Impact of Aminoglycosides-based Antibiotics Combination and Protective Isolation on Outcomes in Critically-ill Neutropenic Patients With Sepsis: (Combination-Lock01)
- Conditions
- Septic ShockSepsisTumorAllogeneic Stem Cell TransplantationHematologic Malignancy
- Interventions
- Drug: Aminoglycosides interventionBehavioral: Lack of protective isolation interventionOther: No systematic aminoglycosides intervention - standard armOther: Protective isolation intervention - standard arm
- Registration Number
- NCT05443854
- Lead Sponsor
- Assistance Publique - Hôpitaux de Paris
- Brief Summary
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).
- Detailed Description
Not available
Recruitment & Eligibility
- Status
- UNKNOWN
- Sex
- All
- Target Recruitment
- 340
- 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
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Pregnancy and breastfeeding
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Moribund patients (death expected within 48 hours by attending physician)
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Previous participation to this study
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No affiliation to social security
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Patients under legal protection according to French Law
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Patient having received more than 1 injection of aminoglycosides in the 3 days preceding ICU admission
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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 & Design
- Study Type
- INTERVENTIONAL
- Study Design
- FACTORIAL
- Arm && Interventions
Group Intervention Description Aminoglycosides intervention 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. Lack of protective isolation intervention 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. No systematic aminoglycosides intervention No systematic aminoglycosides intervention - standard arm Antibiotic therapy and prophylaxis will be in line with more recent IDSA and ESCMID guidelines - standard arm Protective isolation intervention Protective isolation intervention - standard arm Protective isolation will be provided systematically as currently practiced in participating centers - standard arm
- Primary Outcome Measures
Name Time Method Mortality at day 90 Overall death
- Secondary Outcome Measures
Name Time Method Rate of clinical cure within 3 months Major Adverse Kidney Events at day 90 Number of days free from organ support therapy (mechanical ventilation, vasopressors or RRT) at day 28 Incidence of clinically apparent loss of hearing at dat 90 Incidence density of new bacterial episodes within 3 months Mortality at Day-28 Overall death
Duration of acute kidney injury within 3 months Acute kidney injury (AKI) will be defined according to KDIGO criteria
Frequency of initial antibiotic therapy inadequate as regard to microbiological documentation. at inclusion Duration of aminoglycoside therapy within 3 months Incidence density of selected serious adverse events within 3 months Hospital mortality at hospital discharge within 3 months Mortality at hospital discharge
Incidence of acute kidney injury within 3 months Acute kidney injury (AKI) will be defined according to KDIGO criteria
Severity of acute kidney injury within 3 months Acute kidney injury (AKI) will be defined according to KDIGO criteria
Rate of adherence of hand hygiene at 24 hours hand hygiene will be assessed by external observer
Incidence density of new viral infection episodes within 3 months Incidence density of new fungal episodes within 3 months Number of day free of antibiotic therapy at day-28 Rate of aminoglycoside overdosage according to residual concentration within 3 months Rate of overuse when compared to experts recommendations within 3 months