Adjunctive rifampicin to reduce early mortality from Staphylococcus aureus bacteraemia: the ARREST RCT

BACKGROUND

Staphylococcus aureus bacteraemia is a common and frequently fatal infection. Adjunctive rifampicin may enhance early S. aureus killing, sterilise infected foci and blood faster, and thereby reduce the risk of dissemination, metastatic infection and death.

OBJECTIVES

To determine whether or not adjunctive rifampicin reduces bacteriological (microbiologically confirmed) failure/recurrence or death through 12 weeks from randomisation. Secondary objectives included evaluating the impact of rifampicin on all-cause mortality, clinically defined failure/recurrence or death, toxicity, resistance emergence, and duration of bacteraemia; and assessing the cost-effectiveness of rifampicin.

DESIGN

Parallel-group, randomised (1 : 1), blinded, placebo-controlled multicentre trial.

SETTING

UK NHS trust hospitals.

PARTICIPANTS

Adult inpatients (≥ 18 years) with meticillin-resistant or susceptible S. aureus grown from one or more blood cultures, who had received < 96 hours of antibiotic therapy for the current infection, and without contraindications to rifampicin.

INTERVENTIONS

Adjunctive rifampicin (600-900 mg/day, oral or intravenous) or placebo for 14 days in addition to standard antibiotic therapy. Investigators and patients were blinded to trial treatment. Follow-up was for 12 weeks (assessments at 3, 7, 10 and 14 days, weekly until discharge and final assessment at 12 weeks post randomisation).

MAIN OUTCOME MEASURES

The primary outcome was all-cause bacteriological (microbiologically confirmed) failure/recurrence or death through 12 weeks from randomisation.

RESULTS

Between December 2012 and October 2016, 758 eligible participants from 29 UK hospitals were randomised: 370 to rifampicin and 388 to placebo. The median age was 65 years [interquartile range (IQR) 50-76 years]. A total of 485 (64.0%) infections were community acquired and 132 (17.4%) were nosocomial; 47 (6.2%) were caused by meticillin-resistant S. aureus. A total of 301 (39.7%) participants had an initial deep infection focus. Standard antibiotics were given for a median of 29 days (IQR 18-45 days) and 619 (81.7%) participants received flucloxacillin. By 12 weeks, 62 out of 370 (16.8%) patients taking rifampicin versus 71 out of 388 (18.3%) participants taking the placebo experienced bacteriological (microbiologically confirmed) failure/recurrence or died [absolute risk difference -1.4%, 95% confidence interval (CI) -7.0% to 4.3%; hazard ratio 0.96, 95% CI 0.68 to 1.35; p = 0.81]. There were 4 (1.1%) and 5 (1.3%) bacteriological failures (p = 0.82) in the rifampicin and placebo groups, respectively. There were 3 (0.8%) versus 16 (4.1%) bacteriological recurrences (p = 0.01), and 55 (14.9%) versus 50 (12.9%) deaths without bacteriological failure/recurrence (p = 0.30) in the rifampicin and placebo groups, respectively. Over 12 weeks, there was no evidence of differences in clinically defined failure/recurrence/death (p = 0.84), all-cause mortality (p = 0.60), serious (p = 0.17) or grade 3/4 (p = 0.36) adverse events (AEs). However, 63 (17.0%) participants in the rifampicin group versus 39 (10.1%) participants in the placebo group experienced antibiotic or trial drug-modifying AEs (p = 0.004), and 24 (6.5%) participants in the rifampicin group versus 6 (1.5%) participants in the placebo group experienced drug-interactions (p = 0.0005). Evaluation of the costs and health-related quality-of-life impacts revealed that an episode of S. aureus bacteraemia costs an average of £12,197 over 12 weeks. Rifampicin was estimated to save 10% of episode costs (p = 0.14). After adjustment, the effect of rifampicin on total quality-adjusted life-years (QALYs) was positive (0.004 QALYs), but not statistically significant (standard error 0.004 QALYs).

CONCLUSIONS

Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S. aureus bacteraemia.

FUTURE WORK

Given the substantial mortality, other antibiotic combinations or improved source management should be investigated.

TRIAL REGISTRATIONS

Current Controlled Trials ISRCTN37666216, EudraCT 2012-000344-10 and Clinical Trials Authorisation 00316/0243/001.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 59. See the NIHR Journals Library website for further project information.

