Candidemia, Invasive Candidiasis
Conditions
Brief summary
CanTEN is a multicenter, randomized, double-blind, placebo-controlled, adaptive, non-inferiority phase 4 trial investigating a shortened treatment duration in patients with uncomplicated candidemia. Current guidelines recommend a 14-day treatment after documented clearance of candidemia. The traditional 14-day treatment duration for uncomplicated candidemia is not sufficiently evidence-based. In a variety of bacterial infections, shorter treatment has been proven safe and efficacious, thus reducing resistance development, toxicity, and costs. This study aims to demonstrate the non-inferiority of 10 days (Group B) of treatment compared to 14 days (Group A) in patients with a controlled source of candidemia. Once the primary endpoint have been assessed in 50% of the participants, an unblinded interim analysis will be conducted. If non-inferiority can be demonstrated, Group C will be initiated with a 7-day treatment duration. The primary endpoint is the rate of recurrent candidemia and/or other proven invasive candidiasis at 30 days after end of study treatment (Day 37). Secondary endpoints include the time from randomization to recurrent candidemia and/or other proven invasive candidiasis, clinical cure, radiological cure and mycological eradication at the end of study treatment (Day 7) and at 30 days after end of study treatment (Day 37). In addition, all-cause mortality and mortality attributable to candidemia and/or other proven invasive candidiasis will be measured at 30 days after end of study treatment (Day 37) . Additional secondary endpoints include candidemia-attributable healthcare resources use at 30 days after end of study treatment (Day 37), Caspofungin-related adverse events (AEs) occurring until 30 days after last administration of caspofungin and patient reported outcome measures (PROMs; EQ-5D-5L and WHODAS 2.0) on Day 1 and Day 37. As an exploratory endpoint, the study will examine the impact of age, sex, relevant comorbidities, SOFA and qSOFA score, use of vasopressors and Candida species on recurrence of candidemia.
Interventions
DRUGCaspofungin only within the study
Seven days of caspofungin on-study.
DRUGCaspofungin for 3 days within the study
3 days of caspofungin followed by 4 days of placebo.
DRUGPlacebo only within the study
Zero days of caspofungin on-study.
DRUGPlacebo for 4 days within the study
3 days of caspofungin followed by 4 days of placebo.
Sponsors
Oliver Cornely, MD
Nationales Referenzzentrum für Invasive Pilzinfektionen (NRZMyk)
Deutsche Sepsis-Hilfe e.V.
Netzwerk Universitätsmedizin (NUM)
University Medical Center Goettingen
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Intervention model description
CanTEN is an adaptive, multi-armed interventional study. Initially, participants are randomized to Group A (7 days of caspofungin on-study) or Group B (3 days of caspofungin followed by 4 days placebo on-study). An interim analysis will be performed when 50% of participants, relative to the re-estimated total sample size per group, in each Group A and Group B have reached Day 37. Depending on the results, four scenarios are possible: 1. : Non-inferiority of Group B shown --\> Group A will be stopped, Group B will be continued, Group C (7 days of placebo on-study) will be started. 2. : Non-inferiority of Group B not shown, conditional power above threshold --\> Group A and Group B will be continued, Group C will be started. 3. : Non-inferiority of Group B not shown, conditional power below threshold --\> Group A and Group B will be continued, Group C will not be started. 4. : Futility demonstrated --\> Group A and Group B will be stopped, Group C will not be started, trial terminated.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* 1\. Participants ≥18 years on the day of informed consent. * 2\. Written informed consent by participant, according to applicable guidelines and laws. * 3\. For female participants of child-bearing potential only: willingness to practice highly effective contraception or abstinence for the duration of the trial, i.e. until 30 days after end of study treatment. Highly effective contraception methods include sterilization, combined estrogen and progestogen-containing hormonal contraception (oral, intravaginal, transdermal), progestogen-only hormonal contraception (oral, injectable, implantable), intrauterine device (IUD), intrauterine hormone-releasing system, bilateral tubal occlusion, vasectomized partner. In case of nausea, diarrhoea or vomiting, oral contraception cannot be used; a non-oral highly effective method of contraception must be used instead. * 4\. Treatment with caspofungin for candidemia, initially proven by Candida-positive blood culture. * 5\. Uncomplicated candidemia defined as follows: * a. 7 consecutive days of caspofungin treatment after documented clearance of candidemia, i.e. caspofungin treatment on Day -7 to Day -1 prior to study treatment. Documented clearance of candidemia is defined as first (since diagnosis of candidemia) Candida-negative blood-culture on Day -7 AND no Candida-positive blood cultures from Day -6 to Day -1. * b. Treatment is planned for another 7 days, i.e. for the entire duration of study treatment from Day 1 to Day 7. Please note there is no Day 0 in this study. Day -1 is directly followed by Day 1. * c. Less than 120 hours between the initial Candida-positive blood culture and the first Candida-negative blood-culture. * d. Source control for candidemia as follows: * Any central venous access device (e.g., central venous catheter, peripherally inserted central catheters, Shaldon catheters, Hickman and Broviac lines, or implanted port systems) must have been removed/replaced within 48 hours after the start of caspofungin treatment when candidemia was first diagnosed. * Any implantable cardiac electronic device, ventricular assist device, extracorporeal membrane oxygenation support system, or indwelling intravascular foreign body must have been removed/replaced within 48 hours after the start of caspofungin treatment when candidemia was first diagnosed. * Any intraabdominal candidiasis (e.g., intraabdominal abscess, peritonitis) must have been treated successfully within 5 days after start of treatment (caspofungin with or without surgery) when candidemia was first diagnosed.
