A Multi-center, Randomized, Open-label, Non Inferiority Trial to Evaluate the Efficacy and Safety of a Single, Oral Dose of Zoliflodacin Compared to a Combination of a Single Intramuscular Dose of Ceftriaxone and a Single Oral Dose of Azithromycin in the Treatment of Patients With Uncomplicated Gonorrhoea
Phase: PHASE3
Conditions: Gonorrhea
Sponsor: Global Antibiotics Research and Development Partnership

Protocol number STI_Zoli001
Zoliflodacin
Protocol version 5.0 of 12 July 2023
Confidential 
Page 1 of 74
A MULTI-CENTER, RANDOMIZED, OPEN-LABEL, NON-INFERIORITY 
TRIAL TO EVALUATE THE EFFICACY AND SAFETY OF A SINGLE, ORAL 
DOSE OF ZOLIFLODACIN COMPARED TO A COMBINATION OF A 
SINGLE INTRAMUSCULAR DOSE OF CEFTRIAXONE AND A SINGLE 
ORAL DOSE OF AZITHROMYCIN IN THE TREATMENT OF PATIENTS 
WITH UNCOMPLICATED GONORRHOEA
Clinical Trial Protocol
Short title
Zoliflodacin in uncomplicated gonorrhoea
Name of products
Zoliflodacin, ceftriaxone and azithromycin
Drug Class
Antibiotic
Phase
Phase III
Indication
Uncomplicated gonorrhoea
Trial Protocol Number
STI_Zoli001 
EudraCT
2019-000990-22
IND number
139,105
Sponsor
GARDP, Chemin Camille-Vidart, 15, 1202 
Geneva, Switzerland; 
Phone: +41 22 555 19 90
Protocol chair
Prof Edward Hook, University of Alabama at 
Birmingham, United States of America
Clinical Trial Protocol Version / Date
Version 5.0 of 12 July 2023
Clinical Trial Protocol Template 
Version/Date
Version 1.2 of 2 June 2014
Protocol Amendment Number / Date
Amendment 4 / 12 July 2023
The information contained in this document is confidential. It is to be used by investigators, potential 
investigators, consultants, or applicable independent ethics committees. It is understood that this information 
will not be disclosed to others without written authorisation from GARDP, except where required by applicable 
local laws

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 2 of 74 
 
CLINICAL TRIAL PROTOCOL SIGNATURE PAGE 
 
STI Project  Lead 
 
Signature 
 
 
  
 
 
 
 Date of Signature 
(MM/DD/YYYY) 
Name  
 
Pierre Daram 
Title 
 
Project Lead 
Institution 
 
Global Antibiotics Research and Development Partnership (GARDP)  
Address 
 
Chemin Camille-Vidart, 15, 1202 Geneva, Switzerland 
 
GARDP STI Medical Lead  
 
Signature 
 
  
 
 
 Date of Signature 
(MM/DD/YYYY) 
Name  
Alison Luckey 
Title 
Senior Medical Lead 
Institution 
Global Antibiotics Research and Development Partnership (GARDP)  
Address 
Chemin Camille-Vidart, 15, 1202 Geneva, Switzerland 
 
Protocol Chair 
 
Signature 
 
  
 
 
 Date of Signature 
(MM/DD/YYYY) 
Name  
Edward Hook 
Title 
Emeritus Professor of Infectious Disease 
Departments of Medicine 
Institution 
University of Alabama at Birmingham 
Address 
240 Zeigler Research Building, 703 19th St. South, Birmingham, AL 35294-
0006, USA 
 
 
 
 
 
 
 
 

			
	





Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 3 of 74 
 
Scientific Advisory Panel 
People listed in the table below contributed to the initial trial design and protocol v1.0 
writing.  
 
Name 
Affiliation 
Teodora Wi 
Department of Reproductive Health and Research, World Health 
Organization (WHO) 
Carolyn Deal 
National Institute of Allergy and Infectious Diseases, Washington, USA 
David Lewis 
Western Sydney Sexual Health Center, Sydney, Australia 
Sinead Delany 
Wits Reproductive Health and HIV Institute, University of the 
Witwatersrand, Johannesburg, South Africa 
Magnus Unemo 
WHO Collaborating Centre for Gonorrhoea and other sexually 
transmitted infections (STIs) Örebro University Hospital, Sweden  
Suba Srinivasan 
GARDP, Geneva, Switzerland, (formerly Entasis Therapeutics, 
Waltham, USA) 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 4 of 74 
 
INVESTIGATOR SIGNATURE PAGE 
I have read this protocol and agree that it contains all necessary details for carrying out this 
trial. I will conduct the trial as outlined herein and in compliance with GCP/GCLP, the principles 
outlined in the Declaration of Helsinki, all applicable regulatory requirements and local 
regulations. I will complete the trial within the time designated. 
I will provide copies of the protocol and all pertinent information to all individuals responsible 
to me who assist in the conduct of this trial. I will discuss this material with them to ensure 
they are fully informed regarding the investigational product and the conduct of the trial. 
I will use only the informed consent form approved by the sponsor or its representative and 
will fulfill all responsibilities for submitting pertinent information to the Institutional Review 
Board/Independent Ethics Committee (IRB/IEC) responsible for this trial if required by national 
law. 
I agree that the sponsor or its representatives shall have access to any source documents from 
which case report form information may have been generated. 
 
Principal investigator at each trial site 
 
Investigator 
signature 
 
  
 
 
 Date of Signature 
(DD/mmm/YY) 
Name  
 
Title 
 
Institution 
 
Address 
 
 
 
 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 5 of 74 
 
PROTOCOL REVISIONS 
 
Version / 
Date 
Changes 
Sections 
impacted 
V 1.0 / 8 April 
2019 
Original version 
 
V2.0 / 9 
August 2019 
 
 
Addition of methylene blue test as possible NG diagnostic test in inclusion 
criterion #3  
Summary, 4.1 
Clarification on barrier contraception required during participation  in the 
study only 
Summary, 4.1 
Update of exclusion criterion #22 as per SmPC of new source of 
ceftriaxone 
Summary, 4.2 
Exclusion criterion #28 reworded into « previous randomisation in this 
clinical trial » to allow for re-screening 
Summary, 4.2 
Clarification of treatment of participants diagnosed a posteriori as 
infected with CT at baseline 
3.1 
Correction of stratification made on sex at birth 
3.3 
Collection of full date of birth 
5.1, 5.2.1 
Clarifications on clinical assessment of gonorrhoea 
5.1, 5.2.1, 5.2.4, 
5.2.5 
Removal of use of participant diary card 
5.1, 5.2.1, 5.2.4, 
5.2.5, 8.6 
Clarification of collection of microbiological samples 
5.1, 5.2.1, 5.2.5, 
7.4 
Collection of date/time of last meal taken prior to dosing for all 
participants 
5.2.1 
Reference to the MOP for assessment of clinical cure 
5.2.4 
Reference to pharmacy manual for study treatment storage and 
preparation 
6.5, 6.6 
Clarification of physical examination of pharynx required 
7.1 
Correction of total blood volume collected in accordance with ICF 
7.2.1 
Clarification on collection of ART last dose for PK participants 
7.3 
Correction of allowed PK sample processing time 
7.3 
Infant follow up by paediatrician made optional 
8.4 
Renaming of clinical ITT population into clinical cure population  
11.2.2 
Removal of sexual behaviour questionnaire from protocol as provided to 
regulatory authorities and ethics committees as a standalone document 
for review 
5.1, 5.2.1, 5.2.3, 
5.2.4, 5.2.5, 
Appendices 
Correction of typographical errors and abbreviations 
All 
V3.0 / 22 
November 
2019 
Head of Clinical Affairs (A. Janin) replaced by Study Medical Lead (M. 
Heep) 
Protocol 
Signature Page 
Removal of CYP3A4 inhibitors group in PK sub-study 
Summary,2 7.3 
Addition of justification for CYP3A4 exclusion 
3.2.4 
Inclusion age of participants lowered to 12 years old  
Summary, 2, 
4.1, 7.3 
Clarification on methylene blue /gentian violet stain 
Summary, 4.1 
Addition of exclusion criterion for CYP3A4 inhibitors 
Summary,4.2 
Correction of unblinding procedure in case of SUSAR 
3.4 
Clarification on HIV testing as per local practice 
5.1, 5.2.1 
Clarification of capture of last food intake prior to dosing 
5.1, 5.2.1 
Introduction of flexibility on timing of Visit 3 
5.1, 5.2.3 
Correction of assessments to be performed at early withdrawal visits 
5.1, 5.2.6 
Clarification of handling of unscheduled visits 
5.3 
Update of total number of subjects exposed to zoliflodacin 
6.1.2 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 6 of 74 
 
Version / 
Date 
Changes 
Sections 
impacted 
Addition of forbidden concomitant CYP3A4 inhibitors 
6.9 
Clarification on contacting medical monitor regarding newly diagnosed 
HIV positive participants 
6.9 
Addition of nature of food intake around dosing time for PK participants 
7.3  
V4.0 / 22 
October 2021 
Correction of typos, minor edits and clarifications, updating of 
abbreviations 
Throughout 
protocol 
Administrative changes: Updates of study team members and sponsor 
address, Advisory panel role clarification, Simplification of protocol 
signatures to follow to GARDP Standard Operating Procedure (SOP) 
Clinical trial 
protocol 
signature page 
Contingency measure due to COVID-19 pandemic: 
Deletion of Chlamydia trachomatis (CT) assessment at Day 30 visit 
(exploratory endpoint)  
Protocol 
summary, 2, 
3.1, 5.1, 7.4, 
11.4.2 
Contingency measure due to COVID-19 pandemic: 
Deletion of Mycoplasma genitalium (MG) assessment (exploratory 
endpoint) 
Protocol 
summary, 2, 
3.1, 5.1, 5.2.1, 
7.4, 11.4.2 
Clarification of contraception requirements prior to inclusion in the trial 
(Inclusion criteria 5)  
Protocol 
summary, 4.1, 
8.4, Appendix 1 
Clarification of HIV testing requirements for study participation (Inclusion 
criteria 8) 
Protocol 
summary, 4.1, 
5.1, 5.2.1, 7.2.1 
Clarification of treatment of concomitant infections with systemic 
antibiotics with activity against Neisseria gonorrhoeae (NG) (Exclusion 
criteria 13) 
Protocol 
summary, 4.2  
Clarification of selection of participants 
Protocol 
summary, 4, 
11.1 
Background information literature is updated to reflect most recent 
surveillance data on gonorrhoea infections 
1.1 
Addition of recent in vitro data supporting the 3g dose and rewording of 
most common AE 
1.2, 3.2.2 
Update of section 1.3 with latest information on gepotidacin clinical 
development and NABOGO trials preliminary results 
1.3 
Update text to reflect the updated US Centers for Disease Control and 
Prevention (CDC) guidelines for treatment of uncomplicated gonorrhoea. 
References to national treatment guidelines are updated when 
applicable. 
3.2.3 
Update of the clarification of CYP3A4 exclusion and mention of planned 
study STIZoli_003  
 
Contingency measure due to COVID-19 pandemic: 
Addition of Section 3.2.5 Impact of COVID-19 pandemic on trial conduct 
and contingency measures in trial design justification  
3.2.5 
Clarification of how randomisation is performed 
3.3 
Clarification of section on blinding 
3.4 
Update of overall trial duration 
3.5 
Duration of Day 1 visit: Allowing Day 1 visit to happen over 2 days under 
specific conditions 
5.1 and 5.2.1 
Addition of mandatory food intake before dosing 
5.1 and 5.2.1 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 7 of 74 
 
Version / 
Date 
Changes 
Sections 
impacted 
V4.0 / 22 
October 2021 
Clarification of procedure to follow if microbiological assessments results 
are not back in time for the test of cure (TOC) visit 
5.1, 5.2.4 
Addition of sexual history questionnaire assessment at early withdrawal 
visits 
5.1, 5.2.6  
Clarification that direct bilirubin is only required to be performed when 
total bilirubin is out of normal range. 
5.1, 7.2.1 
Addition of text to highlight that those participants who miss the TOC visit 
are considered treatment failure for primary endpoint analysis 
5.2.4 
Contingency measure due to COVID-19 pandemic 
Clarification on handling of out-of-window visits and unscheduled visits 
5.3 
Removal of summary of zoliflodacin non-clinical and clinical experience and 
referral to the Investigator Brochure (IB) 
6.1.2 
Reference is added to the ceftriaxone and azithromycin United States 
prescribing information (USPI) in addition to the summaries of product 
characteristics (SmPC) as applicable. 
6.2.1 
Contingency measure due to COVID-19 pandemic: 
Flexibilities for pharyngeal swab collection  
7.2.2 
Contingency measure due to COVID-19 pandemic: 
NAAT testing allowed with other platforms than Hologic   
7.2.2 
Clarification on food intake recommendations in the pharmacokinetic (PK) 
sub-study 
7.3 
Clarification of section 8.1.1 adverse events (AE) 
1. Assessment whether laboratory/procedures abnormalities should 
be considered as an AE  
2. Clarification of AE definition 
3. Clarification of special cases for AE occurring during screening 
period  
8.1.1 
Minor clarification of the end of the AE reporting period 
8.1.2 
Deletion of duplicated information and clarification of sponsor team in 
section 8.3.1 Reporting of SAEs to sponsor  
8.3.1 
Clarification of events to be reported in an expedited manner 
8.3.2 
Clarification of Exposure during pregnancies section 
8.4 
Clarification of AE follow up 
8.5 
Addition of new analysis population and additional sensitivity analysis 
11.2, 11.2.3, 
11.4.2 
Clarification of definition of microbiological failure 
11.4.1 
Contingency measure due to COVID-19 pandemic: 
Addition of flexibility around monitoring visit format 
13.1 
Addition of the trial clinicaltrials.gov number. 
17.1 
V5.0 / 12 July 
2023 
Administrative changes: Updates of study team members 
Protocol 
Signature Page 
Increase of pre-specified non-inferiority margin to 12% for primary 
endpoint with rationale and re-estimation of evaluable patient population 
for microITT based on blinded pooled data analysis of study performance 
vs baseline assumptions 
 
Summary, 3.2.1, 
4, 11.1, 11.4.2 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 8 of 74 
 
Version / 
Date 
Changes 
Sections 
impacted 
V5.0 / 12 July 
2023 
Clarification that randomisation can occur on Day -1 and trial treatment 
administration the next calendar day (Day 1) to accommodate logistics of 
PK sampling  
(Incorporation in protocol amendment of Note-to-file from 7 July 2022) 
5.1 (Table 3),  
5.2.1 
Reference to UAB central laboratory deleted to reflect change of central 
lab vendor  
(Incorporation in protocol amendment of Note-to-file from 30 January 
2023) 
7.2.2, 11.7 
Correction of error around TOC results in Table 4 Assessments and use for 
clinical management; clarification of anatomical sites and indication for 
sampling at post-baseline visits  
(Incorporation in protocol amendment of Note-to-file from 7 July 2022) 
7.4 (Table 4) 
Minor clarification to definition of trial populations included in the 
analysis to align with Statistical Analysis Plan 
11.2, 11.2.4 
Clarification of contraceptive requirements for male participants to 
reflect how the protocol was conducted 
(Incorporation in protocol amendment of Note-to-file from 7 July 2022) 
16.6 
Inclusion of additional references and correction of error in references 
11.1, 11.7, 
References 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 9 of 74 
 
TABLE OF CONTENTS 
 
TABLE OF CONTENTS ............................................................................................. 9 
ABBREVIATIONS – GLOSSARY OF TERMS ........................................................ 12 
PROTOCOL SUMMARY .......................................................................................... 15 
1. 
BACKGROUND AND TRIAL RATIONALE .................................................. 22 
1.1. 
Background information ................................................................................................... 22 
1.2. 
Zoliflodacin development .................................................................................................. 23 
1.3. 
Overall rationale for the trial ............................................................................................. 24 
2. 
TRIAL OBJECTIVES AND ENDPOINTS ...................................................... 25 
3. 
TRIAL DESIGN.............................................................................................. 27 
3.1. 
Design ................................................................................................................................. 27 
3.2. 
Rationale ............................................................................................................................. 28 
3.2.1. 
Justification for trial design ...................................................................................... 28 
3.2.2. 
Justification for investigational drug dose selection ................................................ 28 
3.2.3. 
Justification for comparator selection ...................................................................... 29 
3.2.4. 
Justification for exclusion of CYP3A4 inhibitors ...................................................... 32 
3.2.5. 
Impact of COVID-19 pandemic on trial conduct and contingency measures ......... 32 
3.3. 
Randomization.................................................................................................................... 33 
3.4. 
Blinding ............................................................................................................................... 33 
3.5. 
Trial duration ...................................................................................................................... 33 
4. 
SELECTION OF PARTICIPANTS ................................................................. 34 
4.1. 
Inclusion criteria ................................................................................................................ 34 
4.2. 
Exclusion criteria ............................................................................................................... 34 
5. 
SCHEDULE OF EVENTS .............................................................................. 36 
5.1. 
Table of assessments ........................................................................................................ 36 
5.2. 
Schedule of assessments ................................................................................................. 36 
5.2.1. 
Visit 1: Day 1 (-1 day) .............................................................................................. 39 
5.2.2. 
Visit 2: Day 2 - PK sub-study .................................................................................. 39 
5.2.3. 
Visit 3: Day 3 (-1 day) .............................................................................................. 40 
5.2.4. 
Visit 4: Day 6 (+/-2 days) ......................................................................................... 40 
5.2.5. 
Visit 5: Day 30 (+/-3 days) ....................................................................................... 40 
5.2.6. 
Early withdrawal ...................................................................................................... 40 
5.3. 
Unscheduled and out-of-window visits ........................................................................... 41 
5.3.1. Out-of-window visits .......................................................................................................... 41 
5.3.2. Unscheduled visits ............................................................................................................ 41 
6. 
INVESTIGATIONAL PRODUCTS ................................................................. 41 
6.1. 
Zoliflodacin treatment ........................................................................................................ 41 
6.1.1. 
Product description and dosage ............................................................................. 41 
6.1.2. 
Summary of non-clinical and clinical experience .................................................... 41 
6.2. 
Comparator trial treatment ................................................................................................ 42 
6.2.1. 
Product description and dosage ............................................................................. 42 
6.2.1. 
Summary of non-clinical and clinical experience .................................................... 42 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 10 of 74 
 
6.3. 
Labelling and packaging ................................................................................................... 42 
6.4. 
Shipment ............................................................................................................................. 42 
6.5. 
Storage ................................................................................................................................ 43 
6.6. 
Preparation and administration of trial treatments ........................................................ 43 
6.7. 
Accountability..................................................................................................................... 43 
6.8. 
Blinding and procedures for un-blinding ........................................................................ 43 
6.9. 
Concomitant treatments .................................................................................................... 43 
6.10. 
Escape treatments ............................................................................................................. 44 
7. 
TRIAL PROCEDURES/EVALUATIONS ....................................................... 44 
7.1. 
Clinical evaluations ............................................................................................................ 44 
7.2. 
Laboratory evaluations ...................................................................................................... 45 
7.2.1. 
Clinical laboratory evaluations ................................................................................ 45 
7.2.2. 
Microbiological evaluations ..................................................................................... 45 
7.3. 
Pharmacokinetic evaluations............................................................................................ 46 
7.4. 
Clinical management of participants ............................................................................... 47 
8. 
ASSESSMENT OF SAFETY ......................................................................... 48 
8.1. 
Definitions ........................................................................................................................... 48 
8.1.1. 
Adverse event ......................................................................................................... 48 
8.1.2. 
Adverse Event reporting period .............................................................................. 49 
8.1.3. 
Serious adverse event ............................................................................................ 49 
8.1.4. 
Overdose ................................................................................................................. 50 
8.1.5. 
Grading of AE severity ............................................................................................ 50 
8.1.6. 
AE causality assessment ........................................................................................ 50 
8.2. 
Detection and recording of AEs ....................................................................................... 51 
8.3. 
Expedited reporting of SAEs ............................................................................................ 51 
8.3.1. 
Reporting of SAEs to sponsor ................................................................................. 51 
8.3.2. 
Reporting of SAEs to national regulatory authorities and ethics committees ......... 52 
8.4. 
Exposure during pregnancies .......................................................................................... 52 
8.5. 
AE follow up........................................................................................................................ 53 
8.6. 
Safety assessments ........................................................................................................... 53 
9. 
WITHDRAWALS ........................................................................................... 53 
10. 
DATA COLLECTION AND MANAGEMENT ................................................. 53 
10.1. 
Source data ......................................................................................................................... 53 
10.2. 
Electronic data capture system ........................................................................................ 54 
11. 
DATA ANALYSIS AND STATISTICAL METHODS ...................................... 55 
11.1. 
Sample size determination ................................................................................................ 55 
11.2. 
Definition of trial populations included in the analysis ................................................. 56 
11.2.1. 
Micro-ITT population ............................................................................................... 57 
11.2.2. 
Clinical cure population ........................................................................................... 57 
11.2.3. 
Evaluable population ............................................................................................... 57 
11.2.4. 
PP population .......................................................................................................... 57 
11.2.5. 
Safety population .................................................................................................... 57 
11.2.6. 
PK population .......................................................................................................... 58 
11.3. 
Baseline characteristics .................................................................................................... 58 
11.4. 
Efficacy analysis ................................................................................................................ 58 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 11 of 74 
 
11.4.1. 
Definitions................................................................................................................ 58 
11.4.2. 
Specification of efficacy analysis ............................................................................ 58 
11.5. 
Safety analysis ................................................................................................................... 60 
11.6. 
Pharmacological endpoints .............................................................................................. 60 
11.7. 
Missing values .................................................................................................................... 61 
12. 
DATA SAFETY MONITORING BOARD ....................................................... 61 
13. 
QUALITY ASSURANCE AND QUALITY CONTROL PROCEDURES ......... 62 
13.1. 
Monitoring, audits and inspections ................................................................................. 62 
13.2. 
Audits and inspections ...................................................................................................... 63 
13.3. 
Laboratory framework ....................................................................................................... 63 
14. 
TRIAL DOCUMENTATION ........................................................................... 63 
14.1. 
Confidentiality and retention of trial documents ............................................................ 63 
14.2. 
Protocol amendment ......................................................................................................... 63 
14.3. 
Final trial reports ................................................................................................................ 64 
15. 
EARLY TERMINATION OF THE TRIAL ....................................................... 64 
16. 
ETHICS .......................................................................................................... 65 
16.1. 
Trial conduct ....................................................................................................................... 65 
16.2. 
Regulatory and ethical approval....................................................................................... 65 
16.3. 
Informed consent process ................................................................................................ 65 
16.4. 
Justification for selection of trial population .................................................................. 66 
16.5. 
Community engagement ................................................................................................... 66 
16.6. 
Risks and benefits ............................................................................................................. 66 
16.7. 
HIV status and voluntary counselling and testing.......................................................... 67 
16.8. 
Compensation .................................................................................................................... 68 
16.9. 
Insurance and liability ....................................................................................................... 68 
16.10. Post-trial access ................................................................................................................. 68 
17. 
REPORTING AND PUBLICATION ............................................................... 68 
17.1. 
International registry of clinical trials .............................................................................. 68 
17.2. 
Publication .......................................................................................................................... 68 
REFERENCES ......................................................................................................... 69 
APPENDIX 1: CONTRACEPTION METHODS CONSIDERED AS HIGHLY 
EFFECTIVE .............................................................................................................. 74 
 
