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Healthcare-Associated PneumoniaTARPPNCT04438187

Trial of Antimicrobial Restraint in Presumed Pneumonia

A study testing antimicrobial initiation in people with Healthcare-Associated Pneumonia and Sepsis, run by University of Kansas Medical Center at 1 site in United States.

Completed

Finished. The study has ended and is not enrolling. Results may be posted on the official record.

Official record
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Trial summary

The objective of this cluster-randomized crossover study is to determine the effect of delaying antimicrobial initiation until objective microbiologic data is obtained in patients with presumed ICU-acquired pneumonia without septic shock. Read more about this study

Who is it for?
Ages 18 to 99 years
Conditions the study is for
Healthcare-Associated Pneumonia, Sepsis
What is being tested?
antimicrobial initiation
Could I receive a placebo?
No, everyone receives an active treatment
How many people
186 participants
Where
1 siteUnited States
Study dates
1 Feb 2021to 30 Jun 2022
Phase
Interventional
Are there results?
None posted in the registry

Key requirements

Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.

  • Ages 18 to 99 years
  • All sexes
  • No healthy volunteers
  • Adult, Older adult

Who may be able to join

  • Intubated patients admitted to a surgical or trauma intensive care unit that have had an appropriate quantitative or semi-quantitative endobronchial sputum culture sent ≥48 hours into their ICU admission
  • Primary pathology managed by surgical specialty
  • Age ≥18 years.

Who cannot join

  • Non-intubated patients.
  • Intubated patients with concern for active infection that is not suspected to be pneumonia (i.e. intra-abdominal infection, skin and soft tissue infection, urinary tract infection, etc.)
  • Primary disease not surgical or traumatic in nature
  • Primary diagnosis of burns
  • Incarcerated status
  • Pregnant status or delivery during this hospitalization.
  • On active immunosuppressive medications (or taking as a home medication prior to arrival)

Trial locations and contacts

1 site in 1 country.

United States1 site
  • KU Medical Center

    Kansas City, Kansas, 66160

Other trials in United States

About this study

The objective of this cluster-randomized crossover study is to determine the effect of delaying antimicrobial initiation until objective microbiologic data is obtained in patients with presumed ICU-acquired pneumonia without septic shock.

Read the detailed description

This study will involve 8 centers is to determine the effect of delaying antimicrobial initiation until objective microbiologic data is obtained in patients with presumed ICU-acquired pneumonia without septic shock. The study team will compare two sequential 4-month periods in each unit, one 'aggressive' antimicrobial initiation period and one 'conservative' antimicrobial initiation period.

This study will serve the following specific aims:

Specific Aim 1: To determine feasibility of a larger multicenter study of the same design as well as assess protocol adherence across multiple centers.

Specific Aim 2: Prospectively determine the all-cause, in-hospital mortality for all patients with suspected pneumonia who were treated under either an aggressive or conservative antimicrobial initiation protocol.

Specific Aim 3: Prospectively determine antimicrobial initiation rates, total days of antimicrobial administration, hospital and ICU length of stay, and ventilator-free alive days for patients treated under each protocol.

Specific Aim 4: To survey physicians that participated in the study to assess their feelings about the study including level of comfort starting antimicrobials aggressively, level of comfort withholding antimicrobials until definitive evidence of infection, perceived protocol adherence, perceived importance of the study, and willingness to participate in other studies of its kind (to be performed after closure of the clinical portion of the study).

Being tested
antimicrobial initiation
Medical subject headings
Healthcare-Associated Pneumonia, Sepsis

What participants receive

What participants receive. In a randomised study each person is assigned to one group by chance.

  • antimicrobial initiationOther

    antimicrobial initiation based on protocol assignment.

Study groups in NCT04438187
Study groupRoleWhat they receive
Aggressive ArmOtherIf an intubated patient is suspected of having an ICU-acquired HAP/VAP during the aggressive period, antimicrobials should be initiated immediately after quantitative or semi-quantitative endobronchial cultures are sent regardless of clinical status. This will include patients who, as determined by the attending intensivist, are in sepsis or septic shock. If, after 72 hours, cultures and other clinical data do not point to a pneumonia, the antimicrobials should be stopped in the absence of another source of infection.
Receives: Other: antimicrobial initiation
Conservative ArmOtherIf a patient is suspected of having an ICU-acquired HAP/VAP during the conservative period, quantitative or semi-quantitative endobronchial cultures should be sent. If the patient is in septic shock persistent hypotension requiring vasoactive medications to maintain mean arterial pressure (MAP) ≥65 mm HG or persistent lactic acidosis (>2 mmol/L) despite adequate resuscitation) antimicrobials will be initiated immediately. If the patient has new onset organ dysfunction that is presumed to be due to infection (sepsis) then antimicrobials will be initiated at the discretion of the attending intensivist. In the absence of septic shock or sepsis (intensivist discretion), antimicrobials will not be initiated unless objective evidence of pneumonia is present or another documented source of infection is identified mandating treatment with antimicrobials.
Receives: Other: antimicrobial initiation

What is being measured

The primary outcome is the main question the study is designed to answer.

