Safe shortening of antibiotic treatment duration for complicated Staphylococcus aureus bacteraemia (SAFE trial): protocol for a randomised, controlled, open-label, non-inferiority trial comparing 4 and 6 weeks of antibiotic treatment

INTRODUCTION

A major knowledge gap in the treatment of complicated Staphylococcus aureus bacteraemia (SAB) is the optimal duration of antibiotic therapy. Safe shortening of antibiotic therapy has the potential to reduce adverse drug events, length of hospital stay and costs. The objective of the SAFE trial is to evaluate whether 4 weeks of antibiotic therapy is non-inferior to 6 weeks in patients with complicated SAB.

METHODS AND ANALYSIS

The SAFE-trial is a multicentre, non-inferiority, open-label, parallel group, randomised controlled trial evaluating 4 versus 6 weeks of antibiotic therapy for complicated SAB. The study is performed in 15 university hospitals and general hospitals in the Netherlands. Eligible patients are adults with methicillin-susceptible SAB with evidence of deep-seated or metastatic infection and/or predictors of complicated SAB. Only patients with a satisfactory clinical response to initial antibiotic treatment are included. Patients with infected prosthetic material or an undrained abscess of 5 cm or more at day 14 of adequate antibiotic treatment are excluded. Primary outcome is success of therapy after 180 days, a combined endpoint of survival without evidence of microbiologically confirmed disease relapse. Assuming a primary endpoint occurrence of 90% in the 6 weeks group, a non-inferiority margin of 7.5% is used. Enrolment of 396 patients in total is required to demonstrate non-inferiority of shorter antibiotic therapy with a power of 80%. Currently, 152 patients are enrolled in the study.

ETHICS AND DISSEMINATION

This is the first randomised controlled trial evaluating duration of antibiotic therapy for complicated SAB. Non-inferiority of 4 weeks of treatment would allow shortening of treatment duration in selected patients with complicated SAB. This study is approved by the Medical Ethics Committee VUmc (Amsterdam, the Netherlands) and registered under NL8347 (the Netherlands Trial Register). Results of the study will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NL8347 (the Netherlands Trial Register).

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

High Treatment Uptake in Human Immunodeficiency Virus/Hepatitis C Virus-Coinfected Patients After Unrestricted Access to Direct-Acting Antivirals in the Netherlands

Background

The Netherlands has provided unrestricted access to direct-acting antivirals (DAAs) since November 2015. We analyzed the nationwide hepatitis C virus (HCV) treatment uptake among patients coinfected with human immunodeficiency virus (HIV) and HCV.

Methods

Data were obtained from the ATHENA HIV observational cohort in which >98% of HIV-infected patients ever registered since 1998 are included. Patients were included if they ever had 1 positive HCV RNA result, did not have spontaneous clearance, and were known to still be in care. Treatment uptake and outcome were assessed. When patients were treated more than once, data were included from only the most recent treatment episode. Data were updated until February 2017. In addition, each treatment center was queried in April 2017 for a data update on DAA treatment and achieved sustained virological response.

Results

Of 23574 HIV-infected patients ever linked to care, 1471 HCV-coinfected patients (69% men who have sex with men, 15% persons who [formerly] injected drugs, and 15% with another HIV transmission route) fulfilled the inclusion criteria. Of these, 87% (1284 of 1471) had ever initiated HCV treatment between 2000 and 2017, 76% (1124 of 1471) had their HCV infection cured; DAA treatment results were pending in 6% (92 of 1471). Among men who have sex with men, 83% (844 of 1022) had their HCV infection cured, and DAA treatment results were pending in 6% (66 of 1022). Overall, 187 patients had never initiated treatment, DAAs had failed in 14, and a pegylated interferon-alfa-based regimen had failed in 54.

Conclusions

Fifteen months after unrestricted DAA availability the majority of HIV/HCV-coinfected patients in the Netherlands have their HCV infection cured (76%) or are awaiting DAA treatment results (6%). This rapid treatment scale-up may contribute to future HCV elimination among these patients.

Antibiotic treatment for 6 days versus 12 days in patients with severe cellulitis: a multicentre randomized, double-blind, placebo-controlled, non-inferiority trial

OBJECTIVES

To investigate whether antibiotic treatment of 6 days' duration is non-inferior to treatment for 12 days in patients hospitalized for cellulitis.

METHODS

This multicentre, randomized, double-blind, placebo-controlled, non-inferiority trial enrolled adult patients hospitalized for severe cellulitis who were treated with intravenous flucloxacillin. At day 6 participants with symptom improvement who were afebrile were randomized between an additional 6 days of oral flucloxacillin or placebo in a 1:1 ratio, stratified for diabetes and hospital. The primary outcome was cure by day 14, without relapse by day 28. Secondary outcomes included a modified cure assessment and relapse rate by day 90.