 
 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 12 of 74 
 
ABBREVIATIONS – GLOSSARY OF TERMS 
 
 
ADL 
Activities of daily living 
ADME 
Absorption, distribution, metabolism, excretion 
AE 
Adverse event 
ALT 
Alanine transaminase 
AMR 
Antimicrobial resistance 
API 
Active pharmaceutical ingredient 
ART 
Anti-retroviral therapy 
AUC 
Area under the time-concentration curve 
BA 
Bioavailability 
BID 
Twice a day 
BV 
Bacterial vaginosis 
CFR 
CT 
Code of Federal Regulations 
Chlamydia trachomatis 
CI 
Confidence interval 
CIOMS 
CKD-EPI 
Council for International Organizations of Medical Sciences 
Chronic kidney disease - epidemiology collaboration 
CL/F 
Apparent total clearance of the drug after oral administration 
Cmax 
Maximum plasma drug concentration 
Cmin 
Minimum plasma drug concentration 
CRF 
CTCAE 
Case report form 
Common Terminology Criteria for Adverse Events  
CV 
CYP3A4 
Coefficient of variation 
Cytochrome P450 family 3 subfamily A member 4 
DMID 
DNA 
Division of Microbiology and Infectious Diseases 
Deoxyribonucleic acid 
DNDi 
Drugs for neglected diseases initiative 
DoH 
Department of Health 
DSMB 
Data and safety monitoring board 
eCRF 
Electronic case report form 
EDC 
eGFR 
Electronic data capture 
Estimated glomerular filtration rate 
EMA 
European Medicines Agency 
EOT 
End of trial 
ESC 
Extended spectrum cephalosporines 
EU 
European Union 
FBC 
Full blood count 
FDA 
Food and Drug Administration 
FPFV 
First participant first visit 
fT>MIC 
Period over which free drug concentrations exceed MIC 
FWA 
g 
Federal-wide assurance 
Gram 
GARDP 
Global Antibiotics Research & Development Partnership 
GCLP 
Good clinical laboratorial practice 
GCP 
Good clinical practice 
GI 
Gastrointestinal 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 13 of 74 
 
GM 
Geometrical mean 
GMP 
GSD 
H 
HCl 
Good manufacturing practice 
Geometrical standard deviation 
Hour  
Hydrochloric acid 
HFIM 
Hollow fibre infection model 
HIC 
HIV 
High income country 
Human immunodeficiency virus 
HLGT 
HPLC 
High level group term 
High performance liquid chromatography 
IB 
Investigator brochure 
ICF 
Informed consent form 
ICH 
International Conferences on Harmonization of Technical Requirements for 
Registration of Pharmaceuticals for Human Use 
ICMJE 
International committee of medical journal editors 
IEC 
Independent ethics committee 
IM 
IMP 
Intramuscular 
Investigational medicinal product 
IRB 
Independent review board 
ITT 
Intention to treat 
IV 
Ke 
Kg 
L 
Intravenous 
Elimination rate 
Kilogram 
Litre 
LFT 
Liver function tests 
LPLV 
MAR 
Last participant last visit 
Missing at random 
MDR 
Multi drug resistant 
MedDRA 
mEq 
mg 
Medical Dictionary for Regulatory Activities 
Milli-equivalent 
Milligram 
MIC 
MIC90 
Minimum inhibitory concentration 
Minimum inhibitory concentration required to inhibit the growth of 90 % of 
organisms 
Micro-ITT 
mL 
MNAR 
Microbiologic – intention to treat 
Millilitre 
Missing not at random 
MoH 
Ministry of Health 
MOP 
Manual of procedures 
MoPH 
MS 
μg 
Ministry of Public Health 
Mass spectroscopy 
Microgram 
NAAT 
Nucleic acid amplification test 
NBTI 
Novel bacterial topoisomerase inhibitors 
NCE 
ng 
NG 
New chemical entity 
Nanogram 
Neisseria gonorrhoeae 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 14 of 74 
 
NIH 
National Institute of Health 
NRA 
PCI 
National regulatory authorities 
Packaging Coordinators Inc. 
PD 
Pharmacodynamics 
PI 
Principal investigator (see note Section 13) 
PID 
Pelvic inflammatory disease 
PK 
Pharmacokinetics 
PO 
Per os 
PP 
Per protocol 
PT 
Preferred term 
PV 
Pharmacovigilance 
QC 
QTc 
Quality control 
Corrected QT interval 
rBA 
Relative bioavailability 
RDT 
RNA 
rRNA 
S. aureus 
Rapid diagnostic test 
Ribonucleic acid 
Ribosomal ribonucleic acid 
Staphylococcus aureus 
SAD 
Single ascending dose 
SAE 
Serious adverse event 
SAPHRA 
South Africa Health Products Regulatory Authority 
SD 
Standard deviation 
SmPC 
Summary of product characteristics 
SOC 
System organ class 
SOP 
Standard operating procedures 
STI 
Sexually transmitted infections 
SUSAR 
Suspected unexpected serious adverse reaction 
t1/2 
Elimination half life 
Thai-FDA 
tlast 
tmax 
Thailand Food and Drug Administration 
Time to last measurable drug concentration following drug administration  
Time to reach Cmax following drug administration 
TOC 
Test of cure 
UD 
Urethral discharge 
ULN 
USA 
Upper limit of normal 
United States of America 
US-CDC 
United States Centers for Disease Control and Prevention 
US-FDA 
VCT 
VZ/F 
United States – Food and Drug Administration 
Voluntary counselling and testing 
Apparent volume of distribution during terminal phase 
USPI 
United States Prescribing Information 
WBC 
WGS 
White blood cell 
Whole genome sequencing 
WHO 
World Health Organization 
WNL 
wt 
Within normal limits 
weight 
 
 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 15 of 74 
 
PROTOCOL SUMMARY 
 
Trial title 
A multi-center, randomized, open-label, non-inferiority trial to 
evaluate the efficacy and safety of a single, oral dose of 
zoliflodacin compared to a combination of a single 
intramuscular dose of ceftriaxone and a single oral dose of 
azithromycin in the treatment of patients with uncomplicated 
gonorrhoea 
Protocol number 
STI_Zoli001 
Phase of development 
Phase III 
Design 
Non-inferiority, parallel, open-label 
Primary objective  
To assess the efficacy of a single, oral, 3 grams (g) dose of 
zoliflodacin compared to a combination of a single 
intramuscular (IM) 500 milligram (mg) dose of ceftriaxone and a 
single 1 g oral dose of azithromycin for the treatment of 
uncomplicated urogenital gonorrhoea 
Secondary objectives 
x To assess the safety and tolerability of a single, oral, 3 g 
dose of zoliflodacin compared to a combination of a 
single IM 500 mg dose of ceftriaxone and a single 1 g oral 
dose of azithromycin in participants with uncomplicated 
gonorrhoea 
x To determine microbiological cure rate of pharyngeal 
gonorrhoea after administration of a single, oral, 3 g 
dose of zoliflodacin compared to a combination of a 
single IM 500 mg dose of ceftriaxone and a single 1 g oral 
dose of azithromycin 
x To determine microbiological cure rate of rectal 
gonorrhoea after administration of a single, oral, 3 g 
dose of zoliflodacin compared to a combination of a 
single IM 500 mg dose of ceftriaxone and a single 1 g oral 
dose of azithromycin 
x To determine the clinical cure rate of symptomatic 
gonorrhoea in male participants after administration of a 
single, oral, 3 g dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of ceftriaxone 
and a single 1 g oral dose of azithromycin 
x To determine the microbiological cure rate of urogenital 
gonorrhoea among women and men, after 
administration of a single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 500 mg dose 
of ceftriaxone and a single 1 g oral dose of azithromycin 
x To determine the microbiological cure rate of Neisseria 
gonorrhoeae (NG) at urethral or cervical sites in the 
subset of participants with pre-existing resistance to 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 16 of 74 
 
antibiotics commonly used for NG treatment (including 
to ceftriaxone alone, to azithromycin alone, and to both) 
x To determine the antimicrobial susceptibility profile of 
gonococcal strains isolated from participants with 
uncomplicated gonorrhoea at baseline and the test of 
cure (TOC) (day 6 ±2) visit 
x To determine the eradication rate of NG nucleic acid 
from urethral, cervical, rectal, pharyngeal specimens 
after administration of a single, oral, 3 g dose of 
zoliflodacin compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin 
PK (pharmacokinetics) 
objective (sub-study 
only) 
To evaluate the plasma PK of a single, oral, 3 g dose of 
zoliflodacin: 
x in adult participants (≥ 18 years old) with uncomplicated 
gonorrhoea who are human immunodeficiency virus 
(HIV) negative or HIV positive 
x in HIV negative adolescent participants (≥ 12 and < 18 
years old) with uncomplicated gonorrhoea 
Exploratory objectives 
x To determine the late eradication rate of NG nucleic 
acids from urethral, cervical, rectal, pharyngeal 
specimens after administration of a single, oral, 3 g dose 
of zoliflodacin compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin 
x To determine the late relapse/re-infection rate of NG 
from urethral, cervical, rectal, pharyngeal specimens 
after administration of a single, oral, 3 g dose of 
zoliflodacin compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin 
x To investigate relationships between pre-treatment and 
post-treatment NG isolates within those participants 
whose cultures at TOC (day 6 ±2) are found positive for 
NG and identify possible determinants of zoliflodacin 
resistance 
Primary endpoint 
Microbiological cure as determined by culture at urethral or 
cervical sites at TOC (day 6 ±2) 
Secondary endpoints 
x 
Incidence, severity, causality, and seriousness of 
treatment-emergent adverse events and the evaluation 
of changes from baseline in safety laboratory test results 
and physical examinations 
x Proportion of participants with microbiological cure as 
determined by culture at pharyngeal sites at TOC (day 6 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 17 of 74 
 
±2) 
x Proportion of participants with microbiological cure as 
determined by culture at rectal sites at TOC (day 6 ±2) 
x Proportion of male participants with clinical cure at TOC 
(day 6 ±2) 
x Proportion of female and male participants with 
microbiological cure as determined by culture at cervical 
or urethral site at TOC (day 6 ±2) 
x Proportion of participants with microbiological cure as 
determined by culture at urethral or cervical sites at TOC 
and for whom the baseline antimicrobial susceptibility 
profile indicated pre-existing resistance to antibiotics 
commonly used for NG treatment (including to 
ceftriaxone alone, to azithromycin alone, and to both) 
x Antimicrobial susceptibility profile of gonococcal strains 
isolated at baseline and at TOC (day 6 ±2) 
x Proportion of participants with a negative NG nucleic 
acid amplification test (NAAT) from urethral or cervical 
sites at TOC (day 6 ±2) 
x Proportion of participants with a negative NG NAAT from 
oropharyngeal sites at TOC (day 6 ±2) 
x Proportion of participants with a negative NG NAAT from 
rectal sites at TOC (day 6 ±2) 
Exploratory endpoints 
x Out of participants with a positive NG NAAT test and a 
negative NG culture at TOC, the below will be 
determined: 
o Proportion of participants with a negative NG 
NAAT and culture from urethral or cervical sites 
at the end of the trial (day 30 +/- 3 days) 
o Proportion of participants with a negative NG 
NAAT and culture from oropharyngeal sites at the 
end of the trial (day 30 +/- 3 days) 
o Proportion of participants with a negative NG 
NAAT and culture from rectal sites at the end of 
the trial (day 30 +/- 3 days) 
x Out of participants with symptoms at end of the trial 
(day 30 +/- 3 days), the following will be determined: 
o Proportion of patients with positive NAAT and/or 
culture at each anatomical site respectively at 
end of the trial (day 30 +/- 3 days)  
o Antimicrobial susceptibility profile of gonococcal 
strains isolated at the end of the trial (day 30 +/- 
3 days 
x Whole genome sequencing (WGS) of NG isolates from 
the TOC and end of trial (EOT) visits plus all baseline 
isolates (urogenital, pharyngeal and rectal) from the 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 18 of 74 
 
same patients with possible microbiological failure 
Pharmacological 
endpoints 
 
Plasma PK parameters of zoliflodacin in HIV negative and HIV 
positive participants (≥ 18 years old) 
Plasma PK parameters of zoliflodacin in HIV negative 
adolescents (≥12 and <18 years old) 
 
Inclusion criteria 
 
1. ≥ 12 years old (if enrolment of minors is in agreement 
with local regulations and ethics guidance) 
2. ≥ 35 kilogram (kg) 
3. Signs and symptoms consistent with urethral or cervical 
gonorrhoea  
OR 
Urethral or cervical uncomplicated gonorrhoea as 
determined by either a positive culture or NAAT or Gram 
stain or methylene blue/gentian violet stain in the past 
14 days prior to screening  
OR 
Unprotected sexual contact with an individual confirmed 
to be infected with NG in the past 14 days prior to 
screening (positive NAAT, Gram stain, methylene 
blue/gentian violet stain or culture) 
4. For females of child-bearing potential, a negative urine 
pregnancy test at screening 
5. For females of child-bearing potential, use of a highly 
effective method of contraception at the time of IMP 
administration on Day 1 (see Appendix 1: Contraception 
methods considered as highly effective and required 
duration) and until at least 28 days after treatment. 
Females on oral contraceptives must also use a barrier 
contraception method during participation in the study. 
6. For males with a female partner of child-bearing age, 
willingness to delay conception during the trial and for 
28 days after treatment 
7. Willingness to comply with trial protocol 
8. For participants in the PK sub-study: Willingness to 
undergo HIV testing 
9. Willingness to abstain from sexual intercourse or use 
condoms for vaginal, anal and oral sex from enrolment 
until the end of trial (EOT) visit 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 19 of 74 
 
10. Willingness and ability to give written informed consent 
or be consented by a legal representative, or provide 
assent and parental consent (for minors, as appropriate) 
Exclusion criteria 
11. Confirmed or suspected complicated or disseminated 
gonorrhoea  
12. Pregnant or breastfeeding females 
13. Known concomitant infection which would require 
immediate additional systemic antibiotics with activity 
against NG 
14. Use of any systemic or intravaginal antibiotics with 
activity against NG within 30 days prior to screening 
15. Use of systemic corticoid drugs or other 
immunosuppressive therapy within 30 days prior to 
screening 
16. Use of moderate or strong CYP3A4 inducers (e.g.  
efavirenz, rifampicin, carbamazepine, phenobarbital) 
within 30 days or five half-lives of the drug, whichever is 
greater, prior to screening (see Section 6.9) 
17. Cytotoxic or radiation therapy within 30 days prior to 
screening 
18. Known chronic renal, hepatic, hematologic impairment 
or other condition interfering with the absorption, 
distribution or elimination of the drug, based on medical 
history and physical examination 
19. History of urogenital sex-reassignment surgery 
20. Immunosuppression as evidenced by medical history, 
clinical examination or a recent (≤1 month) CD4 count 
below 200 cells/microliter (μL) 
21. Known clinically relevant cardiac pro-arrhythmic 
conditions such as cardiac arrhythmia, congenital or 
documented QT prolongation   
22. Known history of severe allergy to cephalosporin, 
penicillin, monobactams, carbapenems, or macrolide 
antibiotics 
23. Known or suspected allergies or hypersensitivities to 
lidocaine, methylparaben, lactose or any of the 
components of the study drugs (refer to the zoliflodacin 
investigator brochure (IB) and summaries of product 
characteristics (SmPC) for the comparator treatments) 
24. Receipt or planned receipt of an investigational product 
in a clinical trial within 30 days or five half-lives of the 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 20 of 74 
 
drug, whichever is greater prior to screening until end of 
participation to this clinical trial 
25. History of alcohol or drug abuse in the 12 months prior 
to screening which would compromise trial participation 
in the judgement of the investigator 
26. Severe medical or psychiatric condition that, in the 
opinion of the investigator, may increase the risk 
associated with trial participation or may interfere with 
the interpretation of trial results or affect the individual’s 
ability to provide informed consent 
27. Individuals whom, in the judgement of the investigator, 
are unlikely or unable to comply with this trial protocol 
28. Previous randomisation in this clinical trial 
29. Use of moderate or strong CYP3A4 inhibitors within 30 
days or five half-lives of the drug, whichever is greater, 
prior to screening (see Section 6.9) 
 
Target sample size 
(estimated) 
696 evaluable trial participants (464 in interventional group and 
232 in control group) including 20-30 adolescents (≥12 and < 18 
years old). The estimated randomised sample size is up to 
approximately 928 trial participants, and the estimated number 
of participants enrolled will be approximately 1092 taking into 
account screen failures. 
Intervention 
Single oral 3 g dose of zoliflodacin granules as oral suspension 
Comparator 
Combination of a single intramuscular 500 mg dose of 
ceftriaxone and a single oral 1 g dose of azithromycin 
Statistical analysis 
The microbiological intent-to-treat (micro-ITT) population will 
be used as the primary analysis population for the assessment 
of microbiological cure. The micro-ITT population will include all 
randomized participants who receive a dose of drug, who have 
urogenital NG isolated at baseline and who are not infected with 
a strain that shows resistance to both ceftriaxone and 
azithromycin at baseline.  
The primary efficacy analysis will claim that zoliflodacin is non-
inferior to the ceftriaxone-azithromycin combination if the 
upper bound of the 2-sided 95% confidence interval (CI) for the 
microbiological cure rate of the combination therapy minus 
zoliflodacin will be 12% or less (prespecified non-inferiority 
margin for the primary endpoint).  
Complementary 
activities 
Microbiological bacterial isolates collected will be stored for 
long-term (no longer than 5 years, with the exception of the 
Netherlands where bacterial isolates will be kept up to 15 years 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 21 of 74 
 
as per local regulations) after the end of the trial analysis (e.g. 
genotyping) for use in future research in relation to diagnosis 
and treatment of gonorrhoea. 
 
 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 22 of 74 
 
1. Background and trial rationale 
1.1. Background information 
Bacterial sexually transmitted infections (STI) are a major public health concern globally, 
affecting over 357 million people every year (1). Neisseria gonorrhoeae (NG), the etiological 
agent of gonorrhoea, is estimated to have caused 78 million infections in 2012.  The Western 
Pacific and African regions have the highest incidence of gonococcal infections worldwide, 
with 89 and 50 cases per 100’000 population respectively. Rates of male urethral discharge 
(UD), which is primarily due to NG or Chlamydia trachomatis (CT), are also highest for these 
two regions, amounting to 567 per 100’000 in Africa and 141 per 100’000 in the Western 
Pacific. In high income countries (HIC), gonorrhoea is also raising significant concerns. In the 
United States of America (USA) it is the second most frequently reported notifiable infectious 
diseases, with over 600’000 infections reported per year (2). NG has been included as one of 
three organisms presenting an urgent threat due to progressive antimicrobial resistance by 
the US Centers for Disease Control and Prevention (US CDC) (3). 
Gonorrhoea affects both men and women. In men, infections commonly manifest as 
urethritis. Symptoms develop in 75% of the men within four to eight days of genital infection 
and in 80 to 90% within two weeks (4). UD is the most frequent presenting symptom and is 
often undistinguishable from non-gonococcal urethritis (e.g. CT infections). Acute unilateral 
epididymitis can be a complication of gonococcal infection, although it is more common with 
CT infections (5, 6). In women, gonococcal infections are often (≥50% of the cases) 
asymptomatic. Genital infections, in particular cervical infections, are the most common 
infections. When symptomatic, cervical infection typically manifests as mucopurulent 
discharge. If left untreated, NG infections can ascend to involve the uterus and fallopian tubes. 
Gonorrhoea is associated with significant morbidity and if not treated appropriately, can have 
serious consequences on reproductive health. Pelvic inflammatory disease (PID), ectopic 
pregnancies, abortions, neonatal conjunctivitis and blindness are among the possible 
complications. Studies have also shown that gonorrhoea enhances the transmission of human 
HIV by three to five-fold (7-9). 
Most individuals with gonorrhoea are managed in the community, and clinical management 
is often empiric and syndromic: treatment is based on the presence of easily recognized signs 
(e.g. urethral or vaginal discharge), and the provision of antibiotics that deal with the majority 
of, or the most serious, organisms responsible for the syndrome. Extended spectrum 
cephalosporins (ESC) constitute the mainstay of gonorrhoea treatment. However, with 
increasing resistance to ESC emerging globally, and in particular to cefixime, several countries 
switched around 2013 from ESC monotherapy to a dual therapy that includes an injectable 
ESC – ceftriaxone- and azithromycin (10, 11), the underlying, unproven, assumption being that 
a dual therapy would slow down resistance emergence.  
Over the past few years, the World Health Organization (WHO) and others have raised 
concerns over the spread of gonococcal antimicrobial resistance (AMR), warning that 
infections due to NG may soon become untreatable (12-14). Reports of treatment failures 
with ESC and azithromycin monotherapy have multiplied over the past few years, and clinical 
failures to dual therapy have been reported (15-17). Despite this, the drug development 
pipeline for NG remains insufficient. In 2012, the WHO launched a global action plan to control 
the spread and impact of AMR in NG. Identifying new treatment options for multi-drug 
resistant (MDR) gonorrhoea is a key element of the WHO global action plan, and has long been 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 23 of 74 
 
