The treatment for MDR-PTB is a complex and long-term undertaking, the content of the present study involves the following aspects.
Sputum will be collected and the M.tb strain will be determined using GeneXpert testing and culture with BD960 system, DST of M.tb stain will performed using the BD960 system. For each patient, M.tb strain identification and DST will be conducted once a week during weeks 0–12, then once per month during months 4–11 (Table 2).
Each patient will undergo chest computed tomography (CT), it will evaluate lesion absorption and cavity closure (Table 2).
The basic demographic information of each subject will be collected using a structured questionnaire, to include age, gender, height, weight, place of birth, residence, level of education, religion, level of income, basic disease characteristics. In addition, the structured questionnaire will be used to collect details of patient lifestyle, such as level of smoking, drinking, history of silicosis, pneumoconiosis, lung infection, contact history with MDR-PTB patients, and so on (Table 2).
Clinical manifestations of each patient will be recorded, including coughing, expectoration, hemoptysis, fever (low fever), fatigue, night sweats, tightness of the chest, chest pain, dyspnea, insomnia, emaciation, loss of appetite, or other symptoms (Table 2).
The short course chemotherapy regimen for MDR-PTB treatment will be consisted of a 6-month intensive treatment period (6MfxAmPtoCsZE) and a 5-month onsolidation phase (5MfxPtoZE). These chemotherapeutic drugs prescribed for each subject for the entire trial. In addition, the MDR-PTB cases with Qi-yin deficiency will be allocated to the treatment or control group at a ratio of 2:1 (treatment group:control group) using a randomization process. The treatment groups will receive chemotherapeutic drugs plus Chinese herbs granules (1 + 3 granules), whereas the control group will receive chemotherapeutic drugs plus Chinese herbs placebo (1 + 3 placebo granules). Meanwhile, MDR-PTB patients with Yin deficiency lung heat syndrome will be allocated randomly to the a treatment or control group at a ratio of 2:1 (treatment group: control group). The treatment group will be treated with chemotherapeutic drugs plus Chinese herbs granules (2 + 4 granules), and the control group will be treated with chemotherapeutic drugs plus Chinese herbs placebo (2 + 4 placebo granules, Table 3).
A drug administrator at each center will have the responsibility for the storage, distribution, recovery, record keeping, and retrieval of the experimental drugs. The chemotherapeutic drugs + Chinese herbs or chemotherapeutic drugs + Chinese herbs placebo will be provided to each subject by enrollment sequence. The grouping allocation of patients will remain unchanged throughout the trial. Drugs will be distributed at each follow-up examination during this study, while any unused drugs will be recovered during subsequent drug allocation.
All supplies of the chemical synthetic drugs and Chinese herbs will be stored at room temperature and protected from light, in a room with limited access, or within a locked cabinet in appropriate environmental conditions. Access to the study medication will be restricted to designated trial personnel. All medication will remain in the original packaging as delivered by the drug suppliers. The storage conditions and expiry date will be supplied with the investigational materials. A monitor will periodically check all supplies of study medication held by each investigator for accountability, and to ensure appropriate conditions of storage of the medication are utilized. At the end of the trial, all unused study medication will be collected by the monitor and returned to the sponsor, unless other arrangements are agreed.
As shown in Table 4, the primary efficacy endpoint is the cure rate, and the secondary efficacy endpoints are time to sputum culture conversion, lesion absorption rate, cavity closure rate and the effect rate of TCM syndrome between treatment group provide with chemotherapeutic drugs + Chinese herbs and control group treated with chemotherapeutic drugs + Chinese herbs placebo in Qi-yin deficiency patients, or in Yin deficiency lung heat syndrome.
Safety will be separately evaluated in terms of AEs (Table 4), clinical laboratory tests, ECG, physical examinations, and vital signs (Additional file 1: Appendix 1) for each trial period (screening stage, therapy process, and follow-up period).
