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Kinamon T, Waack U, Needles M, Rubin D, Collyar D, Doernberg SB, Evans SR, Hamasaki T, Holland TL, Howard-Anderson J, Chambers H, Fowler VG, Nambiar S, Kim P, Boucher HW, Gopinath R. Exploration of a Potential DOOR Endpoint for Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia Using Six Registrational Trials for Antibacterial Drugs. Clin Infect Dis 2024:ciae163. [PMID: 38527855 DOI: 10.1093/cid/ciae163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/08/2024] [Accepted: 02/22/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Desirability of outcome ranking (DOOR) is an innovative approach to clinical trial design and analysis that uses an ordinal ranking system to incorporate the overall risks and benefits of a therapeutic intervention into a single measurement. Here, we derived and evaluated a disease-specific DOOR endpoint for registrational trials for hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia (HABP/VABP). METHODS Through comprehensive examination of data from nearly 4,000 participants enrolled in six registrational trials for HABP/VABP submitted to the FDA between 2005-2022, we derived and applied a HABP/VABP specific endpoint. We estimated the probability that a participant assigned to the study treatment arm would have a more favorable overall DOOR or component outcome than a participant assigned to comparator. RESULTS DOOR distributions between treatment arms were similar in all trials. DOOR probability estimates ranged from 48.3% to 52.9% and were not statistically different. There were no significant differences between treatment arms in the component analyses. Though infectious complications and serious adverse events occurred more frequently in ventilated participants compared to non-ventilated participants, the types of events were similar. CONCLUSIONS Through a data-driven approach, we constructed and applied a potential DOOR endpoint for HABP/VABP trials. The inclusion of syndrome-specific events may help to better delineate and evaluate participant experiences and outcomes in future HABP/VABP trials and could help inform data collection and trial design.
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Affiliation(s)
- Tori Kinamon
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
- Department of Medicine, Duke University Medical Center, Durham, NC USA
- Oak Ridge Institute for Science and Education, United States Department of Energy, Oak Ridge, TN, USA
| | - Ursula Waack
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Mark Needles
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Daniel Rubin
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | | | - Sarah B Doernberg
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA
| | - Scott R Evans
- Biostatistics Center and Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Washington, D.C., USA
- Antibacterial Resistance Leadership Group, Durham, NC, USA
| | - Toshimitsu Hamasaki
- Biostatistics Center and Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Washington, D.C., USA
- Antibacterial Resistance Leadership Group, Durham, NC, USA
| | - Thomas L Holland
- Department of Medicine, Duke University Medical Center, Durham, NC USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Jessica Howard-Anderson
- Antibacterial Resistance Leadership Group, Durham, NC, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Henry Chambers
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA
- Antibacterial Resistance Leadership Group, Durham, NC, USA
| | - Vance G Fowler
- Department of Medicine, Duke University Medical Center, Durham, NC USA
- Antibacterial Resistance Leadership Group, Durham, NC, USA
| | - Sumati Nambiar
- Antibacterial Resistance Leadership Group, Durham, NC, USA
- Johnson and Johnson, Raritan, NJ, USA
| | - Peter Kim
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Helen W Boucher
- Antibacterial Resistance Leadership Group, Durham, NC, USA
- Tufts University School of Medicine and Tufts Medicine, Boston, MA, USA
| | - Ramya Gopinath
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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2
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Howard-Anderson J, Hamasaki T, Dai W, Collyar D, Rubin D, Nambiar S, Kinamon T, Leister-Tebbe H, Hill C, Geres H, Holland TL, Doernberg SB, Chambers HF, Fowler VG, Evans SR, Boucher HW. Moving Beyond Mortality: Development and Application of a Desirability of Outcome Ranking (DOOR) Endpoint for Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia. Clin Infect Dis 2024; 78:259-268. [PMID: 37740559 PMCID: PMC10874265 DOI: 10.1093/cid/ciad576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/10/2023] [Accepted: 09/20/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Hospital-acquired and ventilator-associated bacterial pneumonia (HABP/VABP) are frequently caused by multidrug-resistant organisms. Patient-centered endpoints in clinical trials are needed to develop new antibiotics for HABP/VABP. Desirability