called for by clinicians and microbiologists (18, 19). 
1.2. Zoliflodacin development 
Zoliflodacin (ETX0914) belongs to a new class of antibiotics that inhibit bacterial 
deoxyribonucleic acid (DNA) replication. It shows in vitro antibacterial activity against several 
Gram-positive pathogens such as Staphylococcus spp. and Streptococcus spp. as well as 
fastidious Gram-negative pathogens such as Haemophilus influenzae, Moraxella catarrhalis 
and NG (20). Minimum inhibitory concentration required to inhibit the growth of 90% of 
organisms (MIC90) values for NG range from 0.125 to 0.25 μg/mL.   
A complete program of both oral and intravenous (IV) toxicity studies was performed in the 
rat and dog. Data collected included clinical observations, body weight changes, food 
consumption, clinical pathology and histopathology. Also completed was a battery of genetic 
toxicology studies and single dose safety pharmacology studies to assess cardiovascular, 
central nervous system, renal, respiratory and gastrointestinal endpoints.  
Studies performed in the Staphylococcus aureus (S. aureus) neutropenic thigh model, which 
was the surrogate pathogen model available at the time, indicated that the ratio between the 
area under the concentration-time curve (AUC) and the MIC was the driver of log kill. Those 
studies also supported a predicted efficacious mean AUC in humans of 49 μg*hour(h)/mL. 
Overall, the preclinical data supported progression to phase I trials (20, 21). More recently, 
dose-ranging studies using a hollow fibre infection model (HFIM) for NG confirmed the 
exposure-response previously generated with S. aureus that, accounting for PK variability in 
human, zoliflodacin should be administered as a single oral dose of 3g to provide effective 
killing of NG while suppressing emergence of resistance (22). 
Detailed results of these pre-clinical evaluations are summarized in the investigator brochure 
(IB).  
Zoliflodacin is being developed as an oral, single dose treatment. Final data is available from 
six clinical trials : a phase I single-ascending dose (SAD) trial, a phase I absorption, distribution, 
metabolism, excretion (ADME) trial (23), a phase II trial involving participants with confirmed 
urogenital gonococcal infection (24), a phase I relative bioavailability (rBA) trial 
(clinicaltrials.gov NCT03404167), a phase I food effect trial with healthy volunteers to assess 
the effect of food on the PK characteristics of a newly developed formulation (clinicaltrials.gov 
NCT03718806) and a thorough QT/QTc (TQT) trials (25). The SAD and ADME trials showed that 
zoliflodacin was well tolerated at all doses tested (200 mg- 4’000 mg). The most frequently 
reported AEs in both healthy volunteers and patients with uncomplicated gonorrhoea were 
headache, nausea and diarrhea. Dysgeusia, which is the preferred term for ‘unpleasant taste’ 
in the Medical Dictionary for Regulatory Activities (MedDRA), was reported by healthy 
volunteers receiving an old zoliflodacin formulation, which is not the formulation used in this 
trial.  
In the phase II, 96% (95%CI: 88-100%) cure rates were observed with both the 2 g and the 3 g 
doses in the micro-ITT population at the urogenital site (55 out of 57 and 54 out of 56 
participants respectively) compared to 100% (95% CI:88-100) in the comparator arm of 
ceftriaxone 500 mg IM (24). All participants with concomitant rectal infections were cured 
with either dose of zoliflodacin, while for those with concurrent oropharyngeal infections, 
cure rates were lower (2 g 50% [95%CI: 16-84]; 3 g 82% [95%CI: 48-98]) compared to 100% 
(95%CI: 40-100) for ceftriaxone. The small number of participants with concurrent 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 24 of 74 
 
oropharyngeal infections included in the phase II (8 participants in the 2 g arm, 11 participants 
in the 3 g arm and 4 in the ceftriaxone arm) however precludes any firm conclusion about 
efficacy at this site. In the phase II, the safety profile of zoliflodacin was generally similar to 
ceftriaxone; the most common adverse events (excluding infection-related AEs) were 
diarrhoea, headache, and nausea. The drug was overall generally well tolerated. 
1.3. Overall rationale for the trial 
Despite growing concerns over progressive antimicrobial resistance, the development 
pipeline for uncomplicated gonorrhoea remains relatively empty with only two new chemical 
entities (NCE) currently in development: zoliflodacin and gepotidacin. Gepotidacin, for which 
with single dose treatment a few microbiological failures occurred in phase 2, especially in 
isolates with high baseline MICs (26), is being tested in phase III as a 2-dose treatment for 
uncomplicated gonorrhoea. As fluoroquinolone resistance is already extremely prevalent 
globally (27), the use of gepotidacin will have to be restricted to cases where the antimicrobial 
susceptibility pattern of the infecting strain is known. Zoliflodacin (AZD0914) on the other 
hand, has shown extremely good activity against a large collection of isolates (standard and 
clinical), from different geographical origins, including multi-drug resistant (MDR) and 
extremely drug resistant (XDR) strains (28-31). In vitro studies clearly show the absence of 
cross-resistance between zoliflodacin and pre-existing fluoroquinolone and cephalosporin 
resistance mechanism (32). The frequency of spontaneous resistance to zoliflodacin in vitro 
was found to be low and comparable to frequencies reported for fluoroquinolones (1.5x10-8 
to 5.2x10-9 at 4x MIC) (33-35). 
The utility of commercialized readily-available drugs as new treatments for uncomplicated 
gonorrhoea has been investigated in a few trials. For example, a 4-arm trial (NABOGO) was 
conducted in the Netherlands to formally evaluate ertapenem, fosfomycin and gentamicin 
compared to ceftriaxone (36). Preliminary data shows that ertapenem , but not gentamicin 
nor fosfomycin, was non-inferior to ceftriaxone. Nevertheless, ertapenem must also be 
administered intramuscularly, like ceftriaxone. In case resistance to the currently 
recommended therapies reaches the critical threshold of 5% set by WHO and other public 
health agencies, it could have some utility before a new molecule comes to market. However, 
it does not provide a long-term solution and have well-known drawbacks as the MIC of 
ertapenem is affected by the ESC resistance determinants (37). In contrast, zoliflodacin has 
proven to be an excellent clinical candidate both in terms of efficacy and safety. The drug is 
well tolerated, can be administered orally and has shown high rates of cure for urethral, 
cervical and rectal gonococcal infection in phase II (24). 
In summary, zoliflodacin is a new promising option to address the risk posed by the threat of 
drug-resistant gonorrhoea. The purpose of this phase III multi-center, randomized, open-label, 
non-inferiority trial is to confirm the efficacy and safety outcomes observed in the phase II 
trial and to generate the necessary evidence to support a marketing authorization application 
in the USA, the European Union (EU), South Africa and Thailand.  
 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 25 of 74 
 
2. Trial objectives and endpoints 
Table 1: objectives and endpoints 
OBJECTIVES 
ENDPOINTS 
PRIMARY 
To assess the efficacy of a single, oral, 3 g 
dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of 
ceftriaxone and a single 1 g oral dose of 
azithromycin for the treatment of 
uncomplicated urogenital gonorrhoea 
Microbiological cure as determined by 
culture at urethral or cervical sites at TOC 
(day 6 ±2) 
SECONDARY 
To assess the safety and tolerability of a 
single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g 
oral dose of azithromycin in participants 
with uncomplicated gonorrhoea 
Incidence, severity, causality, and 
seriousness of treatment-emergent adverse 
events and the evaluation of changes from 
baseline in safety laboratory test results 
and physical examinations 
To determine microbiological cure rate of 
pharyngeal gonorrhoea after 
administration of a single, oral, 3 g dose of 
zoliflodacin compared to a combination of 
a single IM 500 mg dose of ceftriaxone and 
a single 1 g oral dose of azithromycin 
Proportion of participants with 
microbiological cure as determined by 
culture at pharyngeal sites at TOC (day 6 
±2) 
To determine microbiological cure rate of 
rectal gonorrhoea after administration of a 
single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g 
oral dose of azithromycin 
Proportion of participants with 
microbiological cure as determined by 
culture at rectal sites at TOC (day 6 ±2) 
To determine the clinical cure rate of 
symptomatic gonorrhoea in male 
participants after administration of a single, 
oral, 3 g dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of 
ceftriaxone and a single 1 g oral dose of 
azithromycin 
Proportion of male participants with clinical 
cure at TOC (day 6 ±2) 
To determine the microbiological cure rate 
of urogenital gonorrhoea among women 
and men, after administration of a single, 
Proportion of female and male participants 
with microbiological cure as determined by 
culture at cervical or urethral site at TOC 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 26 of 74 
 
OBJECTIVES 
ENDPOINTS 
oral, 3 g dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of 
ceftriaxone and a single 1 g oral dose of 
azithromycin 
(day 6 ±2) 
To determine the microbiological cure rate 
of NG at urethral or cervical sites in the 
subset of participants with pre-existing 
resistance to antibiotics commonly used for 
NG treatment (including to ceftriaxone 
alone, to azithromycin alone and to both) 
Proportion of participants with 
microbiological cure as determined by 
culture at urethral or cervical sites at the 
TOC visit and for whom the baseline 
antimicrobial susceptibility profile indicated 
pre-existing resistance to antibiotics 
commonly used for NG treatment 
(including to ceftriaxone alone, to 
azithromycin alone and to both) 
To determine the antimicrobial 
susceptibility profile of gonococcal strains 
isolated from participants with 
uncomplicated gonorrhoea at baseline and 
the TOC visit 
Antimicrobial susceptibility profile of 
gonococcal strains isolated at baseline and 
at TOC (day 6 ±2) 
To determine the eradication rate of NG 
nucleic acid from urethral, cervical, rectal, 
pharyngeal specimens after administration 
of a single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g 
oral dose of azithromycin 
x Proportion of participants with a 
negative NG NAAT from urethral or 
cervical sites at TOC (day 6 ±2) 
x Proportion of participants with a 
negative NG NAAT from 
oropharyngeal sites at TOC (day 6 
±2) 
x Proportion of participants with a 
negative NG NAAT from rectal sites 
at TOC (day 6 ±2) 
PK sub-study only 
To evaluate the plasma PK profile after a 
single, oral, 3 g dose of zoliflodacin: 
x in adult participants (≥ 18 years old) 
with uncomplicated gonorrhoea  
who are HIV negative or HIV positive 
x in HIV negative adolescent 
participants (≥ 12 and < 18 years 
old) with uncomplicated 
gonorrhoea 
 
 
x Plasma PK parameters of 
zoliflodacin in HIV negative and HIV 
positive adult participants  
x Plasma PK parameters of 
zoliflodacin in HIV negative 
adolescents (≥ 12 and < 18 years 
old) 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 27 of 74 
 
OBJECTIVES 
ENDPOINTS 
EXPLORATORY 
To determine the late eradication rate of 
NG nucleic acid from urethral, cervical, 
rectal, pharyngeal specimens after 
administration of a single, oral, 3 g dose of 
zoliflodacin compared to a combination of 
a single IM 500 mg dose of ceftriaxone and 
a single 1 g oral dose of azithromycin 
Out of participants with a positive NG NAAT 
test and a negative NG culture at TOC, the 
below will be determined: 
x Proportion of participants with a 
negative NG NAAT and culture from 
urethral or cervical sites at the end 
of the trial (day 30 +/- 3 days) 
x Proportion of participants with a 
negative NG NAAT and culture from 
oropharyngeal sites at the end of 
the trial (day 30 +/- 3 days) 
x Proportion of participants with a 
negative NG NAAT and culture from 
rectal sites at the end of the trial 
(day 30 +/- 3 days) 
To determine the late relapse/re-infection 
rate of NG from urethral, cervical, rectal, 
pharyngeal specimens after administration 
of a single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g 
oral dose of azithromycin 
Out of participants with symptoms at end 
of the trial (day 30 +/- 3 days), the following 
will be determined: 
x Proportion of patients with positive 
NAAT and/or culture at each 
anatomical site respectively at end 
of the trial (day 30 +/- 3 days)  
x Antimicrobial susceptibility profile 
of gonococcal strains isolated at the 
end of the trial (day 30 +/- 3 days) 
To investigate relationships between pre-
treatment and post-treatment NG isolates 
within those participants whose cultures at 
TOC and EOT are found positive for NG and 
identify possible determinants of 
zoliflodacin resistance 
WGS of NG isolates from the TOC and EOT 
visits plus all baseline isolates (urogenital, 
pharyngeal and rectal) from the same 
patients with possible microbiological 
failure  
 
3. Trial design  
3.1. Design 
This trial will be a multi-center, open label, randomized controlled, non-inferiority phase III 
trial evaluating the safety and efficacy of a 3 g oral dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin for the treatment of uncomplicated gonorrhoea.  
A schematic of the trial schedule is presented in Figure 1. Participants presenting to the clinic 

			
	


Protocol number STI_Zoli001
Zoliflodacin
Protocol version 5.0 of 12 July 2023
Confidential 
Page 28 of 74
will be assessed for eligibility after informed consent is signed on Day 1. Should eligibility be 
confirmed, they will be randomised to either the zoliflodacin group or the ceftriaxone-
azithromycin combination group, undergo baseline assessments and dosed with the trial
treatment. Those participants who are assigned to the zoliflodacin group and who will also 
have consented to be enrolled in the PK sub-study will undergo blood sampling on Day 1 and 
return to the clinic on Day 2 for further blood sampling. Site staff will call all participants on 
Day 3 for safety monitoring purposes and to enquire about sex behaviour since the previous 
clinic visit. Participants will return to the clinic on Day 6 for the TOC visit, involving safety and 
efficacy assessments (primary endpoint for the trial will be assessed at the TOC visit). Those 
participants that will a posteriori have been diagnosed with a CT infection via NAAT at baseline 
and who were randomised to the zoliflodacin arm will then be treated for the CT infection as 
per standard of care. All participants will be asked to return to the clinic for the EOT visit on 
Day 30 for final safety and efficacy assessments. For further details on the schedule of 
assessments refer to Section 5. 
Figure 1: Trial design schematic 
CT: Chlamydia trachomatis; HIV: human immunodeficiency virus; NAAT: nucleic acid amplification test; NG: Neisseria 
gonorrhoeae; PK: pharmacokinetics. 
Note: Culture and NAAT assessments at visits 4 and 5 are conditional to results at previous visits as per the schedule of 
assessments (Section 5).
3.2. Rationale 
3.2.1. Justification for trial design
The choice of a non-inferiority trial design is based on the fact that an efficacious treatment 
already exists for uncomplicated gonorrhoea, although not all participants achieve 
microbiological cure. Given the high cure rate achieved with the ceftriaxone/azithromycin 
combination (≥95%) it would be unethical to conduct a placebo-controlled trial. It would also 
be unfeasible to show superiority of zoliflodacin. On the other hand, zoliflodacin offers some 
advantages over the ceftriaxone/azithromycin combination: it has in-vitro activity against 
azithromycin-, cefixime- and ceftriaxone- resistant strains and it is an oral treatment while 
ceftriaxone is an injectable treatment. A non-inferiority design is therefore justified and is 
consistent with the US Food and Drug Administration (FDA) guidance for industry (38).
Justification for the non-inferiority margin is available in Section 11.1.
3.2.2. Justification for investigational drug dose selection 
Pharmacokinetic/pharmacodynamic (PK/PD) targets have not been developed or established 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 29 of 74 
 
specifically for NG in animal or human studies. Because of spontaneous eradication of the 
bacteria, proven adequate animal models of gonococcal infection do not exist and a mouse S. 
aureus neutropenic thigh model was used as a surrogate to determine the human dose for 
zoliflodacin (20). Based on the S. aureus trial, the highest MIC observed to date (0.25 mg/litre 
[L]) and data from the SAD phase I trial, doses of 2 g and 3 g were investigated in the phase II 
trial. The key assumption behind dose selection was that the PK/PD index best associated with 
clinical efficacy was AUC/MIC (20). In the phase II trial, high cure rates were achieved with 
both a 2 g and a 3 g dose. In the primary analysis of the micro-ITT population, 55 of 57 (96.5%, 
CI: [87.8%, 99.6%]) infected participants in the zoliflodacin 2 g arm achieved microbiological 
cure at the urethral/cervical site. Of the 56 infected participants in the zoliflodacin 3 g arm, 54 
(96.4%, CI: [87.7%, 99.6%]) achieved microbiological cure and of the 28 infected participants 
in the ceftriaxone arm, all 28 (100%, CI: [87.7%, 100%]) achieved microbiological cure. In the 
secondary analysis of the per protocol (PP) population, 48 of 49 (98.0%, CI: [89.2%, 99.9%]) 
infected participants in the zoliflodacin 2 g arm achieved microbiological cure at the 
urethral/cervical site. Of the 47 infected participants in the zoliflodacin 3 g arm, all 47 (100%, 
CI: [92.5%, 100%]) achieved microbiological cure. Of the 21 infected participants in the 
ceftriaxone arm, all 21 (100%, CI: [83.9%, 100%]) achieved microbiological cure. 
Microbiological cures at the rectal and pharyngeal sites were also investigated in the Phase II 
trial. Further details are available in the IB. The phase II trial used a compounded suspension 
of active pharmaceutical ingredient (API) in an aqueous vehicle containing standard 
excipients. This formulation was not commercially viable, hence a granule for oral suspension 
formulation has been developed for further testing in clinical trials and commercialization. 
The rBA trial (clinicaltrials.gov NCT03404167) and the final data from the food effect trial 
(Clinicaltrials.gov NCT 03718806) showed that the exposure achieved with granule 
formulation is comparable to that achieved with the aqueous suspension formulation. The PK 
characteristics measured during these trials may be found in the IB.  
PK/PD modelling suggests that a 3 g dose of the granule formulation will result in an AUC of 
30500 ng•h/mL (5%-95% quantile bounds: 9960 - 78400 ng•h/mL) and 53600 ng•h/mL (5%-
95% quantile bounds: 22400 - 107000 ng•h/mL) in fasted and fed subjects respectively. These 
values are comparable to the AUC achieved with a 3 g dose of the previous aqueous 
suspension formulation. Additional information can be found in the IB. 
Based on those results, to maximize cure rates both at urogenital and extra-genital sites and 
to cover isolates with higher MICs, a 3 g dose was selected as the final dose for the phase III 
trial. This dose was well tolerated in both phase I and II studies. To further support a 3 g dose, 
results of dose-ranging HFIM experiments with NG recently confirmed that, accounting for PK 
variability in human, a 3 g dose provides effective killing of NG while suppressing emergence 
of resistance (22). It thus appears that the 3 g dose provides the best benefit/risk ratio.  
3.2.3. Justification for comparator selection 
The present trial will be the first global trial investigating a new antimicrobial that aims at 
addressing a global public health need. The Global Antibiotic Research and Development 
Partnership (GARDP) overarching goal is to conduct a single phase III trial that meets the 
regulatory requirements of the US FDA, the South African Health Products Regulatory 
Authority (SAHPRA), the Thai Food and Drug Administration (Thai FDA) and the European 
Medicines Agency (EMA), and that enables registration and roll out of zoliflodacin in those 
countries. However, a major challenge is to choose a unique comparator against which 
zoliflodacin can be evaluated in a scientifically robust way.  

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 30 of 74 
 
The comparator for this trial is a single combination of an IM dose of 500 mg ceftriaxone and 
a 1 g oral dose of azithromycin. The rationale for use of this combination is to compare 
zoliflodacin to the first line treatment recommended by most current national and 
international guidelines (see Table 2). With regards to the dose of ceftriaxone, a 500 mg dose 
was chosen for the following reasons: 
1) Dosages of ceftriaxone up to 1 g have proven safe and are approved for use in various 
indications by all regulatory agencies cited above. A dose of 500 mg ceftriaxone is 
recommended for first line treatment of uncomplicated gonorrhoea in the US and the 
EU and for re-treatment/treatment failure by WHO guidelines for the treatment of NG 
(39-41). 
2) There is currently no firm clinical evidence to support (or to oppose) a 500 mg versus 
a 250 mg dose of ceftriaxone for treatment of gonorrhoea. However, modelling data 
suggests a higher dose may achieve higher log kill, in particular in situation where MICs 
are in the upper range (40, 42). It is generally assumed that the clinical efficacy of β-
lactam antibiotics relates to fT > MIC and experiments conducted by Jaffe and 
colleagues found that penicillin efficacy in male urethritis was predicted by total (i.e. 
serum-bound plus free) penicillin levels at least four times above the MIC for at least 
10 h, roughly corresponding to an fT > MIC of 7–10 h (43). For cephalosporins, 
Chisholm et al. postulated that an fT > MIC of 20–24 h is needed for efficacy with 
cephalosporins (42). This is unlikely to be achieved by a 250 mg dose while it is very 
likely by a 500 mg dose. 
3) At the moment the ceftriaxone MICs are still largely within the susceptible range 
(≤0.125 μg/ml) and 250 mg dose is likely to achieve sufficient exposure to cover most 
isolates. However, MIC "creep" is being observed in several countries, including in 
South Africa and Thailand, and reports of treatment failures have been published from 
several countries internationally (28, 44, 45). In the WHO Southeast Asian Region, 
decreased susceptibility or resistance to ceftriaxone was noted by 50% (3/6) of the 
countries (Bhutan, India, and Indonesia) reporting ceftriaxone susceptibility data in 
2014; 33% (2/6; India and Indonesia) reported ≥ 5% decreased susceptibility or 
resistance (27). From 2009 to 2014, 83% (5/6) of countries reported isolates with 
decreased susceptibility or resistance to ceftriaxone, and 50% (3/6) reported ≥ 5% 
decreased susceptibility or resistance (27). The latest estimates from China also show 
that between 9.7% and 12.2% of the isolates have decreased susceptibility to ESC (46). 
In essence, this means that by the time zoliflodacin is licensed it is likely that the WHO-
recommended dosage of ceftriaxone will have also increased. Several countries 
already use 500 mg to 1 g of ceftriaxone (e.g. China, Germany, The Netherlands, Japan 
and the US). Comparing zoliflodacin to 500 mg dose of ceftriaxone during the phase III 
will therefore bring more meaningful data to support registration.  
4) Based on the assumption above, showing non-inferiority of zoliflodacin to 500 mg of 
ceftriaxone + 1 g azithromycin will be more conservative, as well as more widely 
applicable than if a 250 mg ceftriaxone dose + 1 g azithromycin was used as a 
comparator. 
5) This dosage was used in other gonorrhoea trials, including the zoliflodacin phase II trial, 
and achieved high cure rates and excellent safety profile.  
6) The combination of ceftriaxone with azithromycin is the standard of care in many 
countries (See Table 2). 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 31 of 74 
 
Table 2: Summary of currently recommended regimens for the treatment of uncomplicated 
gonorrhoea 
 
Uncomplicated urogenital 
infections due to NG 
Uncomplicated urogenital 
infections due to CT  
Reference 
WHO 
250 mg ceftriaxone, IM, single 
dose + 1 g azithromycin, oral, 
single dose 
Or 
400 mg cefixime1 oral single 
dose +1 g azithromycin, oral, 
single dose 
 
1 g azithromycin, oral, single 
dose 
Or 
100 mg doxycycline, oral, twice 
a day (BID) for 7 days 
(39, 47) 
US CDC 
From December 2020: 500 mg 
ceftriaxone, IM, single dose 
 
From December 2020: 100 mg 
doxycycline, oral, BID for 7 days 
 
(40) 
 
Before December 2020:  
250 mg ceftriaxone, IM, single 
dose + 1 g azithromycin, oral, 
single dose 
Before December 2020:  
1 g azithromycin oral, single 
dose or 100 mg doxycycline, 
oral, BID for 7 days 
(48) 
 
South Africa 
national 
guidelines 
 
 
No differentiation between NG and CT infections 
(49) 
250 mg ceftriaxone + 1 g azithromycin 
 
Thailand 
national 
guidelines 
500 mg ceftriaxone, IM, single 
dose  
Or 
400 mg cefixime1,2 oral, single 
dose 
 
1 g azithromycin, oral, single 
dose 
Or 
100 mg doxycycline, oral, BID 
for 14 days 
 
(50) 
Europe 
guidelines  
 
 
 
Netherlands 
guidelines 
500 mg ceftriaxone, IM, single 
dose 
 + 2 g azithromycin oral, single 
dose 
 
500 mg ceftriaxone, IM, single 
dose 
 
1 g azithromycin oral, single 
dose 
Or 
100 mg doxycycline, oral, BID 
for 7 days 
 
