Pilot Study of the Utility of Empiric Antibiotic Therapy for Suspected ICU-Acquired Infection

NCT ID: NCT00438269

Last Updated: 2007-02-22

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: PHASE2
• Total Enrollment: 80 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2003-02-28
• Study Completion Date: 2005-03-31

Brief Summary

Infection developing in the intensive care unit is a common complication of critical illness, but notoriously difficult to diagnose. A definite diagnosis based on the most reliable tests usually is not possible for at least two days. It is unclear what the optimal management approach should be while awaiting the results of diagnostic tests. In some circumstances, broad spectrum antibiotics are started with a plan to adjust them once the results of cultures are available. Observational studies show that this results in greater antibiotic use, and the risk of superinfection and resistance. In other circumstances, antibiotics may be withheld pending the results of cultures, a strategy that leads to a delay in therapy when cultures are positive, and that may be associated with a worse clinical outcome.

We undertook a randomized pilot study to address the question: "In a critically ill patient for whom clinicians are uncertain whether infection may be present, and in whom potential sites of infection have been managed by removing or changing invasive devices, can a policy of delaying antibiotic treatment until cultures are available reduce the risks of excessive antibiotic use, without increasing the risks associated with delayed therapy?"

Recognizing that the question has not been formally addressed before, and that approaches to clinical management are both widely divergent and passionately held, our pilot study tested the feasibility and acceptability of undertaking a larger trial with sufficient power to determine equivalence.

Detailed Description

We randomized critically ill patients who had been in hospital for at least 72 hours, and in the ICU for at least 24 hours, and who manifested either a temperature >38.5 degrees, or a temperature>38.0 degrees and a white cell count >12,000, and in whom clinicians entertained the possibility of infection as a diagnosis, to either site-specific broad spectrum empiric antibiotics or the corresponding placebo. All patients underwent a comprehensive series of investigations to identify an infectious focus, and all patients had full source control, including changes of central lines and urinary catheters, and change of nasogastric to orogastric tubes.

Patients were maintained in assigned study arm for seven days, or until culture data were available, at which time they were switched to culture-guided narrow spectrum therapy

Conditions

Nosocomial Infection; Pneumonia; Systemic Inflammatory Response Syndrome; Critical Illness; Pyrexia

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: DOUBLE

Interventions

Site-specific empiric regimens included: Meropenem

Intervention Type: DRUG

Piperacillin/tazobactam

Intervention Type: DRUG

Ciprofloxacin and cefazolin +/- metronidazole

Intervention Type: DRUG

Eligibility Criteria

Inclusion Criteria

• In hospital > 72 hrs and in ICU > 24hrs, and
• Core temperature ≥38.5°C, or temperature ≥ 38.0°C with a WBC>12,000/mm3, or temperature ≤ 36.0°C with a WBC > 12,000/mm3
• Suspicion of infection

Exclusion Criteria

• Age < 18 years
• Imminent death (within 24 hrs) or withdrawal of aggressive therapy
• Prosthetic heart valve or vascular graft
• Neutropenia (Absolute neutrophil count < 1000/mm3)
• Received > 16 hours of a broad spectrum antibiotic in the last 24 hours (3rd gen cephalosporin, fluoroquinolone, carbapenem, anti-pseudomonal penicillin) or any combination therapy
• History of allergic reaction to both study medications
• New physical findings consistent with infection:

• Meningeal signs
• Peritonitis + free air on Abdo x-ray
• Soft tissue infection / cellulitis
• Murmur & suspicion of endocarditis
• Newly available (within past 24 hours) culture results consistent with infection

• Minimum Eligible Age: 18 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

The Physicians' Services Incorporated Foundation

OTHER

Sponsor Role: collaborator

Canadian Critical Care Trials Group

OTHER

Sponsor Role: lead

Principal Investigators

Mary-Anne W Aarts, MD MSc

Role: PRINCIPAL_INVESTIGATOR

University of Toronto

John C Marshall, MD

Role: PRINCIPAL_INVESTIGATOR

University of Toronto

Locations

University Health Network

Toronto, Ontario, Canada

Countries

Canada

Other Identifiers

AATICC Pilot Study

Identifier Type: -

Identifier Source: org_study_id