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Trial registered on ANZCTR

Registration number

ACTRN12616000215426

Ethics application status

Approved

Date submitted

29/01/2016

Date registered

17/02/2016

Date last updated

2/04/2024

Date data sharing statement initially provided

29/03/2019

Type of registration

Prospectively registered

Titles & IDs

Public title

The V-QUIN MDR TRIAL: A randomized controlled trial of six months of daily levofloxacin for the prevention of tuberculosis among household contacts of patients with multi-drug resistant tuberculosis

Scientific title

The V-QUIN MDR TRIAL: A randomized controlled trial of six months of daily levofloxacin for the prevention of tuberculosis among household contacts of patients with multi-drug resistant tuberculosis

Secondary ID [1]

NHMRC APP#1081443

Universal Trial Number (UTN)

U1111-1177-9052

Trial acronym

The V-QUIN MDR Trial

Linked study record

Health condition

Health condition(s) or problem(s) studied:

tuberculosis

tuberculosis, multi-drug resistant

Condition category

Condition code

Infection

Other infectious diseases

Intervention/exposure

Study type

Interventional

Description of intervention(s) / exposure

Six months of daily oral levofloxacin (dosing 3-5.9kg 62.5mg, 6-9.9kg 125mg; 10-15.9kg 250mg; 16-24.9kg 375mg; 25-49.99kg 500mg; 50kg and above 750mg).

Compliance monitoring is based on pill count and self-report
Screening for incident disease is performed for 30 months after enrollment, at 6, 12, 18, 24 and 30 months. Screening includes clinical assessment and chest radiography. Additional telephone-based symptom screening will be performed at 9, 15, 21 and 27 months, with clinical evaluation if symptoms are present (including new cough or sputum production for 2 weeks or more).
No maximum duration of therapy. Patients will continue to receive treatment beyond 180 days, if they have not completed the requisite number of doses by that time.

Intervention code [1]

Treatment: Drugs

Intervention code [2]

Prevention

Intervention code [3]

Early detection / Screening

Comparator / control treatment

Six months of daily oral placebo.
A matching placebo is used that is similar in size, colour and shape to the active drug.

Control group

Placebo

Outcomes

Primary outcome [1]

The incidence ratio, that is, the ratio of the incidence rate of bacteriologically-confirmed TB among subjects in the active levofloxacin group to the incidence rate in the placebo control group.

In adults, aged 15 and above, bacteriologically-confirmed TB is defined as a positive identification of Mycobacterium tuberculosis by culture, Xpert or another PCR-based diagnostic test in a contact with clinical or radiological evidence of disease. In adults, aged 15 and above, a result will be considered positive if: (a) at least one sample of sputum, or other body fluid or tissue is positive by culture, Xpert or another PCR-based diagnostic test; or (b) at least 2 samples of sputum or other body fluid or tissue are positive by smear) * AFB-positive TB alone on a single smear (that is not positive on culture, Xpert or another PCR-based diagnostic test) would not be considered “bacteriologically confirmed”. * If available cultures are contaminated or negative, then two samples that are both AFB-positive will satisfy the definition of “bacteriologically confirmed”. * Extrapulmonary TB will be considered “bacteriologically confirmed” if based upon either: additional investigations seeking microbiological confirmation (e.g. lymph node aspirate, CSF) with either a positive culture, Xpert or another PCR-based diagnostic test; OR two or more samples that are AFB positive on smear. Bacteriologically confirmed TB should be classified as pulmonary, extra-pulmonary or both.

Outcome definitions for children <15 years:
Bacteriologically-confirmed TB is defined as a positive identification of Mycobacterium tuberculosis by culture, Xpert or another PCR-based diagnostic test in a child with clinical or radiological evidence of disease.