  1. protocol adherence

    as a pilot study the primary outcome will be protocol adherence as defined by using the criteria below:

    Aggressive Protocol:

    • Failure to send appropriate culture before initiation of antimicrobials in the absence of septic shock
    • Failure to stop antimicrobials in the absence of pneumonia or other documented infection after 72 hours.

    Conservative Protocol:

    • Failure to send appropriate culture
    • Initiation of antimicrobials (in the absence of septic shock, new onset or worsening organ dysfunction, or other indicated source of infection) without any objective evidence of pneumonia.
    • Failure to initiate antimicrobials in the setting of objective evidence of pneumonia.
    • Failure to stop antimicrobials in the absence of other documented infection if final cultures return as negative.

    Measured: by time of culture finalization or 1 week

Secondary outcomes (5)
  1. In-hospital mortality

    All-cause, by treatment protocol assignment (intent-to-treat), ICU mortality, pneumonia-related

    Measured: until hospital discharge or 1 year

  2. Days of antimicrobials administered

    includes empiric, therapeutic, prophylactic, and perioperative antimicrobials

    Measured: until hospital discharge or 1 year

  3. Ventilator-free alive days

    Measured: until hospital discharge or 1 year

  4. ICU length of stay

    Measured: Until discharge from ICU or 1 year

  5. Hospital length of stay

    Measured: until hospital discharge or 1 year

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

  1. First posted18 Jun 2020
  2. Study start1 Feb 2021
  3. Primary completion6 Jan 2022
  4. Study completion30 Jun 2022

Resources

More details

For doctors and researchers: how the study is designed, who runs it, and its registry IDs.

Study design
Study type
Interventional
Phase
Phase N/A
Primary purpose
Treatment
Allocation
Randomised
Intervention model
Crossover
Model description
This will be a pragmatic, before-and-after, cluster-randomized, protocol crossover study.
Masking
None (open label)
Enrolment
186 participants (actual)
IDs, dates and publications
ClinicalTrials.gov ID
NCT04438187
Sponsor's protocol ID
145059
Acronym
TARPP
Status last verified
Aug 2024
First submitted
8 Jun 2020
Last updated
19 Aug 2024
Results posted
No
Data monitoring committee
Yes
FDA-regulated drug
No
FDA-regulated device
No
Individual data sharing
No: aggregated study results

Publications

  • Hranjec T, Rosenberger LH, Swenson B, Metzger R, Flohr TR, Politano AD, Riccio LM, Popovsky KA, Sawyer RG. Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection: a quasi-experimental, before and after observational cohort study. Lancet Infect Dis. 2012 Oct;12(10):774-80. doi: 10.1016/S1473-3099(12)70151-2. Epub 2012 Aug 28.

    PubMed 22951600
  • Barbier F, Andremont A, Wolff M, Bouadma L. Hospital-acquired pneumonia and ventilator-associated pneumonia: recent advances in epidemiology and management. Curr Opin Pulm Med. 2013 May;19(3):216-28. doi: 10.1097/MCP.0b013e32835f27be.

    PubMed 23524477
  • Torres A, Niederman MS, Chastre J, Ewig S, Fernandez-Vandellos P, Hanberger H, Kollef M, Li Bassi G, Luna CM, Martin-Loeches I, Paiva JA, Read RC, Rigau D, Timsit JF, Welte T, Wunderink R. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociacion Latinoamericana del Torax (ALAT). Eur Respir J. 2017 Sep 10;50(3):1700582. doi: 10.1183/13993003.00582-2017. Print 2017 Sep.

    PubMed 28890434
  • Leonard KL, Borst GM, Davies SW, Coogan M, Waibel BH, Poulin NR, Bard MR, Goettler CE, Rinehart SM, Toschlog EA. Ventilator-Associated Pneumonia in Trauma Patients: Different Criteria, Different Rates. Surg Infect (Larchmt). 2016 Jun;17(3):363-8. doi: 10.1089/sur.2014.076. Epub 2016 Mar 3.

    PubMed 26938612
  • Krebs ED, Hassinger TE, Guidry CA, Berry PS, Elwood NR, Sawyer RG. Non-utility of sepsis scores for identifying infection in surgical intensive care unit patients. Am J Surg. 2019 Aug;218(2):243-247. doi: 10.1016/j.amjsurg.2018.11.044. Epub 2018 Dec 8.

    PubMed 30553458
  • Eguia E, Cobb AN, Baker MS, Joyce C, Gilbert E, Gonzalez R, Afshar M, Churpek MM. Risk factors for infection and evaluation of Sepsis-3 in patients with trauma. Am J Surg. 2019 Nov;218(5):851-857. doi: 10.1016/j.amjsurg.2019.03.005. Epub 2019 Mar 8.

