A Phase iv, Interventional, Non-blinded, Randomized Controlled Multicenter Study of Posaconazole Prophylaxis for the Prevention of Influenza-associated Aspergillosis (IAA) in Critically Ill Patients
Phase: PHASE4
Conditions: Aspergillosis; Pulmonary, Invasive (Etiology)
Sponsor: Universitaire Ziekenhuizen KU Leuven

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CLINICAL TRIAL PROTOCOL 
A PHASE IV, INTERVENTIONAL, NON-BLINDED, RANDOMIZED 
CONTROLLED MULTICENTER STUDY OF POSACONAZOLE 
PROPHYLAXIS FOR THE PREVENTION OF INFLUENZA-ASSOCIATED 
ASPERGILLOSIS (IAA) IN CRITICALLY ILL PATIENTS 
 
POSA FLU 
 
Version number: v 1.   –  Date 25-9-2017 
Version number: v IV. – Date 03-01-2018 
EudraCT Nr:  2017-003270-14 
Sponsor 
Universitaire Ziekenhuizen Leuven (UZ Leuven) 
Herestraat 49, 3000 Leuven 
 
Coordinating Investigator 
Nationale coördinator voor POSA-FLU studie 
Prof. Dr. Joost Wauters    
 
 
Intensivist, UZ Leuven 
Herestraat 49, 3000 Leuven, Belgium 
+32-16-344275   
 
 
 
joost.wauters@uzleuven.be 
 
Prof. Dr. Paul Verweij  
 
 
Microbiologist, UMC Radboud Nijmegen 
P.O. box 9101, 6500 HB Nijmegen, the Netherlands 
+31-24-3614356 
Paul.verweij@radboudumc.nl 
 
Nationale coördinator voor PK substudie 
Prof. Apr. Isabel Spriet  
 
 
Clinical pharmacist, UZ Leuven 
Herestraat 49, 3000 Leuven, Belgium 
+32 16/34 12 61 
isabel.spriet@uzleuven.be 

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Prof. Apr. Roger Bruggemann 
 
 
Clinical pharmacist, Radboudumc 
Geert Grootplein Zuid 10, 6525 GA Nijmgen 
+31 24361 6405 
roger.bruggemann@radboudumc.nl 
 
Principal Investigators (participating sites) 
Prof. Dr. Pieter Depuydt 
 
 
Intensivist, UZ Gent 
Dr. Marc Bourgeois 
 
 
 
Intensivist, AZ Sint-Jan Brugge 
Prof. Dr. Bart Rijnders  
 
 
Microbiologist, Erasmus MC Rotterdam 
Prof. Dr. G. Kampinga  
 
 
Microbiologist, Groningen 
 
CLINICAL TRIAL PROTOCOL HISTORY 
 
CSP / Amendment # 
Date 
Reason for amendment 
Clinical Trial Protocol v1 
25-9-2017 
NA 
Clinical Trial Protocol vIV 
3-1-2018 
PK substudy 
 
 
 
 
 
 
 
 
 

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SIGNATURES 
 
Title:  A PHASE IV, INTERVENTIONAL, NON-BLINDED, RANDOMIZED CONTROLLED 
MULTICENTER STUDY OF POSACONAZOLE PROPHYLAXIS FOR THE PREVENTION 
OF INFLUENZA-ASSOCIATED ASPERGILLOSIS (IAA) IN CRITICALLY ILL PATIENTS 
Protocol: POSA FLU 
 
The undersigned confirm that the following protocol has been agreed and accepted and that the 
Principal Investigator agrees to conduct the trial in compliance with the approved protocol and will 
adhere to the principles outlined in the requirements for the conduct of clinical trials in the EU as 
provided for in "Directive 2001/20/EC”,  and any subsequent amendments, GCP guidelines, the Belgian 
law of May 7th 2004 regarding experiments on the human person, the Sponsor’s SOPs, and other 
regulatory requirements as amended. 
I agree to ensure that the confidential information contained in this document will not be used for any 
other purpose other than the evaluation or conduct of the clinical investigation without the prior 
written consent of the Sponsor 
I also confirm that I will make the findings of the trial publically available through publication or other 
dissemination tools without any unnecessary delay and that an honest accurate and transparent 
account of the trial will be given; and that any discrepancies from the trial as planned in this protocol 
will be explained. 
 
Coordinating Investigator 
 
 
………………………… 
………………………… 
………………………… 
 
Name & Title 
Signature 
Date 
 
 
Principal Investigator (participating site) 
 
 
………………………… 
………………………… 
………………………… 
 
Name & Title 
Signature 
Date 
 
 
 

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TABLE OF CONTENTS 
 
CLINICAL TRIAL PROTOCOL ................................................................................................................................ 1 
CLINICAL TRIAL PROTOCOL HISTORY ............................................................................................................. 2 
SIGNATURES ............................................................................................................................................................... 3 
TABLE OF CONTENTS ............................................................................................................................................. 4 
LIST OF ABBREVIATIONS......................................................................................................................................... 6 
FUNDING AND SUPPORT....................................................................................................................................... 7 
CONFLICT OF INTEREST......................................................................................................................................... 7 
ROLES AND RESPONSIBILITIES .............................................................................................................................. 7 
TRIAL SYNOPSIS ......................................................................................................................................................... 8 
TRIAL FLOWCHART ...............................................................................................................................................10 
1 
Background and Rationale ................................................................................................................................11 
2 
Trial Objectives and Design .............................................................................................................................12 
2.1 
Trial objectives .........................................................................................................................................12 
2.2 
Primary Endpoints ....................................................................................................................................12 
2.3 
Secondary Endpoints ...............................................................................................................................13 
2.4 
Trial Design ...............................................................................................................................................13 
3 
Trial Medication / Drug ....................................................................................................................................15 
3.1 
Investigational Medicinal Product and Dosing Regimen.....................................................................15 
3.2 
Drug Accountability and Compliance ...................................................................................................15 
3.3 
Concomitant medication / Prohibited Medication..............................................................................15 
4 
Eligibility Criteria ...............................................................................................................................................16 
4.1 
Inclusion criteria .......................................................................................................................................16 
4.2 
Exclusion criteria ......................................................................................................................................16 
4.3 
Criteria for premature discontinuation of trial product....................................................................17 
4.4 
Withdrawal criteria .................................................................................................................................17 
5 
Trial Procedures ................................................................................................................................................17 
5.1 
Selection of Participants / Recruitment ................................................................................................17 
5.2 
Consent .....................................................................................................................................................17 
5.3 
Expected Duration of the Trial..............................................................................................................18 
5.4 
Randomisation Procedure / Code Break / Allocation concealment ................................................18 
5.5 
Visit schedule and assessments ..............................................................................................................18 
5.5.1 
Screening / Baseline.............................................................................................................................18 
5.5.2 
Treatment Visits ..................................................................................................................................18 
5.5.3 
Discontinuation of Treatment – End of Trial Visit – Withdrawal of Consent ..........................19 
5.5.4 
Follow-up Visits ...................................................................................................................................19 

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6 
Adverse Event Reporting .................................................................................................................................20 
6.1 
Definitions .................................................................................................................................................20 
6.1.1 
Adverse Event ......................................................................................................................................20 
6.1.2 
Serious Adverse Event........................................................................................................................20 
6.1.3 
Adverse Events of Special Interest ...................................................................................................21 
6.2 
Adverse Events that do not require Reporting...................................................................................21 
6.3 
Recording and Reporting of Averse Events .........................................................................................21 
6.3.1 
Assessment ...........................................................................................................................................21 
6.3.2 
Timelines for reporting ......................................................................................................................22 
6.3.3 
Follow-up ..............................................................................................................................................23 
6.3.4 
Pregnancy..............................................................................................................................................23 
6.3.5 
Technical Complaints..........................................................................................................................23 
6.4 
Reporting requirements to Ethics Committee’s and Health Authorities .......................................23 
7 
Statistics and Data Analysis ..............................................................................................................................24 
7.1 
Sample Size ................................................................................................................................................24 
Based on an estimated IAA incidence of 25% and considering a 80% reduction of the incidence (to 5%) 
caused by posaconazole prophylaxis and a power of 80%, a sample size calculation showed that 47 
patients in each study arm are needed. Because it is impossible that the use of posaconazole will 
increase the incidence of IA, a one-sided p-value was used for this sample size calculation. ...................24 
7.2 
Data Analysis.............................................................................................................................................25 
8 
Data handling ......................................................................................................................................................25 
8.1 
Data Collection Tools and Source Document Identification............................................................25 
8.2 
Access to Data, Monitoring, Audit and Inspection .............................................................................27 
8.3 
Archiving....................................................................................................................................................27 
9 
Ethical and Regulatory Considerations ..........................................................................................................28 
9.1 
Ethics Committee (EC) review & reports............................................................................................28 
9.2 
Peer review ...............................................................................................................................................29 
9.3 
Regulatory Compliance ...........................................................................................................................29 
9.4 
Protocol/GCP compliance ......................................................................................................................29 
9.5 
Data protection and patient confidentiality .........................................................................................30 
9.6 
Indemnity ...................................................................................................................................................30 
9.7 
Amendments .............................................................................................................................................30 
9.8 
Post trial care............................................................................................................................................31 
10 
Publication Policy ..........................................................................................................................................31 
11 
References .....................................................................................................................................................31 
12       PK study…………………………………………………………………………………………….33 
 