of outcome ranking (DOOR) is a paradigm for the design, analysis, and interpretation of clinical trials based on a patient-centered, benefit-risk evaluation. METHODS A multidisciplinary committee created an infectious diseases DOOR endpoint customized for HABP/VABP, incorporating infectious complications, serious adverse events, and mortality. We applied this to 2 previously completed, large randomized controlled trials for HABP/VABP. ZEPHyR compared vancomycin to linezolid and VITAL compared linezolid to tedizolid. For each trial, we evaluated the DOOR distribution and probability, including DOOR component and partial credit analyses. We also applied DOOR in subgroup analyses. RESULTS In both trials, the HABP/VABP DOOR demonstrated similar overall clinical outcomes between treatment groups. In ZEPHyR, the probability that a participant treated with linezolid would have a more desirable outcome than a participant treated with vancomycin was 50.2% (95% confidence interval [CI], 45.1%--55.3%). In VITAL, the probability that a participant treated with tedizolid would have a more desirable outcome than a participant treated with linezolid was 48.7% (95% CI, 44.8%-52.6%). The DOOR component analysis revealed that participants treated with tedizolid had a less desirable outcome than those treated with linezolid when considering clinical response alone. However, participants with decreased renal function had improved overall outcomes with tedizolid. CONCLUSIONS The HABP/VABP DOOR provided more granular information about clinical outcomes than is typically presented in clinical trials. HABP/VABP trials would benefit from prospectively using DOOR.
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Affiliation(s)
- Jessica Howard-Anderson
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Toshimitsu Hamasaki
- Biostatistics Center and Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Weixiao Dai
- Biostatistics Center and Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | | | - Daniel Rubin
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Tori Kinamon
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Carol Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Holly Geres
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Thomas L Holland
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California, SanFrancisco, USA
| | - Henry F Chambers
- Division of Infectious Diseases, Department of Medicine, University of California, SanFrancisco, USA
| | - Vance G Fowler
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Scott R Evans
- Biostatistics Center and Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Helen W Boucher
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts University School of Medicine
- Tufts Medicine, Boston, Massachusetts, USA
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Gao W, Passarell J, Patel YT, Zhang Z, Lin G, Fiedler-Kelly J, Bruno CJ, Rhee EG, De Anda CS, Feng HP. Exposure-Efficacy Analyses Support Optimal Dosing Regimens of Ceftolozane/Tazobactam in Participants with Hospital-Acquired/Ventilator-Associated Bacterial Pneumonia in ASPECT-NP. Antimicrob Agents Chemother 2022;:e0139921. [PMID: 35471040 DOI: 10.1128/aac.01399-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
An exposure–efficacy analysis of the phase 3 ASPECT-NP trial was performed to evaluate the relationship between plasma exposure of ceftolozane and tazobactam and efficacy endpoints (primary: 28-day all-cause mortality; key secondary: clinical cure at test-of-cure visit) in adult participants with hospital-acquired or ventilator-associated bacterial pneumonia (HABP/VABP). Participants (N = 231) from the ceftolozane/tazobactam treatment group in the intention-to-treat population who had pharmacokinetic data available and relevant baseline lower respiratory tract (LRT) pathogen(s) susceptibility data were included. Population pharmacokinetic models were used to predict individual ceftolozane and tazobactam plasma exposure measures (percentage of the interdose interval with free drug concentrations above the MIC [%ƒT>MIC] and %ƒT above a threshold [%ƒT>CT = 1 μg/mL], respectively) associated with the last dose using the highest ceftolozane/tazobactam MIC for the relevant baseline LRT pathogens. Efficacy measures were comparable between the baseline LRT pathogens and across MIC cutoffs (1–8 μg/mL). Most participants (82%) had 99% ƒT>MIC for ceftolozane; 9% (N = 21/231) had 0% ƒT>MIC due to high MICs of the LRT pathogen (64–256 μg/mL). The %ƒT>MIC for ceftolozane exceeded 73% for all participants with baseline LRT pathogen(s) MIC ≤4 μg/mL. All 231 participants achieved the tazobactam pharmacokinetic/pharmacodynamic target of >20% ƒT>CT where CT = 1 μg/mL. For either efficacy endpoint, median ceftolozane %ƒT>MIC was 99% in participants achieving efficacy. No exposure–efficacy trend was observed for ceftolozane or tazobactam. These results further support the recommended ceftolozane/tazobactam dosing regimens evaluated in ASPECT-NP for patients with HABP/VABP.
