Efficacy and Safety of E-101 Solution for Preventing Surgical Site Infections After Colorectal Surgery (Triple IN)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT01297959
Recruitment Status : Unknown
Verified September 2015 by Excited States, LLC.
Recruitment status was:  Active, not recruiting
First Posted : February 17, 2011
Last Update Posted : September 17, 2015
Veristat, Inc.
Biotec Services International Ltd
Eurofins Medinet
CBR International Corp.
Information provided by (Responsible Party):
Excited States, LLC

Brief Summary:
This study is intended to determine the efficacy of topical application of E-101 Solution directly into the surgical incisional wound in the prevention of infection of superficial and deep surgical incisional wounds. E-101 Solution is an enzyme-based antiseptic that is being developed for direct application to a surgical incision.

Condition or disease Intervention/treatment Phase
Infections Drug: E-101 Solution 300 GU/ml Drug: Saline solution Phase 3

Detailed Description:
The purpose of this standard-of-care, pivotal Phase 3 study is to evaluate the efficacy and safety of topical E-101 Solution after direct application into the principal surgical incision in the prevention of superficial and deep incisional surgical site infections (SSI) within 30 days after elective colorectal surgery. The study is intended to support a target indication statement of: "E-101 Solution is indicated for the prophylaxis of incisional surgical site infections following elective colorectal surgery". E-101 Solution is comprised of the active ingredients of glucose oxidase (GO) and porcine myeloperoxidase (pMPO) that produce coupled reactions after the addition of glucose substrate. The hypothesis is that E-101 Solution topically applied directly into the principal incision is safe and significantly reduces the incidence of incisional SSI compared to placebo topical application. (The principal surgical incision is ≥ 5cm and < 35 cm used as a hand port, colorectal specimen extraction port, or extracorporeal manipulation port depending on the specific colorectal surgical approach.)

Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 1350 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary Purpose: Prevention
Official Title: Phase 3 Study of the Efficacy and Safety of Topical E-101 Solution to Prevent Incisional Infections Among Colorectal Surgery Patients (Triple IN Study-INhibition of INcisional INfections)
Study Start Date : August 2012
Estimated Primary Completion Date : October 2015
Estimated Study Completion Date : June 2016

Resource links provided by the National Library of Medicine

Drug Information available for: Riboflavin
U.S. FDA Resources

Arm Intervention/treatment
Experimental: E-101 Solution 300 GU/mL Drug: E-101 Solution 300 GU/ml
8 mL of E-101 Solution at a pMPO concentration of 300 GU/ml applied topically twice to surgical wound site (just after incision without penetration of the rectus fascia or linea alba and just prior to skin closure after closure of rectus fascia or linea alba).
Placebo Comparator: Saline solution Drug: Saline solution
8 mL of Placebo topically twice to surgical wound site (just after incision without penetration of the peritoneal fascia and just prior to skin closure).

Primary Outcome Measures :
  1. The incidence of superficial (skin and subcutaneous tissues) and deep (muscle and/or fascia) incisional surgical site infections (SSI) involving the primary open-laparotomy incision. [ Time Frame: 30 days post-surgery ]
    Incisional SSI (both superficial and deep) will be diagnosed by a blinded assessor using a modification of the original SSI definition proposed by the the US Centers for Disease Control (Horan, Andrus and Dudeck. 2008. Am. J. Infect. Cont.)

Secondary Outcome Measures :
  1. Mean CIWS (Clinical Infection Wound Score) [ Time Frame: 30 days post-surgery ]

    Wounds will be assigned a whole integer value on a scale from 0 to 5 based on the severity of signs and symptoms associated with infection (e.g., wound erythema, spontaneous wound dehiscence) by a blinded assessor where a score of 0 is normal post-operative wound appearance and a score of 5 indicates infection of the primary incision involving deep incisional structures manifested by one or more of the following:

    • spontaneous partial or complete wound dehiscence with erythema and/or pain
    • spontaneous purulent drainage
    • a wound abscess
    • clinical or histological evidence of fasciitis or myonecrosis

  2. Proportion of subjects with incidence of incisional SSI, accompanied by findings of purulent drainage, wound abscess, or positive microbial culture from one or more incisional samples [ Time Frame: 30 days post-surgery ]
  3. Proportion of subjects with incidence of superficial and deep incisional SSI [ Time Frame: 14 days post-surgery ]
  4. Quality of life scores based on the EQ-5D-3L questionnaire obtained via interview of the subject by qualified study site personnel [ Time Frame: At Screening, 7, 14, and 30 days post-surgery ]
    This evaluation will only be performed for English-speaking subjects at US sites.

