Clinical trial NCT06892951: CaspoNEB: Efficacy and Safety of Caspofungin Aerosols for the Curative Treatment of Pneumocystis Pneumonia
Official title: Phase I/II Safety lead-in Randomized Blind Placebo-controlled Clinical Trial: Efficacy and Safety of Caspofungin Aerosols for the Curative Treatment of Pneumocystis Pneumonia in Adjunction of Conventional Systemic Antifungal Therapy
Study type: INTERVENTIONAL
Overall status: NOT_YET_RECRUITING
Phase: PHASE1
PHASE2
Conditions: Pneumocystis Pneumonia
Pneumocystis Jirovecii Infection
Pneumocystis Infections
Keywords: ventilation
Pneumocystis
caspofungin
echinocandin
aerosol
inhalation
nebulization
interstitial pneumonia
Lead sponsor: University Hospital, Tours
Sponsor class: OTHER
Collaborators: name: University Hospital, Angers
name: Centre Hospitalier Universitaire de Besancon
name: University Hospital, Bordeaux
name: University Hospital, Brest
name: Centre Hospitalier Universitaire Dijon
name: University Hospital, Grenoble
name: University Hospital, Lille
name: University Hospital, Limoges
name: Hospices Civils de Lyon
name: University Hospital, Montpellier
name: Nantes University Hospital
name: Centre Hospitalier Universitaire de Nice
name: Hospital Avicenne
name: Henri Mondor University Hospital
name: Hopital Foch
name: Hôpital Necker-Enfants Malades
name: Pitié-Salpêtrière Hospital
name: Poitiers University Hospital
name: Reims University hospital
name: Ohre Pharma
name: Aerogen
name: Wako Diagnostics
name: Cape Cod Incorporated
name: Institut National de la Santé Et de la Recherche Médicale, France
name: Tours university
name: Amiens University Hospital
name: Rennes University Hospital
First posted: 2025-03-25
Enrollment: 100
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: The protocol will be carried out in a sequential manner to first provide safety data and the optimal dosing regimen on inhaled caspofungin, prior to inclusion of all the other patients:

1. Part 1: open-label, one arm, non-randomized, three centres study including six patients with ascending scheme regarding the rhythm of administration over one week, depending on the tolerance and closely monitored in intensive care unit to ensure that caspofungin is well tolerated via the inhaled route and to provide data supporting the proposed dose for part 2 (PK modeling)
2. Part 2: comparative, two arms, add-on, multicenter, individually-randomized placebo-controlled trial
Primary purpose: TREATMENT

Brief summary: To assess the efficacy of administrating daily caspofungin aerosols versus placebo for seven days, in adjunction of conventional systemic antifungal therapy during curative treatment of Pneumocystis pneumonia, on the clinical outcome at the end of the nebulized therapy, in order to support a "GO / NO GO" decision towards a phase III trial of nebulized caspofungin in those patients.

Detailed description: Pneumocystis jirovecii is an airborne-transmissible fungus which can induce pneumonia with severely impaired lung function, especially in immunocompromised patients. At least 1,000 new cases of Pneumocystis pneumonia occur each year in France with approximately 50% of cases suffering from hypoxemia. Around 15% HIV+ and 50% HIV- subjects require mechanical ventilation, and mean duration of hospitalization is about 30 days. Average mortality rate is ≈20% at 3 months, higher for critically ill patients (30%-60%).

To date, cotrimoxazole represents the gold standard anti-Pneumocystis treatment commonly associated with systemic corticosteroids in case of moderate-to-severe infection. However, treatment is long (several weeks) to achieve clearance of the fungus, which might favor lung sequelae like persistent inflammation or post-infectious fibrosis. Furthermore, therapeutic failures have been reported as high as 9-44% of patients. Five other drugs have been commonly used as curative alternatives to cotrimoxazole against P. jirovecii: pentamidine, primaquine + clindamycin, dapsone and atovaquone. Some are responsible for serious side effects, while others are complex to administer or less efficient. All exhibit clinically important drug-drug interactions. Therefore, in such a context, it is important to test new drugs and/or alternative delivery routes for existing therapies.

Echinocandin drugs, including caspofungin, are usually administered daily to treat invasive candidiasis and aspergillosis. They target the fungal cell wall, thus inhibiting the β-(1,3)-D glucan synthase enzyme. Intravenous (IV) echinocandins are generally well tolerated and are not responsibles for major drug-drug interactions. IV caspofungin was also proven effective in animal models of Pneumocystis infection and significantly improve the overall survival. Two human studies showed that in-hospital and 3-month mortality rates were similar between patients receiving daily IV echinocandin and those receiving co-trimoxazole alone. Several case reports also showed 47 successful outcomes with IV caspofungin, alone or in combination with standard treatment. A recent study reported better response and lower in-hospital mortality in patients receiving the combination of cotrimoxazole + IV caspofungin with no severe adverse events. Therefore, IV echinocandins are now recommended in the European therapeutic guidelines for non-HIV patients as a salvage therapy (CII-grade) in association with co-trimoxazole.