A result will be considered positive if: (a) at least one sample of sputum, or other body fluid or tissue is positive by culture, Xpert or another PCR-based diagnostic test; or (b) at least 2 samples of sputum or other body fluid or tissue are positive by smear)

AFB-positive TB alone on a single smear (that is not positive on culture, Xpert or another PCR-based diagnostic test) would not be considered “bacteriologically confirmed”.

If available cultures are contaminated or negative, then two samples that are both AFB-positive will satisfy the definition of “bacteriologically confirmed”.

Extrapulmonary TB will be considered “bacteriologically confirmed” if based upon: either additional investigations seeking microbiological confirmation (e.g. lymph node aspirate, CSF) with either a positive culture Xpert or another PCR-based diagnostic test; OR two or more samples that are AFB positive on smear.

Bacteriologically confirmed TB should be classified as pulmonary, extra-pulmonary or both.

Timepoint [1]

Within 30 months of randomization

Secondary outcome [1]

The incidence ratio of all forms of TB (bacteriologically confirmed or clinically probable) in the active levofloxacin group compared to that of the placebo group.

Outcome definitions for adults aged 15 and over:
The definition of bacteriological confirmation is given above. Probable clinical TB: Known exposure to TB plus “Well-defined” clinical evidence AND supportive radiological or laboratory evidence of pulmonary or extra-pulmonary disease in a contact that is not bacteriologically-confirmed. The End Point Review Panel will reach a conclusion about the diagnosis of clinically probable TB on the basis of the following, in adults: * Well-defined clinical evidence of clinically probable TB would include any TB-related symptoms of over 14 days’ duration that was not improving (e.g. cough, fever, night sweats, lethargy) or sign (documented weight loss, moderate or severe malnutrition, neck swelling or other clinical features of EPTB). * In contacts with no clinical evidence, chest radiography is consistent with intrathoracic disease due to Mycobacterium tuberculosis. In contacts with no clinical evidence, radiological evidence to support probable pulmonary TB would only include marked abnormality on CXR. * AFB-positive alone on smear that is not culture or Xpert positive would be considered as supportive laboratory evidence. * Probable EPTB will be based upon either additional investigations seeking microbiological confirmation (e.g. lymph node aspirate, CSF) or supportive clinical/radiological findings from laboratory investigation or imaging (e.g. pleural aspirate or ascitic tap, X-ray) * Any form of EPTB with supportive evidence (see above) that is not also bacteriologically confirmed would be considered as Clinically Probable TB. Clinical TB should be classified as pulmonary, extra-pulmonary or both.

Outcome definitions for children <15 years:
Probable clinical TB: Known exposure to TB plus “Well-defined” clinical evidence AND supportive radiological or laboratory evidence of pulmonary or extra-pulmonary disease in a child that is not bacteriologically-confirmed.

The diagnosis of clinically probable TB is equivalent to the secondary outcome of “Clinical TB”. The End Point Review Panel will reach a conclusion about the diagnosis of clinically probable TB on the basis of the following:
- Well-defined clinical evidence of clinically probable TB would include any TB-related symptoms of over 14 days’ duration that was not improving (e.g. cough, fever, night sweats, lethargy) or sign (e.g. documented failure to thrive i.e. flattening of weight curve crossing centiles, documented weight loss, moderate or severe malnutrition [Weight-for-height Z score <-2], neck swelling or other clinical features of EPTB).
- In children with no clinical evidence, radiological evidence to support pulmonary TB would only include marked parenchymal abnormality on CXR
- AFB-positive alone on smear that is not culture or Xpert positive would be considered as supportive laboratory evidence.
- Probable EPTB will be based upon either additional investigations seeking microbiological confirmation (e.g. lymph node aspirate, CSF) or supportive clinical/radiological findings from laboratory investigation or imaging (e.g. pleural aspirate or ascitic tap, X-ray
- Any form of EPTB with supportive evidence (see above) that is not also bacteriologically confirmed would be considered as Clinically Probable TB.

