PipEracillin/Tazobactam Versus mERoPENem for Treatment of AmpC Producing Blood Stream Infections

Study Overview
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Brief Summary
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Data regarding optimal treatment for extended-spectrum beta-lactamase (ESBL) producing Enterobacterales bloodstream infection are lacking. Observational studies show conflicting results when comparing treatment with combination beta-lactam-beta-lactamase inhibitor and carbapenems. The investigators aim to evaluate the effect of definitive treatment with meropenem vs. piperacillin-tazobactam on the outcome of patients with bacteremia due to cephalosporin-non-susceptible Enterobacteriaceae. The investigators hypothesize that piperacillin-tazobactam is non-inferior to meropenem.

Detailed Description
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PeterPen-SPICE-M will expland the PeterPen trial. In PeterPen we recruit patients with bacteremia caused by 3rd generation cephalosporin-resistant E. coli or Klebsiella pneumoniae. In SPICE-M we will recruit also patients with bacteremia caused by 3rd generation cephalosporin-resistant Serratia marcescens, Providencia stuartii & rettgeri, Indole positive Proteus spp. (Proteus vulgaris), Citrobacter freundii, Enterobacter cloacae, Klebsiella aerogenes and Morganella morganii. In both trials patients will be allocated within 72 hours of blood culture taking to piperacillin-tazobactam vs. meropenem to complete at least 7 days of covering antibiotic therapy.

Official Title
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PipEracillin/Tazobactam vs mERoPENem for Treatment of AmpC-producing Bloodstream Infections: an Extension of the Original PETERPEN Trial

Conditions
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Bacteremia, Beta Lactam Resistant Bacterial Infection, Enterobacteriaceae Infections

Intervention / Treatment
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* Drug: Piperacillin / Tazobactam Injection
* Drug: Meropenem


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adults (age ≥ 18 years) New onset BSI due to Serratia marcescens, Providencia spp., Morganella morganii, Citrobacter freundii, and Enterobacter spp.in one or more blood cultures associated with evidence of infection. The microorganism will have to be non-susceptible to third generation cephalosporins (ceftriaxone and ceftazidime) and susceptible to both PTZ and meropenem (see microbiological methods). Both community and hospital-acquired bacteremias will be included. We will permit the inclusion of bacteremias due to study pathogens with concomitant growth in blood of skin commensals considered as contaminants. Exclusion Criteria: More than 72 hr. elapsed since initial blood culture taken, regardless of the time covering antibiotics were started (up to 72 hrs.). Polymicrobial bacteremia. Polymicrobial bacteremia will be defined as either growth of two or more different species of microorganisms in the same blood culture, or growth of different species in two or more separate blood cultures within the same episode. Patients with prior bacteremia or infection that have not completed antimicrobial therapy for the previous infectious episode. Patients with septic shock at the time of enrollment and randomization, defined as at least 2 measurements of systolic blood pressure < 90 mmHg and/or use of vasopressors (dopamine>15μg/kg/min, adrenalin>0.1μg/kg/min, noradrenalin>0.1μg/kg/min, vasopressin any dose) in the 12 hours prior to randomization. In the absence of the use of vasopressors, a systolic blood pressure <90 would need to represent a deviation for the patient's known normal blood pressure. BSI due to specific infections known at the time of randomization: Endocarditis / endovascular infections Osteomyelitis (not resected) Central nervous system infections Allergy to any of the study drugs confirmed by history taken by the investigator Previous enrollment in this trial Concurrent participation in another interventional clinical trial Imminent death (researcher's assessment of expected death within 48 hrs. of recruitment) or patient in palliative care

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 120 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
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: piperacillin tazobactam<br> | Drug: Piperacillin / Tazobactam Injection<br>* 4.5 grams QID<br>|
| Active Comparator: meropenem<br> | Drug: Meropenem<br>* 1 gram TID<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| All-cause mortality | Primary Outcome Measure | 30 days from randomization | 
| Treatment failure | death OR fever > 38°C in the last 48 hours OR lack of resolution of symptoms attributed to the focus of infection OR Sequential Failure Organ Assessment (SOFA) score increasing OR positive blood cultures by the time point assessed | 7 days from randomization] | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| All-cause mortality | Number of deceased patients | 14 and 90 days from randomization] | 
| Number of participants with treatment failure | death OR fever > 38°C in the last 48 hours OR lack of resolution of symptoms attributed to the focus of infection OR Sequential Failure Organ Assessment (SOFA) score increasing OR positive blood cultures by the time point assessed | 14 days and 30 days from randomization | 
| Number of participants with microbiological failure | Repeat positive blood cultures with index pathogen on day 4 or later from randomization | 7 days and 14 days from randomization | 
| Number of participants with recurrent positive blood cultures (relapse) | recurrent positive blood cultures with the index pathogen after prior sterilization of blood cultures or after end of treatment | 30 days and 90 days from randomization | 
| Number of participants with Clostridium difficile associated diarrhea | Diarrhea with positive Clostridium difficile toxin test | 90 days from randomization | 
| Secondary bacterial infections | Number of participants with a new clinically-significant infection, with or without microbiological documentation. Defined using NHSN criteria for healthcare-associated infections. | 90 days from randomization | 
| Number of participants with hospital re-admissions | Hospital re-admission, excluding index hospitalization | 90 days from randomization | 
| Number of participants with development of antimicrobial resistance | clinical isolates resistant to piperacillin/tazobactam and meropenem and any carbapenem-resistant bacteria | 90 days from randomization | 
| Carriage of carbapenemase-producing Enterobacteriaceae (CPE) and non-CPE carbapenem-resistant Enterobacteriaceae in-hospital detected by weekly rectal surveillance of carriage while in-hospital | New acquisition of carbapenemase-producing Enterobacteriaceae (CPE) and non-CPE carbapenem-resistant Enterobacteriaceae, detected through rectal surveillance or clinical cultures | 90 days from randomization | 
| Total in-hospital days | Total of in-hospital days per participant, including all admissions | 30 days and 90 days from randomization | 
| Total antibiotic days | Total antibiotic days per participant within all admissions | 30 days and 90 days from randomization | 
| Adverse events | diarrhea, liver function test abnormalities, antibiotic rash or other immediate-type allergy, acute kidney injury defined according to RIFLE criteria | 30 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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bacteremia, enterobacteriaceae, extended spectrum beta-lactamase, meropenem, piperacillin tazobactam