Randomized, Embedded, Multifactorial Adaptive Platform Trial for Community- Acquired Pneumonia

Conditions

• Community-acquired Pneumonia, Influenza, COVID-19

Eligibility Criteria

Sex

ALL

Age

18 Years - N/A

Healthy Volunteers

Not accepted

Interventions

• Ceftriaxone — DRUG
  The duration and dose of empiric antibiotics will be determined by the treating clinician and local guidelines or practice.
• Moxifloxacin or Levofloxacin — DRUG
  The duration and dose of empiric antibiotics will be determined by the treating clinician and local guidelines or practice.
• Piperacillin-tazobactam — DRUG
  The duration and dose of empiric antibiotics will be determined by the treating clinician and local guidelines or practice.
• Ceftaroline — DRUG
  The duration and dose of empiric antibiotics will be determined by the treating clinician and local guidelines or practice. Note: this intervention is now closed.
• Amoxicillin-clavulanate — DRUG
  The duration and dose of empiric antibiotics will be determined by the treating clinician and local guidelines or practice.
• Standard course macrolide — DRUG
  Standard course of macrolide therapy, discontinued between study day 3 and the end of study day 5. The dosing of and route of administration is not protocolised, the following guidance is provided: * Initial IV administration of a macrolide is strongly preferred * The preferred IV macrolide is azithromycin, but IV clarithromycin may be substituted. * The preferred enteral macrolide is azithromycin, but enteral clarithromycin or roxithromycin may be substituted.
• Extended course macrolide — DRUG
  Extended course of macrolide therapy discontinued at the end of study day 14 or hospital discharge (whichever occurs first). The dosing of and route of administration is not protocolised, the following guidance is provided: * Initial IV administration of a macrolide is strongly preferred * The preferred IV macrolide is azithromycin, but IV clarithromycin may be substituted. * The preferred enteral macrolide is azithromycin, but enteral clarithromycin or roxithromycin may be substituted.
• No systemic corticosteroid — OTHER
  Patients are not to receive any systemic corticosteroids, including hydrocortisone, to study day 28 or hospital discharge (whichever occurs first).
• Fixed-duration Hydrocortisone — DRUG
  50mg of intravenous hydrocortisone will be administered every 6 hours for up to 7 days. Note: this intervention is now closed.
• Shock-dependent hydrocortisone — DRUG
  50mg IV hydrocortisone every 6 hours while the patient is in septic shock
• Fixed-duration higher dose Hydrocortisone — DRUG
  100mg of intravenous hydrocortisone will be administered every 6 hours for up to 7 days. Note: this intervention was only available to patients with suspected or proven COVID-19 and is now closed.
• No antiviral agent for influenza — OTHER
  No antiviral agent intended to be active against influenza infection is to be administered
• Five-days oseltamivir — DRUG
  Oseltamivir administered enterally twice daily for 5 days or until hospital discharge (whichever occurs first)
• Ten-days oseltamivir — DRUG
  Oseltamivir administered enterally twice daily for 10 days or until hospital discharge (whichever occurs first)
• No antiviral agent for COVID-19 — OTHER
  No antiviral agent intended to be active against SARS-CoV-2 infection is to be administered
• Lopinavir / Ritonavir — DRUG
  Lopinavir/ritonavir 400/100mg administered enterally, or 5ml 80/20mg per mL solution suspension via gastric tube, every 12 hours. Administered for a minimum of 5 days, including if discharged from ICU prior to end of study day 5. For patients discharged from ICU between study day 6 and study day 14, lopinavir/ritonavir is ceased at ICU discharge. Lopinavir/ritonavir is ceased at the end of study day 14 if the patient remains in ICU. Note: this intervention is now closed.
