The colonization of potential pathogenic bacteria in lower respiratory tract is thought to be accountable for acute exacerbation in subjects with moderate to severe COPD. However, there is no accepted therapy for patients with COPD to remove the colonized bacteria in lower respiratory tract. Therefore, we plan to perform a multi-center, randomized, controlled trial to study the efficacy and safety of oral probiotics, aerosol inhaled amikacin or combined vaccination to decolonize bacteria in lower respiratory tract and prevent acute exacerbation of COPD.
Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease characterized by incomplete reversible airflow limitation, small airway obstruction and alveolar structural damage. About 3 million patients die from COPD every year around the world. The prevalence of COPD in Chinese people over the age of 40 is as high as 12 % and has risen by 50 % in the past nine years. Acute exacerbation is the leading cause of death in patients with COPD , and accounts for a majority of expenditure of COPD management. The colonization of potential pathogenic bacteria in the lower respiratory tract is an important cause of the acute exacerbation especially in patients with moderate and severe COPD. Some clinical studies show that aerosol inhaled antibiotics is promising in reducing acute exacerbation, but these exploratory studies have some defects so that they can't back up for the clinical application of aerosol inhaled antibiotics. Amikacin, a kind of aminoglycosides, is sensitive to the common pathogens of acute exacerbation of COPD in China. Therefore it is necessary to carry out a clinical trial to verify its efficacy and safety in pathogen decolonization and prevention of acute exacerbation. In addition, owing to bacterial resistance and insufficient antibiotics concentration in lower respiratory tract, developing new antibacterial materials is necessary. Oral probiotics is an another way to regulate the bacterial load and inflammatory response in lower respiratory tract, which has been proven to effectively prevent acute exacerbation in cystic fibrosis and childhood asthma. Likewise, airway bacterial burden and inflammation are two main mechanisms of acute exacerbation in COPD. Hence, considering its convenience and safety of oral probiotics, we perform a trial to make clinical evaluation for it. What's more, influenza and streptococcus pneumoniae vaccines are separately recommended for patients with COPD in the Global Initiative for Chronic Obstructive Pulmonary Disease(GOLD), but there have been no studies on the effects of combined vaccination on bacterial decolonization in lower respiratory tract or on the prevention of acute exacerbation. Effects of these above methods on the decolonization of potential pathogenic bacteria in lower respiratory tract and the inflammatory reaction are not clear. Therefore, we plan to perform a multi-center, randomized, controlled trial to study the efficacy and safety of oral probiotics, aerosol inhaled amikacin or combined vaccination to decolonize bacteria in lower respiratory tract and prevent acute exacerbation of COPD.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
PREVENTION
Masking
NONE
Enrollment
144
Culturelle™ DIGESTIVE HEALTH 30 CT(VCAP)(10 Billion Claim) which consists of 100% Lactobacillus rhamnosus GG, 1 tablet, q.d., for 3 months. Subjects will take conventional therapy at the same time.
0.4g Amikacin sulfate injection + 5ml saline, aerosol inhalation, b.i.d., 5-7 days per month, for 3 months. In order to observe and cope with adverse events timely, subjects will be admitted to the ward during the course of medication. Subjects will take conventional therapy at the same time.
Influenza Vaccine recommended by World Health Organization(WHO) in that year and imported 23-Valent Pneumococcal Polysaccharide Vaccine approved by China Food and Drug Administration(CFDA) are vaccinated at different body sites by professional nurses. The interval between two vaccinations is 3-5 days to avoid the overlap of adverse events. Subjects will take conventional therapy at the same time.
The First Affiliated Hospital of Guangzhou Medical University
Guangzhou, Guangdong, China
Ruijin Hospital, Shanghai Jiao Tong University
Shanghai, Shanghai Municipality, China
Shanghai Zhongshan Hospital
Shanghai, Shanghai Municipality, China
Time to the first COPD exacerbation
COPD exacerbation refers to deterioration of patients' daily symptoms requiring treatment with antibiotics or systemic glucocorticoid therapy. First COPD exacerbations starting between first dose and one day after last follow-up are included.
