Community Acquired Respiratory Disease Syndrome Clinical Trial
— ESCAPeOfficial title:
CSP #574 - Evaluate the Safety and Efficacy of Methylprednisolone in Hospitalized Veterans With Severe Community-Acquired Pneumonia
NCT number | NCT01283009 |
Other study ID # | 574 |
Secondary ID | |
Status | Completed |
Phase | Phase 3 |
First received | |
Last updated | |
Start date | January 9, 2012 |
Est. completion date | August 31, 2016 |
Verified date | September 2020 |
Source | VA Office of Research and Development |
Contact | n/a |
Is FDA regulated | No |
Health authority | |
Study type | Interventional |
The goal of the study is to determine whether providing early treatment with a glucocorticoid
drug, called methylprednisolone, will improve survival in critically ill patients with severe
community-acquired pneumonia (CAP). Pneumonia develops when bacteria and other agents invade
the lungs. The body's immune system creates a response to produce inflammation to kill the
bacteria. A moderate amount of inflammation is beneficial. But, in patients sick enough to be
admitted to the ICU, inflammation is frequently out of control. When the body cannot regulate
inflammation vital organs (brain, heart, lung, kidney, liver) may be damaged, contributing to
death or residual organ damage for those who survive. Glucocorticoids help reduce
inflammation. Recent studies have shown that when the body is unable to produce sufficient
amounts of glucocorticoids, inflammation can get out of control. Under these circumstances,
glucocorticoids given in small doses may help aid the body's ability to reduce inflammation
and improve recovery. In a small preliminary trial, glucocorticoid treatment, in addition to
standard antibiotic treatment, sped up recovery from pneumonia. It also decreased the length
of hospital stay, and increased survival. This Cooperative Studies Program (CSP) study will
be the first large-scale, prospective, randomized clinical trial evaluating whether or not
this treatment improves recovery.
In this study, at each site, patients with severe CAP will be assigned to one of two
treatment groups. One group will receive methylprednisolone and the other will receive a
placebo (an inert substance that will look like the drug). The investigators have chosen a
total duration of treatment of 20 days (7 days full dose followed by slow reduction over 13
days) to prevent relapse of inflammation and allow the body to recover its own ability to
produce glucocorticoid. All patients will also receive standardized management of CAP in
accordance with current practice guidelines. The study will take into consideration when
assigning the treatment each participating site, and whether or not the patient requires
mechanical ventilation at the time of assignment. Patients will be followed clinically for
180 days. The primary outcome is all cause 60-day mortality. Secondary outcomes are (1)
in-hospital morbidity-mortality, including ventilator-free days, multiorgan dysfunction
syndrome (MODS)-free days, duration of ICU and hospital stay, and hospital discharge; and (2)
posthospital discharge morbidity-mortality, including cardiovascular complications,
functional and general health status in the first 180 days, rehospitalization, and mortality
at 1 year. Serial blood samples will also be collected and stored for future translational
research relating longitudinal inflammation markers to clinical outcomes.
This study will advance knowledge on the relationship between inflammation and long-term
outcome in severe CAP.
Status | Completed |
Enrollment | 584 |
Est. completion date | August 31, 2016 |
Est. primary completion date | July 31, 2016 |
Accepts healthy volunteers | No |
Gender | All |
Age group | 18 Years and older |
Eligibility |
Inclusion Criteria: - Patient's origin. Patients are classified as having Community Acquired Pneumonia (CAP) if they are admitted directly from outside the hospital, including private residence, nursing home, rehabilitation center, other long-term care facility (health care-associated pneumonia (HCAP)). - Clinical diagnosis of CAP. - Have radiographically confirmed pneumonia (new or progressive pulmonary infiltrate(s) on chest radiograph or chest computed tomography scan consistent with bacterial pneumonia) AND have acute illness ( <=7 days' duration) with at least three of the following clinical signs or symptoms consistent with a lower respiratory tract infection: New or increased cough Purulent sputum or change in sputum character Auscultatory findings consistent with pneumonia (e.g., rales, egophony, findings of consolidation) Dyspnea, tachypnea, or hypoxemia (O2 saturation <90% on room air or PaO2 <60 mmHg) Fever >= 38 C oral (>=38.5 C rectally or tympanically) or hypothermia (<=36 C) White blood cell count greater than 10,000 cells/mm3 or less than 4,000 cells/mm3 Greater than 15% immature neutrophils (bands) irrespective of WBC count - Diagnosis of severe CAP. Pneumonia of sufficient severity to require admission to the ICU (including intermediate care unit) and meeting >=1 major or >= 3 minor modified Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) criteria.: - 1 Major Criteria 1. Use of invasive or noninvasive mechanical ventilation 2. Vasopressors for shock despite adequate fluid resuscitation 3. Arterial pH < 7.30 -OR >=3 Minor Criteria 1. New onset of confusion or disorientation 2. Hypothermia (core temperature <=36 C) 3. Respiratory rate >=30 breaths/min 4. Hypotension requiring aggressive fluid resuscitation 5. Uremia (BUN >=20 mg/dL) 6. PaO2: FiO2 ratio <=250 or SaO2:FiO2 ratio <=250 7. Leukopenia (WBC count < 