The purpose of this study is to determine a safe, effective, and systematic approach for the treatment of first isolation of Pseudomonas aemginosa (Pa) from young children with Cystic Fibrosis (CF). There is significant interest in investigating anti-pseudomonal therapies in very young children with the long-term goal of delaying or preventing chronic infection that contributes to irreversible lung disease. There has been minimal evaluation of the long-term clinical and microbiologic efficacy or safety of aggressive early intervention (i.e., intervention based on first isolation of Pa alone, in the absence of symptoms). While anti-pseudomonal therapy for first isolation of Pa will likely result in short-term eradication of Pa from respiratory cultures, it is not known whether it will improve clinical outcomes, be associated with unacceptable toxicities, or increase the rate of acquisition of resistant organisms. In an ongoing effort to address these issues, young children with CF ranging in age from 1 to 12 years will be enrolled at one of 60 clinical centers nationwide in an 18-month clinical trial that will include approximately 300 children. The clinical trial is designed to allow randomized controlled evaluation of early intervention with inhaled and oral antipseudomonal therapy in young patients with CF at first isolation of Pa from respiratory cultures. The clinical trial will investigate two different antimicrobial treatment regimens: (1) Culture-based antibiotic therapy, i.e., treatment based on microbiology findings of Pa positive respiratory cultures, and (2) Cycled antibiotic therapy, i.e., treatment provided systematically in quarterly cycles until the end of the 18-month study period. Inhaled tobramycin and oral ciprofloxacin have bean selected as first choice antimicrobials for this trial, based on a consensus conference at which therapies were selected and ranked based on the amount of evidence and of safety data available. The primary outcome of the clinical trial is the proportion of recurrent Pa positive cultures during the 18-month study period, comparing participants assigned to the culture-based treatment group with participants assigned to the cycled treatment group. Another key clinical outcome measure will evaluate the time to occurrence of a pulmonary exacerbation. The secondary outcomes will evaluate the effect of antibiotic therapy on safety (adverse events profile with particular reference to musculo-skeletal symptoms, renal function as measured by serum creatinine, hearing acuity, liver function tests, and complete blood count); clinical variables (occurrence of hospitalization during 18 months, proportion of patients with pulmonary exacerbations, linear growth, weight gain, FEV1, and total inpatient days); microbiology findings (presence and pattern of mucoid Pa isolates identified by colony morphology, changes in MICs of Pa isolates from oropharyngeal cultures, and changes in the genotype of Pa isolates from baseline to the end of the study); and Pa serology (changes in and patterns of anti-pseudomonal antibody titers against Exotoxin A and other selected pseudomonas antigens). In essence, this study will provide valuable clinical and microbiologic efficacy and safety data regarding the use of antipseudomonal therapy in young children with CF, will provide important data on the effect of PA colonization on subsequent health status, and will provide information on surrogate markers of lower airway infection.

Agency
National Institute of Health (NIH)
Institute
National Heart, Lung, and Blood Institute (NHLBI)
Type
Research Project--Cooperative Agreements (U01)
Project #
5U01HL080310-04
Application #
7265110
Study Section
Special Emphasis Panel (ZDK1-GRB-C (M1))
Program Officer
Banks-Schlegel, Susan P
Project Start
2004-09-29
Project End
2009-06-30
Budget Start
2007-07-01
Budget End
2008-06-30
Support Year
4
Fiscal Year
2007
Total Cost
$1,234,448
Indirect Cost
Name
Seattle Children's Hospital
Department
Type
DUNS #
048682157
City
Seattle
State
WA
Country
United States
Zip Code
98105
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Mayer-Hamblett, Nicole; Kloster, Margaret; Rosenfeld, Margaret et al. (2015) Impact of Sustained Eradication of New Pseudomonas aeruginosa Infection on Long-term Outcomes in Cystic Fibrosis. Clin Infect Dis 61:707-15
Thompson, V; Mayer-Hamblett, N; Kloster, M et al. (2015) Risk of hemoptysis in cystic fibrosis clinical trials: A retrospective cohort study. J Cyst Fibros 14:632-8
Anstead, Michael; Heltshe, Sonya L; Khan, Umer et al. (2013) Pseudomonas aeruginosa serology and risk for re-isolation in the EPIC trial. J Cyst Fibros 12:147-53
Mayer-Hamblett, Nicole; Rosenfeld, Margaret; Treggiari, Miriam M et al. (2013) Standard care versus protocol based therapy for new onset Pseudomonas aeruginosa in cystic fibrosis. Pediatr Pulmonol 48:943-53
Mayer-Hamblett, Nicole; Kloster, Margaret; Ramsey, Bonnie W et al. (2013) Incidence and clinical significance of elevated liver function tests in cystic fibrosis clinical trials. Contemp Clin Trials 34:232-8
Mayer-Hamblett, Nicole; Kronmal, Richard A; Gibson, Ronald L et al. (2012) Initial Pseudomonas aeruginosa treatment failure is associated with exacerbations in cystic fibrosis. Pediatr Pulmonol 47:125-34
Treggiari, Miriam M; Retsch-Bogart, George; Mayer-Hamblett, Nicole et al. (2011) Comparative efficacy and safety of 4 randomized regimens to treat early Pseudomonas aeruginosa infection in children with cystic fibrosis. Arch Pediatr Adolesc Med 165:847-56
Treggiari, Miriam M; Rosenfeld, Margaret; Mayer-Hamblett, Nicole et al. (2009) Early anti-pseudomonal acquisition in young patients with cystic fibrosis: rationale and design of the EPIC clinical trial and observational study'. Contemp Clin Trials 30:256-68
Treggiari, Miriam M; Rosenfeld, Margaret; Retsch-Bogart, George et al. (2007) Approach to eradication of initial Pseudomonas aeruginosa infection in children with cystic fibrosis. Pediatr Pulmonol 42:751-6

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