PipEracillin Tazobactam Versus mERoPENem for Treatment of Bloodstream Infections Caused by Cephalosporin-resistant Enterobacteriaceae (PETERPEN)

Official title

Piperacillin Tazobactam Versus Meropenem for Treatment of Bloodstream Infections Caused by Cephalosporin-resistant Enterobacteriaceae- a Non-inferiority Randomized Controlled Trial

Overview

Data regarding optimal treatment for extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae blood-stream infection are lacking. Observational studies show conflicting results when comparing treatment with combination beta-lactam-beta-lactamase inhibitor and carbapenems. The investigators aim to evaluate the effect of definitive treatment with meropenem vs. piperacillin-tazobactam on the outcome of patients with bacteremia due to cephalosporin-non-susceptible Enterobacteriaceae. The investigators hypothesize that piperacillin-tazobactam is non-inferior to meropenem.

Interventions

• Drug Piperacillin/tazobactam
  4.5 grams QID
• Drug Meropenem
  1 gram TID

Primary outcome measures

• All-cause mortality [Time frame: 30 days from randomization]
• Treatment failure [Time frame: 7 days from randomization]

Secondary outcome measures (12)

• All-cause mortality [Time frame: 14 and 90 days from randomization]
• Treatment failure [Time frame: 14 days and 30 days from randomization]
• Microbiological failure [Time frame: 7 days and 14 days from randomization]
• Recurrent positive blood cultures (relapse) [Time frame: 30 days and 90 days from randomization]
• Clostridium difficile associated diarrhea [Time frame: 90 days from randomization]
• Clinically or microbiologically documented infection other than Gram-negative bacteremia [Time frame: 90 days from randomization]
• Number of hospital re-admissions [Time frame: 90 days from randomization]
• Development of resistance [Time frame: 90 days from randomization]
• Carriage of carbapenemase-producing Enterobacteriaceae (CPE) and non-CPE carbapenem-resistant Enterobacteriaceae in-hospital [Time frame: 90 days from randomization]
• Total in-hospital days [Time frame: 30 days and 90 days from randomization]
• Total antibiotic days [Time frame: 30 days and 90 days from randomization]
• Adverse events [Time frame: 30 days from randomization]

Eligibility criteria

Inclusion criteria

• Adults (age ≥ 18 years)
• New onset BSI due to E. coli or Klebsiella spp. in one or more blood cultures associated with evidence of infection.
• The microorganism will have to be non-susceptible to third generation cephalosporins (ceftriaxone and ceftazidime) and susceptible to both PTZ and meropenem (see microbiological methods).
• Both community and hospital-acquired bacteremias will be included.
• We will permit the inclusion of bacteremias due to E. coli or Klebsiella spp. with concomitant growth in blood of skin commensals considered as contaminants.

Exclusion criteria

• More than 72 hr. elapsed since initial blood culture taken, regardless of the time covering antibiotics were started (up to 72 hrs.).
• Polymicrobial bacteremia. Polymicrobial bacteremia will be defined as either growth of two or more different species of microorganisms in the same blood culture, or growth of different species in two or more separate blood cultures within the same episode.
• Patients with prior bacteremia or infection that have not completed antimicrobial therapy for the previous infectious episode.
• Patients with septic shock at the time of enrollment and randomization, defined as at least 2 measurements of systolic blood pressure < 90 mmHg and/or use of vasopressors (dopamine>15μg/kg/min, adrenalin>0.1μg/kg/min, noradrenalin>0.1μg/kg/min, vasopressin any dose) in the 12 hours prior to randomization. In the absence of the use of vasopressors, a systolic blood pressure <90 would need to represent a deviation for the patient's known normal blood pressure.
• BSI due to specific infections known at the time of randomization:

• Endocarditis / endovascular infections
• Osteomyelitis (not resected)
• Central nervous system infections
• Allergy to any of the study drugs confirmed by history taken by the investigator
• Previous enrollment in this trial
• Concurrent participation in another interventional clinical trial
• Imminent death (researcher's assessment of expected death within 48 hrs. of recruitment)

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Treatment

Study locations

Israel · 8 centers

• Rambam Health Care Campus — Haifa
• Soroka Medical Center — Beersheba
• Hadassah Medical Center — Jerusalem
• Meir Medical Center — Kfar Saba
• Sanz Medical Center-Laniado Hospital — Netanya
• Rabin Medical Center, Beilinson Campus — Petah Tikva
• Sheba Medical Center (Tel HaShomer) — Tel Aviv
• Sourasky Medical Center — Tel Aviv

Canada · 6 centers

• University of Calgary, Cumming School of Medicine, O'Brien Institute for Public Health — Calgary
• Surrey Memorial Hospital - Fraser Health Authority — Surrey
• Eastern Health — St. John's
• Kingston General Hospital — Kingston
• Jewish Genral Hospital — Montreal
• McGill University Health Centre — Montreal, Quebec

Publications

• Bitterman R, Koppel F, Mussini C, Geffen Y, Chowers M, Rahav G, Nesher L, Ben-Ami R, Turjeman A, Huberman Samuel M, Cheng MP, Lee TC, Leibovici L, Yahav D, Paul M. Piperacillin-tazobactam versus meropenem for treatment of bloodstream infections caused by third-generation cephalosporin-resistant Enterobacteriaceae: a study protocol for a non-inferiority open-label randomised controlled trial (Peter PMID 33558347

Identifiers

NCT: NCT03671967 · MOH_2018-12-25_004857

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