Possible TB – Known exposure to TB plus clinical or radiological evidence/abnormality that is not consistent with above definitions AND a decision is made to treat for TB. Possible clinical TB should be classified as pulmonary, extra-pulmonary or both

Timepoint [1]

Within 30 months of randomization

Secondary outcome [2]

The incidence ratio of all forms of TB (bacteriologically confirmed or clinically probable) in the active levofloxacin group compared to that of the placebo group among subjects who completed therapy

The definitions of bacteriologically confirmed and clinically probable TB are given in the previous secondary outcome.

A contact will be defined to have completed the study therapy if they complete 80% or more of the total prescribed doses within a total period of 30 weeks after randomization. This will be confirmed by unused tablet return.

Timepoint [2]

Within 30 months of randomization

Secondary outcome [3]

The incidence ratio of bacteriologically confirmed TB in the active levofloxacin group, compared to that of the placebo group, among contacts of MDR-TB patients with fluoroquinolone susceptible disease.

Bacteriologically confirmed TB is defined above.

Timepoint [3]

Within 30 months of randomization

Secondary outcome [4]

The proportion of participants in each group discontinuing treatment owing to adverse events

This will be assessed by participant self-report, either by telephone or in person.

Timepoint [4]

During treatment with levofloxacin or placebo.

Secondary outcome [5]

The proportion of participants in each group completing six months (180 doses) of preventive therapy

Adherence will be assessed at the end of each month of treatment with pill counts. Standardized questionnaires developed for this study will also be used to assess compliance. Contacts will be considered non-adherent if they fail to complete 80% of the total prescribed doses (i.e. fail to complete 36 doses or more) within 270 days after commencing therapy.

Timepoint [5]

270 days after randomization

Secondary outcome [6]

The ratio of the incidence of grade 3 or 4 adverse events in the active levofloxacin group, compared to that of the placebo group.

These adverse events are classified as follows:
Grade 3 Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; limiting self care activities of daily living. (for example, for QT prolongation, QTc >= 501 ms on at least two separate ECGs)
Grade 4 Life-threatening consequences; urgent intervention indicated. (for example, for QT prolongation QTc >= 501 or >60 ms change from baseline and Torsade de pointes or polymorphic ventricular tachycardia or signs / symptoms of serious arrhythmia).
Grade 5 Death related to the adverse event.

Timepoint [6]

During treatment with levofloxacin or placebo

Secondary outcome [7]

Death from any cause (except for violent (e.g. homicide) or accidental (e.g. motor vehicle accident) causes) among the levofloxacin group compared to placebo

Timepoint [7]

Within 30 months after randomization

Secondary outcome [8]

Cost-effectiveness of therapy, expressed in the total cost per disability adjusted life year (DALY) averted, under programmatic conditions

Timepoint [8]

Within 30 months after randomization

Secondary outcome [9]

The proportion of contacts with incident TB with acquired fluoroquinolone resistance in comparison to bacterial isolates of the index patient, the levofloxacin group compared to the placebo group.

M. tuberculosis isolated from index patients will be archived at central laboratories to enable subsequent molecular comparison with the isolates from contacts. We will study isolates from contacts who develop culture positive TB, at baseline or after treatment, to determine whether acquired drug resistance has developed, based upon concordant phenotypic DST and whether they have matching Mycobacterial Interspersed Repetitive Unit - 24 loci (MIRU-24) patterns. For greater resolution, we will also apply Whole Genome Sequencing to index-contact pairs, with samples to be tested in a facility with appropriate quality assurance, meeting international standards.

Timepoint [9]

Within 30 months after randomization

Secondary outcome [10]

The difference in specific biomarkers (including microRNAs) between treatment initiation and treatment completion for compliant participants allocated to levofloxacin compared to the placebo group;

Biomarkers will be assessed based on a serum assay. Biomarker panels will be derived from published studies, including a microRNA profile. Further work is required to develop the precise biomarker panel.

Timepoint [10]

During treatment with levofloxacin or placebo (no more than 30 months after randomization)

Biomarkers will be measured at baseline, then 6 months post-randomization (at the completion of treatment).