 
 
 

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LIST OF ABBREVIATIONS 
 
Abbreviation 
Definition 
(e)CRF 
(electronic) Case Report Form 
AB 
Antibiotics 
AE 
Adverse Event 
AR 
Adverse Reaction 
BA 
Bronchial Aspirate 
BAL 
Bronchoalveolar Lavage  
CM 
Concomitant Medication 
DMC 
Data Monitoring Committee 
EC 
Ethical Commission 
ECG 
Electrocardiogram 
FAMHP / FAGG 
Federal Agency for for medicines and health products 
FPFV 
First Patient First Visit 
GCP 
Good Clinical Practice 
HSCT 
Hematopoietic Stem Cell Transplanation 
IAA 
Influenza-Associated Aspergillosis 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IMP 
Investigational Medicinal Product 
LPLV 
Last Patient Last Visit 
MIC 
Minimal Inhibitory Concentration 
PD 
Pharmacodynamics 
PI 
Principal Investigator 
PRO 
Patient Reported Outcome 
SAE 
Serious Adverse Event 
SAR 
Serious Adverse Reaction 
SOC 
Standard Of Care 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TMF 
Trial Master File 
TSC 
Trial Steering Committee 
UAR 
Unexpected Adverse Reaction 
 
 
 
 

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FUNDING AND SUPPORT 
Funder 
Kind of Financial or Non-Financial Support 
MSD 
MSD provides posaconazole and partially funds study-related work 
 
 
 
 
CONFLICT OF INTEREST 
Investigator 
Kind of Conflict of Interest 
 
 
 
 
 
 
ROLES AND RESPONSIBILITIES 
The Principal Investigator is accountable for the conduct of the trial at his/her site and must ensure 
adequate supervision of the conduct of the trial at the trial site. If any tasks are delegated, the Principal 
Investigator must maintain a log (link) of appropriately qualified persons to whom he/she has delegated 
specified trial-related duties. The Principal Investigator must ensure that there is adequate and documented 
training for all staff participating in the conduct of the trial. (It is the Principal Investigator's responsibility 
to supervise the conduct of the trial and to protect the rights, safety and well-being of the subjects.) 
 
 
 
 

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TRIAL SYNOPSIS 
Title of clinical trial 
A PHASE IV, INTERVENTIONAL, NON-BLINDED, RANDOMIZED 
CONTROLLED MULTICENTER STUDY OF POSACONAZOLE 
PROPHYLAXIS FOR 
THE 
PREVENTION OF 
INFLUENZA-
ASSOCIATED ASPERGILLOSIS (IAA) IN CRITICALLY ILL PATIENTS 
Protocol 
Short 
Title 
Acronym 
POSA FLU 
Trial Phase 
phase IV  
Sponsor name 
Universitaire Ziekenhuizen Leuven (UZ Leuven) 
Coordinating Investigator 
Prof. Dr. Joost Wauters, Intensivist, UZ Leuven  
             
Prof. Dr. Paul Verweij, Medical microbiologist, UMC Radboud Nijmegen 
Contact Adress 
UZ Leuven, Herestraat 49, 3000 Leuven, Belgium 
Contact Email 
joost.wauters@uzleuven.be 
Contact Phone 
+32-16-344275 
EudraCT number 
2017-003270-14 
Other public database nr  
 
Prinicpal Investigators and 
Participating Sites 
Prof. Dr. Joost Wauters, Intensivist, UZ Leuven  
             
Prof. Dr. Paul Verweij, Medical microbiologist, UMC Radboud Nijmegen 
Medical condition or disease 
under investigation 
Influenza-associated pulmonary aspergillosis (IAA) 
Purpose of clinical trial 
Study the effect of antifungal prophylaxis on the incidence of IAA in 
critically ill patients with severe influenza. 
Primary objective 
Study if antifungal prophylaxis can decrease the incidence of IAA 
compared to SOC in critically ill patients with severe influenza 
pneumonia. 
Secondary objective(s) 
 
Trial Design 
Interventional non-blinded randomized controlled multicenter study 
Endpoints 
The IAA incidence at ICU discharge is the primary endpoint and will 
be compared in patients receiving posaconazole prophylaxis with those 
receiving SOC. 
Secondary outcomes will be time to IAA diagnosis, length of ICU stay, 
length of hospital stay, 30-day mortality and 90-day mortality 
Sample Size 
50 patients in each arm  
IMP, dosage and route of 
administration 
Posaconazole, 2*300mg/d on day 1, followed by 1*300mg/d from day 2 
untill day 7, intravenously administrated 
Active 
comparator 
product(s) 
None, SOC 
Maximum 
duration 
of 
treatment of a Subject 
7 days of prophylaxis 

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Maximum duration of Trial 
4 influenza seasons (the first two influenza seasons will be supported my 
MSD) 
Anticipate First Patient First 
Visit (FPFV) 
Expected 01/12/2017 
Anticipate Last Patient Last 
Visit (LPLV) 
Expected 30/03/2021 
 
 

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TRIAL FLOWCHART 
Schedule of Events – Trial specific Procedures / Assessments 
EVENTS 
Screening 
Randomization 
Treatment Period 
ICU discharge 
Follow-Up Visits 
(phone call) 
Timing (weeks) 
 
Day 1 
Day 2 - ICU discharge 
 
Day 30 and day 90 
Informed consent a 
X 
 
 
 
 
PCR-confirmed influenza b 
X 
 
 
 
 
Inclusion/Exclusion 
X 
X 
 
 
 
Demographics; Medical history 
X 
 
 
 
 
Symptom directed physical examination 
X 
X 
X 
X 
 
Weight / Height  
X 
 
 
 
 
Vital Signs 
X 
X 
X 
X 
 
Randomization 
 
X 
 
 
 
Microbiology sampling 
X  
X c 
X d 
X 
 
Chemistry : laboratory measurements 
X 
X 
X 
X 
 
Radiological Assessments (CT / RX) 
 
X 
X 
 
 
Trial drug administration (max 7 days) 
 
X 
X 
 
 
IAA mycological evidence e 
X 
X 
X 
X 
X 
IAA signs and symptoms assessment 
X 
X 
X 
X 
 
Survival status  
 
X 
X 
X 
X 
Adverse event (AE) assessment f 
 
 
 
 
 
Serious Adverse Event (SAE) assessment 
 
 
 
 
 
Concomitant Medication (CM) 
 
 
 
 
 
a: Informed Consent process should take place prior to all other trial-related procedures at the screening visit 
b: On NS, BA or BAL within the last 7 days before ICU admission or within 2 days after ICU admission; or based on a positive rapid test if PCR not available 
c: BAL GM, BAL culture and serum GM within 48h after influenza diagnosis to collect mycological evidence for IAA-infection 
d: BAL GM, BAL culture and serum GM between day 2 after randomization and ICU discharge, at the discretion of the treating physician, or later during ICU admission in case of clinical respiratory deterioration  
e: Provided by either (A) a positive culture of Aspergillus cultured from BAL, (B) ≥2 positive cultures of Aspergillus cultured from a sputum or a bronchial aspirate or (C) a galactomannan (GM) optical density of ≥1 in BAL or ≥0.5 in serum 
f: Study drug related adverse events 

