1. International Neonatal Immunotherapy Study (INIS)

2. An international, placebo-controlled, multi-centre randomised trial Aust / NZ Coordinatiing Centre at the NHMRC Clinical Trials Centre, University of Sydney Main INIS Coordinating Centre is at the National Perinatal Epidemiology Unit, Oxford, UK What is INIS?

3. Primary hypothesis that adding non-specific polyclonal intravenous immunoglobulin (IVIG) to standard antibiotic therapy in suspected or proven serious infection of early or late onset reduces death and/or major disability at two years of age

4. BACKGROUND

5. Incidence & mortality Annual incidence 6.6/1000 live births (Isaacs et al. MJA 1995) ~ 25% early onset sepsis ( 48 hrs) ANZNN 2000 Report: 14% of cohort had clinically proven systemic infection, with 15% all-cause mortality & 6% mortality due to infection Sepsis is often undiagnosed, so incidence & sepsis-specific mortality rates may be unreliable

6. (1) Intravenous immunoglobulin for suspected or subsequently proven infection in neonates; Ohlsson A, Lacy JB; Issue 2, 2003 6 studies, N = 318, RR = 0.63 [95% CI 0.40 – 1.00] (2) Intravenous immunoglobulin for treating sepsis & septic shock; Alejandria M, Issue 2, 2003 Adults: 6 studies, N = 251, RR = 0.62 [95% CI 0.49 – 0.79]; Neonates: 5 studies, N=241, RR = 0.70 [95% CI 0.42 – 1.18]; In neonates, IVIG treatment demonstrated a 30% - 37% reduction in all-cause mortality Current evidence that IVIG reduces mortality Cochrane reviews

8. Problems encountered in Cochrane reviews (1) The confidence intervals were wide and the studies included in the analyses were small and not of high methodological quality. Problems identified by the reviewers were lack of allocation concealment, lack of blinding of outcome assessment and high levels of post-randomisation exclusions in some of the trials.

9. Disability in survivors: an unanswered question No comparisons of morbidity or disability in survivors were available in the Cochrane Reviews. Without such data, it may not be ethical to introduce IVIG into routine practice. Problems encountered in Cochrane reviews (2)

10. Cochrane reviewers conclusions Large, multi-centre studies are needed to confirm the effectiveness of polyclonal IVIG in reducing mortality in patients with sepsis. These are particularly indicated for neonatal sepsis, where evidence for benefit is still conflicting The reduced mortality following treatment with IVIG for subsequently proven infection, the imprecise estimate of the effect size, and the borderline statistical significance for the outcome of mortality in neonates with suspected infection justify further research. Researchers should be encouraged to undertake well-designed trials to confirm or refute the effectiveness of IVIG

11. Infection and perinatal brain damage

12. Cerebral Palsy after preterm rupture of membranes In babies born after pPROM and before 32 weeks gestation, cerebral palsy was twice as likely, after adjusting for gestation RR 2.3 [ 1.3 - 4.2 ] If the mother had clinical chorio-amnionitis, cerebral palsy was four times more likely, after adjusting for gestation RR 4.2 [ 1.4 - 12.0 ] (Murphy et al, Lancet 1995)

13. CP after neonatal sepsis Cerebral palsy was four times more likely after neonatal sepsis in preterm infants Population-based case control study in 293 3-5 year olds born before 32 weeks gestation Cohort study in 923 18 month olds who were VLBW infants (Wheater & Rennie, Dev Med Child Neurol 2000) (Murphy et al, BMJ 1997)

14. Brain damage Infection / inflammation is an important proposed pathway in neonatal brain damage Dammann & Leviton, Pediatrics 1999

15. Infection & inflammation may lead to: Release of pro-inflammatory cytokines (in peripheral blood & affected areas of the brain) T-cell activation Release of matrix metallo-proteinases Disruption of blood brain barrier Disruption of oligodendrocyte myelination Cellular apoptosis White matter damage / PVL

16. Evidence that cytokines cause cerebral injury Increased cytokines (e.g. IL-1, IL-6, TNF ): in neonatal blood spots are associated with Cerebral Palsy at 3 yrs of age Nelson et al, Ann Neurol 1998 in amniotic fluid are associated with cerebral white matter lesions, PVL Yoon et al, 1996, 1997 In transgenic mice which produce excessive IL-6, no Blood Brain Barrier forms, and there is widespread axonal degeneration and CNS parenchymal injury Brett et al, 1995

18. Which pathogens have been associated with CP following perinatal infection? A wide range pathogens have been implicated in the pathogenesis of pre- term brain injury and Cerebral Palsy These include Coagulase Negative Staphylocci which were associated with subsequent CP in a preliminary study by Mittendorf et al Lancet 1999

