Phase 2a Randomized, Single-Blind, Placebo-Controlled, 12-week Escalating Dose Study to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally Applied MBN-101 to Infected Bone Sites
Phase: PHASE2
Conditions: Bacterial Infection
Sponsor: Microbion Corporation

MBN-101-201 
Study to Assess Safety and Clinical Activity of Local MBN-101 in Treatment of Infected Bone Sites 
NCT No.: NCT02436876 
Date: December 13, 2017 

 
 
 
16. 
APPENDICES 
APPENDIX 16.1: 
STUDY INFORMATION 
APPENDIX 16.1.1: PROTOCOL AND PROTOCOL AMENDMENTS 
Protocol Clarifications Memo, 13 December 2017 ........................................................................ 2 
Summary of Changes for Protocol Amendment 05, Version 5.0, 27 July 2017 ............................. 3 
Protocol Amendment 05, Version 5.0, 27 July 2017 .................................................................... 18 
Summary of Changes for Protocol Amendment 04, Version 4.0, 18 January 2017 ..................... 81 
Protocol Amendment 04, Version 4.0, 18 January 2017 .............................................................. 84 
Summary of Changes for Protocol Amendment 03, Version 3.0, 09 May 2016 ........................ 147 
Protocol Amendment 03, Version 3.0, 05 May 2016 ................................................................. 149 
Summary of Changes for Protocol Amendment 02, Version 2.1, 29 December 2015 ............... 212 
Protocol Amendment 02, Version 2.1, 29 December 2015 ........................................................ 215 
Summary of Changes for Protocol Amendment 01, Version 2.0, 08 October 2015 .................. 278 
Protocol Amendment 01, Version 2.0, 08 October 2015 ............................................................ 282 
Summary of Changes for Version 1.0, 06 May 2015 ................................................................. 345 
Original Protocol, Version 1.0, 06 May 2015 ............................................................................. 347 
 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
1

December 13, 2017 
To Whom It May Concern, 
Microbion wishes to clarify a specific aspect of the conduct for Study MBN-101-201. 
As currently written in Section 3.2 of the protocol, “Patients who are randomized but do not 
receive study drug may be replaced.” In order to better achieve the stated protocol objective 
of “having a total of 6 patients per dose level in the MBN-101-treated group”, Microbion 
asserts that they may also choose to replace a patient who is randomized but is discontinued 
from the study for reasons other than safety or is lost to follow up. 
Sincerely, 
Brett Baker, Microbion President and CSO 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
2

 
 
CLINICAL TRIAL PROTOCOL: MBN-101-201 
Version 5.0, 27 July 2017 
Summary of Changes 
Study Title: 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 
12-week Escalating Dose Study to Assess the Safety, 
Tolerability and Clinical Activity of 3 Concentrations 
of Locally Applied MBN-101 to Infected Bone Sites 
Study Phase: 
2a 
Product Name: 
MBN-101 
Sponsor: 
Microbion Corporation 
REASON(S) FOR CHANGES(S): 
1. Expand target population. 
2. Expand eligibility criteria. 
3. Administrative changes and corrections. 
CHANGES(S): 
Note – All changes refer to page numbers in the revised version. 
(1) Cover page (and where appropriate) 
From 
To 
Version 4.0 Issue Date: 18 January 2017 
Replaces Version 3.0 Issue Date: 05 May 2016 
Version 5.0 Issue Date: 27 July 2017 
Replaces Version 4.0 Issue Date: 18 January 2017 
A Phase 2a Randomized, Single-Blind, Placebo-
Controlled, 24-week Escalating Dose Study to 
Assess the Safety, Tolerability and Clinical 
Activity of 3 Concentrations of Locally Applied 
MBN-101 to Infected Osteosynthesis Sites 
A Phase 2a Randomized, Single-Blind, Placebo-
Controlled, 12-week Escalating Dose Study to 
Assess the Safety, Tolerability and Clinical 
Activity of 3 Concentrations of Locally Applied 
MBN-101 to Infected Bone Sites 
Rationale: 
Administrative change. 
(2) Page 4: Synopsis (Investigators/Study Centers) 
From 
To 
Up to eight Study Centers in the United States 
Up to twelve Study Centers in the United States 
Rationale: 
Administrative change. 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
3

Clinical Trial Protocol: MBN-101-201 
Microbion Corporation 
Summary of Changes: Version 5.0, 27 July 2017 
Page 2 of 15 
 
(3) Pages 4-5, 22: Synopsis (Study Design and Methodology) and 
Section 3.1 (Study Description) 
From 
To 
This is a randomized, single-blind, placebo-
controlled, multi-center study to assess the safety 
and tolerability of single escalating doses of 
MBN-101 applied directly to target structures 
within infected osteosynthesis sites during revision 
surgery with or without hardware removal and 
replacement for patients diagnosed with an 
apparent fracture site infection. 
This is a randomized, single-blind, placebo-
controlled, multi-center study to assess the safety 
and tolerability of single escalating doses of 
MBN-101 applied directly to target structures 
within infected osteosynthesis sites during revision 
surgery with or without hardware removal and 
replacement for patients diagnosed with an 
apparent fracture site infection or to sites of 
chronic or acute-on-chronic osteomyelitis of the 
long bone extremities or residual amputated limbs. 
Consecutive patients from each of the study sites 
will be screened for potential participation as they 
present to the orthopedic service for clinical care 
for their postoperative infections. 
Consecutive patients from each of the study sites 
will be screened for potential participation as they 
present to the orthopedic service for clinical care 
for their infections. 
Following baseline evaluation, patients will receive 
standard of care treatment for their postoperative 
fracture site infection that includes systemic 
antibacterial treatment per institutional standard of 
care guidelines and revision surgery with or 
without hardware removal and replacement as 
indicated. 
Following baseline evaluation, patients will receive 
standard of care treatment for their postoperative 
fracture site infection or osteomyelitis that includes 
systemic antibacterial treatment per institutional 
standard of care guidelines and debridement/revision 
surgery with or without hardware removal and 
placement/replacement as indicated. 
A single application of MBN-101 or placebo, 
applied intraoperatively directly to target structures 
within infected osteosynthesis sites, will be 
performed following the final irrigation and 
debridement procedure and immediately prior to 
definitive closure. 
A single application of MBN-101 or placebo, 
applied intraoperatively directly to target structures 
within infected bone sites, will be performed 
following the final irrigation and debridement 
procedure and immediately prior to definitive 
closure. 
In cases where hardware is replaced or in cases of 
two-stage procedures, MBN-101 will be applied to 
all accessible surfaces of hardware and adjacent 
bone (target structures) following implantation of 
hardware and immediately prior to definitive 
closure. 
In cases where hardware is placed or replaced, or 
in cases of two-stage procedures, MBN-101 will 
be applied to all accessible surfaces of hardware 
and adjacent bone (target structures) following 
implantation of hardware and immediately prior 
to definitive closure. 
Added 
In cases where hardware is not required, MBN-101 will be applied to affected areas of bone only prior to 
definitive closure. If wounds are left open, the investigational product will be applied immediately prior 
to definitive closure. 
From 
To 
The minimum amount of MBN-101 required to 
achieve a thin coat of the relevant target structures 
within the infected osteosynthesis site will be used. 
The minimum amount of MBN-101 required to 
achieve a thin coat of the relevant target structures 
within the infected bone site will be used. 
Patients will undergo study visits at Hour 48 and 
Weeks 2, 6, 12, and 24. All patients will be 
followed for a total of 24 weeks after surgery. 
Patients will undergo study visits at Hour 48 and 
Weeks 2, 6 and 12. All patients will be followed 
for a total of 12 weeks after surgery. 
Rationale: 
Expand target population. 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
4

Clinical Trial Protocol: MBN-101-201 
Microbion Corporation 
Summary of Changes: Version 5.0, 27 July 2017 
Page 3 of 15 
 
(4) Pages 5-6, 25: Synopsis (Inclusion Criteria) and Section 4.1 (Inclusion Criteria) 
From 
To 
1. Patients who: 
 
• 
have had operative fracture fixation of the 
upper extremity (AO/OTA class 15, 11-13, 
21-23), lower extremity (AO/OTA class 
31-34, 41-44, 81, 82) or pelvis (61, 62), or 
have undergone arthrodesis 
• 
have had operative fracture fixation of the 
upper extremity (AO/OTA class 15, 11-13, 
21-23), lower extremity (AO/OTA class 
31-34, 41-44, 81, 82) or pelvis (61, 62), or 
have undergone arthrodesis, and have 
subsequently been diagnosed with an 
apparent fracture site infection 
or 
are diagnosed with chronic or acute-on-
chronic osteomyelitis of the long bone 
extremities (including residual amputated 
limbs) 
• 
are diagnosed with an apparent 
fracture site infection and have at least 
one of the following: 
• 
have at least one of the following: 
• 
require revision surgery with or 
without removal and replacement of 
existing hardware 
• 
require surgical debridement of 
infected soft tissue and/or bone, with 
or without removal and/or 
placement/replacement of hardware 
4. Patients requiring postoperative hospitalization 
for at least 48 hours after revision surgery 
4. Patients requiring postoperative hospitalization 
for at least 48 hours after surgery 
5. Female subjects of childbearing potential, 
defined as not surgically sterile or at least 
2 years postmenopausal, must agree to use 
one of the following forms of contraception 
from screening through the Week 24 visit: 
hormonal (oral, implant, or injection) begun 
>30 days prior to screening, barrier (condom, 
diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner 
(6 months minimum) 
5. Female subjects of childbearing potential, 
defined as not surgically sterile or at least 
2 years postmenopausal, must agree to use 
one of the following forms of contraception 
from screening through the Week 12 visit: 
hormonal (oral, implant, or injection) begun 
>30 days prior to screening, barrier (condom, 
diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner 
(6 months minimum) 
5. Male participants must meet at least one of the 
following specifications and they must ensure 
their female sexual partner complies with the 
contraception requirements: 
 
• 
Be sexually abstinent from Baseline 
through Week 24 
• 
Be sexually abstinent from Baseline 
through Week 12 
• 
Agree to use a condom with spermicide 
from Baseline through Week 24 
• 
Agree to use a condom with spermicide 
from Baseline through Week 12 
Rationale: 
Expand target population. 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
5

Clinical Trial Protocol: MBN-101-201 
Microbion Corporation 
Summary of Changes: Version 5.0, 27 July 2017 
Page 4 of 15 
 
(5) Pages 6-7 and 26: Synopsis (Exclusion Criteria) and Section 4.2 (Exclusion Criteria) 
Deleted 
1. Patients who are no longer hardware dependent or are definitively treated for their infection by 
hardware removal without replacement 
From 
To 
2. Patients with multiple, non-contiguous fracture 
site infections 
1. Patients with multiple, non-contiguous sites of 
infection 
5. Serum creatinine, ALT, AST or Alkaline 
Phosphatase >1.5 times the upper limit of the 
normal range of the local testing laboratory 
4. Serum creatinine, ALT, AST or Alkaline 
Phosphatase >2.0 times the upper limit of the 
normal range of the local testing laboratory 
10. Individuals undergoing surgical treatment for 
more than one infected fracture 
9. Individuals undergoing surgical treatment for 
more than one infected site 
14. History of chronic or recurrent infections 
(≥ 3 infections at the same site within 
12 months) other than the index infected 
osteosynthesis site 
13. History of chronic or recurrent infections 
(≥ 3 infections at the same site within 
12 months) other than the index infected 
bone site 
Rationale: 
Expand target population; expand eligibility criteria. 
(6) Page 7: Synopsis (Investigational Product, Dose and Mode of Administration) 
From 
To 
MBN-101: A suspension of 0.025, 0.075, or 
0.25 mg/mL (w:v) BisEDT powder in 3% 
methylcellulose / 0.5% Tween 80 / 10 mM sodium 
chloride / 10 mM sodium phosphate, pH 7.4 (up to 
8 mL dose volume) applied directly to structures 
within infected osteosynthesis sites during revision 
surgery with or without hardware removal and 
replacement as an adjunct to standard care 
systemic antimicrobial therapy. 
MBN-101: A suspension of 0.025, 0.075, or 
0.25 mg/mL (w:v) BisEDT powder in 3% 
methylcellulose / 0.5% Tween 80 / 10 mM 
sodium chloride / 10 mM sodium phosphate, 
pH 7.4 (up to 8 mL dose volume) applied directly 
to structures within infected osteosynthesis sites 
during revision surgery with or without hardware 
removal and replacement or directly to the 
immediate soft tissue and bone in patients with 
chronic or acute-on-chronic osteomyelitis of the 
long bone extremities, both as an adjunct to 
standard care systemic antimicrobial therapy. 
Rationale: 
Expand target population; administrative change. 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
6

Clinical Trial Protocol: MBN-101-201 
Microbion Corporation 
Summary of Changes: Version 5.0, 27 July 2017 
Page 5 of 15 
 
(7) Page 7: Synopsis (Reference Therapy, Dose and Mode of Administration) 
From 
To 
MBN-101 diluent (placebo): 3% methylcellulose / 
0.5% Tween 80 / 10 mM sodium chloride / 10 mM 
sodium phosphate, pH 7.4 (up to 8 mL dose 
volume) applied directly to structures within 
infected osteosynthesis sites during revision 
surgery with or without hardware removal and 
replacement as an adjunct to standard care 
systemic antimicrobial therapy. 
MBN-101 diluent (placebo): 3% methylcellulose / 
0.5% Tween 80 / 10 mM sodium chloride / 10 mM 
sodium phosphate, pH 7.4 (up to 8 mL dose 
volume) applied directly to structures within 
infected osteosynthesis sites during revision 
surgery with or without hardware removal and 
replacement or directly to the immediate soft tissue 
and bone in patients with chronic or acute-on-
chronic osteomyelitis of the long bone extremities, 
both as an adjunct to standard care systemic 
antimicrobial therapy. 
Rationale: 
Expand target population; administrative change. 
(8) Page 7: Synopsis (Study Duration) 
From 
To 
24 weeks 
12 weeks 
Rationale: 
Expand eligibility criteria; administrative change. 
(9) Pages 8, 37 and 49: Synopsis (Criteria for Evaluation: Efficacy Endpoints), Section 8.2 
(Efficacy Endpoints) and Section 12.1 (Efficacy Endpoints) 
From 
To 
• 
Proportion of treatment failures. A treatment 
failure is defined as a subject with non-healing 
or worsening status of their surgical site 
requiring serious intervention by Week 24. 
• 
Proportion of treatment failures. A treatment 
failure is defined as a subject with non-healing 
or worsening status of their surgical site 
requiring serious intervention by Week 12. 
• 
Cumulative number of serious interventions 
(as defined in Section 12.6.2) at Week 24. 
• 
Cumulative number of serious interventions 
(as defined in Section 12.6.2) at Week 12. 
• 
Time to first serious intervention, time to 
readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and 
reoperations associated with a healed fracture 
site. 
• 
Time to first serious intervention, time to 
readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and 
reoperations associated with a healed bone 
site. 
• 
Number of subjects undergoing removal of 
stabilizing orthopedic hardware due to a healed 
fracture site by Week 24. 
• 
Number of subjects undergoing removal of 
stabilizing orthopedic hardware due to a healed 
bone site by Week 12. 
• 
Time to removal of orthopedic hardware due 
to a healed fracture site. 
• 
Time to removal of orthopedic hardware due 
to a healed bone site. 
Rationale: 
Expand eligibility criteria; administrative change. 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
7

Clinical Trial Protocol: MBN-101-201 
Microbion Corporation 
Summary of Changes: Version 5.0, 27 July 2017 
Page 6 of 15 
 
(10) Page 18: Section 1.1 (Clinical Problem) 
From 
To 
The high incidence of postoperative orthopedic 
device-related infections, as well as the 
shortcomings of the standard of care treatment in 
resolving those infections, particularly considering 
the increasing prevalence of antibiotic-resistant 
pathogens, has resulted in an expanding unmet 
need for safe, innovative, new and effective 
therapies to reduce the infectious risks and 
consequences of these infections, which 
increasingly involve antibiotic- resistant strains 
(Gessman, 2012; Morris, 2013; Tosh, 2012). 
Antibiotic resistance adds significantly to the 
challenge of successfully resolving these 
orthopedic infections (Ferry, 2010; Salgado, 2007). 
For example, infection treatment failures are nine 
times more frequent in orthopedic patients with 
MRSA infections than methicillin-sensitive 
S. aureus (MSSA) infections (Salgado, 2007). 
The high incidence of postoperative orthopedic 
device-related infections and of osteomyelitis, 
as well as the shortcomings of the standard of care 
treatment in resolving those infections, particularly 
considering the increasing prevalence of antibiotic-
resistant pathogens, has resulted in an expanding 
unmet need for safe, innovative, new and effective 
therapies to reduce the infectious risks and 
consequences of these infections, which 
increasingly involve antibiotic- resistant strains 
(Gessman, 2012; Morris, 2013; Tosh, 2012; 
Sheehy, 2010). Antibiotic resistance adds 
significantly to the challenge of successfully 
resolving these orthopedic infections (Ferry, 2010; 
Salgado, 2007). For example, infection treatment 
failures are nine times more frequent in orthopedic 
patients with MRSA infections than methicillin-
sensitive S. aureus (MSSA) infections (Salgado, 
2007). 
Rationale: 
Administrative change. 
(11) Page 20: Section 1.3 (Value of MBN-101 for the Treatment of the Clinical Problem) 
From 
To 
With comparatively elevated rates of postoperative 
infection associated with repair of traumatic 
orthopedic wounds, the development of a new and 
innovative treatment strategy to complement the 
current standard of care would therefore be 
expected to result in a substantial reduction in 
mortality, amputation, morbidity, and disability, 
along with a reduction in patient treatment costs. 
With comparatively elevated rates of both 
postoperative infection associated with repair of 
traumatic orthopedic wounds, and antibiotic-
resistance associated with osteomyelitis, the 
development of a new and innovative treatment 
strategy to complement the current standard of care 
would therefore be expected to result in a 
substantial reduction in mortality, amputation, 
morbidity, and disability, along with a reduction in 
patient treatment costs. 
Rationale: 
Administrative change. 
(12) Page 23: Section 3.3 (Number of Sites) 
From 
To 
Up to eight U.S. study sites are anticipated to 
enroll an adequate number of eligible patients. 
Up to twelve U.S. study sites are anticipated to 
enroll an adequate number of eligible patients. 
Rationale: 
Administrative change. 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
8

Clinical Trial Protocol: MBN-101-201 
Microbion Corporation 
Summary of Changes: Version 5.0, 27 July 2017 
Page 7 of 15 
 