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1 Background and Rationale 
Invasive aspergillosis has been regarded as an infectious complication of specific immunocompromised 
patients, which affects a relatively small group of patients. However, in recent years aspergillus disease has 
become a prominent problem in ICU-patients. 
Influenza-associated aspergillosis (IAA) was recently found to be a frequent and severe complication of 
influenza pneumonia in critically-ill patients.[1] A retrospective observational study during the 2015/2016 
influenza season indicated that among 144 patients admitted to the ICUs of all eight Dutch University 
Medical Centres with influenza, 23 (16%) developed IAA.[2] The underlying diseases in these patients were 
diverse, and 7 patients had been previously healthy. A 61% mortality rate was observed, including 5 of 7 
previously healthy patients who died.[2] It is thus clear that IAA is an early and frequent complication of 
severe influenza pneumonia, and that delay in diagnosis and treatment increases the probability of death in 
these critically ill patients. Early diagnosis is difficult due to unspecific clinical and radiological presentation. 
[1,2] 
As influenza virus infection leads to lysis of infected cells, we believe that a severe influenza infection causes 
cytopathology of the epithelial lining of the trachea and bronchi, providing A. fumigatus the opportunity for 
invasive growth. Many patients developed invasive Aspergillus tracheobronchitis, which is a manifestation of 
invasive aspergillosis that is difficult to diagnose due to lack of specific radiologic features.[3] Furthermore, 
influenza may contribute to a hyperinflammatory status known as macrophage activation syndrome that 
contributes to pulmonary damage.[4] Disruption of anatomical barriers and the dysregulated host defense 
provides an opportunity for A. fumigatus to cause fulminant invasive disease. Although biomarkers, such as 
galactomannan, in BAL and serum are useful tools in diagnosing IAA, early diagnosis proved difficult in the 
above-mentioned Dutch observational study. Moreover, the median time to initiation of antifungal therapy 
after influenza diagnosis in survivors and non-survivors was two days versus nine days (P<0.06), which 
underscores that early intervention is critical for survival. Finally, a high azole resistance rate of 29% was 
observed in these Dutch ICUs, which further complicates patient management.[2,5] 
Therefore we propose to perform an interventional non-blinded randomized controlled 
multicentric Dutch-Belgian proof-of-concept interventional study in patients with severe 
influenza admitted to the ICU, randomizing patients either to oseltamivir therapy with standard care for 
diagnosis and treatment of secondary infectious complications or to oseltamivir plus posaconazole 
prophylaxis. 
Currently there is no mold-active antifungal agent licensed for prophylaxis of invasive mold disease in ICU 
patients. The antifungal azole posaconazole is the drug of choice for antifungal prophylaxis in neutropenic 
patients with acute myeloid leukemia and those with graft-versus host disease following allogeneic 
HSCT.[6,7] These studies showed that posaconazole prophylaxis reduced the prevalence of invasive 
aspergillosis to below 2% in these high risk patients. Posaconazole is however not licensed for prophylaxis 
in other patient groups, i.e. critically ill patients. Based on the experience in patients with hematological 

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malignancy we anticipate that posaconazole prophylaxis will be effective to reduce the IAA incidence and 
eventually outcome in patients at risk for IAA.  
Although the planned study is a multicenter Dutch-Belgian study, a specific concern in Dutch ICUs is the 
high rate of azole resistance.[2,8] Although the efficacy of triazoles, including posaconazole, is reduced in 
experimental models of azole-resistant invasive aspergillosis,[9,10] these animal experiments do indicate 
that posaconazole prophylaxis is effective to prevent infection due to azole-resistant A. fumigatus.[11] 
Infection was prevented in animals challenged with A. fumigatus with a posaconazole MIC of 0.5 mg/l, which 
represents the vast majority of resistant isolates that are encountered. There is already substantial 
experience with posaconazole in terms of target PD, toxicity and drug interactions, which will facilitate a 
rapid implementation into clinical practice if this and future studies demonstrate the efficacy of the 
intervention.  
2 Trial Objectives and Design 
2.1 Trial objectives 
Our hypothesis is that antifungal prophylaxis can reduce the IAA incidence in critically ill patients with 
influenza pneumonia. 
The objective of this study is to deliver proof of concept that antifungal prophylaxis in addition to SOC 
in comparison with SOC alone can reduce the IAA incidence in ICU patients with severe influenza. 
 
2.2 Primary Endpoints 
The incidence of IAA-infection at ICU discharge is the primary endpoint and will be compared for 
patients receiving posaconazole prophylaxis with those receiving standard of care.  
 
A patient with IAA-infection is defined as a patient having mycological evidence of Aspergillus and at least 
one Aspergillus compatible sign or symptom and radiological abnormalities (other than interstitial infiltrates) 
based on chest CT, or chest X-Ray when CT imaging is not available. Mycological evidence can be provided 
by either (A) a positive culture of Aspergillus cultured from BAL sample, (B) ≥2 positive cultures of Aspergillus 
cultured from a sputum or a bronchial aspirate or (C) a galactomannan (GM) optical density of ≥1 in BAL 
or ≥0.5 in serum. Galactomannan antigen detection is conducted through sandwich enzyme-linked 
immunosorbent assay (ELISA) (Platelia Aspergillus; Bio-Rad Laboratories, Marnes-la-Coquette, France) and 
will be performed according to the instructions of the manufacturer. For the isolation of fungi, lower tract 
respiratory samples will be inoculated on a Sabouraud agar (2 days at 37°C and another 19 days at 30°). 
Aspergillus species are identified by their culture characteristics and morphologies. 
Aspergillus compatible signs or symptoms are defined as at least one of the following: 
 
Worsening respiratory insufficiency in spite of proper antibiotic and ventilator support 
 
Dyspnea 
 
Haemoptysis 

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 
Fever 
refractory 
to 
at 
least 
3 
days 
of 
appropriate 
antibiotic 
therapy. 
Recrudescent fever after a period of defervescence of at least 48 h while still on AB without 
apparent cause. 
The presence of hyphae in lung biopsy or autopsy are also considered as sufficient evidence for IAA.  
 
An independent review committee, consisting of a clinician and a microbiologist with substantial expertise 
in invasive fungal infections, will evaluate at the end of the study whether IAA-infection is present, based 
on the above mentioned criteria. 
 
2.3 Secondary Endpoints 
Secondary outcomes will be time to IAA diagnosis, length of ICU stay, length of hospital stay, 30-day 
mortality and 90-day mortality. 
 
2.4 Trial Design 
This study is an interventional non-blinded randomized controlled multicenter study.  
 
Critically ill patients with PCR-confirmed influenza (for details: see inclusion criteria) are eligible 
for inclusion in this study and will be randomized to or the posaconazole prophylaxis group or the 
SOC group. Within 48 hours after influenza diagnosis with a bronchoscopy with BAL (minimum 
volume of 2x20mL, 0.9% NaCl) and a with a serum galactomannan will be performed as part of 
routine ICU care in this type of patients. As any bronchoscopy, this bronchoscopy will only be 
performed if the safety of the patient will not be compromised. If an IAA-infection is suspected 
based on the result of this BAL ((A) Aspergillus cultured from BAL, or (B) a galactomannan (GM) 
≥1 in BAL or ≥0.5 in serum), the patient will be withdrawn from the study and antifungal treatment 
will be started. The type and duration of antifungal therapy will be at the discretion of the treating 
physician. 
 
 
SOC further includes: 
o The treating physician can decide to perform an additional bronchoscopy with BAL 
between day 2 after randomisation and ICU discharge in case of respiratory deterioration 
and clinical suspicion of an IAA-infection. Any bronchoscopy will only be performed if the 
safety of the patient will not be compromised. In case of positive mycological evidence of 
an IAA-infection, a CT thorax without IV contrast is performed if possible. If an IAA-
infection is documented, antifungal treatment will be started and - in case the IAA-
infection is diagnosed before the ending of the study drug - the patient will be withdrawn 
from the study. Again, type and duration of antifungal therapy will be at the discretion of 
the treating physician. 

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o Oseltamivir (non-IMP) will be started at the discretion of the treating physiscian from the 
first day of ICU admission as 2*150 mg/day for a duration of 10 days. If oseltamivir had 
already been started up before ICU admission, oseltamivir treatment will be continued up 
to a total of 10 days.  
 
 
 
 
 
*If Aspergillus is only cultured from sputum (and not from BAL) within the first 48 hours after the influenza 
diagnosis, the patient will not be witdrawn from the study 
 
 
 
 
 

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3 Trial Medication / Drug 
Drug Name 
IMP or non-IMP 
Posaconazole 
IMP 
 
3.1 Investigational Medicinal Product and Dosing Regimen 
If a patient is randomized non-blinded to the posaconazole prophylaxis group, posaconazole (Noxafil, 
MSD) will be started intravenously from day 1 of randomization (2*300mg/d on day 1, followed by 
1*300mg/d from day 2 for 7 days). Noxafil concentrate injections (vials made of type I glass containing 
18mg posaconazole /mL, 300mg posaconazole/vial in total) for intravenous use will be provided by MSD.  
In both patient groups (prophylaxis and SOC) oseltamivir (non-IMP) will be started at the discretion of 
the treating from the first day of ICU admission as 2*150 mg/day for 10 days. If oseltamivir had already 
been started up before ICU admission, oseltamivir treatment will be continued up to a total of 10 days.  
 
