Effect of Antimicrobial Therapy on Respiratory Hospitalization or Death in Adults with Idiopathic Pulmonary Fibrosis: The CleanUP-IPF Randomized Clinical Trial

Fernando J. Martinez, Eric Yow, Kevin R. Flaherty, Laurie D. Snyder, Michael T. Durheim, Stephen R. Wisniewski, Frank C. Sciurba, Ganesh Raghu, Maria M. Brooks, Dong Yun Kim, Daniel F. Dilling, Gerard J. Criner, Hyun Kim, Elizabeth A. Belloli, Anoop M. Nambiar, Mary Beth Scholand, Kevin J. Anstrom, Imre Noth, Maneesh Bhargava

Research output: Contribution to journalArticlepeer-review

15 Scopus citations


Importance: Alteration in lung microbes is associated with disease progression in idiopathic pulmonary fibrosis.

Objective: To assess the effect of antimicrobial therapy on clinical outcomes.

Design, Setting, and Participants: Pragmatic, randomized, unblinded clinical trial conducted across 35 US sites. A total of 513 patients older than 40 years were randomized from August 2017 to June 2019 (final follow-up was January 2020).

Interventions: Patients were randomized in a 1:1 allocation ratio to receive antimicrobials (n = 254) or usual care alone (n = 259). Antimicrobials included co-trimoxazole (trimethoprim 160 mg/sulfamethoxazole 800 mg twice daily plus folic acid 5 mg daily, n = 128) or doxycycline (100 mg once daily if body weight <50 kg or 100 mg twice daily if ≥50 kg, n = 126). No placebo was administered in the usual care alone group.

Main Outcomes and Measures: The primary end point was time to first nonelective respiratory hospitalization or all-cause mortality.

Results: Among the 513 patients who were randomized (mean age, 71 years; 23.6% women), all (100%) were included in the analysis. The study was terminated for futility on December 18, 2019. After a mean follow-up time of 13.1 months (median, 12.7 months), a total of 108 primary end point events occurred: 52 events (20.4 events per 100 patient-years [95% CI, 14.8-25.9]) in the usual care plus antimicrobial therapy group and 56 events (18.4 events per 100 patient-years [95% CI, 13.2-23.6]) in the usual care group, with no significant difference between groups (adjusted HR, 1.04 [95% CI, 0.71-1.53; P = .83]. There was no statistically significant interaction between the effect of the prespecified antimicrobial agent (co-trimoxazole vs doxycycline) on the primary end point (adjusted HR, 1.15 [95% CI 0.68-1.95] in the co-trimoxazole group vs 0.82 [95% CI, 0.46-1.47] in the doxycycline group; P = .66). Serious adverse events occurring at 5% or greater among those treated with usual care plus antimicrobials vs usual care alone included respiratory events (16.5% vs 10.0%) and infections (2.8% vs 6.6%); adverse events of special interest included diarrhea (10.2% vs 3.1%) and rash (6.7% vs 0%).

Conclusions and Relevance: Among adults with idiopathic pulmonary fibrosis, the addition of co-trimoxazole or doxycycline to usual care, compared with usual care alone, did not significantly improve time to nonelective respiratory hospitalization or death. These findings do not support treatment with these antibiotics for the underlying disease.

Trial Registration: ClinicalTrials.gov Identifier: NCT02759120.

Original languageEnglish (US)
Pages (from-to)1841-1851
Number of pages11
JournalJAMA - Journal of the American Medical Association
Issue number18
StatePublished - May 11 2021

Bibliographical note

Funding Information:
Ingelheim, Genentech, GlaxoSmithKline, and Medtronic; advisory boards/consultation on COVID-19 related topics for AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Raziel; receiving personal fees for continuing medical education from the Academy for Continuing Healthcare Learning, CME Outfitters, Dartmouth University, Integritas, Integrity Communications, MedScape, Methodist Hospital Brooklyn, Miller Communications, National Association for Continuing Education/Haymarket, PeerView Communications, Physicians Education Resource Program, Projects in Knowledge, UpToDate, Vindico, and WebMD; grants from the National Institutes of Health (NIH); and personal fees for serving as deputy editor of the American Journal of Respiratory and Critical Care Medicine. Dr Durheim reported receiving grants from the National Heart, Lung, and Blood Institute (NHLBI) and personal fees from Boehringer Ingelheim and Roche. Dr Sciurba reported receiving institutional grants from the NIH. Dr Raghu reported receiving institutional grants from the NIH and consulting fees from Boehringer Ingelheim and Roche-Genentech. Dr Brooks reported receiving grants from NIH. Dr Dilling reported receiving grants from University of Pittsburgh Pulmonary Trials Cooperative (PTC), personal fees from the Genentech and Boehringer Ingelheim, grant support from Boehringer Ingelheim, Nitto Denko Corp, Galapagos NV, Gilead Sciences, Bellerophon Pulse Technologies, and Duke Clinical Research Institute. Dr Criner reported receiving grants from Boehringer Ingelheim, personal fees from Boehringer Ingelheim, grants from Galapagos and Patara. Dr Belloli reported receiving grants from the NIH. Dr Nambiar reported receiving grants

Funding Information:
Funding/Support: This work was supported by grants U01HL128964 from the NIH/NHLBI, Three Lakes Foundation, IPF Foundation, and Veracyte Inc.

Funding Information:
from the University of Pittsburgh, the NHLBI, Roche/Genentech, Pulmonary Fibrosis Foundation, Nitto Denko, FibroGen, and Galapagos; and personal fees from Boehringer Ingelheim, Roche/ Genentech, and Veracyte. Dr Scholand reported receiving personal fees from Genentech, Boerhinger Ingelheim, Veracyte, and United Therapeutics. Dr Anstrom reported receiving grants from Merck, Bayer, and the NIH. Dr Noth reported receiving grants from the NIH, Veracyte, and Three Lakes Foundation; personal fees from Boerhinger Ingelheim, Genentech, and Confo and having a patent for TOLLIP in IPF pending. No other disclosures were reported.

Publisher Copyright:
© 2021 American Medical Association. All rights reserved.


  • Aged
  • Anti-Bacterial Agents/adverse effects
  • Doxycycline/adverse effects
  • Female
  • Hospitalization
  • Humans
  • Idiopathic Pulmonary Fibrosis/drug therapy
  • Lung/microbiology
  • Male
  • Middle Aged
  • Respiratory Function Tests
  • Respiratory Tract Infections/prevention & control
  • Treatment Outcome
  • Trimethoprim, Sulfamethoxazole Drug Combination/adverse effects

PubMed: MeSH publication types

  • Randomized Controlled Trial
  • Multicenter Study
  • Pragmatic Clinical Trial
  • Journal Article
  • Research Support, N.I.H., Extramural
  • Comparative Study


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