Clinical Trial Details
— Status: Completed
Administrative data
| NCT number |
NCT02058316 |
| Other study ID # |
25-221 |
| Secondary ID |
|
| Status |
Completed |
| Phase |
|
| First received |
|
| Last updated |
|
| Start date |
February 2013 |
| Est. completion date |
February 2019 |
Study information
| Verified date |
September 2021 |
| Source |
Medical University of Graz |
| Contact |
n/a |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Observational
|
Clinical Trial Summary
Background Invasive pulmonary aspergillosis (IPA) remains an important cause of morbidity and
mortality among patients with hemato-oncological malignancies. Due to the crude mortality of
>90% in absence of adequate treatment, timely diagnosis and early start of antifungal therapy
are key factors in the successful treatment of IPA. Various studies have shown that early
initiation of antifungal therapy may improve IPA survival to above 70%. Diagnosis of IPA,
however, remains difficult as clinical signs and symptoms as well as radiological findings
are often unspecific and conventional culture methods lack sensitivity. In recent years
antigen testing has therefore become one of the cornerstones of IPA diagnostics.
Brochoalveolar lavage (BAL) Galactomannan (GM) testing is currently the most promising
approach for early detection of pulmonary infections by this fungus. However, limitations of
GM detection are assay turn-around time, which varies widely between centers (less than a day
to several days), and the need for appropriately equipped laboratories that routinely test
for this antigen. These limitations are overcome by the Aspergillus Lateral-Flow Device
(LFD), a novel point-of-care (POC) test for IPA diagnosis developed by Dr Thornton at the
University of Exeter, UK. This simple, rapid (15 min), single-use test can be performed in
rudimentary facilities using BAL specimens. In a retrospective single centre study we have
recently evaluated the LFD test in 39 BAL samples from hematologic malignancy patients and
solid organ transplant recipients. Sensitivities and specificities of BAL LFD tests for
probable IPA were 100% and 81%, respectively. Galactomannan levels in cases with negative LFD
were significantly lower than in patients with positive LFD (P <0.0001). We concluded that
the LFD test of BAL specimens is performed easily and provides accurate and rapidly available
results. Therefore, this new point-of-care test may be a very promising diagnostic approach
for detecting IPA in BAL specimens from haematological malignancy and SOT patients. For
routine clinical use, however, multicenter studies with larger sample sizes also from other
patient collectives are necessary. In this multicenter study we will evaluate the LFD test in
BAL samples.
Study Objectives Primary Objectives To evaluate the Lateral Flow Device test, a rapid (15
min), point-of-care test for IPA diagnosis using bronchoalveolar lavage (BAL) fluids from
patients at risk for IPA.
Secondary Objective To evaluate the potential of BAL Lateral Flow Device test for prognosis
in patients with IPA.
Study Design This is a prospective multi-center study conducted in three centers in Austria
(Graz, Vienna and Innsbruck) and one centre in Germany (Mannheim). In order to meet the
objectives an estimated number of 300 BAL samples from patients at risk for IPA (50 to 100
per centre) will be included in the study cohort. The Lateral Flow Device test will be
performed prospectively in BAL samples from the patients and results will be compared to GM
results, PCR findings, clinical/radiological findings as well as conventional culture
results. In addition, retrospective testing of BAL samples that were previously routinely
tested for GM will be performed in up to three participating centers (Graz, Innsbruck and
Mannheim) to ensure to reach the proposed number of 300 BAL samples. The treating clinicians
will not be informed about BAL Lateral Flow Device test results and the test will therefore
have no impact on patient management / treatment decisions.
Description:
Project Outlook Sensitive and specific biomarkers for early diagnosis of IPA are urgently
needed to improve survival. In this multicenter study we will evaluate the potential of the
novel Lateral Flow Device test for early, bedside diagnosis of IPA.
A successful implementation of the studies hypothesis requires a solid background in the
field of IPA. Considering this I am confident that my professional experience combined with
the technical and scientific expertise at my host institute and the associated laboratories
generates a highly competitive and promising setting. The success of the proposed research
will vitally depend on collaborations. Over the last four years I have worked extensively in
the field of IPA among patients with hemato-oncological malignancies, which allowed me to
establish the necessary contacts and cooperations that are vital for the project's success.
The major strength of this multi-center study is therefore the cooperation with three major
centers for IPA diagnosis under the leadership of three outstanding experts (Prof.
Lass-Flörl, Prof. Buchheidt and Prof. Willinger) who have published extensively in the field
of IPA diagnosis over recent years/decades. I am certain that our results will have
far-reaching implementations for the whole field of IPA. Clearly, they will significantly
advance our understanding of the clinical performance of the novel point of care
applications.
The project is expected to have a big impact on patient care. Establishment of the Lateral
Flow Device test may lead to rapidly, frankly on the bedside, available test results and may
therefore enable earlier initiation of appropriate antifungal therapy which may help to save
lives.
