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Antibiotic "Dysbiosis" in Preterm Infants

Primary Purpose

Enterocolitis, Necrotizing, Bacteremia, Bronchopulmonary Dysplasia

Status
Completed
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
Antibiotic
Gastric fluid
Breast milk
Stool samples
Antibiotics - pre-emptive
Sponsored by
University of Florida
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Enterocolitis, Necrotizing

Eligibility Criteria

23 Weeks - 33 Weeks (Child)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • All infants less than 33 weeks gestation.

Exclusion Criteria:

  • Infants who are non-viable at birth.

Sites / Locations

  • University of Florida

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm 4

Arm Type

Other

Other

Other

Other

Arm Label

Antibiotics Control

No Antibiotics Control

Randomized to pre-emptive antibiotics

Randomized to no pre-emptive antibiotics

Arm Description

These neonates have a clinical indication to receive antibiotics, such as maternal chorioamnionitis with fetal tachycardia. The standard of care antibiotics include Ampicillin and Gentamicin or Cefotaxime and as part of standard of care blood tests such as complete blood cell counts, blood cultures, and C-reactive proteins will be performed. Study interventions will include the collection of samples for the following: breast milk, gastric fluid and stool samples for analysis of the microbiome and metabolome.

These neonates show no signs of respiratory distress(RDS) or have no indications of maternal chorioamnionitis. Antibiotics is not indicated for this group as standard of care. Study interventions will include the collection of samples for the following: breast milk, gastric fluid and stool samples for analysis of the microbiome and metabolome, along with standard of care complete blood counts, blood cultures, and C-reactive proteins.

This group will be randomized to receive standard of care antibiotics which include Ampicillin and Gentamicin or Cefotaxime. Standard of care blood tests such as complete blood cell counts, blood cultures, and C-reactive proteins will be performed. Study interventions will include the collection of samples for the following: breast milk, gastric fluid and stool samples for analysis of the microbiome and metabolome.

This group will be randomized not to receive standard of care antibiotics. Study interventions will include the collection of samples for the following: breast milk, gastric fluid and stool samples for analysis of the microbiome and metabolome, along with standard of care complete blood counts, blood cultures, and C-reactive proteins.

Outcomes

Primary Outcome Measures

Rates of composite morbidities and mortality, including necrotizing enterocolitis(NEC), late onset sepsis (LOS), bronchopulmonary dysplasia (BPD) and death
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and the components of the composite outcome

Secondary Outcome Measures

Rates of bacteremia
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and the development of bacteremia after the first week of life.
Microbiota 16s ribosomal ribonucleic acid (rRNA) metagenomic sequencing
Pacific BioSciences or Illumina sequencing will be done and the data analyzed using metagenomics Rapid Annotation using Subsystem Technology (MG-RAST).
Microbial diversity analysis
Microbial diversity is assessed using Chao1, Shannon, and ordination methods implemented using a software program called phyloseq package in R.42 Chao1 estimates the species richness for each sample, while the Shannon Index scores richness and abundance, though is not sufficient in assessing overall microbiome differences. Detrended Correspondence Analysis (DCA), a multivariate statistical method, will be applied to detect overall microbiome differences. Adonis methods were used to attribute additional variables' contribution to microbial variance.
Calprotectin (microgram per gram) levels in stool
Calprotectin levels will be analyzed using an ELISA kit.
Metabolomic analysis (microMol per gram) in gastric aspirate, stool, and breast milk
Metabolites as biomarkers of microbial-host metabolism will be identified by nuclear magnetic resonance and mass spectrometry. Levels of vitamins(microMol per gram), polyphenols(microMol per gram), cholesterol (microMol per gram), and short chain fatty acids(microMol per gram) will be measured.
S1000A12 (microgram per gram) in stool
S1000A12 levels will be analyzed using an ELISA kit.
Intraleukin-6 (micrograms per gram) in stool
Intraleukin-6 values will be assessed using multiplex technologies.
Intraleukin-8 (micrograms per gram) in stool
Intraleukin-8 values will be assessed using multiplex technologies.
Intraleukin-10 (micrograms per gram) in stool
Intraleukin-10 values will be assessed using multiplex technologies.
Rates of bronchopulmonary dysplasia (BPD)
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and diagnosis of BPD.
Rates of spontaneous ileal perforation
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and spontaneous ileal perforation
Rates of intraventricular hemorrhage
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and intraventricular hemorrhage
Rates of necrotizing enterocolitis (NEC)
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and intraventricular hemorrhage
Rates of retinopathy of prematurity
Enrolled subjects' medical record will be reviewed to determine the association
Rates of periventricular leukomalacia
Enrolled subjects' medical record will be reviewed to determine the association

