Sepsis, a life-threatening condition due to a dysregulated response to infection, is the leading cause of global mortality and is frequently driven by tuberculosis (TB) and drug-resistant bacteria in sub-Saharan Africa, particularly among people living with HIV. The prevailing standard of care in the region, ceftriaxone alone, is insufficient as it does not address TB, drug-resistant bacteria, or adrenal insufficiency, which is common in HIV-related sepsis. Therefore, the investigators propose a randomized 2x2 factorial clinical trial to compare 28-day survival from sepsis between study participants who along with a standard of care that includes immediate conventional anti-TB treatment receive 1) hydrocortisone to treat septic shock and 2) rifampin, isoniazid, levofloxacin and linezolid to treat TB and other drug-resistant bacteria in order to deliver important and scalable knowledge that may alter the standard of care for sepsis in HIV endemic settings of sub-Saharan Africa. Improving understanding of the physiology and treatment alternatives for HIV related critical illness globally will have reciprocal benefit for health in the U.S.
Sepsis is defined as life-threatening organ dysfunction due to a dysregulated host response to infection and is the leading cause of global mortality. The World Health Organization has declared sepsis a global priority. Yet, little is known about sepsis in the global South and specifically sub-Saharan Africa where there are an estimated 17 million cases and 3.5 million attributable deaths per year. The majority of these patients are living with human immunodeficiency virus (HIV). The investigators have determined the leading cause of sepsis in this region is tuberculosis (TB) which is responsible for 25-30% of bloodstream infections in septic patients. TB sepsis is associated with 20-50% mortality rates with the majority of deaths occurring within the first 4-5 days of admission. Other causative pathogens include bacteria commonly or intrinsically resistant to third-generation cephalosporins which are the standard antimicrobial treatment for sepsis adopted from the global North. The investigators have also studied anti-TB pharmacokinetics/pharmacodynamics in septic patients and discovered considerably low circulating drug concentrations that are suboptimal for microbial kill. Concurrently, the investigators have also found a high burden of corticosteroid insufficiency in people with critical illness at collaborative study sites in Uganda and Tanzania. HIV and TB, independently and in combination, contribute to adrenal infection and endogenous steroid insufficiency. In further observational study, adults with sepsis at the collaborative study sites treated with corticosteroids have significantly improved survival from septic shock in-line with some, but not all, trials of adjunctive steroids in infection associated critical illness. Therefore, hypotheses are that immediate hydrocortisone administered over 7 days followed by a 7-day taper will improve 28 day mortality compared to the standard of care where corticosteroids are not administered, and that an enhanced antimicrobial regimen for 14 days to target TB and other drug-resistant bacteria of sepsis (rifampin, isoniazid, levofloxacin and linezolid) will improve 28 day mortality compared to the standard of care of immediate conventional anti-TB treatment and ceftriaxone alone. These hypotheses will be tested through a randomized 2x2 factorial clinical trial where participants hospitalized with HIV and sepsis will be randomized to 1) hydrocortisone or the standard care without hydrocortisone, and 2) the enhanced antimicrobial regimen plus ceftriaxone or the standard care with ceftriaxone alone. This randomized 2x2 factorial clinical trial is strongly endorsed by Tanzanian and Ugandan stakeholders, utilizes drugs that are available within national formularies and regional pharmacies, and if successful will be scalable for adults with sepsis in HIV endemic regions of sub-Saharan Africa. Improved understanding of the physiology and treatment alternatives for HIV related critical illness globally will have reciprocal benefit for health in the U.S.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
344
Immediate hydrocortisone at 200 mg IV daily for 7 days and a tapering schedule for an additional 7 days
empiric initiation of the enhanced spectrum antimicrobial therapy regimen (rifampin, isoniazid, linezolid, and levofloxacin) for 14 days plus standard care which includes ceftriaxone for 7 days or diagnosis dependent conventional anti-TB therapy
Sekou Toure Regional Referral Hospital
Mwanza, Tanzania
Kibong'oto Infectious Diseases Hospital
Sanya Juu, Tanzania
Fort Portal Regional Referral Hospital
Fort Portal, Uganda
Mbarara Regional Referral Hospital
Mbarara, Uganda
Mortality
Primary outcome measure
Time frame: 28 days from date of randomization
In-hospital mortality
Mortality
Time frame: from enrollment through hospitalization, an average of 14 days
6-month mortality
Mortality
Time frame: From the date of randomization until death or 180 days from randomization
Time to death
Mortality
Time frame: From date of randomization to death or 180 days from randomization
Incidence of new post-admission shock
New post-admission shock
Time frame: From the time of enrollment through hospital discharge, an average of 14 days
Duration of hospitalization
Duration of hospitalization
Time frame: From the time of randomization until date of hospital discharge up to 180 days, or death if before hospital discharge
Volume of IV fluids received
Volume of IV fluids received
Time frame: From the date of randomization until date of hospital discharge up to 180 days, or date of death if occurring before discharge
Adverse drug events during the 28-day study period
Adverse drug events
Time frame: From date of randomization to 28 days post randomization or date of death if death occurred before 28 days
Time to ambulation
Time to ambulation
Time frame: From date of randomization until the date of first documented ambulation during hospitalization, or date of death from any cause, whichever came first, on average over 14 days, but up to 180 days
Time to temperature normalization
Time to temperature normalization
Time frame: From date of randomization until the date of first documented normal temperature during hospitalization, or date of death from any cause, whichever came first, on average over 14 days, but up to 180 days
Lactate/delta lactate
Lactate concentration change
Time frame: From the date of randomization until the date of hospital discharge or the date of death if death occurred before discharge, on average 14 days
Capillary fill time/delta capillary fill time
Change in capillary fill time
Time frame: From the date of randomization until the date of hospital discharge or the date of death if death occurred before discharge, on average 14 days
Universal Vital Assessment score and delta Universal Vital Assessment score: component number one, heart rate
Calculation of initial Universal Vital Assessment mortality risk score at randomization and 72 hours after randomization: component number one, measure heart rate
Time frame: From the time of randomization to 72 hours after randomization
Universal Vital Assessment mortality risk score at randomization and 72 hours after randomization: component number two, respiratory rate
Calculation of initial Universal Vital Assessment mortality risk score at randomization and 72 hours after randomization: component number two, measure respiratory rate
Time frame: From time to randomization to 72 hours
Calculation of initial Universal Vital Assessment mortality risk score at randomization and 72 hours after randomization: component number three, systolic blood pressure
Calculation of initial Universal Vital Assessment mortality risk score at randomization and 72 hours after randomization: component number three, measure systolic blood pressure
Time frame: From time to randomization to 72 hours
Calculation of initial Universal Vital Assessment mortality risk score at randomization and 72 hours after randomization: component number four, oxygen saturation
Calculation of initial Universal Vital Assessment mortality risk score at randomization and 72 hours after randomization: component number four, measure oxygen saturation
Time frame: From time to randomization to 72 hours
Calculation of initial Universal Vital Assessment mortality risk score at randomization and 72 hours after randomization: component number five, glascow coma scale
Calculation of initial Universal Vital Assessment mortality risk score at randomization and 72 hours after randomization: component number five, record record level of consciousness by glascow come scale
Time frame: From time to randomization to 72 hours
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