연구원:
          • Kevin Afra
        • 연락하다:
      • Vancouver, British Columbia, 캐나다
        • 모병
        • Vancouver General Hospital
        • 수석 연구원:
          • Jennifer Grant
        • 연락하다:
    • Manitoba
      • Winnipeg, Manitoba, 캐나다
        • 모병
        • Health Sciences Centre
        • 연락하다:
        • 수석 연구원:
          • Sylvain Lother
      • Winnipeg, Manitoba, 캐나다
        • 모병
        • St. Boniface Hospital
        • 수석 연구원:
          • Terry Wuerz
        • 연락하다:
      • Winnipeg, Manitoba, 캐나다
        • 모병
        • Grace Hospital
        • 연락하다:
        • 수석 연구원:
          • Gloria Vazquez-Grande
    • New Brunswick
      • Fredericton, New Brunswick, 캐나다
        • 모병
        • Dr. Everett Chalmers Regional Hospital
        • 연락하다:
        • 수석 연구원:
          • Rosa Rossana
    • Newfoundland and Labrador
      • St. John's, Newfoundland and Labrador, 캐나다
        • 모병
        • Eastern Regional Health Authority
        • 연락하다:
          • Peter Daley, MD
    • Ontario
      • Mississauga, Ontario, 캐나다
        • 모병
        • Trillium Health Partners - Mississauga Hospital
        • 연락하다:
        • 연락하다:
          • Mobina Khurram
        • 수석 연구원:
          • Christopher Graham
      • North York, Ontario, 캐나다
        • 모병
        • Humber River Health system
        • 연락하다:
          • Ian Brasg
          • 전화번호: (416) 242-1000
          • 이메일: ibrasg@hrh.ca
        • 수석 연구원:
          • Ian Brasg
      • North York, Ontario, 캐나다
        • 모병
        • North York General Hospital
        • 연락하다:
        • 수석 연구원:
          • Pavani Das
      • Ottawa, Ontario, 캐나다
        • 모병
        • The Ottawa Hospital
        • 연락하다:
          • Derek McFadden, MD
      • St. Catharines, Ontario, 캐나다
        • 모병
        • Niagara Health System
        • 연락하다:
          • Aidan Findlater, MD
      • Toronto, Ontario, 캐나다
        • 모병
        • University Health Network
        • 연락하다:
          • Bryan Coburn, MD
      • Toronto, Ontario, 캐나다, M4N3M5
        • 모병
        • Sunnybrook Health Sciences Centre
        • 연락하다:
        • 연락하다:
        • 수석 연구원:
          • Rob A Fowler, MD
        • 수석 연구원:
          • Nick Daneman, MD
      • Toronto, Ontario, 캐나다
        • 모병
        • Michael Garron Hospital
        • 연락하다:
          • Christopher Kandel, MD
      • Toronto, Ontario, 캐나다
        • 모병
        • Mount Sinai Hospital
        • 연락하다:
          • Michael Fralick, PhD
      • Toronto, Ontario, 캐나다
        • 모병
        • St. Joseph's Health Centre
        • 연락하다:
        • 수석 연구원:
          • Kevin Schwartz
    • Quebec
      • Laval, Quebec, 캐나다
        • 모병
        • Hôpital de la Cité de la Santé
        • 연락하다:
        • 수석 연구원:
          • Marco Bergevin
        • 부수사관:
          • Stéphanie Castonguay
        • 부수사관:
          • Olivier Haeck
        • 부수사관:
          • Esther Simoneau
        • 부수사관:
          • Marios Roussos
        • 부수사관:
          • Natalie Rivest
        • 부수사관:
          • Tuyen Nguyen
      • Laval, Quebec, 캐나다
        • 모병
        • CHU de Québec - Université Laval
        • 연락하다:
        • 수석 연구원:
          • Francois Lauzier
        • 부수사관:
          • Julie Bestman-Smith
      • Montreal, Quebec, 캐나다
        • 모병
        • Montreal General Hospital- McGill
        • 연락하다:
        • 수석 연구원:
          • Todd C Lee
        • 수석 연구원:
          • Emily Mcdonald
      • Montreal, Quebec, 캐나다
        • 모병
        • Royal Victoria Hospital- McGill
        • 연락하다:
        • 수석 연구원:
          • Emily McDonald
        • 수석 연구원:
          • Todd C Lee
      • Sherbrooke, Quebec, 캐나다
        • 모병
        • Université de Sherbrooke
        • 연락하다:
          • François Lamontagne, MD
      • Trois-Rivières, Quebec, 캐나다, G8Z 3R9
        • 모병
        • Centre hospitalier affilié universitaire régional (CHAUR)
        • 연락하다:
        • 수석 연구원:
          • Jean-François Naud
    • Cundinamarca
      • Chía, Cundinamarca, 콜롬비아
        • 모병
        • Universidad de La Sabana
        • 연락하다:
        • 수석 연구원:
          • Luis Felipe Reyes Velasco
    • New South Wales
      • Kogarah, New South Wales, 호주, 2217
        • 모병
        • St George Hospital
        • 수석 연구원:
          • Richard Sullivan
        • 연락하다:
        • 부수사관:
          • Pam Konecny
        • 연락하다:
          • Rachael Roberts, Research Coordinator
      • New Lambton, New South Wales, 호주
        • 모병
        • John Hunter Hospital
        • 연락하다:
        • 연락하다:
          • 전화번호: +61 2 4921 3000
        • 수석 연구원:
          • Joshua Davis
    • Queensland
      • Herston, Queensland, 호주, 4006
        • 모병
        • Royal Brisbane and Women's Hospital
        • 연락하다:
        • 수석 연구원:
          • Patrick Harris, Infectious Disease Physician
      • Redcliffe, Queensland, 호주
        • 모병
        • Redcliffe Hospital
        • 수석 연구원:
          • Kevin O'Callaghan
        • 연락하다:
      • Sunshine Coast, Queensland, 호주
        • 모병
        • Sunshine Coast University Hospital
        • 연락하다:
        • 수석 연구원:
          • Gururaj Nagaraj
    • Victoria
      • Clayton, Victoria, 호주
        • 모병
        • Monash Medical Center
        • 수석 연구원:
          • Ben Rogers
        • 연락하다:
    • Western Australia
      • Murdoch, Western Australia, 호주
        • 모병
        • Fiona Stanley Hospital
        • 연락하다:
        • 수석 연구원:
          • Edward Raby
      • Murdoch, Western Australia, 호주
        • 모병
        • St John of God
        • 연락하다:
        • 수석 연구원:
          • Adrian Regli