Secondary outcome [11]

The difference in specific biomarkers (including microRNAs) for patients with microbiologically proven TB, compared with enrolled contacts with infection, and enrolled contacts that are uninfected.

Biomarkers will be assessed based on a serum assay. Biomarker panels will be derived from published studies, including a microRNA profile. Further work is required to develop the precise biomarker panel.

Timepoint [11]

At baseline and 6 months

Eligibility

Key inclusion criteria

Eligibility for screening, prior to randomization, include:
1. Any age
2. Living in the same household** as the index patient within the previous 3 months

Eligibility for randomization include:
1. Living in the same household as the index patient within the previous 3 months
2. Any age
3. One of:
(a) Tuberculin skin test positive (a size of 10mm or greater at first reading); OR
(b) Any TST size if known to be HIV positive or severely malnourished; OR
(c) New TST conversion on the second reading

*Note that in the initial period of the study, we enrolled contacts <15 years and conducted periodic screening for disease. However, they were not randomised to receive the intervention. From February 16th 2019, contacts of all ages were eligible randomisation to receive the intervention, following approval by the relevant institutional review boards / ethics committees.

**A household contact is defined as: “A person who shares (or has shared) the same enclosed living space for one or more nights each week, or for frequent or extended time periods during the day with the index case, during the 3 months before the commencement of the current treatment episode.

Minimum age

0 Years

Maximum age

No limit

Sex

Both males and females

Can healthy volunteers participate?

Yes

Key exclusion criteria

Eligibility for participants 15 years and over:

1. A diagnosis of current active TB disease made during initial assessment¶
2. Known to be pregnant*
3. Unable to take oral medication
4. Body weight < 3kg
5. Unwilling or unable to participate in follow-up for 30 months
6. Currently breast feeding**
7. Known allergy to fluoroquinolone antibiotics, or history of severe tendinopathy related to fluoroquinolones
8. Currently taking another medication reported to increase the cardiac QTc interval (e.g. amiodarone, sotalol, disopyramide, quinidine, procainamide, terfenadine).
9. Documented previous treatment for MDR-TB
10. Documented treatment with antibiotics that are active against MDR-TB in the previous month (including fluoroquinolones).
11. Prior severe blistering reaction to tuberculin
12. End stage liver failure (class Child-Pugh C).
Dialysis-dependent chronic kidney disease
13. A baseline liver function test (AST, ALT or ALP) more than 3 times the upper limit of normal
14. Baseline ECG shows the QT segment (corrected for the R-R interval) is >450ms
15. Kidney tests show end stage kidney disease (defined as an EGFR < 20mL/min)
16. The platelet count is < 50x109 cells/L

For children aged <15 years:

1. Body weight < 3kg
2. Current active TB disease
3. Unable to take oral medication
4. Unwilling or unable to participate in follow-up for 30 months
5. Known allergy to fluoroquinolone antibiotics, or history of severe tendinopathy related to fluoroquinolones
6. Currently taking another medication reported to increase the cardiac QTc interval (e.g. amiodarone, sotalol, disopyramide, quinidine, procainamide, terfenadine).
7. Documented previous treatment for MDR-TB
8. Documented treatment with antibiotics that are active against MDR-TB in the previous month (including fluoroquinolones).
9. Prior severe blistering reaction to tuberculin
10. End stage liver failure (class Child-Pugh C).
11. Dialysis-dependent chronic kidney disease
12. A baseline liver function test (AST or ALT) more than 3 times the upper limit of normal
13. Kidney tests show end stage kidney disease (EGFR < 20mL/min)
14. Platelet count < 50x109 cells/L
15. Absence of informed parental consent

Study design

Purpose of the study

Treatment

Allocation to intervention

Randomised controlled trial

Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)

Allocation concealment present.

Allocation will be performed by central randomization, by computer and/or telephone. The holder of the allocation will be located off-site.