• Hydroxychloroquine — DRUG
  Loading dose of 800mg hydroxychloroquine administered enterally every 6 hours until 2 doses have been administered. Subsequently, 400mg hydroxychloroquine will be administered enterally every 12 hours for 12 doses or ICU discharge (whichever occurs first). Note: this intervention is now closed.
• Hydroxychloroquine + lopinavir/ritonavir — DRUG
  Lopinavir/ritonavir 400/100mg administered enterally, or 5ml 80/20mg per mL solution suspension via gastric tube, every 12 hours. Administered for a minimum of 5 days, including if discharged from ICU prior to end of study day 5. For patients discharged from ICU between study day 6 and study day 14, lopinavir/ritonavir is ceased at ICU discharge. Lopinavir/ritonavir is ceased at the end of study day 14 if the patient remains in ICU. Loading dose of 800mg hydroxychloroquine administered enterally every 6 hours until 2 doses have been administered. Subsequently, 400mg hydroxychloroquine will be administered enterally every 12 hours for 12 doses or ICU discharge (whichever occurs first). Note: this intervention is now closed.
• Ivermectin — DRUG
  Ivermectin administered enterally at a dose of 0.2 mg/kg once daily with a maximum daily dose of 24mg/day. Note: this intervention is now closed.
• No immune modulation for COVID-19 — OTHER
  No immune modulating agent intended to be active against COVID-19 is to be administered. Note: this intervention is now closed.
• Interferon beta-1a — DRUG
  IFN-β1a 10 μg will be administered as an intravenous bolus injection via a central or peripheral line. IFN-β1a will be administered once daily for 6 days or until ICU discharge, whichever occurs first. Note: this intervention is now closed.
• Anakinra — DRUG
  A loading dose of 300mg anakinra will be administered as a bolus via central or peripheral line. This is followed by maintenance doses of 100mg of anakinra administered every 6 hours. In patients with renal impairment, anakinra will be administered on alternate days. Note: this intervention is now closed.
• Tocilizumab — DRUG
  Tocilizumab will be administered as a single dose of 8mg/kg estimated or measured body weight, with a maximum total dose of 800mg. Tocilizumab will be administered as an IV infusion via central or peripheral line over a one-hour period. Note: this intervention is now closed.
• Sarilumab — DRUG
  Sarilumab will be administered as a single dose of 400mg, via IV infusion through peripheral or central line over a one-hour period. Note: this intervention is now closed.
• Local standard venous thromboprophylaxis — DRUG
  Standard venous thromboprophylaxis that complies with local guidelines or usual practice will be administered for 14 days following randomisation or until hospital discharge, whichever occurs first. Note: this intervention is now closed.
• Therapeutic dose anticoagulation — DRUG
  Patients will be administered either low molecular weight heparin (LMWH) or unfractionated heparin (UFH) to achieve systemic anticoagulation. Either agent may be used and the same patient may be switched between UFH and LMWH at the discretion of the treating clinician. Note: this intervention is now closed.
• Conventional low dose thromboprophylaxis — DRUG
  Low dose thromboprophylaxis will be administered for 14 days following randomisation or until hospital discharge, whichever occurs first. Dosing is outlined in the relevant protocol documents for this domain.
• Intermediate dose thromboprophylaxis — DRUG