(13) Page 24: Section 3.5 (Dose) 
From 
To 
With dose volume determined according to Section 
6.5.2, the volume of MBN-101 required to achieve 
a thin coat of the relevant structures within the 
infected osteosynthesis site will be applied. 
Following application, OR personnel will record in 
the CRF the actual volume (in tenths of milliliters) 
of any unapplied Treatment Dose remaining in the 
syringe. 
With dose volume determined according to Section 
6.5.2, the volume of MBN-101 required to achieve 
a thin coat of the relevant structures within the 
infected bone site will be applied. Following 
application, OR personnel will record in the Case 
Report Form (CRF) the actual volume (in tenths of 
milliliters) of any unapplied Treatment Dose 
remaining in the syringe. 
Rationale: 
Administrative change. 
(14) Page 27: Section 5.2 (Physical Exam)  
From 
To 
Each patient will receive a physical examination 
(head, ears, eyes, nose, throat, chest, heart, 
abdomen, and skin) including vital signs, weight 
(kg), and height (cm). Each patient will also 
receive a detailed evaluation of the index fracture 
site and involved extremity. 
Each patient will receive a physical examination 
(head, ears, eyes, nose, throat, chest, heart, 
abdomen, and skin) including vital signs, weight 
(kg), and height (cm). Each patient will also 
receive a detailed evaluation of the index infection 
site and involved extremity. 
Rationale: 
Administrative change. 
(15) Page 28: Section 6 (Study Procedures)  
From 
To 
See the Table of Study Events outlining study 
procedures in Appendix 1. For the study site visit 
at Week 2, a visit window of + 4 days will be 
allowed; for study site visits Weeks 6 – 24, a visit 
window of ± 8 days will be allowed. 
See the Table of Study Events outlining study 
procedures in Appendix 1. For the study site visit 
at Week 2, a visit window of + 4 days will be 
allowed; for study site visits Weeks 6 and 12, a 
visit window of ± 8 days will be allowed. 
Rationale: 
Expand eligibility criteria; administrative change. 
(16) Page 29: Section 6.1.7 (Pain Assessments)  
From 
To 
Pain related specifically to the surgical site 
(Surgical Site Pain Score) will be assessed via a 
Visual Analog Scale (VAS, 0-10 scale, where 
0=no pain at all and 10 =the worst possible pain) 
utilizing a 24 hour recall at screening, baseline, 
Hour 48 and Weeks 2, 6, 12, and 24. 
Pain related specifically to the surgical site 
(Surgical Site Pain Score) will be assessed via a 
Visual Analog Scale (VAS, 0-10 scale, where 
0=no pain at all and 10 =the worst possible pain) 
utilizing a 24 hour recall at screening, baseline, 
Hour 48 and Weeks 2, 6 and 12. 
Rationale: 
Expand eligibility criteria; administrative change. 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
9

Clinical Trial Protocol: MBN-101-201 
Microbion Corporation 
Summary of Changes: Version 5.0, 27 July 2017 
Page 8 of 15 
 
(17) Page 29: Section 6.1.9.1 (Specimen Collection) 
From 
To 
Samples collected will include at least one tissue 
site (bone when possible; eraser head size, suitable 
for dividing into two samples) from the fracture 
site (if accessed) or involved tissue adjacent to the 
implant(s), two swabs of the peri-implant deep 
tissue, and two swabs of the superficial 
tissue/wound closure site. 
Samples collected will include at least one tissue 
site (bone when possible; eraser head size, suitable 
for dividing into two samples) from the infected 
bone site (if accessed) or involved tissue adjacent 
to any implant(s), two swabs of the deep infection 
site, and two swabs of the superficial tissue/wound 
closure/sinus tract site. 
Rationale: 
Administrative change. 
(18) Page 31: Section 6.1.10 (Radiographic Evaluation) 
From 
To 
Radiographic evaluation will be performed at 
baseline and Weeks 2, 6, 12, and 24. Radiographs 
(at least two orthogonal views) will be reviewed 
for union, interval callus formation, loss or change 
in reduction, and hardware failure. 
Radiographic evaluation will be performed at 
baseline and Weeks 2, 6 and 12. Radiographs 
(at least two orthogonal views) will be reviewed 
for bone morphology and integrity, periosteal 
reaction, union, interval callus formation, loss or 
change in reduction, and hardware integrity/failure. 
Rationale: 
Expand eligibility criteria; administrative change. 
(19) Page 32: Section 6.5.1 (Surgical Site Identification) 
From 
To 
Individuals undergoing surgical treatment for more than 
one infected fracture are excluded from participation in 
this study. 
Individuals undergoing surgical treatment for more than 
one infected bone site are excluded from participation in 
this study. 
Rationale: 
Expand target population; administrative change. 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
10

Clinical Trial Protocol: MBN-101-201 
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Summary of Changes: Version 5.0, 27 July 2017 
Page 9 of 15 
 
(20) Page 32: Section 6.5.2 (Study Drug Administration) 
From 
To 
In all cases, the minimum amount of MBN-101 
required to coat the relevant structures within the 
infected osteosynthesis site should be used. 
In all cases, the minimum amount of MBN-101 
required to coat the relevant structures within the 
infected site should be used. 
The approximate area of the osteosynthesis site 
should be calculated based on the length of 
exposed bone multiplied by the width of bone 
exposed; the surface area of the hardware should 
be added to this value to derive the approximate 
area of the osteosynthesis site. Recommended 
maximum volumes of MBN-101 for various areas 
of the osteosynthesis site are provided in the table 
below. 
The approximate area of the infected site should be 
calculated based on the length of exposed bone 
multiplied by the width of bone exposed; the 
surface area of the hardware should be added to 
this value to derive the approximate area of the 
infected site. Recommended maximum volumes of 
MBN-101 for various areas of the infected site are 
provided in the table below. For infected bone 
surface areas that fall between the specified areas, 
the applied volume should be rounded up to the 
volume for the next area specified in the table 
(e.g., an 80 cm2 wound would be rounded up to 
100 cm2, and the volume of MBN-101 Study Dose 
administered would be 2.0 mL). 
Area of Osteosynthesis Site 
 
Area of Infected Bone Site 
 
The table shows the specified volume of MBN-101 
to be applied based on the area (in cm2) of the 
target infected osteosynthesis site. 
The table shows the specified volume of MBN-101 
to be applied based on the area (in cm2) of the 
target infected site. 
The use of drains and vacuum assisted closure 
devices at the site of hardware will be allowed per 
surgeon preference. The drainage volume over the 
first 24 hours or prior to discontinuation of the 
drain will be recorded in the eCRF. 
The use of drains and vacuum assisted closure 
devices will be allowed per surgeon preference. 
The drainage volume over the first 24 hours or 
prior to discontinuation of the drain will be 
recorded in the CRF. 
Rationale: 
Expand target population; administrative change. 
(21) Page 35: Section (6.6 Study Assessments) 
From 
To 
Each patient enrolled in the study will have an 
assessment at 48 hours following surgery and at 
Weeks 2, 6, 12, and 24. Study assessments will be 
performed according to Section 6.1 and Appendix 1. 
The Week 24 assessment will be the final 
assessment for adverse events. Any adverse events 
ongoing at the Week 24 assessment will be 
followed until resolution of the event or 
stabilization of the condition. 
Each patient enrolled in the study will have an 
assessment at 48 hours following surgery and at 
Weeks 2, 6 and 12. Study assessments will be 
performed according to Section 6.1 and Appendix 1. 
The Week 12 assessment will be the final 
assessment for adverse events. Any adverse events 
ongoing at the Week 12 assessment will be 
followed until resolution of the event or 
stabilization of the condition. 
Rationale: 
Expand eligibility criteria; administrative change. 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
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Clinical Trial Protocol: MBN-101-201 
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Summary of Changes: Version 5.0, 27 July 2017 
Page 10 of 15 
 
(22) Page 35: Section (6.9 Patient Withdrawals) 
From 
To 
All efforts should be made to have subjects 
complete the Week 24 (end of study) procedures 
prior to withdrawal from the study. 
All efforts should be made to have subjects 
complete the Week 12 (end of study) procedures 
prior to withdrawal from the study. 
Rationale: 
Expand eligibility criteria; administrative change. 
(23) Page 36: Section 7 (Concomitant Medications) 
From 
To 
Efforts should be made to maintain all concomitant 
medications at a stable dose for the duration of the 
24 week study. 
Efforts should be made to maintain all concomitant 
medications at a stable dose for the duration of the 
12 week study. 
Rationale: 
Expand eligibility criteria; administrative change. 
(24) Page 40: Section 9.2 (Severity) 
From 
To 
A severity category of mild, moderate, or severe, 
as defined below, should be determined and 
entered on the Adverse Events page of the Case 
Report Form (CRF). 
A severity category of mild, moderate, or severe, 
as defined below, should be determined and 
entered on the Adverse Events page of the CRF. 
Rationale: 
Administrative change and correction. 
(25) Page 48: Section 11.9 (Independent Medical Monitor) 
From 
To 
The independent medical monitor should be 
physicians, dentists, psychologists, nurses, or other 
healthcare providers capable of overseeing the 
progress of research protocols, especially issues of 
individual volunteer management and safety. 
The independent medical monitor should be a 
physician, dentist, psychologist, nurse, or other 
healthcare provider capable of overseeing the 
progress of research protocols, especially issues of 
individual volunteer management and safety. 
Rationale: 
Administrative change and correction. 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
12

Clinical Trial Protocol: MBN-101-201 
Microbion Corporation 
Summary of Changes: Version 5.0, 27 July 2017 
Page 11 of 15 
 
(26) Page 51: Section 12.5 (Disposition and Study Population Characteristics) 
From 
To 
Subject characteristics summaries will include 
demographics (age, gender, race, and ethnicity), 
baseline characteristics (weight, height, BMI), 
surgery site characteristics (type of injuries, type 
of fraction fixation, surgical site location), 
microbiology analysis results, time from previous 
surgery to study enrollment, and type of previous 
treatment), current surgery characteristics (area of 
the osteosynthesis site, with or without hardware 
replacement, etc.), and medical history. 
Subject characteristics summaries will include 
demographics (age, gender, race, and ethnicity), 
baseline characteristics (weight, height, BMI), 
surgery site characteristics (type of injuries, type 
of fraction fixation, surgical site location), 
microbiology analysis results, time from previous 
surgery to study enrollment, and type of previous 
treatment), current surgery characteristics (area of 
the osteosynthesis or osteomyelitis site, with or 
without hardware placement/replacement, etc.), 
and medical history. 
Rationale: 
Administrative change. 
(27) Page 52: Section 12.6.1 (Treatment Failure) 
From 
To 
A treatment failure is defined as a subject with 
non-healing or worsening status of their surgical 
site requiring serious intervention by Week 24. 
A treatment failure is defined as a subject with 
non-healing or worsening status of their surgical 
site requiring serious intervention by Week 12. 
Rationale: 
Expand eligibility criteria; administrative change. 
(28) Page 52: Section 12.6.2 (Incidence of Serious Interventions) 
From 
To 
• 
Readmission (exclusive of readmissions 
associated with a healed fracture site) 
• 
Reoperation (exclusive of reoperations 
associated with a healed fracture site) 
• 
Readmission (exclusive of readmissions 
associated with a healed bone site) 
• 
Reoperation (exclusive of reoperations 
associated with a healed bone site) 
The number of subjects with at least one serious 
intervention (exclusive of serious interventions, 
readmissions, and reoperations associated with a 
healed fracture site) and total number of serious 
interventions will be tabulated for the following 
periods: 
The number of subjects with at least one serious 
intervention (exclusive of serious interventions, 
readmissions, and reoperations associated with a 
healed bone site) and total number of serious 
interventions will be tabulated for the following 
periods: 
• 
from week 4 to week 8 
• 
from week 8 to week 12  
• 
from week 12 to week 24 
• 
from week 4 to week 8; and 
• 
from week 8 to week 12.  
Rationale: 
Expand eligibility criteria; administrative change. 
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(29) Page 53: Section 12.6.3 (Time to First Serious Interventions) 
From 
To 
Time to the first serious intervention exclusive 
of serious interventions, readmissions, and 
reoperations associated with a healed fracture site 
will be derived. 
Time to the first serious intervention exclusive 
of serious interventions, readmissions, and 
reoperations associated with a healed bone site 
will be derived. 
Rationale: 
Administrative change. 
(30) Page 53: Section 12.6.4 (Subjects Undergoing Removal of Stabilizing Orthopedic 
Hardware) 
From 
To 
The number of subjects undergoing removal of 
hardware due to a healed fracture site and the time 
to removal of hardware due to a healed fracture 
site will be derived. 
The number of subjects undergoing removal of 
hardware due to a healed bone site and the time to 
removal of hardware due to a healed bone site will 
be derived. 
Rationale: 
Administrative change. 
(31) Page 54: Section 12.6.7 (Pain Assessments) 
From 
To 
Surgical site pain score utilizing a 24 hour recall 
will be assessed via Visual Analog Scale (VAS) 
(Burckhardt, 2003; Brokelman, 2012; Briggs, 
1999) at baseline, and Weeks 2, 6, 12, and 24. 
Surgical site pain score utilizing a 24 hour recall 
will be assessed via Visual Analog Scale (VAS) 
(Burckhardt, 2003; Brokelman, 2012; Briggs, 
1999) at baseline, and Weeks 2, 6 and 12. 
Rationale: 
Expand eligibility criteria; administrative change. 
(32) Page 54: Section 12.6.8 (Microbiology) 
From 
To 
Samples collected will include at least one tissue 
site (eraser head size; suitable for dividing into two 
samples) from the fracture site (if accessed) or 
involved tissue adjacent to the implant(s), two 
swabs of the infected hardware (in situ or ex vivo), 
two swabs of the deep infection site, and two 
swabs of the superficial tissue/wound closure site 
when possible. 
Samples collected will include at least one tissue 
site (eraser head size; suitable for dividing into two 
samples) from the infected bone site (if accessed) 
or involved tissue adjacent to any implant(s), two 
swabs of the deep infection site, and two swabs of 
the superficial tissue/wound closure/sinus tract 
site. 
Rationale: 
Administrative change. 
(33) Page 55: Section 12.6.9 (Radiographic Evaluation) 
From 
To 
Radiographic evaluation will be performed at 
baseline and Weeks 2, 6, 12, and 24. 
Radiographic evaluation will be performed at 
baseline and Weeks 2, 6 and 12. 
Rationale: 
Expand eligibility criteria; administrative change. 
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(34) Page 55: Section 12.6.10 (Serologic Markers) 
From 
To 
Serology markers CRP and ESR will be assessed 
at baseline and Weeks 2, 6, 12, and 24. 
Serology markers CRP and ESR will be assessed 
at baseline and Weeks 2, 6 and 12. 
Rationale: 
Expand eligibility criteria; administrative change. 
(35) Page 55: Section 12.6.11 (Subgroup Analyses for Efficacy Endpoints) 
From 
To 
1. Area of the osteosynthesis site 
1. Area of the infected site 
Rationale: 
Administrative change. 
(36) Page 57: Section 13 (References) 
Added 
Sheehy SH, Atkins BA, Bejon P, Byren I, Wyllie D, Athanasou NA, Berendt AR, McNally MA. The 
microbiology of chronic osteomyelitis: Prevalence of resistance to common empirical anti-microbial 
regimens. Journal of Infection. 2010;60:338-43. 
Rationale: 
Administrative change. 
(37) Page 62: Appendix 1 (Table of Study Events) 
From 
To 
Week 12 
Day 84 
±8 days 
 
Week 12, EOT 
Day 84 
±8 days 
 
Deleted 
Week 24, EOT 
Day 168 
±8 days 
 
 
Rationale: 
Administrative change. 
(38) Page 63: Appendix 2 (Flowchart for Microbiological Specimen Processing) 
From 
To 
see Page 14 
see Page 15 
Rationale: 
Administrative change. 
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Old text: 
 
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Page 15 of 15 
 
New text: 
 
Microbion Corporation 
Clinical Study Report MBN-101-201
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17

1 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 
12-week Escalating Dose Study to Assess the Safety, 
Tolerability and Clinical Activity of 3 Concentrations 
of Locally Applied MBN-101 to Infected Bone Sites 
PROTOCOL NUMBER: MBN-101-201 
Version 5.0 Issue Date: 27 July 2017 
Replaces Version 4.0 Issue Date: 18 January 2017 
Regulatory Sponsor: 
Microbion Corporation 
1102 West Babcock, Suite B 
Bozeman MT 59715 
Version: 5.0 
Microbion Corporation 
 
Reviewed and Approved by: 
 
 
 
27 July 2017 
Dr. Brett Baker 
Microbion Corporation 
President and Chief Scientific Officer 
 
Date 
Confidentiality 
This document is the confidential property of Microbion Corporation. 
No part of it may be reproduced, published, or transmitted by other persons 
without written permission of Microbion Corporation. 
 
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Protocol MBN-101-201 
CONFIDENTIAL 
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Page 2 of 63 
GRANT SUPPORT 
This Phase 2a clinical study is supported in part by a $2.5 million grant awarded through the 
"Defense Medical Research and Development Program (DMRDP) Military Infectious Diseases 
Clinical Trial Award, W81XWH-12-DMRDP-MID-CTA". The grant award number is 
W81XWH-12-2-0100. 
The Awardee is the University of Pennsylvania, and the Principal Investigator (PI) for this grant 
award is Dr. Samir Mehta, Chief, Division of Orthopaedic Trauma, and Assistant Professor of 
Orthopaedic Surgery at the Hospital of the University of Pennsylvania. Dr. Mehta is also serving 
as the clinical PI for the University of Pennsylvania orthopaedic trauma clinical site. 
Participating as a Co-Investigator in this grant award is Dr. Saam Morshed, attending 
orthopaedic trauma surgeon and Director of the Clinical Research Center at the University of 
California San Francisco (UCSF) and the San Francisco General Hospital Orthopaedic Trauma 
Institute (OTI). Dr. Morshed will also serve as the clinical PI for the UCSF orthopaedic trauma 
clinical site. 
The Program Sponsor, Microbion Corporation, is represented by Dr. Brett Baker, President and 
Chief Scientific Officer. 
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Protocol MBN-101-201 
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Page 3 of 63 
INVESTIGATOR AGREEMENT 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 12-week Escalating Dose Study 
to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally 
Applied MBN-101 to Infected Bone Sites 
I have read the protocol and agree that it contains all necessary details for carrying out the study 
as described. I will conduct this protocol as outlined therein and will make all reasonable efforts 
to complete the study within the designated time. 
I will provide copies of the protocol and access to all information furnished by Microbion 
Corporation to study personnel under my supervision. I will discuss this material with them to 
ensure that they are fully informed about the drug and the study. 
I understand that the study may be terminated or enrollment suspended at any time by Microbion 
Corporation with or without cause, or by me, if it becomes necessary to protect the best interests 
of the study subjects. 
I agree to conduct this study in accordance with the requirements of this protocol and in 
accordance with the following: 
• Good Clinical Practice: Consolidated Guideline International Conference on Harmonisation 
of Technical Requirements for the Registration of Pharmaceuticals for Human Use, ICH E6 
(May 1996) 
• United States (U.S.) Code of Federal Regulations (CFR) associated with clinical studies 
(21 CFR parts 50, 56, 312) 
• Declaration of Helsinki, concerning medical research in humans (“Ethical Principles for 
Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 1975, Venice 
1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, Washington 
2002 and Tokyo 2004). 
 
