Inhalation of Liposomal Amphotericin B to Prevent Invasive Aspergillosis

• SAFETY: Discontinuation for >1week due to intolerance
  
• EFFICACY: Proven/probable invasive pulmonary aspergillosis
  

• SAFETY STUDY:
  
• A probably or definitely related AE of the respiratory tract (CTC grade > 2)
  
• Any probably or definitely related AE by type and severity (CTC grade > 2)
  
• Requirement of pre-medication to tolerate nebulization of the study drug
  
• Spirometric changes after inhalation
  
• EFFICACY STUDY:
  
• Proven, probable or possible invasive pulmonary aspergillosis
  
• A confirmed positive serum galactomannan concentration of 0.5 ng/ml or more
  
• The use of systemic antifungal drugs (days) during the neutropenic episodes
  
• The number of days of fever of unknown origin during neutropenia
  
• Mortality due to a pulmonary fungal infection
  

The morbidity, mortality and costs of invasive pulmonary aspergillosis (IPA) in neutropenic patients are high. An effective intervention to prevent IPA would therefore be welcome. The incidence of IPA in neutropenic hematology patients in our institution was recently estimated to be 5-10%. Currently, only HEPA filtration is routinely used for the prevention of IPA. In 1988, Schmitt et al. showed a significant delayed mortality in rat model of IPA when rats were treated with aerosolized conventional amphotericin-B (amB) two days before infection (1). Conventional amB may interfere with surfactant function in the lungs. In contrast, liposomal amphotericin-B contains phospholipids that are structurally related to surfactant and inhibits natural surfactant function only slightly. Furthermore, in rats, mean concentrations of AmB in lungs were 3.7 times higher at day one and almost 6 times higher at day seven after a single dose treatment with aerosolized liposomal amB when compared with conventional AmB (2). Only one non-placebo controlled randomized clinical trial evaluated the prophylactic use of inhalation therapy with conventional amB for the prevention of IPA and a non-significant 43% reduction was observed (3). We postulate that the weekly inhalation of liposomal AmB in neutropenic hematology patients can prevent IPA.

In this randomised placebo controlled clinical trial we compare the safety and efficacy of the administration of nebulized liposomal AmB (2x/week) with placebo for the prevention of IPA in haematological patients with an expected duration of neutropenia of >10d. To demonstrate a reduction in incidence of invasive pulmonary aspergillosis from 7% to 1%, a total of 170 neutropenic episodes in each arm will be included (power 80%, two-tailed alfa=0.05). The primary efficacy endpoint is the cumulative percentage of patients developing a proven or probable IPA. Per protocol serum galactomannan levels are monitored 2x/week and a HR-CT of the lungs will be performed for unexplained fever (>5d) unresponsive to broad-spectrum antibiotic therapy. EORTC/MSG criteria are used for diagnosis of IPA. The primary safety endpoint is a premature discontinuation of the study drug for >1week due to intolerance.