참여기준

연구원은 적격성 기준이라는 특정 설명에 맞는 사람을 찾습니다. 이러한 기준의 몇 가지 예는 개인의 일반적인 건강 상태 또는 이전 치료입니다.

자격 기준

공부할 수 있는 나이

1초 (어린이, 성인, 고령자)

건강한 자원 봉사자를 받아들입니다

아니

연구 대상 성별

모두

설명

PLATFORM INCLUSION CRITERIA

Platform Inclusion Criteria:

  • admitted to a participating hospital
  • positive blood culture with Gram negative (GN) bacterium

Platform Exclusion Criteria:

  • patient's goals of care are for palliation with no active treatment
  • moribund patient, not expected to survive > 72 hours
  • previously enrolled in the platform trial
  • not eligible for any domain at the time of screening

DOMAIN SPECIFIC INCLUSION AND EXCLUSION CRITERIA

  1. De-escalation versus no de-escalation domain

    Inclusion Criteria

    - included in BALANCE+ platform

    Exclusion Criteria

    • receiving an empiric antibiotic regimen at the time of blood culture finalization to which the GN pathogen(s) are not sensitive

    • arbapenem-non-susceptible

    • no de-escalation option due to any or all of:

      • antimicrobial resistance
      • allergies
      • medical contraindications
      • drug-drug interaction risk
      • other relevant reason
    • patients with a suspected or proven polymicrobial source of infection

    • > 24 hours since index blood culture susceptibility results finalization

  2. Beta-lactam versus non-beta-lactam oral/enteral treatment domain

    Inclusion Criteria

    • included in BALANCE+ platform
    • initially treated with intravenous antibiotics, but clinical team transitioning patient to oral/enteral antibiotic within 7 days of starting treatment

    Exclusion Criteria

    • enrolled in an arm of another BALANCE+ platform domain which limits the use of oral/enteral therapy:

    • no-de-escalation arm (patients in the no de-escalation arm cannot be randomized into this domain unless they are ready for discharge home, in which case de-escalation is allowable to oral agents at discharge)

    • no non-beta-lactam options due to any or all of:

      • resistance
      • allergies
      • medical contraindications
      • drug-interaction risk
      • other relevant reason
    • no beta-lactam options due to any or all of:

      • resistance
      • allergies
      • medical contraindications
      • drug-interaction risk
      • other relevant reason
    • pregnancy

    • already received >24 hours of oral antibiotics after index blood culture finalization