  Intermediate dose thromboprophylaxis will be administered for 14 days following randomisation or until hospital discharge, whichever occurs first. Dosing is outlined in the relevant protocol documents for this domain.
• Continuation of therapeutic dose anticoagulation — DRUG
  Patients already receiving therapeutic dose anticoagulation at the time of randomisation to this intervention will be administered either unfractionated heparin by IV infusion or low-molecular weight heparin to achieve systemic anticoagulation according to local practice for acute VTE treatment for 14 days following randomisation or until hospital discharge, whichever occurs first. Note: this intervention is now closed.
• No immunoglobulin — OTHER
  No immunoglobulin intended to be active against SARS-CoV-2 infection is to be administered.
• Convalescent plasma — BIOLOGICAL
  Patients will receive at least one and no more than two units of ABO compatible convalescent plasma within 48 hours of randomisation.
• Delayed administration of convalescent plasma — BIOLOGICAL
  Note: this intervention is now closed.
• No vitamin C — OTHER
  No high dose intravenous vitamin C is to be administered Note: this intervention is now closed.
• Vitamin C — DRUG
  Intravenous Vitamin C 50mg/kg administered every 6 hours for 16 doses Note: this intervention is now closed.
• No antiplatelet — OTHER
  No antiplatelet agent or NSAID to be administered. Note: this intervention is now closed.
• Aspirin — DRUG
  Aspirin administered at either 75mg or 100mg once per day for 14 days or until hospital discharge, whichever occurs first. Note: this intervention is now closed.
• P2Y12 inhibitor — DRUG
  Site-selected P2Y12 inhibitor: * Clopidogrel: administered 75 mg once per day for 14 days or until hospital discharge, whichever occurs first. * Prasugrel: If patient is aged less than 75 years and measured or estimated weight if 60kg or more, and initial loading dose of prasugrel 60 mg will be administered, followed by maintenance dose of 10 mg per day. * Ticagrelor: administered enterally at 60mg twice daily for 14 days or until hospital discharge, whichever occurs first. Note: this intervention is now closed.
• No simvastatin — OTHER
  No simvastatin intended to be active against COVID-19 is to be administered Note: this intervention is now closed.
• Simvastatin — DRUG
  Simvastatin 80mg administered once daily via enteral route, while the patient remains in hospital up to 28 days after randomisation Note: this intervention is now closed.
• Eritoran — DRUG
  Eritoran initiated with a 26.24 mg loading dose (6.56 mg/h IV for 4 hours), followed by a second 13.12 mg loading dose (6.56 mg/h IV for 2 hours) at 12 hours after initiation. Patients will then receive twenty-six 6.56 mg maintenance doses (3.28 mg/h IV for 2 hours) every 12 hours thereafter (total of 14 days). Dosing will be stopped if the patient is discharged from hospital Note: this intervention is now closed.
• Apremilast — DRUG
  Apremilast administered 30mg twice daily for 14 days or until hospital discharge, whichever occurs first. Note: this intervention is now closed.
• Clinician-preferred mechanical ventilation strategy — PROCEDURE
  Clinician-preferred ventilation strategy, including mode of ventilation and all ventilatory parameters
• Protocolised mechanical ventilation strategy — PROCEDURE
  Invasive mechanical ventilation strategy delivered as outlined in relevant protocol documents for this domain.
• No renin-angiotensin system inhibitor — OTHER
  No RAS inhibitor (i.e. no ACEi or ARB) is to be administered up to the end of study day 10. Note: this intervention is now closed.