  
Investigator’s Printed Name 
  
Investigator’s Signature 
 Date 
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PROTOCOL SYNOPSIS 
Protocol Number 
MBN-101-201 
Title 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 12-week 
Escalating Dose Study to Assess the Safety, Tolerability and Clinical 
Activity of 3 Concentrations of Locally Applied MBN-101 to Infected 
Bone Sites 
Regulatory Sponsor 
Microbion Corporation, 1102 West Babcock, Suite B, Bozeman MT 59715 
Name of 
Investigational 
Product 
MBN-101 
Phase 
2a 
Investigators/Study 
Centers 
Up to twelve Study Centers in the United States  
Objectives: 
Primary Objective 
To evaluate the safety and tolerability of single escalating doses of locally 
administered MBN-101 or placebo as adjunct to standard of care 
antimicrobial and surgical therapy 
Secondary Objectives • 
To evaluate the clinical activity of single escalating doses of locally 
administered MBN-101 
• 
To evaluate the pharmacokinetics of single escalating doses of locally 
administered MBN-101 
Number of Subjects 
24 
Study Design and 
Methodology 
This is a randomized, single-blind, placebo-controlled, multi-center study to 
assess the safety and tolerability of single escalating doses of MBN-101 
applied directly to target structures within infected osteosynthesis sites during 
revision surgery with or without hardware removal and replacement for 
patients diagnosed with an apparent fracture site infection or to sites of 
chronic or acute-on-chronic osteomyelitis of the long bone extremities or 
residual amputated limbs. Three successive cohorts of 8 patients will be 
enrolled in this trial. Consecutive patients from each of the study sites will be 
screened for potential participation as they present to the orthopedic service 
for clinical care for their infections. Patients meeting eligibility criteria on 
screening will be offered participation in the study. 
Following baseline evaluation, patients will receive standard of care 
treatment for their postoperative fracture site infection or osteomyelitis that 
includes systemic antibacterial treatment per institutional standard of care 
guidelines and debridement/revision surgery with or without hardware 
removal and placement/replacement as indicated. A single application of 
MBN-101 or placebo, applied intraoperatively directly to target structures 
within infected bone sites, will be performed following the final irrigation 
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Protocol MBN-101-201 
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and debridement procedure and immediately prior to definitive closure. In 
cases where original hardware is retained, MBN-101 will be applied to all 
accessible surfaces of hardware and adjacent bone (target structures). In cases 
where hardware is placed or replaced, or in cases of two-stage procedures, 
MBN-101 will be applied to all accessible surfaces of hardware and adjacent 
bone (target structures) following implantation of hardware and immediately 
prior to definitive closure. In cases where hardware is not required, MBN-
101 will be applied to affected areas of bone only prior to definitive closure. 
If wounds are left open, the investigational product will be applied 
immediately prior to definitive closure. The minimum amount of MBN-101 
required to achieve a thin coat of the relevant target structures within the 
infected bone site will be used. 
Patients will be randomized 3:1 (active:control) to three successive doses 
(0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up 
to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent). Enrollment to the 
next dose cohort will not commence until an evaluation by the Data Review 
Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort. 
PK assessments will be performed predose and at nominal 1, 6, 12, 24, 36, 48 
(Day 2), 60, 72 (Day 3), 96 (Day 4), and 336 (Day 14; Week 2) hours after 
administration of study drug. 
Patients will undergo study visits at Hour 48 and Weeks 2, 6 and 12. All 
patients will be followed for a total of 12 weeks after surgery. 
Study Population: 
Inclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “YES” answer (unless not applicable): 
1. Patients who: 
• 
have had operative fracture fixation of the upper extremity 
(AO/OTA class 15, 11-13, 21-23), lower extremity (AO/OTA class 
31-34, 41-44, 81, 82) or pelvis (61, 62), or have undergone 
arthrodesis, and have subsequently been diagnosed with an apparent 
fracture site infection 
or 
are diagnosed with chronic or acute-on-chronic osteomyelitis of the 
long bone extremities (including residual amputated limbs) 
• 
have at least one of the following: 
 
Elevated ESR above the upper limit of normal 
 
Elevated CRP above the upper limit of normal 
 
Draining wound / sinus tract 
 
Positive culture from site of prior surgery by aspirate or other 
modality 
 
Local erythema or induration at the site of prior surgery 
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 
Exposed hardware 
 
Periosteal reaction on x-ray 
 
Loose or broken hardware  
• 
require surgical debridement of infected soft tissue and/or bone, with 
or without removal and/or placement/replacement of hardware 
2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed 
and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as 
per institution’s standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after 
surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile 
or at least 2 years postmenopausal, must agree to use one of the 
following forms of contraception from screening through the Week 12 
visit: hormonal (oral, implant, or injection) begun >30 days prior to 
screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications 
and they must ensure their female sexual partner complies with the 
contraception requirements: 
• 
Be sexually abstinent from Baseline through Week 12 
• 
Be > 6 months post-vasectomy  
• 
Agree to use a condom with spermicide from Baseline through 
Week 12 
7. Have read and signed the Informed Consent Form (ICF) after the nature 
of the study has been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of 
personal health information in accordance with Health Insurance 
Portability and Accountability Act (HIPAA) 
Exclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “NO” answer (unless not applicable): 
1. Patients with multiple, non-contiguous sites of infection 
2. Pathologic fracture (not including osteoporosis) 
3. Patient requires immunosuppressive therapy (Topical or inhaled 
corticosteroids are permitted) 
4. Serum creatinine, ALT, AST or Alkaline Phosphatase >2.0 times the 
upper limit of the normal range of the local testing laboratory 
5. Absolute neutrophil count <1000 
6. Patients without definitive soft-tissue coverage over the surgical site at 
time of study product administration 
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7. Any condition that has required treatment with any other bismuth 
containing compound within the last 2 weeks (i.e., Kaopectate or 
Pepto-Bismol) 
8. Participation in an investigational trial to evaluate pharmaceuticals or 
biologics within the past 3 months 
9. Individuals undergoing surgical treatment for more than one infected site 
10. Known allergy to metals or materials comprising the orthopedic 
hardware, bismuth and/or MBN-101 excipients (methylcellulose, 
Tween 80 (polysorbate 80)) 
11. Patients who are pregnant, lactating, or female patients who have a 
positive serum hCG as determined by laboratory testing 
12. Immunocompromised due to illness or organ transplant 
13. History of chronic or recurrent infections (≥ 3 infections at the same site 
within 12 months) other than the index infected bone site 
14. History of any type of cancer (excluding non-melanomatous localized 
skin cancer or completely excised and cured carcinoma-in-situ of uterine 
cervix) 
15. Poorly controlled diabetes mellitus (hemoglobin A1c > 9.0% for 
≥ 6 months despite management by a physician) 
16. History of medical noncompliance 
17. Other medical conditions which, in the opinion of the Principal 
Investigator, would jeopardize the safety of the study subject or impact 
the validity of the study results 
18. Current incarceration 
Investigational 
Product, Dose and 
Mode of 
Administration: 
MBN-101: A suspension of 0.025, 0.075, or 0.25 mg/mL (w:v) BisEDT 
powder in 3% methylcellulose / 0.5% Tween 80 / 10 mM sodium chloride / 
10 mM sodium phosphate, pH 7.4 (up to 8 mL dose volume) applied directly 
to structures within infected osteosynthesis sites during revision surgery with 
or without hardware removal and replacement or directly to the immediate 
soft tissue and bone in patients with chronic or acute-on-chronic 
osteomyelitis of the long bone extremities, both as an adjunct to standard care 
systemic antimicrobial therapy. 
Reference Therapy, 
Dose and Mode of 
Administration: 
MBN-101 diluent (placebo): 3% methylcellulose / 0.5% Tween 80 / 
10 mM sodium chloride / 10 mM sodium phosphate, pH 7.4 (up to 8 mL dose 
volume) applied directly to structures within infected osteosynthesis sites 
during revision surgery with or without hardware removal and replacement or 
directly to the immediate soft tissue and bone in patients with chronic or 
acute-on-chronic osteomyelitis of the long bone extremities, both as an 
adjunct to standard care systemic antimicrobial therapy. 
Study Duration 
12 weeks 
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Criteria for Evaluation: 
Efficacy Endpoints 
• 
Proportion of treatment failures. A treatment failure is defined as a 
subject with non-healing or worsening status of their surgical site 
requiring serious intervention by Week 12. 
• 
Cumulative number of serious interventions (as defined in Section 
12.6.2) at Week 12. 
• 
Time to first serious intervention, time to readmission and time to 
reoperation, exclusive of serious interventions, readmissions, and 
reoperations associated with a healed bone site. 
• 
Number of subjects undergoing removal of stabilizing orthopedic 
hardware due to a healed bone site by Week 12. 
• 
Time to removal of orthopedic hardware due to a healed bone site. 
• 
Incidence and intensity of surgical site signs and symptoms, including 
local erythema, induration, drainage and degree of healing. 
• 
Change from baseline in patient-reported outcomes at each post baseline 
time point. Patient-reported outcomes will include Veterans Rand 12 
Item Health Survey (VR-12) and Short Musculoskeletal Function 
Assessment (SMFA). 
• 
Surgical site pain score and change from baseline in pain score at each 
post baseline time point. Pain intensity at the surgical site will be 
assessed by Visual Analog Scale (VAS, 0-10 scale). 
• 
Findings of microbiology evaluations at the surgical site. Microbiologic 
success is assessed by clearance of infection. 
• 
Findings of radiographic evaluations at the surgical site. Radiographic 
success is assessed by healing on radiologic examination. 
• 
Changes in serologic markers CRP and ESR at each post baseline time 
point. 
Safety Endpoints 
• 
Treatment-emergent adverse events. 
• 
Treatment-emergent serious adverse events. 
• 
Changes in clinical laboratory tests (clinical chemistry, hematology, and 
urinalysis). 
• 
Changes in vital signs (blood pressure, pulse, respiratory rate and body 
temperature). 
• 
Changes in physical exams. 
• 
Clinical findings of 12-lead electrocardiograms. 
• 
Change in microbiology status. 
Pharmacokinetic 
Endpoints 
• 
Whole blood concentrations of Bismuth (Bi) will be measured after 
administration of single escalating doses of MBN-101 (bismuth as a 
surrogate for BisEDT) and will be used to calculate pharmacokinetic 
parameters (i.e., Tmax, Cmax, AUC0-t, AUC0- ∞, T1/2, CL/F, Vz/F). 
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Statistical Methods: 
Statistical Analysis 
Consideration: 
The study sample of size of 24 subjects was chosen empirically for the 
purpose of the study without considering any formal statistical hypothesis 
testing. 
The safety analysis set will include all subjects who are randomized and 
receive any study drug; the efficacy analysis set will include all randomized 
subject with at least one post treatment assessment. Pharmacokinetic analysis 
set will include all subjects who have sufficient plasma samples to allow for 
calculation of pharmacokinetic parameters. 
All safety and efficacy endpoints will be tabulated with descriptive statistics; 
data from all placebo subjects (2 per cohort; 6 subjects in total) will be 
pooled. Data from BisEDT treated subjects will be presented by dose 
(6 subjects per dose) and combined (a total of 18 subjects). If data permits, 
differences between the treatment groups and 95% confidence intervals for 
the difference will be presented. 
If data permit, exploratory dose-response analyses will be performed for 
selected efficacy and safety endpoints.  
The primary analyses of efficacy and safety endpoints will be based on the 
actual treatment received in the event that the received treatment is not the 
assigned treatment; however, ‘as assigned’ sensitivity analyses are planned to 
evaluate the robustness of the efficacy data. 
 
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SPONSOR CONTACT INFORMATION 
Medical Monitor 
Name: 
Brian Murphy, MD 
Sr. Medical Director, Medpace Infectious Diseases 
Office Phone Number: 
513-579-9911, ext. 12416 
Mobile Phone Number: 
859-619-0037 
E-mail: 
b.murphy1@medpace.com 
Other Appropriate Trial Contact Personnel 
Name 
Tracy Robertson 
Clinical Trial Manager, Medpace 
Office Phone Number 
513-579-9911, ext. 12140 
Mobile Phone Number 
859-512-5183 
Fax 
513-579-0444 
E-mail: 
t.robertson@medpace.com 
Medpace Clinical Safety:  
SAE hotline: 
866-336-0930 or 
800-730-5779, ext. 2999 
Facsimile: 
866-336-5320 
E-mail: 
medpace-safetynotification@medpace.com 
 
