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Candida in the Respiratory Tract Secretions of Critically Ill Patients and The Efficacy of Antifungal Treatment

Information source: Clinical Evaluation Research Unit at Kingston General Hospital
ClinicalTrials.gov processed this data on August 23, 2015
Link to the current ClinicalTrials.gov record.

Condition(s) targeted: Ventilator Associated Pneumonia; Respiratory Tract Infection

Intervention: Normal Saline (Other); anidulafungin (Drug)

Phase: Phase 2

Status: Terminated

Sponsored by: Daren K. Heyland

Official(s) and/or principal investigator(s):
Daren Heyland, MD, Study Chair, Affiliation: Clinical Evaluation Research Unit

Summary

The purpose of the study is to determine whether the effect of treating Candida spp. isolated in the respiratory tract secretions of patients with a clinical suspicion of ventilator associated pneumonia (VAP) on clinical outcomes will be feasible and supported by biomarker data obtained.

Clinical Details

Official title: Candida in the Respiratory Tract Secretions of Critically Ill Patients and The Efficacy of Antifungal Treatment (The CANTREAT Study): A Prospective, Randomized, Double Blind, Placebo Controlled Pilot Study

Study design: Allocation: Randomized, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor)

Primary outcome: Feasibility will be assessed as follows: 1) Recruitment rates; 2) time required to capture required data; 3) acceptability of treatment protocol and requirement for open-label antifungal agents; 4)acceptability of laboratory procedures.

Secondary outcome:

Duration of stay in ICU

Adjudicated diagnosis of superinfection

Acquired resistance to antifungal therapy

Ventilator free days

ICU free days

Antibiotic free days 28-day post randomization

Hospital length of stay (hospital survival and 90 day mortality)

Change in organ function as measured by Sequential Organ Failure Assessment (COFA) post randomization

Sequential procalcitonin, C-reactive protein, interleukin-6 and B-glucan levels

Detailed description: Candida spp. is commonly retrieved from microbiologic specimens of ICU patients with suspected VAP. It has been associated with increased systemic inflammation and worse clinical outcomes. This association may be due to the propensity for Candida to colonize those who are sicker, who have increased levels of systemic inflammation and worse clinical outcomes. However, an alternate possibility is that Candida is more than a colonizer and is responsible for the clinical and biochemical features observed. The only way to clarify the pathogenic role of Candida from this patient population is to treat the organism and see if patients improve compared to an untreated group. The purpose of this research program is to conduct such a study to determine if Candida in respiratory tract secretions should be routinely treated in critically ill patients. Since a definitive randomized controlled trial designed to demonstrate a reduction in mortality would be large, require the commitment of large amount of resources including both time and money, the investigators propose to first conduct a small pilot feasibility study. Eligible patients will be randomized to receive antifungal treatment with anidulafungin or placebo. Following enrollment, study treatment (or placebo) will be started as soon as possible. When the Candida or yeast organisms have been speciated and/or a susceptibility profile is known, the study medication will be adjusted based on susceptibility patterns. The investigators propose to treat with antifungal therapy for a total of 14 days. Patients will be followed daily for their entire stay in ICU or till day 28, whichever comes first. For patients discharged from the ICU to the ward, they will be followed until study treatment is complete (i. e. day 14). Mortality will be determined for the ICU stay, hospital stay and at 90 days. The investigators will record admission and discharge dates to ICU, step down units, and to hospital. All patients will have 13 mL of blood/day drawn at baseline, day 3, day 8 and at the end of the treatment period on day 14 (or last day of treatment). The samples will be prepared on site and shipped to a central lab for processing. The investigators will use the blood specimens to measure markers of inflammation (C-reactive protein, Procalcitonin, and Interleukin-6 and others as determined by the investigators), markers of candida presence (b-glucan and other potential future markers) and markers of immune dysfunction (to be determined by investigators).

Eligibility

Minimum age: 18 Years. Maximum age: N/A. Gender(s): Both.

Criteria:

Inclusion Criteria: 1. Adult patients (>18 years old) 2. In the ICU > 48 hours 3. Mechanically ventilated (>48 hours) 4. Grow a Candida spp. on respiratory tract secretion culture (either by Bronchoalveolar Lavage or Endotracheal Aspirate) taken on or between 48 hours before or after the day of their suspicion of respiratory tract infection. 5. Develop a clinical suspicion of respiratory tract infection while ventilated as defined by the following criteria (as defined previously in our VAP trial)5:

- The presence of new, worsening or persistent radiographic features suggestive of

pneumonia without another obvious cause AND

- The presence of any two of the following:

- Fever > 38C (core temperature)

- Leukocytosis (>11. 0 x109/L) or neutropenia (<3. 5 x109/L)

- Purulent endotracheal aspirates or change in character of aspirates

- Isolation of pathogenic bacteria from endotracheal aspirates

- Increasing oxygen requirements

Exclusion Criteria: 1. Patients not expected to be in ICU for more than 72 hours (due to imminent death, withdrawal of aggressive care or discharge). 2. Patients with Candida spp. in the blood or another sterile body site. 3. Patients colonized at other non-pulmonary body site(s) with Candida. 4. Already being treated with antifungal drugs (because of documented fungal infection, pre-emptive therapy, or prophylaxis). 5. Allergy to study drugs (Fluconazole or the Echinocandin on formulary at treating institution). 6. Immunocompromised patients (post-organ transplantation, Acquired Immunodeficiency Syndrome [AIDS], neutropenia [<1000 absolute neutrophils], corticosteroids [>20 mgs/day of prednisone or equivalent for more than 6 months]). These patients are excluded since Candida may be more invasive and these patients are much more likely to require systemic antifungal therapy. 7. Patients with fulminant liver failure or end stage liver disease (Child's Class C). 8. Women who are pregnant or lactating. 9. Enrollment in industry sponsored interventional trial (co-enrollment in other academic studies would be allowed with the proviso that there was no potential interaction between the protocols). 10. Prior randomization in this study.

Locations and Contacts

Hopital l'Enfant-Jesus, Quebec G1J 1Z4, Canada

Hamilton Health Sciences Centre, Hamilton, Ontario, Canada

Kingston General Hospital, Kingston, Ontario K7L 2V7, Canada

Ottawa General Hospital, Ottawa, Ontario, Canada

Hopital du Sacre-Coeur do Montreal, Montreal, Quebec H4J 1C5, Canada

Hopital Maisonneuve-Rosemont, Montreal, Quebec H1T 2M4, Canada

Additional Information

Related publications:

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Canadian Institutes of Health Research. Available at: www.cihr.ca Accessed February 9, 2009.

Starting date: April 2010
Last updated: July 31, 2013

Page last updated: August 23, 2015

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