4000 cells/mm3) 8. Platelet count < 100,000 cells/mm3 or > 400,000 cells/mm3 9. Multilobar infiltrates Exclusion Criteria: - Patient's age 17 years or younger. - Vasopressor-dependent shock requiring moderate-to-high dose vasopressor (i.e., norepinephrine >=0.3 mcg/Kg/min) treatment for greater than 2 hours in patient that is adequately fluid-resuscitated (at least 4 liters of crystalloids) WITH central venous pressure (CVP) equal to or greater than 8 mm Hg for nonventilated patients and equal to or greater than 12 mm Hg for ventilated patients. (See explanation below)* - Major gastrointestinal bleeding requiring transfusion of 5 units or more of packed red blood cells within 3 months of current hospitalization. - Any condition requiring 20 mg of prednisone equivalent/day for greater than 14 days, over the last 3 months. - Chronic obstructive pulmonary disease (COPD) with acute exacerbation requiring glucocorticoid treatment at hospital admission. Patients with short-term glucocorticoid use (e.g., methylprednisolone up to 300 mg within 5 days of randomization) will not be excluded. - Patients enrolled in another experimental (interventional) protocol. - Pregnancy, confirmed by urine or serum test. - Presence of postobstructive pneumonia or cystic fibrosis. - Clinical history consistent with aspiration of gastric content (i.e., loss of consciousness or seizure). - Active tuberculosis or fungal infection. - Moribund patient (i.e., not expected to live more than 24 h) or with recent (within 7 days) cardiopulmonary arrest, or with (known or suspected) irreversible cessation of all brain function, or comfort measure status. - Presence of preexisting medical condition that is irreversible and expected to be fatal within 3 months. - Patients with severe immunosuppression (i.e., HIV with CD4 <200), neutropenia (less than 1000 neutrophils) not related to pneumonia, acute burn injury, or receiving immunosuppressive or cytotoxic therapy for any reason. - Chronic severe cognitive impairment caused by dementia or central nervous system pathologies (tumor, cerebro-vascular accident, infections, or head injuries) as defined by the site investigator by obtaining medical history and reviewing medical record. - The physician doesn't feel the patient is a viable candidate for the study (e.g., presence of hypersensitivity or previous severe adverse reaction to cosyntropin or any glucocorticoid, history of adrenal insufficiency or chronic systemic steroid use placing the patient at risk for relative adrenal insufficiency). |
Country | Name | City | State |
---|---|---|---|
Puerto Rico | VA Caribbean Healthcare System, San Juan, PR | San Juan | |
United States | Asheville VA Medical Center, Asheville, NC | Asheville | North Carolina |
United States | Bay Pines VA Healthcare System, Pay Pines, FL | Bay Pines | Florida |
United States | VA Western New York Healthcare System, Buffalo, NY | Buffalo | New York |
United States | Cincinnati VA Medical Center, Cincinnati, OH | Cincinnati | Ohio |
United States | Louis Stokes VA Medical Center, Cleveland, OH | Cleveland | Ohio |
United States | Wm. Jennings Bryan Dorn VA Medical Center, Columbia SC | Columbia | South Carolina |
United States | Atlanta VA Medical and Rehab Center, Decatur | Decatur | Georgia |
United States | North Florida/South Georgia Veterans Health System, Gainesville, FL | Gainesville | Florida |
United States | Michael E. DeBakey VA Medical Center, Houston, TX | Houston | Texas |
United States | Richard L. Roudebush VA Medical Center, Indianapolis, IN | Indianapolis | Indiana |
United States | VA Loma Linda Healthcare System, Loma Linda, CA | Loma Linda | California |
United States | VA Long Beach Healthcare System, Long Beach, CA | Long Beach | California |
United States | Robley Rex VA Medical Center, Louisville, KY | Louisville | Kentucky |
United States | Memphis VA Medical Center, Memphis, TN | Memphis | Tennessee |
United States | Miami VA Healthcare System, Miami, FL | Miami | Florida |
United States | Clement J. Zablocki VA Medical Center, Milwaukee, WI | Milwaukee | Wisconsin |
United States | Minneapolis VA Health Care System, Minneapolis, MN | Minneapolis | Minnesota |
United States | Oklahoma City VA Medical Center, Oklahoma City, OK | Oklahoma City | Oklahoma |
United States | Omaha VA Nebraska-Western Iowa Health Care System, Omaha, NE | Omaha | Nebraska |
United States | VA Palo Alto Health Care System, Palo Alto, CA | Palo Alto | California |
United States | Phoenix VA Health Care System Carl T. Hayden VA Medical Center, Phoenix, AZ | Phoenix | Arizona |
United States | VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA | Pittsburgh | Pennsylvania |
United States | VA Sierra Nevada Health Care System, Reno, NV | Reno | Nevada |
United States | Salem VA Medical Center, Salem, VA | Salem | Virginia |
United States | VA Salt Lake City Health Care System, Salt Lake City, UT | Salt Lake City | Utah |
United States | South Texas Health Care System, San Antonio, TX | San Antonio | Texas |
United States | VA San Diego Healthcare System, San Diego, CA | San Diego | California |
United States | Syracuse VA Medical Center, Syracuse, NY | Syracuse | New York |
United States | VA Greater Los Angeles Healthcare System, West Los Angeles, CA | West Los Angeles | California |
Lead Sponsor | Collaborator |
---|---|
VA Office of Research and Development |
United States, Puerto Rico,
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Primary | 60-day Mortality | The primary outcome is all-cause mortality at 60 days, defined by whether the patient has died by the end of study day 60. | 60-day |