If any Sponsor contact information needs to be changed during the course of the study, this will 
be done by the Sponsor, with written notification to the Investigator, and will not require a 
protocol amendment. 
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LIST OF ABBREVIATIONS 
AE 
Adverse event 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase (Serum glutamic pyruvic transaminase [SGPT]) 
AO/OTA 
Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association 
AST 
Aspartate aminotransferase (Serum glutamic oxaloacetic transaminase 
[SGOT]) 
AUC0-∞ 
Area under the curve from time 0 to infinity 
AUC0-t 
Area under the curve from time 0 to the time of the last measurable 
concentration 
Bi 
Bismuth, used as a surrogate in concentration and PK analyses after MBN-101 
administration 
BisEDT 
Bismuth-1,2-ethanedithiol 
BMI 
Body mass index 
BUN 
Blood urea nitrogen 
CFR 
Code of Federal Regulations 
CK 
Creatinine kinase 
CL/F 
Apparent clearance after extravascular administration  
CLSI 
Clinical and Laboratory Standards Institute 
Cm 
Centimeter 
Cmax 
Maximum observed concentration 
CRF 
Case report form 
CRP 
C-reactive protein 
DFU 
Directions for Use 
DOD 
Department of Defense 
DRC 
Data Review Committee 
ECG 
Electrocardiogram 
ESBL 
Extended spectrum beta lactamase 
ESR 
Erythrocyte sedimentation rate 
FDA 
U.S. Food and Drug Administration 
GCP 
Good Clinical Practice 
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GGT 
Gamma glutamyl transferase 
hCG 
Human chorionic gonadotropin 
HIPAA 
Health Insurance Portability and Accountability Act 
ICF 
Informed Consent Form  
ICH 
International Conference on Harmonization  
ICP-MS 
Inductively coupled plasma mass spectrometry 
IHMA 
International Health Management Associates, Inc. 
IRB 
Institutional Review Board  
ITT 
Intent to treat 
IUD 
Intrauterine device 
IV 
Intravenous 
IWRS 
Interactive Web Response System 
Kg 
Kilogram 
MBN-101 
Bismuth-1,2-ethanedithiol (BisEDT) suspension 
MC 
Methylcellulose 
MCS 
Mental health domain score 
MCV 
Mean corpuscular volume 
MDR 
Multidrug Resistant 
MedDRA 
Medical Dictionary for Regulatory Activities 
mg 
Milligram 
mg/mL 
Milligrams per milliliter 
MIC 
Minimal inhibitory concentration 
mITT 
Modified intent to treat 
mL 
Milliliter 
mm 
Millimeter 
mM 
Millimolar 
MRSA 
Methicillin resistant Staphylococcus aureus 
MRSE 
Methicillin resistant Staphylococcus epidermidis 
MSSA 
Methicillin-sensitive Staphylococcus aureus 
NCA 
Non-compartmental (PK) analysis 
ng/mL 
Nanograms per milliliter 
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OR 
Operating room 
ORP 
Office of Research Protections 
PCS 
Physical health domain score 
PI 
Principal investigator 
PK 
Pharmacokinetics 
PT 
Prothrombin time 
PTT 
Partial thromboplastin time 
QIDP 
Qualified Infectious Disease Product 
RBC 
Red blood cells 
SAE 
Serious Adverse Event 
SAE CRF 
Serious Adverse Event Case Report Form 
SAP 
Statistical Analysis Plan 
SGOT 
Serum glutamic oxaloacetic transaminase 
SGPT 
Serum glutamic pyruvic transaminase 
SMFA 
Short Musculoskeletal Function Assessment 
SOC 
System organ class 
SOP 
Standard Operating Procedure 
T1/2 
Apparent half-life after extravascular administration 
TEAE 
Treatment-emergent adverse event 
Tmax 
Time of the maximal observed concentration 
USAMRMC US Army Medical Research and Materiel Command 
VAS 
Visual Analog Scale 
VR-12 
Veterans Rand 12 Item Health Survey 
Vz/F 
Apparent volume of distribution after extravascular administration 
w/v 
Weight:volume 
w:w 
Weight:weight 
WBC 
White blood cells 
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TABLE OF CONTENTS 
Grant Support .................................................................................................................................. 2 
Investigator Agreement ................................................................................................................... 3 
Protocol Synopsis............................................................................................................................ 4 
Sponsor Contact Information ........................................................................................................ 10 
List of Abbreviations .................................................................................................................... 11 
1 
INTRODUCTION ................................................................................................................18 
1.1 
Clinical Problem .......................................................................................................18 
1.2 
Investigational Therapy ............................................................................................19 
1.3 
Value of MBN-101 for the Treatment of the Clinical Problem ................................20 
2 
OBJECTIVES .......................................................................................................................21 
2.1 
Primary ......................................................................................................................21 
2.2 
Secondary ..................................................................................................................21 
3 
INVESTIGATIONAL PLAN ...............................................................................................22 
3.1 
Study Description......................................................................................................22 
3.2 
Number of Subjects...................................................................................................23 
3.3 
Number of Sites ........................................................................................................23 
3.4 
Clinical Trial Material ...............................................................................................23 
3.4.1 
MBN-101 .....................................................................................................23 
3.4.2 
Placebo (MBN-101 diluent) ........................................................................23 
3.5 
Dose ..........................................................................................................................24 
4 
STUDY POPULATION .......................................................................................................25 
4.1 
Inclusion Criteria ......................................................................................................25 
4.2 
Exclusion Criteria .....................................................................................................26 
5 
SUBJECT ENROLLMENT .................................................................................................27 
5.1 
Medical History ........................................................................................................27 
5.2 
Physical Exam ...........................................................................................................27 
5.3 
Studies .......................................................................................................................27 
5.4 
Laboratory Tests at Screening Visit ..........................................................................27 
6 
STUDY PROCEDURES ......................................................................................................28 
6.1 
Description of Study Procedures ..............................................................................28 
6.1.1 
Medical History ...........................................................................................28 
6.1.2 
Physical Exams ............................................................................................28 
6.1.3 
Vital Signs ...................................................................................................28 
6.1.4 
12-lead ECG ................................................................................................28 
6.1.5 
Laboratory Tests ..........................................................................................28 
6.1.6 
BisEDT (MBN-101) Blood Levels .............................................................29 
6.1.7 
Pain Assessments ........................................................................................29 
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6.1.8 
Patient Reported Outcomes .........................................................................29 
6.1.9 
Microbiology ...............................................................................................29 
6.1.9.1 
Specimen Collection ...................................................................29 
6.1.9.2 
Specimen Processing: Local Laboratory ....................................29 
6.1.9.3 
Specimen Processing: IHMA (Central Laboratory) ...................30 
6.1.9.4 
Integration of Local Site Laboratory and Central Laboratory 
Primary Isolation and Identification Results ..............................30 
6.1.10 Radiographic Evaluation .............................................................................31 
6.1.11 Surgical Site Signs and Symptoms Evaluation ...........................................31 
6.2 
Screening and Baseline Assessments ........................................................................31 
6.3 
Randomization Procedure .........................................................................................31 
6.4 
Unblinding Procedure ...............................................................................................32 
6.5 
Investigational Product Administration ....................................................................32 
6.5.1 
Surgical Site Identification ..........................................................................32 
6.5.2 
Study Drug Administration .........................................................................32 
6.6 
Study Assessments ....................................................................................................35 
6.7 
Safety Monitoring .....................................................................................................35 
6.8 
Study Monitoring ......................................................................................................35 
6.9 
Patient Withdrawals ..................................................................................................35 
6.10 
Individual Patient Stopping Rules ............................................................................35 
6.11 
Study Stopping Rules ................................................................................................35 
7 
CONCOMITANT MEDICATIONS ....................................................................................36 
8 
STUDY ENDPOINTS ..........................................................................................................37 
8.1 
Safety Endpoints .......................................................................................................37 
8.2 
Efficacy Endpoints ....................................................................................................37 
8.3 
Pharmacokinetic Endpoint ........................................................................................38 
8.3.1 
Sample Collection and Handling .................................................................38 
8.3.2 
Assay Methodology .....................................................................................38 
8.3.3 
PK Analysis .................................................................................................38 
9 
ADVERSE EVENTS ............................................................................................................39 
9.1 
Reporting and Following Adverse Events ................................................................39 
9.2 
Severity .....................................................................................................................40 
9.3 
Relationship to Clinical Trial Material .....................................................................40 
9.4 
Serious Adverse Events ............................................................................................41 
9.4.1 
Definition .....................................................................................................41 
9.4.2 
Reporting .....................................................................................................41 
9.5 
Pregnancies ...............................................................................................................42 
9.6 
Data Review Committee (DRC) ...............................................................................42 
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10 
INVESTIGATIONAL PRODUCT MANAGEMENT .........................................................43 
10.1 
Study Drug ................................................................................................................43 
10.2 
Study Drug Packaging and Labeling ........................................................................44 
10.3 
Study Drug Storage ...................................................................................................44 
10.4 
Study Drug Accountability .......................................................................................44 
10.5 
Study Drug Handling and Disposal ..........................................................................44 
11 
GENERAL CONSIDERATIONS ........................................................................................45 
11.1 
Basic Principles .........................................................................................................45 
11.2 
Institutional Review Board .......................................................................................45 
11.3 
Informed Consent......................................................................................................45 
11.4 
Study Termination ....................................................................................................46 
11.5 
Regulatory Documentation .......................................................................................46 
11.6 
Study Documentation................................................................................................46 
11.7 
Data Handling and Record Keeping .........................................................................47 
11.8 
Use of Information and Publication ..........................................................................47 
11.9 
Independent Medical Monitor ...................................................................................48 
12 
STATISTICAL ANALYSIS METHODOLOGY ................................................................49 
12.1 
Efficacy Endpoints ....................................................................................................49 
12.2 
Safety Endpoints .......................................................................................................50 
12.3 
Sample Size Considerations ......................................................................................50 
12.4 
Analysis Datasets ......................................................................................................51 
12.5 
Disposition and Study Population Characteristics ....................................................51 
12.6 
Efficacy Analysis ......................................................................................................52 
12.6.1 Treatment Failure ........................................................................................52 
12.6.2 Incidence of Serious Interventions ..............................................................52 
12.6.3 Time to First Serious Interventions .............................................................53 
12.6.4 Subjects Undergoing Removal of Stabilizing Orthopedic Hardware .........53 
12.6.5 Surgical Site Signs and Symptoms ..............................................................53 
12.6.6 Patient-Report Outcomes ............................................................................53 
12.6.6.1 The Veterans RAND 12 Item Health Survey (VR-12) 
Questionnaire ..............................................................................53 
12.6.6.2 The Short Musculoskeletal Function Assessment 
Questionnaire (SMFA) ...............................................................53 
12.6.7 Pain Assessments ........................................................................................54 
12.6.8 Microbiology ...............................................................................................54 
12.6.9 Radiographic Evaluation .............................................................................55 
12.6.10 Serologic Markers .......................................................................................55 
12.6.11 Subgroup Analyses for Efficacy Endpoints ................................................55 
12.6.12 Sensitivity Analyses for Efficacy Endpoints ...............................................55 
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12.7 
Safety Analysis .........................................................................................................56 
12.7.1 Study Drug Exposure and Concentrations ..................................................56 
12.7.2 Adverse Events ............................................................................................56 
12.7.3 Clinical Laboratory Tests ............................................................................56 
12.7.4 12-lead ECG ................................................................................................56 
12.7.5 Vital Sign Measurements ............................................................................57 
12.7.6 Physical Examinations ................................................................................57 
12.7.7 Subgroup Analyses for Safety Endpoints ....................................................57 
12.8 
PK Analysis ..............................................................................................................57 
12.9 
Interim Evaluation ....................................................................................................57 
13 
REFERENCES .....................................................................................................................58 
14 
APPENDICES ......................................................................................................................61 
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1 
INTRODUCTION 
1.1 
Clinical Problem 
Postoperative orthopedic infections, particularly antibiotic-resistant infections, present a serious 
clinical challenge to surgeons and other treating physicians, since these infections involve 
foreign materials (stabilizing orthopedic hardware) which are frequently associated with 
persistent microbial biofilms (Hetrick, 2006). Surgical intervention, including irrigation, 
debridement and potential replacement of orthopedic hardware, combined with a prolonged 
course of systemic antibiotics, is the standard of care for postoperative infections (Schmidt, 
2000; Patzakis, 2005). However, outcomes associated with these infections are often poor, 
including chronic/recurrent infections, repeated hospitalizations, repeated surgeries, multiple 
courses of systemic antibiotic treatment, loss of function, disability, amputation and death 
(Berkes, 2010). 
Systemic antibiotics are poorly efficacious in the treatment of heavily contaminated or infected 
wounds (Zalavras, 2003; Robson, 1997) and often antibiotics “…have practical and potential 
value only if a therapeutic blood level or, more importantly, tissue level is achieved within the 
first 4 hours after wounding” (Robson, 1999), i.e., before biofilm formation. The ‘contest’ 
between bacteria and host tissues with respect to speed of colonization of foreign objects such as 
orthopedic medical devices has been described as the “race for the surface’ (Gristina, 1988). 
Bacteria are able to adhere to foreign, implanted objects almost immediately, facilitating rapid 
formation of microbial biofilms which drastically increase the resistance of wound-associated 
bacteria and contribute significantly to persistence and virulence of the infection (Parra-Ruiz, 
2012; Gristina, 1994). Such biofilms can serve as quiescent reservoirs of adherent, antibiotic-
tolerant or antibiotic-resistant bacteria within the wound, or as foci of active infections, which 
helps to explain the chronic and/or recurrent nature of many device-related infections. In 
addition, biofilms are hypermutable (Ciofu, 2011), increasing the likelihood of developing 
genetically-based antibiotic resistance. Finally, biofilms serve as environments in which bacteria 
can exchange genetic material encoding antibiotic resistance genes (Ghigo, 2001). Recent studies 
have shown that the most highly multidrug resistant (MDR) bacteria are also the strongest 
biofilm-forming bacteria (Kwon, 2008), and similarly, that invasive MDR bacteria are usually 
biofilm-forming bacteria (Reiter, 2011). 
The high incidence of postoperative orthopedic device-related infections and of osteomyelitis, 
as well as the shortcomings of the standard of care treatment in resolving those infections, 
particularly considering the increasing prevalence of antibiotic-resistant pathogens, has resulted 
in an expanding unmet need for safe, innovative, new and effective therapies to reduce the 
infectious risks and consequences of these infections, which increasingly involve antibiotic- 
resistant strains (Gessman, 2012; Morris, 2013; Tosh, 2012; Sheehy, 2010). Antibiotic resistance 
adds significantly to the challenge of successfully resolving these orthopedic infections (Ferry, 
2010; Salgado, 2007). For example, infection treatment failures are nine times more frequent in 
orthopedic patients with MRSA infections than methicillin-sensitive S. aureus (MSSA) 
infections (Salgado, 2007). 
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Development of local therapies that eradicate established biofilms or prevent the formation of 
biofilms (as a new target) is an innovative new clinical strategy, particularly considering the 
shortcomings of systemically administered antibiotics for treatment of wound infections. For 
example, several groups have investigated the direct, local application of vancomycin powder on 
the surgical wound in combination with systemic prophylaxis to prevent or treat infection. The 
outcomes of these studies have been mixed, with some groups reporting a reduced infection rate 
and/or a reduction in patient treatment costs (Heller, 2013; Godil, 2013) and others reporting no 
benefit (Tubaki, 2013; Martin, 2013). Antibiotic-loaded bone cement containing tobramycin, 
gentamicin, or vancomycin/tobramycin or other antibiotic combinations have been investigated 
for their ability to reduce infection rates and /or reduce costs when applied locally in a variety of 
orthopedic surgical procedures (Cummins, 2009; Nowinski, 2012; Selhi, 2012). Evidence 
suggests that local therapies may reduce implant related surgical site infections. 
1.2 
Investigational Therapy 
MBN-101 [Bismuth-1,2-ethanedithiol (BisEDT) suspension] represents the first drug product 
from a new class of antimicrobial agents with apparently unique mechanisms of action. In 
nonclinical models, BisEDT has been shown to be effective against a broad-spectrum of 
orthopedic device-associated bacteria including antibiotic-resistant strains. 
BisEDT has several characteristics especially suited to the treatment of postoperative orthopedic 
infections: 
a) Broad spectrum antimicrobial activity against the most critically important antibiotic-
resistant bacteria, including MRSA, MRSE, antibiotic-resistant Pseudomonas 
aeruginosa, ESBL-positive Klebsiella pneumoniae, and antibiotic-resistant Enterobacter 
species. 
b) Apparently unique mechanisms of action. 
c) Anti-biofilm capabilities. 
d) Extremely low spontaneous mutation frequency, superior to many conventional 
antibiotics. 
e) Efficacy against both aerobic and anaerobic bacteria. 
f) Demonstrated lack of interference with the activity of a wide range of antibiotics. 
g) Enhanced activity in combination with specific antibiotics; in some cases, synergy has 
been demonstrated in vitro and in vivo. 
h) Maintenance of antimicrobial activity in the presence of excessive protein. 
i) A favorable safety and tolerability profile in nonclinical toxicology studies in a variety of 
species, including absence of effect on wound healing or bone repair 
j) A favorable safety and tolerability profile in a clinical Phase 1 study evaluating topical 
administration. 
Based in part on these characteristics, BisEDT has been granted Qualified Infectious Disease 
Product (QIDP) designation by the FDA for the local, intra-operative treatment of resistant post-
surgical orthopedic implant infections. 
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1.3 
Value of MBN-101 for the Treatment of the Clinical Problem 
The broad-spectrum antimicrobial, anti-biofilm activity of BisEDT, its activity against relevant 
antibiotic-resistant pathogens, and its ability to enhance the activity of certain other antibiotics 
are properties that will promote more rapid and/or more complete eradication of infection, and 
reduce infectious risks to patients. With comparatively elevated rates of both postoperative 
infection associated with repair of traumatic orthopedic wounds, and antibiotic-resistance 
associated with osteomyelitis, the development of a new and innovative treatment strategy to 
complement the current standard of care would therefore be expected to result in a substantial 
reduction in mortality, amputation, morbidity, and disability, along with a reduction in patient 
treatment costs. 
MBN-101 provides important potential advantages over current standard of care treatment for 
orthopedic infections. Direct, local contact of MBN-101 with infected target tissue and 
contaminated device surfaces immediately delivers a therapeutically active dose of BisEDT to 
the site of infection. Combined antimicrobial and anti-biofilm effects are achieved with minimal 
systemic exposure. Systemic antibiotics administered alone are frequently ineffective, in part 
because altered perfusion at the surgical wound site hinders effective and timely delivery of 
systemic antibiotics, making it difficult to reach therapeutic antibiotic levels at wound 
tissues/surfaces. The combined effect of IV administered antibiotics, which already serve as a 
pillar of the current standard of care for orthopedic device-related infections, along with the local 
administration of MBN-101, is expected to eradicate bacteria from postoperative orthopedic 
wounds, and will ultimately also serve to reduce the likelihood of development of antibiotic-
resistant bacteria. By reducing the time to resolution of infection and improving the ability of 
current antibiotic therapies to effectively control and eliminate post-surgical orthopedic device-
related infections, MBN-101 will contribute to reductions in the number of additional serious 
interventions needed to resolve infections including reduction in repeat surgeries, additional 
rounds of systemic antibiotics, patient hospitalization time, morbidity and mortality in both 
civilian and military populations. 
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2 
OBJECTIVES 
2.1 
Primary 
To evaluate the safety and tolerability of single escalating doses of locally administered 
MBN-101 or placebo as adjunct to standard of care antimicrobial and surgical therapy. 
2.2 
Secondary 
• To evaluate the clinical activity of single escalating doses of locally administered MBN-101. 
• To evaluate the pharmacokinetics of single escalating doses of locally administered 
MBN-101. 
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3 
INVESTIGATIONAL PLAN 
3.1 
Study Description 
This is a randomized, single-blind, placebo-controlled multi-center study to assess the safety and 
tolerability of escalating doses of MBN-101 applied directly to target structures within infected 
osteosynthesis sites during revision surgery with or without hardware removal and replacement 
for patients diagnosed with an apparent fracture site infection or to sites of chronic or acute-on-
chronic osteomyelitis of the long bone extremities or residual amputated limbs. Three successive 
cohorts of 8 patients will be enrolled in this trial. Consecutive patients from each of the study 
sites will be screened for potential participation as they present to the orthopedic service for 
clinical care for their infections. After signing an Informed Consent Form (ICF), subjects will 
complete screening procedures. Patients meeting all eligibility criteria on screening will be 
offered participation in the study. Patients accepting participation in the study will be 
randomized 3:1 (active:control) to three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of 
MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent). 
Enrollment to the next dose cohort will not commence until an evaluation by the Data Review 
Committee (DRC) of all available safety data on all patients through Week 6 of study supports 
escalation to the next cohort. The DRC will monitor all safety data in an ongoing manner from 
all patients enrolled onto this study. 
Following baseline evaluation, patients will receive standard of care treatment for their post-
operative fracture site infection or osteomyelitis that includes systemic antibacterial treatment 
per institutional standard of care guidelines and debridement/revision surgery with or without 
hardware removal and placement/replacement as indicated. Multiple debridements, soft tissue 
transfer, and revision fixation procedures may be performed prior to definitive closure. A single 
application of the investigational product, MBN-101 or placebo, applied intraoperatively directly 
to target structures within infected bone sites, will be performed following the final irrigation and 
debridement procedure and immediately prior to definitive closure. In cases where original 
hardware is retained, the investigational product will be sparingly applied to all accessible 
surfaces of hardware and adjacent bone. In cases where hardware is placed or replaced, or in 
cases of two-stage procedures, MBN-101 will be applied to all accessible surfaces of hardware 
and adjacent bone (target structures) following implantation of hardware and immediately prior 
to definitive closure. In cases where hardware is not required, MBN-101 will be applied to 
affected areas of bone only prior to definitive closure. The volume applied will be determined by 
the surgeon’s assessment of the size (in cm2) of the target area, and guided by the Table in 
Section 6.5.2. If wounds are left open, the investigational product will be applied immediately 
prior to definitive closure. The minimum amount of MBN-101 required to achieve a thin coat of 
the relevant target structures within the infected bone site will be used (see Section 6.5.2). 
All patients will receive standard postoperative care per institutional guidelines, and will be 
discharged from the hospital in accordance with local standards. Patients will undergo study 
visits at Hour 48 and Weeks 2, 6 and 12. All patients will be followed for a minimum of 
12 weeks after surgery. 
See Appendix 1 for a Schedule of Activities. 
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3.2 
Number of Subjects 
Twenty-four adult male or female patients meeting protocol-specified eligibility criteria may 
participate in the study, with the objective of having a total of 6 patients per dose level in the 
MBN-101-treated group and 6 patients in a pooled placebo-treated group. Patients who are 
randomized but do not receive study drug may be replaced. 
3.3 
Number of Sites 
Up to twelve U.S. study sites are anticipated to enroll an adequate number of eligible patients. 
3.4 
Clinical Trial Material 
Patients will be randomized 3:1 (active:control) to three successive doses (0.025, 0.075, or 
0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 2.0 mg, respectively) 
or placebo (diluent). Enrollment to the next dose cohort will not commence until an evaluation 
by the Data Review Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort. 
3.4.1 
MBN-101 
MBN-101 is Bismuth-1,2-ethanedithiol (BisEDT) suspension (0.025, 0.075, or 0.25 mg/mL, w:v) 
in diluent (3% methylcellulose / 0.5% Tween 80 / 10mM sodium chloride / 10 mM sodium 
phosphate, pH 7.4). 
Structural Formula 
Molecular Formula 
C6H12S6Bi2 
Molecular Weight 
694.51 g/mol 
Stereochemistry/Chirality 
BisEDT has no chiral centers. 
 