  5. Proportion of subjects re-hospitalized for SSI. [ Time Frame: 30 days post-surgery ]
  6. Proportion of subjects with each wound healing score by a blinded assessor on a standardized quantitative scale (termed Clinical Wound Healing Score [CWHS]) [ Time Frame: 3, 5, 7, 14, and 30 days post-surgery ]

    The points on the CWHS scale are the following:

    • 0 = normal, intact incision without any spontaneous wound dehiscence
    • 1 = spontaneous wound dehiscence that extends < 2 cm along primary incision in the absence of erythema and/or pain
    • 2 = spontaneous wound dehiscence that extends ≥ 2 cm along primary incision in the absence of erythema and/or pain

  7. Wound pain score assessments [ Time Frame: 3, 5, 7, 14, and 30 days post-surgery ]
    Wound pain assessment will be based on a categorical scale ranging from 0 to 10, where 0 is no pain and 10 is unimaginable, unspeakable pain. The worst assessment over all days will be summarized by treatment group whereby the number and percent of subjects whose worst pain assessment is 0, 1, 2, 3...10 will be presented.

  8. Incidence of detectable, induced antibodies to components of E-101 Solution [ Time Frame: Up to 6 months post-surgery ]
    Serum samples collected 14 days and 30 days after surgery will be screened for antibodies to components of E-101 solution as compared to results from pre-treatment samples. For any subject in which there is detectable, induced antibodies by ELISA, the serum samples will be screened for neutralization. Subjects who have detectable induced antibodies 30 days after surgery will be asked to provide an additional sample 3 months after surgery, and again at 6 months after surgery if induced antibodies are still detectable at the 3 month visit

  9. Independent Adjudication Committee Review [ Time Frame: 30 days post-surgery ]
    As a sensitivity analysis, an independent, blinded adjudication committee will be convened to review all cases of SSI with CIWS scores of 1, 2, or 3 that lack positive microbiological findings). The independent adjudication committee will score cases as likely or unlikely SSI, based on review of photographs of the primary incision and on key study data collected prior to the SSI diagnosis.

  10. Incidence of perinuclear anti-neutrophilic cytoplasmic antibody (p-ANCA)-associated vasculitis [ Time Frame: 30 days, 6 months ]
    A subset of 300 subjects (150 subjects from each study arm) at selected study sites will be evaluated for p-ANCA-associated vasculitis. Incidence of p-ANCA-associated vasculitis will be determined by ELISA screening for induced antibodies to human myeloperoxidase, serum anti-nuclear antigen test detected by immunofluorescent microscopy (IFM), serum complement 3 [C3], serum complement 4 [C4], complete blood count, urinalysis (microscopic and chemistry), coagulation tests, serum chemistries, and physical examinations for vasculitis symptoms.

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Ages Eligible for Study:   18 Years and older   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  1. Scheduled to undergo elective colon and/or rectal surgical procedures involving open laparotomy, hand-assisted laparoscopy, and laparoscopic-assisted approaches. The principal incision must have a length of > 5 cm and < 35 cm in length. Eligible surgeries are: left hemicolectomy, right hemicolectomy, transverse colectomy, ileocolic resection, total abdominal colectomy with ileorectal anastomosis, total abdominal proctocolectomy (portion of specimen to be extracted via laparotomy), low anterior resection, sigmoid resection, non-emergent Hartmann procedure, colostomy takedown through laparotomy (not peristomal) incision, ileo-pouch anal anastomosis, and abdominal perineal resection of the rectum.
  2. Able to give informed consent.
  3. Male or female ≥18 years of age.
  4. If female, is non-pregnant (negative pregnancy test result at the Screening/Randomization Visit) and non-lactating.
  5. If female, is either not of childbearing potential (defined as postmenopausal for at least 1 year or surgically sterile [status post bilateral tubal occlusion, bilateral oophorectomy, or hysterectomy]) or practicing 1 of the following methods of birth control and agrees to continue with this regimen over the study surveillance period:

    • Oral, implantable, or injectable contraceptives for 3 consecutive months before the Baseline/Randomization Visit
    • Intrauterine device
    • Double barrier method (condoms, sponge, or diaphragm with spermicidal jellies or cream)
    • Not sexually-active. Agreement to be available for evaluation at the study site for scheduled visits.