1 g azithromycin, oral, single 
dose 
Or 
100 mg doxycycline, oral, BID 
for 7 days 
(41) 
 
 
 
 
(51) 
 
CT: Chlamydia trachomatis; IM: intramuscular; NG: Neisseria gonorrhoeae; US-CDC: United States Centers for 
Disease Control and Prevention; WHO: World health Organisation. 
1. Provided recent local resistance data shows susceptibility to the antibiotic 
2. Azithromycin is not a requirement for treatment of uncomplicated gonorrhoea but recommended for 
the empiric treatment of symptomatic individuals 
 
 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 32 of 74 
 
3.2.4. Justification for exclusion of CYP3A4 inhibitors 
In the initial development of zoliflodacin a physiologically-based PK (PBPK) model 
incorporating physicochemical properties, absorption, distribution, metabolism, and 
excretion of zoliflodacin was developed to investigate the systemic exposure of the drug after 
oral administration to healthy adults and determine the potential for drug-drug interactions 
(DDIs) (see IB for details). Based on the output of these simulations using data derived from 
the original amorphous formulation, the totality of the data indicated that zoliflodacin has low 
potential for significant DDIs across a broad range of CYP P450s and transporters except 
CYP3A4. Strong CYP3A4 inhibitors were predicted to have a modest impact on zoliflodacin 
(~1.3 fold increase on Cmax and a 2.4 - 2.6 fold increase in AUC) while moderate to strong 
CYP3A4 inducers have the potential to reduce zoliflodacin exposure below what is required 
for efficacy.  
The increase in AUC predicted by physiologically-based PK model in zoliflodacin in the 
presence of strong inhibitors (ketoconazole and ritonavir) was used directly to adjust the 
typical value estimate of clearance (tvCL) in the population PK model. The population PK 
model was then used to conduct Monte Carlo simulations of a virtual patient population. In 
this manner the potential effect of a strong CYP3A4 inhibitor on the simulated PK could be 
considered across fed/fasted status and body weight range. 
In light of the substantive food effect observed in the recent Phase I Food Effect study 
(DNDi/GARDP STI_Zoli002) of the new immediate release formulation ("Phase III 
formulation"), the Sponsor has undertaken further in silico evaluation of the potential impact 
of CYP3A4 inhibition on zoliflodacin exposure using the refined population PK model used to 
extrapolate exposure in lower body weight ranges of 35 to 50 kg; for these analyses, the 
potential effect of a strong CYP3A4 inhibitor on zoliflodacin concentrations was considered by 
reducing the tvCL value in the model by 2.37 and 2.61 fold based upon mean predicted fold 
changes in AUC (derived from SimCYP simulations) with ketoconazole and ritonavir as 
inhibitors. 
Output of Monte Carlo simulations for a 3000 mg dose utilizing these predicted fold changes 
in AUC of zoliflodacin in the presence of each strong CYP3A4 inhibitor suggested the highest 
mean Cmax achieved in the lowest bodyweight of 35 kg (weight cut-off limit in the ongoing 
Phase III study GARDP STI_Zoli001), would be nearly equivalent to the maximum 
concentration that has been observed clinically; i.e. mean geometric mean Cmax of 37.5 
μg/mL in subjects administered a 4000 mg (“Phase III formulation”) with a high fat meal.  
Based on this analysis, the Sponsor concluded that it was prudent to prohibit concomitant 
dosing of zoliflodacin with moderate/strong CYP3A4 inhibitors until further clinical and PK 
data are available from PK subset groups in the present Phase III study and from a planned 
study that is investigating drug-drug interactions and food effect (STIZoli_003, EudraCT 
number 2020-000379-19). 
 
3.2.5. Impact of COVID-19 pandemic on trial conduct and contingency measures 
The COVID-19 pandemic is providing unprecedented challenges to all healthcare workers 
and patients in general and for recruitment and running of clinical trials.  
GARDP therefore took, and continues to take, contingency measures to mitigate the impact 
of the pandemic on the trial, to support site staff and patients, and to minimise risks to 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 33 of 74 
 
them, while being able to continue recruitment to the trial and to guarantee data quality 
and integrity.  
Contingency measures are described in a separate COVID-19 mitigation plan.  
  
3.3. Randomization 
The randomization sequence will be obtained by computer-generated random numbers and 
provided to each trial site through a web-based randomization system. Trial participants will 
be assigned to receive either zoliflodacin or a ceftriaxone/azithromycin combination in a 2:1 
allocation ratio. Unequal randomization has been chosen to increase the number of 
individuals from which safety data is gathered. Randomisation will be performed using 
random permutated blocks of 3, 6, and 9 with stratification by sex at birth and with each block 
maintaining the 2:1 randomisation. At each trial site, a dedicated pharmacist or designated 
clinician will be responsible for monitoring drug storage and for dispensing trial drugs in 
accordance with the treatment allocation. 
3.4. Blinding 
This will be an open-label trial. With a double-dummy design, participants would have to 
receive an IM injection and a tablet as well as an oral sachet, which would be likely to decrease 
their willingness to participate in the trial. Moreover, placebo injections might not be 
acceptable from an ethical perspective, and as a consequence the majority of gonorrhoea 
trials conducted over the past 30 years that included ceftriaxone treatment arm have been 
unblinded trials.  
Nevertheless, the laboratory staff who performs assessment of the primary outcome will be 
blinded to treatment allocation. This is achievable as the treatment allocation will not be 
mentioned on the trial specimen sent to the laboratory. Samples collected throughout the 
trial will be anonymized and a unique participant identifier will be used for sample tracking 
and result reporting. Laboratory results will be entered in the electronic case report form 
(eCRF) by site staff, or reported directly to data management as per pre-determined data 
specifications. For sites participating in the PK sub-study, it will be ensured that trial personnel 
handling PK samples are different from the laboratory personnel handling microbiological 
samples.  
With the exception of medical monitors and country specific personnel who interact regularly 
and are required to advise unblinded site teams, the sponsor remains blinded as detailed in 
the Blinding convention document. All the data will remain blinded to the sponsor until 
database lock, except in case of expedited reporting of suspected unexpected serious adverse 
reaction (SUSAR). 
3.5. Trial duration  
The planned total duration for individual participants will be 30 days (± 3 days). The trial 
treatment will be a single dose of either the investigational treatment or the comparator 
treatment. The duration of the follow-up period will be 29 days (± 3 days). The end of the trial 
is defined as the last participant’s last visit. Overall and taking into consideration an evaluation 
of the impact of the COVID-19 pandemic on recruitment, recruitment into the trial is expected 
to last for approximately 3.5 years. 
 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 34 of 74 
 
4. Selection of participants 
The target sample size is 696 evaluable participants: 464 in the zoliflodacin group and 232 in 
the comparator group, with an estimated randomisation sample size of up to approximately 
928. Details of the sample size calculation can be found in Section 11.1. Accounting for 
anticipated screening failures, the enrolment sample size is estimated to be around 1092. 
Only participants who meet ALL inclusion criteria and NONE of the exclusion criteria will be 
eligible for enrolment into the trial. All relevant medical and non-medical conditions should 
be taken into consideration when deciding whether this protocol is suitable for a particular 
participant. Eligibility criteria must not be waived by the investigator nor by the sponsor. 
4.1. Inclusion criteria 
Participants must meet ALL the following inclusion criteria to be eligible for enrollment into 
the trial:  
1. Age ≥ 12 years old (if enrolment of minors is in agreement with local regulations and 
ethics guidance) 
2. Weight ≥ 35 kg 
3. Signs and symptoms consistent with urethral or cervical gonorrhoea  
OR 
Urethral or cervical uncomplicated gonorrhoea as determined by either a positive 
culture or NAAT or Gram stain or methylene blue/gentian violet stain in the past 14 
days prior to screening 
OR 
Unprotected sexual contact with an individual reported to be infected with NG in the 
past 14 days prior to screening (confirmation by a positive NAAT, Gram stain, 
methylene blue/gentian violet stain or culture) 
4. For females of child-bearing potential, a negative urine pregnancy test at screening 
5. For females of child-bearing potential, use of a highly effective method of 
contraception at the time of IMP administration on Day 1 (see Appendix 1: 
Contraception methods considered as highly effective and required duration) and 
during at least 28 days after treatment. Females on oral contraceptives must also use 
a barrier contraception method during participation in the trial 
6. For males with a female partner of child-bearing age, willingness to delay conception 
for 28 days after treatment 
7. Willingness to comply with trial protocol 
8. For participants in PK sub-study: Willingness to undergo HIV testing 
9. Willingness to abstain from sexual intercourse or use condoms for vaginal, anal and 
oral sex until the EOT visit 
10. Willingness and ability to give written informed consent or be consented by a legal 
representative or provide assent and parental consent (for minors, as appropriate). 
4.2. Exclusion criteria 
The presence of any of the following will exclude a potential participant from trial enrolment: 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 35 of 74 
 
11. Confirmed or suspected complicated or disseminated gonorrhoea  
12. Pregnant or breastfeeding women 
13. Known concomitant infection which would require immediate additional systemic 
antibiotics with activity against NG 
14. Use of any systemic or intravaginal antibiotics with activity against NG within 30 days 
prior to screening 
15. Use of systemic corticoid drugs or other immunosuppressive therapy within 30 days 
prior to screening 
16. Use of moderate or strong CYP3A4 inducers (e.g. efavirenz, rifampicin, carbamazepine, 
phenobarbital) within 30 days or five half-lives of the drug, whichever is greater, prior 
to screening (see Section 6.9) 
17. Cytotoxic or radiation therapy within 30 days prior to screening 
18. Known chronic renal, hepatic, hematologic impairment or other condition interfering 
with the absorption, distribution or elimination of the drug based on medical history 
and physical examination 
19. History of urogenital sex-reassignment surgery 
20. Immunosuppression as evidenced by medical history, clinical examination or a recent 
(≤ 1 month) CD4 count <200 cells/μL 
21. Know clinically relevant cardiac pro-arrhythmic conditions such as cardiac arrhythmia, 
congenital or documented QT prolongation   
22. Known history of severe allergy to cephalosporin, penicillin, monobactams, 
carbapenems or macrolide antibiotics  
23. Known or suspected allergies or hypersensitivities to lidocaine, methylparaben, lactose 
or any of the components of the study drugs (refer to the zoliflodacin IB and SmPC for 
the comparators treatments)  
24. Receipt or planned receipt of an investigational product in a clinical trial within 30 days 
or five half-lives of the drug, whichever is greater, prior to screening until end of 
participation to this clinical trial 
25. History of alcohol or drug abuse within 12 months prior to screening which would 
compromise trial participation in the judgment of the investigator 
26. Severe medical or psychiatric condition which, in the opinion of the investigator, may 
increase the risk associated with trial participation or may interfere with the 
interpretation of trial results or affect the individual’s ability to provide informed 
consent 
27. Individuals whom, in the judgement of the investigator, are unlikely or unable to 
comply with this trial protocol 
28. Previous randomisation in this clinical trial 
29. Use of moderate or strong CYP3A4 inhibitors (see manual of operating procedures 
[MOP]) within 30 days or five half-lives of the drug, whichever is greater, prior to 
screening (see Section 6.9) 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 36 of 74 
 
 
5. Schedule of events  
5.1. Table of assessments 
The trial investigational schedule is shown in Table 3. 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 37 of 74 
 
Table 3: Trial investigational schedule 
Visit number 
11 
2 
3 
4 
5 
 
Timing (window) 
Day 1 (- 1 
day) 
Day 1 
Day 2 
Day 3 (-1 
day) 
Day 6 (± 2 
days)2 
Day 30 (± 3 
days) 
 
Visit type 
Screening 
Baseline 
Dosing 
PK 
Phone 
call 
Test of 
cure 
(TOC) 
End of trial 
(EOT) 
Early 
withdrawal / 
unscheduled 
visit3 
Screening assessments 
 
 
 
 
 
 
 
 
Informed consent4 
X 
 
Demographics5 
X 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
Sexual history6 
X 
 
 
 
X 
X 
X 
X 
Targeted physical examination7 
X8 
 
 
 
 
X 
X 
X 
Pregnancy test 
X 
 
X 
X 
X 
Assessment of eligibility 
X 
 
 
 
 
 
 
 
 
 
 
Randomization  
X17 
 
 
 
 
 
 
 
 
 
 
Laboratory investigations   
 
HIV testing9 
 
X 
 
 
 
 
 
 
Full blood count (FBC) and differentials 
X 
 
X 
X 
X 
Liver function tests (LFTs)10 
X 
 
X 
X 
X 
Creatinine and estimated glomerular filtration rate (eGFR) 
X 
 
X 
X 
X 
Urethral/endocervical Gram stain and microscopy 
examination11   
X 
 
 
 
 
 
 
 
 
 
 
Efficacy outcomes    
 
Urogenital NG culture and NAAT 
X 
 
X12 
X13 
Rectal NG culture and NAAT 
X 
 
X12 
X13 
Pharyngeal NG culture and NAAT 
X 
 
X12 
X13 
Antimicrobial susceptibility testing14 
X 
 
X 
X 
NAAT for CT (urogenital) 
 
X 
 
 
 
 
 
 
NAAT for CT (rectal) 
X 
 
NAAT for CT (pharyngeal) 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 38 of 74 
 
Pharmacokinetic sampling15 
X 
 
X 
 
 
 
 
 
 
 
 
 
Food intake16 
 
 
X 
 
 
 
 
 
Trial treatment administration 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse events 
Å--------------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------¦ 
Prior / concomitant medications 
Å--------------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------¦ 
CT: Chlamydia trachomatis; HIV: human immunodeficiency virus;  NAAT: nucleic acid amplification test; NG: Neisseria gonorrhoeae.PK: pharmacokinetics. 
1. 
Assessments for Visit 1 can be performed over 2 days as long as ALL Baseline assessments and Dosing are performed on the 2nd day. Day 1 is the day of dosing. For details see Section 5.2.1. 
2. 
In case ANY of the NG microbiological test results for a specific anatomical site is not available prior to the collection of the TOC visit specimens, both NG culture and NAAT microbiology specimens should 
be collected for that particular anatomical site and microbiological evaluations should be performed.  
3. 
If a participant has completed scheduled visits as per protocol and returns to the clinic on an additional occurrence on a day that does not correspond to a scheduled trial visit, site staff should handle them 
as per their routine practice. In this case no assessment is mandated as per protocol. See Section 5.3 for details. 
4. 
Including counselling on sexual risk behaviour, and partner(s) notification and treatment 
5. 
Including date of birth, gender, sex at birth, ethnicity 
6. 
Using sexual history questionnaires provided 
7. 
Including clinical assessment of gonorrhoea 
8. 
Screening physical examination will act as baseline too 
9. 
HIV testing is mandatory only for participants to the PK sub-study. For all other participants, HIV testing is proposed, but not mandatory for inclusion in the study. An HIV test result obtained on the day of 
enrolment may be used as baseline assessment. Participants with a documented positive HIV diagnosis or documented prescription of ART also do not need to be tested again. 
10. Alanine transaminase (ALT) and total and direct bilirubin (direct bilirubin only required if total bilirubin is elevated) 
11. A Gram stain result obtained on the day of enrolment may be used as baseline assessment 
12. In cases where both baseline NG NAAT and NG culture results are negative, no further samples should be taken at subsequent visits. This applies to each anatomical site respectively. 
13. Only take sample if: 
- symptoms at any anatomical site are present. If symptoms at any anatomical site are observed, take samples from all 3 anatomical sites. 
- a negative culture and a positive NG NAAT results were obtained at TOC. This applies to each anatomical site respectively. 
14. Only for culture samples with confirmed identification of NG 
15. Only for participants who consent to participate in the PK sub-study. The PK sub-study will take place in select sites only. See Section 7.3 for time points.  
16. Food must be taken before trial treatment. Details on timing of food intake in relation with dosing time and required food content are available in the MOP.   
17. For participants of the PK sub-study only, randomisation can occur on Day -1 (Screening) once eligibility has been confirmed and participants can return to complete baseline assessments and receive study 
treatment the following calendar day, to assist with scheduling of the visit. 
 

			
	


Protocol number STI_Zoli001
Zoliflodacin
Version 5.0 of 12 July 2023
Confidential 
Page 39 of 74
5.2. Schedule of assessments
Changes in health and concomitant medications will be recorded from signature of the 
informed consent until the EOT visit. See Section 8 for further details on adverse events.
5.2.1. Visit 1: Day 1 (-1 day)
Assessments for Visit 1 can be performed over 2 days as long as ALL Baseline assessments 
and Dosing are performed on the 2nd day. The day that is considered Day 1 is the day of 
Dosing. 
Screening Day 1 (-1 day)
After signing the informed consent, participants will be asked demographic information, 
including date of birth (only year of birth and age will be reported in the eCRF), gender, sex at 
birth and ethnicity. Eligibility criteria will be reviewed, and a complete medical history, and 
sexual history over the past 3 months will be obtained as part of this process. A targeted 
physical examination will be performed (the physical examination performed at screening will 
be regarded as the baseline), including a clinical assessment of gonorrhoea, as well as a urine 
pregnancy test for females of child-bearing potential.
For participants taking part in the PK sub-study, randomization can occur on Day -1 (Screening) 
once eligibility has been confirmed, and participants can return to complete Day 1 baseline 
assessments and receive study treatment the following calendar day, to assist with scheduling 
of the visit.
Baseline (Day 1) 
Eligible participants will be randomised to either the zoliflodacin or the comparator group. 
They will then undergo baseline assessments, including safety laboratory tests and HIV rapid 
testing if applicable. HIV testing is mandatory only for participants to the PK sub-study. For all 
other participants, HIV testing is proposed, but not mandatory for inclusion in the study. An 
HIV test result obtained on the day of enrolment may be used as baseline assessment. 
Participants with a documented positive HIV diagnosis or documented prescription of ART do 
not require repeat testing. Swabs will also be taken for microbiology outcomes (1 swab for NG 
culture and 1 swab for NG/CT NAAT evaluations) from the urethra or cervix, rectum and 
pharynx. 
Absorption of zoliflodacin and tolerability of azithromycin tablets are improved when patients 
are fed, and not fasted. Therefore, food must be taken before trial treatment. Details on 
timing of food intake in relation with dosing time and required food content are available in 
the MOP. The date and time of last food intake prior to trial treatment administration will be 
captured.
Once ALL baseline assessments are completed, participants will receive trial treatment.
Blood samples for PK analysis will be taken as per schedule described in Section 7.3 from those 
participants who will have signed the PK sub-study informed consent.
5.2.2. Visit 2: Day 2 - PK sub-study
Visit 2 is for participants enrolled in the PK sub-study only. See Section 7.3 for further details.

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 40 of 74 
 
5.2.3. Visit 3: Day 3 (-1 day) 
On day 3, the medical staff will call participants on the phone to enquire about their health 
condition and sexual history since the last visit. This day is not a clinic visit. 
5.2.4. Visit 4: Day 6 (+/-2 days) 
At the TOC visit, participants will undergo safety lab assessments, a physical examination 
including a clinical assessment of gonorrhoea, and females of child-bearing potential will 
perform a urine pregnancy test. Males at birth will be assessed for clinical cure as per guidance 
in the MOP. Sexual history since the previous visit will also be assessed. The medical staff will 
enquire with the participant whether they experienced any potential AE and took any 
medication since the last visit. 
Swabs will be collected for microbiology outcomes (1 swab for NG culture and 1 swab for NG 
NAAT evaluations) from each anatomical site (urogenital, rectal and pharyngeal), unless both 
NG culture and NG NAAT results at that specific anatomical site were negative at baseline. 
In case ANY of the NG microbiological test results for a specific anatomical site is not available 
prior to the collection of the TOC visit specimens, both NG culture and NAAT microbiology 
specimens should be collected for that particular anatomical site and microbiological 
evaluations should be performed. 
Once all specimens are collected, participants randomised to the zoliflodacin arm with a 
positive CT NAAT at baseline will be treated for CT infection as per local standard of care.  
If a participant returns for a TOC visit outside the allowed time window, the primary TOC 
assessments will be considered missed and the participant will therefore be regarded as a 
treatment failure for primary endpoint analysis. It is therefore of crucial importance to ensure 
all participants have a TOC visit within the allowed time window (Day 6 +/- 2 days). 
5.2.5. Visit 5: Day 30 (+/-3 days) 
At the EOT visit, participants will undergo safety lab assessments, a physical examination 
including a clinical assessment of gonorrhoea, and females of child-bearing potential will 
perform a urine pregnancy test. Sexual history since the previous visit will also be assessed. 
The medical staff will enquire with the participant whether they experienced any potential AE 
and took any medication since the last visit. 
Swabs will be collected for microbiology outcomes as per Table 4 in Section 7.4.  
5.2.6. Early withdrawal 
In case a participant is withdrawn or withdraws consent prior to Visit 5 (EOT), they will be 
asked to return to the clinic to undergo safety lab assessments, a physical examination and a 
urine pregnancy test if they are a female of child-bearing potential, as well as the sexual 
history questionnaire, should they agree.  The medical staff will enquire with the participant 
whether they experienced any potential AE and took any medication since the last visit. 
If a participant withdraws during the timeframe for Visit 4 or Visit 5, trial staff should attempt 
to collect samples as per the schedule of assessment at that visit, should the participant agree. 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 41 of 74 
 
5.3. Unscheduled and out-of-window visits 
5.3.1. Out-of-window visits 
Protocol-specified visits that occur outside of the protocol-specified time windows will be 
considered out-of-window visits. Results of assessments and procedures for these should be 
documented in the eCRF pages for the intended visit and a protocol deviation must be 
documented. In case of doubt or question on which visit should be performed, the Investigator 
should contact the medical monitor. 
 
