OnCo
ideasIdea

Protect the gut flora of patients about to start immunotherapy

Antibiotics given in the weeks before immunotherapy are linked to much worse results. A simple stewardship rule could preserve benefit at no cost.

Multiple cohort studies and meta-analyses report substantially worse survival in patients receiving broad-spectrum antibiotics within roughly 30 days before checkpoint blockade. Causality is uncertain because antibiotic use marks infection and frailty. A stewardship intervention — narrow-spectrum choice, shortest effective duration, deferral of non-urgent prophylaxis, and where necessary delaying checkpoint start — is testable and cheap either way.

Hypothesis
A protocolised antibiotic stewardship bundle before checkpoint therapy improves 12-month survival compared with usual prescribing, which would establish that at least part of the observed association is causal and modifiable.
Rationale
The association is large and consistent across tumour types, and antibiotic prescribing is highly modifiable. If the effect is confounding rather than causation, the trial establishes that cheaply and stops a growing body of over-interpretation.
What would test it
A cluster-randomised stewardship trial across oncology units, with antibiotic exposure metrics as process outcomes and survival as the clinical endpoint, plus a microbiome substudy.
Maturity
early clinical
Who has to act
clinic
Cost to try
Small (under $1M)
Years to first evidence
3
Bottlenecks it attacks

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