3.2 Drug Accountability and Compliance 
For each randomized patient 8 drug preparations (posaconazole or placebo) will be delivered by the 
hospital pharmacy. The amount of used and non-used posaconazole vials will be stated in a drug 
accountability log. 
3.3 Concomitant medication / Prohibited Medication 
Medication for the treatment of common adverse events related to posaconazole treatment such as 
headache, abdominal pain, nausea, diarrhea, constipation, vomiting, cough and dyspnoea are permitted 
concurrently with the trial medication. Other treatments related to standard of care of critically ill influenza 
patients are allowed during treatment with posaconazole, taking in to account the precautions below. 
Patients being treated with the following medication should be continuously monitored for AEs: sirolimus, 
CYP3A4 substrates (pimozide, quinidine), HMG-CoA Reductase Inhibitors Primarily Metabolized Through 
CYP3A4 (simvastatin), ergot alkaloids (ergotamine and dihydroergotamine), vincristine, terfenadine, 
cisapride, ebastine, astemizole, cimetidine, rifampin, carbamazepine, phenytoin, rifabutin, barbiturates, 
isoniazid and anthracyclines. 
In patients being treated with calcineurin-inhibitors (cyclosporine or tacrolimus) frequent monitoring of 
cyclosporine and tacrolimus whole blood concentrations should be performed during and at 
discontinuation of posaconazole treatment since elevated concentrations of these drugs can lead to 
nefrotoxicity and leukoencephalopathy. Cyclosporine an tacrolimus dosing should be adjusted according 
to their whole blood concentrations.  
 

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4 Eligibility Criteria 
4.1 Inclusion criteria 
Patients eligible for inclusion in this trial have to meet all of the following criteria: 
1. Written informed consent must be obtained from the patient or his/her legal representative prior 
to any study procedures  
2. Adult patient (≥ 18 years) 
3. PCR-confirmed influenza based on nasopharyngeal swab (NS), bronchial aspirate (BA) or broncho-
alveolar lavage (BAL) within 7 days before ICU admission or within 48 hours after ICU admission. 
If PCR is not available a positive result of a rapid test is required (a negative rapid test does not 
imply absence of influenza and thus requires confirmation by PCR) 
4. Influenza symptoms present for no more than 10 days before ICU admission 
5. Respiratory distress as the main reason for ICU admission. Respiratory distress will be defined as 
tachypnea with an respiratory rate ≥ 25x/min and a paO2/fiO2-ration ≤ 300 with or without 
(bilateral) infiltrates. 
 
 
4.2 Exclusion criteria 
Patients eligible for this trial must not meet any of the following criteria: 
1. Patients with age < 18 years 
2. Pregnant women (based on a positive serum sample) 
3. Expected survival on ICU admission ≤ 48h 
4. Patients having influenza symptoms for more than 10 days before ICU admission 
5. Patients being transferred from another hospital ward or another hospital who already have 
mycological evidence for an IAA-infection (based on sputum, BA or BAL culture, BAL or serum 
GM)  
6. Patients with known intolerance or hypersensitivity to posaconazole or other azole antifungal 
agents 
7. Patients that are being treated actively with antifungal agents for invasive aspergillosis 
8. Patients with a QTc interval ≥500 msec 
9. Patients with liver cirrhosis (Child C) 
10. Participation in another interventional clinical trial 

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11. Any disorder, which in the investigator’s opinion might jeopardise subject’s safety or compliance 
with the protocol 
12. Patients or their legal representatives who did not sign the informed consent form 
 
4.3 Criteria for premature discontinuation of trial product 
 
Safety concerns related to trial product (see paragraph 6) or unacceptable intolerability.  
 
Included in the trial in violation of the inclusion and/or exclusion criteria  
 
Pregnancy  
 
Simultaneous participation in another clinical trial of an approved or non-approved investigational 
medicinal product (IMP)  
 
4.4 Withdrawal criteria 
The subject may withdraw consent at will at any time. The subject’s request to withdraw from the trial 
must always be respected. Patients will also be withdrawn from the study when an IAA-infection is 
diagnosed based on clinical and mycological evidence with radiological abnormalities, between day 1 and 
day 7 of posaconazole prophylaxis. At that time antifungal treatment will be started. The type and duration 
of antifungal therapy will be at the discretion of the treating physician. 
 
5 Trial Procedures 
5.1 Selection of Participants / Recruitment 
Patients admitted to ICU with a severe influenza pneumonia will be screened by the study nurse. When all 
eligibility criteria are met, the PI or the treating physician will approach the patient or his/her relatives in 
order to give study information and request informed consent. 
 
5.2 Consent  
The Principal Investigator (PI) retains overall responsibility for the informed consent of participants at their 
site and must ensure that any person delegated responsibility to participate in the informed consent process 
is duly authorised, trained and competent to participate according to the ethically approved protocol, 
principles of Good Clinical Practice (GCP) and Declaration of Helsinki. If delegation of consent is acceptable 
then details should be provided.  Adequate documention will be performed.  
Informed consent must be obtained prior to the participant undergoing procedures that are specifically for 
the purposes of the trial and are out-with standard routine care at the participating site (including the 
collection of identifiable participant). All obtained original informed consent forms must remain at the site 
and cannot be destroyed (even when a scanned copy is available). 

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The right of a participant to refuse participation without giving reasons must be respected.   The participant 
must remain free to withdraw at any time from the trial without giving reasons and without prejudicing 
his/her further treatment and must be provided with a contact point where he/she may obtain further 
information about the trial. Where a participant is required to re-consent or new information is required 
to be provided to a participant it is the responsibility of the PI to ensure this is done in a timely manner.  
The PI takes responsibility for ensuring that all vulnerable subjects are protected and participate voluntarily 
in an environment free from coercion or undue influence.  Where the participant population is likely to 
include a significant proportion of participants who cannot read or write, require translators or have 
cognitive impairment, appropriate alternative methods for supporting the informed consent process should 
be employed. This may include allowing a witness to sign on a participant’s behalf (in the case of problems 
with reading or writing), designate a legal representative , or providing Participant Information Sheets in 
other languages or in a format easily understood by the participant population (in the case of minors or 
cognitive impairment) providing they are approved by the EC. 
 
5.3 Expected Duration of the Trial 
The expected duration of the trial will be 90 days. If the patient is not hospitalized any more at the 90th day 
after randomization, the patient or his/her relatives will be contacted by telephone in order to obtain 90-
day mortality data. 
 
5.4 Randomisation Procedure / Code Break / Allocation concealment 
Patients will be randomly assigned to the posaconazole prophylaxis group or the SOC group by using the 
Sealed Envelope randomization procedure (www.sealedenvelope.com). Block randomization will be used.  
 
5.5 Visit schedule and assessments 
5.5.1 
Screening / Baseline 
 
After eligibility screening and signing the trial ICF, the following screening assessments will be done: 
 
Patient demographics and baseline parameters (SOC) 
 
Medical History (SOC) 
 
5.5.2 
Treatment Visits 
 
Day 1 = day of randomization:   
 
Bronchoscopy with BAL sampling, serum galactomannan (SOC)  
 
Pregnancy screening negative  
 
Start study medication  
 
Gather baseline clinical data including demographic, biochemical, microbiological and radiological 
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Day 2 – ICU discharge: 
 
Withdrawal of patients from study if mycological evicdence of IAA-infection on BAL of day I 
 
Continuation of study medication up to day 7 
 
Gather clinical data including demographic, biochemical, microbiological and radiological data 
(SOC) 
 
Assess presence of IAA-infection (SOC) 
 
Assess outcome parameters: ICU mortality, IAA-infection (SOC) 
 
30 days after randomization: 
Assess outcome parameters: hospital and/or 30-day mortality and a retrospective assessment of IAA-
infection (SOC) 
 
90 days after randomization: 
 
Assess outcome parameters: hospital/or and 90-day mortality and a retrospective assessment of 
IAA-infection (SOC) 
 
5.5.3 
Discontinuation of Treatment – End of Trial Visit – Withdrawal of Consent 
Patients may voluntarily discontinue from the trial treatment for any reason at any time. If a patient decides 
to discontinue from the trial treatment, the investigator must make a reasonable effort (e.g. telephone, e-
mail, letter) to understand the primary reason for this decision and record this information in the patient’s 
chart and on the appropriate CRF pages. They may be considered withdrawn if they state an intention to 
withdraw, fail to return for visits, or become lost to follow-up for any other reason. The investigator should 
discontinue trial treatment for a given patient if, he/she believes that continuation would be detrimental to 
the patient’s well-being. 
Patients may voluntarily withdraw consent to participate in the trial for any reason at any time. Withdrawal 
of consent occurs only when a patient does not want to participate in the trial any longer, and does not 
want any further visits or assessments, and does not want any further trial related contact. Sponsor will 
continue to retain and use all research results that have already been collected for the trial evaluation. All 
biological samples that have already been collected may be retained and analyzed at a later date (or as 
required by local regulations). If a patient withdraws consent, the investigator should make a reasonable 
effort (e.g. telephone, e-mail, letter) to understand the primary reason for this decision and record this 
information. Trial treatment must be discontinued and no further assessments conducted. Further attempts 
to contact the patient are not allowed unless safety findings require communication or follow up. 
 