AE is any inappropriate medical occurrence in a patient administered a pharmaceutical product that is not necessarily causally associated with the treatment. An AE can represent any unfavorable or unintended manifestation (including abnormal laboratory finding), symptoms, or disease temporally associated with the use of an investigational medicinal product, whether or not it is related to its administration. All AEs will be followed until they have abated, or until a stable situation has been reached. Depending on the event, follow-up may require additional tests or medical procedures, and/or referral to a general physician or a medical specialist.
Serious adverse event (SAE) is any unfavorable medical occurrence that shows in Table 4. SAEs need to be reported by the end of the study in China, as defined in the protocol.
Serious adverse reaction (SAR) is judged by either the reporting investigator or the sponsor as having a reasonable causal relationship. The expression “reasonable causal relationship” in general is used to indicate that there is evidence or an argument to suggest a causal relationship. Factors to consider when assessing causality of SARs are: (i) the nature of the reaction, (ii) timing of the reaction, and (iii) its relationship to the dose (Additional file 1: Appendix 1).
Discontinuation of study intervention
Participation in the clinical trial will be voluntary, all subjects having the right to suspend their consent from the trial prematurely, at any time and without stating a reason, and without disadvantaging any potential future medical treatment. In rare instances, it may be necessary for a participant to permanently discontinue study intervention (definitive discontinuation or withdrawal). Reasons for definitive discontinuation of the study intervention may include participant request, investigator request, pregnancy, protocol deviation (no longer satisfying all inclusion criteria, or fulfilling one or more of the exclusion criteria).
Note that discontinuation of study intervention does not represent a withdrawal from the study. If trial intervention is definitively discontinued, the participant will remain in the study and be evaluated for safety, immunogenicity, and potential efficacy. Follow-up for any evaluation required at the time of discontinuation will be conducted.
Discontinuation of study intervention, it must be documented on the appropriate CRF and in the medical records, including the participant has discontinued from further administration of study intervention alone, or also from the study procedures, post-treatment study follow-up, and/or future collection of additional information.
Participant withdrawal from the study
A participant may withdraw from this trial at any time at his/her own request. Reasons for discontinuation from the study may include the following: (1) Refusal to attend additional follow-up examinations. (2) Lost to follow-up. (3) Death. (4) Advice to withdraw because of poor compliance, comorbidities, or serious adverse events. (5) Participant request. (6) Investigator request. (7) Protocol deviation. (8) Patients who withdraw on their own due to poor curative effect, adverse reactions, or other reasons. (9) After allocation to a particular group, it is determined that some other drugs are required for treatment.
Participants should notify the investigator in writing of their decision to withdraw consent from future follow-up at the earliest opportunity. Withdrawal of consent should be explained in detail in the medical records by the investigator, and whether withdrawal is only from further receipt of study intervention or also from study procedures and/or post-treatment study follow-up, to be entered on the appropriate page of the CRF.
Lost to follow-up
A participant will be considered lost to follow-up if he or she repeatedly fails to return for scheduled visits and cannot be contacted by the study site. The following actions will be taken if a participant fails to attend a required study visit. The site will attempt to contact the participant and reschedule the missed visit as soon as possible and counsel the participant on the importance of maintaining the assigned visit schedule and ascertain whether or not the participant wishes to and/or should continue in the study.
Prior to a participant being deemed lost to follow-up, the investigator or researcher will make every effort to regain contact with the participant (if possible). The site coordinator will make at least 3 telephone calls and, if necessary, a certified letter to the participant’s last known mailing address, or a locally equivalent method, to prevent loss to follow-up. These contact attempts will be documented in the participant’s medical records.
If the participant continues to be unreachable, he/she will be considered to have withdrawn from the study.
Criteria for subjects’ rejection
Subjects fulfilling one or more of the following criteria will be rejected for the trial and the reasons will be recorded in detail. Their CRF will be maintained for examination purposes: (1) Cases not conforming to the inclusion criteria. (2) Cases conforming to the exclusion criteria. (3) Cases have received the course of standard chemotherapy regimen for less than 3 months. (4) Cases without any recorded test results. (5) Actual drug was not within the range of the planned dose (80–120%), although the study was completed. (6) Cases in which efficacy cannot be evaluated due to the use of a prohibited drug. 7) Cases in which the course of standard chemotherapy was less than 3 months. (8) Cases consume Chinese herbs during the trial.
