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Early Versus Late Stopping of Antibiotics in Children With Cancer and High-risk Febrile Neutropenia

PHASE4RECRUITING

This randomised controlled trial will determine the non-inferiority of stopping empiric antibiotics prior to absolute neutrophil count (ANC) recovery (Early Stopping) versus stopping antibiotics upon ANC recovery (Standard of Care/ Late Stopping) , in children with cancer and high-risk febrile neutropenia (FN).

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Study details:

Febrile neutropenia (FN) is a common complication of childhood cancer treatment and a leading cause of hospital admission and antibiotic exposure. Management typically involves broad-spectrum antibiotics until resolution of fever and absolute neutrophil count (ANC) recovery \>500 cells/mm3. However, despite the frequency with which FN occurs, evidence to guide duration of antibiotics is limited to observational studies and small randomised controlled trials.

Current international clinical guidelines provide conflicting recommendations on when to cease empiric antibiotics for FN. Early cessation of antibiotics in FN may translate to reduced antibiotic exposure and limit potential harms including drug side-effects, antimicrobial resistance, Clostridioides difficile infection and microbiome disruption. This randomised controlled trial will use a composite endpoint of fever recurrence, physiological instability, new bacteremia, intensive care admission and death to determine the non-inferiority of stopping antibiotics prior to ANC recovery compared with standard of care (SOC), in children with cancer and high-risk FN.

Adopting a health informatics approach, patient identification, consent, randomisation and reporting of outcomes will be embedded within the electronic medical record (EMR). Children with high-risk FN who have been afebrile and clinically stable for at least 48 hours will be randomised to cease antibiotics or continue SOC. Data on primary outcomes, antibiotic duration, length of stay, C.

difficile infection and antimicrobial resistance will be automatically collected by the EMR. This is the first study of its kind in children with high-risk FN and adopts a novel embedded trial design. Results will inform optimal antibiotic duration in FN, potentially reducing unnecessary antibiotic exposure.

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Eligibility criteria

Researchers look for people who fit a certain description, called eligibility criteria. See if you qualify.

Inclusion criteria

Diagnosis of * Acute myeloid leukemia (AML) or acute lymphoblastic leukaemia (ALL) in dose-intensive phases of induction/re-induction, intensification or consolidation or * ALL or acute lymphoblastic lymphoma patients on a TOT17 protocol or * Any disease within 100 days of allogeneic or autologous HSCT

Neutropenia (<500 cells/mm3)

Afebrile (temperature <38.0°C) period for at least 48 hours and no more than 96 hours after at least one temperature measured by axillary or tympanic thermometer (≥38.0°C)

Commenced on empiric FN antibiotics (any of piperacillin-tazobactam, cefepime, ceftazidime or vancomycin and ciprofloxacin)

Exclusion criteria

Prolonged febrile neutropenia (documented daily temperature ≥38.0°C for ≥5 days)

Documented positive blood culture since onset of FN episode and prior to randomisation

Documented other infection (microbiologically or clinically documented) requiring antibiotic treatment since onset of FN episode and prior to randomisation

Admitted to the ICU at the time of randomisation

Clinical instability (One or more conscious state, respiratory rate, blood pressure, heart rate or oxygen saturations in MET criteria OR two or more respiratory rate, blood pressure, heart rate or oxygen saturations simultaneously (+/- 4 hrs) in the clinical review criteria in 48 hours prior to randomisation)

Within 28 days of last randomisation

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Eligibility

Age eligible for study : 0 and older

Healthy volunteers accepted : No

Gender eligible for study: All

Things to know

Study dates

Study start: 2021-11-15

Primary completion: 2026-07-01

Study completion finish: 2026-08-01

Study type

TREATMENT

Phase

PHASE4

Trial ID

NCT04948463

Intervention or treatment

DRUG: Piperacillin and Tazobactam for Injection

DRUG: Cefepime Injection

DRUG: Ceftazidime Injection

DRUG: Vancomycin Injection

DRUG: Amikacin Injection

DRUG: Ciprofloxacin

DRUG: Piperacillin and Tazobactam for Injection

DRUG: Cefepime Injection

DRUG: Ceftazidime Injection

DRUG: Vancomycin Injection

DRUG: Amikacin Injection

DRUG: Ciprofloxacin

Conditions

• Febrile Neutropenia

Condition: Febrile Neutropenia
DRUG: Piperacillin and Tazobactam for Injection and other drugs
Melbourne, Victoria, Australia
Sponsor: Murdoch Childrens Research Institute