RESULTS

Between August 2014 and June 2017, 151 of 248 included participants were randomized. The intention-to-treat population consisted of 76 and 73 participants allocated to 12 and 6 days of antibiotic therapy, respectively (mean age 62 years, 67% males, 24% diabetics); 38/76 (50.0%) and 36/73 (49.3%) were cured in the 12- and 6-day groups respectively (ARR 0.7 percentage points, 95%CI: -15.0 to 16.3). Cure rates were 56/76 (73.7%) and 49/73 (67.1%) with the modified cure assessment (ARR 6.6, 95%CI: -8.0 to 20.8). After initial cure without relapse, day 90 relapse rates were higher in the 6-day group (6% versus 24%, p < 0.05).

CONCLUSIONS

Given the wide confidence intervals, we can neither confirm nor refute our hypothesis that 6 days of therapy is non-inferior to 12 days of therapy. However, a 6-day course resulted in significantly more frequent relapses by day 90. These findings require confirmation in future studies.

Good clinical outcome in a case of Listeria-associated multiple liver abscesses and clinical hepatitis

This case report describes a patient with the rare phenomenon of multiple liver abscesses and signs of hepatitis, secondary to disseminated listeriosis. All signs and symptoms resolved with antibiotic treatment only, contradicting current literature. This suggests that the development of multiple liver abscesses following infection with Listeria monocytogenes does not necessarily yield a poor prognosis, even without drainage.

Effect of an antibiotic checklist on length of hospital stay and appropriate antibiotic use in adult patients treated with intravenous antibiotics: a stepped wedge cluster randomized trial

OBJECTIVES

Quality indicators (QIs) have been developed to define appropriate antibiotic use in hospitalized patients. We evaluated whether a checklist based on these QIs affects appropriate antibiotic use and length of hospital stay.

METHODS

An antibiotic checklist for patients treated with intravenous antibiotics was introduced in nine Dutch hospitals in a stepped wedge cluster randomized trial. Prophylaxis was excluded. We included a random sample before (baseline), and all eligible patients after (intervention) checklist introduction. Baseline and intervention outcomes were compared. Primary endpoint was length of stay (LOS), analysed by intention to treat. Secondary endpoints, including QI performances, QI sum score (performance on all QIs per patient), and quality of checklist use, were analysed per protocol.

RESULTS

Between 1 November 2014 and 1 October 2015 we included 853 baseline and 5354 intervention patients, of whom 993 (19%) had a completed checklist. The LOS did not change (baseline geometric mean 10.0 days (95% CI 8.6-11.5) versus intervention 10.1 days (95% CI 8.9-11.5), p 0.8). QI performances increased between +3.0% and +23.9% per QI, and the percentage of patients with a QI sum score above 50% increased significantly (OR 2.4 (95% CI 2.0-3.0), p<0.001). Higher QI sum scores were significantly associated with shorter LOS. Discordance existed between checklist-answers and actual performance.

CONCLUSIONS

Use of an antibiotic checklist resulted in a significant increase in appropriateness of antibiotic use, but not in a reduction of LOS. Low overall checklist completion rates and discordance between checklist-answers and actual provided care might have attenuated the impact of the checklist.

Procoagulant protein levels are differentially increased during human endotoxemia

On the basis of plasma interleukin levels it was suggested that there is an inflammatory component to the risk of venous thrombotic disease. Other evidence shows that elevated levels of coagulation factor (F)VIII, FIX, FX and FXI are risk indicators for venous thrombosis, but the reasons for elevation remain unclear. We tested the hypothesis that the elevated levels could reflect an inflammatory reaction by measuring coagulation factor levels during experimental human endotoxemia. Male volunteers received endotoxin (4 ng kg-1), and blood samples were obtained before and at multiple time points after the challenge. Plasma was used for a panel of coagulation tests. Antigen levels of FVIII, von Willebrand factor (VWF), FIX, and FX were increased after endotoxin administration, reaching peak levels between 2 and 5 h. Within 24 h levels normalized, except for FVIII and VWF levels that remained at > 200%. Fibrinogen levels, and to a lesser extent FXI levels, also responded with an increase, but slower. These levels did not return to normal during the observation period. FVII levels were strongly depressed. FVIII, FIX and FX reacted immediately and strongly to endotoxin administration. The time pattern of this response is different from the slower so-called acute phase response, which appeared to be followed by FXI and fibrinogen. These increased levels of coagulation factors during an inflammatory state provide new ways of explaining why elevated levels of FVIII, FIX and FXI behave as risk indicators disease.

