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E5 Murine Monoclonal Antiendotoxin Antibody in Gram-Negative Sepsis
A Randomized Controlled Trial
Derek C. Angus, MB, ChB, MPH;
Mary C. Birmingham, PharmD;
Robert A. Balk, MD;
Patrick J. Scannon, MD;
David Collins, MA;
James A. Kruse, MD;
Donald R. Graham, MD;
Harakh V. Dedhia, MD;
Scott Homann, MD;
Neil MacIntyre, MD;
for the E5 Study Investigators
JAMA. 2000;283:1723-1730.
Context Knowledge and understanding of gram-negative sepsis have grown over the past 20 years, but the ability to treat severe sepsis successfully has not.
Objective To assess the efficacy and safety of E5 in the treatment of patients with severe gram-negative sepsis.
Design A multicenter, double-blind, randomized, placebo-controlled trial conducted at 136 US medical centers from April 1993 to April 1997, designed with 90% power to detect a 25% relative risk reduction, incorporating 2 planned interim analyses.
Setting Intensive care units at university medical centers, Veterans Affairs medical centers, and community hospitals.
Patients Adults aged 18 years or older, with signs and symptoms consistent with severe sepsis and documented or probable gram-negative infection.
Intervention Patients were assigned to receive 2 doses of either E5, a murine monoclonal antibody directed against endotoxin (n = 550; 2 mg/kg per day by intravenous infusion 24 hours apart) or placebo (n = 552).
Main Outcome Measures The primary end point was mortality at day 14; secondary end points were mortality at day 28, adverse event rates, and 14-day and 28-day mortality in the subgroup without shock at presentation.
Results The trial was stopped after the second interim analysis. A total of 1090 patients received study medication and 915 had gram-negative infection confirmed by culture. There were no statistically significant differences in mortality between the E5 and placebo groups at either day 14 (29.7% vs 31.1%; P = .67) or day 28 (38.5% vs 40.3%; P = .56). Patients presenting without shock had a slightly lower mortality when treated with E5 but the difference was not significant (28.9% vs 33.0% for the E5 and placebo groups, respectively, at day 28; P = .32). There was a similar profile of adverse event rates between E5 and placebo.
Conclusions Despite adequate sample size and high enrollment of patients with confirmed gram-negative sepsis, E5 did not improve short-term survival. Current study rationale and designs should be carefully reviewed before further large-scale studies of patients with sepsis are conducted.
Author Affiliations: Department of Anesthesiology and Critical Care Medicine, Critical Care Medicine Division, and Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pa (Dr Angus); Kaleida Health/Millard Fillmore Hospital and the State University of New York, Buffalo (Dr Birmingham and Mr Collins); Rush-Presbyterian-St Luke's Medical Center, Chicago, Ill (Dr Balk); XOMA Corporation, Berkeley, Calif (Dr Scannon); Detroit Receiving Hospital, Detroit, Mich (Dr Kruse); St John's Hospital-Springfield Clinic, Springfield, Ill (Dr Graham); West Virginia University Health Science Center, Morgantown (Dr Dedhia); Swedish-American Hospital, Rockford, Ill (Dr Homann); and Duke University Medical Center, Durham, NC (Dr MacIntyre).
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