    PubMed 30885453
  • Anand V, Zhang Z, Kadri SS, Klompas M, Rhee C; CDC Prevention Epicenters Program. Epidemiology of Quick Sequential Organ Failure Assessment Criteria in Undifferentiated Patients and Association With Suspected Infection and Sepsis. Chest. 2019 Aug;156(2):289-297. doi: 10.1016/j.chest.2019.03.032. Epub 2019 Apr 9.

    PubMed 30978329
  • Piriyapatsom A, Lin H, Pirrone M, De Pascale G, Corona De Lapuerta J, Bittner EA, Schmidt UH, De Moya M, Berra L. Evaluation of the Infection-Related Ventilator-Associated Events Algorithm for Ventilator-Associated Pneumonia Surveillance in a Trauma Population. Respir Care. 2016 Mar;61(3):269-76. doi: 10.4187/respcare.04280. Epub 2015 Nov 10.

    PubMed 26556896
  • Pieracci FM, Rodil M, Haenel J, Stovall RT, Johnson JL, Burlew CC, Jurkovich GJ, Moore EE. Screening for Ventilator-Associated Pneumonia in the Surgical Intensive Care Unit: A Single-Institution Analysis of 1,013 Lower Respiratory Tract Cultures. Surg Infect (Larchmt). 2015 Aug;16(4):368-74. doi: 10.1089/sur.2014.086. Epub 2015 May 28.

    PubMed 26207397
  • Carraro E, Cook C, Evans D, Stawicki S, Postoev A, Olcese V, Phillips G, Eiferman D. Lack of added predictive value of portable chest radiography in diagnosing ventilator-associated pulmonary infection. Surg Infect (Larchmt). 2014 Dec;15(6):739-44. doi: 10.1089/sur.2013.239.

    PubMed 25314257
  • Croce MA, Swanson JM, Magnotti LJ, Claridge JA, Weinberg JA, Wood GC, Boucher BA, Fabian TC. The futility of the clinical pulmonary infection score in trauma patients. J Trauma. 2006 Mar;60(3):523-7; discussion 527-8. doi: 10.1097/01.ta.0000204033.78125.1b.

    PubMed 16531849
  • Quick JA, Breite MD, Barnes SL. Inadequacy of Algorithmic Ventilator-Associated Pneumonia Diagnosis in Acute Care Surgery. Am Surg. 2018 Feb 1;84(2):300-304.

    PubMed 29580362
  • Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O'Grady NP, Bartlett JG, Carratala J, El Solh AA, Ewig S, Fey PD, File TM Jr, Restrepo MI, Roberts JA, Waterer GW, Cruse P, Knight SL, Brozek JL. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63(5):e61-e111. doi: 10.1093/cid/ciw353. Epub 2016 Jul 14.

    PubMed 27418577
  • Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM; Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004 Mar;32(3):858-73. doi: 10.1097/01.ccm.0000117317.18092.e4.

    PubMed 15090974
  • Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B, Rubenfeld GD, Angus DC, Annane D, Beale RJ, Bellinghan GJ, Bernard GR, Chiche JD, Coopersmith C, De Backer DP, French CJ, Fujishima S, Gerlach H, Hidalgo JL, Hollenberg SM, Jones AE, Karnad DR, Kleinpell RM, Koh Y, Lisboa TC, Machado FR, Marini JJ, Marshall JC, Mazuski JE, McIntyre LA, McLean AS, Mehta S, Moreno RP, Myburgh J, Navalesi P, Nishida O, Osborn TM, Perner A, Plunkett CM, Ranieri M, Schorr CA, Seckel MA, Seymour CW, Shieh L, Shukri KA, Simpson SQ, Singer M, Thompson BT, Townsend SR, Van der Poll T, Vincent JL, Wiersinga WJ, Zimmerman JL, Dellinger RP. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017 Mar;45(3):486-552. doi: 10.1097/CCM.0000000000002255.

    PubMed 28098591

Questions about this trial

What is this clinical trial studying?

A study testing antimicrobial initiation in people with Healthcare-Associated Pneumonia and Sepsis, run by University of Kansas Medical Center at 1 site in United States.

The full registered description is in the About this study section and the official record.

Who may be eligible to take part?

The sponsor lists 3 inclusion and 7 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.

Is this clinical trial currently recruiting?

The record says: finished, as of the sponsor's last update on 19 Aug 2024. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 1 site in United States. Whether a site is taking part right now should be confirmed with that site. See every site.

What are the possible benefits and risks?

They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.

Are results available for this study?

The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.

How can a doctor refer a patient or contact the research team?

The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.

What does the primary outcome measure?

protocol adherence (time frame: by time of culture finalization or 1 week). It is what the study was designed to measure, not a finding.

Where can I read the original study information?

On the ClinicalTrials.gov record for NCT04438187, which also lists 30 linked publications.

Does a listing mean the treatment is approved or proven to work?

No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.

How often is this information updated?

AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 19 Aug 2024.

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