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Drwiega EN, Griffith NC, Danziger LH. Pharmacokinetic evaluation of cefiderocol for the treatment of multidrug resistant Gram-negative infections. Expert Opin Drug Metab Toxicol 2022; 18:245-259. [PMID: 35594628 DOI: 10.1080/17425255.2022.2081148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 05/19/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Cefiderocol is a siderophore cephalosporin antibiotic and first of its kind approved by the Food and Drug Administration for the treatment of complicated urinary tract infections (cUTI) and hospital-acquired and ventilator-associated bacterial pneumonia (HABP/VABP) in patients 18 years or older caused by susceptible organisms. Cefiderocol's unique mechanism of iron chelation improves Gram-negative membrane penetration as the bacteria's iron uptake mechanism recognizes the chelated iron antibiotic and iron for entry. This also allows for the evasion of cefiderocol from cell entry-related resistance mechanisms. AREAS COVERED This review covers the mechanism of action, resistance mechanisms, pharmacokinetics in various patient populations, and pharmacodynamics. Relevant literature evaluating efficacy and safety are discussed. EXPERT OPINION Limited treatment options are available for the treatment of carbapenem-resistantorganisms. Clinical trials have demonstrated that cefiderocol is no worse than alternative treatment options for cUTIs and HABP/VABP, but more data are currently available to support the use of beta-lactam beta-lactamase inhibitor agents, where susceptible. Mortality differences demonstrated in patients with pneumonia and bloodstream infections must further be explored and logistical and practical considerations regarding susceptibility testing and use as monotherapy vs. combination therapy must be considered prior to confidently recommending cefiderocol for regular use in systemic infections.
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Affiliation(s)
- Emily N Drwiega
- College of Pharmacy, University of Illinois at Chicago, Chicaco, IL, USA
| | - Nicole C Griffith
- College of Pharmacy, University of Illinois at Chicago, Chicaco, IL, USA
| | - Larry H Danziger
- College of Pharmacy, University of Illinois at Chicago, Chicaco, IL, USA
- College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
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5
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Bart SM, Rubin D, Kim P, Farley JJ, Nambiar S. Trends in Hospital-Acquired and Ventilator-Associated Bacterial Pneumonia Trials. Clin Infect Dis 2021; 73:e602-e608. [PMID: 33173946 DOI: 10.1093/cid/ciaa1712] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND New drug development for hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) is critical. Challenges remain in the conduct of HABP/VABP trials, especially in the contexts of enrollment, endpoints, nonstudy antibacterial drug therapy, and antimicrobial resistance. METHODS Four Phase 3 noninferiority trials (n = 2433 participants) submitted to the Food and Drug Administration after 2015 were analyzed for enrollment statistics, participant characteristics associated with 28-day all-cause mortality (ACM), microbiology, and receipt of nonstudy antibacterial drugs. All trials primarily enrolled patients with gram-negative bacterial infections. RESULTS The mean trial length was 2.7 years and the mean recruitment rate was 0.17 participants/site/month. ACM at 28 days was 17.1% and was higher among participants diagnosed with ventilated HABP (31.9%) or VABP (19.0%) than nonventilated HABP (9.9%). VABP participants tended to be younger, less likely to have chronic obstructive pulmonary disease, and more likely to have previously sustained an injury. Age, South American residence, diagnosis of ventilated HABP or VABP, and Acinetobacter baumannii infection were all associated with 28-day ACM in a multivariate logistic regression model. Infection by A. baumannii was most common in Eastern European and Asia/Pacific participants, and Eastern European isolates exhibited the highest levels of meropenem resistance. Concomitant nonstudy antibacterial drug therapy most commonly included beta-lactams and was initiated earliest in Western Europe. CONCLUSION This analysis of recent trials may assist in trial considerations for HABP/VABP development programs and promote needed antibacterial drug development for patients with serious infections.