5.5.4 
Follow-up Visits 
A follow-up visit will be perfomed at day 90 by phone in case of discharge. Patient data after the ICU 
discharge will be gathered through the patient medical file .  

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6 Adverse Event Reporting 
6.1 Definitions 
6.1.1 
Adverse Event  
This study uses posaconazole, which is an antifungal agent licensed for prophylaxis as well treatment of 
invasive fungal infections. The clinical indications and dosages used in this trial are similar to the licensed 
indications and dosages or lower; therefore no potential harmful risks are expected in this cohort. 
Furthermore, the study medication, posaconazole, given as antifungal prophylaxis, is given on top of 
standard intensive diagnostic work-up to detect a fungal infection as soon as possible. 
We strongly believe the burden for the patient as well as the risk for severe adverse events is reduced to 
an absolute minimum. The risk-classification is assessed as negligible to the patient population receiving 
study drug at the current regimens.  
An Adverse Event (AE) is any untoward medical occurrence in a patient or subject during an experiment, 
and which does not necessarily have a causal relationship with this treatment. 
An AE can therefore be any unfavourable and unintended sign (including an abnormal laboratory finding), 
symptom or disease temporally associated with the use of a product, whether or not considered related 
to the product. Any worsening (i.e., any clinically significant adverse change in the frequency or intensity of 
a pre-existing condition) should be considered an AE. 
 
The following AEs should be reported: 
 
New ALAT elevation after the start of posaconazole to >10x ULN, not being explained by 
another overt reason  
 
QTc interval prolongation (QTc > 500 msec) 
These adverse events are monitored as a part of SOC on ICU. 
 
6.1.2 
Serious Adverse Event  
A Serious Adverse Event (SAE) is any untoward medical occurrence that results in any of the following: 
 
Death 
 
A life-threateninga experience 
 
In-patient hospitalisation or prolongation of existing hospitalisation 
 
A persistent or significant disability or incapacity 
 
A congenital anomaly or birth defect 
 
Important medical events that may be considered an SAE when - based on appropriate medical 
judgement - they may jeopardise the subject and may require medical or surgical intervention to 
prevent one of the above outcomes 
 
a The term “life threatening” in the definition of SAE refers to an event in which the subject was at risk of death at the time of the event. 
It does not refer to an event which hypothetically might have caused death if it was more severe. 
 

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6.1.3 
Adverse Events of Special Interest 
The following events should be reported within the same timelines as SAEs: 
- 
Overdose 
- 
Misuse/abuse 
- 
Medication error 
 
6.2 Adverse Events that do not require Reporting 
In general, the following should not be reported as AEs: 
 
Pre-existing conditions, including those found as a result of screening (these should be reported 
as medical history or concomitant illness. 
 
Pre-planned procedures unless the condition for which the procedure was planned has worsened 
from the first trial-related activity after the subject has signed the informed consent. 
Adverse events other than the above mentioned AE that should be reported, will be reported at the 
discretion of the treating physician. 
Although these events should not be reported to the sponsor, these should be recorded in the patient’s 
medical notes according to routine practice.  
The following events not to be considered as SAEs are hospitalisations for : 
 
Pre-planned hospitalisation unless the condition for which the hospitalisation was planned has 
worsened from the first trial-related activity after the subject has signed the informed consent.  
 
A standard procedure for protocol therapy administration. However, hospitalisation or prolonged 
hospitalisation for a complication of therapy administration will be reported as an SAE. 
 
Hospitalisation or prolongation of hospitalisation for technical, practical, or social reasons, in 
absence of an AE. 
 
6.3 Recording and Reporting of Averse Events 
Investigators will seek information on AE at each patient contact. All events, whether reported by the 
patient or noted by trial personnel, will be recorded in the patient’s medical record and in the (e)CRF 
within a reasonable time after becoming aware. If available, the diagnosis should be reported on the AE 
page, rather than the individual signs or symptoms. If no diagnosis is available, the investigator should record 
each sign and symptom as individual AEs using separate AE forms. 
 
6.3.1 
Assessment  
All AEs must be evaluated by an Investigator as to: 
 
Seriousness: wether the AE is an SAE. See above for the seriousness criteria. 
 
 
Severity:  

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o If applicable: grading must be evaluated by an Investigator according to the current active 
minor version fo the National Cancer Institute (NCI) Common Terminology Criteria for 
Adverse Events (CTCAE, version 4.0) OR 
o If applicable: severity must be evaluated by an Investigator according to the following 
definitions: 
 
Mild – no or transient symptoms, no interference with the subject’s daily activities 
 
Moderate – marked symptoms, moderate interference with the subject’s daily 
activities 
 
Severe – considerable interference with the subject’s daily activities, unacceptable 
 
Causality: 
 
None – An AE which is not related to the trial product or experiment 
 
Unlikely – An AE for which an alternative explanation is more likely (e.g. concomitant 
medication(s), concomitant disease(s)), and/or the relationship in time suggests that a 
causal relationship is unlikely 
 
Possible – An AE which might be due to the use of the trial product or the experiment. 
An alternative explanation is inconclusive. The relationship in time is reasonable; therefore 
the causal relationship cannot be ruled out. 
 
Probable - An AE which might be due to the use of the trial product or the experiment. 
The relationship in time is suggestive (e.g. confirmed by dechallenge). An alternative 
explanation is less likely. 
 
Definitely – An AE which is listed as a possible adverse reaction and cannot be reasonably 
explained by an alternative explanation. The relationship in time is very suggestive (e.g. it 
is confirmed by dechallenge and rechallenge). 
 
6.3.2 
Timelines for reporting 
 
- 
After informed consent has been obtained but prior to initiation of trial treatment, only serious 
adverse events caused by a protocol-mandated intervention (e.g…….) should be reported  
- 
After initiation of trial treatment, adverse events will be reported as follows:  
o All adverse events will be reported  during study treatment 
o Serious adverse events and adverse events of special interest will continue to be reported 
until 90 days  
 
All SAEs/AESI as defined in the protocol must be reported to the Sponsor within 24 hours of the 
research staff becoming aware of the event.  
 
Describe here the details of how the SAE must be reported by the Investigator to the Sponsor:  
 
By completing the SAE form in the (e)CRF 

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If an authorised Investigator from the reporting site is unavailable, initial reports without causality and 
expectedness assessment should be submitted to the Sponsor by a healthcare professional within 24 hours 
of becoming aware of the SAE, but must be followed-up by medical assessment as soon as possible 
thereafter. 
 
6.3.3 
Follow-up  
The Investigator must record follow-up information by updating the medical records and the appropriate 
forms in the (e)CRF. The worst case severity and seriousness of an event must be kept throughout the 
trial. 
SAE follow-up information should only include new (e.g. corrections or additional) information and must 
be reported within 24 hours of the Investigator’s first knowledge of the information. This is also the case 
for previously non-serious AEs which subsequently become SAEs. 
 
All SAEs must be followed until the outcome of the event is ‘recovered’, ‘recovered with 
sequelae’, ‘not recovered’ (in case of death due to another cause) or ‘death’ (due to the SAE) and 
until all related queries have been resolved. 
 
Non-serious AEs must be followed unil the end of the follow-up period, and until all related 
queries have been resolved. 
 
SAEs after the end of the trial: If the Investigator becomes aware of an SAE with suspected causal 
relationship to the trial product or experiment after the subject has ended the trial, the investigator should 
report this SAE within the same timelines as for SAEs during the trial. 
 
6.3.4 
Pregnancy 
Female subjects must be instructed to notify the investigator immediately if they become pregnant during 
the trial. The investigator must report any pregnancy in subjects who have received trial product(s), as 
soon as possible using an SAE form. 
 
6.3.5 
Technical Complaints 
Technical complaints should be reported to the Market Authorisation Holder. 
 
6.4 Reporting requirements to Ethics Committee’s and Health Authorities 
The investigator is responsible for ensuring that all safety events are recorded in the (e)CRF and reported 
to the Sponsor in accordance with instructions provided below: 
Who 
reports 
What 
To 
Within which period 
Investigator 
AE 
(e)CRF 
Cfr protocol 

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Investigator 
SAE (including death) 
AESI Pregnancy 
Coordinating 
Investigator / sponsor  
Immediately (within 24 hours of 
becoming aware of the event) 
Exceptions: cfr protocol 
PI /sponsor 
 
 
 
PI (Belgian 
site) 
 
PI (non-
Belgian site) 
Each death of a 
subject from a 
Belgian site 
 
Each death of a 
subject from an 
external Belgian site 
Each death of a 
subject from an 
external non-Belgian 
site 
Central EC 
 
 
 
Local EC 
 
 
According to local 
legislation 
Immediately 
 
 
 
Immediately 
 
 
According to local legislation 
PI / sponsor 
Any SUSAR that is 
fatal or life-
threatening 
-  Competent 
Authorities 
- All other member 
states if applicable 
- EC  
- Investigators 
- Marketing 
Authorisation Holder if 
applicable 
Within 7 calendar days, every 
additional information within 
additional 8 calendar days 
PI / sponsor 
All other SUSAR's 
Within 15 calendar days 
PI / sponsor 
Report of all SAE's 
Competent Authorities 
Annually or final report 
  
  
All other member 
states if applicable 
Annually or final report 
  
  
EC 
Annually a summary of the past year 
with a safety analysis and risk-benefit 
evaluation  
The Sponsor will promptly evaluate all serious adverse events and adverse events of special interest against 
experience to identify and expeditiously communicate possible new safety findings to investigators, ECs 
and applicable health authorities based on applicable legislation. 
 
