Efficacy of Cotrimoxazole as a De-escalation Treatment of Ventilator-Associated Pneumonia in Intensive Care Unit

Study Overview
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Brief Summary
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Efficacy of cotrimoxazole as a de-escalation treatment for adult patients Ventilator-Associated Pneumonia in intensive care unit Multicentre randomized non-inferiority trial comparing cotrimoxazole to standard antibiotic therapy for enterobacterial VAP

Detailed Description
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Multicentre randomized non-inferiority trial comparing cotrimoxazole to standard antibiotic therapy for enterobacterial VAP. Selection of patients will be done by physicians in ICU. All clinically suspected VAP will be confirmed with a lung sample (preferably bronchoalveolar lavage or protected distal specimen, otherwise endotracheal aspiration). Patients with a microbiologically confirmed VAP due to an Enterobacteriaceae susceptible to cotrimoxazole and at least one antibiotic of the empiric antibiotic therapy (based on international recommendations) will be included. After written informed consent, they will be randomized (1:1), using a computer-generated randomization scheme of various-sized blocks, stratified by presence of septic shock at VAP diagnosis and by presence of COVID-19 pneumonia on ICU admission, through a centralized 24 hours internet service (CleanWEB™) to cotrimoxazole, or best standard of care (either a beta-lactam or a fluoroquinolone), after randomization for a total duration of 7 days (including empiric initial appropriate treatment). Posology and modalities of antibiotic administration will be optimized based on most recent recommendations for ICU patients. Because antibiotic therapy will be variable in the control group, single or double blind is not appropriate. Daily follow-up until death or ICU discharge or day 28 will be performed (vital status, antibiotic therapy, new infection, Clostridium-difficile infection). Clinical (arterial blood gas, temperature, haematology, tracheal secretions) and radiological cure (chest X-ray) will be assessed at Day 7. Systematic MDR bacteria screening will be performed weekly and at ICU discharge. Vital status will be assessed at day 90. Alive patients leaving ICU before 90 days will be contacted by phone (if discharge at home) or by interview at hospital (if transferred in a different ward). Assessment of the clinical and radiological cure by an independent committee (1 specialist in infectious disease and 1 intensivist), blinded of the randomization arm (PROBE methodology).

Official Title
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Efficacy of Cotrimoxazole as a De-escalation Treatment of Ventilator-Associated Pneumonia in Intensive Care Unit. Multicentric Non-inferiority Randomised Controlled Trial

Conditions
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Ventilator Associated Pneumonia

Intervention / Treatment
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* Drug: cotrimoxazole
* Drug: standard antibiotic therapy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adult patients hospitalized in an ICU Under mechanical ventilation for at least five days Microbiologically confirmed VAP preferably on a distal lung sample (bronchoalveolar lavage or protected distal specimen) otherwise endotracheal aspiration Enterobacteriaceae susceptible to cotrimoxazole, and for polymicrobial VAP, all bacteria susceptible to cotrimoxazole Treated for at least 24 hours by an appropriate empiric antibiotic therapy (at least one effective antibiotic from the initiation of treatment for this VAP episode) Stability of haemodynamic (stability or decrease in catecholamine dose) and respiratory (stability or improvement of FIO2) parameters Exclusion Criteria: Haemodynamic instability (increasing dose of a catecholamine in the last 24 hours) Contra-indication to cotrimoxazole: allergy, advanced liver insufficiency, renal dysfunction with clearance <15 mL/min/1.73 m² without hemodialysis G6PD deficiency history of hypersensitivity to one of the components (in particular, hypersensitivity to sulphonamides known macrocytic anemia defined by VGM > treatment with methotrexate Infection requiring prolonged antibiotic-therapy (pleural empyema, lung abscess, necrotizing pneumonia, etc…) Cystic fibrosis Immunosuppression (neutropenia, HIV with CD4 lymphocytes below 200/mm3, immunosuppressive therapy or corticosteroid therapy >0.5 mg/kg/j before ICU admission) Cardiac arrest without awakening Moribund state (patient likely to die within 24h) Limitation of life support (comfort care applied only) at the time of screening Enrolment to another interventional study on VAP care/management Pregnancy or breastfeeding Subject deprived of freedom, subject under a legal protective measure No affiliation to any health insurance system Refusal to participate to the study (patient or legal representative or family member or close relative if present) Patients previously included in the study