However, high molecular weight and elevated protein binding hamper optimal diffusion of IV caspofungin towards the lung alveoli (\<5% plasma concentration), where P. jirovecii thrives. Administration through an aerosol directly delivered into the lung may circumvent this limitation. Technical feasibility of echinocandin nebulization was demonstrated in vitro with several commercial nebulizers that provided aerosol particles with adequat size and pH to ensure lung tolerance. In vivo, nebulized caspofungin, at a dosage equivalent to the usual IV dosage, showed an excellent safety profile in rats. It also reduced the fungal burden by -99% and induced elevated and prolonged concentrations of the drug in the lungs (almost 50% of the total amounts of caspofungin initially deposited into the lungs of infected rats were still detectable at 48 hours) - largely above the usual minimal inhibitory concentrations of fungal pathogens -, while caspofungin detection was almost null in other organs and blood.

Therefore, we hypothesize herein the therapeutic interest of caspofungin aerosols in adjunction with conventional antifungal therapy, as first-line curative treatment, to enhance the clinical recovery and to reduce the morbidity due to Pneumocystis pneumonia. As no clinical trials have been worldwide initiated, human efficacy and safety data of nebulized caspofungin are still lacking and will be first investigated in this study in patients. Thus organized in two successive parts, this phase I/II clinical trial represents a mandatory prelude for this original administration modality of caspofungin.

Eligibility criteria: Inclusion criteria:

* Male and female ≥18 years
* Medical management of Pneumocystis pneumonia based on :

  * Microbiological diagnosis of Pneumocystis pneumonia
  * Respiratory support (oxygen therapy or ventilatory assistance)
  * Systemic co-trimoxazole therapy or systemic second-line anti-Pneumocystis salvage therapy (switch to another anti-Pneumocystis drug is possible, but should be notified) (initiated within 48 hours or less before enrolment)
* Person affiliated to a French social security system or equivalent
* Written informed consent obtained from the participant or, if the patient is not able to give consent from representative (trusted person, family member) or if the delay in obtaining the consent is assumed not compatible with the enrollment requirements, a temporary approval can be obtained from the investigator. In all cases, the patient's written informed consent will have to be obtained as soon as possible.

Non-inclusion criteria:

* Persons covered by articles L1121-5 to L1121-8 of the CSP (corresponding to all protected persons: pregnant women, parturients, nursing mothers, persons deprived of their liberty by judicial or administrative decision, minors, and persons subject to a legal protection measure: guardianship or trusteeship). Pregnancy test to be performed in all women from 15 to 45 years old who have not had an ovariectomy.
* Other indication(s) for systemic administration of an echinocandin drug
* Known allergy to echinocandin drugs
* Absolute contraindication to aerosol therapy
* Concomitant co-infection at time of diagnosis (except HIV infection)
* Severe liver impairment (i.e. documented severe liver cirrhosis (Child C), or Factor-V protein \< 50% and/or INR for prothrombin time of blood coagulation \> 1.5)
* history of toxic epidermal necrosis (TEN) and Steven-Johnson syndrome (SJS)
* Participation in other pharmacological study that focuses on echinocandins and/or anti-infectious aerosol therapy or other anti-pneumocystis treatment
* Participation in a trial with an investigational product known to have pulmonary toxicity or of which the safety is not known