• Angiotensin converting enzyme inhibitor — DRUG
  Site-preferred ACEi agent administered as directed by the treating clinician for 10 days or until hospital discharge, whichever occurs first. Note: this intervention is now closed.
• Angiotensin Receptor Blockers — DRUG
  Site-preferred ARB agent administered as directed by the treating clinician for 10 days or until hospital discharge, whichever occurs first. Note: this intervention is now closed.
• ARB + DMX-200 — DRUG
  Site-preferred ARB agent administered in combination with DMX-200 for 10 days or until hospital discharge, whichever occurs first. ARB administered as directed by the treating clinician. DMX-200 administered enterally at a dose of 120mg twice daily. Note: this intervention is now closed.
• No cysteamine — OTHER
  No cysteamine to be administered until the end of study day 10 or hospital discharge, whichever occurs first. Note: this intervention is now closed.
• Cysteamine — DRUG
  Cysteamine administered every 8 hours at a dose of 5 mg/kg estimated or measured body weight (maximum dose of 500mg), for ten days or until ICU discharge, whichever occurs first. Note: this intervention is now closed.
• Fixed-duration dexamethasone — DRUG
  6 mg of IV or enteral dexamethasone will be administered daily for up to 10 days while in hospital.
• Baloxavir Marboxil — DRUG
  Baloxavir marboxil administered on days 1 and 4 post-randomisation.
• Five-days oseltamivir + baloxavir marboxil — DRUG
  Oseltamivir administered enterally twice daily for 5 days or until hospital discharge (whichever occurs first), in addition to baloxavir marboxil administered on days 1 and 4 post-randomisation.
• Ten-days oseltamivir + baloxavir marboxil — DRUG
  Oseltamivir administered enterally twice daily for 10 days or until hospital discharge (whichever occurs first), in addition to baloxavir marboxil administered on days 1 and 4 post-randomisation.
• No endothelial modulator — OTHER
  No endothelial modulator (imatinib or another tyrosine kinase inhibitor targeting the same pathway as imatinib) is to be administered.
• Imatinib — DRUG
  Enteral imatinib will be administered as a single 800mg loading dose (study day 1) followed by 400mg daily until study day 14 or discharge.
• No Immune Modulator for Influenza — OTHER
  No immune modulating agent intended to be active against influenza is to be administered.
• Tocilizumab — DRUG
  Tocilizumab will be administered as a single dose of 8mg/kg estimated or measured body weight, with a maximum total dose of 800mg. In children weighing less than 30kg, tocilizumab dose will be 12mg/kg. Tocilizumab will be administered as an IV infusion via central or peripheral line over a one-hour period.
• Baricitinib — DRUG
  Baricitinib will be administered at a dose that is determined by age and renal function, for up to 10 days or hospital discharge (whichever occurs first).
• No antiviral agent for COVID-19 — OTHER
  No antiviral agent intended to be active against SARS-CoV-2 infection is to be administered
• Nirmatrelvir/ritonavir — DRUG
  Nirmatrelvir-ritonavir will be administered at a dose that is dependent on renal function, for five days.
• Remdesivir — DRUG
  Remdesivir is administered at 200 mg on day one followed by 100 mg daily for a further four doses (i.e., for five doses in total) or until hospital discharge, whichever occurs first.
• Nirmatrelvir/ritonavir + remdesivir — DRUG
  Nirmatrelvir-ritonavir will be administered at a dose that is dependent on renal function, for five days. Remdesivir is administered at 200 mg on day one followed by 100 mg daily for a further four doses (i.e., for five doses in total) or until hospital discharge, whichever occurs first.