[Fitz-Hugh-Curtis syndrome: 2 patients with perihepatitis and sepsis]

Two women aged 53 and 22 years presented with abdominal pain and signs of sepsis with metabolic acidosis. The first patient had ecchymoses all over her body, the second patient had an enlarged left kidney with wedge-shaped hypo-intense areas on the CT scan. The clinical condition of both women deteriorated. On laparoscopy perihepatitis with fibrin wires ('violin strings') was seen, pathognomonic for Fitz-Hugh-Curtis syndrome. Upon appropriate antibiotic treatment, both patients fully recovered. Although it is common belief that Fitz-Hugh-Curtis syndrome is caused by local spread from the fallopian tubes into the peritoneal cavity, these presentations suggest a haematogenous spread of Neisseria gonorrhoeae as well as Chlamydia trachomatis in the first case, and C. trachomatis in the second case.

TNF-alpha compensates for the impaired host defense of IL-1 type I receptor-deficient mice during pneumococcal pneumonia

To determine the role of IL-1 in the host defense against pneumonia, IL-1R type I-deficient (IL-1R(-/-)) and wild-type (Wt) mice were intranasally inoculated with Streptococcus pneumoniae. Pneumonia resulted in elevated IL-1alpha and IL-1beta mRNA and protein levels in the lungs. Survival rates did not differ between IL-1R(-/-) and Wt mice after inoculation with 5 x 10(4) or 2 x 10(5) CFU. At early time points (24 and 48 h) IL-1R(-/-) mice had 2-log more S. pneumoniae CFU in lungs than Wt mice; at 72 h bacterial outgrowth in lungs was similar in both groups. Upon histopathologic examination IL-1R(-/-) mice displayed a reduced capacity to form inflammatory infiltrates at 24 h after the induction of pneumonia. IL-1R(-/-) mice also had significantly less granulocyte influx in bronchoalveolar lavage fluid at 24 h after inoculation. Since TNF is known to enhance host defense during pneumonia, we determined the role of endogenous TNF in the early impairment and subsequent recovery of defense mechanisms in IL-1R(-/-) mice. All IL-1R(-/-) mice treated with anti-TNF rapidly died (no survivors (of 14 mice) after 4 days), while 10-day survival in IL-1R(-/-) mice (control Ab), Wt mice (anti-TNF), and Wt mice (control Ab) was 7 of 13, 3 of 14, and 12 of 13, respectively. These data suggest that TNF is more important for host defense against pneumococcal pneumonia than IL-1, and that the impaired early host defense in IL-1R(-/-) mice is compensated for by TNF at a later phase.

Human endotoxemia activates p38 MAP kinase and p42/44 MAP kinase, but not c-Jun N-terminal kinase

BACKGROUND

All three major members of the MAPK family (i.e., p38 MAPK, p42/p44 MAPK, and c-Jun N terminal kinase (JNK)) have been shown to control cellular responses to inflammation in vitro. Therefore these kinases have been designated suitable targets for anti-inflammatory therapy. However, the extent to which these kinases are actually activated during inflammation in humans in vivo has not been investigated. We employed experimental human endotoxemia, a model of systemic inflammation, to address this question.

MATERIALS AND METHODS

Male volunteers were intravenously infused with 4 ng/kg bw lipopolysaccharide (LPS). Directly before LPS infusion and up to 24 h thereafter, activation of p38 MAPK, p42/p44 MAPK and JNK was assessed in peripheral blood, using Western blot and in vitro kinase assays.

RESULTS

We observed that LPS induced a strong but transient phosphorylation and activation of p38 MAPK and p42/p44 MAPK, maximal activity being reached after 1 hr of LPS infusion. Strikingly, no JNK phosphorylation or activation was detected under these circumstances.

CONCLUSIONS

These results suggest that both inhibitors of p38 MAPK and p42/p44 MAPK but not JNK are potentially useful for anti-inflammatory therapy.

CXC chemokine receptor 2 contributes to host defense in murine urinary tract infection

CXC chemokines have been implicated in the recruitment of neutrophils to sites of infection. To determine the role of CXC chemokines in the host response to urinary tract infection (UTI), female mice were treated with an antibody against the major CXC chemokine receptor in the mouse, CXCR2, before intravesical inoculation with Escherichia coli. Anti-CXCR2 prevented the influx of neutrophils in urine and kidneys. The absence of a neutrophil response only temporarily impaired the clearance of bacteria from the urinary tract, as indicated by 100- and 1000-fold more E. coli colony-forming units in urine and kidneys of anti-CXCR2-treated mice at 24 h, but not at 48 h, after the infection. UTI induced increases in the renal concentrations of the CXCR2 ligands macrophage inflammatory protein-2 and KC, which were not influenced by anti-CXCR2 administration. CXC chemokines play an important role in the development of a local inflammatory response to UTI.

