PIRATE project: point-of-care, informatics-based randomised controlled trial for decreasing overuse of antibiotic therapy in Gram-negative bacteraemia

• Published in: BMJ open 2017-07, Vol.7 (7), p.e017996-e017996
• Main Authors: Huttner, Angela, Albrich, Werner C, Bochud, Pierre-Yves, Gayet-Ageron, Angèle, Rossel, Anne, Dach, Elodie von, Harbarth, Stephan, Kaiser, Laurent
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Aged; Anti-Bacterial Agents - therapeutic use; Antibiotics; Bacteremia - drug therapy; Biomarkers; C-Reactive Protein - analysis; Cross Infection - drug therapy; Drug resistance; Drug Resistance, Microbial; Evidence-based medicine; Female; Gram-Negative Bacteria - drug effects; Gram-Negative Bacterial Infections - drug therapy; Hospitals; Humans; Infections; Infectious Diseases; Intensive care; Laboratories; Male; Microbial Sensitivity Tests; Middle Aged; Mortality; Patients; Pneumonia; Point-of-Care Systems; Prescription Drug Overuse - prevention & control; Regression Analysis; Sepsis; Switzerland; Young Adult
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2017-017996

IntroductionAntibiotic overuse drives antibiotic resistance. The optimal duration of antibiotic therapy for Gram-negative bacteraemia (GNB), a common community and hospital-associated infection, remains unknown and unstudied via randomised controlled trials (RCTs).Methods and analysisThis investigator-initiated, multicentre, non-inferiority, informatics-based point-of-care RCT will randomly assign adult hospitalised patients receiving microbiologically efficacious antibiotic(s) for GNB to (1) 14 days of antibiotic therapy, (2) 7 days of therapy or (3) an individualised duration determined by clinical response and 75% reduction in peak C reactive protein (CRP) values. The randomisation will occur in equal proportions (1:1:1) on day 5 (±1) of efficacious antibiotic therapy as determined by antibiogram; patients, their physicians and study investigators will be blind to treatment duration allocation until the day of antibiotic discontinuation. Immunosuppressed patients and those with GNB due to complicated infections (endocarditis, osteomyelitis, etc) and/or non-fermenting bacilli (Acinetobacter spp, Burkholderia spp, Pseudomonas spp) Brucella spp, Fusobacterium spp or polymicrobial growth with Gram-positive organisms will be ineligible. The primary outcome is incidence of clinical failure at day 30; secondary outcomes include clinical failure, all-cause mortality and incidence of Clostridiumdifficile infection in the 90-day study period. An interim safety analysis will be performed after the first 150 patients have been followed for ≤30 days. Given a chosen margin of 10%, the required sample size to determine non-inferiority is roughly 500 patients. Analyses will be performed on both intention-to-treat and per-protocol populations.Ethics and disseminationEthics approval was obtained from the cantonal ethics committees of all three participating sites. Results of the main trial and each of the secondary endpoints will be submitted for publication in a peer-reviewed journal.Trial registration numberThis trial is registered at www.clinicaltrials.gov (NCT03101072; pre-results).