Study Details

REMAP-CAP is a randomised, embedded, multifactorial, adaptive platform trial for community-acquired pneumonia. The purpose of this study is to evaluate the effect of a range of interventions to improve outcome of patients admitted to intensive care with community-acquired pneumonia. In addition, REMAP-CAP provides and adaptive research platform for evaluation of multiple treatment modalities in the event of a respiratory pandemic such as COVID-19. REMAP-COVID is a sub-platform of REMAP-CAP that evaluates treatments specific to COVID-19 in the United States of America.

Key Dates

Start date

Apr 11, 2016

Status verified

Jul 2024

Primary completion

Feb 28, 2026

Completion

Feb 29, 2028

Study Design

Enrollment

20,000 participants (estimated)

Allocation

RANDOMIZED

Intervention model

FACTORIAL

Primary purpose

TREATMENT

Arms

• Other: Antibiotic Domain
  Patients with community-acquired pneumonia admitted to participating intensive care units and requiring empiric antibiotic therapy will be randomised one of five antibiotic interventions. Note: the ceftaroline + macrolide intervention has been closed to recruitment.
• Other: Macrolide Duration Domain
  Patients with community-acquired pneumonia admitted to participating intensive care units who have been allocated to a beta-lactam antibiotic intervention in the Antibiotic Domain will be randomised to either a standard course or extended course of macrolide therapy
• Other: Corticosteroid Domain
  Patients with community acquired pneumonia (CAP) admitted to participating hospitals will be randomised to a steroid use strategy. Note: this domain is now closed to patients with suspected or proven COVID-19. It remains open to patients with CAP without COVID-19. Note: the fixed-course hydrocortisone has been closed to recruitment
• Other: Influenza Antiviral Domain
  Patients with community-acquired pneumonia admitted to participating hospitals with microbiological testing confirmed influenza infection will be randomised to one of six interventions.
• Other: COVID-19 Antiviral Domain
  Patients admitted to participating hospitals with suspected or microbiological testing confirmed COVID-19 will be randomised to no ivermectin or ivermectin. Note: an earlier version of this domain evaluated lopinavir-ritonavir, hydroxychloroquine, and combination lopinavir-ritonavir and hydroxychloroquine against a 'no antiviral' control. This domain is now closed.
• Other: COVID-19 Immune Modulation Domain
  Patients admitted to participating hospitals with suspected or microbiological testing confirmed COVID-19 will be randomised to one of up to five interventions. Note: this domain is now closed.
• Other: Anticoagulation Domain
  Patients admitted to participating intensive care units with suspected or microbiological testing confirmed COVID-19 will be randomised to an anticoagulation strategy. Note: A previous version of this domain evaluated local standard venous thromboprophylaxis against therapeutic dose anticoagulation. This domain is now closed.
• Other: Immunoglobulin Domain
  Immunosuppressed patients admitted to participating hospitals with microbiological testing confirmed COVID-19 will be randomised to receive no immunoglobulin for COVID-19, or to receive high-titre convalescent plasma. Note: an earlier version of this domain was not restricted to immunosuppressed patients.
• Other: Vitamin C Domain
  Patients admitted to participating hospitals with community-acquired pneumonia will be randomised to receive no vitamin C, or vitamin C. Note: this domain is now closed.
• Other: Simvastatin Domain
  Patients admitted to participating hospitals with suspected or microbiological testing confirmed COVID-19 will be randomised to receive no simvastatin, or simvastatin. Note: this domain is now closed.
• Other: Antiplatelet Domain
  Patients admitted to participating hospitals with suspected or microbiological testing confirmed COVID-19 will be randomised to receive no antiplatelet, aspirin, or site-preferred P2Y12 inhibitor. Note: this domain is now closed.
• Other: Mechanical Ventilation Domain
  Patients with community-acquired pneumonia admitted to participating intensive care units who are intubated and receiving invasive mechanical ventilation will be randomised to protocolised mechanical ventilation strategy, or clinician-preferred mechanical ventilation strategy
• Other: COVID-19 Immune Modulation (2) Domain
  Patients admitted to participating hospitals with microbiological testing confirmed COVID-19 will be randomised to receive one of three interventions. Note: this domain is now closed.
• Other: ACE2 RAS Domain
  Patients admitted to participating hospitals with suspected or microbiological testing confirmed COVID-19 will be randomised to one of up to five renin-angiotensin system blockade strategies. Note: this domain is now closed.
• Other: Cysteamine Domain
  Patients admitted to participating hospitals with severe community-acquired pneumonia, including patients with suspected or proven influenza or COVID-19, will be randomised to receive no cysteamine, or cysteamine. Note: this domain is now closed.
• Other: Endothelial Domain
  Patients admitted to participating hospitals with severe community-acquired pneumonia, including patients with suspected or proven influenza or COVID-19, will be randomised to receive no endothelial modulator or enteral imatinib.
• Other: Influenza Immune Modulation
  Patients with community-acquired pneumonia admitted to participating intensive care units with microbiological testing confirmed influenza infection will be randomised to one of three interventions.
• Other: COVID-19 Antiviral (II) Domain
  Patients admitted to participating hospitals with microbiological testing confirmed COVID-19 will be randomised to one of up to four interventions.

Primary Outcome Measure

All-cause mortality [ Time Frame: Day 90 ]

Central Contacts

• Cameron Green, MSc
  [email protected]
• Svenja Peters, MSc
  [email protected]

Locations (11)

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