1. Background
Invasive fungal infections (IFI) are an important cause of morbidity and mortality among
patients with haemato-oncological malignancies (1-3). Invasive mould infections (IMI),
in particular invasive aspergillosis (IA) are the leading cause of IFI among these
patients, followed by invasive Candida infections (2, 4). Due to the crude mortality of
80-90% in absence of adequate treatment, timely diagnosis and early start of antifungal
therapy are key factors in the successful treatment of IFI. Various studies have shown
that early initiation of antifungal therapy may improve IFI survival to above 80% (5,
6). Clinical signs and symptoms of IFI as well as radiological findings, however, are
often unspecific. The inability to consistently make an early and convincing diagnosis
remains, therefore, one central problem. The European Organization for Research and
Treatment of Cancer Invasive Fungal Infections Cooperative Group (EORTC) and the Mycoses
Study Group of the National Institute of Allergy and Infectious Disease (MSG) had some
success in tackling this problem by establishing consensus definitions for opportunistic
IFI (7). However, definitions in EORTC/MSG guidelines were based not only on review of
the literature, but also expert opinion and subsequent international consensus. The main
reason was that studies evaluating details of the definitions were in part simply not
available. In a recent cohort study our working group proposed some modifications to the
criteria (8).
When using EORTC/MSG criteria the prevalence of IFI strongly depends on mycological
evidence which is not easy to get. Culture-based diagnostic approaches do not only
require invasive diagnostic procedures, which are often hindered by the severe medical
condition in patients at risk for IFI, but do also, in fact, frequently result falsely
negative. Antigen testing with rapidly available test results has therefore become
increasingly important to produce a realistic picture of the burden of IFI and enable
early diagnosis and treatment in patients with IFI (1). Antigen testing may not only
facilitate early diagnosis but may also prevent overtreatment which has become frequent.
A recent study by Azoulay and colleagues who evaluated antifungal therapy on one day in
multiple French hospitals confirmed that in fact most of the patients that received
antifungals did in fact not have IFI (9). Overtreatment may not only increase costs
significantly (daily costs for most antifungals 600-1000€) but may also lead to
development of resistance (10). The use of highly sensitive and specific rapidly
available antigen tests/ biomarkers may guide the clinician to initiate antifungal
therapy only in patients that benefit from treatment as they really have IFI. Last but
not least antigen testing may be also useful for early response assessment, therapy
monitoring and treatment stratification including the decision when to stop antifungal
therapy in patients with IA (11-12).
One of the major limitations of the GM test is that time to results varies between
centres (between less than a day and up to several days), mainly depending on the number
of specimens tested in routine (as the test is performed with plates covering 96 tests),
and the distance/duration of transport between the clinical setting and the laboratory
where the test is performed. These limitations are overcome by the Lateral Flow Device
Test, a point of care test for IA developed by Prof. Thornton of the University of
Exeter, United Kingdom. This single sample test can be easily performed in every
laboratory using BAL and serum specimens and time to result is approximately 20 minutes.
Recent studies have shown the immense potential of the test in human BAL and serum
samples (13-15). In a very recent study our working group retrospectively evaluated the
LFD test by using bronchoalveolar lavage (BAL) samples from patients with haematological
malignancies and patients after solid organ transplantation (SOT). Thirty-nine BAL
samples from 37 patients were included (29 samples haematological malignancies and 10
samples SOT; 12 probable IPA, 9 possible IPA, 16 no IPA). Sensitivity and specificity of
BAL LFD test for probable IPA were 100% and 81%, respectively. GM levels in cases with
negative LFD were significantly lower than in patients with positive LFD (P <0.0001). We
concluded that the LFD test of BAL specimens is performed easily and provides accurate
and rapidly available results. Therefore, this new point-of-care test may be a very
promising diagnostic approach for detecting IPA in BAL specimens from haematological
malignancy and SOT patients (16). Another recent study demonstrated in a neutropenic
guinea pig model that the LFD assay is reproducible between different laboratories and
studies (17). Multi-center studies are needed, however, to further evaluate the test
(16).
In the proposed study we will evaluate the BAL Lateral Flow Device Test and compare
results to routinely performed Galactomannan values as well as, culture and PCR results.
2. Study design and methods 2.1. Study design The study design is exploratory,
retrospective, and multi-centric. The study will start in March 2013 with duration of 13
months.
2.2. Study sites
1. Section of Infectious Diseases, Department of Internal Medicine, Medical University
of Graz, Austria
2. Division of Hygiene and Medical Microbiology, Innsbruck Medical University, Austria
3. Division of Clinical Microbiology, Medical University of Vienna, Austria
4. Mannheim University Hospital, University of Heidelberg, Germany
2.3. Study population All stored or routinely obtained BAL samples from adult patients
at risk for invasive pulmonary Aspergillosis will be eligible for study inclusion. The
treating clinicians will be blinded to BAL Lateral Flow Device test results and the test
will therefore have no impact on patient management / treatment decisions. The treating
clinicians will be blinded to BAL Lateral Flow Device test results. Test results will
therefore have no impact on clinical / treatment decisions and therefore not affect the
included patients.