Methods used to generate the sequence in which subjects will be randomised (sequence generation)

Permuted block randomization, stratified by province

Masking / blinding

Blinded (masking used)

Who is / are masked / blinded?

The people receiving the treatment/s
The people administering the treatment/s
The people assessing the outcomes
The people analysing the results/data

Intervention assignment

Parallel

Other design features

If another member of the household has already been randomized in the within a 90 day period, then additional household members will also be allocated to that same group. There will be no more than 90 days between the first and last contact that are allocated to the same group.

Phase

Phase 3

Type of endpoint/s

Efficacy

Statistical methods / analysis

Sample size estimate:
The intra-class correlation coefficients are 1.04 at the district level and 1.07 at the level of the household, with 2.1 contacts recruited per patient (data from the ACT2 contact screening study, previously conducted in VIetnam). An average of 21 index patients will be recruited per district (based on reported PMDT data). Hence, the overall design effect is 1.1. The prevalence of LTBI in household contacts of MDR-TB patients is expected to be at least 60%, and the incidence of TB among untreated MDR-TB contacts over a 2-year follow-up period will be 3.0%. We estimate levofloxacin will reduce incidence by 70% in the treatment group, based upon a mid-range estimate of the effectiveness of isoniazid treatment for LTBI in drug-susceptible disease. The prevalence of fluroquinolone resistance among MDR-TB patients in Vietnam was measured in the 4th National Drug Resistance Survey to be 16.7%. Hence we will increase the sample size to allow for a sub-group analysis of those contacts of patients with MDR-TB that is susceptible to fluroquinolones. We will allow for a 10% drop-out rate. We assume alpha = 0.05 and the power to detect superiority is 80%. Hence, we will randomize 2,006 infected contacts

Analytic methods:
Analysis will be by intention to treat. We plan to use a marginal Poisson regression model estimated via a generalised estimating equation (GEE) to test the effect of treatment group allocation on the incidence ratio of TB.

Recruitment

Recruitment status

Completed

Date of first participant enrolment

Anticipated

22/02/2016

Actual

14/03/2016

Date of last participant enrolment

Anticipated

1/08/2019

Actual

2/09/2019

Date of last data collection

Anticipated

1/03/2022

Actual

1/04/2022

Sample size

Target

2006

Accrual to date

Final

2041

Recruitment outside Australia

Country [1]

Viet Nam

State/province [1]

Hanoi, Nam Dinh, Da Nang, Quang Nam, Thanh Hoa, Khanh Hoa, Ho Chi Minh City, Can Tho, Tien Giang, An Giang

Funding & Sponsors

Funding source category [1]

Government body

Name [1]

National Health and Medical Reserach Council

Address [1]

GPO Box 1421 Canberra ACT 2601

Country [1]

Australia

Primary sponsor type

University

Name

University of Sydney

Address

Woolcock Institute of Medical Research
431 Glebe Point Road
Glebe NSW 2037

Country

Australia

Secondary sponsor category [1]

None

Name [1]

N/A

Address [1]

N/A

Country [1]

Other collaborator category [1]

Hospital

Name [1]

Vietnam National Lung Hospital

Address [1]

463 Hoang Hoa Tham, Ba Dinh, Ha Noi

Country [1]

Viet Nam

Ethics approval

Ethics application status

Approved

Ethics committee name [1]

Human Research Ethics Committee, University of Sydney

Ethics committee address [1]

Human Ethics Office
Margaret Telfer Building (K07)
University of Sydney
NSW 2006

Ethics committee country [1]

Australia

Date submitted for ethics approval [1]

07/11/2014

Approval date [1]

17/12/2015

Ethics approval number [1]

2014/929

Ethics committee name [2]

Institutional Review Board of the Vietnam Ministry of Health

Ethics committee address [2]

138A Giang Vo, Ba Dinh, Hanoi

Ethics committee country [2]

Viet Nam

Date submitted for ethics approval [2]

29/06/2015

Approval date [2]

30/09/2015

Ethics approval number [2]

4040/QD-BYT

Summary

Brief summary

This is a randomized controlled trial of a six month course of an oral antibiotic treatment for latent tuberculosis infection (LTBI) in contacts of patients with MDR-TB. It will be conducted in 10 Provinces throughout Vietnam, in a study that will be integrated within the Vietnam National TB Program. The study will compare the incidence of TB, over 30 months follow-up, in participants randomised to six months of oral levofloxacin with the incidence of those randomised to placebo.