Collection of samples
Sputum will be collected once per week during weeks 0–12, and once per month during months 4–11. When collecting sputum, patients will be asked to spit out any water in their mouth and take a deep breath prior to coughing up sputum into the collection vessel. Sputum will be induced prior to collection by asking patients to rinse their mouth with water, and then using an ultrasonic atomizer to spray 7 ml of 3% hypertonic saline over 15 min after which patients will attempt to cough up sputum from deep within their lungs. Qualified sputum specimens should be purulent and cheese or mucus-like, preferably with a volume of 3–5 ml. The container for collecting the sputum specimens will be an international, universal screw cap sputum container marked with the patient’s name, identification number, inspection items, sputum specimen serial number, and date of production. The sputum will be submitted for inspection within 24 h.
Venous blood and urine
Venous blood and morning urine sample will be collected at the screening visit time, once a week during weeks 0–12, then once a month during months 4–11. A proportion of them will be analyzed by routine laboratory testing and the remainder frozen at − 80 °C for future study.
Ziehl–Neelsen method to find M.tb strain
Smears for M.tb strain will be performed by Ziehl–Neelsen staining using an Acid-Fast Stain Kit (Cat. G1170. Beijing Solarbio Science & Technology Co., Ltd, Beijing, China). M.tb strain (H37Rv, ATCC 27294; or H37Ra, ATCC 21577) and Escherichia coli (ATCC25922) will be used as quality control.
M.tb strain culture and DST
The sputum specimens from each subject will be digested and decontaminated using an N-acetyl-l-cysteine-sodium hydroxide method. DST will be performed at the clinical laboratories. The final concentration of each drug in the culture medium will be defined by the M.tb strain growth indicator tube operating procedure guidelines provided by Becton Dickinson and Company.
At the specified time points, ECGs (supine, following at least 5 min rest) will be recorded by an ECG provider. All ECGs will be reviewed by a cardiologist.
Samples will be collected to measure the prothrombin time, hematocrit, hemoglobin levels, and platelet, red blood cell (RBC), white blood cell (WBC), and differential WBC counts (neutrophils, lymphocytes, monocytes, eosinophils, basophils). In addition, total protein, alkaline phosphatase (ALP), AST, ALT, lactate dehydrogenase (LDH), total cholesterol, triglycerides, direct bilirubin, indirect bilirubin, total bilirubin, blood urea nitrogen (BUN), uric acid, creatinine phosphokinase (CPK), cardiac troponin I, electrolytes (sodium, potassium, phosphate, chloride, and chloride, calcium), glucose, pancreatic amylase, lipase, human serum albumin, and trypsin-like immunoreactivity will be assessed. Gastrin and pepsinogen will also be measured for gastrointestinal evaluation (Additional file 1: Appendix 1).
A midstream urine sample will be provided for levels of protein, glucose, occult blood, ketones, bilirubin, urobilinogen, nitrite, and specific gravity, the results of which will be documented in the source documents. If abnormal, microscopic examination for WBCs, RBCs, epithelial cells, crystals, bacteria, or casts will be conducted.
Data management and monitoring
Data safety monitoring board (DSMB)
The trial will be monitored by an independent DSMB to ensure data safety, and an independent data monitoring committee (DMC) will also be established for this trial. DMC will include at least one statistician, one TB expert and one methodology specialist. DMC will meet annually to review all collected data and may meet more frequently if required after analysis of the available data. The DMC will advise the trial management committee and the independent trial steering committee on the safety of the trial. All unexpected SAEs will be reported to the trial management committee and the trial sponsors by facsimile within 24 h of their occurrence, or learning of the occurrence, by local investigators. All data regarding AEs will be made available to the DMC for review.
