Evaluation of Safety and Dosing of a Vitamin C Bundle for Sepsis Treatment in Africa (REVISTA-DOSE)

Evaluation of Pharmacokinetics, Safety and Feasibility for Administration of Two Doses of Intravenous Vitamin C Combined With Vitamin B1 for the Management of Adult Patients Admitted With Sepsis to Kiruddu National Referral Hospital

Open-label phase 2a Randomized Controlled Trial (RCT) assessing the pharmacokinetics of two different doses of intravenous vitamin C given alongside vitamin B1 in adult medical patients with sepsis and hypotension.

Sepsis is a life-threatening infection which, due to a dysregulated host response to infection, is responsible for more than 11 million deaths annually, a large percentage of which occur in sub-Saharan Africa (sSA). Emerging research shows promising benefits in treating sepsis patients with "metabolic resuscitation" using combinations of hydrocortisone, intravenous (IV) ascorbic acid (vitamin C) and IV thiamine (vitamin B1), alone or in combination. Studies are currently underway in the USA, Europe, Asia, and South America to understand whether combinations of these medicines or the medicines individually can improve outcomes for patients with sepsis. Although none of these studies are being conducted in sSA, the medicines comprising these metabolic 'bundles' are inexpensive, readily available and relatively safe to administer. It is critical that similar studies are conducted in sSA to evaluate whether or not these inexpensive medicines (or a combination of them) are efficacious for improved survival among patients with sepsis. If these studies prove that these medicines can improve survival from sepsis, there is a large potential to save many lives. Through the Preparation for Randomised Evaluation of a VItamin C bundle for Sepsis Treatment in Africa (REVISTA-Prep) studies, the investigators intend to conduct preliminary research in Uganda to help define parameters for a future RCT aimed at identifying the optimal vitamin C and vitamin B1 combination for improving survival from sepsis among adults in sSA, where resources are constrained, intensive care units are rare and issues like poverty, malnutrition and HIV are common. The study described in this protocol (i.e., REVISTA-DOSE) aims to establish the optimal vitamin C dosing strategy for the future REVISTA-RCT (assessing the efficacy of variations of a treatment bundle comprising vitamin C/B1 and/or hydrocortisone for reducing mortality among adult patients with sepsis in Africa).

intravenous vitamin C (1.5 grams) every 6 hours for 16 doses in combination with intravenous vitamin B1 (200 mg) every 12 hours

Intravenous vitamin C (3 grams) every 6 hours for 16 doses in combination with intravenous vitamin B1 (200 mg) every 12 hours

Vitamin C (ascor), infused intravenously in 50 mls sodium chloride (NaCl) over 30 minutes every 6 hours for 16 doses

Vitamin C plasma concentrations will be measured during the intervention period using high-performance liquid chromatography (HPLC) with ultraviolet (UV) analysis and compared to baseline (pre-intervention) concentrations

Acute hemolysis is defined as: hemoglobin drop of at least 2.5 g/dl within 24 hours of a study drug; OR reticulocyte count >2 times upper limit of normal at clinical site lab; AND at least two of the following: i. haptoglobin < lower limit of normal; ii. indirect (unconjugated) bilirubin >2 times upper limit of normal; iii. lactate dehydrogenase (LDH) >2 times upper limit of normal

Increasing procalcitonin levels may be an indicator of increased severity of bacterial infection or sepsis. PCT-c calculated using the following formula: initial PCT minus PCT at 0 and 24 and 72 hours, divided by the initial PCT multiplied by 100.

Duration of hypotension assessed by systolic and mean arterial pressures during 4-day administration of vitamin C (in combination with vitamin B1)

Lower blood pressures are associated with worsening shock and poor organ perfusion. Non invasive blood pressure readings will be recorded.

qSOFA score is a 3 point measurement of sepsis severity made up of systolic blood pressure under 100 mmHg, Glasgow Coma Scale (GCS) score <15 and respiratory rate >22. Scores increase with severity from 0-3.

The UVA score includes points for temperature, heart and respiratory rates, systolic blood pressure, oxygen saturation, GCS score and HIV serostatus. Patients are scored from zero to 13 with increasing severity

MEWS is a physiologic scoring system for bedside assessment of patients. Patients are scored from 0-14 with increasing severity according to systolic blood pressure, heart rate (HR), respiratory rate (RR), temperature and the 'alert, verbal, pain, unresponsive' (AVPU) score

Walking independently is defined by being able to stand independently and walk at least 10 steps without assistance

Number of vitamin B1 deficient participants alive at hospital discharge (or day 7 if still an inpatient)

number of days of hospitalization during which the participant does not require supplemental oxygen for hypoxia and/or respiratory distress

Vitamin C plasma concentrations will be measured after the intervention period (at 28 days post enrolment) using HPLC with UV analysis and compared to baseline (pre-intervention) concentrations

Inclusion Criteria: Adult (≥18 years old) patients presenting to the emergency department of Kiruddu National Referral Hospital (KNRH) with: suspected infection [(any of): temperature >38 degrees Celsius or <36 degrees Celsius or (in the past seven days) fevers, rigors, night sweats or antibiotic use]; AND systolic blood pressure (SBP) <90 mmHg Evidence of a personally signed and dated informed consent document indicating that the subject (or a legal representative) has been informed of all pertinent aspects of the study. Subjects who are willing and able to comply with scheduled visits, treatment plan, laboratory tests and other study procedures. Exclusion Criteria: Pregnant or known active breast feeding Non-severe, localized, uncomplicated infection (e.g., cellulitis with only local symptoms) which is apparent on clinical examination Severe bleeding or hemorrhagic shock Hypotension likely secondary to a cause other than sepsis or sepsis-induced cardiac insufficiency Detainee or prisoner Admission to a surgical or obstetric/gynecological ward Emergency surgery required Previously recruited to the REVISTA-DOSE study History of end stage renal disease requiring dialysis Current symptomatic renal stones or or a previous diagnosis of primary hyperoxaluria or oxalate nephropathy History of allergic reactions to vitamin C or vitamin B1 Use of vitamin C at a dose greater than 1 g (oral or intravenous) within 24 hours of screening Chronic disease/illness that, in the opinion of the site investigator, has a lifespan of less than 30 days unrelated to current sepsis diagnosis (e.g., advanced malignancy or neurodegenerative disease). Previous or current enrolment in a trial in which co-enrolment is not allowed