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Affiliation(s)
- Stephen M Bart
- Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Daniel Rubin
- Division of Biometrics IV, Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Peter Kim
- Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - John J Farley
- Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sumathi Nambiar
- Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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6
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Sellarès-Nadal J, Eremiev S, Burgos J, Almirante B. An overview of cilastatin + imipenem + relebactam as a therapeutic option for hospital-acquired and ventilator-associated bacterial pneumonia: evidence to date. Expert Opin Pharmacother 2021; 22:1521-1531. [PMID: 34120547 DOI: 10.1080/14656566.2021.1939680] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are prevalent nosocomial infections with a worrisomely increasing prevalence of multidrug-resistant causative organisms, including those with resistance to carbapenems. The addition of relebactam, a β-lactamase inhibitor, to imipenem treatment restores the antimicrobial activity against the most of multidrug-resistant Gram-negative bacteria, including some carrying β-lactamase enzyme-type carbapenemases.Areas covered: The aim of this article is to summarize the current evidence regarding imipenem/relebactam for the treatment of HAP/VAP. The authors discuss its chemistry, pharmacokinetics/pharmacodynamics, microbiology, tolerance and clinical efficacy. The results of clinical trials have demonstrated an efficacy of imipenem/relebactam similar to that of its comparator for the treatment of patients with HAP/VAP. Different studies have also shown its good safety profile, which is better than that of the combination of other β-lactams with other antibiotics.Expert opinion: This drug should be incorporated as a new therapeutic option for the treatment of patients with HAP/VAP, especially as an alternative treatment in patients with confirmed infections caused by multidrug-resistant Gram-negatives.
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Affiliation(s)
- Júlia Sellarès-Nadal
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain.,Spanish Network for the Study of Infectious Diseases (REIPI), Spain
| | - Simeón Eremiev
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Joaquin Burgos
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain.,Spanish Network for the Study of HIV (RIS), Spain
| | - Benito Almirante
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain.,Spanish Network for the Study of Infectious Diseases (REIPI), Spain
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Weiss E, Zahar JR, Alder J, Asehnoune K, Bassetti M, Bonten MJM, Chastre J, De Waele J, Dimopoulos G, Eggimann P, Engelhardt M, Ewig S, Kollef M, Lipman J, Luna C, Martin-Loeches I, Pagani L, Palmer LB, Papazian L, Poulakou G, Prokocimer P, Rello J, Rex JH, Shorr AF, Talbot GH, Thamlikitkul V, Torres A, Wunderink RG, Timsit JF. Elaboration of Consensus Clinical Endpoints to Evaluate Antimicrobial Treatment Efficacy in Future Hospital-acquired/Ventilator-associated Bacterial Pneumonia Clinical Trials. Clin Infect Dis 2020; 69:1912-1918. [PMID: 30722013 DOI: 10.1093/cid/ciz093] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/26/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Randomized clinical trials (RCTs) in hospital-acquired and ventilator-associated bacterial pneumonia (HABP and VABP, respectively) are important for the evaluation of new antimicrobials. However, the heterogeneity in endpoints used in RCTs evaluating treatment of HABP/VABP may puzzle clinicians. The aim of this work was to reach a consensus on clinical endpoints to consider in future clinical trials evaluating antimicrobial treatment efficacy for HABP/VABP. METHODS Twenty-six international experts from intensive care, infectious diseases, and the pharmaceutical industry were polled using the Delphi method. RESULTS The panel recommended a hierarchical composite endpoint including, by priority order, (1) survival at day 28, (2) mechanical ventilation-free days through day 28, and (3) clinical cure between study days 7 and 10 for VABP; and (1) survival (day 28) and (2) clinical cure (days 7-10) for HABP. Clinical cure was defined as the combination of resolution of signs and symptoms present at enrollment and improvement or lack of progression of radiological signs. More than 70% of the experts agreed to assess survival and mechanical ventilation-free days though day 28, and clinical cure between day 7 and day 10 after treatment initiation. Finally, the hierarchical order of endpoint components was reached after 3 Delphi rounds (72% agreement). CONCLUSIONS We provide a multinational expert consensus on separate hierarchical composite endpoints for VABP and HABP, and on a definition of clinical cure that could be considered for use in future HABP/VABP clinical trials.