5.3.2. Unscheduled visits 
Unscheduled visits can occur at any time during study participation.  Assessments are not 
mandated per protocol but if a participant has completed scheduled visits as per protocol 
and returns to the clinic on an additional occurrence on a day that does not correspond to a 
scheduled trial visit, site staff should handle them as per their routine practice. No 
assessments are mandated as per protocol, but can be performed and recorded for safety 
reasons as relevant to the study (e.g. follow-up safety laboratory tests). Site staff will take 
the opportunity to question the participant about any potential adverse event or medication 
taken. In case of identification of either, this must be recorded in source notes and 
transcribed into the eCRF into the adverse event and concomitant medication forms 
respectively.  
6. Investigational products 
6.1. Zoliflodacin treatment  
6.1.1. Product description and dosage 
Zoliflodacin is a first-in-class drug (spiropyrimidinetrione) with a specific mode of action 
against bacterial topoisomerase II distinct from the fluoroquinolone class of antibiotics. The 
chemical name for zoliflodacin is (2R,4S,4aS)-11-fluoro-2,4-dimethyl-8-[(4S)-4-methyl-2-oxo-
1,3-oxazolidin-3-yl]-1,2,4,4a-tetrahydro-2'H,6H-spiro[1,4-oxazino[4,3-a][1,2]oxazolo[4,5-g] 
quinoline-5,5'-pyrimidine]-2',4',6'(1'H,3'H)-trione. Zoliflodacin is presented as white granules 
for oral suspension, packaged in a single sachet. Each sachet contains 3 g amorphous 
zoliflodacin, co-formulated with mannitol, microcrystalline cellulose, croscarmellose sodium, 
colloidal silicon dioxide, xanthan gum, talc, and magnesium stearate. Zoliflodacin is active 
against several STI pathogens, including NG, CT and Mycoplasma genitalium (33, 52).  It shows 
excellent in vitro activity against all clinical NG isolates tested so far, including isolates that 
were resistant to fluoroquinolones, azithromycin, and ESC, and several reference strains such 
as the XDR H401 strain (28, 32, 53).  
6.1.2. Summary of non-clinical and clinical experience 
Please refer to the zoliflodacin IB for full descriptions of the zoliflodacin properties, non-
clinical and clinical data available to date and identified and potential risks associated with 
zoliflodacin. 
 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 42 of 74 
 
6.2. Comparator trial treatment 
6.2.1. Product description and dosage 
Ceftriaxone is a sterile, semi-synthetic, broad-spectrum cephalosporin antibiotic. The 
chemical name of ceftriaxone sodium is (6R, 7R)-7-[2-(2-Amino-4-thiazolyl) glyoxylamido]-8-
oxo-3-[[(1,2,5,6-tetrahydro-2-methyl-5,6-dioxo-as-triazin-3-yl)thio]methyl]-5-thia-1 
azabicyclo [4.2.0]oct-2-ene-2-carboxylic acid, 72-(Z)-(O-methyloxime), disodium salt, 
sesquaterhydrate. The bactericidal activity of ceftriaxone results from the inhibition of cell 
wall synthesis and is mediated through binding to penicillin binding proteins. Ceftriaxone is a 
white to yellowish sterile powder in a clear glass vial. For the purpose of this trial, a single dose 
of ceftriaxone 500 mg, dissolved in lidocaine hydrochloride (HCl) 1% will be used for IM 
injection. Lidocaine is a local anaesthetic that will be used to numb the area of injection and 
therefore limit injection pain.  
Azithromycin is a macrolide antibacterial, for oral administration. The chemical name of 
azithromycin monohydrate is (2R,3S,4R,5R,8R,10R,11R,12S,13S,14R)-13-[(2,6-dideoxy-3-C-
methyl-3-O-methyl-α-L-ribohexopyranosyl) oxy]-2-ethyl- 3,4,10-trihydroxy-3,5,6,8,10,12,14-
heptamethyl-11-[[3,4,6- 
trideoxy-3-(dimethylamino)-β-D-xylo-hexopyranosyl]oxy]-1-oxa-6-
azacyclopentadecan-15-one monohydrate. Azithromycin acts by binding to the 23S ribosomal 
ribonucleic acid (rRNA) of the 50S ribosomal subunit of susceptible microorganisms inhibiting 
bacterial protein synthesis and impeding the assembly of the 50S ribosomal subunit. 
Azithromycin will be supplied as oral tablets containing 250 mg azithromycin.  
6.2.1. Summary of non-clinical and clinical experience 
Please refer to the ceftriaxone and azithromycin summaries of product characteristics (SmPC) 
or United States Prescribing Information (USPI), as applicable, for full descriptions of the 
identified and potential risks associated with ceftriaxone and azithromycin. 
6.3. Labelling and packaging 
The labelling and secondary packaging of zoliflodacin sachets and comparators treatments will 
be performed by Packaging Coordinators Inc. (PCI) Pharma Services on behalf of the sponsor. 
All trial treatments, including those used in the comparator group, will be labelled in 
compliance with applicable regulatory requirements.  
6.4. Shipment  
All necessary documentation, including favourable opinion from independent review boards 
(IRB) /independent ethics committees (IEC) and national regulatory authorities (NRAs), and 
import authorizations, will be obtained prior to shipment of trial treatments to trial sites. 
Upon receipt, trial treatments and their packaging shall be inspected by the pharmacist or 
designee in charge at the trial site. All suspected defects or deterioration are to be reported 
to the sponsor as per the procedure outlined in the MOP. Suspected defective products are 
to be placed in a secure quarantine area pending investigation and further advice from the 
sponsor. 
In the event of a batch recall, the sponsor will be responsible for informing all principal 
investigators and, in collaboration with trial site pharmacists, of facilitating collection of 
recalled batches and delivery of alternative batches to trial sites. All movements will be 
documented in the drug accountability forms (see Section 6.7).  

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 43 of 74 
 
6.5. Storage 
All trial treatments will be stored in the trial site pharmacy, separated and secured, accessible 
only to the trial site staff. All drugs should be stored in accordance with the pharmacy manual.  
The trial site pharmacist or designee will be responsible for monitoring and recording the 
storage temperature and ensuring appropriate measures are in place to protect the trial 
treatments from damage and/or destruction.  
6.6. Preparation and administration of trial treatments 
Trial treatments will only be dispensed and administered to individuals enrolled in the trial 
and who have been randomised. Participants randomized to the zoliflodacin group will receive 
a single 3 g per os (PO) dose (one sachet) of zoliflodacin reconstituted with water. Detailed 
information on the preparation and administration of zoliflodacin can be found in the 
pharmacy manual. Participants randomized to the comparator group will receive ceftriaxone 
as a 500 mg IM injection and azithromycin as four 250 mg oral tablets. The 500 mg ceftriaxone 
vial will be reconstituted with lidocaine HCl 1%. Detailed information on the preparation and 
administration of ceftriaxone can be found in the pharmacy manual. 
6.7. Accountability 
The principal investigator at each site is responsible for the distribution and disposition of the 
trial treatments and has ultimate responsibility for accountability of trial treatments. He/she 
may delegate this responsibility to a trial site pharmacist or nurse. Adequate records on 
receipt, use, return, loss, or other disposition of trial treatments must be maintained. 
Administration of trial treatments will be directly observed and documented in appropriate 
forms by the responsible trial staff. The investigator or site staff are not authorised to supply 
trial treatment to other investigators or sites, or allow trial treatments to be used other than 
as instructed by this protocol without prior written authorisation of GARDP. At the end of the 
trial, unused drugs will be either be destroyed or returned as per sponsor instruction. 
6.8. Blinding and procedures for un-blinding 
As this is an open-label trial, procedures for un-blinding by the investigator in case of medical 
emergency are not applicable. 
6.9. Concomitant treatments 
Medications taken before or after dosing through EOT visit or early termination whichever 
occurs first will be reported as prior medications or concomitant medications, respectively. 
Prior medication taken over the 30 days prior to screening will be recorded as part of the 
screening process (Visit 1). This will also include over-the-counter drugs as well as vitamins, 
herbals and supplements. 
Zoliflodacin should not be co-administered with strong (such as carbamazepine, 
enzalutamine, mitotane, phenytoin, rifampin, or St. John's wort) or moderate (such as 
efavirenz, bosentan, etravirine, modafinil, or nafcillin) inducers of CYP3A4. These drugs should 
not be taken for 30 days before dosing and during the whole trial period.  
Zoliflodacin should not be co-administered with strong or moderate inhibitors of CYP3A4. See 
MOP for examples of such inhibitors. These drugs should not be taken for 30 days before 
dosing and during the whole trial period.  
If a participant is newly diagnosed as HIV positive in the trial and needs to start ART as per 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 44 of 74 
 
local standard of care, or if a participant needs post exposure prophylaxis with a prohibited 
ART, the medical monitor should be contacted immediately to discuss each instance on a case-
by-case basis. Depending on the timing of the required administration of the ART, its 
administration may either be approved, or the participant may be withdrawn from the trial.  
In addition, medications that might interfere with the evaluation of the investigational product 
(e.g. antibiotics with activity against NG) should not be used until the TOC visit. Any 
circumstances that require urgent use of an antibiotic with activity against NG should be 
discussed with the medical monitor.  
Following dosing, any drug (e.g., non-prescription medications, herbal supplements, vitamins, 
or prescription medications) or vaccine or blood/blood products used by the participant 
during the trial will be recorded in the participant’s source documents and on the appropriate 
eCRF.  
Any antacids if taken must be administered more than 1 hour before administration of 
azithromycin. 
Participants who receive trial treatment and are subsequently diagnosed with a concomitant 
infection requiring systemic antibiotics (e.g. bacterial vaginosis [BV]) or infections due to CT, 
Mycoplasma genitalium or Trichomonas vaginalis) will receive treatment according to the 
local clinic’s standard protocols. Whenever possible, additional treatment with antibiotics 
with activity against NG should be deferred up until the TOC visit.  
6.10. Escape treatments 
Participants with persisting signs and symptoms or with a positive NG culture at the TOC visit 
will be treated in accordance with national or local guidelines for treatment failures. 
Treatment received will be recorded in the eCRF. 
7. Trial procedures/evaluations 
Detailed instructions on procedures as well as collection, processing and shipment of samples 
may be found in the laboratory manual and the MOP. 
7.1. Clinical evaluations 
x 
Complete medical history will be obtained by interview of the participants at Visit 1 and 
will be updated at each clinic visit. Participants will be queried regarding a history of 
significant medical disorders of the head, eyes, ears, nose, throat, mouth, cardiovascular 
system, lungs, gastrointestinal tract, liver, pancreas, kidney, urologic system, nervous 
system, blood, lymph nodes, endocrine system, musculoskeletal system, skin, and 
genital/reproductive tract. A history of any allergies, cancer, immunodeficiency, 
psychiatric illness, substance abuse, and autoimmune disease will be solicited. At follow-
up visits, an interim medical history will be obtained by interview of the participants 
noting any changes since the previous visit.  
x 
Sexual history over the past 3 months including sexual orientation will be obtained by 
interview of the participants at Visit 1.  Participants will be queried at Visit 3, Visit 4 and 
Visit 5 regarding sexual activity and condom use since the previous clinic visit. 
Questionnaires to assess sexual behaviour will be provided. 
x 
A targeted physical examination including height and weight and examination of the 
pharynx and genitals (including pelvic exam for women) will be performed on Visit 1, Visit 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 45 of 74 
 
4 and Visit 5. In particular, presence of signs and symptoms of gonorrhoea (e.g. UD, 
dysuria, dyspareunia, visible discharge from urethra and/or anus) will be assessed as per 
the MOP. All physical examinations will be performed by a trial clinician licensed to make 
medical diagnoses. The physical examination performed at screening will act as a baseline 
for subsequent visits . 
x 
A phone interview will be conducted at Visit 3 to check for any changes in health and any 
new medication taken. Participants will also be asked about their sexual activity since the 
previous visit and be reminded about the mandatory sexual behaviour recommendations 
during their involvement in the trial. 
x 
Any changes in health or concomitant medications taken during the trial will be enquired 
and recorded. 
7.2. Laboratory evaluations 
7.2.1. Clinical laboratory evaluations 
x 
A urine pregnancy test will be performed at Visit 1, Visit 4, Visit 5 and early withdrawal on 
all female participants of child-bearing potential. 
x 
HIV testing will be performed at Visit 1 according to standard local practise. HIV testing is 
mandatory only for participants to the PK sub-study. For all other participants, HIV testing 
is proposed, but not mandatory. Participants with a documented positive HIV diagnosis 
or documented prescription for ARTs are considered to be HIV positive and therefore do 
not need to undergo a test. A maximum of 5 ml of venous blood might be collected for 
this test depending on local practice. Any discordant results should be followed up as per 
standard local practice. Further details may be found in the MOP. 
x 
Venous blood samples (a maximum of 15 mL) for haematology and chemistry will be 
collected at Visit 1, Visit 4 and Visit 5. FBC, ALT, direct and total bilirubin (direct bilirubin 
only required if total bilirubin is elevated), and creatinine will be measured. eGFR will be 
calculated using the chronic kidney disease - epidemiology collaboration (CKD-EPI) 
formula. A total volume of a maximum of 50 ml will be taken from each participant during 
the course of the trial (with the exclusion of the PK sub-study). 
7.2.2. Microbiological evaluations 
x 
Microbiological evaluations (Gram stain, culture and NAAT) will be based on the collection 
of appropriate clinical specimen (i.e. a urethral swab for male participants or an 
endocervical swab for female participants for urogenital swabs, a pharyngeal swab or a 
rectal swab) and in accordance with the laboratory manual and MOP. Specimens are 
collected by trained study staff, except pharyngeal specimens which can be self-collected, 
where permitted and as detailed in the MOP. A specific swab for NG culture will be taken 
followed by bedside inoculation of NG selective agar plates. 
x 
Assessment of efficacy in the present trial follows recommendations from the US FDA 
(38). All cultures will be performed in certified national or state/provincial or local 
reference laboratories (see the laboratory manual for a complete list). Local laboratories 
will perform presumptive NG identification, while confirmatory NG identification will be 
carried out by the central laboratory also assessing antimicrobial susceptibility testing. 
x 
Detection of nucleic acid will be based on collection of swabs as above and use of  NAAT. 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 46 of 74 
 
A single swab using the applicable manufacturer’s recommended collection kits will be 
taken to assess the presence of NG and/or CT from the same clinical specimen to minimise 
patient discomfort. Acceptable NAAT platforms/systems and assays are listed in the 
laboratory manual. Detailed methods for NAAT performance can be found in the trial 
laboratory manual. 
x 
Presumed positive cultures will be processed and frozen bacterial isolates will be sent to 
the central laboratory for confirmatory identification and antimicrobial susceptibility 
testing. Aliquots of these frozen bacterial isolates will be stored at a local laboratory for 
future research up to 5 years after the end of the trial, should participants agree (with the 
exception of the Netherlands where bacterial isolates will be kept up to 15 years as per 
standard local practice). 
x 
The MIC, defined as the lowest concentration of an antimicrobial that inhibited the visible 
growth of a microorganism after overnight incubation, will be determined for the 
following antibiotics: zoliflodacin, azithromycin, cefixime, ceftriaxone, ciprofloxacin, 
gentamicin, tetracycline and spectinomycin. Detailed methods for MIC determination can 
be found in the trial laboratory manual. Confirmatory identification of NG by the central 
lab will constitute data for the primary outcome of the trial. 
x 
WGS will be conducted on all NG isolates cultured at the TOC and EOT visits, as well as on 
pre-treatment isolates from the respective participants and on baseline isolates with 
zoliflodacin MIC >0.25 μg/mL. The main objective is to investigate relationships between 
pre-treatment and post-treatment NG isolates within those participants whose cultures 
at TOC are found positive for NG, evaluate the likelihood of re-infection vs treatment 
failure and identify possible genetic determinants of zoliflodacin resistance. The analyses 
will be performed at the microbiology laboratory of the University of Örebro in Sweden.  
7.3. Pharmacokinetic evaluations 
The PK sub-study will be run at select sites (see MOP for list).  
The plasma concentration of zoliflodacin will be determined in the following subsets of 
participants: 
x HIV negative participants and HIV positive participants (≥ 18 years old) 
x HIV negative adolescents (≥12 and <18 years old) 
Each group will include approximately 20 to 30 participants, with PK assessed at five time-
points: 
x 15 min – 1 h post treatment 
x 2 h – 2.5 h post treatment 
x 4.5 h – 5 h post treatment 
x 10 h - 12 h post treatment 
x 24 h - 36 h post treatment 
The time periods will cover Cmax and at least a 10-fold decline in plasma concentration from 
this, this decline being adequately defined as mono-exponential. Sampling time post dose 
will be accurately recorded in the eCRF. Plasma concentrations of zoliflodacin will be 
determined by K-CAS laboratories using a validated high-performance liquid 
chromatography (HPLC) – mass spectroscopy (MS)/MS method. 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 47 of 74 
 
At each time point, a 4 ml venous blood sample will be collected. Samples will be centrifuged 
to allow for extraction of plasma. Plasma should be frozen at about – 70 °C within a 
maximum of 60 minutes after collection of the blood samples. Further details are available in 
the MOP.  
The same food intake recommendations detailed in Section 5.2.1 apply to the participants to 
the PK sub-study. 
7.4. Clinical management of participants 
Assessments performed at site level will be used for patient management. This includes HIV 
and pregnancy testing. Safety laboratory results will be communicated to sites in a timely 
manner to ensure appropriate management of any laboratory finding that is out-of-normal 
range (see laboratory manual for details).  
Table 4 highlights how microbiology test results should dictate clinical management of 
participants and sampling schedule in the trial.  
Table 4: Assessments and use for clinical management 
 
 
Action(s) if result is: 
 
 
Positive 
Negative 
Baseline 
results1, 4 
NG culture and 
NG NAAT 
If either culture and/or NAAT is/are 
positive, take further swabs for 
both culture and NAAT at TOC 
If both NG culture and NG NAAT are 
negative, no further swabs to be 
taken for NG in the trial 
CT NAAT 
 
o Treat as per standard of care at 
TOC after collection of all 
specimens if participant was 
randomised to zoliflodacin 
group 
o No further swabs to be taken 
for CT (except if participant is 
symptomatic at day 30) 
No further swabs to be taken for CT 
(except if participant is symptomatic 
at day 30) 
 
TOC 
results 
NG culture and 
NG NAAT 
o If NG culture is positive, treat 
as per standard of care 
o No further swabs to be taken 
for NG2 
If both NG culture and NG NAAT are 
negative, no further swabs to be 
taken for NG in the trial (except if 
participant is symptomatic at day 
30)1, 3 
o 
If NG culture is negative and NG NAAT is positive at TOC, both NG 
culture and NG NAAT to be done at day 301 
Day 30 
results3 
NG culture and 
NG/CT NAAT 
Treat as per standard of care if any 
of the test results is positive 
 
CT: Chlamydia trachomatis; NAAT: nucleic acid amplification test; NG: Neisseria gonorrhoeae. 
1 Applies to each of the three anatomical sites independently. 
2 If NG culture is positive in any of the three anatomical sites, no further swabs need be taken from any site at 
day 30, except if participant is symptomatic at day 30. 
3 If a participant presents with signs and/or symptoms of an NG infection at Day 30, swabs for NG culture and 
NG/CT NAAT should be collected from all three anatomical sites. 
4 In the event that Baseline results are not available at the time of the TOC visit, all swabs from each of the 
three anatomical sites should be taken. 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 48 of 74 
 
 
Antimicrobial susceptibility testing will be performed in batches during the trial and 
therefore will not be available to sites for clinical management. WGS is exploratory in nature 
and will moreover be analysed in batches. As a consequence, results are not to be used for 
clinical management. 
8. Assessment of safety  
8.1. Definitions 
8.1.1. Adverse event 
An AE is defined as any untoward medical occurrence in a clinical trial participant administered 
a medicinal product and which does not necessarily have a causal relationship with this 
treatment. 
An AE can therefore be any unfavourable and unintended sign (including an abnormal 
laboratory finding or a procedure abnormality that are deemed clinically significant by the 
investigator), symptom, or disease temporally associated with the use of a medicinal product, 
whether or not considered related to the medicinal product. 
Furthermore, the definition of an AE includes worsening (in severity and frequency) of pre-
existing conditions ("medical history") after trial drug administration and abnormalities of 
procedures (i.e. electrocardiogram, X-ray…) or laboratory results which are assessed as 
“clinically significant”. 
What laboratory/procedures abnormalities should be considered as an AE? 
All treatment-emergent laboratory/procedures abnormalities (or worsening in severity or 
frequency of pre-existing abnormalities) assessed as “clinically significant” must be reported 
as an AE. 
When reporting an abnormal laboratory/procedure result, a clinical diagnosis should be 
recorded rather than the abnormal value itself, if available (for example, “anaemia” rather 
than “decreased red blood cell count”).  
What is not an AE? 
• Medical conditions or abnormal safety laboratory results present at the initial trial 
visit that do not worsen in severity or frequency during the trial are NOT considered 
as AE and should be documented as medical history if significant. 
x Symptoms, exacerbation or worsening of the studied disease will NOT be considered 
as AE and will not be captured in the AE page of the eCRF if consistent with the 
anticipated natural progression of the disease (overall and for this given participant). 
• Lack of efficacy of the trial treatment is NOT considered as AE. 
Special Cases: screening period: 
With the exception of abnormal safety laboratory findings detected at baseline (which are 
assumed to have been present prior to informed consent), events occurring after informed 
consent but prior to study treatment administration must be reported as adverse events using 
the applicable form in the eCRF, but will not be classified as treatment-emergent adverse 
events.  