Electronic data management system
An electronic database will be established to manage trial data. (1) Design electronic case report form (eCRF): the data manager will construct an eCRF specific for this research project and medical records. (2) Authority allocation: the sponsor, monitors and inspectors, the data manager will create accounts and grant the appropriate permissions to access the electronic clinical data management system (eCDM). In instance, researchers in each center will only see content appropriate for that center and only have the right to modify the data, whereas the sponsors will be limited to viewing from all centers. The monitors and inspectors will be able to read the case histories without having permission to modify the data, but they can add comments or questions. (3) Data entry: Clinical investigators or data entry officers designated by the investigator will input the data from the study records into eCRFs in a timely and accurate manner. (4) Data query and questions: Monitors will inspect data using the eCDM. If errors are evident, they can raise queries online at any time, to which researchers will provide answers online, and modify any incorrect data. (5) Data locking and exporting: After each subject has completed particular tests and the data has been reviewed by the monitor, the data manager will lock data. The data manager will import the study data into a designated database after all data has been entered, then provide it to statisticians for data analysis.
Full analysis set (FAS): Data consisting of all eligible cases. Baseline data and demographic characteristics will be compared. Where the main efficacy indicators are absent, previous results will be carried forward according to intention to treat (ITT) analysis. Missing values of the secondary efficacy indicators will not be date-carried-forward or compared, but analyzed using data actually present within the FAS.
Per protocol set (PPS): The set of cases satisfying the inclusion criteria, not excluded by the exclusion criteria, and completed the treatment regimen, that is, the analysis of cases that correctly has undergone the test regimen with good compliance, and completed all CRF requirements (PP analysis). Per protocol analysis will be used mainly for principal efficacy indicators.
Security data set (SS): This represents patients that have received at least one treatment, with actual data on security indicators recorded. Missing security values will not be carried forward. The incidence of adverse reactions within a SS represents the denominator for case numbers.
The analysis will encompass all randomized patients using ITT, except for those who fail to respond to prednisolone following randomization. Exclusion of these patients will not result in bias as: (1) these dropouts will have occurred prior to commencement of randomized treatment, and (2) clinicians will be unaware of the treatment assigned to each patient. It is anticipated that rates of missing data will be low, and there will be no need for imputation.
For the baseline data of MDR-PTB cases with Qi-yin deficiency syndrome, the continuous values (age, height, weight, BMI) will be compared across the treatment and control groups using a student’s t-test (t value) or a Wilcoxon rank-sum test (Z value). Categorical values (gender, occupation, contacting MDR-PTB patients, etc.) will be compared between two groups using Chi-square test (χ2 value). Meantime, the same analysis process and method will be performed between two groups in MDR-TB patients with Yin deficiency lung heat syndrome.
For the primary efficacy endpoint, the rate difference (RD) for cure rate between chemotherapeutic drugs + Chinese herbs group and chemotherapeutic drugs + Chinese herbs placebo group will be calculated in MDR-PTB cases with Qi-yin deficiency syndrome. Meantime, the point estimation values and 95% confidence intervals (CIs) of RD will be reported. In addition, the same analysis process and method will be conducted between two groups in MDR-PTB patients with Yin deficiency lung heat syndrome.
For the secondary efficacy endpoints, the RDs for lesion absorption rate, cavity change rate and effect rate of the TCM syndrome between two groups will be calculated in MDR-PTB cases with Qi-yin deficiency syndrome, with which the point estimation values and 95% CIs values will be reported. Meantime, the median difference of time to sputum culture conversion between two groups will be compared using Kaplan–Meier method (Log-rank, Breslow, Tarone tests). In addition, the same analysis process and method will be carried out between two groups in MDR-PTB patients with Yin deficiency lung heat syndrome.
For the safety endpoints, which are all binary variables (abnormal liver function, electrocardiographic abnormality, abnormal creatinine, etc., Additional file 1: Appendix 1), statistical description (percentage and rate) will be conducted for the MDR-PTB patients with Qi-yin deficiency syndrome and Yin deficiency lung heat syndrome, respectively.