19. IVIG in other conditions Widely used in inflammatory and autoimmune conditions to improve clinical function (e.g. Kawasaki Disease, Idiopathic Thrombocytopenic Purpura, chronic demyelinating inflammatroy polyneuropathy etc.) Multiple Sclerosis: IVIG reduced number and size of inflammatory cerebral lesions, including existing lesions Sorensen et al. Neurology 1998 Beneficial effect on clinical disability (Fazekas et al, Lancet, 1997) and relapses (Clegg et al, Health Tech Assess 2000)

20. Duggan et al, Lancet 2001 36% of babies born before 30 weeks gestation had MRI cerebral lesions on scans done at a median 2 days after birth The risk of cerebral lesions increased after – raised maternal CRP – preterm rupture of membranes Could postnatal IVIG benefit pre-existing cerebral inflammation (as in adult MS)?

22. IVIG: Mechanisms of action IVIG has multiple anti- inflammatory properties & mechanisms of action (indicated by purple arrows on the next slide)

24. Summary Neonatal sepsis causes significant mortality and morbidity Cerebral injury may be caused, in part, by an excessive inflammatory response to bacterial, viral or fungal antigens Immunoglobulin (IgG) has potent anti- inflammatory properties Preterm infants may lack an adequate endogenous reservoir of anti-inflammatory IgG This may partly explain their increased risk of brain damage and cerebral palsy

25. Safety of IVIG Intragam® P (IVIG in Aust & NZ) uses plasma from non-remunerated Australian/NZ donors. 2 specific viral inactivation steps, pasteurisation and low pH incubation. No transmitted infections have ever been recorded using Intragam® P, or its predecessor Intragam®. The risk of transmission of a virus is estimated by CSL as less than 1 in 10 million (which is 100 times safer than a blood transfusion). In trials of prophylactic IVIG involving more than 5000 infants, no serious adverse effects were reported.

26. RESEARCH PLAN

27. Eligibility criteria Proven or suspected serious infection and - less than 1500 g birth weight or - has evidence of infection in blood or CSF or a normally sterile siteor - on respiratory support by ETT and Receiving antibiotics Exclusions: already had IVIG or IVIG considered necessary or contraindicated

28. A pragmatic approach inactivity unresponsiveness poor perfusion prolonged bleeding ileus bowel perforation or definite NEC [ SEVERE SIGNS, HIGH RISK GROUP ] pneumonia white cells < 5000/ l platelets < 50,000/ l CRP > 15 mg/l pathogen in blood or CSF [ MODERATE SIGNS, MEDIUM RISK GROUP ] clinical chorioamnionitis, PROM or maternal CRP > 8 mg/ L very likely to need, or has had, 5 days antibiotics As a guide, serious infection may include any of:

29. What is serious infection ? Sepsis is a systemic inflammatory response of the body to severe infection caused by various micro-organisms such as bacteria, fungi or viruses. … Alejandria, Lansang, Dans, Mantaring. Cochrane Library, Issue 1, 2002 Over 50 clinical and laboratory criteria have been used to describe neonatal sepsis, so a precise definition is not practical.

30. Eligibility Case Scenarios 28 weeks GA, B Wt 980 g, born after pPROM of 48 hrs; Day 1, ventilated, poor response to surfactant, on antibiotics for suspected sepsis Eligible for INIS because of – Suspected neonatal sepsis (after pPROM, which increases the risk of brain injury/CP) – Birthweight <1500 g – Receiving antibiotics

31. 38 weeks GA, B Wt 2700 g, Day 4, Caesarean section for non-progression of labour, fits on postnatal ward, LP yields turbid CSF, latex +ve for pneumococcus, on antibiotics Eligible for INIS because of – evidence of infection in usually sterile body fluid (CSF) Eligibility Case Scenarios

32. 31 weeks GA, B Wt 1450 g, mother had fever >39 C and uterine tenderness, maternal CRP =15 mg/L, antibiotics started before delivery. Day 1: not ventilated, infant pyrexial 38 C, on antibiotics. Eligible for INIS because of – Suspected neonatal sepsis (after clinical chorio- amnionitis, which increases the risk of CP) – Birthweight <1500 g – Receiving antiobiotics Eligibility Case Scenarios

33. 40 weeks GA, B Wt 3800 g, vaginal swab +ve for GBS. Day 1: grunting, on CPAP, FiO2 > 60%, ventilated, poor activity, screened for infection, antibiotics started Eligible for INIS because – Suspected serious infection – Ventilated – Receiving antibiotics Eligibility Case Scenarios

34. 24 weeks GA, 580 g, Day 17: 3 rd episode of suspected sepsis - not recruited to INIS before, ventilated, long line - blood culture growing Staph epidermidis, on vancomycin and cefotaxime Eligible for INIS because of – Proven serious infection (clinical evidence of sepsis with Staph epidermidis, which is associated with increased duration of hospitalisation and morbidity) – Birthweight <1500 g – Receiving antiobiotics Eligibility Case Scenarios