3.4.2 
Placebo (MBN-101 diluent) 
Placebo is MBN-101 diluent comprised of 3% methylcellulose / 0.5% Tween 80 / 10mM sodium 
chloride / 10 mM sodium phosphate, pH 7.4. 
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3.5 
Dose 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
Investigational product kits (MBN-101 and placebo) configured for each dose cohort will be 
provided and will contain the supplies necessary for preparation of the specified concentrations 
of MBN-101 or placebo for administration to each patient. 
Additionally, each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the Stock Formulation and Diluent 
provided in the Drug Product Kit according to the Directions for Use (DFU) provided. The 
Treatment Dose will be provided to the surgeon in a vial from which an 8 mL volume will be 
drawn up in the operating room into a sterile 10 mL syringe. Surgeons will be instructed to use 
sufficient volume (up to the full 8 mL provided for the largest exposed target areas) to sparingly 
coat the bone at the site of infection, the exposed surfaces of any retained hardware, and the 
surfaces of any new hardware to be implanted. With dose volume determined according to 
Section 6.5.2, the volume of MBN-101 required to achieve a thin coat of the relevant structures 
within the infected bone site will be applied. Following application, OR personnel will record in 
the Case Report Form (CRF) the actual volume (in tenths of milliliters) of any unapplied 
Treatment Dose remaining in the syringe. 
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4 
STUDY POPULATION 
The study population will include 24 male or female adults who meet all of the study entry 
requirements. 
4.1 
Inclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “YES” answer 
(unless not applicable): 
1. Patients who: 
• have had operative fracture fixation of the upper extremity (AO/OTA class 15, 11-13, 
21-23), lower extremity (AO/OTA class 31-34, 41-44, 81, 82) or pelvis (61, 62), or 
have undergone arthrodesis, and have subsequently been diagnosed with an apparent 
fracture site infection 
or 
• are diagnosed with chronic or acute-on-chronic osteomyelitis of the long bone 
extremities (including residual amputated limbs) 
• have at least one of the following: 
 Elevated ESR above the upper limit of normal 
 Elevated CRP above the upper limit of normal 
 Draining wound / sinus tract 
 Positive culture from site of prior surgery by aspirate or other modality 
 Local erythema or induration at the site of prior surgery 
 Exposed hardware 
 Periosteal reaction on x-ray 
 Loose or broken hardware  
• require surgical debridement of infected soft tissue and/or bone, with or without 
removal and/or placement/replacement of hardware 
2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as per institution’s 
standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile or at least 
2 years postmenopausal, must agree to use one of the following forms of contraception 
from screening through the Week 12 visit: hormonal (oral, implant, or injection) begun 
>30 days prior to screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications and they must 
ensure their female sexual partner complies with the contraception requirements: 
• Be sexually abstinent from Baseline through Week 12  
• Be > 6 months post-vasectomy 
• Agree to use a condom with spermicide from Baseline through Week 12 
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7. Have read and signed the Informed Consent Form (ICF) after the nature of the study has 
been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of personal health 
information in accordance with Health Insurance Portability and Accountability Act 
(HIPAA) 
4.2 
Exclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “NO” answer 
(unless not applicable): 
1. Patients with multiple, non-contiguous sites of infection 
2. Pathologic fracture (not including osteoporosis) 
3. Patient requires immunosuppressive therapy (Topical or inhaled corticosteroids are 
permitted) 
4. Serum creatinine, ALT, AST or Alkaline Phosphatase >2.0 times the upper limit of the 
normal range of the local testing laboratory 
5. Absolute neutrophil count <1000 
6. Patients without definitive soft-tissue coverage over the surgical site at time of study 
product administration 
7. Any condition that has required treatment with any other bismuth containing compound 
within the last 2 weeks (i.e., Kaopectate or Pepto-Bismol) 
8. Participation in an investigational trial to evaluate pharmaceuticals or biologics within the 
past 3 months 
9. Individuals undergoing surgical treatment for more than one infected site 
10. Known allergy to metals or materials comprising the orthopedic hardware, bismuth 
and/or MBN-101 excipients (methylcellulose, Tween 80 (polysorbate 80)) 
11. Patients who are pregnant, lactating, or female patients who have a positive serum hCG 
as determined by laboratory testing 
12. Immunocompromised due to illness or organ transplant 
13. History of chronic or recurrent infections (≥ 3 infections at the same site within 
12 months) other than the index infected bone site 
14. History of any type of cancer (excluding non-melanomatous localized skin cancer or 
completely excised and cured carcinoma-in-situ of uterine cervix) 
15. Poorly controlled diabetes mellitus (hemoglobin A1c > 9.0% for ≥ 6 months despite 
management by a physician) 
16. History of medical noncompliance 
17. Other medical conditions which, in the opinion of the Principal Investigator, would 
jeopardize the safety of the study subject or impact the validity of the study results 
18. Current incarceration 
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5 
SUBJECT ENROLLMENT 
Potential patients will undergo screening medical history and physical examination. If they are 
deemed appropriate candidates for study, they will be asked to provide appropriate informed 
consent. After informed consent is signed, additional baseline evaluation will be performed, 
including but not limited to clinical laboratory assessment, radiographic evaluation, 
electrocardiogram (ECG) and pregnancy test if applicable. Only patients with an acceptable 
medical history and physical exam, ECG without clinically significant abnormalities, and 
laboratory results within acceptable limits will be randomized in the study. Randomization will 
occur using an IWRS system immediately after a patient has met all study entry criteria. 
5.1 
Medical History 
Medical history and demographic data, including gender, date of birth, ethnicity, and race will be 
recorded. 
5.2 
Physical Exam 
Each patient will receive a physical examination (head, ears, eyes, nose, throat, chest, heart, 
abdomen, and skin) including vital signs, weight (kg), and height (cm). Each patient will also 
receive a detailed evaluation of the index infection site and involved extremity. 
5.3 
Studies 
Following signing of the informed consent form, each patient will undergo all screening 
evaluations as provided in the Table of Study Events. These evaluations should be completed no 
more than 2 weeks prior to surgery date; after a screened subject is confirmed to be eligible for 
the study, this qualified subject will be randomized prior to surgery to receive the investigational 
product. 
5.4 
Laboratory Tests at Screening Visit 
Hematology White blood cells (WBC), red blood cells (RBC), hemoglobin, hematocrit, platelet count, 
MCV, absolute neutrophils, absolute lymphocytes, absolute monocytes, absolute 
eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, blood urea nitrogen (BUN), glucose, 
creatinine, total protein, albumin, total bilirubin, direct bilirubin, alkaline phosphatase 
(ALP), AST (SGOT), ALT (SGPT), GGT, creatinine kinase (CK), calcium, magnesium, 
Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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6 
STUDY PROCEDURES 
See the Table of Study Events outlining study procedures in Appendix 1. For the study site visit 
at Week 2, a visit window of + 4 days will be allowed; for study site visits Weeks 6 and 12, a 
visit window of ± 8 days will be allowed. 
6.1 
Description of Study Procedures 
6.1.1 
Medical History 
A comprehensive medical history will be taken on all patients at Screening, including but not 
limited to past medical history, past surgical history, current medications, allergic history and 
psychosocial history. 
6.1.2 
Physical Exams 
A comprehensive physical examination will be performed on all patients at Screening, including 
assessments of height, weight, head, ears, eyes, nose, throat, chest, heart, abdomen, and skin. 
Interval physical exams will be performed at all subsequent study visits according to the 
schedule in Appendix 1 and will focus on the surgical site, with assessments of local erythema, 
induration, drainage and degree of healing. 
6.1.3 
Vital Signs 
Vital signs include blood pressure, pulse, respiratory rate and body temperature; vital signs will 
be assessed according to the schedule in Appendix 1. 
6.1.4 
12-lead ECG 
Testing will be conducted at screening, baseline, and 48 hours. The ECG trace will be stored at 
the investigational sites as source document; clinical interpretation, including normal, abnormal 
but not clinically significant, and abnormal and clinically significant, will be determined by the 
investigator and reported on the CRFs. 
6.1.5 
Laboratory Tests 
All clinical laboratory tests will be performed by the local clinical site laboratory. 
Blood and urine will be collected for hematology, serology, serum chemistry, urinalysis, and 
pregnancy testing (as indicated) according to the schedule in Appendix 1. 
Hematology WBC, RBC, hemoglobin, hematocrit, platelet count, MCV, absolute neutrophils, absolute 
lymphocytes, absolute monocytes, absolute eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, BUN, glucose, creatinine, total protein, 
albumin, total bilirubin, direct bilirubin, alkaline phosphatase (ALP), AST (SGOT), ALT 
(SGPT), GGT, creatinine kinase (CK), calcium, magnesium, Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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6.1.6 
BisEDT (MBN-101) Blood Levels 
BisEDT levels in whole blood after MBN-101 administration will be assessed with a qualified 
Inductively Coupled Plasma Mass Spectrometry (ICP-MS) assay method using bismuth as a 
surrogate for BisEDT according to the schedule in Appendix 1. 
6.1.7 
Pain Assessments 
Pain related specifically to the surgical site (Surgical Site Pain Score) will be assessed via a 
Visual Analog Scale (VAS, 0-10 scale, where 0=no pain at all and 10 =the worst possible pain) 
utilizing a 24 hour recall at screening, baseline, Hour 48 and Weeks 2, 6 and 12. 
6.1.8 
Patient Reported Outcomes 
Patient-reported outcomes will be collected using the Veterans Rand 12 Item Health Survey 
(VR-12) and Short Musculoskeletal Function Assessment (SMFA) according to the schedule in 
Appendix 1. 
6.1.9 
Microbiology 
The microbiology of the index site will be assessed at baseline and at the time of any subsequent 
surgical procedure at the index site. The presence of viable microorganisms will be determined 
by standard microbiological culture methods and include speciation and antimicrobial 
susceptibility testing of any bacterial isolates found (see flowchart, Appendix 2). 
6.1.9.1 
Specimen Collection 
Samples collected will include at least one tissue site (bone when possible; eraser head size, 
suitable for dividing into two samples) from the infected bone site (if accessed) or involved 
tissue adjacent to any implant(s), two swabs of the deep infection site, and two swabs of the 
superficial tissue/wound closure/sinus tract site. One set of specimens (i.e. 1 tissue specimen, 
1 deep swab, 1 superficial swab) will be placed into local site transport vessels. The duplicate set 
of samples will be placed into transport vessels provided by the central laboratory (International 
Health Management Associates, Inc.; IHMA). One set of specimens will be delivered to the local 
site microbiology laboratory using the standard storage and transport procedures employed at 
each site. The duplicate set of specimens will be transported to IHMA. The details regarding 
specimen packaging, transport, and processing will be described in the central laboratory study 
manual that will be provided to each study site. 
6.1.9.2 
Specimen Processing: Local Laboratory 
The tissue site sample and swabs will be analyzed immediately in the local laboratory for the 
presence of infectious pathogens by Gram stain and microbiological culture for both aerobic and 
anaerobic bacteria. The specimens will be processed (primary isolation, identification to species 
level and susceptibility testing) per the standard methods of each local site microbiology 
laboratory. Following isolation and identification of each microorganism, the susceptibility of 
each to one or more standard antibacterial agents (but not including MBN-101), as specified by 
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the surgeon or per local site standard procedures, will be determined. It is recognized that the 
local site laboratory may be using one of a variety of susceptibility test methods, and therefore, 
the susceptibility result may be reported as a specific Minimal Inhibitory Concentration (MIC) 
value or as a categorical result (i.e. Susceptible, Intermediate or Resistant). Susceptibility to 
MBN-101 will not be determined at the local site laboratory; the susceptibility results determined 
locally are for the use of the surgeon in the care of the patient. All Gram stain and microbiology 
results from the local site laboratory will be recorded on the CRF. 
6.1.9.3 
Specimen Processing: IHMA (Central Laboratory) 
The tissue site sample and swabs will be analyzed immediately in the central laboratory for the 
presence of infectious pathogens by microbiological culture for both aerobic and anaerobic 
bacteria. The specimens will be processed (primary isolation, identification to species level, and 
susceptibility testing) per the central laboratory methods, as described in the central laboratory 
study manual. 
Following identification, the susceptibility of the isolates to MBN-101 and comparator agents 
will be determined using either the reference broth microdilution method (for aerobic/facultative 
bacteria) or the reference agar dilution method (for anaerobic bacteria) as detailed by the Clinical 
and Laboratory Standards Institute (CLSI). Susceptibility tests for aerobic/facultative bacteria 
will be quality-controlled as detailed by CLSI using reference quality control strains and 
previously-established ranges for MBN-101 and comparators. Susceptibility tests for anaerobic 
bacteria will also include CLSI reference quality control strains, however, since quality control 
ranges for anaerobic bacteria are not yet established, the MIC values for the quality control 
strains will be collected then retrospectively compared to the quality control ranges once they are 
available.  Susceptibility testing will be conducted with batches of study isolates as each study 
cohort is completed. Patient and specimen identifier and microbiology results will be recorded in 
the database. The bacterial isolates recovered from the specimens will be propagated and 
archived at the central laboratory. 
6.1.9.4 
Integration of Local Site Laboratory and Central Laboratory Primary Isolation and 
Identification Results 
There may be instances where the organism(s) isolated from a given specimen may be different 
at the local site laboratory and the central laboratory. In this instance, the central laboratory will 
first confirm the identification of the archived isolate. If the identification is confirmed, the 
pathogens present in the specimen will be defined as the total number of pathogens recovered by 
the local site laboratory and the central laboratory. For example, if the local site laboratory were 
to recover S. aureus and the central laboratory recovered S. aureus and P. acnes, the specimen 
would be defined as containing both S. aureus and P. acnes following merger of the data. 
It is possible that local site laboratory may perform susceptibility tests with agents that are also 
present in the central laboratory test panel. The MIC value (and interpretation) provided by the 
central laboratory supersedes the local site determination for the purposes of clinical trial data 
analysis and inclusion in the Clinical Study Report. The local site susceptibility test results are 
for use by the surgeon in the local care of the patient; however, these data will also be captured 
in the study database. 
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6.1.10 
Radiographic Evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6 and 12. Radiographs 
(at least two orthogonal views) will be reviewed for bone morphology and integrity, periosteal 
reaction, union, interval callus formation, loss or change in reduction, and hardware 
integrity/failure. 
6.1.11 
Surgical Site Signs and Symptoms Evaluation 
The following signs and symptoms of the surgical site will be evaluated: 
• 
local erythema extending beyond suture material or staples 
• 
induration 
• 
drainage from surgical incision 
• 
degree of healing of the surgical incision 
Patients with non-healing or worsening status of their surgical site may be considered for 
additional standard of care treatment, but should be encouraged to remain in the study in order to 
complete study evaluations. In case additional treatment is given, the start/stop dates and dose 
regimen of the new treatment will be recorded on the CRFs. 
6.2 
Screening and Baseline Assessments 
Patients who meet initial screening criteria by medical history and physical exam will be offered 
participation on study. If the patient agrees to participate, they will be asked to provide written 
informed consent, after which additional evaluation may be performed, including but not limited 
to clinical laboratory assessments, electrocardiogram (ECG), radiographic evaluation and 
pregnancy test if applicable. Only patients with an acceptable medical history and physical exam, 
ECG without clinically significant abnormalities, and laboratory results within acceptable limits 
will be randomized in the study prior to surgery. 
6.3 
Randomization Procedure 
Subjects will be randomized in a 3:1 (active:placebo) ratio up to 24 hours prior to surgery via a 
central randomization scheme. The central randomization will be accomplished using an IWRS 
system linked to study drug treatment kits securely stored under appropriate conditions at the 
study site pharmacy. The randomization number assigned to a subject will be captured on the 
CRF. The specific study drug treatment kit will be utilized by the study pharmacist or other 
qualified individual to perform the appropriate dilution of drug product under sterile conditions 
into a vial to be transported to the operating room. Verification of study patient and study drug 
treatment kit will take place in the operating room prior to treatment with the investigational 
product. The appropriately diluted drug product must be administered within 8 hours of 
preparation. 
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6.4 
Unblinding Procedure 
This study is a single blind study; however, knowledge of treatment assignment should remain 
limited to those directly involved with the patient’s surgical procedure and other individuals on a 
need to know basis. In order to provide unblinding data in an emergency in the absence of an 
individual privy to treatment assignment, sites will be provided with a numbered unblinding 
envelope corresponding to each numbered test kit the site is delivered. These envelopes will be 
securely stored in the pharmacy. The unblinding envelope specifies the treatment group of the kit 
and should only be opened when absolutely necessary. For treatment of adverse events, it should 
be assumed that the patient has received study drug, thus avoiding the need to unblind the 
patient. However, in the event the Investigator determines the randomization assignment 
information is required to treat the patient for an adverse event, the Medical Monitor should be 
contacted. If the Medical Monitor cannot be reached, the blind may be broken by opening the 
envelope. The site should document the unblinding process in the patient’s source documents. 
6.5 
Investigational Product Administration 
6.5.1 
Surgical Site Identification 
Individuals undergoing surgical treatment for more than one infected bone site are excluded from 
participation in this study. 
6.5.2 
Study Drug Administration 
On the day of surgery, randomized subjects will receive the investigational product during their 
surgical procedure. Investigational product is only administered during the surgical procedure by 
the operating surgeon; therefore, 100% compliance with investigational product administration is 
assured. The operating surgeon will record the approximate surface area of the surgical site as 
well as the amount and location of investigational product administration in the operative note 
and on the CRF. All other details of the surgical procedure will be recorded in the operative note. 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 18 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
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4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
5. Alcohol wipes 
6. One pre-printed "Diluted MBN-101 Drug Product" label 
7. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose”) 
Additionally, each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the MBN-101 Stock Formulation and 
Diluent provided in the Drug Product Kit according to the DFU provided. The Treatment Dose 
will be provided to the surgeon in a vial from which an 8 mL volume will be drawn up in the 
operating room into a sterile 10 mL syringe. Surgeons will be instructed to use sufficient volume 
(up to the full 8 mL provided) to sparingly coat the bone at the site of infection, the exposed 
surfaces of any retained hardware, and the surfaces of any new hardware to be implanted. 
Following application, OR personnel will record in the CRF the actual volume (in tenths of 
milliliters) of any unapplied Treatment Dose remaining in the syringe. 
Application to retained hardware:  Access to infected wound surfaces and implanted orthopedic 
hardware will be provided by surgical intervention. The surgeon will use a 10 mL syringe to 
apply, followed by a gloved finger to spread, a thin layer of the investigational product directly 
onto all accessible surfaces of the orthopedic hardware, as well as surrounding bone. Other 
wound surfaces will not be coated, resulting in administration of the investigational product to 
only a limited area of the wound. 
Application to new hardware:  In cases where hardware is replaced or in cases of two-stage 
procedures, MBN-101 will be applied to all accessible surfaces of hardware and adjacent bone 
(target structures) following implantation of hardware and immediately prior to definitive 
closure. Other wound surfaces will not be coated, resulting in administration of the 
investigational product to only a limited area of the wound. 
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In all cases, the minimum amount of MBN-101 required to coat the relevant structures within the 
infected site should be used. The suspension should be applied in a thin layer to cover all 
affected areas of bone as well as any exposed hardware. Direct application to muscle and other 
soft tissues should be avoided. The approximate area of the infected site should be calculated 
based on the length of exposed bone multiplied by the width of bone exposed; the surface area of 
the hardware should be added to this value to derive the approximate area of the infected site. 
Recommended maximum volumes of MBN-101 for various areas of the infected site are 
provided in the table below. For infected bone surface areas that fall between the specified areas, 
the applied volume should be rounded up to the volume for the next area specified in the table 
(e.g., an 80 cm2 wound would be rounded up to 100 cm2, and the volume of MBN-101 Study 
Dose administered would be 2.0 mL). 
Area of Infected Bone Site 
Recommended Volume of MBN-101 
25 cm2 
0.5 mL 
50 cm2 
1.0 mL 
75 cm2 
1.5 mL 
100 cm2 
2.0 mL 
125 cm2 
2.5 mL 
150 cm2 
3.0 mL 
175 cm2 
3.5 mL 
200 cm2 
4.0 mL 
225 cm2 
4.5 mL 
250 cm2 
5.0 mL 
275 cm2 
5.5 mL 
300 cm2 
6.0 mL 
325 cm2 
6.5 mL 
350 cm2 
7.0 mL 
375 cm2 
7.5 mL 
400 cm2 
8.0 mL 
 