Exclusion Criteria:

  1. Hypersensitivity to porcine products.
  2. History of known anti-myeloperoxidase autoantibodies (i.e., pANCA), as well as patients with known idiopathic necrotizing glomerulonephritis and certain systemic vasculitis conditions [e.g., microscopic polyangiitis of small blood vessels, Wegener's granulomatosis, and Churg-Strauss Syndrome]).
  3. Use of microbial sealant (IntegusealTM), any antibiotic-embedded suture, or any antimicrobial-embedded suture to close the principal incision or any suture in the surgical field that has not been formally approved by the relevant local national regulatory authority.
  4. Absolute contraindication to general anesthesia.
  5. Hypersensitivity reactions to steri-strip tapes, medical-surgery tapes, adhesives, or sutures. (Note: If there can be assurances that the subject will not be exposed to these materials that cause hypersensitivity, alternatives will be allowed.)
  6. History of keloid or hypertrophic scarring within or near an incision from a prior surgery.
  7. Body mass index [BMI]: > 50 or < 20 (both due to the extremely high risk of poor wound healing).
  8. ASA score > 3.
  9. Undergoing emergency colorectal surgery such that standard bowel preparation and other standard preoperative precautions and assessments cannot be performed in time before the index-surgery.
  10. The planned index-surgery involves removal or placement of mesh (either synthetic or biological) as part of closure in the principal incision or traversing any part of a pre-existing mesh (either synthetic or biological) in the principal incision.
  11. There are clinical signs of overt infection necessitating systemic antibiotics via oral, intramuscular, or intravenous routes (e.g., infection of the abdominal wall, peritonitis, pneumonia, and sepsis/septic shock) prior to the index-surgery.
  12. Preoperative severe neutropenia (total neutrophil count ≤500 X 109/L). (Note: Testing should be performed at the local laboratory.)
  13. Receiving any oral or intravenous antibiotics within 24 hours prior to the index-surgery. (Note: It is permissible to administer conventional oral prophylactic antibiotics as bowel preparation up to the time of the index- surgical procedure, as well as intravenous or intramuscular prophylactic antibiotics just prior to the index-surgery as per the treating surgeon's standard of care.)
  14. Preoperative evaluation that the intra-abdominal process might preclude full closure of the skin incision due to severe or morbid obesity (i.e., any mechanical reason that would prevent/preclude primary intent wound healing) at the principal incision.
  15. History of major organ transplantation (e.g., lung, liver, or kidney), including bone marrow transplantation, or intent to perform major organ transplant as a concomitant surgery.
  16. History of a complicated laparotomy within 30 days prior to planned index-surgery.
  17. Planning to undergo a second colorectal surgical procedure (e.g., colostomy or ileostomy takedown) or any other general surgery in less than 30 days of index-surgery.
  18. Likely preoperative urinary tract infection, as evident by: i) symptoms of upper urinary tract infection (e.g., fever and/or flank pain) or ii) symptoms of lower urinary tract infection (e.g., urinary frequency, dysuria, urgency, and/or suprapubic pain); accompanied by any one of the following: 1) bacteriuria of ≥104 bacteria/mL urine or 2) positive urine leucocyte esterase or positive nitrite urine dipstick tests. Also exclude any man under age 60 years who has both positive urine nitrite and leucocyte esterase dipstick tests - even if he is asymptomatic (unless he has predisposing factors for urinary tract infection - e.g., spinal cord injury). (Note: Testing should be performed at the local laboratory.)
  19. Undergoing a significant concomitant surgical procedure (e.g., hysterectomy) or any mesh repair (either synthetic or biological mesh) as part of closure. The following concomitant procedures are allowed: appendectomy, cholecystectomy, oophorectomy, removal of Meckel's diverticulum, primary repair of small ventral hernia (i.e., <30 cm2), liver biopsy/wedge resection (but not liver resection).
  20. Patients with a condition (e.g., recurrent urinary tract infections, nail infections, sinusitis, dental infections, vaginitis/vaginosis, or chronic bronchitis) requiring frequent or chronic administration of antimicrobials (received antibiotics/antimicrobials at least twice for ≥ 2 weeks during past 6 months).
  21. Preoperative prothrombin time or INR > 2 x upper limit of normal. (Note: Testing should be performed at the local laboratory.)
  22. Postsurgical life expectancy ≤ 60 days (in the Investigator's or Sponsor's opinion).
  23. Any patient in which the planned surgery would include: i) placement of a stoma in the principal incision; ii) placement of a drain into the supra-peritoneal fascia space that emerges through the principal incision; iii) placement of a drain into the intraperitoneal space that emerges through the principal incision; and iv) supplementation of any of the irrigation fluid with antibiotic or antiseptic drugs.
  24. Patients with severe COPD that are likely to need > 24 hours postoperative ventilator support (e.g., patients on chronic or intermittent supplemental oxygen or an estimated forced expiratory volume in 1 second (FEV1) less than 50% of expected based on bedside spirometry).
  25. If, in the opinion of Investigator, the potential subject would likely be unable to maintain adequate care of the principal incision post-operatively.
  26. Anticipate that patient will not be available for study visits/ procedures or if in the opinion of Investigator there is concern that patient might not comply with study visits/procedures (e.g., due to ongoing illicit drug usage or alcohol abuse).
  27. Lack of willingness to have personal study-related data collected, archived, or transmitted under a blinded condition to regulatory agencies.
  28. Participation within 30 days before the start of this study in any experimental drug or device study; or currently participating in a study in which the administration of investigational drug or device within 60 days is anticipated.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT01297959