  3. Central vascular catheter replacement domain

    Inclusion Criteria

    • included in BALANCE+ platform
    • has an indwelling central vascular catheter that was already in place within the 48-hour period before the onset of bloodstream infection (i.e. is not a new catheter placed within 48 hours of the onset of infection)

    Exclusion Criteria

    • patient has no ongoing need for a central vascular catheter

    • patient has definite indication for central vascular catheter removal

    • ongoing septic shock with definite/probable line source o concomitant S. aureus bacteremia

      • concomitant candidemia
    • local suppurative signs (severe redness, warmth, pain, swelling or fluctuance/collection) necessitating catheter removal, or other clinical evidence of infected line (e.g. imaging/echocardiographic findings)

  4. Low-risk AmpC domain

    Inclusion Criteria

    • included in BALANCE+ platform
    • positive blood culture with GN bacterium, of the following species: i. Serratia spp. ii Morganella spp. iii Providencia spp. iv Proteus spp. other than P.mirabilis
    • organism is susceptible to ceftriaxone

    Exclusion Criteria

    - severe allergy to beta-lactams (e.g., type 4 hypersensitivity reaction or DRESS)

    • baseline phenotypic non-susceptiblity to ceftriaxone
    • more than 1 calendar day beyond availability of susceptibility results
  5. Follow up blood culture domain

    Inclusion Criteria

    - included in BALANCE+ platform

    Exclusion Criteria

    • patient died or discharged from hospital prior to day 4
    • blood culture already collected by the treating team at day 4±1
    • >5 days since index positive blood culture collection
    • definite indication for repeat blood culture testing o concomitant S. aureus bacteremia o concomitant Candidemia o clinical suspicion for infective endocarditis
  6. 4 day versus 7-day antibiotic duration

    Inclusion Criteria • improving clinical trajectory, based on meeting all of these criteria by the 4th calendar day of adequate antibiotics:

    o temperature 35.0ºC-37.9ºC

    o not on vasopressors

    o FiO2 ≤ 50%

    Exclusion Criteria

    • Has not undergone successful source control (if required) before completing 4th calendar day of adequate antibiotics

    • Neutropenia (<0.5 × 10⁹/L)

    • solid organ or bone marrow transplantation
    • suspected or documented deep-seated infection requiring prolonged antibiotics

공부 계획

이 섹션에서는 연구 설계 방법과 연구가 측정하는 내용을 포함하여 연구 계획에 대한 세부 정보를 제공합니다.

연구는 어떻게 설계됩니까?

디자인 세부사항

  • 주 목적: 치료
  • 할당: 무작위
  • 중재 모델: 병렬 할당
  • 마스킹: 없음(오픈 라벨)

무기와 개입

참가자 그룹 / 팔
개입 / 치료
활성 비교기: 축소 VS 축소 없음

No de-escalation group: continue to receive the same antibiotic that was started initially (as long as it is confirmed to be effective based on the blood culture sensitivity result). De-escalation is only allowed within 7 days if patient is being discharged from hospital.

De-escalation group: switched to narrower spectrum antibiotic (based on spectrum scale specified in protocol).

활성 비교기: 경구 베타락탐 VS 경구 비베타락탐

Beta-lactam antibiotic: This can be, but not limited to, amoxicillin, amoxicillin-clavulanate, cephalexin, cefadroxil, or cefixime.

Non beta-lactam antibiotic: This can be ciprofloxacin, moxifloxacin, levofloxacin or trimethoprim-sulfamethoxazole.

활성 비교기: 중심혈관 카테터 유지 VS 중심혈관 카테터 교체

Central vascular catheter replacement: the catheter will be changed by the treating team as soon as possible and within a maximum of 3 calendar days from blood culture finalization (removal must happen within that time; replacement can occur after that time point)

Central vascular catheter retention: the catheter will not be changed and will be retained until it is non functional or no longer needed.

활성 비교기: 저위험 AmpC 미생물에 대한 Cephalosporin VS Carbapenem

Cephalosporin (ceftriaxone) at standard doses

Carbapenem (Meropenem or Ertapenem) at standard doses

활성 비교기: Routine follow-up blood culture VS No routine follow-up blood culture

Enrollment to the domain has been completed.

Routine follow-up blood culture: routine repeat blood collection 4 days from the index blood collection with positive bacteria.

No follow-up blood culture: no routine repeat blood collection 4 days from the index blood collection with positive bacteria

활성 비교기: 4-day versus 7-day antibiotic duration

The shorter duration arm will receive 4 days of adequate antibiotics. The longer duration arm will receive 7 days of adequate antibiotics.