The table shows the specified volume of MBN-101 to be applied based on the area (in cm2) of 
the target infected site. By following these application requirements, the administered doses will 
be: 
• Cohort 1: 0.025 mg/mL MBN-101 = 0.5 µg/cm2 
• Cohort 2: 0.075 mg/mL MBN-101 = 1.5 µg/cm2 
• Cohort 3: 0.250 mg/mL MBN-101 = 5.0 µg/cm2 
The use of drains and vacuum assisted closure devices will be allowed per surgeon preference. 
The drainage volume over the first 24 hours or prior to discontinuation of the drain will be 
recorded in the CRF. 
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6.6 
Study Assessments 
Each patient enrolled in the study will have an assessment at 48 hours following surgery and at 
Weeks 2, 6 and 12. Study assessments will be performed according to Section 6.1 and Appendix 1. 
The Week 12 assessment will be the final assessment for adverse events. Any adverse events 
ongoing at the Week 12 assessment will be followed until resolution of the event or stabilization 
of the condition. 
6.7 
Safety Monitoring 
Patients will be instructed to inform the Investigator and/or a member of the study staff of any 
adverse events that occur at any time during the study. Patients will be asked a general health 
question at each clinic visit to identify changes in the state of their health since their last study visit. 
6.8 
Study Monitoring 
The Sponsor or the Sponsor’s designee will provide training on the protocol for the study site 
personnel prior to giving the site permission to begin enrollment. Once the enrollment and 
dosing phases of the study have begun, the Sponsor or the Sponsor’s designee will visit the site 
to monitor the clinical conduct of the trial, the adequacy of study documentation and compliance 
with safety reporting. Clinical site monitoring will continue on a periodic basis until the site has 
been closed or all patients at the site have completed the study. The frequency of monitoring 
visits may vary depending on enrollment at the study site. 
6.9 
Patient Withdrawals 
Patients will be free to withdraw at any time for any reason, or they may be withdrawn if 
necessary to protect their health and safety or the integrity of the study. Any patient that is 
randomized but not treated will be replaced. The final report will include reasons for 
withdrawals. As this study involves a single administration of study drug, significant patient 
withdrawals are not anticipated. 
All efforts should be made to have subjects complete the Week 12 (end of study) procedures 
prior to withdrawal from the study. 
6.10 Individual Patient Stopping Rules 
Patients who develop adverse events at any time during the study will be treated appropriately 
according to standard of care. Adverse events will be assessed and followed as described in 
Section 9. As this is a single dose study with the investigational product applied directly into a 
surgical site, specific stopping rules for individual patients have not been established. 
6.11 Study Stopping Rules 
Patient enrollment on study will be stopped if the number of individual patients experiencing 
possibly-related or probably-related adverse events > Grade 2 exceeds 2 in any dose cohort or if 
there is any death on study. Should the study stopping rules be invoked, all safety data on all 
patients will be assembled for review by the Data Review Committee (DRC). The study will not 
resume until this information has been reviewed by the DRC and the Sponsor, discussed with the 
FDA, and concurrence reached with the FDA as to the resumption of the study. 
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7 
CONCOMITANT MEDICATIONS 
All patients will receive their usual concomitant medications for any underlying medical 
conditions without interruption. Efforts should be made to maintain all concomitant medications 
at a stable dose for the duration of the 12 week study. Patients will also receive standard of care 
treatment for their infection that includes systemic antibacterial treatment per prevailing standard 
of care guidelines (i.e., national, institutional, or physician preference) and other indicated 
postoperative medications, including pain medications. All concomitant medications will be 
recorded in the CRF. Pain medication usage, including medication, dose, route, day and time of 
administration, will be recorded on a separate CRF. Use of any other bismuth-containing 
compounds is prohibited from Screening through Week 4. 
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8 
STUDY ENDPOINTS 
8.1 
Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
• Treatment-emergent adverse events. 
• Treatment-emergent serious adverse events. 
• Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
• Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
• Changes in physical exams. 
• Clinical findings of 12-lead electrocardiograms. 
• Change in microbiology status. 
8.2 
Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
• Proportion of treatment failures. A treatment failure defined as a subject with non-healing 
or worsening status of their surgical site requiring serious intervention by Week 12. 
• Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 12. 
• Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed bone 
site. 
• Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed bone site by Week 12. 
• Time to removal of orthopedic hardware due to a healed bone site. 
• Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
• Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
• Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale 
(VAS, 0-10 scale). 
• Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
• Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination. 
• Change in serologic markers CRP and ESR at each post baseline time point. 
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8.3 
Pharmacokinetic Endpoint 
8.3.1 
Sample Collection and Handling 
Blood samples will be obtained to measure blood concentrations of Bismuth (Bi) as a surrogate 
for BisEDT. A pre-dose sample will be collected prior to administration of the investigational 
product. Blood will be drawn for PK samples at nominal 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 
(Day 3), 96 (Day 4), and 336 (Day 14) hr after application of MBN-101 to the surgical site. 
Documentation stating the exact time of blood sampling (4 mL per timepoint) in relation to the 
time of study drug administration will be collected and provided. 
Primary and back-up blood samples will be stored at -70°C. 
8.3.2 
Assay Methodology 
Bismuth (Bi) levels, a surrogate for BisEDT, will be assayed in whole blood using a validated 
inductively coupled plasma mass spectrometry (ICP-MS) assay performed by Medpace 
Bioanalytical Laboratories (Cincinnati, Ohio). The samples are prepared for analysis by 
digestion with nitric acid and H2O2 for 2 hours, followed by centrifugation and dilution in water 
with subsequent quantitation of Bi by ICP-MS analysis. 
A detailed method description, including validation, calibration and quality assurance 
procedures, will be included in the analytical report which will be part of the Final Study Report. 
8.3.3 
PK Analysis 
Bismuth (Bi) concentration data will be analyzed by noncompartmental analysis (NCA) with 
Phoenix™ WinNonlin® Version 6.4 or higher, using an extravascular administration model and 
actual sampling times. Interim analyses may use nominal sampling times. The following PK 
parameters will be derived from blood concentrations of Bi using extravascular 
noncompartmental PK analysis (as feasible): 
Tmax 
Time to maximum observed concentrations of Bi 
Cmax 
Maximum observed concentrations of Bi 
AUC0-t Area under the Bi concentration vs time curve from time zero to the time of the last 
measurable concentration. 
AUC0-∞ Area under the Bi concentration vs time curve from time zero and extrapolated to 
infinity. 
T1/2 
The apparent half-life of Bi after extravascular administration of BisEDT 
CL/F 
Apparent clearance after extravascular administration of BisEDT 
Vz/F 
Apparent volume of distribution after extravascular administration of BisEDT 
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9 
ADVERSE EVENTS 
An adverse event is an undesirable medical occurrence (sign, symptom, or diagnosis) or 
worsening of a pre-existing medical condition (e.g., diabetes) that occurs after initiation of the 
investigational study whether or not it is considered to be related to the investigational product. 
A worsening of an existing medical condition is one that was present at Day 1 (e.g., diabetes) 
and became more severe, more frequent, or increased in duration during investigational product 
treatment. Clinically relevant abnormal results of diagnostic procedures including abnormal 
laboratory findings (e.g., requiring unscheduled diagnostic procedures or treatment measures, or 
resulting in withdrawal from the study) are considered to be AEs. 
All adverse events (AEs) will be recorded throughout the study, beginning when the subject 
signs the Informed Consent Form. 
A treatment-emergent adverse event (TEAE) is defined as any AE starting after the first dose of 
the investigational agent or placebo is administered. If the AE is present prior to the 
administration of the first dose of the investigational agent or placebo but increases in severity, it 
will also be considered a TEAE. 
Treatment-emergent adverse events will be recorded beginning with the first exposure to 
investigational product and continuing until the subject is discharged from the study due to 
completion or early termination. 
Adverse events will be categorized as local adverse events and as systemic adverse events. 
The Principal Investigator, or medically qualified designee, must completely and promptly 
record each AE on the appropriate CRF. The Principal Investigator should attempt, if possible, to 
establish a diagnosis based on the presenting signs and symptoms. In such cases, the diagnosis 
should be documented as the AE and not the individual sign/symptom. If a clear diagnosis 
cannot be established, each sign and symptom must be recorded individually. Once a diagnosis is 
established, the CRFs should be updated with the final diagnosis. 
Any adverse event ongoing at the time of study completion will be recorded and followed-up 
according to the safety procedures described in the following sections. 
9.1 
Reporting and Following Adverse Events 
All AEs encountered during the study will be reported on the AE page of the CRF in a timely 
manner. All AEs should be followed in accordance with good medical practice until resolved or 
fully characterized. 
Serious adverse events: Section 9.4 presents the definition and reporting obligations for Serious 
Adverse Events (SAEs). After the initial report, a follow-up SAE Report Form should be filled 
out and sent to Medpace Clinical Safety within 24 hours. Updates are to be provided by the site 
as soon as relevant information (especially regarding outcome) is available. 
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9.2 
Severity 
The Investigator must indicate the severity of the adverse event in the description of the adverse 
event. A severity category of mild, moderate, or severe, as defined below, should be determined 
and entered on the Adverse Events page of the CRF. 
• 
Mild (Grade 1): Transient or mild symptoms; no limitation in activity; no intervention 
required. The AE does not interfere with the participant’s baseline functioning level. It 
may be an annoyance. 
• 
Moderate (Grade 2): Symptom results in mild to moderate limitation in activity; no or 
minimal intervention required. The AE produces some impairment of baseline 
functioning, but it is not hazardous to health. It is uncomfortable or an embarrassment. 
• Severe (Grade 3): Symptom results in significant limitation in activity; medical 
intervention may be required. The AE produces significant impairment of functioning or 
incapacitation. 
• Potentially Life-Threatening (Grade 4): Symptoms cause inability to perform basic self-
care functions immediately necessary to sustain life or require medical or operative 
intervention to prevent permanent impairment, persistent disability or death. 
9.3 
Relationship to Clinical Trial Material 
The Investigator must document their opinion of the relationship of the event to the 
investigational product as follows: 
• 
NONE: The event can be readily explained by the subject’s underlying medical condition, 
a concomitant therapy or other cause and the Investigator believes no relationship exists 
between the event and the investigational product. In this case, the Investigator should 
document the condition, concurrent/underlying illness, medication, study procedure or 
other cause they believe to be the cause of the adverse event. 
• 
UNLIKELY: The event does not follow a reasonable temporal sequence from 
administration of the investigational product nor does the event follow a known or expected 
response pattern to the investigational product and may have another cause. In this case, 
the Investigator should document the condition, concurrent/underlying illness, medication, 
study procedure or cause they believe may have contributed to the adverse event. 
• 
POSSIBLE: The subject’s condition, concurrent/underlying illness, medication, or study 
procedures cannot explain the event, and there is a plausible temporal relationship 
between the event and the investigational product administration. 
• PROBABLE: The temporal relationship between the administration of the investigational 
product and the adverse event strongly suggests a relationship, and/or the adverse event 
cannot be reasonably explained by another condition, concurrent/underlying illness, 
medication, study procedure or other cause, or the adverse event abates with 
discontinuation of the investigational product, and recurs with re-administration. 
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9.4 
Serious Adverse Events 
To report SAEs in a timely manner, monitor subject care, and to fulfill regulatory requirements, 
SAEs (regardless of their relationship to the investigational product) must be reported to 
Medpace Clinical Safety within 24 hours of knowledge of the event by the Investigator or 
members of the study staff. 
9.4.1 
Definition 
SAEs are defined as those adverse events that meet any of the following criteria: 
• 
Life threatening, that is, any event that, in the opinion of the Investigator, poses an 
immediate risk of death from that event 
• 
Results in death 
• 
Results in or prolongs hospitalization 
• 
Results in persistent or significant disability/incapacity 
• 
Results in congenital anomaly/birth defect 
In addition, events which may not meet these criteria, but, in the opinion of the Investigator, are 
very unusual, potentially serious, or require medical or surgical intervention to prevent one of the 
outcomes listed above, should also be reported in the same manner as events which meet the 
serious adverse event criteria. 
9.4.2 
Reporting 
Serious AEs require immediate reporting (within 24 hours of the site’s knowledge of the event) 
to Medpace Clinical Safety whether or not the Investigator believes that the experience is related 
to the investigational product. A completed SAE CRF signed by the Investigator must be faxed 
to Medpace Clinical Safety. Criteria for documenting the relationship to study product and 
severity will be the same as those previously described in Sections 9.2 and 9.3. 
SAEs must also be reported by the study site to the responsible IRB immediately. The 
Investigator is responsible for complying with the local IRB regulations regarding the reporting 
of AEs. 
Reporting of a suspected SAE should not be delayed in order to obtain additional information. 
Any additional information, if collected, can be reported as a follow-up to the initial report. Any 
SAE that occurs at any time during the study, whether or not related to the investigational 
product, must be reported to Medpace Clinical Safety. 
All possibly- and probably-related serious adverse events must be followed until the outcome is 
known or the event is otherwise explained. All serious adverse events that are not resolved at the 
end of the study are to be followed until resolution, the condition stabilizes, the event is 
otherwise explained, or the subject is lost to follow-up. 
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9.5 
Pregnancies 
Pregnancies occurring after the first dose of investigational product are considered immediately 
reportable events. While not considered a serious adverse event unless a serious criterion is met, 
pregnancies occurring in subjects enrolled on the study must be reported and followed to 
outcome. The investigator should complete the pregnancy report form and fax it to Medpace 
Clinical Safety within one working day of knowledge of the pregnancy. Following delivery or 
termination of pregnancy, the follow-up pregnancy report form should be completed and 
submitted via fax to Medpace Clinical Safety. Spontaneous abortions should always be reported 
as SAEs. Follow-up information regarding the outcome of the pregnancy and any postnatal 
sequelae in the infant will be required. 
9.6 
Data Review Committee (DRC) 
An independent Data Review Committee will be established to review unblinded clinical trial 
data prior to dose escalation and on an as-needed basis. A statistician, serving as a non-voting 
member to the DRC, will provide data preparation support to the DRC. A sponsor representative 
will also serve as a non-voting member of the DRC to facilitate sponsor internal planning. 
The primary role of the DRC will be to assess unblinded safety data on all patients in a dose 
cohort completing the Week 6 visit, and to determine whether dose escalation should occur. The 
DRC may recommend dose escalation, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
The DRC will also be asked to assess unblinded safety data on an as-needed basis. The Chair of 
the DRC will be informed by Microbion Corporation of the potential need for ad hoc meetings 
and will coordinate any ad hoc meeting with the remainder of the DRC members. The DRC may 
recommend no modifications to the study, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
A formal DRC Charter will be prepared and finalized prior to study enrollment. The DRC will 
meet prior to initiation of the clinical trial in order to review, revise and reach concurrence on the 
content of a DRC charter. The draft charter will be provided by Microbion Corporation to the 
DRC prior to the initial meeting. 
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10 INVESTIGATIONAL PRODUCT MANAGEMENT 
10.1 Study Drug 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 18 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
5. Alcohol wipes 
6. One pre-printed "Diluted MBN-101 Drug Product" label 
7. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose” 
Additionally, each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
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10.2 Study Drug Packaging and Labeling 
All shipments of the investigational product will be accompanied by an inventory form. The 
contents of the shipments should be inventoried immediately upon receipt and confirmation of 
inventory shall be performed according to instructions provided by the clinical supplies 
distributor. 
The following information will be provided with each shipment of study drug: Sponsor name and 
contact information (telephone number), study protocol number, description of the contents of 
the container, conditions for storage, and a statement regarding the investigational (clinical trial) 
use of the study drug. 
Each package unit of the investigational product will be labeled with the following information: 
Sponsor name, study protocol number, description of the contents, a statement regarding the 
investigational (clinical trial) use of the study drug, and a packaging lot number. 
10.3 Study Drug Storage 
The investigational product should be kept in a limited-access area at 15-30 degrees C at the 
study site. 
10.4 Study Drug Accountability 
It is the responsibility of the Principal Investigator or his/her designee at each site to ensure that 
all investigational product quantities received at the site will be inventoried and reconciled 
throughout the study and the result recorded on the drug accountability form maintained in the 
study file. 
10.5 Study Drug Handling and Disposal 
Only qualified study personnel familiar with procedures that minimize undue exposure to 
themselves and to the environment should undertake the handling of pharmaceutical agents. 
The study monitor will verify that the disposition of all investigational materials at the trial site is 
in accordance with Sponsor specifications and applicable regulatory requirements. Requirements 
for disposition of used, unused, damaged/quarantined, and expired investigational materials will 
be provided to applicable site personnel. The study monitor will confirm associated 
documentation is filed in the Investigator site file and copies retrieved for the Sponsor or 
Sponsor-designee Investigator File. 
Used, damaged, and expired investigational materials will be destroyed as directed by the Study 
Monitoring Plan. Specific instructions of on-site destruction, return of materials to a 3rd party 
vendor, or any other mechanism of removal of the investigational materials from the site will be 
detailed in the Study Monitoring Plan. 
The study monitor will not take possession of investigational materials. Any deviations from this 
process must be approved in advance by the Sponsor or Sponsor-designee. 
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11 GENERAL CONSIDERATIONS 
11.1 Basic Principles 
This research will be carried out in accordance with the clinical research guidelines established 
by the Basic Principles defined in the U.S. 21 CFR Parts 50, 56, and 312, the principles 
enunciated in the Declaration of Helsinki concerning medical research in humans (“Ethical 
Principles for Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 
1975, Venice 1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, 
Washington 2002 and Tokyo 2004), and the Good Clinical Practice (GCP) guidelines of the 
International Conference on Harmonization (ICH) of the Technical Requirements for 
Registration of Pharmaceuticals for Human Use, ICH E6 (May 1996). 
11.2 Institutional Review Board 
Prior to initiation of any study procedures, the Clinical Study Protocol, Informed Consent Form, 
and Product Information will be submitted to the IRB for review and approval. In addition, any 
amendments to the protocol or informed consent document will be reviewed and approved (if 
necessary) by the IRB. The Principal Investigator (PI) at each clinical site assumes responsibility 
for ensuring that the protocol is submitted to the IRB for any required periodic review. The PI 
must receive a letter documenting the IRB approval at the clinical site prior to the initiation of 
the study. Any subsequent IRB correspondence must also be submitted to the investigator. The 
Investigator is responsible for providing the appropriate reports to the reviewing IRB during the 
course of the clinical study. This will include the following: 
• Informing the IRB of the study progress periodically as required, but at least annually 
• Reporting any unanticipated adverse product per IRB Policies & Procedures 
• Reporting any deviations from the clinical protocol to protect the life or well-being of a 
subject in the case of an emergency within 5 working days after the emergency occurred 
• Providing any other reports requested by the IRB 
After the final visit of the last subject, a final report will be sent to the IRB per their Policies & 
Procedures that includes a summary of the results of the study by the PI. 
The IRB must be constituted and operate in accordance with the principles and requirements 
described in the U.S. Code of Federal Regulations (21 CFR Part 56). 
11.3 Informed Consent 
The purpose of the study, the procedures to be carried out and the potential hazards will be 
described to the subjects in non-technical terms. Subjects will be required to read and sign a 
consent form summarizing the discussion prior to enrollment, and will be assured that they may 
withdraw from the study at any time without jeopardizing their medical care. 
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11.4 Study Termination 
The Investigator reserves the right to terminate the study in the interest of subject safety and 
welfare. The Sponsor reserves the right to terminate the study at any time for administrative 
reasons. 
11.5 Regulatory Documentation 
Documents that must be provided to the Sponsor prior to study drug shipment are as follows: 
• Up-to-date curriculum vitae for each investigator and sub-investigator 
• Signed and dated Investigator Agreement 
• Applicable local regulatory documentation (e.g., FDA 1572 Form) 
• A copy of the formal written notification to the investigator regarding approval of the 
protocol by an IRB that is in compliance with regulatory guidelines. The written 
notification is to be signed by the chairman or authorized designee and must identify the 
specific protocol. In cases where an IRB member has a known conflict of interest, 
abstention of that individual from voting should be documented; an investigator 
(or sub-investigator) may be a member of the IRB, but may not vote on any research in 
which he or she is involved. 
• Name and address of the IRB with a statement that it is organized and operates according 
to GCP and the applicable laws and regulations, and a current list of the IRB members. 
If accompanied by a letter of explanation from the IRB, a general statement may be 
substituted for this list. 
• A copy of the IRB approved informed consent form and other adjunctive materials 
(e.g., advertising) to be used in the study, including written documentation of IRB 
approval of these items. 
• Name and address of any local laboratory conducting tests for the study, a dated copy of 
the laboratory reference values for tests to be performed during the study and a copy of 
the certification or other documentation establishing adequacy of the facility. 
• Required financial agreement. 
In addition to the documents required prior to the study, other documentation may be required 
during the course of the study. 
11.6 Study Documentation 
All documents pertaining to the study, including a copy of the approved protocol, copy of the 
Informed Consent Form, and case report forms, will be retained in the permanent archives of the 
study site. These will be available for inspection at any time by the Sponsor or the U.S. Food and 
Drug Administration (FDA). 
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11.7 Data Handling and Record Keeping 
As electronic trial data handling and/or remote electronic trial data systems will be used, 
Microbion and/or its designee will: 
• Ensure and document that the electronic data processing system(s) conforms to the 
Sponsor’s established requirements for completeness, accuracy, reliability, and consistent 
intended performance 
• Maintain SOPs for using these systems 
• Ensure that the systems are designed to permit data changes in such a way that the data 
changes are documented and that there is no deletion of entered data (i.e., maintain an 
audit trail, data trail, edit trail) 
• Maintain a security system that prevents unauthorized access to the data 
• Maintain a list of the individuals who are authorized to make data changes 
• Maintain adequate backup of the data 
• Safeguard the blinding, if any (e.g., maintain the blinding during data entry and 
processing) 
Moreover: 
• An unambiguous subject identification code will be used that will allow identification of 
all the data reported for each subject 
• Microbion and/or its designee will retain all of the Sponsor-specific essential documents 
pertaining to the trial in conformance with the applicable regulatory requirement(s) of the 
country(ies) where the product is approved and/or where it intends to apply for approval  
• Specific essential documents will be retained until at least 2 years after the last approval 
of a marketing application in an ICH region and until there are no pending or 
contemplated marketing applications in an ICH region or at least 2 years have elapsed 
since the formal discontinuation of clinical development of the investigational product. 
These documents should be retained for a longer period, however, if required by the 
applicable regulatory requirement(s) or if needed by the Sponsor. 
• Microbion and/or its designee will inform the investigator(s)/institution(s) in writing of 
the need for record retention and should notify the investigator(s)/institution(s) in writing 
when the trial related records are no longer needed 
11.8 Use of Information and Publication 
All information concerning BisEDT, MBN-101, MBN-101 diluent, Microbion operations, patent 
applications, formulas, manufacturing processes, basic scientific data, and formulation 
information, supplied by the Sponsor to the investigator and not previously published, is 
considered confidential and remains the sole property of Microbion Corporation. The 
investigator agrees to use this information only to accomplish this study and will not use it for 
other purposes without the Sponsor’s written consent. 
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The investigator understands that the information developed in the clinical study will be used by 
Microbion in connection with the continued development of MBN-101 and BisEDT, and thus 