Full Information

First Posted
May 3, 2016
Last Updated
April 6, 2020
Sponsor
University of Florida
Collaborators
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Society for Pediatric Dermatology
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1. Study Identification

Unique Protocol Identification Number
NCT02784821
Brief Title
Antibiotic "Dysbiosis" in Preterm Infants
Official Title
Antibiotic Effects on the Developing Microbiome, Metabolome and Morbidities in Preterm Neonates
Study Type
Interventional

2. Study Status

Record Verification Date
April 2020
Overall Recruitment Status
Completed
Study Start Date
January 16, 2017 (Actual)
Primary Completion Date
September 11, 2019 (Actual)
Study Completion Date
September 11, 2019 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
University of Florida
Collaborators
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Society for Pediatric Dermatology

4. Oversight

Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
Prolonged antibiotic use in preterm neonates has significant consequences on the developing intestinal microbiome, metabolome and host response, predisposing the neonate to various major morbidities, including necrotizing enterocolitis (NEC), late-onset sepsis, bronchopulmonary dysplasia (BPD), and mortality. The hypothesis is that early and prolonged antibiotic use in preterm neonates has significant consequences on the developing intestinal microbiome, metabolome and host response, predisposing the neonate to various major morbidities. It is possible that the effect of this widespread antibiotic use outweighs the potential benefits. This study will randomize preterm infants born at less than 33 weeks gestation to either pre-emptive antibiotics or no-pre-emptive antibiotics. The purpose of this research is to evaluate the risks and benefits of current practice to determine optimal levels of antibiotic use that protects the babies from infection with minimal effect on the microbiome and subsequent adverse outcomes related to overuse of antibiotics.
Detailed Description
A majority of preterm very low birthweight (VLBW) infants are exposed to antibiotics. Surveys from large databases in the US show that the rate of culture proven bacteremia in these infants at birth is only between 1-2 percent. Antibiotic use, especially when repeated, induces a perturbation ("dysbiosis") in gut microbiota that may not recover to the basal state. Antibiotic use increases the risk of subsequent disease and adverse outcomes. The dependence of the developing immune system on the intestinal microbiota is supported by emerging evidence from studies in animals demonstrating decreased resistance to subsequent disease with early exposure to antibiotics. A retrospective review of 50,0261 neonates across 127 neonatal intensive care units (NICUs) from California showed a forty-fold variation in NICU antibiotic prescribing practice with similar burdens of proven infection and mortality. A large number of preterm infants are thus subjected to a potentially harmful course of antibiotics that provides no clear benefit. There remains a major gap in our understanding of antibiotic-related intestinal microbial dysbiosis and how this may result in disease. There will be two aims. In the first aim, a prospective, randomized pilot study, will test the effects of pre-emptive postnatal antibiotics on the microbiome, metabolome and inflammatory responses in the neonate during the NICU course. The second aim will assess the effects of pre-emptive postnatal antibiotics on adverse outcomes in the neonate while in the NICU. The hypothesis is that higher antibiotic use will not be associated with decreased early onset sepsis and in fact, will be associated with increased adverse outcomes including retinopathy of prematurity, necrotizing enterocolitis, spontaneous ileal perforation, late onset sepsis, chronic lung disease, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, and mortality.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Enterocolitis, Necrotizing, Bacteremia, Bronchopulmonary Dysplasia, Intraventricular Hemorrhage, Periventricular Leukomalacia, Chronic Lung Disease, Ileal Perforation