Adjunctive rifampicin for Staphylococcus aureus bacteraemia (ARREST): a multicentre, randomised, double-blind, placebo-controlled trial

BACKGROUND

Staphylococcus aureus bacteraemia is a common cause of severe community-acquired and hospital-acquired infection worldwide. We tested the hypothesis that adjunctive rifampicin would reduce bacteriologically confirmed treatment failure or disease recurrence, or death, by enhancing early S aureus killing, sterilising infected foci and blood faster, and reducing risks of dissemination and metastatic infection.

METHODS

In this multicentre, randomised, double-blind, placebo-controlled trial, adults (≥18 years) with S aureus bacteraemia who had received ≤96 h of active antibiotic therapy were recruited from 29 UK hospitals. Patients were randomly assigned (1:1) via a computer-generated sequential randomisation list to receive 2 weeks of adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) versus identical placebo, together with standard antibiotic therapy. Randomisation was stratified by centre. Patients, investigators, and those caring for the patients were masked to group allocation. The primary outcome was time to bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomisation to 12 weeks, adjudicated by an independent review committee masked to the treatment. Analysis was intention to treat. This trial was registered, number ISRCTN37666216, and is closed to new participants.

FINDINGS

Between Dec 10, 2012, and Oct 25, 2016, 758 eligible participants were randomly assigned: 370 to rifampicin and 388 to placebo. 485 (64%) participants had community-acquired S aureus infections, and 132 (17%) had nosocomial S aureus infections. 47 (6%) had meticillin-resistant infections. 301 (40%) participants had an initial deep infection focus. Standard antibiotics were given for 29 (IQR 18-45) days; 619 (82%) participants received flucloxacillin. By week 12, 62 (17%) of participants who received rifampicin versus 71 (18%) who received placebo experienced treatment failure or disease recurrence, or died (absolute risk difference -1·4%, 95% CI -7·0 to 4·3; hazard ratio 0·96, 0·68-1·35, p=0·81). From randomisation to 12 weeks, no evidence of differences in serious (p=0·17) or grade 3-4 (p=0·36) adverse events were observed; however, 63 (17%) participants in the rifampicin group versus 39 (10%) in the placebo group had antibiotic or trial drug-modifying adverse events (p=0·004), and 24 (6%) versus six (2%) had drug interactions (p=0·0005).

INTERPRETATION

Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S aureus bacteraemia.

FUNDING

UK National Institute for Health Research Health Technology Assessment.

Efficacy and side-effect profile of long-term bisphosphonate therapy in patients (pts) with multiple myeloma (MM): MRC myeloma IX study results

8015

Background: Bisphosphonates (BPs) are recommended in pts with osteolytic lesions from MM. However, data on the long-term efficacy and safety of BPs beyond 2 y is somewhat limited. The MRC Myeloma IX study has already revealed significant overall survival (OS) and progression-free survival (PFS) benefits for zoledronic acid (ZOL) over clodronate (CLO) in MM pts (N = 1960) initiating chemotherapy (Morgan GJ, et al. Lancet. 2010). We now report the efficacy and safety of BP therapy with long-term follow-up. Methods: Newly diagnosed MM pts were randomized to ZOL (4 mg IV q 21-28 days) or CLO (1600 mg/day PO) plus antimyeloma therapy. BPs continued at least until disease progression. PFS and OS were estimated using Kaplan-Meier methodology. Hazard ratios (HRs) were calculated using stratified Cox models. Adverse events (AEs) were monitored continuously and analyzed using cumulative incidence functions. Results: At a median follow-up of 5.8 y in 1960 evaluable pts, ZOL improved PFS (HR = 0.88; P = .01) and OS (HR = 0.88; P = .03) vs CLO. Both BPs were generally well tolerated, and acute renal failure events were similar between groups (ZOL 5.2% vs CLO 5.8% at 2 y, with incidence plateaued thereafter). Overall incidence of confirmed osteonecrosis of the jaw (ONJ) has remained low (ZOL 3.7% vs CLO 0.5%; P < .0001). ONJ incidence was lower among pts receiving thalidomide-containing regimens (1.4%) vs no thalidomide (2.76%; P = .041). Events were generally low-grade, most occurred between 8 and 30 mo (median time to ONJ = 23.7 mo), and cumulative incidence plateaued at ~36 mo. Ten pts had data on ONJ recovery: complete recovery in 4 pts, improvement in 2 pts, no change in 3 pts in the ZOL group; and no change in 1 CLO pt. Dental surgery or trauma preceded ONJ in 6 ZOL pts. Conclusions: ZOL provided sustained PFS and OS improvements vs CLO during long-term therapy in the MRC Myeloma IX study. Overall incidence of AEs was similar between groups, with no notable changes during long-term therapy. ONJ incidence remained low during long-term (> 2.5 y) therapy and was reduced in pts receiving thalidomide (possibly because of anticytokine effects of this agent).