  Hide Study Locations
United States, Alabama
University of South Alabama Medical Center
Mobile, Alabama, United States, 36617
United States, California
University of Southern California
Los Angeles, California, United States, 90033
Stanford University Medical Center
Stanford, California, United States, 94305
United States, Florida
Sheridan Clinical Research, Inc.
Sunrise, Florida, United States, 33323
University of South Florida/Tampa General Hospital
Tampa, Florida, United States, 33606
Cleveland Clinic Florida
Weston, Florida, United States, 33331
United States, Illinois
Stoger Hospital of Cook County
Chicago, Illinois, United States, 60612
United States, Indiana
Indiana University
Indianapolis, Indiana, United States, 46202
United States, Kentucky
University of Louisville
Louisville, Kentucky, United States, 40202
United States, Louisiana
Colon & Rectal Surgery Associates
Metairie, Louisiana, United States, 70006
Tulane University Health Sciences Center
New Orleans, Louisiana, United States, 70112
Ochsner Clinic Foundation / Colon and Rectal Surgery
New Orleans, Louisiana, United States, 70121
United States, Massachusetts
Berkshire Medical Center, Inc
Pittsfield, Massachusetts, United States, 01201
United States, Michigan
Henry Ford Hospital
Detriot, Michigan, United States, 48202
United States, Mississippi
Medical IQ
Brandon, Mississippi, United States, 39042
United States, Missouri
Washington University School of Medicine
St. Louis, Missouri, United States, 63110
United States, Nebraska
Colon and Rectal Surgery, Inc.
Omaha, Nebraska, United States, 68114
United States, New Jersey
CentraState Medical Center
Freehold, New Jersey, United States, 07728
Saint Barnabas Medical Center
Livingston, New Jersey, United States, 07039
Meridian Health Jersey Shore University Medical Center
Neptune, New Jersey, United States, 07753
United States, New York
Albany Medical Center
Albany, New York, United States, 12208
Montefiore Medical Center
Bronx, New York, United States, 10467
Mount Sinai School of Medicine
New York, New York, United States, 10029
Stony Brook University Medical Center
Stony Brook, New York, United States, 11794
SUNY Upstate Medical University
Syracuse, New York, United States, 13210
United States, Ohio
The Christ Hospital
Cincinnati, Ohio, United States, 45219
United States, Oregon
Oregon Health Sciences University
Portland, Oregon, United States, 97239
United States, Texas
Baylor Research Institute
Dallas, Texas, United States, 75207
Methodist Hospital
Houston, Texas, United States, 77030
Southwest Surgical Associates, L.L.P.
Houston, Texas, United States, 77074
Methodist Hospital
San Antonio, Texas, United States, 78229
Southwest Surgical Associates, LLP
Sugarland, Texas, United States, 77479
United States, Virginia
University of Virginia Health System
Charlottesville, Virginia, United States, 22908
United States, Washington
University of Washington Medical Center
Seattle, Washington, United States, 98195
Rambam Medical Center
Haifa, Israel
Hadasit Medical Research Services & Development LTD
Jerusalem, Israel
Rabin Medical Center, Beilinson Hospital
Petah Tikva, Israel
The Tel Aviv Sourasky Medical Center
Tel Aviv, Israel
The Chaim Sheba Medical Center
Tel Hashomer, Israel
Sponsors and Collaborators
Excited States, LLC
Veristat, Inc.
Biotec Services International Ltd
Eurofins Medinet
CBR International Corp.
Study Director: Peter O'Hanley, PhD, MD, MPH Excited States, LLC
Study Chair: Robert Martindale, MD, PhD Oregon Health and Science University
Principal Investigator: Michael J Stamos, MD University of California, Irvine
Principal Investigator: Jerrold H Levy, MD Emory Healthcare

Responsible Party: Excited States, LLC Identifier: NCT01297959     History of Changes
Other Study ID Numbers: E-101:PH3:2012:004
First Posted: February 17, 2011    Key Record Dates
Last Update Posted: September 17, 2015
Last Verified: September 2015

Keywords provided by Excited States, LLC:
Surgical Wound Infection
Therapeutic Enzyme System
Singlet Oxygen
Glucose Oxidase
Colorectal surgery
Incisional Surgical Site Infections (SSI)
Anti-infective Agents, Local
Clinical Trial, Phase III

Additional relevant MeSH terms:
Communicable Diseases
Surgical Wound Infection
Wound Infection
Postoperative Complications
Pathologic Processes
Pharmaceutical Solutions
Vitamin B Complex
Growth Substances
Physiological Effects of Drugs
Photosensitizing Agents
Dermatologic Agents