Exclusion criteria
* 1\. Any Candida-positive blood culture within 7 days prior to the start of study treatment, i.e. on Day -7 to Day -1. * 2\. Complicated candidemia defined by any of the following: * a. History of candidemia within 3 months prior to the current candidemia episode. * b. History or current presence of extra-abdominal deep-seated candidiasis, i.e. central nervous system infection, chorioretinitis, endophthalmitis, intravascular infection, endocarditis, renal abscess, osteomyelitis, or joint infection. * c. History of intra-abdominal candidiasis within 3 months prior to the current candidemia episode. Only exception: a very first episode of intra-abdominal candidiasis has been treated successfully within 5 days after the initial diagnosis of the current candidemia episode. * d. Candidemia caused by echinocandin-resistant Candida isolate. * 3\. Hematological malignancy without remission. * 4\. Allogeneic hematopoietic stem-cell transplantation within 1 year prior to screening. * 5\. Acute graft-versus-host disease grade III or IV. * 6\. Hypersensitivity to caspofungin or any of the excipients. * 7\. Ongoing glucocorticosteroids ≥0.3 mg/kg of prednisone equivalent per day at the initial diagnosis of the current candidemia episode with a planned cumulative administration of more than 3 weeks or ongoing administration of more than three weeks. * 8\. Concomitant rifampin/rifampicin, phenytoin, carbamazepine, efavirenz or nevirapine during study participation. * 9\. Absolute neutrophil count \<0.5 G/L at screening. * 10\. Absolute neutrophil count \<0.5 G/L of any duration expected during study treatment. * 11\. Child-Pugh score \>9 at screening. * 12\. Pregnant women and breastfeeding mothers. Prior to enrolment, pregnancy must be ruled out by a negative blood pregnancy test for all women of child-bearing potential. * 13\. Active intravenous illicit drug use. * 14\. Administration of an investigational drug (i.e. not yet authorized) * a. Within 30 days before the first dose of study treatment in this trial OR * b. Within five half-lives before the first dose of study treatment in this trial whichever is longer. An investigational drug is defined as a drug not authorized for any indication in the country where this trial is conducted. * 15\. Previous participation in this trial. * 16\. Person who is in a relationship of dependence/employment with the Sponsor or the investigator.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Rate of recurrent candidemia and/or other proven invasive candidiasis at 30 days after end of study treatment (Day 37) | Day 37 of study (end of the study for the individual participant) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Time from randomization to recurrent candidemia and/or other proven invasive candidiasis | From enrolment to Day 37 of study | — |
| Clinical cure, radiological cure and mycological eradication at end of study treatment (Day 7) | Day 7 of study | The outcome is cure "yes/no" as secondary outcome measure. The specifier "clinical", "radiological" and "mycological eradication" is only ancillary information for "cure", each answered with "yes" or "no". |
| Clinical cure, radiological cure and mycological eradication at 30 days after end of study treatment (Day 37) | Day 37 of study | The outcome is cure "yes/no" as secondary outcome measure. The specifier "clinical", "radiological" and "mycological eradication" is only ancillary information for "cure", each answered with "yes" or "no". |
| All-cause mortality at 30 days after end of study treatment (Day 37) | Day 37 of study | — |
| Mortality attributable to candidemia and/or other invasive candidiasis at 30 days after end of study treatment, as determined by the DSMB | Day 37 of study | — |
| Candidemia-attributable healthcare resources at 30 days after end of study treatment, including length of stay in ICU or IMC or general ward, duration of mechanical ventilation, cost of antifungal therapy since onset of candidemia | Day 37 of study | This is a composite outcome that will be analyzed descriptively only. |
| Caspofungin-related adverse events (AEs) occurring until 30 days after last administration of caspofungin. | From enrolment to Day 37 of study | — |
| Patient reported outcome measures (PROMs) on Day 1 and Day 37: Health-related quality of life per EQ-5D-5L + Physical fuctioning as per WHODAS 2.0 | Day 1 and Day 37 of study | EQ-5D-5L = 5-level EQ-5D version WHODAS 2.0 = WHO Disability Assessment Schedule 2.0 EQ-5D-5L and WHODAS 2.0 are questionnaires that will yield point scores without units. Results will be analyzed descriptively as, all analysis will be carried out in accordance with standard of practice. |
Countries
Germany
Contacts
CONTACTUniv.-Prof. Dr. med. Oliver A. Cornely - CanTEN Sponsor Team
Outcome results
None listed