may be disclosed as required to other clinical investigators or government regulatory agencies. 
To permit the information derived from the clinical studies to be used, the investigator is 
obligated to provide the Sponsor with all data obtained in the study. 
Any publication or other public presentation of results from this study requires prior review and 
written approval of Microbion Corporation. Draft abstracts, manuscripts, and materials for 
presentation at scientific meetings should be provided to the Sponsor at least 30 working days 
prior to abstract or other relevant submission deadlines. Authorship of publications resulting 
from this study will be based on generally accepted criteria for major medical journals. 
11.9 Independent Medical Monitor 
In accordance with US Army Medical Research and Materiel Command (USAMRMC) and 
Department of Defense (DOD) requirements, an independent medical monitor will be identified. 
The independent medical monitor should be a physician, dentist, psychologist, nurse, or other 
healthcare provider capable of overseeing the progress of research protocols, especially issues of 
individual volunteer management and safety. The medical monitor must be independent of the 
investigative team and possess sufficient educational and professional experience to serve as the 
volunteer advocate. Depending on the nature of the study, the medical monitor may be assigned 
to assess one or more of the following phases of research project: volunteer recruitment, 
volunteer enrollment, data collection, or data storage and analysis. The medical monitor provides 
an independent evaluation of serious adverse events and unanticipated problems involving risk to 
subjects or others to the IRB and the Office of Research Protections (ORP). The medical monitor 
may be assigned to discuss research progress with the PI, interview volunteers, consult on 
individual cases, or evaluate adverse event reports. The medical monitor must promptly report 
discrepancies or problems to the IRB and the ORP. They shall have the authority to stop a 
research study in progress, remove individual volunteers from a study, and take whatever steps 
are necessary to protect the safety and well-being of research volunteers until the IRB can assess 
the medical monitor report. 
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12 STATISTICAL ANALYSIS METHODOLOGY 
A formal statistical analysis plan (SAP) will be prepared and finalized before database lock for 
the final analysis for the study report. The SAP will provide details regarding the definition of 
analysis subjects (populations), analysis variables and analysis methodology to meet all study 
objectives. 
The principle and key elements of the SAP are provided as follows: 
In general, safety and efficacy data will be summarized with descriptive statistics, including 
means, standard deviations, medians, minimums and maximums for continuous variables, the 
number of subjects and percent in each category for categorical variables. 
Data from all subjects randomized and treated with placebo in each cohort will be pooled for the 
analysis; data from the subjects randomized and treated with MBN-101 will be presented by dose 
as well as combined. 
Data from each individual will be tabulated as appropriate. Efficacy and safety endpoints will be 
tabulated by treatment group and time point. 
12.1 Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
• Proportion of treatment failures. A treatment failure is defined as a subject with 
non-healing or worsening status of their surgical site requiring serious intervention by 
Week 12. 
• Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 12. 
• Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed bone 
site. 
• Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed bone site by Week 12. 
• Time to removal of orthopedic hardware due to a healed bone site. 
• Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
• Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
• Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale (VAS, 
0-10 scale). 
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• Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
• Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination. 
• Changes in serologic markers CRP and ESR at each post baseline time point. 
12.2 Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
• Treatment-emergent adverse events. 
• Treatment-emergent serious adverse events. 
• Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
• Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
• Changes in physical exams. 
• Clinical findings of 12-lead electrocardiograms. 
• Change in microbiology status. 
12.3 Sample Size Considerations 
Sample size for this study was chosen empirically for the purpose of the study without any 
formal statistical hypothesis to be tested. 
Six subjects will receive active drug in each dose cohort. With 6 subjects receiving active drug, 
the probability of observing at least one of 6 subjects in a dose cohort exhibiting an AE of a 
specific type is 95% if the true background incidence rate for that event-type were approximately 
0.385 or greater. Hence, if an AE of a specific type is not observed in the study in a sample size 
of 6 subjects receiving active study drug at a given dose, one would “rule-out” this AE as having 
an incidence rate of more than 0.385 with 95% confidence. 
Similarly, if a rare event of interest is not reported in the 18 subjects treated with the active study 
drug, one could conclude that the rate of the event would be 0.153 or less with 95% confidence. 
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12.4 Analysis Datasets 
The following analysis datasets will be identified for the purpose of analysis: 
Screened Subjects: All subjects who signed informed consent for the study will be included in 
the Screened Subjects analysis set. 
Randomized Subjects: All subjects who were randomized in the study will be included in the 
Randomized Subjects analysis set. A randomized subject may or may not be treated with the 
assigned study drug. This is the classic Intent-to-Treat (ITT) analysis set. 
Treated Subjects: All subjects who received any amount of study drug (active or placebo) will be 
included in the Treated Subjects analysis set. All treated subject will be included in the safety 
analysis. This analysis set is also referenced as the Safety Analysis Set. 
Modified Intent-to-Treat (mITT) Subjects: the ITT subjects who received any amount of study 
(active or placebo) and have at least one post-treatment assessment will be included in the mITT 
analysis set. The mITT analysis set is the primary dataset for efficacy analysis. 
PK Concentration Subjects (i.e., PK Concentration Population): The PK Concentration 
Population will include all subjects with any measurable bismuth blood concentrations. 
PK Evaluable Subjects (i.e., PK Evaluable Population): The PK Evaluable Population will 
include all subjects providing sufficient measurable bismuth blood concentrations to facilitate 
determination of PK parameters. 
In the event that a subject received study drug treatment that is not the assigned/randomized 
treatment group, the subject has a major protocol deviation. The subject, however, will be 
included in the analysis for safety and efficacy in the actual treatment group received. 
Subjects randomized but not treated for any reason will be included in the disposition tabulation 
and will be excluded from the safety and efficacy analysis. 
12.5 Disposition and Study Population Characteristics 
Disposition summaries will be prepared to include number and percent of subjects screened, 
randomized, treated, subjects that completed the study and reason for discontinuation. Reason for 
screening failure will also be tabulated. 
Subject characteristics summaries will include demographics (age, gender, race, and ethnicity), 
baseline characteristics (weight, height, BMI), surgery site characteristics (type of injuries, type 
of fraction fixation, surgical site location), microbiology analysis results, time from previous 
surgery to study enrollment, and type of previous treatment), current surgery characteristics 
(area of the osteosynthesis or osteomyelitis site, with or without hardware 
placement/replacement, etc.), and medical history. 
Disposition summary will be based on randomized treatment group (i.e., planned treatment) 
whereas the baseline characteristics summaries will be based on the actual treatment group. 
Subjects with protocol deviations will be identified. The nature of the deviation and potential 
impact on the deviation on study outcome will also be assessed. 
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12.6 Efficacy Analysis 
12.6.1 
Treatment Failure 
A treatment failure is defined as a subject with non-healing or worsening status of their surgical 
site requiring serious intervention by Week 12. 
The number of subjects meeting treatment failure criteria during the study will be tabulated by 
treatment group. If data permit, the difference in proportion of treatment failures between the 
groups and the corresponding 95% confidence intervals for the difference will be presented. 
Fisher’s exact test may be used to test the difference between the groups; difference in rates and 
95% confidence intervals for the relative risk will be derived. Dose-response assessment may be 
performed. 
12.6.2 
Incidence of Serious Interventions 
All interventions meeting the following criteria are serious interventions: 
• Initiation of antibiotic treatment in patient not previously on antibiotics 
• Change in the route of antibiotic administration from oral to intravenous for escalation of 
treatment 
• Change in the type or dosage of antibiotic drug for escalation of treatment 
• Readmission (exclusive of readmissions associated with a healed bone site) 
• Reoperation (exclusive of reoperations associated with a healed bone site) 
The number of subjects with at least one serious intervention (exclusive of serious interventions, 
readmissions, and reoperations associated with a healed bone site) and total number of serious 
interventions will be tabulated for the following periods: 
• duration of the study;  
• within the first 4 weeks after the surgery; 
• from week 4 to week 8; and 
• from week 8 to week 12. 
The difference between the placebo arm and the active arms will be evaluated as follows if data 
permits: Fisher’s exact test may be used to test the difference between the groups; difference in 
rates and 95% confidence intervals for the relative risk will be derived. 
Similar summaries will be prepared for incidence of re-admission and incidence of re-operation. 
Time elapsed between the initial hospital discharge to hospital readmission and between the 
operations will be derived and tabulated. 
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12.6.3 
Time to First Serious Interventions  
Time to the first serious intervention exclusive of serious interventions, readmissions, and 
reoperations associated with a healed bone site will be derived. Time to first serious intervention 
will be calculated as the number of study days from the study surgery date to the event onset date 
plus 1. Subjects who do not have any serious intervention will be censored to the last observation 
date. 
No formal inferential statistics will be carried out for this endpoint. 
12.6.4 
Subjects Undergoing Removal of Stabilizing Orthopedic Hardware 
The number of subjects undergoing removal of hardware due to a healed bone site and the time 
to removal of hardware due to a healed bone site will be derived. Time to removal of hardware 
will be calculated as the number of study days from the study surgery date to the event date plus 1. 
12.6.5 
Surgical Site Signs and Symptoms 
The surgical site will be examined for local erythema, induration, drainage and degree of 
healing. 
Subjects with non-healing or worsening status of their surgical sites will be tabulated. 
12.6.6 
Patient-Report Outcomes 
12.6.6.1 
The Veterans RAND 12 Item Health Survey (VR-12) Questionnaire 
The Veterans RAND 12 Item Health Survey (VR-12) is a brief, generic, multi-use, self-
administered health survey comprised of 12 items. The instrument is primarily used to measure 
health related quality of life, to estimate disease burden and to evaluate disease-specific 
benchmarks with other populations. The 12 items in the questionnaire correspond to eight 
principal physical and mental health domains including general health perceptions; physical 
functioning; role limitations due to physical and emotional problems; bodily pain; energy-
fatigue, social functioning and mental health (Selim, 2009; Veterans Affairs website, 2014). 
VR-12 total score, physical health domain score (PCS), and mental health domain score (MCS) 
will be tabulated by visit; change from baseline in total score, physical health domain score and 
mental health domain score will also be derived and tabulated. 
12.6.6.2 
The Short Musculoskeletal Function Assessment Questionnaire (SMFA) 
The 46-item SMFA questionnaire comprises two parts: the dysfunction index with 34 items and 
the bother index with 12 items. The dysfunction index assesses the patient’s perceptions of the 
amount of difficulty they have in the performance of certain functions (25 items) and how often 
the patients have difficulty when performing certain functions (9 items). The dysfunction items 
are grouped into four categories: daily activities, emotional status, function of the arm and hand, 
and mobility. Each item has a 5-point response format (1 point for good function and 5 points for 
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poor function). The bother index asks the patients to assess how much they are bothered by 
problems in various areas of life (e.g., recreation, work, sleep and rest). These items also have a 
5-point response format (1 point for not at all bothered and 5 points for extremely bothered). 
The scores of the dysfunction and the bother indices are calculated by summing up the responses 
to the items and then transforming the scores according to the formula: (actual raw score - lowest 
possible raw score)/(possible range of raw score) ×100. 
This transformation formula gives the final scores, which ranged from 0 to 100. The higher 
scores indicate poorer function. In the case of the dysfunction index, unanswered items in a 
category are replaced by the individual’s mean score for that category, as long as more than 
50 per cent of the items in that category have been answered. Substitution with the mean is not 
appropriate for the bother index as each item addresses a unique area of function (Swiontkowski, 
1999; Short Musculoskeletal Function Assessment Injury and Arthritis Survey, 
www.grossortho.com/forms/injury.pdf). 
SMFA results and change from baseline will be summarized by visit and treatment group with 
descriptive statistics. 
12.6.7 
Pain Assessments 
Surgical site pain score utilizing a 24 hour recall will be assessed via Visual Analog Scale (VAS) 
(Burckhardt, 2003; Brokelman, 2012; Briggs, 1999) at baseline, and Weeks 2, 6 and 12. 
Change in pain from baseline will be derived; observed pain score and change from baseline will 
be tabulated by visit and treatment group. 
12.6.8 
Microbiology 
Microbiology will be assessed at baseline and at the time of any subsequent surgical procedure at 
the index site. The presence of viable microorganisms will be determined by standard 
microbiological culture methods and include speciation and antimicrobial susceptibility testing 
of any bacterial isolates found (see flowchart, Appendix 2). Samples collected will include at 
least one tissue site (eraser head size; suitable for dividing into two samples) from the infected 
bone site (if accessed) or involved tissue adjacent to any implant(s), two swabs of the deep 
infection site, and two swabs of the superficial tissue/wound closure/sinus tract site. Duplicate 
specimens will be transported aerobically and anaerobically, respectively. Specimens will be 
processed by the local laboratory and the central laboratory as presented in Sections 6.1.9.3 and 
6.1.9.2. 
Microorganisms isolated from each assessment will be listed. This information may also be used 
to identify potential subgroups. 
Microbiological success is assessed by clearance of infection. The proportion of subjects that 
meet the treatment success criteria per microbiologic evaluations will be identified and tabulated 
by each treatment group. 
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12.6.9 
Radiographic Evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6 and 12. 
Radiographic success is assessed by healing on radiographic examination. The proportion of 
subjects that met the treatment success criteria per radiographic examination will be identified 
and tabulated by each treatment group. 
12.6.10 Serologic Markers 
Serology markers CRP and ESR will be assessed at baseline and Weeks 2, 6 and 12. 
Serology markers CRP and ESR have been used together with clinical signs and symptoms for 
periprosthetic infection diagnosis. The values for each serologic marker and the number of 
subjects with normal or abnormal serologic marker values at each visit will be tabulated by 
treatment group. 
12.6.11 Subgroup Analyses for Efficacy Endpoints 
If data permit, the following potential covariates will be identified and subgroup analysis may be 
performed for those subgroups. 
1. 
Area of the infected site 
2. 
Method of fracture fixation 
3. 
Type of infection (per identified microorganism) 
4. 
Anatomic location of the surgery site 
5. 
Hardware retention status (retained vs. exchanged) 
6. 
Influence of host factors 
7. 
Method of wound closure / wound management 
12.6.12 Sensitivity Analyses for Efficacy Endpoints 
The primary efficacy analysis set (mITT) will included all randomized subjects who received 
any amount of study drug and have at least one post-treatment assessment. In addition, in the 
event that a subject received treatment that is different from the assigned treatment, the subject 
will be included in the actual treatment received in the mITT analysis. 
An ‘as assigned’ analysis will be performed on the mITT subjects as a sensitivity analysis for the 
primary efficacy endpoint. In this analysis, subjects who received a treatment that is not the 
assigned treatment will be included in the ‘assigned’ treatment group for this analysis. 
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12.7 Safety Analysis 
12.7.1 
Study Drug Exposure and Concentrations 
Study drug exposure will be presented by treatment group. Descriptive statistics will be provided 
without any formal inferential statistics. 
12.7.2 
Adverse Events 
The Medical Dictionary for Regulatory Activities (MedDRA Version 16 or higher) will be used 
to classify all AEs with respect to system organ class (SOC) and preferred term. Summary of 
adverse events will include: 
1. Treatment emergent adverse events by SOC, preferred term, and intensity 
2. Treatment emergent adverse events by SOC, preferred term, and relationship to study 
drug 
3. All AEs leading to study discontinuation by SOC and preferred term 
4. All serious adverse events by SOC and preferred term 
Summary tables will provide total number of events and number of subjects with the event. 
The incidence and intensity of each pre-specified local AEs will be tabulated by visit and 
treatment groups. 
12.7.3 
Clinical Laboratory Tests 
Laboratory includes hematology, serology, serum chemistry, and urinalysis; laboratory collected 
prior to surgery will be the baseline laboratory. The study will utilize local lab for all clinical 
laboratory testing. Laboratory data will be tabulated based on the following result class. 
• Normal: result is within the local lab normal range 
• Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each lab test without formal inferential statistics. If data permits shift 
in result class from baseline to post baseline may also be tabulated. 
12.7.4 
12-lead ECG 
ECG findings at each time point will be tabulated by treatment group without inferential 
statistics. 
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12.7.5 
Vital Sign Measurements 
Vital signs collected immediately prior to receiving study drug will be the baseline vital signs. 
Observed vital sign values and change from baseline in vital signs at each visit will be 
summarized without formal statistical testing. 
Vital sign result may also be tabulated based on the following result class. 
• Normal: result is within the normal range 
• Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each vital sign. 
12.7.6 
Physical Examinations  
Findings of physical examinations will be tabulated by treatment groups without inferential 
statistics. 
12.7.7 
Subgroup Analyses for Safety Endpoints 
No subgroup analysis is planned for safety endpoints. 
12.8 PK Analysis 
Blood bismuth concentration vs. time profiles after administration of MBN-101 will be 
summarized for each nominal sampling time point and by dose group using descriptive statistics 
generated by WinNonlin. The NCA PK parameters (AUC0-t, AUC0-inf, Tmax, Cmax, T1/2, CL/F, 
Vz/F) will also be summarized with descriptive statistics (generated by WinNonlin) for each dose 
group as well as for all treated subjects in the PK Evaluable Population. 
If data permit, the correlation between Bismuth concentration and efficacy and/or safety 
endpoints may be explored. 
12.9 Interim Evaluation 
Interim analyses are planned for this study for the purpose of DRC. The purpose of the interim 
analysis is to allow the DRC to review the data and to make recommendation to the Sponsor on 
whether or not the next cohort of the subjects should be studied as planned. 
An analysis plan for the DRC will be prepared as an appendix of the DRC charter. The scope of 
the interim analyses for the DRC will be defined in this analysis plan. 
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13 REFERENCES 
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hardware after early postoperative infection following fracture internal fixation. J Bone Joint 
Surg Am. 2010;92(4):823-28. 
2. Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and verbal rating 
scales for the assessment of post-operative pain in orthopedic patients. J Pain Symptom 
Manage. 1999:18(6);438-46. 
3. Brokelman RBG, Haverkamp D, van Loon C, Hol A, van Kampen A, Veth R. The validation 
of the visual analogue scale for patient satisfaction after total hip arthroplasty. Eur Orthop 
Traumatol. 2012;3(2):101–5. doi:10.1007/s12570-012-0100-3. PMCID: PMC3389603. 
4. Burckhardt CS, Jones KD. Adult measures of pain: The McGill Pain Questionnaire (MPQ), 
Rheumatoid Arthritis Pain Scale (RAPS), Short-Form McGill Pain Questionnaire (SF-MPQ), 
Verbal Descriptive Scale (VDS), Visual Analog Scale (VAS), and West Haven-Yale 
Multidisciplinary Pain Inventory (WHYMPI). Arthritis Rheum. 2003;49;S96-104. 
5. Ciofu O, Tolker-Nielson T. Antibiotic Tolerance and Resistance in Biofilms. In: Bjarnsholt 
T, Jensen PØ, Moser C, Høiby N, editors. Biofilm Infections. New York: Springer; 2011. 
pp 215-29. doi: 10.1007/978-1-4419-6084-9_13. 
6. Cummins JS, Tomek IM, Kantor SR, Furnes O, Engesaeter LB, Finlayson SR. 
Cost‑effectiveness of antibiotic-impregnated bone cement used in primary total hip 
arthroplasty. J Bone Joint Surg Am. 2009;91(3):634-41. PubMed PMID: 19255224. 
doi:10.2106/JBJS.G.01029. 
7. Ferry T, Uckay I, Vaudaux P, Francois P, Schrenzel J, Harbarth S. Laurent F, Bernard L, 
Vandenesch F, Etienne J, Hoffmeyer P, Lew D. Risk factors for treatment failure in 
orthopedic device-related methicillin-resistant Staphylococcus aureus infection. Eur J Clin 
Microbiol Infect Dis. 2010;29(2):171-80. 
8. Gessmann J, Kammler J, Schildhauer TA, Kaminski A. MRSA colonisation in patients with 
proximal femur fractures in a German trauma centre: incidence, infection rates and outcomes. 
Langenbecks Arch Surg. 2012;397(1):117-23. 
9. Ghigo J-M. Natural conjugative plasmids induce bacterial biofilm development. Nature. 
2001;412(26):442-5. 
10. Godil SS, Parker SL, O'Neill KR, Devin CJ, McGirt MJ. Comparative effectiveness and cost-
benefit analysis of local application of vancomycin powder in posterior spinal fusion for 
spine trauma: clinical article. J Neurosurg Spine. 2013;19(3):331-5. 
11. Gristina AG, Naylor P, Myrvik Q. Infections from biomaterials and implants: a race for the 
surface. Medical Progress Through Technology. 1988;14:205-24. 
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12. Gristina AG, Shibata Y, Giridhar G, Kreger A, Myrvik QN. The glycocalyx, biofilm, 
microbes, and resistant infection. Semin Arthroplasty. 1994;5(4):160-70. 
13. Heller A, McIff TE, Lai SM, Burton DC. Intrawound vancomycin powder decreases 
Staphylococcal surgical site infections following posterior instrumented spinal arthrodesis. 
J Spinal Disord Tech. Epub ahead of print 2013. PubMed PMID: 24189484. 
14. Hetrick EM, Schoenfisch MH. Reducing implant-related infections: active release strategies. 
Chem Soc Rev. 2006;35(9):780-9. 
15. Kwon A, Park G, Ryu S, Lim D, Lim D, Choi C, Park Y, Lim Y. Higher biofilm formation in 
multidrug-resistant clinical isolates of Staphylococcus aureus. Int J Antimicrob Ag. 
2008;32:68-72. 
16. Martin JR, Adogwa O, Brown CR, Bagley CA, Richardson WJ, Lad SP, Kuchibhatla M, 
Gottfried ON. Experience with intrawound vancomycin powder for spinal deformity surgery. 
Spine (Phila Pa 1976). Epub ahead of print 2013. PubMed PMID: 24158179. 
17. Morris BJ, Unger RZ, Archer KR, Mathis SL, Perdue AM, Obremskey WT. Risk factors of 
infection after ORIF of bichondylar tibial plateau fractures. J Orthop Trauma. 
2013;27(9):e196-e200. 
18. Nowinski RJ, Gillespie, RJ, Shishani Y, Cohen B, Walch G, Gobezie R. Antibiotic-loaded 
bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a 
retrospective, cohort study of 501 shoulders. J Shoulder and Elbow Surgery. 
2012;21(3):324-8. doi: 10.1016/j/jse.2011.08.072. 
19. Parra-Ruiz J, Vidaillac C, Rybak MJ.Macrolides and staphylococcal biofilms. Rev Esp 
Quimioter. 2012;25(1):10-16. 
20. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the 
tibia: current management concepts. Journal of the American Academy of Orthopaedic 
Surgeons. 2005;13(6):417-27. 
21. Reiter K, Da Silva Paim TG, De Oliveira CF, D’Azevedo PA. High biofilm production by 
invasive multiresistant staphylococci. Acta Pathologica Microbiologica et Immunologica 
Scandinavia. 2011;119:776-81. 
22. Robson MC. Wound infection. A failure of wound healing caused by an imbalance of 
bacteria. Surg Clin North Am. 1997;77(3):637-50. 
23. Robson MC. Award recipient address: Lessons gleaned from the sport of wound watching. 
Wound Repair Regen. 1999;7(1):2-6. 
24. Salgado CD, Dash S, Cantey JR, Marculescu CE. Higher risk of failure of methicillin-
resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res. 
2007;461:48-53. 
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25. Schmidt AH, Swiontkowski MF. Pathophysiology of infections after internal fixation of 
fractures. Journal of the American Academy of Orthopaedic Surgeons. 2000;8(5):285-91. 
26. Selhi HS, Mahindra R, Yamin M, Jain D, De Long WG, Singh J. Outcomes in patients with 
an infected nonunion of the long bones treated with a reinforced antibiotic cement rod. 
J Orthop Trauma. 2012;26(3):184-8. 
27. Selim AJ, Rogers W, Fleishman JA, Qian SX, Fincke BG, Rothendler JA, Kazis LE. 
Updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12). 
Qual Life Res. 2009;18(1):43-52. doi: 10.1007/s11136-008-9418-2. Epub 2008 Dec 3. 
28. Sheehy SH, Atkins BA, Bejon P, Byren I, Wyllie D, Athanasou NA, Berendt AR, McNally 
MA. The microbiology of chronic osteomyelitis: Prevalence of resistance to common 
empirical anti-microbial regimens. Journal of Infection. 2010;60:338-43. 
29. Short Musculokeletal Function Assessment Injury and Arthritis Survey; 
http://www.grossortho.com/forms/injury.pdf, accessed 05-16-2014. 
30. Swiontkowski MF, Engelberg R, Martin DP, Angel J. Short musculoskeletal function 
assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am. 
1999;81(9):1245-60. 
31. Tosh PK, McDonald LC. Infection control in the multidrug-resistant era: tending the human 
microbiome. Clin Infect Dis. 2012;54(5);707-13. 
32. Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic only versus 
local intrawound vancomycin antibiotic powder application in addition to intravenous 
antibiotics on postoperative infection in spine surgery in 907 patients. Spine (Phila Pa 1976), 
2013;38(25):2149-55. doi:10.1097/BRS.0000000000000015. PubMed PMID: 24048091. 
33. U.S. Department of Veterans Affairs [internet]. Washington: U.S. Department of Veterans 
Affairs; last updated 21 January 2014. Health Economics Resource Center: Cost-Effective 
Analysis. Available from: http://www.herc.research.va.gov/include/page.asp?id=cost-
effectiveness-analysis#vr36. 
34. Zalavras CG Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop 
Surg. 2003;11(3):212-9. 
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14 APPENDICES 
Appendix 1 
Table of Study Events ............................................................................................62 
Appendix 2 
Flowchart for Microbiological Specimen Processing ............................................63 
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Appendix 1 
Table of Study Events 
Procedure 
Screening 
Baseline/ 
Day of Surgery 
Hour 48- 60 
Hour 72 
Hour 96 
Week 2 
Week 6 
Week 12, EOT 
Early Term / 
Tx Failure 
Day 1 
Day 2 
Day 3 
Day 4 
Day 14 
±4 days 
Day 42 
±8 days 
Day 84 
±8 days 
Review of eligibility criteria 
X 
X 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
Surgery/Administration of the 
Investigational Product 
 