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Crossover Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
186 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Antibiotics Control
Arm Type
Other
Arm Description
These neonates have a clinical indication to receive antibiotics, such as maternal chorioamnionitis with fetal tachycardia. The standard of care antibiotics include Ampicillin and Gentamicin or Cefotaxime and as part of standard of care blood tests such as complete blood cell counts, blood cultures, and C-reactive proteins will be performed. Study interventions will include the collection of samples for the following: breast milk, gastric fluid and stool samples for analysis of the microbiome and metabolome.
Arm Title
No Antibiotics Control
Arm Type
Other
Arm Description
These neonates show no signs of respiratory distress(RDS) or have no indications of maternal chorioamnionitis. Antibiotics is not indicated for this group as standard of care. Study interventions will include the collection of samples for the following: breast milk, gastric fluid and stool samples for analysis of the microbiome and metabolome, along with standard of care complete blood counts, blood cultures, and C-reactive proteins.
Arm Title
Randomized to pre-emptive antibiotics
Arm Type
Other
Arm Description
This group will be randomized to receive standard of care antibiotics which include Ampicillin and Gentamicin or Cefotaxime. Standard of care blood tests such as complete blood cell counts, blood cultures, and C-reactive proteins will be performed. Study interventions will include the collection of samples for the following: breast milk, gastric fluid and stool samples for analysis of the microbiome and metabolome.
Arm Title
Randomized to no pre-emptive antibiotics
Arm Type
Other
Arm Description
This group will be randomized not to receive standard of care antibiotics. Study interventions will include the collection of samples for the following: breast milk, gastric fluid and stool samples for analysis of the microbiome and metabolome, along with standard of care complete blood counts, blood cultures, and C-reactive proteins.
Intervention Type
Drug
Intervention Name(s)
Antibiotic
Other Intervention Name(s)
Ampicillin or Gentamicin or Cefotaxime
Intervention Description
Babies that are assigned to antibiotics receive therapy based on the clinical team's discretion.
Intervention Type
Other
Intervention Name(s)
Gastric fluid
Other Intervention Name(s)
Gastric aspirate
Intervention Description
Microbiome, metabolome, and inflammatory mediators will be evaluated using gastric aspirate.
Intervention Type
Other
Intervention Name(s)
Breast milk
Intervention Description
Microbiome, metabolome, and inflammatory mediators will be evaluated using mother's breast milk.
Intervention Type
Other
Intervention Name(s)
Stool samples
Intervention Description
Microbiome, metabolome, and inflammatory mediators will be evaluated using infant's stool.
Intervention Type
Drug
Intervention Name(s)
Antibiotics - pre-emptive
Other Intervention Name(s)
Ampicillin or Gentamicin or Cefotaxime
Intervention Description
Babies that are randomized to antibiotics receive therapy based on the clinical team's discretion.
Primary Outcome Measure Information:
Title
Rates of composite morbidities and mortality, including necrotizing enterocolitis(NEC), late onset sepsis (LOS), bronchopulmonary dysplasia (BPD) and death
Description
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and the components of the composite outcome
Time Frame
Until discharge from the NICU, up to 1 year
Secondary Outcome Measure Information:
Title
Rates of bacteremia
Description
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and the development of bacteremia after the first week of life.
Time Frame
Until discharge from the NICU, up to 1 year
Title
Microbiota 16s ribosomal ribonucleic acid (rRNA) metagenomic sequencing
Description
Pacific BioSciences or Illumina sequencing will be done and the data analyzed using metagenomics Rapid Annotation using Subsystem Technology (MG-RAST).
Time Frame
Until discharge from the NICU, up to 1 year
Title
Microbial diversity analysis
Description