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 49 of 74 
 
8.1.2. Adverse Event reporting period 
The adverse events reporting period begins upon participant enrolment in the trial (after 
signature of informed consent) and ends at an EOT or early withdrawal visit.  
All adverse events that occur during the adverse event reporting period specified in the 
protocol must be reported, whether the event is considered medication related or not. In 
addition, any adverse event that occurs after the adverse event reporting period that the 
investigator assesses as possibly related to the investigational medication should also be 
reported as an adverse event. 
Special Cases: screening failures:  
For screening failure participants, events and updates must be recorded in the eCRF and using 
the AE or serious adverse event (SAE) forms (as appropriate) until the date the participant was 
determined to be a screening failure. Beyond that date, only serious or medically relevant 
protocol-related events will be followed-up. The date and time of screening failure will also 
be recorded in the source notes and the eCRF. 
8.1.3. Serious adverse event 
An AE is defined as serious if it:  
x results in death 
x is life-threatening: in this context refers to an AE in which the participant was at risk of 
death at the time of the AE; it does not refer to an AE that hypothetically might have 
caused death if more severe 
x requires or prolongs hospitalization, i.e. the AE requires at least an overnight admission 
or prolongs a hospitalisation beyond the expected length of stay. Hospital admissions 
for social reasons and respite care in the absence of any deterioration in the 
participant’s general condition, as well as hospitalisation for elective surgery or for 
normal disease management (including treatment adjustment) are NOT to be 
considered as SAE according to this criterion  
x results in persistent or significant disability, i.e. the AE resulted in a substantial 
disruption of the participant’s ability to conduct normal activities 
x is a congenital anomaly/birth defect, i.e. an AE outcome in a child or foetus of a 
participant exposed to the IMP before conception or during pregnancy 
x is an important medical event.  
Medical and scientific judgment should be exercised in deciding whether other situations 
should be considered serious events, such as important medical events that might not be 
immediately life-threatening or result in death or hospitalisation but might jeopardise the 
participant or might require intervention to prevent one of the other outcomes listed above. 
Examples of such events include, but are not limited to, intensive treatment in an emergency 
room or at home for allergic bronchospasm; blood dyscrasias or convulsions that do not result 
in hospitalization. In addition, any suspected transmission via a medicinal product of an 
infectious agent is also considered a serious adverse event/reaction.  
Although exposure during pregnancy and overdose are not always serious by regulatory 
definition, these events must be handled as defined in Section 8.4 for reporting trial treatment 
exposure during pregnancies and Section 8.1.4 for overdose. 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 50 of 74 
 
8.1.4. Overdose 
An overdose is defined as a dose greater than the dose evaluated in the present trial as 
described in Sections 6.1 and 6.2 of the protocol.  
All overdoses should be reported in the eCRF. If the overdose is associated with an AE, then 
the AE should also be reported.  
In the event of an overdose of trial treatment, the investigator should use clinical judgment in 
treating the overdose and contact the sponsor medical monitor. The investigator should refer 
to the IB for detailed information regarding warnings, precautions, contraindications, AEs, and 
other significant data pertaining to zoliflodacin. Investigators should refer to ceftriaxone and 
azithromycin SmPCs respectively in case of overdose with either comparator treatment. 
Trial treatment dosing errors made by the research facility staff that result in a possible 
overdose (as well as all dosing errors) of trial treatment must be documented as protocol 
deviations and reported to the sponsor and the IRB/IEC in accordance with the IRB/IEC 
requirements.  
8.1.5. Grading of AE severity 
The severity is used to describe the medical intensity of a specific event. In this clinical trial, 
the severity of AEs must be primarily assessed by investigators according to the Common 
Terminology Criteria for Adverse Events (CTCAE) (54) tables as a guide in the grading of the 
severity of AEs (grades 1-5). The tables will be provided in the MOP.  
Whenever the AE grading is not detailed in the CTCAE tables, the investigator should use the 
following grading for that specific AE: 
MILD: The participant is aware of the event or symptom, but the event or symptom is easily 
tolerated. Does not interfere with the trial participant’s activities of daily living (ADL). 
MODERATE: The participant experiences sufficient discomfort to interfere with or reduce his 
or her usual level of ADL. 
SEVERE: Significant impairment of functioning: the participant is unable to carry out usual ADL 
and/or the participant’s life is at risk from the event.  
LIFE-THREATENING: The participant’s life is at significant risk; extreme limitation in ADL, 
significant assistance required; significant medical intervention/therapy required, 
hospitalization or hospice care probable. 
The investigator should continue using the above grading for all other subsequent evaluations 
of this particular AE for that participant and all others. When the intensity of an AE changes 
over time, each change in intensity will be recorded in the source documents until the event 
resolves. However, only one AE and the maximum intensity will be recorded in the eCRF for 
each separate event. If the AE resolves but then recurs, each will be recorded as a separate 
AE, with the appropriate start and stop dates and times. 
8.1.6. AE causality assessment 
For both serious and non-serious AEs, the investigator is required to assess if there is a causal 
relationship between the AE and the trial treatments, ie. to determine whether there exists a 
reasonable possibility that the trial treatments caused or contributed to the AE. 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 51 of 74 
 
The following categories for relationship to each trial treatment will be used during AE 
reporting: 
RELATED: There is at least a reasonable possibility of causal relationship between the AE and 
the trial treatment. This means that there are facts (evidence) or arguments to suggest a 
causal relationship. 
NOT RELATED: There is no reasonable possibility that the AE is related to the trial treatment. 
8.2. Detection and recording of AEs 
The investigator is required to report all directly observed adverse events and all adverse 
events spontaneously reported by the trial participant using concise medical terminology. In 
addition, at each visit the participant will be questioned about the occurrence of adverse 
events, with a generic question such as “Since last visit have you felt any health problem?”. 
AEs can be spontaneously reported by trial participants or elicited through open-ended 
questioning, examination, or evaluation of trial participants during trial visits. The investigator 
should also review all results of assessments performed as part of the trial, such as laboratory 
assessment results and physical examinations, and assess them for clinically relevant changes 
compared to baseline (Section 8.1.1). 
All AEs occurring during the trial must be recorded in the AE section of the eCRF. AE recording 
applies to both investigational and control group. AEs (including lab or procedures 
abnormalities) should be described using a diagnosis whenever possible, rather than 
individual underlying signs and symptoms. When a clear diagnosis cannot be identified, each 
sign or symptom should be reported as a separate AE.  
As far as possible, each AE should be evaluated to determine: 
x The severity grade based on the CTCAE (54) Grade 1-5 (Section 8.1.5) or on grading scale 
described above (only for those AEs not described in CTCAE) 
x Its duration (start and end dates or if continuing at the end-of-trial visit) 
x Its relationship to each trial treatment (causality; see Section 8.1.6) 
x Action taken with respect to each trial treatment (treatment maintained, dose reduced, 
permanently discontinued, temporarily discontinued, not applicable) 
x Whether medication or therapy was taken/given in relation to the AE 
x Whether it is serious (see Section 8.1.3). 
AE recording shall begin upon signature of the informed consent form (ICF) and should 
continue until the participant’s last visit. 
8.3. Expedited reporting of SAEs 
8.3.1. Reporting of SAEs to sponsor 
Every SAE occurring in a trial participant during the trial (whether or not the event is 
considered trial treatment related) must be reported by the investigator to the sponsor on 
SAE e-mail address (mentioned below) within 24 hours of learning of its occurrence, 
preferably using an SAE report form in English (dated, signed and scanned). All relevant 
information concerning the SAE must be obtained from the appropriate points of contact, 
such as description of the event, onset date and type, duration, severity, relationship to each 
trial treatment, outcome, actions taken, emergency room records, laboratory testing and 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 52 of 74 
 
treatment of the SAE, and all other relevant clinical and laboratory data as soon as possible. 
SAE email address: SAESTI_Zoli001@gardp.org 
The original copy of the SAE report form and the confirmation of receipt email must be kept 
with the participant medical file at the trial site. 
Recurrent episodes, complications, or progression of the initial SAE must be reported as 
follow-up to the original episode within 24 hours of the investigator receiving the follow-up 
information.  
Alike non-serious AEs, information about all SAEs should also be collected and recorded in the 
AE section of the eCRF.  
8.3.2. Reporting of SAEs to national regulatory authorities and ethics committees 
Related SAEs and SUSARs will be reported in an expedited manner to the national regulatory 
authorities (NRA), ethics committees and any other relevant institutions/bodies as per local 
safety reporting regulations. Further details will be provided in the trial safety management 
plan. 
8.4. Exposure during pregnancies 
The effect of zoliflodacin administration has not been studied in pregnant women. Therefore, 
all eligible women of reproductive age must not be pregnant and have a negative pregnancy 
test before they can be included in the trial. All female participants must also agree on using  
a highly effective method of contraception at the time of IMP administration on Day 1 (see 
Appendix 1 for acceptable methods and required duration) and until at least 28 days after 
administration of the trial treatment.  
All participants must be instructed to inform the investigator immediately if there is a 
suspicion of pregnancy. If following trial treatment, it is subsequently discovered that a trial 
participant, or the female partner of a trial participant, is pregnant or may have been pregnant 
at the time of investigational drug exposure, the sponsor must be notified immediately (within 
24 hours). The principal investigator must report all cases of exposure to study treatment 
during pregnancies using the “pregnancy surveillance form”. This must be done irrespective 
of whether an adverse event has occurred. The information submitted should include the 
anticipated date of delivery. 
The investigator must follow the women exposed during pregnancy from day of awareness of 
pregnancy until completion of the pregnancy at definite intervals (at 3 months, 6 months, at 
9 month/child birth) or until pregnancy termination (i.e., induced / spontaneous abortion). 
The investigator will provide pregnancy outcome information as a follow up to the initial 
pregnancy surveillance form.  
Stillbirth infants should be seen by a doctor as soon as possible to assess the cause of death. 
In the case of a live birth, a doctor (preferably a paediatrician if possible) should assess the 
infant at the time of birth and submit a child surveillance report to the sponsor. 
Follow-up of children exposed to drug in utero is proposed to the parents by the Investigator, 
until the children reach 2 years of age. If an event presented by a child exposed to drug in 
utero during child monitoring is identified as meeting a seriousness criterion (e.g. congenital 
anomaly or death), it shall be reported using the SAE form (in addition to the “Child 
Surveillance form”) within the same timelines as for SAE reporting (see timelines in Section 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 53 of 74 
 
8.1.2).  
8.5. AE follow up 
All AEs should be treated appropriately by the investigator. Once an AE is detected, it should 
be followed until its resolution or until stabilization. Assessment should be made at each visit 
(or more frequently, if necessary) of any changes in severity, suspected relationship to the 
trial regimen, interventions required to treat it, and outcome. For AEs that have not resolved 
at the end of the trial, it is the responsibility of the principal investigator to ensure that 
participants are appropriately referred to their treating physician or to an adequate specialist. 
In addition, all serious adverse events and those non-serious events assessed by the 
investigator as related to the investigational drug must continue to be followed even after the 
subject participation in the trial is over. Such events should be followed until they resolve or 
until the investigator assesses them as “chronic” or “stable”. 
8.6.  Safety assessments 
Safety assessments include physical examination, safety lab assessment and review of 
potential AEs. They will be performed at each visit, as per the schedule of events (Section 5).  
 
9. Withdrawals 
At any point in time, participants may withdraw consent. Participants who withdraw from the 
trial will benefit from the same conditions of care as those who remain in the trial. Samples 
collected up until the date of withdrawal will be kept and analyzed, and this will be explained 
in the ICF. 
The investigator is responsible for completing a final assessment form in the eCRF at the time 
of the participant’s withdrawal. The investigator should make a reasonable effort to ascertain 
the reason(s) for consent withdrawal, while fully respecting the participant's rights.  
If a participant does not return for a scheduled visit, every effort should be made to contact 
him/her. In any circumstance, every effort (a minimum of 2 phone calls, documented in the 
source documents) should be made to document participant outcome, if possible. 
The investigator may also decide to withdraw a participant from the trial at any time without 
penalty and for any reason without prejudice to his or her future medical care. Participants 
may be withdrawn for non-compliance with trial procedures or trial drug administration.  
In all cases, the date and reason(s) for withdrawal (including the primary reason) must be 
recorded in the source documents and the eCRF. If a participant is prematurely withdrawn 
from the trial for any reason, the investigator must make every effort to perform the 
evaluations in accordance with Section 5.2.6. Every effort will be made to follow up 
participants who prematurely discontinue from the trial to determine final outcome. 
10. Data collection and management 
10.1. Source data 
According to the International Council on Harmonization of Technical Requirements for 
Registration of Pharmaceuticals for Human Use (ICH), source documents are “original 
documents, data and records (e.g. hospital records, clinical and office charts, laboratory notes, 
memoranda, participant’s diaries or checklists, pharmacy dispensing records, recorded data 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 54 of 74 
 
from automated instruments, microfiches, photographic negatives, microfilms or magnetic 
media, X-rays, participant files, and records kept at the pharmacy at the laboratory and at 
medico-technical departments involved in the clinical trial)” (ICH E6, 1.52) 
According to the ICH, source data are “all information in original records and certified copies 
of original records of clinical findings, observations, or other activities in a clinical trial 
necessary for the reconstruction and evaluation of the trial. Source data are contained in 
source documents (original records or certified copies)” (ICH E6, 1.51). 
In the present trial, all trial data will be first recorded in source documents before being 
transcribed in the eCRF or data provided to PV.  
The source documents must remain available at the trial site after data have been transcribed 
in the eCRF/data or forms sent to PV, to allow retrospective checks that source data have been 
accurately and completely transcribed in the eCRF/data sent to PV. The investigator will allow 
the monitors, the persons responsible for the audit, the representatives of the ethics 
committees, and of the regulatory authorities to have direct access to source data and 
documents in order to analyse, examine, verify and reproduce any report and record that is 
important for the evaluation of the trial. 
10.2. Electronic data capture system 
An eCRF will be designed to record all the data to be collected as per the protocol. An eCRF 
will be completed for each participant. The eCRF, together with all trial related forms and logs 
will be produced by the sponsor before being distributed to investigators. The eCRFs have 
been built using Clinical Studio, a fully validated secure web-enabled software that conforms 
to 21 CFR Part 11 requirements.  
The designated investigator staff will enter the data required by the protocol into the eCRF. 
The principal investigator will be responsible for assuring that the data entered into the eCRF 
is complete, accurate, consistent with the source documents and that entry and updates are 
performed in a timely manner (including in consistency with data sent to PV). Corrections and 
alterations of data on the eCRF or source documents must be made by the investigator or by 
the designated person from his/her team and must be dated and signed. Investigator site staff 
will not be given access to the electronic data capture (EDC) system until they have been 
adequately trained.  
Medical history/current medical conditions and adverse events will be coded using the 
MedDRA terminology. Prior and concomitant medications will be coded using WHO-DRUG 
dictionary. 
ICON GPHS data management will review the eCRF data entered by investigator staff for 
completeness and accuracy. Electronic data queries stating the nature of the problem and 
requesting clarification will be created for discrepancies and missing values and sent to the 
investigational site via the EDC system. Designated investigator site staff are required to 
respond promptly to queries and to make any necessary changes to the data. 
Protocol deviations will be detected through appropriate monitoring (see Section 13 quality 
assurance and quality control). These should be appropriately documented and upon 
conclusion of the trial, the list of deviations will be communicated to ICON GPHS data 
management and statistics. Once the trial data has been verified for completeness and 
accuracy, the database will be locked.  

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 55 of 74 
 
11. Data analysis and statistical methods 
11.1. Sample size determination 
The efficacy of the combination therapy 500 mg IM ceftriaxone and 1 g oral azithromycin in 
the SOLITAIRE-U trial was initially used as the cure rate reference (55, 56). This trial had 
assessed the non-inferiority of a single dose of 1 g oral solithromycin in comparison with the 
combination therapy in uncomplicated urogenital gonorrhoea; it reported 84.5% (95% CI, 72.4 
to 87.1%) microbiological cure rate under the combination therapy (56). In addition, the trial 
observed 14% of participants with indeterminate outcome (participants who did not return 
for TOC assessment).  
For this study, the initial assumption was that there would be no treatment difference 
between the parenteral comparator ceftriaxone and azithromycin) and zoliflodacin. A 10% 
non-inferiority margin was initially selected, based on the US FDA guidelines on drug 
development for NG (38). An unequal allocation ratio was chosen to provide sufficient data 
on the safety of zoliflodacin (57). The initial hypothesis was that a single oral 3 g of zoliflodacin 
would be non-inferior to a combination of a single IM 500 mg dose of ceftriaxone and a single 
1 g oral dose of azithromycin if the upper bound of the 2-sided 95% CI for the microbiological 
cure rate of the combination therapy minus zoliflodacin was 10% or less (prespecified non-
inferiority margin for the primary endpoint). Based on an 85% cure rate in the comparator 
arm (combination therapy), and a non-inferiority margin of 10%, it was calculated that 603 
participants (402 in the intervention group and 201 in the control group, with a two-sided α 
of 5% and 2:1 allocation ratio) would provide 90% power to show that a single oral 3 g dose 
of zoliflodacin was non-inferior to a combination of a single IM 500 mg dose of ceftriaxone 
and a single 1 g oral dose of azithromycin with respect to microbiological cure rate at TOC. 
Taking into account criteria for inclusion in the micro-ITT population (see Section 11.2.1), it 
was estimated that a maximum of 35% of the randomized population would be potentially 
ineligible for inclusion in the micro-ITT population. Therefore, it was anticipated that up to 
approximately 928 participants would be randomized into the trial in order to achieve the 
target sample size of 603 in the micro-ITT population. Accounting for anticipated screening 
failures, the enrolment sample size was estimated to be around 1092. 
During the study however, GARDP reassessed the cure rates of all recent Phase 2 and 3 trials 
investigating the efficacy of a new oral investigational product for uncomplicated gonorrhoea 
(24, 26, 56, 58). This indicated that when comparing an oral therapy (even with 100% 
susceptibility) against a parenteral combination that rarely fails, a true underlying treatment 
difference of at least -4% should be assumed, rather than the assumption of equal underlying 
cure rates used in the initial sample size calculation. This is hypothesized to be due to intrinsic 
differences in the bioavailability of an oral versus parenteral drug. Under these assumptions, 
the oral therapy would still be estimated to yield a true cure rate of over 95% which is 
acceptable for single dose oral therapy for gonorrhoea as stated in the CDC criteria (59, 60). 
In addition, Mitrani-Gold et al. published in 2022 a systematic literature review and meta-
analysis (using a weighted, non-iterative random-effects model) to estimate the 
microbiological response rate and 95% CIs for ceftriaxone and proxy-for-placebo (61). The 
analysis proposed that by reviewing data from more recent studies, a non-inferiority margin 
of 15% was shown to robustly preserve estimated ceftriaxone treatment effect in a Phase 3 
microbiologically evaluable population. Using the same methodology, GARDP conducted a 
conservative analysis in a microbiologically evaluable population comparing ceftriaxone 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 56 of 74 
 
treatment effect in the micro-ITT population with the proxy-for-placebo estimate, which 
showed a margin of 12% would preserve 57% of the estimated ceftriaxone treatment effect.  
Therefore in a Type C interaction with the US FDA held in October 2022 wherein GARDP 
requested consideration by the Agency of an increase in the non-inferiority margin, taking into 
account the -4% treatment difference, the published meta-analysis (61) and the unmet public 
health need for new drugs active against ceftriaxone-resistant NG (see Section 1.3), the US 
FDA indicated that a wider non-inferiority margin of 12% for the primary endpoint could be 
acceptable. In the Appendix ‘Justification for noninferiority margin’, the US FDA guidance (38) 
estimates the benefit of an effective treatment over placebo to be 11.9%, but this is 
acknowledged by the US FDA to be a conservative estimate due to the limitation of the data 
included in the meta-analysis. Additionally, the Agency added that, dependent on 
demonstrated efficacy, consideration would be given for a broad or limited population 
indication for the treatment of uncomplicated gonorrhoea. 
Consequently, it will be considered that a single oral 3 g of zoliflodacin will be non-inferior to 
a combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin if the upper bound of the 2-sided 95% CI for the microbiological cure rate of the 
combination therapy minus zoliflodacin would be 12% or less (prespecified non-inferiority 
margin for the primary endpoint). 
Keeping in mind the trial was conducted for the most part during the high peaks of the COVID-
19 pandemic, monitoring of blinded pooled data was conducted to assess the performance of 
the study against assumptions used in the sample size determination described above in these 
higher risk circumstances. When approximately 70% of participants were enrolled, the 
proportion of participants ineligible for the micro-ITT population were estimated to be 
approximately 20% (vs 35% in original assumptions), and the proportion of nonassessable 
outcomes due to missed TOC assessments at 10% (foreseen at 15% in original assumptions).  
Based on these estimations, a blinded pooled data analysis was performed taking into account 
as well the-4% treatment difference and a 12% non-inferiority margin. It was concluded that 
696 participants evaluable for the micro-ITT analysis set (464 in the intervention group and 
232 in the control group, with a two-sided α of 5% and 2:1 allocation ratio) would provide 
approximately 90% power to show that a single oral 3 g dose of zoliflodacin is non-inferior to 
a combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin with respect to microbiological cure rate at TOC. Taking into account criteria for 
inclusion in the micro-ITT population (see Section 11.2.1) and blinded analysis of study 
conduct, it is estimated conservatively that a maximum of 25% of the randomized population 
would be potentially ineligible for inclusion in the micro-ITT population. Therefore, up to 
approximately 928 participants are to be randomized into the trial in order to achieve the 
target sample size of 696 in the micro-ITT population (remains unchanged). Similarly, 
accounting for anticipated screening failures, the enrolment sample size remains estimated to 
be around 1092. 
11.2. Definition of trial populations included in the analysis 
For each microbiological outcome and anatomical site (see Section 2), there will be three 
analysis population types used for the efficacy analysis: the micro-ITT, the evaluable and the 
PP population. The micro-ITT will be the primary analysis population while the evaluable and 
PP population will be the secondary. For clinical outcomes, the clinical cure and PP populations 
will be used.  

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 57 of 74 
 
11.2.1. Micro-ITT population 
The micro-ITT population will include all randomized participants who had a positive NG 
culture at baseline and whose baseline antimicrobial susceptibility testing result showed no 
pre-existing resistance to both ceftriaxone and azithromycin. It will include participants who 
do not comply with trial treatment, those who are lost-to-follow-up, those who are 
nonassessable for microbiological outcome, or who receive antibacterial therapy with activity 
against NG prior to the TOC visit. A participant’s eligibility for the micro-ITT population will 
depend on the particular anatomical site in question.  
Resistance will be defined as per local standards. Further details may be found in the SAP. 
Participants who receive the trial treatment and are found to have a negative NG culture at 
the urethral or cervical site at baseline (visit 1) will be excluded from the micro-ITT population 
and thus of the primary efficacy endpoint analysis and secondary analyses corresponding to 
the urethral or cervical sites. Participants who receive trial product and are found to be NG 
culture negative at the rectal or pharyngeal site at visit 1 will be excluded from the micro-ITT 
population for the corresponding secondary efficacy endpoint analyses at the rectal or 
pharyngeal sites. 
The modified micro-ITT population will include all randomized participants who had a positive 
NG culture at baseline. 
11.2.2. Clinical cure population 
For the efficacy analyses of clinical cure, the clinical cure population will include all male at 
birth participants included in the micro-ITT population and who had at least one sign or 
symptom of urethral gonorrhoea at baseline.  
11.2.3. Evaluable population 
The evaluable population will include all randomized participants who have a positive NG 
culture at baseline and whose baseline antimicrobial susceptibility testing result showed no 
pre-existing resistance to both ceftriaxone and azithromycin, who do not vomit within 30 
mins of administration of zoliflodacin or azithromycin and who have a NG culture result at 
the TOC visit. 
11.2.4. PP population 
The PP efficacy population will include all participants in the micro-ITT population who meet 
all inclusion/exclusion criteria, complied with trial treatment, did not vomit within 30 mins of 
administration of zoliflodacin or azithromycin, did not receive any systemic antibiotic with 
known activity against NG prior to TOC visit, did not receive any of the prohibited medications, 
abstained from sexual intercourse and used condoms for vaginal, anal and oral sex prior to 
TOC and returned to the trial site for the TOC visit within the specified window (Visit 4, trial 
day 6±2).  
The clinical-PP population will include male participants in the PP population with at least one 
sign or symptom of gonorrhoea at baseline and with an evaluable clinical cure outcome. 
11.2.5. Safety population 
The safety population will include all randomized participants who have received trial 
treatment. 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 58 of 74 
 