Healing response to various forms of human demineralized bone matrix in athymic rat cranial defects

PURPOSE

This study compared the ability of a bone autograft and four distinct forms of human demineralized bone (DBM) to elicit bone repair in a critical size cranial defect in athymic rats.

MATERIALS AND METHODS

Cranial defects were created in athymic rats and then grafted with either an autograft, rat DBM particles in glycerol (rGel), or one of four forms of human DBM: 1) hGel; 2) Putty (DBM fibers in glycerol); 3) Sheet (sheet of DBM fibers); or 4) Flex (DBM fiber sheet with glycerol). Histology, histomorphometry, and radiographic density of the graft sites were evaluated at 8 weeks.

RESULTS

Of the grafted defects, 29% to 58% were found to be filled with new bone. The rGel and human forms of DBM stimulated similar amounts of new bone growth in comparison with the autograft-filled defects. The fiber-based grafts produced the largest amounts of new bone.

CONCLUSIONS

Human DBM in gel, putty and sheet forms were found to perform as well as an autograft in a critical size cranial defect in the athymic rat.

A randomized study to compare oral fluconazole to amphotericin B in the prevention of fungal infections in patients with acute leukaemia

In a prospective randomized study the efficacy of fluconazole (50 mg in one single daily dose) was compared with oral amphotericin B in suspension and tablets (each 200 mg four times daily) for prevention of colonization and subsequent infection by yeasts in 50 patients undergoing remission induction treatment for acute leukaemia. All patients received ciprofloxacin for prevention of bacterial infections. Fluconazole was as effective as amphotericin B in preventing severe local and disseminated fungal disease (one documented and one highly suspected infection in each group of patients). Fluconazole effectively prevented yeast colonization of the oropharynx but was less effective than amphotericin B in preventing colonization of the lower alimentary tract. Fifty-two percent of patients receiving fluconazole had persistent positive stool cultures as compared to 4% in the amphotericin B group (P less than 0.01). Fluconazole was better tolerated than amphotericin B. One patient developed an extended rash leading to the termination of fluconazole.

Growth-stimulating effects of somatomedin-/insulin-like peptides in Snell dwarf mice

The effect of the somatomedin-/insulin-like growth factors IGF-I, IGF-II and N2, as well as of semi-purified SM fractions separated by isoelectric focusing derived from human Cohn IV on different growth parameters, have been studied in the Snell dwarf mouse. HPLC-pure IGF-II, N2 and IGF-I stimulate to a similar extent the sulphate incorporation into costal cartilage, the osteochondral junction and epiphyseal cartilage. After 4 weeks of treatment, increase in body length and weight as well as the weights of several organs is obtained with SM fractions, focusing at acid and neutral pH, and containing mainly IGF-II- and less than 5% IGF-I-like peptides. Fractions containing mainly IGF-I-like peptides and focusing at basic pH at the dosage used seem to be less stimulatory on most of these parameters. The rump/tail ratio and weight/length ratio is comparable to that obtained after treatment with human growth hormone (hGH). hGH induced a significant stimulation of the weight of the liver, kidneys, heart, thymus and spleen. The acid and neutral SM fractions induced growth of the liver, kidneys and spleen. The basic fractions only produced a significant weight gain in kidneys and spleen. The skinfold thickness is stimulated by the SM preparations and only slightly by hGH.

Growth and differentiation of pluripotent embryonal carcinoma cells in the Snell dwarf mouse

To investigate the influence of hormones on the process of cellular differentiation the growth and differentiation of a transplantable tumour, induced by inoculation of pluripotent mouse embryonal carcinoma (EC) cells have been studied in athymic nude mice and, normal and hypopituitary Snell dwarf mice. All athymic nude mice developed tumours independent of the numbers of cells inoculated. In contrast, the tumour percentage in normal Snell mice was lower, showing a dose-dependent increase of takes. In dwarfs tumour percentage was comparable with that observed in normal Snell mice. The morphological differentiation of teratocarcinomas grown in athymic nude mice, normal and dwarfed Snell mice shows derivatives of all three germ layers next to undifferentiated embryonal carcinoma cells. This suggests that the pituitary hormonal deficiencies of the dwarfs (growth hormone, thyroid stimulating hormone and prolactin) did not influence the tumour induction nor the development of the different tissues present in this type of tumour.