연구는 무엇을 측정합니까?

주요 결과 측정

결과 측정
측정값 설명
기간
Desirability of Outcome Ranking (DOOR) Ordinal Scale which incorporates death, reinfection, readmission, and for some domains incorporates a tie-breaker of new antimicrobial resistance (AMR).
기간: 90 days

The primary outcome for each domain will use a Desirability of Outcome Ranking (DOOR) ordinal scale in which patients are categorized into the following mutually exclusive categories, ranked from best to worst status:

  1. Alive with no reinfection or readmission.
  2. Alive with reinfection OR readmission.
  3. Alive with reinfection AND readmission.
  4. Dead

For the 4 antibiotic-related domains (the de-escalation versus no de-escalation domain, the beta-lactam versus non-beta-lactam domain, the low risk AmpC domain, and the 4 versus 7 day duration domain) there will be an additional tie-breaker within ordinal levels 1, 2 and 3 based on whether there was new detection of antimicrobial resistance (AMR).

90 days

2차 결과 측정

결과 측정
측정값 설명
기간
30일 사망률
기간: 30 일
30 일
90일 사망
기간: 90일
90일
60일 사망
기간: 60일
60일
90일 모든 원인 재입원
기간: 90일
90일
90일 AMR 집락화/감염
기간: 90일
90일
90일 클로스트리디오이데스 디피실 감염(CDI)
기간: 90일
90일
90일 재감염
기간: 90일
90일
Additional Secondary Outcomes for Follow up blood culture domain
기간: 90 days
  • total duration of antibiotic therapy
  • hospital length of stay
90 days
Additional Secondary Outcomes for De-escalation versus no de-escalation Domain
기간: 90 days
  • change in total microbiome diversity between the day of randomization and discharge (or day 30 if earlier)
  • net change in resistome AMR burden between the day of randomization and discharge (or day 30 if earlier).
90 days
Additional Secondary Outcomes for Beta-lactam versus non-beta-lactam domain
기간: 90 days
  • antibiotic-related allergic reaction
  • antibiotic-related adverse event
90 days
Additional Secondary Outcomes for Central vascular catheter replacement versus retention domain
기간: 90 days
  • pneumothorax or thoracotomy tube insertion related to vascular catheter
  • clinically important bleeding
  • line associated thrombus
  • persistent bacteremia >5d from initial index culture
  • secondary bloodstream infection with new bacterial or fungal organism
90 days
Additional Secondary Outcomes for Low-risk AmpC domain
기간: 90 days
  • isolation of ESBL producing organism or third generation cephalosporin resistant Gram negative organism
  • isolation of a carbapenem-resistant organism
90 days
Additional domain-specific secondary outcomes in 4-day versus 7-day antibiotic duration
기간: 90 days
  • antibiotic-related allergic reaction

  • antibiotic-related (non-allergic) adverse event (grade 4+ or 3+ with treatment change)

  • microbiome/resistome sub-study

    • change in total microbiome diversity (Shannon diversity index) between the day of randomization and day 30
    • change in total microbiome diversity (Shannon diversity index) between the day of randomization and day 7
    • net change in resistome AMR burden between the day of randomization and day 30
    • change in total microbiome diversity (Shannon diversity index) between the day of randomization and day 7
90 days

공동 작업자 및 조사자

여기에서 이 연구와 관련된 사람과 조직을 찾을 수 있습니다.

스폰서

협력자

수사관

  • 수석 연구원: Nick Daneman, MD, Sunnybrook Health Sciences Centre
  • 수석 연구원: Rob Fowler, MD, Sunnybrook Health Sciences Centre

연구 기록 날짜

이 날짜는 ClinicalTrials.gov에 대한 연구 기록 및 요약 결과 제출의 진행 상황을 추적합니다. 연구 기록 및 보고된 결과는 공개 웹사이트에 게시되기 전에 특정 품질 관리 기준을 충족하는지 확인하기 위해 국립 의학 도서관(NLM)에서 검토합니다.

연구 주요 날짜

연구 시작 (실제)

2024년 4월 24일

기본 완료 (추정된)

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약물 및 장치 정보, 연구 문서

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이 정보는 변경 없이 clinicaltrials.gov 웹사이트에서 직접 가져온 것입니다. 귀하의 연구 세부 정보를 변경, 제거 또는 업데이트하도록 요청하는 경우 register@clinicaltrials.gov. 문의하십시오. 변경 사항이 clinicaltrials.gov에 구현되는 즉시 저희 웹사이트에도 자동으로 업데이트됩니다. .