Efficacy and safety of a structured de-escalation from antipseudomonal ß-lactams in bloodstream infections due to Enterobacterales (SIMPLIFY): an open-label, multicentre, randomised trial.

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Autores de IDIVAL

Autores ajenos al IDIVAL

  • López-Cortés LE
  • Delgado-Valverde M
  • Moreno-Mellado E
  • Goikoetxea Aguirre J
  • Guio Carrión L
  • Blanco Vidal MJ
  • López Soria LM
  • Pérez-Rodríguez MT
  • Martínez Lamas L
  • Jiménez Aguilar P
  • Del Carmen Martínez-Rubio M
  • Sáez-Bejar C
  • de Las Cuevas C
  • Martín-Aspas A
  • Galán F
  • Yuste JR
  • Leiva-León J
  • Bou G
  • Capón González P
  • Boix-Palop L
  • Xercavins-Valls M
  • Goenaga-Sánchez MÁ
  • Anza DV
  • Castón JJ
  • Rufián MR
  • Merino E
  • Rodríguez JC
  • Loeches B
  • Cuervo G
  • Guerra Laso JM
  • Plata A
  • Pérez Cortés S
  • López Mato P
  • Sierra Monzón JL
  • Rosso-Fernández C
  • Bravo-Ferrer JM
  • Retamar-Gentil P
  • Rodríguez-Baño J
  • SIMPLIFY study group

Unidades

Abstract

BACKGROUND: De-escalation from broad-spectrum to narrow-spectrum antibiotics is considered an important measure to reduce the selective pressure of antibiotics, but a scarcity of adequate evidence is a barrier to its implementation. We aimed to determine whether de-escalation from an antipseudomonal ß-lactam to a narrower-spectrum drug was non-inferior to continuing the antipseudomonal drug in patients with Enterobacterales bacteraemia. METHODS: An open-label, pragmatic, randomised trial was performed in 21 Spanish hospitals. Patients with bacteraemia caused by Enterobacterales susceptible to one of the de-escalation options and treated empirically with an antipseudomonal ß-lactam were eligible. Patients were randomly assigned (1:1; stratified by urinary source) to de-escalate to ampicillin, trimethoprim-sulfamethoxazole (urinary tract infections only), cefuroxime, cefotaxime or ceftriaxone, amoxicillin-clavulanic acid, ciprofloxacin, or ertapenem in that order according to susceptibility (de-escalation group), or to continue with the empiric antipseudomonal ß-lactam (control group). Oral switching was allowed in both groups. The primary outcome was clinical cure 3-5 days after end of treatment in the modified intention-to-treat (mITT) population, formed of patients who received at least one dose of study drug. Safety was assessed in all participants. Non-inferiority was declared when the lower bound of the 95% CI of the absolute difference in cure rate was above the -10% non-inferiority margin. This trial is registered with EudraCT (2015-004219-19) and ClinicalTrials.gov (NCT02795949) and is complete. FINDINGS: 2030 patients were screened between Oct 5, 2016, and Jan 23, 2020, of whom 171 were randomly assigned to the de-escalation group and 173 to the control group. 164 (50%) patients in the de-escalation group and 167 (50%) in the control group were included in the mITT population. 148 (90%) patients in the de-escalation group and 148 (89%) in the control group had clinical cure (risk difference 1·6 percentage points, 95% CI -5·0 to 8·2). The number of adverse events reported was 219 in the de-escalation group and 175 in the control group, of these, 53 (24%) in the de-escalation group and 56 (32%) in the control group were considered severe. Seven (5%) of 164 patients in the de-escalation group and nine (6%) of 167 patients in the control group died during the 60-day follow-up. There were no treatment-related deaths. INTERPRETATION: De-escalation from an antipseudomonal ß-lactam in Enterobacterales bacteraemia following a predefined rule was non-inferior to continuing the empiric antipseudomonal drug. These results support de-escalation in this setting. FUNDING: Plan Nacional de I+D+i 2013-2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, Spanish Network for Research in Infectious Diseases; Spanish Clinical Research and Clinical Trials Platform, co-financed by the EU; European Development Regional Fund "A way to achieve Europe", Operative Program Intelligence Growth 2014-2020.

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Datos de la publicación

ISSN/ISSNe:
1473-3099, 1474-4457

LANCET INFECTIOUS DISEASES  ELSEVIER SCI LTD

Tipo:
Article
Páginas:
375-385

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