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Affiliation(s)
- Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Assistance Publique-Hôpitaux de Paris (AP-HP), Beaujon Hospital, Clichy.,Unité Mixte de Recherche (UMR) 1149, Centre for Research on Inflammation, Institut national de la santé et de la recherche médicale (INSERM)/Université Paris Diderot, Paris
| | - Jean-Ralph Zahar
- Department of Clinical Microbiology and Infection Control Unit, Avicennes Hospital, AP-HP, Bobigny.,Infection, Antibiotics, Modelisation, Epidemiology (IAME), UMR 1137, Université Paris 13, Sorbonne Paris Cité, France
| | | | - Karim Asehnoune
- University Hospital of Nantes, Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu, Nantes, France
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Santa Maria Misericordia University Hospital, Italy
| | - Marc J M Bonten
- Department of Medical Microbiology and Julius Center for Health Science and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Jean Chastre
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Belgium
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, National and Kapodistrian University of Athens, Greece
| | - Philippe Eggimann
- Department of Critical Care, Centre Hospitalier Universitaire Vaudois, Lausanne
| | | | - Santiago Ewig
- Department of Respiratory Medicine and Infectious Diseases, Evangelic Hospital in Herne and Augusta Hospital, Bochum, Germany
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey Lipman
- Royal Brisbane and Womens Hospital, Australia.,University of the Witwatersrand, Johannesburg, South Africa
| | - Carlos Luna
- Department of Medicine, Pulmonary Diseases Division, Hospital de Clínicas, Universidad de Buenos Aires, Argentina
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, Multidisciplinary Intensive Care Research Organization, St James's Hospital, Trinity Centre for Health Sciences, Dublin, Ireland
| | | | - Lucy B Palmer
- Pulmonary, Critical Care and Sleep Division, State University of New York at Stony Brook, France
| | - Laurent Papazian
- Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, France
| | - Garyphallia Poulakou
- Third Department of Medicine, Sotiria General Hospital, Greece.,Medical School, National and Kapodistrian University of Athens, Greece
| | | | - Jordi Rello
- Centro Investigacion Biomedica En Red de Enfermedades Respiratorias (CIBERES), Vall d'Hebron Barcelona Hospital Campus, Spain
| | | | - Andrew F Shorr
- Medstar Washington Hospital Center, Washington, District of Columbia
| | | | - Visanu Thamlikitkul
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Antoni Torres
- Servei de Pneumologia, Hospital Clinic, Universitat de Barcelona, Institut De Investigacio Biomedica Agusti Pi i Sunyer, CIBERES, Spain
| | | | - Jean-François Timsit
- AP-HP, Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, Paris.,UMR 1137 IAME, INSERM, Université Paris Diderot, France
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Ericson JE, McGuire J, Michaels MG, Schwarz A, Frenck R, Deville JG, Agarwal S, Bressler AM, Gao J, Spears T, Benjamin DK, Smith PB, Bradley JS. Hospital-acquired Pneumonia and Ventilator-associated Pneumonia in Children: A Prospective Natural History and Case-Control Study. Pediatr Infect Dis J 2020; 39:658-664. [PMID: 32150005 PMCID: PMC8293907 DOI: 10.1097/inf.0000000000002642] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Clinical trials for antibiotics designed to treat hospital-acquired and ventilator-associated bacterial pneumonias (HABP/VABP) are hampered by making these diagnoses in a way that is acceptable to the United States Food and Drug Administration and consistent with standards of care. We examined laboratory and clinical features that might improve pediatric HABP/VABP trial efficiency by identifying risk factors predisposing children to HABP/VABP and describing the epidemiology of pediatric HABP/VABP. METHODS