Time frame: 15 months
Colonization of potential pathogenic bacteria in induced sputum
Induced sputum represents the specimen from lower respiratory tract and should be processed within six hours after collection. Sputum plugs were separated from contaminating saliva by macroscopic examination using sterile forceps. Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis and Pseudomonas aeruginosa which are the top four bacteria involved in acute exacerbation of COPD are defined as potential pathogenic bacteria. Using the plate count method, when the colony number of above four bacteria is over 100 cfu/ml，we define this bacteria as colonized bacteria in lower respiratory tract.
Time frame: Baseline, 3 months
Microbiome in induced sputum
Induced sputum represents the specimen from lower respiratory tract and should be processed within six hours after collection. Sputum plugs were separated from contaminating saliva by macroscopic examination using sterile forceps and weighed. Bacterial genomic DNA was isolated from sputum plugs of the same weight using the specific kits. The 16S bacterial ribosomal RNA genes were Polymerase Chain Reaction (PCR)-amplified with the appropriate controls against reagent contamination. Amplified DNA fragments were sequenced using the specific sequencing platform. Sequencing reads were processed and analyzed by the specific algorithm and software. The composition and diversity of microbiome are represented by major taxonomic groups at both phylum and genus levels. If necessary, Quantitative PCR for 16S rRNA gene will be performed to validate the results of sequencing. By using these methos, we can detect the microbiome's composition and its shift.
Time frame: Baseline, 3 months
Forced Expiratory Volume in 1 Second
Change from baseline. Pulmonary function assessments were performed using centralized spirometry according to international standards. FEV1 was measured after 15 minutes of inhaling salbutamol 400ug.
Time frame: Baseline, 3 months, 15 months
COPD Assessment Test(CAT) Score
The COPD Assessment Test (CAT) is an 8-item uni-dimensional measure of health status impairment in COPD, containing 6 grades from 0 to 5.
Time frame: Baseline, 3 months, 6 months, 9 months, 12 months, 15 months
modified Medical Research Council(mMRC) scale
The modified Medical Research Council scale is a simple and powerful tool to evaluate the breathlessness, containing 5 grades from 0 to 4.
Time frame: Baseline, 3 months, 6 months, 9 months, 12 months, 15 months
serum C-reactive protein(CRP) levels
Serum CRP level is a sensitive marker of the systemic inflammation.
Time frame: Baseline, 3 months
interleukin(IL)-6 in induced sputum
Induced sputum represents the specimen from lower respiratory tract. Sputum supernatant was batch analysed for the cytokines IL-6 using commercial highsensitivity sandwich ELISA kits. Inflammatory factors represent local inflammation levels in lower respiratory tract.
Time frame: Baseline, 3 months
IL-8 in induced sputum
Induced sputum represents the specimen from lower respiratory tract. Sputum supernatant was batch analysed for the cytokines IL-8 using commercial highsensitivity sandwich ELISA kits. Inflammatory factors represent local inflammation levels in lower respiratory tract.
Time frame: Baseline, 3 months
IL-1β in induced sputum
Induced sputum represents the specimen from lower respiratory tract. Sputum supernatant was batch analysed for the cytokines IL-1β using commercial highsensitivity sandwich ELISA kits. Inflammatory factors represent local inflammation levels in lower respiratory tract.
Time frame: Baseline, 3 months
Number of Patients With Adverse Events, Serious Adverse Events, and Death
The overall rate of adverse events reported from initiation to the last time follow-up. Some laboratory examinations, such as blood routine, hepatorenal function and electrocardiogram, are performed twice separately at baseline and completion of intervention(3 months) in order to evaluate the safety of interventions.
Time frame: Baseline, 3 months, 6 months, 9 months, 12 months, 15 months
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