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Multicentre randomized non-inferiority trial comparing cotrimoxazole to standard antibiotic therapy for enterobacterial VAP.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: cotrimoxazole<br>Use of cotrimoxazole for enterobacterial VAP. Posology and modalities of antibiotic administration will be optimized based on most recent recommendations for ICU patient. They will receive the treatment for 28 days or until death or until ICU discharge if its before 28days. | Drug: cotrimoxazole<br>* Use of cotrimoxazole therapy for enterobacterial VAP<br>|
| Active Comparator: standard antibiotic therapy<br>Use of standard antibiotic therapy enterobacterial VAP. Posology and modalities of antibiotic administration will be optimized based on most recent recommendations for ICU patient. They will receive the treatment for 28 days or until death or until ICU discharge if its before 28days. | Drug: standard antibiotic therapy<br>* Use of standard antibiotic therapy for enterobacterial VAP<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| To demonstrate that cotrimoxazole is non-inferior to best standard of care for the treatment of VAP in ICU in term of survival at day 28 | Vital status at day 28 | 28 days after inclusion | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| To demonstrate that cotrimoxazole is superior to best standard of care for the treatment of VAP in ICU in term of mortality at day 90 | Vital status at day 90 | 90 days after inclusion | 
| To demonstrate that cotrimoxazole is superior to best standard of care for the treatment of VAP in IC in terms of mechanical ventilation (MV)-free-days at day 28 | number of MV-free-days through day 28 | 28 days after inclusion | 
| To demonstrate that cotrimoxazole is superior to best standard of care for the treatment of VAP in ICU in terms of rate of cure between days 7 and 10 | Clinical, biological and radiological cure evaluated 7 to 10 days after VAP diagnosis, defined as the combination of resolution of signs and symptoms present at enrolment, biological improvement, and improvement or lack of progression of radiological signs, as adjudicated by an independent committee (PROBE methodology) | days 7 and 10 after inclusion | 
| To demonstrate that cotrimoxazole is superior to best standard of care for the treatment of VAP in ICU in terms of VAP recurrence | new episode of VAP with the same Enterobacteriaceae | 28 days after inclusion | 
| To demonstrate that cotrimoxazole is superior to best standard of care for the treatment of VAP in ICU in terms of ICU length of stay | ICU length of stay | 28 days after inclusion | 
| To demonstrate that cotrimoxazole is superior to best standard of care for the treatment of VAP in ICU in terms of hospital length of stay | hospital length of stay | 28 days after inclusion | 
| To assess the safety of cotrimoxazole compared to best standard of care at day 28 in terms of allergy to antibiotics | safety (rate of allergy due to antimicrobial drug) | 28 days after inclusion | 
| To demonstrate that cotrimoxazole is superior to best standard of care for the treatment of VAP in ICU in terms of mortality at day 28 | Vital status at day 28 | 28 days after inclusion | 
| To demonstrate that cotrimoxazole is superior to best standard of care for the treatment of VAP in ICU in terms of overall antibiotic consumption | antibiotic-free days at day 28 | day 28 after inclusion | 
| To assess the ecological impact of the treatment in terms of acquisition of MDR bacteria in ICU | evolution of rate of MDR bacterial colonization on systematic screening at enrolment until ICU discharge | 28 days after inclsuion | 
| To assess the ecological impact of the treatment in terms of rate of Clostridioides difficile infection | diagnostic of Clostridioides difficile infection between inclusion and day 28 | 28 days after inclusion | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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intensive care unit, de-escalation, cotrimoxazole, Ventilator Associated Pneumonia