We prospectively reviewed the electronic medical records of patients <18 years of age admitted to intensive and intermediate care units (ICUs) if they received qualifying respiratory support or were started on antibiotics for a lower respiratory tract infection or undifferentiated sepsis. Subjects were followed until HABP/VABP was diagnosed or they were discharged from the ICU. Clinical, laboratory and imaging data were abstracted using structured chart review. We calculated HABP/VABP incidence and used a stepwise backward selection multivariable model to identify risk factors associated with development of HABP/VABP. RESULTS A total of 862 neonates, infants and children were evaluated for development of HABP/VABP; 10% (82/800) of those receiving respiratory support and 12% (103/862) overall developed HABP/VABP. Increasing age, shorter height/length, longer ICU length of stay, aspiration risk, blood product transfusion in the prior 7 days and frequent suctioning were associated with increased odds of HABP/VABP. The use of noninvasive ventilation and gastric acid suppression were both associated with decreased odds of HABP/VABP. CONCLUSIONS Food and Drug Administration-defined HABP/VABP occurred in 10%-12% of pediatric patients admitted to ICUs. Risk factors vary by age group.
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Affiliation(s)
| | | | | | - Adam Schwarz
- Children’s Hospital of Orange County, Orange, CA, USA
| | - Robert Frenck
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | - Jamie Gao
- Duke Clinical Research Institute, Durham, NC, USA
| | - Tracy Spears
- Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Durham, NC, USA
- Duke University Medical Center, Durham, NC USA
| | - P. Brian Smith
- Duke Clinical Research Institute, Durham, NC, USA
- Duke University Medical Center, Durham, NC USA
| | - John S. Bradley
- University of California, San Diego School of Medicine and Rady Children’s Hospital San Diego, San Diego, CA USA
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9
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Talbot GH, Das A, Cush S, Dane A, Wible M, Echols R, Torres A, Cammarata S, Rex JH, Powers JH, Fleming T, Loutit J, Hoffmann S. Evidence-Based Study Design for Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia. J Infect Dis 2020; 219:1536-1544. [PMID: 30649434 DOI: 10.1093/infdis/jiy578] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/22/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The US Food and Drug Administration solicited evidence-based recommendations to improve guidance for studies of hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP). METHODS We analyzed 7 HABP/VABP datasets to explore novel noninferiority study endpoints and designs, focusing on alternatives to all-cause mortality (ACM). RESULTS ACM at day 28 differed for ventilated HABP (27.8%), VABP (18.0%), and nonventilated HABP (14.5%). A "mortality-plus" (ACM+) composite endpoint was constructed by combining ACM with patient-relevant, infection-related adverse events from the Medical Dictionary for Regulatory Activities toxic/septic shock standardized query. The ACM+ rate was 3-10 percentage points above that of ACM across the studies and treatment groups. Predictors of higher ACM/ACM+ rates included older age and elevated acute physiology and chronic health evaluation (APACHE) II score. Only patients in the nonventilated HABP group were able to report pneumonia symptom changes. CONCLUSIONS If disease groups and patient characteristics in future studies produce an ACM rate so low (<10%-15%) that a fixed noninferiority margin of 10% cannot be justified (requiring an odds ratio analysis), an ACM+ endpoint could lower sample size. Enrichment of studies with patients with a higher severity of illness would increase ACM. Data on symptom resolution in nonventilated HABP support development of a patient-reported outcome instrument.