7 Statistics and Data Analysis 
7.1 Sample Size 
Based on an estimated IAA incidence of 25% and considering a 80% reduction of the incidence (to 5%) 
caused by posaconazole prophylaxis and a power of 80%, a sample size calculation showed that 47 patients 
in each study arm are needed. Because it is impossible that the use of posaconazole will increase the 

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incidence of IA, a one-sided p-value was used for this sample size calculation. To include at least 100 patients 
in the MITT endpoint analysis, 110 patients will be included in the study (55 in each arm). 
 
7.2 Data Analysis 
Appropriate statistical tools will be used to test for significance with respect to the primary and secondary 
endpoints. 
 
Categorical variables will be reported as a percentage and continuous variables as mean ± standard 
deviation (SD) or median and interquartile range (IQR), as appropriate. Differences in categorical variables 
will be assessed using the Chi squared test or the Fischer’s Exact test and for the analysis of 
continuous variables the Student’s t test or the Mann-Whitney U test will be used, where appropriate. P 
values <0.05 are considered significant. Patients that die during the trial duration will also be included in 
the statistical analysis.  
 
The primary endpoint analysis will consist of a one-sided fisher-exact test in which the proportion of cases 
of IAA will be compared between both groups. The population included in this analysis will consist of a 
modified intent to treat population. This MITT population consists of all patients that received at least 1 
posaco/placebo administration but excluding the patients in which a diagnosis of IAA was made on the basis 
of the BAL sample taken on day 1 because these patients in fact had an IAA at the day of inclusion. 
 
8 Data handling  
Patient data will be encoded: which means that personal data can only be related to an identified or 
identifiable person by means of a code. 
Demographic, biochemical, microbiological and radiological data will be collected prospectively as a part of 
clinical routine. Samples will be obtained for characterization of the influenza type and for Aspergillus 
diagnosis including culture, galactomannan and PCR. These samples are part of daily routine, no additional 
samples for this study will be taken. All Aspergillus colonies will be screened for azole resistance, using an 
agar-based selection tool, and relevant samples, i.e. BAL fluid, will be stored for direct detection of 
resistance mutations by PCR. Clinical A. fumigatus isolates will be sent the National Mycology Reference 
Laboratory in Leuven (Belgium) or Nijmegen (the Netherlands) for MIC-testing and analysis of azole-
resistance mutations. A blinded data review committee following a pre-defined case definition will classify 
patients with evidence for primary and breakthrough IAA-infection.  
 
 
8.1 Data Collection Tools and Source Document Identification 
Source data will be collected and recorded in the trial participants files/medical records. They will be kept 
on a secured location at all times. The collection and processing of source data (from subjects enrolled in 
this trial) will be limited to those data that are necessary to fulfill the objectives of the trial. These data 

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must be collected and processed with adequate precautions to ensure confidentiality and compliance with 
applicable data privacy protection laws and regulations. Appropriate technical and organizational measures 
to protect the data against unauthorized disclosures or access, accidental or unlawful destruction, or 
accidental loss or alteration must be put in place. Personnel whose responsibilities require access to 
personal data agree to keep the data confidential. 
Documentation of source data is necessary for the evaluation and validation of clinical findings, observations 
and other activities during a clinical trial.  Source documentation serves to substantiate the integrity of trial 
data, confirms observations that are recorded and confirms the existence of trial participants. Furthermore 
source documentation must be available for the following to confirm data collected in the (e)CRF: subject 
identification, eligibility, and trial identification; trial discussion and date of informed consent; dates of visits; 
results of safety and efficacy parameters as required by the protocol; record of all adverse events and 
follow-up of adverse events; concomitant medication; drug receipt/dispensing/return records; trial drug 
administration information; and date of trial completion and reason for early discontinuation of trial drug 
or withdrawal from the trial, if applicable.   
Data collection is the responsibility of the clinical trial staff at the site under the supervision of the 
investigator.  The investigator will maintain complete and accurate documentation for the trial. All source 
documents will be reviewed by the clinical team to ensure that they are accurate and complete. 
As defined in section 1.52 of the ICH Guideline for Good Clinical Practice (latest version of ICH E6) source 
documents may include: original documents, data and records (e.g. hospital records, clinical and office 
charts, laboratory notes….) 
Case report forms 
CRFs are provided for each subject in electronic/paper format. The trial data will be transcribed on a 
regular basis by trial personnel from the source documents onto an (e)CRF in a pseudonymised manner, 
and transmitted in a secure manner to the PI within the timeframe agreed upon between PI and the sites. 
The file will be considered to be the (e)CRF.  
Worksheets may be used for the capture of some data to facilitate completion of the (e)CRF. Any such 
worksheets (including but not limited to copies of the (e)CRF)  will become part of the trial participant's 
source documentation. All data relating to the trial must be recorded in (e)CRFs prepared by the 
investigator. Data must be entered into (e)CRFs in English. Designated site personnel must complete the 
(e)CRF as soon as possible after a subject visit, and the forms should be available for review at the next 
scheduled monitoring visit. 
All subjective measurements (e.g., dairies, questionnaires, or …) will be completed by the same individual 
who made the initial baseline determinations whenever possible. The investigator will ensure that data are 
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All (e)CRF entries, corrections, and alterations must be made by the investigator or other authorized trial-
site personnel. Proper audit trails are available to demonstrate the validity of the trial data. A certified copy 
of the completed (e)CRFs will be archived at the trial site. 
Data handling and record keeping 
The Investigator and the Participating Site shall treat all information and data relating to the Trial disclosed 
to Participating Site and/or Investigator in this Trial as confidential and shall not disclose such information 
to any third parties or use such information for any purpose other than the performance of the Trial. The 
collection, processing and disclosure of personal data, such as patient health and medical information is 
subject to compliance with applicable personal data protection and the processing of personal data . 
The investigator will maintain a certified copy of (e)CRFs and all source documents that support the data 
collected from each trial participant, as well as all trial documents as specified in ICH/GCP Section 8, 
Essential Documents for the Conduct of a Clinical Trial, and all trial documents as specified by the applicable 
regulatory requirement(s). A Certified copy as specified in addendum 1.63 in ICH/GCP is a copy 
(irrespective of the type of media used) of the original record that has been verified (i.e. by a dated signature 
or by generation through a validated process) to have the same information, including data that describe 
the context, content and structure, as the original. The investigator will take measures to prevent accidental 
or premature destruction of these documents. 
If data need to be transferred, this will be performed via a secured method of transfer taking into account 
all applicable security arrangements and regulations (such as the Belgian Privacy Act of 8 December 1992 
on the protection of privacy in relation to the processing of personal data and the European Data 
Protection Act). Receiving party will agree to keep the transferred data confidential at all times.  
 
8.2 Access to Data, Monitoring, Audit and Inspection 
The investigator will permit trial-related monitoring, audits, EC review and regulatory inspection, providing 
direct access to all related source data / documents. 
(e)CRFs and all source documents, including progress notes and copies of laboratory and medical test 
results must be available at all times for review by the sponsor’s clinical trial monitor, auditor and inspection 
by health authorities. The accuracy of the data will be verified by review of the source documents. 
 
8.3 Archiving  
As specified in in ICH/GCP Section 8.1 Addendum the sponsor and investigator/institution should maintain 
a record of the location(s) of their respective essential documents including source documents. The storage 
system used during the trial and for archiving (irrespective of the media used) should provide for document 
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Essential documents for the the trial should be supplemented or may be reduced where justified (in advance 
of trial initiation) based on the importance and relevance of the specific documents to the trial. 
The sponsor should ensure that the investigator has control of and continuous access to the CRF data 
reported to the sponsor. The sponsor should not have exclusive control of those data. When a copy is 
used to replace an original document (e.g. source documents, CRF), the copy should fulfill the resuirements 
for certified copies. The investigator/institution should have control of all essential documents and records 
generated by the investigator/institution before, during and after the trial. 
The Sponsor is responsible for archiving trial specific documentation (such as but not limited to protocol, 
potential amendments, copy of (e)CRF burned on CD, final report and database) for at least twenty years. 
Site-specific trial documents (such as but not limited to ICF) will be archived locally on site according to 
local practice and guidelines. Archived data may be held on electronic record, provided that a back-up 
exists and that hard copies can be obtained, if required.  Destruction of essential documents will require 
authorisation from the Sponsor.   
 