Primary outcomes:
measure: Part 1: safety of inhaled caspofungin
timeFrame: D-7 (day-7)
measure: Part 2: proportion of patients alive and with a favorable clinical course* at the seventh day (day-7) after the first administration.
timeFrame: D7 (day-7)
Secondary outcomes:
measure: Individual components of the composite primary outcome at day-7 (d-7)
timeFrame: D7 (day-7)
measure: Safety of nebulized caspofungin in patients with Pneumocystis pneumonia through
timeFrame: day-1 (d-1), d-2, d-3, d-4, d-5, d-6, and d-7
measure: Pharmacokinetics of nebulized caspofungin
timeFrame: 0, 2, 4, 6, 12, 24 hours, plus residual concentration at day (d-3) and d-7
measure: Mortality
timeFrame: day-28 (d-28) and d-90
measure: Morbidity
timeFrame: day-1 (d-1), d-7 and d-21
measure: Pulmonary and systemic markers of lung infection (to assess the fungal clearance)
timeFrame: day-1 (d-1), d-3, d-7, d-28 and d-90
Other outcomes:
Locations:
city: Tours
country: France
facility: CHU Tours
Study officials:
affiliation: University Hospital of TOURS
name: Guillaume DESOUBEAUX, Prof
role: STUDY_DIRECTOR
affiliation: University Hospital of TOURS
name: Stephan EHRMANN, Prof
role: STUDY_DIRECTOR
affiliation: University Hospital of TOURS
name: Adrien LEMAIGNEN, Dr
role: STUDY_DIRECTOR
References:
citation: Limper AH. Alveolar macrophage and glycoprotein responses to Pneumocystis carinii. Semin Respir Infect. 1998 Dec;13(4):339-47.
citation: McKinnell JA, Cannella AP, Kunz DF, Hook EW 3rd, Moser SA, Miller LG, Baddley JW, Pappas PG. Pneumocystis pneumonia in hospitalized patients: a detailed examination of symptoms, management, and outcomes in human immunodeficiency virus (HIV)-infected and HIV-uninfected persons. Transpl Infect Dis. 2012 Oct;14(5):510-8. doi: 10.1111/j.1399-3062.2012.00739.x. Epub 2012 May 1.
citation: Lobo ML, Esteves F, de Sousa B, Cardoso F, Cushion MT, Antunes F, Matos O. Therapeutic potential of caspofungin combined with trimethoprim-sulfamethoxazole for pneumocystis pneumonia: a pilot study in mice. PLoS One. 2013 Aug 5;8(8):e70619. doi: 10.1371/journal.pone.0070619. Print 2013.
citation: Wong-Beringer A, Lambros MP, Beringer PM, Johnson DL. Suitability of caspofungin for aerosol delivery: physicochemical profiling and nebulizer choice. Chest. 2005 Nov;128(5):3711-6. doi: 10.1378/chest.128.5.3711.
citation: Ehrmann S, Mercier E, Vecellio L, Ternant D, Paintaud G, Dequin PF. Pharmacokinetics of high-dose nebulized amikacin in mechanically ventilated healthy subjects. Intensive Care Med. 2008 Apr;34(4):755-62. doi: 10.1007/s00134-007-0935-1. Epub 2007 Nov 29.
citation: Beitler JR, Sarge T, Banner-Goodspeed VM, Gong MN, Cook D, Novack V, Loring SH, Talmor D; EPVent-2 Study Group. Effect of Titrating Positive End-Expiratory Pressure (PEEP) With an Esophageal Pressure-Guided Strategy vs an Empirical High PEEP-Fio2 Strategy on Death and Days Free From Mechanical Ventilation Among Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2019 Mar 5;321(9):846-857. doi: 10.1001/jama.2019.0555.
citation: Desoubeaux G, Lemaignen A, Ehrmann S. Scientific rationale for inhaled caspofungin to treat Pneumocystis pneumonia: A therapeutic innovation likely relevant to investigate in a near future.... Int J Infect Dis. 2020 Jun;95:464-467. doi: 10.1016/j.ijid.2020.03.029. Epub 2020 Mar 16. No abstract available.
citation: Le Gal S, Toubas D, Totet A, Dalle F, Abou Bacar A, Le Meur Y, Nevez G; Anofel Association. Pneumocystis Infection Outbreaks in Organ Transplantation Units in France: A Nation-Wide Survey. Clin Infect Dis. 2020 May 6;70(10):2216-2220. doi: 10.1093/cid/ciz901.
citation: Desoubeaux G, Dominique M, Morio F, Thepault RA, Franck-Martel C, Tellier AC, Ferrandiere M, Hennequin C, Bernard L, Salame E, Bailly E, Chandenier J. Epidemiological Outbreaks of Pneumocystis jirovecii Pneumonia Are Not Limited to Kidney Transplant Recipients: Genotyping Confirms Common Source of Transmission in a Liver Transplantation Unit. J Clin Microbiol. 2016 May;54(5):1314-20. doi: 10.1128/JCM.00133-16. Epub 2016 Mar 2.
citation: Alanio A, Desoubeaux G, Sarfati C, Hamane S, Bergeron A, Azoulay E, Molina JM, Derouin F, Menotti J. Real-time PCR assay-based strategy for differentiation between active Pneumocystis jirovecii pneumonia and colonization in immunocompromised patients. Clin Microbiol Infect. 2011 Oct;17(10):1531-7. doi: 10.1111/j.1469-0691.2010.03400.x. Epub 2011 Apr 12.
citation: Nevez G, Le Gal S. Caspofungin and Pneumocystis Pneumonia: It Is Time To Go Ahead. Antimicrob Agents Chemother. 2019 Sep 23;63(10):e01296-19. doi: 10.1128/AAC.01296-19. Print 2019 Oct. No abstract available.