Trial website

Trial related presentations / publications

Public notes

Contacts

Principal investigator

Name

Prof Greg Fox

Address

University of Sydney
Rm 5216, Level 2 Medical Foundation Building K25
92-94 Parramatta Road, The University of Sydney, NSW, 2006

Country

Australia

Phone

+61 2 9036 3121

Fax

[email protected]

Contact person for public queries

Name

Greg Fox

Address

University of Sydney
Rm 5216, Level 2 Medical Foundation Building K25
92-94 Parramatta Road, The University of Sydney, NSW, 2006

Country

Australia

Phone

+61 2 9036 3121

Fax

[email protected]

Contact person for scientific queries

Name

Greg Fox

Address

University of Sydney
Rm 5216, Level 2 Medical Foundation Building K25
92-94 Parramatta Road, The University of Sydney, NSW, 2006

Country

Australia

Phone

+61 2 9036 3121

Fax

[email protected]

Data sharing statement

Will individual participant data (IPD) for this trial be available (including data dictionaries)?

No/undecided IPD sharing reason/comment

Undecided.

What supporting documents are/will be available?

Doc. No.	Type	Citation	Link	Email	Other Details	Attachment
1381	Study protocol				This will be included with the manuscript during p... [More Details]

Results publications and other study-related documents

Documents added manually

No documents have been uploaded by study researchers.

Documents added automatically

Source	Title	Year of Publication	DOI
Embase	The paradigm shift to end tuberculosis. Are we ready to assume the changes?.	2017	https://dx.doi.org/10.1080/17476348.2017.1335599
Embase	News on therapeutic management of MDR-tuberculosis: a literature review.	2018	https://dx.doi.org/10.1080/1120009X.2017.1338845
Embase	Tuberculosis: progress and advances in development of new drugs, treatment regimens, and host-directed therapies.	2018	https://dx.doi.org/10.1016/S1473-3099%2818%2930110-5
Embase	Advances in the diagnosis, treatment, and prevention of tuberculosis in children.	2019	https://dx.doi.org/10.1080/17476348.2019.1569518
Embase	Feasibility of identifying household contacts of rifampinand multidrug-resistant tuberculosis cases at high risk of progression to tuberculosis disease.	2020	https://dx.doi.org/10.1093/cid/ciz235
Embase	Preventing tuberculosis in children: A global health emergency.	2020	https://dx.doi.org/10.1016/j.prrv.2020.02.004
Embase	Challenges in recruiting children to a multidrug-resistant TB prevention trial.	2021	https://dx.doi.org/10.5588/ijtld.21.0098
Embase	Concordance of Drug-resistance Profiles between Persons with Drug-resistant Tuberculosis and Their Household Contacts: A Systematic Review and Meta-analysis.	2021	https://dx.doi.org/10.1093/cid/ciaa613
Embase	Tuberculosis: current scenario, drug targets, and future prospects.	2021	https://dx.doi.org/10.1007/s00044-020-02691-5
Embase	Caregiver willingness to give TPT to children living with drugresistant TB patients.	2022	https://dx.doi.org/10.5588/ijtld.21.0760
Embase	Pediatric Tuberculosis Research and Development: Progress, Priorities and Funding Opportunities.	2022	https://dx.doi.org/10.3390/pathogens11020128

N.B. These documents automatically identified may not have been verified by the study sponsor.

Trial Review

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