9 Ethical and Regulatory Considerations 
9.1 Ethics Committee (EC) review & reports  
The trial will be conducted in compliance with the principles of the Declaration of Helsinki (most recent 
version), the principles of GCP and in accordance with all applicable regulatory requirements. Before the 
start of the trial, this protocol, the informed consent forms and other related documents e.g. 
advertisements and general practisioners information letters, will be submitted for review to the EC and 
to the Federal Agency for for medicines and health products (FAMHP) for Clinical Authorization (the below 
mentioned obligations shall only apply to the extent applicable). The trial shall not commence until such 
approvals have been obtained. 
Any subsequent protocol amendments will be submitted to the EC and Regulatory Authorities for approval. 
No substantial amendment that require review by EC will be implemented until the EC grants a favorable 
opinion for the trial. The CI acknowledges that amendments may also need to be reviewed and accepted 
by the FAMHP before they can be implemented in practice at sites. 
The trial can and will be conducted only on the basis of prior informed consent by the trial participants, or 
their legal representatives, to participate in the trial. Extensive discussion of risks and possible benefits of 
participation will be provided to the patients and/or their families. The  participating site shall obtain a 
signed informed consent form for all trial participants prior to their enrollment and participation in the 
trial in compliance with all applicable laws, regulations and the approval of the (local) Ethics Committee, if 
required. The participating site shall retain such ICFs in accordance with the requirements of all applicable 
regulatory agencies and laws. All correspondence with the EC/FAMHP shall be retained in the Trial Master 
File/Investigator Site File. 

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The CI acknowledges that it is his responsibility to produce annual progress reports (APR) and he will do 
so by submitting to the EC/FAMHP within 30 days of the anniversary date on which the favorable opinion 
was given, and annually until the trial is declared ended. 
The PI shall notify the EC/FAMHP of the end of the Trial. Should the trial be ended prematurely, the PI will 
notify the EC/FAMHP and include the reasons for the premature termination. The PI will submit a final 
report with the results, including any publications/abstracts, to the EC/FAMHP. 
9.2 Peer review  
This trial protocol was peer reviewed by certain independent experts. Peer review was conducted by 
expert referees to the professional and scientific standards expected for clinical studies. 
9.3 Regulatory Compliance 
Before the start of the trial, this protocol and other related documents will be submitted for review to the 
Federal Agency for medicinal products for Clinical Trial Authorisation (FAMHP). The trial shall not 
commence until such approvals have been obtained. 
This trial protocol and the conduct of the trial in general is in compliance with applicable law, including but 
not limited to the Belgian law of May 7th 2004 regarding experiments on the human person and any relevant 
amendments. 
9.4 Protocol/GCP compliance 
The CI is responsible for ensuring that the clinical trial is performed in accordance with the protocol, 
current ICH guidelines on GCP, and applicable regulatory and country-specific requirements. GCP is an 
international ethical and scientific quality standard for designing, conducting, recording, and reporting 
studies that involve the participation of human subjects. Compliance with this standard provides public 
assurance that the rights, safety, and well-being of trial participants are protected, consistent with the 
principles that originated in the Declaration of Helsinki, and that the clinical trial data are credible. 
It is acknowledged and agreed that prospective, planned deviations or waivers to the protocol are not 
allowed under applicable regulations on clinical studies and must not be used. However, should there be 
an accidental protocol deviation, such deviation shall be adequately documented on the source documents 
and on the relevant forms and reported to the Chief Investigator and Sponsor immediately. Protocol 
deviations which are found to frequently recur, will require immediate action. CI acknowledges that such 
recurring protocol breaches could be potentially classified as a serious violation. 
It is understood that “a serious violation” is likely to effect to a significant degree 
- 
the safety or physical or mental integrity of the participants of the trial; or 
- 
the scientific value of the trial 
 

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9.5 Data protection and patient confidentiality 
The trial will be conducted in compliance with the requirements of the Belgian Privacy Act of 8 December 
1992 on the protection of privacy in relation to the processing of personal data and the European Data 
Protection Act. Any collection, processing and disclosure of personal data, such as patient health and 
medical information is subject to compliance with the aforementioned personal data protection laws. 
Any personal data shall be treated as confidential at all times including during collection, handling and use, 
and that the personal data (including in any electronic format) shall be stored securely at all times and with 
all technical and organizational security measures that would be necessary for compliance with data 
protection legislation. The Sponsor shall take appropriate measures to ensure the security of all personal 
data and guard against unauthorized access thereto or disclosure thereof or loss or destruction while in 
its custody. 
The personal data of trial participants will be encoded, which means that they can only be related to an 
identifiable person by means of a unique code. The unique code will only be in the possession of the 
members of the trial team who are in direct contact with the trial participants. In no event will the coded 
personal data include personal identifiers, including any Trial participant’s initials. Such coded personal data 
can only be traced or linked back by said trial team members, and said trial team members shall treat these 
codes as strictly confidential. 
All trial related data and documents will be stored for at least twenty (20) years, in accordance with Belgian 
legislation. 
 
9.6 Indemnity 
The Sponsor shall throughout the duration of the trial effect and maintain with a reputable insurance 
company a policy or policies of insurance providing an adequate level of cover in respect of all risks which 
may be incurred by the Sponsor arising out of the Sponsor 's performance of the trial, including the 
insurance that is required to be taken out as sponsor of the trial as set out in the Law of 2004.  
In accordance with the Belgian Law relating to experiments on human persons dated May 7, 2004, Sponsor 
shall assume, even without fault, the responsibility of any damages incurred by a Trial Patient and linked 
directly or indirectly to the participation to the Trial, and shall provide compensation therefore through 
its insurance. 
The terms or the amount of cover of any insurance shall not relieve the Sponsor of any liabilities under 
the clinical trial agreement. 
 
9.7 Amendments 
In accordance with the Belgian law of May 7th 2004 regarding experiments on the human person, the 
Sponsor may make a non-substantial amendment at any time during a trial. If the Sponsor wishes to make 
a substantial amendment to the clinical trial agreement or the documents that supported the original 

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application for the CTA, the Sponsor must submit a valid notice of amendment to the licencing authority 
(FAMHP; if applicable) for consideration. If the Sponsor wishes to make a substantial amendment to the 
EC application or the supporting documents, the Sponsor must submit a valid notice of amendment to the 
EC for consideration. The FAMHP and/or the EC will provide a response regarding the amendment within 
28 days of receipt of the notice. It is the Sponsor’s responsibility to decide whether an amendment is 
substantial or non-substantial for the purposes of submission to the FAMHP and/or EC (if applicable). 
 
9.8 Post trial care 
Not applicable to this study.  
 
10 Publication Policy 
Publications will be coordinated by the Investigator of Sponsor. Authorship to publications will be 
determined in accordance with the requirements published by the International Committee of Medical 
Journal Editors and in accordance with the requirements of the respective medical journal.  
For multi-centric trials, it is anticipated that the results of the overall Trial shall be published in a multi-
centre publication, involving the data of all clinical sites participating in the Trial. 
Participating Site is not allowed to publish any data or results from the Trial prior to the multicentre 
publication, provided however that Participating Site is allowed to publish the results generated at the 
Participating Site if the multicentre publication has not occurred after 12 months from Trial database lock. 
Any publication by Participating Site will be submitted to the Sponsor for review at least thirty (30) days 
prior to submission or disclosure. Sponsor shall have the right to delay the projected publication for a 
period of up to three (3) months from the date of first submission to the Sponsor in order to enable the 
Sponsor to take steps to protect its intellectual property rights and know-how.  
 
11 References 
 
1. Wauters J, Baar I, Meersseman P, et al. Invasive pulmonary aspergillosis is a frequent complication 
of critically ill H1N1 patients: a retrospective study. Intensive Care Med. 2012;38:1761-8. 
2. van de Veerdonk FL, Kolwijck E, Lestrade PPA, et al. Invasive pulmonary aspergillosis complicating 
influenza in critically ill patients: a nationwide retrospective observational cohort study. AJRCCM 
2017; doi: 10.1164/rccm.201612-2540LE. [Epub ahead of print] 
3. Patterson TF, Thompson GR 3rd, Denning DW, et al. Practice guidelines for the diagnosis and 
management of aspergillosis: 2016 update by the Infectious Diseases Society of America. ClinInfect 
Dis. 2016; 63:e1-e60. 