11.2.6. PK population 
The PK population will include all participants randomized to the zoliflodacin group who 
consent to participate to the PK sub-study and from whom at least one valid PK sample post 
treatment is obtained. 
11.3. Baseline characteristics 
Baseline demographics and clinical characteristics will be described overall and by treatment 
group and trial site. Demographic data will include age, gender, sex at birth and ethnicity. 
Baseline clinical data will include initial clinical presentation, sexual history, previous or 
coexisting sexually transmitted infections, results of laboratory investigations including results 
of culture, NAAT and Gram stain, and antibiotics susceptibility testing where available. 
Summary tables will present descriptive statistics: for continuous variables, mean ± standard 
deviation or median and range (whichever is most appropriate); for categorical variables, 
frequency counts and percentage of participants within each category.  
Any missing data pattern will be investigated and reasons for missing data obtained and 
summarised where possible. A second table summarising baseline characteristics of 
participants by trial groups with no missing outcome will be presented to assess whether these 
characteristics were balanced between the treatment groups when only participants with 
non-missing outcomes are considered. 
11.4. Efficacy analysis 
11.4.1. Definitions 
x Microbiological cure: a participant with a positive NG culture at baseline and a negative 
NG culture at the TOC visit. A positive NG culture is defined as a culture with confirmed 
microbiological identification by the central laboratory. 
x Microbiological failure: a participant with a positive NG culture at baseline and at the 
TOC visit and for whom there is no supportive evidence of a re-infection or a 
participant experiencing an intercurrent event before the TOC visit which is possibly 
related to a lack of efficacy of the study treatment. Supportive evidence of re-infection 
includes re-exposure to an untreated sex partner or a NG strain genotype different 
from the strain identified at baseline and/or history of unprotected sex. A participant 
with a positive NG culture at baseline and who is nonassessable for microbiological 
outcome at TOC (e.g. who has a missing microbiological outcome at the TOC due to a 
missed visit or a lost/damaged microbiological specimen) is also considered a failure. 
x Clinical cure: a male at birth participant experiencing resolution of signs and symptoms 
of urogenital gonococcal infection that were present at enrolment. Further details on 
assessment of clinical cure are included in the MOP. 
x Lost-to-follow-up: a participant who has missed his/her appointment after completing 
treatment and cannot be traced until and including the end of the expected follow-up 
period (30 days± 3 days) 
x Non-evaluable for microbiological outcome: a participant who did not have a 
urogenital positive culture result for NG at baseline (visit 1). 
11.4.2. Specification of efficacy analysis 
Efficacy endpoints are defined in Section 2. The primary efficacy endpoint is defined as a 
negative culture to NG at urethral or cervical sites at TOC (day 6 ±2) among patients included 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 59 of 74 
 
in the micro-ITT population.  
The difference in the proportions of participants, in the micro-ITT population, with negative 
culture at the TOC visit will be estimated between the ceftriaxone/azithromycin and the 
zoliflodacin groups and a 2-sided 95% CI will be calculated. The primary efficacy analysis will 
claim zoliflodacin as non-inferior to the ceftriaxone/azithromycin combination if the upper 
bound of the 2-sided 95% CI for the microbiological cure rate of the combination therapy 
minus zoliflodacin lies below the 12% prespecified non-inferiority margin. The primary analysis 
will be conducted on the micro-ITT analysis, which includes participants who are non-
assessable for microbiological outcome or who are lost-to-follow-up.  
To include all randomized participants, missing outcomes will be replaced using multiple 
imputation (62). Sensitivity analyses will also be performed to explore departures from 
assumptions about missing data. To take into account the possibility that missing outcomes 
are not completely at random, a pattern mixture model will be fitted under missing at random 
(MAR) and it will be expanded to allow for the context of missing not at random (MNAR) (62). 
Results of sensitivity analyses will be presented graphically by an estimation of the treatment 
effect (microbiological cure rate) in the combination therapy group, in the zoliflodacin group 
and in both groups depending on the departures from assumptions about missing data (62).  
This efficacy analysis will also be performed on the PP and evaluable population as part of the 
secondary objectives.  
For secondary efficacy endpoints, Chi-2 or Fisher exact tests will be performed, depending on 
applicability criteria, for the comparison of: 
1) The proportions of microbiological cure at TOC between both trial groups at 
pharyngeal and rectal sites  
2) The proportions of clinical cure at TOC between both trial groups.  
These analyses will be conducted in the micro-ITT population and repeated in the modified 
micro-ITT, the evaluable and PP populations, unless stated otherwise. In particular, the 
proportion of clinical cure will be assessed in the clinical cure population. All statistical tests 
will be 2-sided with a level of significance set at 5%. In addition, the following comparison will 
be made 
3) The proportions of participants with a negative NG NAAT from urethral or cervical sites 
at TOC between both trial groups 
4) The proportions of participants with a negative NG NAAT from oropharyngeal sites at 
TOC between both trial groups 
5) The proportions of participants with a negative NG NAAT from rectal sites at TOC 
between both trial groups 
These analyses will be conducted among participants that have a positive NG NAAT from the 
corresponding site at baseline. 
Regarding the antimicrobial susceptibility testing profile of gonococcal isolates, all analyses 
will be descriptive. The MIC breakpoint plus the median, 90th percentile, 50th percentile, modal 
MIC and range of MICs will be reported by treatment group and by site of infection. The 
proportion of isolates at or above MIC breakpoint (n/N) at baseline and TOC (if applicable) will 
also be reported by treatment group and by site of infection. Moreover, changes in 
antimicrobial susceptibility testing between the baseline and TOC isolates will be reported for 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 60 of 74 
 
all participants with microbiological failure without any statistical comparison.  
A descriptive analysis of participants with baseline isolates resistant to ceftriaxone, to 
azithromycin and to both will also be reported. Sensitivity analyses will also be performed. 
In addition, the following exploratory, comparative analyses will be conducted using Mann-
Whitney non-parametric test: 
x Antimicrobial susceptibility testing profile (MIC distribution) of baseline and TOC 
isolates for participants with multiple sites of infection vs participants with unique site 
of infection. 
x Antimicrobial susceptibility testing profile (MIC distribution) of baseline and TOC 
isolates for isolates that are resistant to fluoroquinolones at baseline vs isolates that 
are fluoroquinolone-sensitive. 
x Antimicrobial susceptibility testing profile (MIC distribution) of baseline and TOC 
isolates for isolates that are resistant to other antibiotics commonly used for NG 
treatment (e.g. azithromycin and ceftriaxone) at baseline vs isolates that are sensitive 
to those antibiotics. 
x Antimicrobial susceptibility testing profile (MIC distribution) of baseline isolates of 
participants with subsequent microbiological failure vs microbiological cure. 
11.5. Safety analysis 
Safety endpoints are defined in Section 2. All safety analyses will be descriptive, and endpoints 
will be reported by trial group.  
AEs will be coded using the latest version of the MedDRA. All AEs and SAEs occurring after trial 
drug dosing will be summarized using frequency counts and percentages and their exact 95% 
CI in the following groups: 
x Overall (i.e., regardless of severity or relationship to treatment); 
x By severity grade (mild, moderate, or severe); 
x By relationship to trial drug; 
x By MedDRA level hierarchy (system organ class [SOC], higher level group term [HLGT], 
and preferred term [PT]). 
Descriptive statistics (mean, standard deviation, 95% CI or median and interquartile range, 
whichever is appropriate) will be used to summarize clinical laboratory data at baseline and 
during follow-up visits. Changes in laboratory results pre- and post-treatment will be 
examined and those that are clinically significant will be highlighted and reported as AE. 
11.6. Pharmacological endpoints  
The following PK parameters will be estimated for zoliflodacin: 
x AUC(0-last): Area under the concentration time-curve from time zero to the last 
concentration above the lower limit of quantitation 
x AUC(0-∞): Area under the concentration time-curve from time zero to infinity  
x AUC(0-t): Area under the concentration time-curve from time zero to time t 
x Cmax: Maximum observed concentration 
x Tmax: Time of maximum observed concentration 
x Ke: Elimination rate constant 
x t1/2: Terminal elimination half-life 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 61 of 74 
 
x CL/F: Apparent total clearance of the drug after oral administration 
x Vz/F: Apparent volume of distribution 
The PK analysis will be addressed in a separate report. 
11.7. Missing values 
Prior to analysis, any missing data will be investigated and reasons for missing data obtained 
and summarised where possible. All attempts will be made to avoid any missing outcome data 
and to correct for it. Because the definition of the micro-ITT includes participants who are non-
assessable for microbiological outcome or who are lost-to-follow-up, we will replace missing 
outcomes using multiple imputation (as described under 11.4). The missing data will be 
imputed with predicted values from a multivariable logistic regression model that will include 
these observed participant data and that will be adjusted for baseline covariates (e.g. trial 
centre, age, history of unprotected sex). The multivariable model will yield a probability of a 
Bernoulli process that is used to generate values for the outcome data. The probability will be 
used to impute the missing outcome value by rounding it to the nearest integer (0 or 1) or by 
sampling from a Bernoulli distribution. To avoid any bias, the imprecision due to imputation 
will be accounted for by means of multiple imputation (M=20 imputations). Hence, multiple 
datasets with imputed outcomes will be generated and results will be pooled by using 
standard techniques taking into account the variation between imputed data sets (62). To take 
into account the possibility that missing outcomes are not completely at random, we will also 
fit a pattern mixture model under MAR that will be expanded to allow for the context of MNAR 
(62). For those participants with a missing primary outcome from the central laboratory  but 
with existing outcome from the local microbiology laboratory, the local laboratory data will 
be used, and a sensitivity analysis will be performed. A sensitivity analysis measuring the 
impact of the different reasons for missing values will also be performed. 
 
12. Data safety monitoring board 
An independent data and safety monitoring board (DSMB), composed of 3 members 
independent of the investigators and sponsor, will be constituted prior to trial 
implementation. Its role will be to monitor the accumulated trial data for participants’ safety.  
Depending on this evaluation, the DSMB will make recommendations to the sponsor 
concerning the continuation, modification or termination of the trial. There will be no planned 
interim analysis in this trial. 
The DSMB will consist of at least one STI clinical expert. Support from an independent 
statistician will be provided by ICON GPHS. An unblinded statistician will be available should 
specific requests requiring an unblinded statistician from the data safety monitoring board 
arise. Prior to trial start, a DSMB charter and SOP will be established and the schedule for 
subsequent, interim meetings will be determined. The format of DSMB reports will also be 
discussed.  
During the trial, the sponsor will be responsible for timely communicating to the DSMB all 
SAEs. In addition, the sponsor will communicate quarterly progress reports to the DSMB that 
will include safety listings and Council for International Organizations for Medical Science 
(CIOMS) reports.  
The DSMB will be responsible for interpreting the information communicated by the sponsor 
and for determining: 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 62 of 74 
 
x whether the overall incidence, seriousness and severity of AEs jeopardizes 
participants’ safety 
x whether the investigational drug poses significant, new, safety concern compared to 
the reference information. 
 
13. Quality assurance and quality control procedures 
13.1. Monitoring, audits and inspections 
Prior to trial start, a monitoring plan will be developed. The site principal investigator will allow 
the monitors to visit the site and facilities where the trial will take place in order to verify 
compliance with the trial protocol, ICH-good clinical practice (GCP) and WHO-good clinical 
laboratory practice (GCLP) for laboratories. Training sessions on GCP, GCLP and on protocol 
implementation will be organised for the investigators and all trial staff prior to recruitment 
start. A MOP will be distributed to all the trial centres and a laboratory manual will be 
distributed to all laboratories.  
Trial monitoring will be carried out by dedicated monitors at ICON GPHS at regular intervals, 
depending on the recruitment rate, to verify data quality and trial integrity. When travel of 
monitors and/or access to clinics is limited due to COVID-19 restrictions, remote monitoring 
is allowed to ensure continuity of monitoring where permitted and feasible locally.  
The principal investigator must allow the monitor to: 
x inspect the site, the laboratories, the facilities, the equipment and the material used 
for the trial, 
x meet all members of his/her team involved in the trial, 
x consult all of the documents relevant to the trial, including those filled by the trial 
nurse and trial pharmacist 
x check that the eCRF has been correctly completed 
x review the completion and accuracy of pharmacovigilance documentation and 
consistency with the eCRF 
x directly access source documents for comparison of data therein with the data in the 
eCRF/data or forms sent to PV, 
x verifying that randomization has been conducted in accordance with the 
corresponding SOP and that no breach occurred in allocation concealment 
x verify the collection, transport, storage and shipment of biological samples 
x verify that the trial is carried out in compliance with the protocol and national 
regulatory requirements 
x verify the proper handling and management of trial treatments 
At the end of each monitoring visit, and based on monitoring visit reports, the sponsor will be 
responsible for controlling: 
x recruitment rates, ineligibility, non-compliance, protocol violations and dropouts 
overall and in each trial centre 
x completeness and timeliness of data 
x compliance with GCP, GCLP and applicable regulations  
x any protocol deviations as defined in the monitoring plan. 
A final monitoring visit will be conducted at the end of the trial, after the last participant last 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 63 of 74 
 
visit (LPLV), and once the database is locked. 
13.2. Audits and inspections 
In addition to the monitoring activities foreseen above, the trial may be evaluated by external 
auditors appointed by the sponsor and by representatives from national regulatory authorities 
or ethics committees who must be allowed access to eCRFs, source documents, trial files, and 
trial facilities. 
13.3. Laboratory framework 
All laboratory activities will be carried out according to the trial laboratory manual. The 
laboratory manual compiles all procedures that are relevant to the evaluation of trial 
outcomes, and encompass pre-analytical, analytical and post-analytical phases. 
Most laboratory investigations to be performed during the trial are already in use in the trial 
sites. Hence existing quality control (QC) procedures will be followed for all laboratory 
investigations. Additional quality assurance activities will be implemented as necessary to 
meet GCLP standards, and oversight will be provided by the sponsor. Details can be found in 
the trial laboratory manual. 
14. Trial documentation 
14.1. Confidentiality and retention of trial documents 
Due to the social harm and stigma that is often associated with STIs, all trial sites are 
accustomed to maintaining strict confidentiality with regards to their patients. Most sites are 
dedicated STI clinics. All trial-related information will be stored securely at the trial sites. All 
participant information will be stored in locked file cabinets in areas with access limited to site 
staff.  
All laboratory specimens, reports, trial data collection, process, and administrative forms will 
be identified by a coded number only to maintain participant confidentiality. All records that 
contain names or other personal identifiers, such as locator forms and informed consent 
forms, will be stored separately from trial records identified by code number. All local 
databases will be secured with password-protected access systems. Forms, lists, logbooks, 
appointment books, and any other listings that link participant ID numbers to other identifying 
information will be stored in a separate, locked file in an area with limited access. 
Participant’s trial information will not be released without the written permission of the 
participant, except as necessary for monitoring by the sponsor, the DSMB, the NRAs or 
IRBs/IECs. The principal investigator should agree to provide access to all trial information and 
documents to sponsor representatives, auditors and inspector mandated by NRAs. The 
information will be treated in compliance with professional secrecy. 
The investigators must arrange for the retention of all information relevant to the trial, 
including a copy of the eCRF along with audit trail and essential documents listed in Section 8 
of ICH-GCP, for at least 15 years after completion or termination of the trial. After that period 
of time, the documents may be destroyed with prior permission from the sponsor, subject to 
local regulations. Should the investigator wish to assign the trial records to another party or 
move them to another location, the sponsor must be notified in advance. 
14.2. Protocol amendment 
If the protocol must be altered after it has been signed, the modification or amendment must 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 64 of 74 
 
be discussed and approved by the sponsor. The protocol amendment must be drafted and 
signed by both parties. All amendments must be submitted to the relevant ethics committees 
and NRAs. Administrative amendments can be implemented immediately but amendments 
that affect other aspects can only be implemented after a favourable opinion of the ethics 
committee and NRA has been obtained and local regulatory requirements have been complied 
with. An amendment needed to eliminate immediate hazards to the participants in the trial is 
exempted from this rule. When the submission is performed by the principal investigator, the 
latter must transmit a copy of ethics committee’s new written opinion to the sponsor, 
immediately upon receipt. 
When a protocol amendment results in revised informed consent forms, after IRB/EC 
approval, re-consent will be obtained from participants currently enrolled into the trial in a 
timely manner at or before the participant’s next trial visit. This will allow sufficient time and 
information to make a decision about continued participation in the research trial. 
14.3. Final trial reports 
A final trial report summarising the trial outcome will be drafted by the investigators and 
provided to the local IEC/IRB.  
A clinical trial report will be prepared by the sponsor with input from investigators as 
appropriate. One copy of the final trial report must be dated and signed by the sponsor’s 
medical monitor, principal investigators, trial statistician and the clinical trial manager before 
being transmitted to the IRB/IECs and NRAs. 
 
15. Early termination of the trial 
Both the sponsor and the investigators reserve the right to terminate the trial at any time prior 
to inclusion of the intended number of participants, but they intend to exercise this right only 
for valid scientific or administrative reasons. Should this be necessary, both parties will 
arrange the procedures after review and consultation. In terminating the trial, the sponsor 
and the investigators will ensure that adequate consideration is given to the protection of the 
participants’ interests. 
Reasons for early termination of the trial by the sponsor may include but are not limited to:  
x enrolment rate too low 
x protocol violations 
x inaccurate or incomplete data 
x unsafe or unethical practices 
x questionable safety of the test article 
x following the recommendation of the DSMB or IEC 
x administrative decision 
Reasons for early termination of the trial by the investigators may be: 
x insufficient time or resource to conduct the trial 
x lack of eligible participants. 
In the event that the trial is terminated early, the investigator has to: 
x complete the eCRF to the greater extent possible 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 65 of 74 
 
x answer all questions of the sponsors or their representatives related to data of 
participants enrolled at the site prior to trial termination 
x ensure that participants enrolled in the trial who had not yet reached a follow up time 
point are informed promptly and followed up with the necessary medical care 
x provide in writing the reasons for their decision to the IEC/IRB and the sponsor 
x follow end of trial procedures as per the protocol and MOP. 
 
16. Ethics 
16.1. Trial conduct 
The trial will be conducted in accordance with the ethical principles laid down in the 
declaration of Helsinki 1964, as revised in Fortaleza in 2013, the ICH-GCP, the WHO-GCLP and 
with all applicable national regulations. 
16.2. Regulatory and ethical approval  
The trial protocol, the participant ICF, the eCRF, up-to-date versions of the IB or SmPC, as well 
as principal investigators qualifications will be submitted to appropriate IRBs/IECs.  
The trial will not start in any centre before written approval by these IRBs/IECs has been 
obtained, the local regulatory requirements have been complied with, and the signature of 
the clinical trial protocol of each contractual party involved has been obtained. 
16.3. Informed consent process 
An ICF in clear, simple language complying with new Common Rule (45 CFR part 46 subpart A) 
requirements will be provided to the participant. The investigator or designee is to collect 
written consent from each participant before any trial-specific procedure is conducted. Two 
original ICFs must be completed, dated and signed personally by the participant and by the 
investigator or designated trial staff. The participant should be given one signed original form; 
the second original should be kept by the investigator. 
Adolescent participants (≥ 12 and < 18 years old) will be consented according to the practice 
in use in their country of origin. If required by local research ethics guidelines, assent will be 
sought from participants and consent will be sought from a legal representative in addition. 
In countries that recognize the status of emancipated minors, consent will be sought from the 
participant directly.  
If the participant is unable to read, a relative or an impartial witness should be present during 
the informed consent discussion. The participant must give consent orally and, if capable of 
doing so, complete, sign (or thumbprint) and personally date the information and consent 
form. The witness must then complete, sign and date the form to testify of the participant’s 
understanding of the trial information and his/her willingness to participate, together with the 
investigator. 
The ICF will be provided to the principal investigators by the sponsor. Any changes to the ICF 
suggested by the principal investigator must be agreed to by the sponsor before submission 
to the IRB/IEC, and a copy of the approved version must be provided to the sponsor after 
IRB/IEC approval. Any change to the ICF after the initial approval constitutes an amendment 
and must be submitted for approval to the IRB/IEC, and to the NRA. 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 66 of 74 
 
16.4. Justification for selection of trial population 
The inclusion of minors in the present trial is justified from an ethical perspective by the fact 
that prevalence of STIs among adolescents is usually high and zoliflodacin given as a single 
dose appears to be safe based on non-clinical and clinical studies (see IB). This vulnerable 
group will benefit from the knowledge and intervention generated by the present trial. 
Gathering of PK data from adolescents, who usually have lower body weights, is key to inform 
dosing adjustment if necessary. 
HIV positive participants will be eligible for inclusion in the trial, as long as their ART does not 
contain any of the prohibited medications.  
16.5. Community engagement 
Prior to trial start, relevant communities, such as women’s group, youth, men who have sex 
with men (MSM) groups, and other key populations in trial sites will be informed. Community 
meetings will be held to inform these groups of the trial prior to the trial. Feedback on the trial 
concept will also be gathered through community meetings wherever possible. Follow-up 
meetings will also be done to provide progress of the trial. Moreover, results of the trial will 
be disseminated to these communities. During these meeting the communities will be assured 
of maintaining confidentiality and reducing stigma.  
16.6. Risks and benefits 
Clinical findings with zoliflodacin:  
To date, zoliflodacin as a single dose has been well tolerated by both healthy subjects and 
patients included in the clinical development program. Most commonly reported AEs included 
excluding infection-related AEs were mild gastro-intestinal events (nausea and diarrhoea) and 
headache. There were no AEs reported at a frequency of ≥5%  
Non-clinical findings with zoliflodacin:  
Mild testicular degenerations were observed in rat and dog studies, and reprotoxicity studies 
in rodent showed a slight adverse effect on male and female fertility as well as embryofoetal 
development after multiple dosing for 14-28 days. Zoliflodacin has not been studied in 
pregnant women, and hence all women participants of child bearing potential should not be 
pregnant or have a negative pregnancy test at enrolment and use effective contraceptive 
methods for 30 days after receipt of zoliflodacin. Male participants with female partners of 
child bearing potential must agree to delay conception for 28 days after treatment, and 
conduct abstinence/use effective barrier contraceptive methods to avoid exposure during 
pregnancy for 30 days after receipt of zoliflodacin. As with all antibiotics, allergic and 
hypersensitivity reactions are a potential risk. Please refer to section 6.1.2 of this protocol and 
to the latest version of the IB for a full description of the identified and potential risks 
associated with zoliflodacin.  
Potential risks associated with ceftriaxone: 
The main risk associated with ceftriaxone is the risk of anaphylaxis, and ceftriaxone is contra-
indicated in individuals with known severe allergy to cephalosporins or penicillin. In clinical 
trials, the most frequently reported AEs for ceftriaxone are eosinophilia, leukopenia, 
thrombocytopenia, diarrhoea, rash, and hepatic enzymes increased. Injection site reaction at 
site of intramuscular injection are expected and the use of concomitant lidocaine will mitigate 
risk of severe injection site pain. Please refer to the ceftriaxone SmPC for a full description of 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 67 of 74 
 
the identified and potential risks associated with ceftriaxone. 
Potential risks associated with azithromycin: 
As with erythromycin and other macrolides, rare serious allergic reactions including 
angioneurotic oedema and anaphylaxis (rarely fatal), dermatologic reactions including acute 
generalised exanthematous pustulosis, Stevens Johnson syndrome, toxic epidermal necrolysis 
(rarely fatal) and drug reaction with eosinophilia and systemic symptoms have been reported. 
If an allergic reaction occurs, appropriate therapy should be instituted. Physicians should be 
aware that reappearance of the allergic symptoms may occur when symptomatic therapy is 
discontinued. Please refer to the azithromycin SmPC for a full description of the identified and 
potential risks associated with azithromycin. 
Potential risks associated with lidocaine: 
Lidocaine is a local anaesthetic of the amide type that is approved for use as a diluent for 
ceftriaxone. Reactions to lidocaine include cutaneous lesions, urticaria, oedema or 
anaphylactoid reactions. Pruritis, burning, oedema, erythema, purpura, and bleeding may 
occur at the local injection site. Allergic reactions may occur as a result of sensitivity to local 
anaesthetic agents or to the methylparaben used as a preservative in multiple dose vials. 
Allergic reactions as a result of sensitivity to lidocaine are extremely rare. 
Risks associated with trial participation: 
Trial procedures related risks include risks associated with some of the trial procedures. For 
instance, venepuncture causes transient discomfort and may cause fainting. Bruising at the 
site of venepuncture may occur. Infection at the site is possible but highly unlikely as aseptic 
technique will be used.  
It is possible that participants' involvement in the trial could become known to others, and 
that a social impact may result. For example, participants could be treated unfairly, or could 
have problems being accepted by their families and/or communities. In the event that a 
participant reports a social impact, every effort will be made by trial staff to provide 
appropriate care and counselling to the participant as necessary, and/or referral to 
appropriate resources for the safety of the participant.  
Benefits from trial participation: 
Participants in this trial will benefit from having a comprehensive STI case management 
including laboratory tests for NG and CT resulting in faster and better-informed treatment of 
STIs.  
If positive, the trial will benefit future patients with gonorrhoea by providing the necessary 
evidence to support introduction of a new antibiotic against drug sensitive and drug-resistant 
gonorrhoea. Given the pace at which resistance to ESC is emerging and spreading globally, it 
is likely that the incidence of treatment failures to the currently-recommended treatment will 
increase in the near future. At the same time the 5% resistance threshold set by WHO, US-
CDC and other organizations will soon be reached, and alternative treatment options are 
urgently required.   
16.7. HIV status and voluntary counselling and testing 
HIV positive participants are eligible for inclusion in this trial. Participants without a 
documented positive HIV diagnosis or documented prescription of ART will undergo voluntary 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 68 of 74 
 
counselling and testing (VCT) for HIV as part of the trial baseline assessments, and as per local 
routine procedures. All HIV positive individuals will be offered counselling, referred for HIV 
care and treatment, in line with routine practice in trial sites. This may either be done at the 
same time as consent is obtained for inclusion in the trial or at a later date according to 
hospital practice. Participants who are found to be HIV positive will be referred onwards for 
treatment, surveillance and follow up according to the national protocol for HIV positive 
participants. Participants on pre- or post- exposure prophylaxis for HIV infection may enrol in 
the trial provided they meet all inclusion criteria and none of the exclusion criteria including 
those pertinent to disallowed concomitant medications. 
16.8. Compensation 
All trial treatments and diagnostic test costs will be supported by the sponsor. Participants will 
receive compensation for their time spent for trial participation as per local standards.  
16.9. Insurance and liability 
As sponsor of the trial, GARDP is liable for and shall indemnify any claims and damages brought 
by a trial participant suffering from an injury, which arises out of the performance of the trial 
in accordance with the protocol. To this end, GARDP has taken an insurance covering the 
conduct of the trial and all participants. 
16.10. Post-trial access 
If the present trial is successful in demonstrating zoliflodacin is non-inferior to the comparator 
regimen, the sponsor intends to use trial results to support a request for registration in all trial 
countries. In addition, the sponsor will develop a stewardship and access strategy that will 
accompany the roll out of zoliflodacin in target countries and ensure zoliflodacin is promptly 
available to future gonorrhoea patients.  
 