35. 32 weeks GA, no chorio-amnionitis, no pPROM, B Wt 1600 g, in air, day 1, on antibiotics pending results of blood cultures. NOT eligible for INIS because – no evidence of suspected clinical sepsis with potentially serious sequelae – birth weight > 1500 g, no evidence of infection, not ventilated Eligibility Case Scenarios

36. Statistical analyses Intention-to-treat analysis of all babies randomised to IVIG vs placebo Subgroup analyses will stratify by birthweight, gestation, clinical severity, clinical chorioamnionitis, small for gestation, elevated maternal CRP, duration of membrane rupture, type of infection, and type of IVIG.

37. Sample size 5,000 infants will be recruited to INIS This will provide over 90% power (2p = 0.05) to detect a difference from 25% versus 21% in the rate of primary outcome between IVIG & control groups This would give a Number needed to treat (NNT) to prevent one case of death or major disability, of 25 1500 recruited in Australia and New Zealand > 80% power to detect important treatment differences stratified by initial mortality risk

38. Economic evaluation An economic evaluation will be performed in Australia and New Zealand. If hypothesis is confirmed, INIS is likely to be cost-saving

39. PRACTICALITIES

40. Funding & support Funding: UK Medical Research Council New Zealand Health Research Council NHMRC - pending Financial Markets Foundation for Children Telstra Foundation Ian Potter travel grant INIS has the additional support of: Australian Red Cross Blood Service & New Zealand Blood Service (who distribute the IVIG) the Commonwealth (who have given us a free and reserved supply of IVIG for the study in Australia) CSL (who make Intragam® P) NHMRC Clinical Trials Centre

41. Central Coordination INIS Coordinating Centre (A&NZ) NHMRC Clinical Trials Centre University of Sydney Ph: 02 9562 5335 Fax: 02 9565 1863 Email: inis@ctc.usyd.edu.au Project Coordinator: Anne Cust Clinical Trials Research Assistant: Megan Hay

42. Local Coordination Each participating hospital nominates a Principal Investigator and a Research Nurse Coordinator to help locally coordinate INIS The INIS research nurse is funded to work several hours a week on INIS, to help identify eligible babies discuss the study with parents & medical staff complete the data forms and data queries help maintain contact with families help arrange 2 year follow-up appointments All other study costs are covered by INIS

43. Intervention Prepared by pharmacist [Pharmacy play a key role in the team] Intravenous infusion of 500 mg/ kg (8.3 ml/ kg) Intragam P or placebo solution over 4 – 6 hours, repeated after 48 hours Pharmacist primes line, yellow contact mask Double-blind No more IVIG can be given

44. Information Sheet on admission or when eligible If baby becomes eligible, seek parental consent in person or by telephone if necessary Contact pharmacy Caregiver completes Entry Form booklet & administers 1 st infusion Ensure 2 nd infusion is given 48 hrs later Fill in simple Drug Accountability Form and Enrolment Log Recruitment Procedures (1)

45. Fax copy of Entry Form to INIS Coordinating Centre ASAP Local INIS research coordinator completes remaining CRFs, and ensures complete data until discharge home from this or another hospital No further IVIG can be given Recruitment Procedures (2)

46. Serious Adverse Events (SAEs) If a serious adverse event is unexpected, then an SAE form must be completed and sent to the INIS Coordinating Centre (NHMRC Clinical Trials Centre, Uni of Sydney) within 24 hours of identification The Coordinating Centre will ensure that the regulatory authorities are informed The local investigator should inform their own hospitals ethics committee of SAEs The SDMC will evaluate interim data in strict confidence to ensure the safety of patients

47. Outcomes PRIMARY Death or major disability at 2 years corrected for gestational age SECONDARY hospital mortality, chronic lung disease or major cerebral abnormality before hospital discharge, significant positive culture after trial entry, pneumonia, necrotising enterocolitis, duration of respiratory support, mortality before two years, major disability at 2 years, non-major disability at 2 years, length of hospital stay and number of hospital admissions.

48. Follow-up is very important!! Parents receive a Discharge letter (with contact numbers, change of address slip & Reply Paid envelope) & optional letter for their GP Local research coordinator & central INIS Coordinator keep in touch with parents Parent Newsletters, birthday cards, 1 st year questionnaire 2 year follow-up corrected for GA includes parent questionnaire, paediatrician questionnaire, (& Bayley II Scales at many ANZ centres)

49. Conclusion INIS is a simple, pragmatic study that will address an issue of fundamental public health and strategic importance in neonatal care Assessment of neuro-developmental status in survivors is essential if neonatal trials are to contribute fully to evidence-based policy