Human cystic and alveolar echinococcoses as indication to liver transplantation

The human cystic and alveolar echinococcoses are zoonotic diseases caused by larval stages of the tapeworms Echinococcus granulosus and E multilocularis. In man the liver form of the diseases develops most frequently. Recent epidemiological data indicate that the distribution of E multilocularis in the central Europe is wider than was previously anticipated; more cases of human alveococcosis during the last years have also been noted in Poland. In the present paper we analyzed several cases of human echinococcoses from Poland with respect to diagnosis and treatment as well as the indications for liver transplantation.

Liver cystadenocarcinoma--case report

A 69-year-old woman was admitted to our Department with the diagnosis of liver cyst. She had previously undergone liver cyst fenestration 10 years before. After abdominal spiral CT, the patient was qualified for laparotomy. A cystic formation was localized in the central part of the liver, in the 4th segment and was found to compress the hilar bile ducts. A 4.5 bisegmentectomy was performed. During the postoperative course, a biliary fistula was observed, which resolved spontaneously. The treatment was also complicated by myocardial infarction. The patient was discharged in good condition 30 days postoperatively. The pathological diagnosis revealed cystadenocarcinoma.

Liver regeneration after anatomical resections

BACKGROUND

The authors present the results of investigation of liver regeneration after partial parenchyma resection.

MATERIAL AND METHODS

20 patients (16 females, 4 male) aged 31-67 years were operated on because of metastatic colon cancer (7 cases), cavernous hemangioma (6 cases), hepatocellular carcinoma (1), alveococcosis (2), metastases of malignant melanoma (1), gall bladder carcinoma (1), FNH (1) and mucous cystadenocarcinoma (1). The resection according to anatomical segments by Couinaud were performed. Spiral CTs including liver volumetry were taken before and 30 days after the operation. on the 7-th day after the surgery, liver biopsy was performed and the material was examined under light and electron microscope.

RESULTS

There was no postoperative mortality. We observed transient elevation of transaminases, bilirubin levels and decrease of albumin level. Control spiral CT revealed increased liver volume in 15 cases (75 percent). In 16 cases (80 percent), electron microscopy investigations showed regeneration of the liver (mitotic figures).

CONCLUSIONS

Our material shows that hyperplasia as well as blood vessel and bile duct neogenesis play a very important role in liver regeneration process.

Risk factors for morbidity following liver surgery

The aim of this study is to define risk factors for severe complications following anatomical liver resections. The study material consists of the first 50 patients (26 women, 24 men, at mean age 50.6 years) treated at 3rd Department of Surgery 2nd Faculty of Medicine, Medical University in Warsaw. The indications for resection included benign neoplasm in 19 cases and malignancy in 31 cases. All the patients underwent anatomical liver resection in accordance with Couinaund's segmental division. In order to define prognostic factors for severe postoperative complications, a multi-factor statistical analysis was conducted. The following parameters were analysed: patient's age, the levels of bilirubin, total protein, albumin, prothrombin time, kaolin-kephalin time, range of resection and blood loss during operation. Eleven patients (22%) died in postoperative period. In 8 cases the death was caused by liver failure. Statistical analysis showed that blood loss, albumin level on fifth postoperative day and kaolin-kephalin time before and after surgery are independent risk factors predisposing to the development of complications.