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Affiliation(s)
| | | | - Stephanie Cush
- Foundation for the National Institutes of Health, North Bethesda, Maryland
| | - Aaron Dane
- DaneStat, Macclesfield, Cheshire, United Kingdom
| | | | - Roger Echols
- Infectious Disease Drug Development Consulting, LLC, Easton, Connecticut
| | - Antoni Torres
- Servei de Pneumologia, Hospital Clinic, IDIBAPS, CIBERES, Universitat de Barcelona, Spain
| | | | - John H Rex
- F2G Ltd, Eccles, Manchester, United Kingdom
| | - John H Powers
- George Washington University School of Medicine, Washington, District of Columbia
| | | | | | - Steve Hoffmann
- Foundation for the National Institutes of Health, North Bethesda, Maryland
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Stergiopoulos S, Calvert SB, Brown CA, Awatin J, Tenaerts P, Holland TL, DiMasi JA, Getz KA. Cost Drivers of a Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia Phase 3 Clinical Trial. Clin Infect Dis 2019; 66:72-80. [PMID: 29020279 PMCID: PMC5848330 DOI: 10.1093/cid/cix726] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/11/2017] [Indexed: 01/15/2023] Open
Abstract
Background Studies indicate that the prevalence of multidrug-resistant infections, including hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia (HABP/VABP), has been rising. There are many challenges associated with these disease conditions and the ability to develop new treatments. Additionally, HABP/VABP clinical trials are very costly to conduct given their complex protocol designs and the difficulty in recruiting and retaining patients. Methods With input from clinicians, representatives from industry, and the US Food and Drug Administration, we conducted a study to (1) evaluate the drivers of HABP/VABP phase 3 direct and indirect clinical trial costs; (2) to identify opportunities to lower these costs; and (3) to compare (1) and (2) to endocrine and oncology clinical trials. Benchmark data were gathered from proprietary and commercial databases and used to create a model that calculates the fully loaded (direct and indirect) cost of typical phase 3 HABP/VABP endocrine and oncology clinical trials. Results Results indicate that the cost per patient for a 200-site, 1000-patient phase 3 HABP/VABP study is $89600 per patient. The cost of screen failures and screen failure rates are the main cost drivers. Conclusions Results indicate that biopharmaceutical companies and regulatory agencies should consider strategies to improve screening and recruitment to decrease HABP/VABP clinical trial costs.
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Affiliation(s)
- Stella Stergiopoulos
- Tufts Center for the Study of Drug Development, Tufts University School of Medicine, Boston, Massachusetts
| | - Sara B Calvert
- Clinical Trials Transformation Initiative, Durham, North Carolina
| | - Carrie A Brown
- Tufts Center for the Study of Drug Development, Tufts University School of Medicine, Boston, Massachusetts
| | - Josephine Awatin
- Tufts Center for the Study of Drug Development, Tufts University School of Medicine, Boston, Massachusetts
| | - Pamela Tenaerts
- Clinical Trials Transformation Initiative, Durham, North Carolina
| | - Thomas L Holland
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Joseph A DiMasi
- Tufts Center for the Study of Drug Development, Tufts University School of Medicine, Boston, Massachusetts
| | - Kenneth A Getz
- Tufts Center for the Study of Drug Development, Tufts University School of Medicine, Boston, Massachusetts
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Knirsch C, Alemayehu D, Botgros R, Comic-Savic S, Friedland D, Holland TL, Merchant K, Noel GJ, Pelfrene E, Reith C, Santiago J, Tiernan R, Tenearts P, Goldsack JC, Fowler VG. Improving Conduct and Feasibility of Clinical Trials to Evaluate Antibacterial Drugs to Treat Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia: Recommendations of the Clinical Trials Transformation Initiative Antibacterial Drug Development Project Team. Clin Infect Dis 2017; 63 Suppl 2:S29-36. [PMID: 27481950 DOI: 10.1093/cid/ciw258] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The etiology of hospital-acquired or ventilator-associated bacterial pneumonia (HABP/VABP) is often multidrug-resistant infections. The evaluation of new antibacterial drugs for efficacy in this population is important, as many antibacterial drugs have demonstrated limitations when studied in this population. HABP/VABP trials are expensive and challenging to conduct due to protocol complexity and low patient enrollment, among other factors. The Clinical Trials Transformation Initiative (CTTI) seeks to advance antibacterial drug development by streamlining HABP/VABP clinical trials to improve efficiency and feasibility while maintaining ethical rigor, patient safety, information value, and scientific validity. METHODS In 2013, CTTI engaged a multidisciplinary group of experts to discuss challenges impeding the conduct of HABP/VABP trials. Separate workstreams identified challenges associated with HABP/VABP protocol complexity. The Project Team developed potential solutions to streamline HABP/VABP trials using a Quality by Design approach. RESULTS CTTI recommendations focus on 4 key areas to improve HABP/VABP trials: informed consent processes/practices, protocol design, choice of an institutional review board (IRB), and trial outcomes. Informed consent processes should include legally authorized representatives. Protocol design decisions should focus on eligibility criteria, prestudy antibacterial therapy considerations, use of new diagnostics, and sample size. CTTI recommends that sponsors use a central IRB and discuss trial endpoints with regulators, including defining a clinical failure and evaluating the impact of concomitant antibacterial drugs. CONCLUSIONS Streamlining HABP/VABP trials by addressing key protocol elements can improve trial startup and patient recruitment/retention, reduce trial complexity and costs, and ensure patient safety while advancing antibacterial drug development.