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Find a site

Closest Location:

Royal Children's Hospital

Research sites nearby

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Royal Children's Hospital
Melbourne, Victoria, Australia

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Participant Group/Arm	Intervention/Treatment
EXPERIMENTAL: Early Stopping Stopping empiric FN antibiotics after resolution of fever for 48 hours, irrespective of absolute neutrophil count (ANC)	DRUG: Piperacillin and Tazobactam for Injection Given if patient has no known allergies at 100mg/kg (max 4g) 6 hourly, stopping 48 hours post-fever resolution.
ACTIVE_COMPARATOR: Standard of care Continuing empiric FN antibiotics until resolution of fever for 48 hours and recovery of ANC as defined by the treating clinician but usually to ≥200-500/mm3	DRUG: Piperacillin and Tazobactam for Injection Given if patient has no known allergies, until ANC recovery at 100mg/kg (max 4g) 6 hourly.

What is the study measuring?

Primary outcome

Primary Outcome Measure	Primary Outcome Description	Primary Outcome Time Frame
Unfavourable clinical course occurring during the same period of severe neutropenia	Incidence of unfavourable clinical course, defined as any of the following: recurrence of fever, clinical instability (see below definition), admission to the intensive care unit, new positive blood culture collected after randomisation, or death	During the same episode of neutropenia, up to 28 days post-enrolment.

Secondary outcome

Secondary Outcome Measure	Secondary Outcome Description	Secondary Outcome Time Frame
Fever recurrence	Incidence of fever recurrence (temperature ≥38 degrees Celsius)	Up to 28 days post-enrolment
Clinical instability	Incidence of clinical instability defined as; one or more vital signs (conscious state, respiratory rate, blood pressure, heart rate, oxygen saturation) meeting mandatory emergency (MET) call criteria OR two or more vital signs simultaneously (within 4 hours of each other) meeting clinical review criteria.	Up to 28 days post-enrolment
Admission to intensive care unit (ICU)	Incidence of admission to intensive care unit (all cause)	Up to 28 days post-enrolment
New positive blood culture	Incidence of positive blood culture	Up to 28 days post-enrolment
28 day all-cause and infection-related mortality	Incidence of all-cause and infection-related mortality, as defined post-mortem	Up to 28 days post-enrolment
Duration of neutropenia	Mean days of neutropenia defined as ANC \<500 cells/mm3	During the same episode of neutropenia or up to 28 days post-enrolment
Clinician confidence and acceptability	Measured by number of patients for which randomisation is overridden in the Early Stopping arm and the recorded reason	Up to 28 days post-enrolment
Total antibiotic duration	Mean number of days antibiotics are administered	Up to 28 days post-enrolment
Length of hospital stay	Mean number of days admitted to the study site hospital ward	Up to 28 days post-enrolment, or until discharge from hospital (whichever is the later)
Readmission to hospital	Incidence of unplanned admission to the study site hospital	Up to 28 days post-enrolment
Development of C. difficile infection	Incidence of C. difficile infection detected in unformed stool	Up to 28 days post-enrolment
Development of an antibiotic resistant infection or colonisation	Incidence of antibiotic resistant infection or colonisation including Methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta-lactamases (ESBL)-producing enterobacterales, carbapenem-resistant enterobacteriaceae (CRE), Vancomycin-resistant Enterococcus (VRE)	Up to 28 days post-enrolment
Patient/parent/caregiver confidence	Number of patients that consent to study as proportion of patients eligible	Within 48 hours of having informed consent discussion with the study team
Patient/parent/caregiver acceptability	Number of patients for which randomisation is overridden in the Early Stopping arm due to withdrawn consent	Within 48-96 hours post assignment to intervention arm

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References

Clinical Trials Gov: Early Versus Late Stopping of Antibiotics in Children With Cancer and High-risk Febrile Neutropenia