Underlying diseases, EORTC status of IFI (both available from the clinical order
accompanying the BAL sample) and other microbiological/mycological test results will be
recorded in an electronic data base. No patient related personal data will be required.
2.3.1 Key Inclusion criteria
1. Patients above 18 years of age.
2. BAL sample obtained in clinical routine.
3. At risk for IFI (according to attending clinicians). Risk factors may include:
- febrile neutropenia
- induction chemotherapy
- allogeneic stem cell transplant/graft versus host disease
- clinical/radiological/mycological findings suspicious for IFI
- Solid Organ transplantation
- ICU patient
- Liver cirrhosis 2.3.2 Key exclusion criteria
1. Under 18 years of age.
2. No BAL sample obtained in clinical routine.
d.) Not at risk for IFI.
2.4. Lateral Flow Device testing The previously described lateral flow device is
evaluated in BALs from patients at risk for invasive aspergillosis. Briefly, an
immunoglobulin G (IgG) monoclonal antibody (JF5) to an epitope on an extracellular
antigen secreted constitutively during active growth of Aspergillus is immobilized to a
capture zone on a porous nitrocellulose membrane. JF5 IgG is also conjugated to
colloidal gold particles to serve as the detection reagent. BAL fluid (100 μl of neat
sample, with no pre-treatment) is added to a release pad containing the antibody-gold
conjugate, which bound the target antigen, and then passed along the porous membrane and
bound to JF5 IgG monoclonal antibody immobilized in the capture zone. Lateral Flow
Device (LFD) Results will be read 15 minutes after loading the sample. Bound
antigen-antibody-gold complexes are observed as a red line (T for test) with an
intensity proportional to the antigen concentration and were classified as negative,
weakly positive, moderately positive, or strongly positive (Fig. 1). Anti-mouse
immunoglobulin immobilized to the membrane in a separate zone (C for control) serves as
an internal control (13, 15). Detailed product information can be found in the attached
publication "Development of an Immunochromatographic Lateral-Flow Device for Rapid
Serodiagnosis of Invasive Aspergillosis" (14).
As the device is in the process of being CE marked for European use as a medical
diagnostic device, one can only view the current results as a multicentre prototype test
comparison (with no clinical implications for patient management).
3. Statistical Considerations Statistical analysis including multivariate analyses will be
performed in cooperation with ao. Univ. Prof. Dipl.-Ing. Dr. tech. Josef Haas from the
Institute for Medical Informatics, Statistics and Documentation, Medical University of
Graz and Univ. Doz. Mag. Dr. Herbert Schwetz, University of Salzburg.
3.1. Sample size calculation Due to the explorative study design statistical sample size
calculation is not possible. The samples size has been calculated by using recent published
epidemiological data from involved centres (3, 16). The proposed number of patients to be
investigated is representative and appropriate to generate data for further studies and has
been considered to be adequate by the statistical advisor.
3.2. Statistical Analysis Statistical analysis will be performed by using SPSS in cooperation
with our specialized co-operators mentioned above.
References
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burden of invasive fungal infections in hematopoietic stem cell transplant recipients?
Clin Infect Dis. 2010 Jul 15;51(2):253,4; author reply 254-5.
2. Kontoyiannis DP, Marr KA, Park BJ, Alexander BD, Anaissie EJ, Walsh TJ, et al.
Prospective surveillance for invasive fungal infections in hematopoietic stem cell
transplant recipients, 2001-2006: Overview of the transplant-associated infection
surveillance network (TRANSNET) database. Clin Infect Dis. 2010 Apr 15;50(8):1091-100.
3. Hoenigl M, Salzer HJ, Raggam RB, Valentin T, Rohn A, Woelfler A, et al. Impact of
galactomannan testing on the prevalence of invasive aspergillosis in patients with
hematological malignancies. Med Mycol. 2012 Apr;50(3):266-9.
4. Perkhofer S, Lass-Florl C, Hell M, Russ G, Krause R, Honigl M, et al. The nationwide
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patients. Int J Antimicrob Agents. 2010 Dec;36(6):531-6.
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host factors and invasive fungal infections in patients with haematological
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antifungal therapy in critically ill patients without invasive fungal infection*. Crit
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YJ, et al. Clinical implications of azole resistance in aspergillus fumigatus, the
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for early response assessment and treatment stratifications of invasive aspergillosis.
Curr Fungal Infect Rep [DOI: 10.1007/s12281-012-0099-5]. 2012 Online First™, 29 Juni
2012;DOI: 10.1007/s12281-012-0099-5.
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An autopsy study over a 15-year period (1989-2003). Haematologica. 2006 Jul;91(7):986-9.
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22;(61). pii: 3721. doi(61):10.3791/3721.
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Clin Microbiol. 2013; epup ahead of print