17. Reporting and publication 
17.1. International registry of clinical trials  
The present trial was registered in the clinicaltrials.gov public register prior to start (NCT # 
NCT03959527). 
17.2. Publication 
Upon trial completion and finalisation of the trial report, the results of the trial will be either 
submitted for publication and/or posted in a publicly accessible database of clinical trial 
results. Authorship of any publication will be based on the uniform requirements for 
manuscripts submitted to biomedical journals as defined by the International Committee of 
Medical Journal Editors (ICMJE). 
 
 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 69 of 74 
 
References 
 
1. 
Newman L, Rowley J, Vander Hoorn S, Wijesooriya NS, Unemo M, Low N, et al. Global 
Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted 
Infections in 2012 Based on Systematic Review and Global Reporting. PLoS One. 
2015;10(12):e0143304. 
2. 
Centers for Disease Control and Prevention. Sexually Transmitted Disease 
Surveillance 2019 [Internet]. Atlanta; 2021. [cited 2021 Oct 4]. Available from: 
https://www.cdc.gov/std/statistics/2019/overview.htm#Gonorrhea. 
3. 
U.S. Department of Health and Human Services CDC. Antibiotic resistance threats in 
the United States, 2019 [Internet]. Atlanta, GA; 2019. [cited 2021 Oct 4]. Available 
from: https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-
report-508.pdf. 
4. 
Harrison WO, Hooper RR, Wiesner PJ, Campbell AF, Karney WW, Reynolds GH, et al. 
A trial of minocycline given after exposure to prevent gonorrhea. The New England 
journal of medicine. 1979;300(19):1074-8. 
5. 
Harnisch JP, Berger RE, Alexander ER, Monda G, Holmes KK. Aetiology of acute 
epididymitis. The Lancet. 1977;1(8016):819-21. 
6. 
Hawkins DA, Taylor-Robinson D, Thomas BJ, Harris JR. Microbiological survey of acute 
epididymitis. Genitourin Med. 1986;62(5):342-4. 
7. 
Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and 
practice: the contribution of other sexually transmitted diseases to sexual 
transmission of HIV infection. Sexually transmitted infections. 1999;75(1):3-17. 
8. 
Cohen MS, Hoffman IF, Royce RA, Kazembe P, Dyer JR, Daly CC, et al. Reduction of 
concentration of HIV-1 in semen after treatment of urethritis: implications for 
prevention of sexual transmission of HIV-1. The Lancet. 1997;349(9069):1868-1873. 
9. 
Moss GB, Overbaugh J, Welch M, Reilly M, Bwayo J, Plummer FA, et al. Human 
immunodeficiency virus DNA in urethral secretions in men: association with 
gonococcal urethritis and CD4 cell depletion. J Infect Dis. 1995;172(6):1469-74. 
10. 
Bignell C, Unemo M, European STI Guidelines Editorial Board. 2012 European 
guideline on the diagnosis and treatment of gonorrhoea in adults. International 
journal of STD & AIDS. 2013;24(2):85-92. 
11. 
Maldonado NG, Takhar SS. Update on Emerging Infections: news from the Centers 
for Disease Control and Prevention. Update to the CDC's Sexually Transmitted 
Diseases Treatment Guidelines, 2010: Oral cephalosporins no longer a recommended 
treatment for gonococcal infections. Annals of emergency medicine. 2013;61(1):91-5. 
12. 
Tapsall JW, Ndowa F, Lewis DA, Unemo M. Meeting the public health challenge of 
multidrug- and extensively drug-resistant Neisseria gonorrhoeae. Expert review of 
anti-infective therapy. 2009;7(7):821-34. 
13. 
Unemo M, Golparian D, Shafer WM. Challenges with gonorrhea in the era of multi-
drug and extensively drug resistance - are we on the right track? Expert review of 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 70 of 74 
 
anti-infective therapy. 2014;12(6):653-6. 
14. 
Unemo M, Nicholas RA. Emergence of multidrug-resistant, extensively drug-resistant 
and untreatable gonorrhea. Future Microbiology. 2012;7(12):1401-22. 
15. 
Fifer H, Natarajan U, Jones L, Alexander S, Hughes G, Golparian D, et al. Failure of 
Dual Antimicrobial Therapy in Treatment of Gonorrhea. N Engl J Med. 
2016;374(25):2504-6. 
16. 
Department of Health. Multi-drug resistant gonorrhoea. 2018; 
17. 
Public Health England. UK case of Neisseria gonorrhoeae with high-level resistance to 
azithromycin and resistance to ceftriaxone acquired abroad. Vol. 12. 2018. 
18. 
WHO. Global action plan to control the spread and impact of AMR in Neisseria 
gonorrhoeae. Geneva; 2012. 
19. 
Lee H, Lee K, Chong Y. New treatment options for infections caused by increasingly 
antimicrobial-resistant Neisseria gonorrhoeae. Expert Review of Anti-Infective 
Therapy. 2016;14(2):243-56. 
20. 
Basarab GS, Kern GH, McNulty J, Mueller JP, Lawrence K, Vishwanathan K, et al. 
Responding to the challenge of untreatable gonorrhea: ETX0914, a first-in-class agent 
with a distinct mechanism-of-action against bacterial Type II topoisomerases. 
Scientific Reports. 2015;5(11827. 
21. 
Craig WA. Pharmacokinetic/pharmacodynamic parameters: rationale for antibacterial 
dosing of mice and men. Clinical Infectious Diseases. 1998;26(1):1-10; quiz 11-2. 
22. 
Jacobsson S, Golparian D, Oxelbark J, Alirol E, Franceschi F, Gustafsson TN, et al. 
Pharmacodynamic Evaluation of Dosing, Bacterial Kill, and Resistance Suppression for 
Zoliflodacin Against Neisseria gonorrhoeae in a Dynamic Hollow Fiber Infection 
Model. Frontiers in Pharmacology. 2021;12(682135. 
23. 
O'Donnell J, Lawrence K, Vishwanathan K, Hosagrahara V, Mueller JP. Single-Dose 
Pharmacokinetics, Excretion, and Metabolism of Zoliflodacin, a Novel 
Spiropyrimidinetrione Antibiotic, in Healthy Volunteers. Antimicrobial Agents and 
Chemotherapy. 2019;63(1):e01808-18. 
24. 
Taylor SN, Marrazzo J, Batteiger BE, Hook EW, 3rd, Sena AC, Long J, et al. Single-Dose 
Zoliflodacin (ETX0914) for Treatment of Urogenital Gonorrhea. New England Journal 
of Medicine. 2018;379(19):1835-1845. 
25. 
Newman LM, Kankam M, Nakamura A, Conrad T, Mueller J, O'Donnell J, et al. 
Thorough QT Study To Evaluate the Effect of Zoliflodacin, a Novel Therapeutic for 
Gonorrhea, on Cardiac Repolarization in Healthy Adults. Antimicrobial Agents and 
Chemotherapy. 2021;65(12):e0129221. 
26. 
Taylor SN, Morris DH, Avery AK, Workowski KA, Batteiger BE, Tiffany CA, et al. 
Gepotidacin for the Treatment of Uncomplicated Urogenital Gonorrhea: A Phase 2, 
Randomized, Dose-Ranging, Single-Oral Dose Evaluation. Clinical Infectious Diseases. 
2018;67(4):504-512. 
27. 
Wi T, Lahra MM, Ndowa F, Bala M, Dillon JR, Ramon-Pardo P, et al. Antimicrobial 
resistance in Neisseria gonorrhoeae: Global surveillance and a call for international 
collaborative action. PLoS Medicine. 2017;14(7):e1002344. 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 71 of 74 
 
28. 
Unemo M, Ringlander J, Wiggins C, Fredlund H, Jacobsson S, Cole M. High in vitro 
susceptibility to the novel spiropyrimidinetrione ETX0914 (AZD0914) among 873 
contemporary clinical Neisseria gonorrhoeae isolates from 21 European countries 
from 2012 to 2014. Antimicrobial Agents and Chemotherapy. 2015;59(9):5220-5. 
29. 
Papp JR, Lawrence K, Sharpe S, Mueller J, Kirkcaldy RD. In vitro growth of multidrug-
resistant Neisseria gonorrhoeae isolates is inhibited by ETX0914, a novel 
spiropyrimidinetrione. International journal of antimicrobial agents. 2016;48(3):328-
30. 
30. 
Su XH, Wang BX, Le WJ, Liu YR, Wan C, Li S, et al. Multidrug-Resistant Neisseria 
gonorrhoeae Isolates from Nanjing, China, Are Sensitive to Killing by a Novel DNA 
Gyrase Inhibitor, ETX0914 (AZD0914). Antimicrobial Agents and Chemotherapy. 
2016;60(1):621-3. 
31. 
Bradford PA, Miller AA, O'Donnell J, Mueller JP. Zoliflodacin: An Oral 
Spiropyrimidinetrione Antibiotic for the Treatment of Neisseria gonorrheae, Including 
Multi-Drug-Resistant Isolates. ACS Infectious Diseases. 2020;6(6):1332-1345. 
32. 
Alm RA, Lahiri SD, Kutschke A, Otterson LG, McLaughlin RE, Whiteaker JD, et al. 
Characterization of the novel DNA gyrase inhibitor AZD0914: low resistance potential 
and lack of cross-resistance in Neisseria gonorrhoeae. Antimicrobial Agents and 
Chemotherapy. 2015;59(3):1478-86. 
33. 
Huband MD, Bradford PA, Otterson LG, Basarab GS, Kutschke AC, Giacobbe RA, et al. 
In vitro antibacterial activity of AZD0914, a new spiropyrimidinetrione DNA 
gyrase/topoisomerase inhibitor with potent activity against Gram-positive, fastidious 
Gram-Negative, and atypical bacteria. Antimicrobial Agents and Chemotherapy. 
2015;59(1):467-74. 
34. 
Jacobsson S, Golparian D, Alm RA, Huband M, Mueller J, Jensen JS, et al. High in vitro 
activity of the novel spiropyrimidinetrione AZD0914, a DNA gyrase inhibitor, against 
multidrug-resistant Neisseria gonorrhoeae isolates suggests a new effective option 
for oral treatment of gonorrhea. Antimicrobial Agents and Chemotherapy. 
2014;58(9):5585-8. 
35. 
Ruiz J, Jurado A, Garcia-Mendez E, Marco F, Aguilar L, Jimenez de Anta MT, et al. 
Frequency of selection of fluoroquinolone-resistant mutants of Neisseria 
gonorrhoeae exposed to gemifloxacin and four other quinolones. The Journal of 
antimicrobial chemotherapy. 2001;48(4):545-8. 
36. 
de Vries H, Jongen V, Heyman T, Wind C, de Korne-Elenbaas J, van Dam A, et al. 
Poster O20.2 Ertapenem is non-inferior to ceftriaxone for the treatment of 
anogenital gonorrhea: the NABOGO randomized double blind non-inferiority trial. 
Sexually Transmitted Infections. 2021;97(Suppl 1):A63. 
37. 
Unemo M, Golparian D, Limnios A, Whiley D, Ohnishi M, Lahra MM, et al. In vitro 
activity of ertapenem versus ceftriaxone against Neisseria gonorrhoeae isolates with 
highly diverse ceftriaxone MIC values and effects of ceftriaxone resistance 
determinants: ertapenem for treatment of gonorrhea? Antimicrobial agents and 
chemotherapy. 2012;56(7):3603-9. 
38. 
US FDA. Uncomplicated Gonorrhea: Developing Drugs for Treatment - Guidance for 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 72 of 74 
 
Industry. Silver Spring; 2015. Available from: 
https://fda.report/media/88904/Uncomplicated-Gonorrhea--Developing-Drugs-for-
Treatment.pdf. 
39. 
WHO. WHO Guidelines for the Treatment of Neisseria gonorrhoeae. Geneva; 2016. 
Available from: 
https://apps.who.int/iris/bitstream/handle/10665/246114/9789241549691-eng.pdf. 
40. 
St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K, et al. Update 
to CDC's Treatment Guidelines for Gonococcal Infection, 2020. Morbidity and 
Mortality Weekly Report. 2020;69(50):1911-6. 
41. 
Unemo M, Ross J, Serwin AB, Gomberg M, Cusini M, Jensen JS. 2020 European 
guideline for the diagnosis and treatment of gonorrhoea in adults. International 
Journal of STD and AIDS. 2020;1-17. 
42. 
Chisholm SA, Mouton JW, Lewis DA, Nichols T, Ison CA, Livermore DM. Cephalosporin 
MIC creep among gonococci: time for a pharmacodynamic rethink? Journal of 
Antimicrobial Chemotherapy. 2010;65(10):2141-8. 
43. 
Jaffe HW, Schroeter AL, Reynolds GH, Zaidi AA, Martin JE, Jr., Thayer JD. 
Pharmacokinetic determinants of penicillin cure of gonococcal urethritis. 
Antimicrobial agents and chemotherapy. 1979;15(4):587-91. 
44. 
Golparian D, Ohlsson A, Janson H, Lidbrink P, Richtner T, Ekelund O, et al. Four 
treatment failures of pharyngeal gonorrhoea with ceftriaxone (500 mg) or cefotaxime 
(500 mg), Sweden, 2013 and 2014. Eurosurveillance. 2014;19(30): 
45. 
Singh AE, Gratrix J, Martin I, Friedman DS, Hoang L, Lester R, et al. Gonorrhea 
Treatment Failures With Oral and Injectable Expanded Spectrum Cephalosporin 
Monotherapy vs Dual Therapy at 4 Canadian Sexually Transmitted Infection Clinics, 
2010-2013. Sexually Transmitted Diseases. 2015;42(6):331-6. 
46. 
Yin YP, Han Y, Dai XQ, Zheng HP, Chen SC, Zhu BY, et al. Susceptibility of Neisseria 
gonorrhoeae to azithromycin and ceftriaxone in China: A retrospective study of 
national surveillance data from 2013 to 2016. PLoS Medicine. 2018;15(2):e1002499. 
47. 
WHO. WHO guidelines for the treatment of Chlamydia trachomatis. Geneva; 2016. 
Available from: 
https://apps.who.int/iris/bitstream/handle/10665/246165/9789241549714-eng.pdf. 
48. 
Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually 
transmitted diseases treatment guidelines, 2015. Morbidity and Mortality Weekly 
Report Recommendations and Reports. 2015;64(RR-03):1-137. 
49. 
Department of Health, Republic of South Africa. Sexually transmitted infections - 
Management guidelines 2018 [Internet]. 2018. [cited 2021 Oct 4]. Available from: 
http://www.health.gov.za/wp-content/uploads/2020/11/sti-guidelines-27-08-19.pdf. 
50. 
Thailand Ministry of Public Health. Guidelines for treatment of gonorrhea (in Thai) 
[Internet]. Bangkok; 2019. [cited 2021 Oct 12]. Available from: 
http://klb.ddc.moph.go.th/dataentry/handbook/form/70. 
51. 
Van Bergen J, Dekker J, Boeke A, Kronenberg E, Van der Spruit R, Burgers J, et al. 
Dutch College of General Practitioners’ guideline STD consultation (NHG standaar: 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 73 of 74 
 
Het soa-consult) v2.0 [Internet]. 2013. [cited 2021 Oct 12]. Available from: 
https://richtlijnen.nhg.org/files/pdf/70_Het%20soa-consult_september-2013.pdf. 
52. 
Waites KB, Crabb DM, Duffy LB, Huband MD. In vitro antibacterial activity of AZD0914 
against human Mycoplasmas and Ureaplasmas. Antimicrobial agents and 
chemotherapy. 2015;59(6):3627-9. 
53. 
Foerster S, Golparian D, Jacobsson S, Hathaway LJ, Low N, Shafer WM, et al. Genetic 
Resistance Determinants, In Vitro Time-Kill Curve Analysis and Pharmacodynamic 
Functions for the Novel Topoisomerase II Inhibitor ETX0914 (AZD0914) in Neisseria 
gonorrhoeae. Frontiers in microbiology. 2015;6(1377. 
54. 
National Institute of Health. Common Terminology Criteria for Adverse Events 
(CTCAE) version 5.0. NIH Publication; 2017. 
55. 
WHO. WHO guidelines for the treatment of Neisseria gonorrhoeae - Annex D 
evidence profiles and evidence-to-decision frameworks. 2016. 
56. 
Chen MY, McNulty A, Avery A, Whiley D, Tabrizi SN, Hardy D, et al. Solithromycin 
versus ceftriaxone plus azithromycin for the treatment of uncomplicated genital 
gonorrhoea (SOLITAIRE-U): a randomised phase 3 non-inferiority trial. The Lancet 
Infectious Diseases. 2019;19(8):833-842. 
57. 
Dumville JC, Hahn S, Miles JN, Torgerson DJ. The use of unequal randomisation ratios 
in clinical trials: a review. Contemporary Clinical Trials. 2006;27(1):1-12. 
58. 
Hook EW, 3rd, Golden MR, Taylor SN, Henry E, Tseng C, Workowski KA, et al. Efficacy 
and Safety of Single-Dose Oral Delafloxacin Compared With Intramuscular 
Ceftriaxone for Uncomplicated Gonorrhea Treatment: An Open-Label, Noninferiority, 
Phase 3, Multicenter, Randomized Study. Sexually Transmitted Diseases. 
2019;46(5):279-286. 
59. 
Hook EW, Newman L, Drusano G, Evans S, Handsfield HH, Jerse AE, et al. 
Development of New Antimicrobials for Urogenital Gonorrhea Therapy: Clinical Trial 
Design Considerations. Clinical Infectious Diseases. 2020;70(7):1495-1500. 
60. 
Moran JS, Levine WC. Drugs of choice for the treatment of uncomplicated gonococcal 
infections. Clinical Infectious Diseases. 1995;20 Suppl 1(S47-65. 
61. 
Mitrani-Gold FS, Fix J, Donald A. Systematic Review and Meta-Analysis to Estimate 
the Treatment Effect and Inform a Non-Inferiority Margin for a Phase 3 Non-
Inferiority Trial in Uncomplicated Urogenital Gonorrhea. Sexually Transmitted 
Diseases. 2022;49(9):635-43. 
62. 
White IR, Royston P, Wood AM. Multiple imputation using chained equations: Issues 
and guidance for practice. Statistics in Medicine. 2011;30(4):377-99. 
 
 
 

			
	


Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 74 of 74 
 
Appendix 1: Contraception methods considered as highly effective 
For the purpose of this trial methods that can achieve a failure rate of less than 1% per year 
when used consistently and correctly are considered as highly effective birth control 
methods. Such methods, and the duration of required adherence prior to IMP 
administration, include:  
- 
combined (estrogen and progestogen containing) hormonal contraception associated 
with inhibition of ovulation:  
x 
oral (required for at least 7 days prior to IMP administration) 
x 
intravaginal (required for at least 7 days prior to IMP administration) 
x 
transdermal (required for at least 7 days prior to IMP administration) 
- 
progestogen-only hormonal contraception associated with inhibition of ovulation:  
x 
oral (required for at least 7 days prior to IMP administration)  
x 
injectable (required for at least 7 days prior to IMP administration) 
x 
implantable (required for at least 7 days prior to IMP administration) 
- 
intrauterine device (IUD) (any time prior to IMP administration) 
- 
intrauterine hormone-releasing system (IUS) (any time prior to IMP administration) 
- 
bilateral tubal occlusion (any time prior to IMP administration) 
- 
vasectomised partner1 (at least 3 months prior to IMP administration and verified by 
partner semen analysis) 
All contraceptive methods must be continued until at least 28 days post IMP administration. 
1 Vasectomised partner is a highly effective birth control method provided that partner is the sole sexual partner of the 
female of child-bearing potential trial participant and that the vasectomised partner has received medical assessment of 
the surgical success.   
 
 
 
 

			
	
