HIV-1-infection Clinical Trial
— CoTrimResistOfficial title:
Randomized Clinical Trial to Assess Whether the Duration of Cotrimoxazole Preventive Therapy in HIV Patients With CD4 Counts >350 CD4 Cells/µL by Antiretroviral Treatment Influences the Rate of Carriage of Multidrug-resistant Bacteria
Verified date | October 2019 |
Source | University of Bergen |
Contact | n/a |
Is FDA regulated | No |
Health authority | |
Study type | Interventional |
Cotrimoxazole preventive therapy (CPT) is recommended for prevention of morbidity and mortality due to Pneumocystis pneumonia and other infections in HIV positive patients with low immunity. Common clinical practice is to start CPT in any patient with CD4 counts below 200/µL, and, conversely, to stop CPT when immunity has been restored by antiretroviral treatment to CD4 counts above 200/µL or when viral suppression has been documented for 3 months. However, the latest WHO guidelines widely expands the indication for CPT by advocating for settings with high prevalence of malaria and bacterial infections, that all patients with HIV start CPT regardless of CD4 counts and clinical stage. Furthermore, WHO recommends these patients to continue CPT indefinitely regardless of evidence of immune restoration (The recommendation is for settings with high prevalence of malaria and bacterial infections, not for high-income countries). There is limited scientific evidence to recommend prolonged CPT, as studies have shown it is associated with modestly reduced morbidity due to pneumonia, meningitis and malaria, but no corresponding reduction in mortality. The impact of such a large increase in antibiotic use on the emergence of antimicrobial resistance has not been thoroughly considered. Our previous studies in Tanzania showed that multidrug-resistant bacteria frequently cause bloodstream infections with resultant very high case-fatality rates. As genes encoding for multiple antibiotic resistance traits are transferred by plasmids together with resistance towards cotrimoxazole, prolonged CPT will likely favor the selection of carriage of multidrug-resistant gut bacteria. The proposed randomized clinical trial is designed to assess whether prolonged CPT in HIV-positive patients results in increased fecal carriage of multi-drug resistant gut microbes or increased nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA). Secondary endpoints are morbidity (clinical events, hospitalizations) and mortality. Stool specimens, nasal swabs and clinical data will be collected from persons attending voluntary counseling and testing facilities and HIV-clinics in Dar es Salaam, Tanzania. The study results may have important impact on public health in terms of assisting development of rational recommendations for CPT use, and may help prevent emerging antibiotic resistance.
Status | Completed |
Enrollment | 537 |
Est. completion date | July 25, 2019 |
Est. primary completion date | July 25, 2019 |
Accepts healthy volunteers | Accepts Healthy Volunteers |
Gender | All |
Age group | 18 Years and older |
Eligibility |
Inclusion Criteria: - Only patients who provide written informed consent will be included - Patients aged 18 years or older with newly diagnosed HIV-infection and CD4 counts of = 350 per microliter will be included for randomisation to receive placebo or cotrimoxazole preventive treatment. - Persons testing hiv negative at the participating clinics will be included as additional control group but not randomised to interventions - Persons testing hiv-positive and having impaired immunity with CD4 count below will be included as additional control group but not randomised for intervention. This group will routinely receive cotrimoxazole prophylaxis from the national AIDS control program, and not followed-up further in this study. Exclusion Criteria: - CD4<350 per microliter at enrollment - Patients allergic to cotrimoxazole - Children under age of 18 years - Pregnant women |
Country | Name | City | State |
---|---|---|---|
Tanzania | Amana Regional Referral Hospital | Dar es Salaam | |
Tanzania | Mbagala District Hospital | Dar es Salaam | |
Tanzania | Mnazimmoja Health Centre | Dar Es Salaam | |
Tanzania | Mwananyamala Regional Referral Hospital | Dar es Salaam | |
Tanzania | Pasada Upendano | Dar es Salaam | |
Tanzania | Temeke Regional Referral Hospital | Dar es Salaam |
Lead Sponsor | Collaborator |
---|---|
University of Bergen | Haukeland University Hospital, Helse Vest, Muhimbili University of Health and Allied Sciences |
Tanzania,
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* Note: There are 14 references in all — Click here to view all references
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Other | Difference in carriage of resistant bacteria in gut and/or nose between HIV positive patients and HIV negative controls | Difference in the proportion who carry antibiotic-resistant bacteria, including presence of extended-spectrum beta-lactamase (ESBL) producing gram-negative bacteria or vancomycin-resistant enterococci (VRE) on microbiological examination of fecal swab, or methicillin-resistant Staphylococcus aureus (MRSA) on microbiological examination of nasal swab, between HIV positive patients and HIV negative controls | At baseline | |
Other | Difference in carriage of resistant bacteria in gut and/or nose between HIV positive patients with CD4 counts above and below 350 | Difference in the proportion who carry antibiotic-resistant bacteria, including presence of extended-spectrum beta-lactamase (ESBL) producing gram-negative bacteria or vancomycin-resistant enterococci (VRE) on microbiological examination of fecal swab, or methicillin-resistant Staphylococcus aureus (MRSA) on microbiological examination of nasal swab, between HIV positive patients with CD4 counts above and below 350 | At baseline | |
Primary | Change in carriage of resistant bacteria in gut and/or nose by week 2 | Change in the proportion who carry antibiotic-resistant bacteria, including presence of extended-spectrum beta-lactamase (ESBL) producing gram-negative bacteria or vancomycin-resistant enterococci (VRE) on microbiological examination of fecal swab, or methicillin-resistant Staphylococcus aureus (MRSA) on microbiological examination of nasal swab, from baseline to day 14 | From baseline to day 14 | |
Primary | Change in carriage of resistant bacteria in gut and/or nose by week 24 | Change in the proportion who carry antibiotic-resistant bacteria, including presence of extended-spectrum beta-lactamase (ESBL) producing gram-negative bacteria or vancomycin-resistant enterococci (VRE) on microbiological examination of fecal swab, or methicillin-resistant Staphylococcus aureus (MRSA) on microbiological examination of nasal swab, from baseline to week 24 | From baseline to week 24 | |
Primary | Change in carriage of resistant bacteria in gut and/or nose by week 48 | Change in the proportion who carry antibiotic-resistant bacteria, including presence of extended-spectrum beta-lactamase (ESBL) producing gram-negative bacteria or vancomycin-resistant enterococci (VRE) on microbiological examination of fecal swab, or methicillin-resistant Staphylococcus aureus (MRSA) on microbiological examination of nasal swab, from baseline to week 48 | From baseline to week 48 | |
Secondary | Adverse events | Adverse events graded as a) light, b) moderate, c) severe, d) life-threatening or e) fatal will be registered through patients' monthly visits to clinic and additional follow-up as required | From baseline to 48 weeks | |
Secondary | Mortality | All cause mortality | From baseline to 48 weeks | |
Secondary | Morbidity | Documented episode of malaria, pneumonia, diarrhea and hospital admission | From baseline to 48 weeks |
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