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Affiliation(s)
| | | | - Radu Botgros
- Office of Anti-infectives and Vaccines, European Medicines Agency, London, United Kingdom
| | | | | | | | | | | | - Eric Pelfrene
- Office of Anti-infectives and Vaccines, European Medicines Agency, London, United Kingdom
| | | | - Jonas Santiago
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Rosemary Tiernan
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Pamela Tenearts
- Clinical Trials Transformation Initiative, Durham, North Carolina
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12
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Donnelly H, Alemayehu D, Botgros R, Comic-Savic S, Eisenstein B, Lorenz B, Merchant K, Pelfrene E, Reith C, Santiago J, Tiernan R, Wunderink R, Tenaerts P, Knirsch C. Streamlining Safety Data Collection in Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia Trials: Recommendations of the Clinical Trials Transformation Initiative Antibacterial Drug Development Project Team. Clin Infect Dis 2017; 63 Suppl 2:S39-45. [PMID: 27481952 DOI: 10.1093/cid/ciw316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Resistant bacteria are one of the leading causes of hospital-acquired/ventilator-associated bacterial pneumonia (HABP/VABP). HABP/VABP trials are complex and difficult to conduct due to the large number of medical procedures, adverse events, and concomitant medications involved. Differences in the legislative frameworks between different regions of the world may also lead to excessive data collection. The Clinical Trials Transformation Initiative (CTTI) seeks to advance antibacterial drug development (ABDD) by streamlining clinical trials to improve efficiency and feasibility while maintaining ethical rigor, patient safety, information value, and scientific validity. METHODS In 2013, CTTI engaged a multidisciplinary group of experts to discuss challenges impeding the conduct of HABP/VABP trials. Separate workstreams identified challenges associated with current data collection processes. Experts defined "data collection" as the act of capturing and reporting certain data on the case report form as opposed to recording of data as part of routine clinical care. The ABDD Project Team developed strategies for streamlining safety data collection in HABP/VABP trials using a Quality by Design approach. RESULTS Current safety data collection processes in HABP/VABP trials often include extraneous information. More targeted strategies for safety data collection in HABP/VABP trials will rely on optimal protocol design and prespecification of which safety data are essential to satisfy regulatory reporting requirements. CONCLUSIONS A consensus and a cultural change in clinical trial design and conduct, which involve recognition of the need for more efficient data collection, are urgently needed to advance ABDD and to improve HABP/VABP trials in particular.
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Affiliation(s)
- Helen Donnelly
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Radu Botgros
- Office of Anti-infectives and Vaccines, European Medicines Agency, London, United Kingdom
| | | | | | - Benjamin Lorenz
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring
| | | | - Eric Pelfrene
- Office of Anti-infectives and Vaccines, European Medicines Agency, London, United Kingdom
| | | | - Jonas Santiago
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring
| | - Rosemary Tiernan
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring
| | - Richard Wunderink
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Pamela Tenaerts
- Clinical Trials Transformation Initiative, Durham, North Carolina
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