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4. Schulert GS, Zhang M, Fall N, et al. Whole-exome sequencing reveals mutations in genes linked to 
hemophagocytic lymphohistiocytosis and macrophage activation syndrome in fatal cases of H1N1 
influenza. J Infect Dis. 2016;213:1180-8. 
5. Verweij PE, Chowdhary A, Melchers WJG, Meis JF. Azole resistance in Aspergillus fumigatus: can 
we retain the clinical use of mold-active antifungal azoles? Clin Infect Dis 2016;62:362-8 
6. Cornely OA, Maertens J, Winston DJ, et al. Posaconazole vs. fluconazole or itraconazole 
prophylaxis in patients with neutropenia. N Engl J Med. 2007;356:348-59. 
7. Ullmann AJ, Lipton JH, Vesole DH, et al. Posaconazole or fluconazole for prophylaxis in severe 
graft-versus-host disease. N Engl J Med. 2007;356:335-47 
8. van Paassen J, Russcher A, in ’t Veld-van Wingerden AW, Verweij PE, Kuijper EJ. Emerging 
aspergillosis by azole-resistant Aspergillus fumigatus at an intensive care unit in the Netherlands, 
2010 to 2013. Euro Surveill 2016;21:30. 
9. Seyedmousavi S, Brüggemann RJM, Meis JF, Melchers WJG, Verweij PE, Mouton JW. 
Pharmacodynamics of isavuconazole in an Aspergillus fumigatus mouse infection model. 
Antimicrob Agents Chemother 2015;59:2855-66. 
10. Seyedmousavi S, Brüggemann RJM, Melchers JWG, Mouton JW, Verweij PE. The role of azoles in 
the management of azole-resistant aspergillosis: from the bench to the bedside. Drug Resist Updat 
2014;17:37-50. 
11. Seyedmousavi S, Mouton JW, Melchers WJG, Verweij PE. Posaconazole prophylaxis in 
experimental azole-resistant invasive pulmonary aspergillosis. Antimicrob Agents Chemother 
2015;59:1487-94. 
 
 
 

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PHARMACOKINETICS OF POSACONAZOLE AS 
PROPHYLAXIS FOR INVASIVE FUNGAL DISEASE ON ICU 
 
De farmacokinetiek van posaconazole als profylaxe voor invasieve schimmelinfecties op Intensieve Zorgen 
 
This study is an amendment on the principal study “A phase IV, interventional, non-blinded, randomized 
controlled multicenter study of posaconazole prophylaxis for the prevention of influenza-associated 
aspergillosis (IAA) in critically ill patients” (S60744,  coordinating investigator Joost Wauters, MD PhD). 
 
 
1. RESEARCH TEAM 
Ruth Van Daele, PhamD 
 
Clinical pharmacist (PhD-student), UZ Leuven & Clinical  
 
 
 
 
 
Pharmacology and Pharmacotherapy, KU Leuven 
Isabel Spriet, PharmD, PhD  
 
Clinical pharmacist, UZ Leuven & Clinical Pharmacology and  
Pharmacotherapy, KU Leuven  
Joost Wauters, MD, PhD  
Intensivist, UZ Leuven & Laboratory for Clinical Infectious and 
Inflammatory Disorders, KU Leuven 
Roger Brüggemann, PharmD  
 
PhD Clinical pharmacist and clinical pharmacologist,  
 
 
 
 
 
Radboudumc & Radboud Institute for Health Sciences 
 
UZ Leuven, Herestraat 49, 3000 Leuven, Belgium  
Isabel Spriet +32 16/34 12 61 isabel.spriet@uzleuven.be  
Joost Wauters +32 16/34 03 85 joost.wauters@uzleuven.be 
 
Radboudumc, Geert Grootplein Zuid 10, 6525 GA Nijmegen, The Netherlands  
Roger Brüggemann +31 24361 6405 roger.bruggemann@radboudumc.nl 
 
This study is supported by DB-MSG. 
 
 

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2. GENERAL BACKGROUND, OBJECTIVES AND AIMS 
Fungal infections cause a serious threat to critically ill patients. The triazole antifungal drugs are the most 
important drugs for managing infections due to aspergillus moulds and the principal study  (S60744) will 
investigate the role for those drugs in prophylaxis. Adequate treatment and prophylaxis of IAA is of the 
greatest essence but regrettably failure to therapy can occur. One of the shortcomings in previous studies 
is that pop-PK in critically ill patients haven’t been investigated. As a consequence, solid recommendations 
of regimens other than the once investigated in hematology patients cannot be drawn based on previous 
models.  
 
With this research we believe we can resolve multiple critical questions/objectives  
1) Document pharmacokinetics of posaconazole in a cohort of critically ill patients on IV posaconazole to 
help determine the PK 
2) Determine the impact of known and unknown covariates on posaconazole PK  
The derived PK model can be used for modeling and simulation purposes to demonstrate target attainment 
in a wide distribution of patients.  
 
As a general statement, we hypothesize that altered clearance is more likely in critically ill patients than 
altered clearance in hematology patients. We expect that a difference in clearance is largest in critically ill 
patients. Thus if we want to identify changes in PK of posaconazole, this is the cohort that is best used to 
address the question.  
 
 
3. PATIENTS AND METHODS 
 
3.1. Study characteristics 
Open label, multiple dose, pharmacokinetic study on intravenous posaconazole. 
 
3.2. Inclusion and exclusion criteria 
Patients who are randomized in the posaconazole prophylaxis-group in de principal study (S60744) are 
automatically eligible for this PK study. 
 
 
 
 
 
 

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3.3. Study design 
1) Posaconazole sampling 
a. Group 1: extensive sampling (UZ Leuven and Radboudumc) 
o Plasma 
 
A full PK curve will be taken on two extensive sampling days: day 2 and day 5. 
Intravenous administration of posaconazole sampling scheme: t = 0 (pre-dose), 1.5 
(= end of infusion), 2, 3, 4, 6, 8, 10, 12, 18, and 24 hours post infusion (11 samples).  
 
On non-PK days (until day 7), samples will be taken daily just prior to the daily 
infusion therapy. The exact times of sampling will be recorded in the case report 
forms.  
 
In the full PK group a maximum of 30 PK plasma samples will be taken. The total 
volume associated with this setup is 60 ml. No problems for the patients are 
expected with this limited amount of blood taken. In previous studies similar setup 
was used and approved by the ethics committee. 
 
Together with the posaconazole concentration, the concentration of the glucuronide 
metabolite will be reported (no extra sample). 
o BAL (bronchoalveolar lavage) – only in patients with mechanical ventilation and when 
medically indicated 
 
The BAL fluid and alveolar cells from the BAL carried out 48 hours after influenza 
diagnosis (see principal study (S60744)) will be analyzed to measure the 
posaconazole concentration. Bronchoscopy will only be performed if the safety of 
the patient will not be compromised. 
 
If other BALs are carried out by the treating physician, a part of that BAL fluid and 
alveolar cells will be analyzed to measure the posaconazole concentration. 
 
BAL sampling by mini broncho-alveolar lavage (2 x 20 mL NaCL 0.9%) and a plasma 
sample at the same time. 
 
Urea is determined simultaneously on BAL fluid and in plasma to correct for the 
dilution with NaCL 0,9%. 
 
b. Group II: limited sampling (other investigation sites) 
o Plasma 
 
A limited sampling strategy will be deployed taking samples on the same days (day 
2 and 5) but at less frequent time points : between 1.5 – 3 hours ; between 4-8 
hours ; between 8-12 hours and between 12-24 hours (4 samples in total).  
 
On non-PK days (until day 7), samples will be taken daily just prior to the daily 
infusion therapy. The exact times of sampling will be recorded in the case report 
forms. 
 
 

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2) Other data: 
a. Data on critical illness, albumin, renal and liver function and albumin will be used for 
covariate analysis of posaconazole pharmacokinetics. One extra whole blood cell sampling 
tube will be used for genotyping (UGT1A4).  
b. The clinical response of the posaconazole prophylaxis will be evaluated in the principal 
study (S60744). 
 
3.4. Sample analysis and quantification 
The samples will be analyzed in Radboudumc, Nijmegen. 
 
3.5. Pharmacokinetic and statistical analysis of the data 
To assess the sampling design for development of a population pharmacokinetic model, we evaluated a 
design using an 11 point sampling pharmacokinetic study. This was performed by means of stochastic 
simulation and estimation (SSE) of 500 virtual pharmacokinetic studies, based on a previously developed 
pharmacokinetic model for concentrations of posaconazole patients [Dolton and Bruggemann et al.] 
and this was performed with the SSE tool in Perl Speaks NONMEM and the non-linear mixed effects 
modelling program NONMEM V7.3.  
 
3.6. Sample size 
We will include all patients who are eligible for the principal study (S60744) and of who Informed 
Consent was attained. Intensive sampling will be done for all patients in UZ Leuven and Nijmegen and 
for the remainder of patients the limited sampling strategy will be used.