Microbial diversity is assessed using Chao1, Shannon, and ordination methods implemented using a software program called phyloseq package in R.42 Chao1 estimates the species richness for each sample, while the Shannon Index scores richness and abundance, though is not sufficient in assessing overall microbiome differences. Detrended Correspondence Analysis (DCA), a multivariate statistical method, will be applied to detect overall microbiome differences. Adonis methods were used to attribute additional variables' contribution to microbial variance.
Time Frame
Until discharge from the NICU, up to 1 year
Title
Calprotectin (microgram per gram) levels in stool
Description
Calprotectin levels will be analyzed using an ELISA kit.
Time Frame
Until discharge from the NICU, up to 1 year
Title
Metabolomic analysis (microMol per gram) in gastric aspirate, stool, and breast milk
Description
Metabolites as biomarkers of microbial-host metabolism will be identified by nuclear magnetic resonance and mass spectrometry. Levels of vitamins(microMol per gram), polyphenols(microMol per gram), cholesterol (microMol per gram), and short chain fatty acids(microMol per gram) will be measured.
Time Frame
Until discharge from the NICU, up to 1 year
Title
S1000A12 (microgram per gram) in stool
Description
S1000A12 levels will be analyzed using an ELISA kit.
Time Frame
Until discharge from the NICU, up to 1 year
Title
Intraleukin-6 (micrograms per gram) in stool
Description
Intraleukin-6 values will be assessed using multiplex technologies.
Time Frame
Until discharge from the NICU, up to 1 year
Title
Intraleukin-8 (micrograms per gram) in stool
Description
Intraleukin-8 values will be assessed using multiplex technologies.
Time Frame
Until discharge from the NICU, up to 1 year
Title
Intraleukin-10 (micrograms per gram) in stool
Description
Intraleukin-10 values will be assessed using multiplex technologies.
Time Frame
Until discharge from the NICU, up to 1 year
Title
Rates of bronchopulmonary dysplasia (BPD)
Description
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and diagnosis of BPD.
Time Frame
Until discharge from the NICU, up to 1 year
Title
Rates of spontaneous ileal perforation
Description
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and spontaneous ileal perforation
Time Frame
Until discharge from the NICU, up to 1 year
Title
Rates of intraventricular hemorrhage
Description
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and intraventricular hemorrhage
Time Frame
Until discharge from the NICU, up to 1 year
Title
Rates of necrotizing enterocolitis (NEC)
Description
Enrolled subjects' medical record will be reviewed to determine the association between antibiotic administration and intraventricular hemorrhage
Time Frame
Until discharge from the NICU, up to 1 year
Title
Rates of retinopathy of prematurity
Description
Enrolled subjects' medical record will be reviewed to determine the association
Time Frame
Until discharge from the NICU, up to 1 year
Title
Rates of periventricular leukomalacia
Description
Enrolled subjects' medical record will be reviewed to determine the association
Time Frame
Until discharge from the NICU, up to 1 year

10. Eligibility

Sex
All
Minimum Age & Unit of Time
23 Weeks
Maximum Age & Unit of Time
33 Weeks
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: All infants less than 33 weeks gestation. Exclusion Criteria: Infants who are non-viable at birth.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Josef Neu, MD
Organizational Affiliation
University of Florida
Official's Role
Principal Investigator
Facility Information:
Facility Name
University of Florida
City
Gainesville
State/Province
Florida
ZIP/Postal Code
32610
Country
United States

12. IPD Sharing Statement

Plan to Share IPD
No
Citations:
PubMed Identifier
33479274
Citation
Russell JT, Lauren Ruoss J, de la Cruz D, Li N, Bazacliu C, Patton L, McKinley KL, Garrett TJ, Polin RA, Triplett EW, Neu J. Antibiotics and the developing intestinal microbiome, metabolome and inflammatory environment in a randomized trial of preterm infants. Sci Rep. 2021 Jan 21;11(1):1943. doi: 10.1038/s41598-021-80982-6.
Results Reference
derived

Learn more about this trial

Antibiotic "Dysbiosis" in Preterm Infants

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