Aldehyde dehydrogenase isoenzymes in tumours--assay with possible prognostic value for oxazaphosphorine chemotherapy

A novel fluorimetric assay, allowing independent measurement of the activities of two principal cytosolic forms of human aldehyde dehydrogenase, ALDH-1 and ALDH-3 (known as a tumour-associated ALDH) was applied to estimate the activities of these isoenzymes in human liver and thyroid tumours. The assay is based on two artificial substrates, 6-methoxy-2-naphthaldehyde (MONAL-62) and 7-methoxy-1-naphthaldehyde (MONAL-71), exhibiting excellent substrate properties toward various forms of human ALDH (see Wierzchowski et al., 1997, Anal. Biochem. 245, 69-78). We have found significant differences in ALDH activities between malignant and non-malignant tissue fragments, particularly in cancerous livers. Out of 16 tumours examined, only 4 exhibited ALDH-1 activities comparable to that found in the tumour-free tissue (0.5-2.5 U/g), while in the remaining 12 this activity was at least 10-fold lower. The ALDH-3 activity was detectable in about 40% of both tumour and tumour-free liver samples (maximum value 1.5 U/g). Comparison of 13 pathological thyroid fragments revealed ALDH activities in the range of 0.02 to 0.35 U/g, with two malignant samples showing activities of 0.27 and 0.18 U/g. Both substrate specificity and kinetic behaviour of the thyroid ALDH (Km values for the fluorogenic naphthaldehydes as well as propanal inhibition profile) were similar to those of the purified ALDH-1. In 5 thyroid samples traces of ALDH-3 activity was detected, using MONAL-62 and NADP+ as substrates (maximum value 0.04 U/g). Possible prognostic value of the foregoing measurements for cyclophosphamide chemotherapy is discussed.

Aldehyde dehydrogenase isoenzymes in tumours--assay with possible prognostic value for oxazaphosphorine chemotherapy

A novel fluorimetric assay, allowing independent measurement of the activities of two principal cytosolic forms of human aldehyde dehydrogenase, ALDH-1 and ALDH-3 (known as a tumour-associated ALDH) was applied to estimate the activities of these isoenzymes in human liver and thyroid tumours. The assay is based on two artificial substrates, 6-methoxy-2-naphthaldehyde (MONAL-62) and 7-methoxy-1-naphthaldehyde (MONAL-71), exhibiting excellent substrate properties toward various forms of human ALDH (see Wierzchowski et al., 1997, Anal. Biochem. 245, 69-78). We have found significant differences in ALDH activities between malignant and non-malignant tissue fragments, particularly in cancerous livers. Out of 16 tumours examined, only 4 exhibited ALDH-1 activities comparable to that found in the tumour-free tissue (0.5-2.5 U/g), while in the remaining 12 this activity was at least 10-fold lower. The ALDH-3 activity was detectable in about 40% of both tumour and tumour-free liver samples (maximum value 1.5 U/g). Comparison of 13 pathological thyroid fragments revealed ALDH activities in the range of 0.02 to 0.35 U/g, with two malignant samples showing activities of 0.27 and 0.18 U/g. Both substrate specificity and kinetic behaviour of the thyroid ALDH (Km values for the fluorogenic naphthaldehydes as well as propanal inhibition profile) were similar to those of the purified ALDH-1. In 5 thyroid samples traces of ALDH-3 activity was detected, using MONAL-62 and NADP+ as substrates (maximum value 0.04 U/g). Possible prognostic value of the foregoing measurements for cyclophosphamide chemotherapy is discussed.

Clostridium difficile in a department of surgery

The colonization and transmission of Clostridium difficile strains was investigated at the Department of Surgery. Anaerobes were isolated from fecal samples of 27 patients among 308 investigated (mean age: 59.5 years). The majority of them (22 out of 27 patients) received anti-microbial agents prior to investigation for Clostridium difficile. Eighteen of them had undergone various surgical procedures including laparotomies. Only four Clostridium difficile positive patients had diarrhea, but pseudomembranes were not observed endoscopically. The highest colonization rate of C. difficile (20/27) was found to occur in autumn. All 54 samples from medical personnel were C. difficile free. C. difficile was isolated in 7% of samples taken from hospital environment. Toxigenicity of Clostridium difficile strains isolated from fecal samples taken from patients and from environment was 78% and 80%, respectively, as determined by cytotoxicity tissue assay, or 70% and 20%, respectively, in the latex agglutination test.