X 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
 
 
 
Interval physical exam 
 
X 
X 
 
 
X 
X 
X 
X 
Hematology 
X 
 
X 
 
 
 
X 
X 
X 
Serology 
 
X 
 
 
 
X 
X 
X 
X 
Serum chemistry 
X 
 
X 
 
 
 
X 
X 
X 
Urinalysis 
X 
 
X 
 
 
 
X 
X 
X 
Pregnancy test 
X 
X 
 
 
 
 
 
X 
X 
BisEDT Blood levels1 
 
X 
X 
X 
X 
X 
 
 
 
12-lead ECG 
X 
X 
X 
 
 
 
 
X 
X 
Vital signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Patient-reported outcomes2 
X 
 
 
 
 
X 
X 
X 
X 
Surgical site signs and symptoms 
 
X 
X 
X 
X 
X 
X 
X 
X 
Surgical site pain score 
 
X 
X 
X 
X 
X 
X 
X 
X 
Microbiology 
 
X 
(X)3 
 
 
(X) 
(X) 
(X) 
(X) 
Radiographic evaluation 
 
X 
 
 
 
X 
X 
X 
X 
Concomitant medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
X 
1 PK blood samples will be collected pre-dose and at nominal 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 (Day 3), 96 (Day 4) and 336 (Day 14; Week 2) hours after administration of the investigational 
product 
2 Patient-reported outcomes include the Veterans Rand 12 Item Health Survey (VR-12) and Short Musculoskeletal Function Assessment (SMFA) 
3 Microbiology will be performed at any time that a new surgical intervention is required. 
 
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Appendix 2 
Flowchart for Microbiological Specimen Processing 
Microbiology: Specimen Processing 
 
* IHMA: International Health Management Associates, Inc (Central Laboratory 
Local Site Transport Vessels 
1
Tissue Specimen 
1
Deep Swab 
1
Superficial Swab 
IHMA* Transport Vessels 
1
Tissue Specimen 
1
Deep Swab 
1
Superficial Swab 
Delivery to Local Site 
Microbiology Laboratory 
Overnight Transport to IHMA 
(Central Laboratory) 
Local Site Microbiology Laboratory 

Microbiological culture 
(aerobic and anaerobic) 

Identification 

Susceptibility testing 
(per site; not inc MBN-101 

Reporting per local site procedures 
IHMA 

Microbiological culture 
(aerobic and anaerobic) 

Identification 

Susceptibility testing 
(MBN-101 & comparators) 

Archiving of isolates 

Reporting per clinical protocol 
requirements 
Tissue Specimens 
(1) Infected Bone or involved tissue adjacent 
to any implant, divided into two pieces 
Swabs (Deep) 
(2) Deep infection site 
Swabs (Superficial) 
(2) Superficial tissue/wound closure site/sinus tract 
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PROTOCOL AMENDMENT FORM 
DATE: 01/18/17 
AMENDMENT NUMBER: 04 
PROTOCOL NUMBER: MBN-101-201 (Version 4) 
SPONSOR: Microbion Corporation 
 
PROTOCOL TITLE: A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week Escalating Dose 
Study to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally Applied 
MBN-101 to Infected Osteosynthesis Sites 
 
CHANGE(S): 
Note – All changes refer to page numbers in the clean Version 4.0 
 
Location 
From 
To 
Comment 
Header 
Version 3.0, 
Issue Date 05 May 2016 
Version 4.0, 
Issue Date 18 January 2017 
Update version 
Page 1 
Version 3.0, 
Issue Date 05 May 2016 
 
Replaces Version 2.1 
Dated 29 December 2015 
Version 4.0, 
Issue Date 18 January 2017 
 
Replaces Version 3.0 
Dated 05 May 2016 
Update version 
Page 1 
Version: 2.1 
Version: 3.0 
Update version 
Pages 
4, 9, 25 
Synopsis (Number of Subjects), 
Synopsis (Statistical Analysis 
Consideration) and Section 4 
(Study Population) 
 
Decrease cohort size 
36 
24 
Pages 
4, 22 
Synopsis (Study Design and 
Methodology) and Section 3.1 
(Study Description) 
 
Decrease cohort size 
 
Three successive cohorts of 
12 patients will be enrolled in 
this trial. 
Three successive cohorts of 8 
patients will be enrolled in this 
trial. 
Page 9 
Synopsis (Statistical Analysis 
Consideration) 
 
Decrease cohort size 
All safety and efficacy endpoints 
will be tabulated with descriptive 
statistics; data from all placebo 
subjects (3 per cohort; 9 subjects 
in total) will be pooled. Data from 
BisEDT treated subjects will be 
presented by dose (9 subjects per 
dose) and combined (a total of 
27 subjects). 
All safety and efficacy endpoints 
will be tabulated with descriptive 
statistics; data from all placebo 
subjects (2 per cohort; 6 subjects 
in total) will be pooled. Data from 
BisEDT treated subjects will be 
presented by dose (6 subjects per 
dose) and combined (a total of 
18 subjects). 
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PROTOCOL AMENDMENT FORM 
DATE: 01/18/17 
AMENDMENT NUMBER: 04 
PROTOCOL NUMBER: MBN-101-201 (Version 4) 
Location 
From 
To 
Comment 
Page 10 
Other Appropriate Trial Contact 
Personnel 
 
Update information 
Ronnie McAdams 
Clinical Trial Manager, 
Associate Director, Medpace 
513-579-9911, ext. 2845 
513-394-0516 
r.mcadams@medpace.com 
Tracy Robertson 
Clinical Trial Manager, Medpace 
513-579-9911, ext. 12140 
859-512-5183 
t.robertson@medpace.com 
Page 10 
Medpace Clinical Safety 
Update information 
 
Added: 866-336-0930 or 
 
Pages 12, 
27, 31 
List of Abbreviations, Section 5 
(Subject Enrollment) and 
Section 6.3 (Randomization 
Procedure) 
 
Update randomization 
procedure 
 
IVRS: Interactive Voice Response 
System 
IWRS: Interactive Web Response 
System 
 
Page 23 
Section 3.2 (Number of Subjects) 
 
Decrease cohort size 
 
Thirty-six adult male or female 
patients meeting protocol-specified 
eligibility criteria may participate 
in the study, with the objective of 
having a total of 9 patients per dose 
level in the MBN-101-treated 
group and 9 patients in a pooled 
placebo-treated group. 
Twenty-four adult male or female 
patients meeting protocol-specified 
eligibility criteria may participate 
in the study, with the objective of 
having a total of 6 patients per dose 
level in the MBN-101-treated 
group and 6 patients in a pooled 
placebo-treated group. 
 
Page 50 
Section 12.3 (Sample Size 
Considerations) 
 
Decrease cohort size 
 
Nine subjects will receive active 
drug in each dose cohort. With 
9 subjects receiving active drug, 
the probability of observing at least 
one of 9 subjects in a dose cohort 
exhibiting an AE of a specific type 
is 95% if the true background 
incidence rate for that event-type 
were approximately 0.283 or 
greater. Hence, if an AE of a 
specific type is not observed in the 
study in a sample size of 9 subjects 
receiving active study drug at a 
given dose, one would “rule-out” 
this AE as having an incidence rate 
of more than 0.283 with 95% 
confidence. 
Six subjects will receive active 
drug in each dose cohort. With 
6 subjects receiving active drug, 
the probability of observing at least 
one of 6 subjects in a dose cohort 
exhibiting an AE of a specific type 
is 95% if the true background 
incidence rate for that event-type 
were approximately 0.385 or 
greater. Hence, if an AE of a 
specific type is not observed in the 
study in a sample size of 6 subjects 
receiving active study drug at a 
given dose, one would “rule-out” 
this AE as having an incidence rate 
of more than 0.385 with 95% 
confidence. 
 
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PROTOCOL AMENDMENT FORM 
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AMENDMENT NUMBER: 04 
PROTOCOL NUMBER: MBN-101-201 (Version 4) 
Location 
From 
To 
Comment 
 
Similarly, if a rare event of interest 
is not reported in the 27 subjects 
treated with the active study drug, 
one could conclude that the rate of 
the event would be 0.105 or less 
with 95% confidence. 
Similarly, if a rare event of interest 
is not reported in the 18 subjects 
treated with the active study drug, 
one could conclude that the rate of 
the event would be 0.153 or less 
with 95% confidence. 
 
 
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1 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 
24-week Escalating Dose Study to Assess the Safety, Tolerability 
and Clinical Activity of 3 Concentrations of Locally Applied MBN-101 
to Infected Osteosynthesis Sites 
PROTOCOL NUMBER: MBN-101-201 
Version 4.0 Issue Date: 18 January 2017 
Replaces Version 3.0 Issue Date: 05 May 2016 
Regulatory Sponsor: 
Microbion Corporation 
1102 West Babcock, Suite B 
Bozeman MT 59715 
Version: 4.0 
Microbion Corporation 
 
Reviewed and Approved by: 
 
 
 
18 January 2017 
Dr. Brett Baker 
Microbion Corporation 
President and Chief Scientific Officer 
 
Date 
Confidentiality 
This document is the confidential property of Microbion Corporation. 
No part of it may be reproduced, published, or transmitted by other persons 
without written permission of Microbion Corporation. 
 
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Protocol MBN-101-201 
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GRANT SUPPORT 
This Phase 2a clinical study is supported in part by a $2.5 million grant awarded through the 
"Defense Medical Research and Development Program (DMRDP) Military Infectious Diseases 
Clinical Trial Award, W81XWH-12-DMRDP-MID-CTA". The grant award number is 
W81XWH-12-2-0100.  
The Awardee is the University of Pennsylvania, and the Principal Investigator (PI) for this grant 
award is Dr. Samir Mehta, Chief, Division of Orthopaedic Trauma, and Assistant Professor of 
Orthopaedic Surgery at the Hospital of the University of Pennsylvania. Dr. Mehta is also serving 
as the clinical PI for the University of Pennsylvania orthopaedic trauma clinical site. 
Participating as a Co-Investigator in this grant award is Dr. Saam Morshed, attending 
orthopaedic trauma surgeon and Director of the Clinical Research Center at the University of 
California San Francisco (UCSF) and the San Francisco General Hospital Orthopaedic Trauma 
Institute (OTI). Dr. Morshed will also serve as the clinical PI for the UCSF orthopaedic trauma 
clinical site.  
The Program Sponsor, Microbion Corporation, is represented by Dr. Brett Baker, President and 
Chief Scientific Officer. 
 
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INVESTIGATOR AGREEMENT 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week Escalating Dose Study 
to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally 
Applied MBN-101 to Infected Osteosynthesis Sites 
I have read the protocol and agree that it contains all necessary details for carrying out the study 
as described. I will conduct this protocol as outlined therein and will make all reasonable efforts 
to complete the study within the designated time. 
I will provide copies of the protocol and access to all information furnished by Microbion 
Corporation to study personnel under my supervision. I will discuss this material with them to 
ensure that they are fully informed about the drug and the study. 
I understand that the study may be terminated or enrollment suspended at any time by Microbion 
Corporation with or without cause, or by me, if it becomes necessary to protect the best interests 
of the study subjects. 
I agree to conduct this study in accordance with the requirements of this protocol and in 
accordance with the following: 
 Good Clinical Practice: Consolidated Guideline International Conference on Harmonisation 
of Technical Requirements for the Registration of Pharmaceuticals for Human Use, ICH E6 
(May 1996) 
 United States (U.S.) Code of Federal Regulations (CFR) associated with clinical studies 
(21 CFR parts 50, 56, 312) 
 Declaration of Helsinki, concerning medical research in humans (“Ethical Principles for 
Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 1975, Venice 
1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, Washington 
2002 and Tokyo 2004). 
 
  
Investigator’s Printed Name 
  
Investigator’s Signature 
 Date 
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PROTOCOL SYNOPSIS 
Protocol Number 
MBN-101-201 
Title 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week 
Escalating Dose Study to Assess the Safety, Tolerability and Clinical 
Activity of 3 Concentrations of Locally Applied MBN-101 to Infected 
Osteosynthesis Sites 
Regulatory Sponsor 
Microbion Corporation, 1102 West Babcock, Suite B, Bozeman MT 59715 
Name of 
Investigational 
Product 
MBN-101 
Phase 
2a 
Investigators/Study 
Centers 
Up to eight Study Centers in the United States  
Objectives: 
Primary Objective 
To evaluate the safety and tolerability of single escalating doses of locally 
administered MBN-101 or placebo as adjunct to standard of care 
antimicrobial and surgical therapy 
Secondary Objectives  
To evaluate the clinical activity of single escalating doses of locally 
administered MBN-101 
 
To evaluate the pharmacokinetics of single escalating doses of locally 
administered MBN-101 
Number of Subjects 
24 
Study Design and 
Methodology 
This is a randomized, single-blind, placebo-controlled, multi-center study to 
assess the safety and tolerability of single escalating doses of MBN-101 
applied directly to target structures within infected osteosynthesis sites during 
revision surgery with or without hardware removal and replacement for 
patients diagnosed with an apparent fracture site infection. Three successive 
cohorts of 8 patients will be enrolled in this trial. Consecutive patients from 
each of the study sites will be screened for potential participation as they 
present to the orthopedic service for clinical care for their postoperative 
infections. Patients meeting eligibility criteria on screening will be offered 
participation in the study. 
Following baseline evaluation, patients will receive standard of care 
treatment for their postoperative fracture site infection that includes systemic 
antibacterial treatment per institutional standard of care guidelines and 
revision surgery with or without hardware removal and replacement as 
indicated. A single application of MBN-101 or placebo, applied 
intraoperatively directly to target structures within infected osteosynthesis 
sites, will be performed following the final irrigation and debridement 
procedure and immediately prior to definitive closure. In cases where original 
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hardware is retained, MBN-101 will be applied to all accessible surfaces of 
hardware and adjacent bone (target structures). In cases where hardware is 
replaced or in cases of two-stage procedures, MBN-101 will be applied to all 
accessible surfaces of hardware and adjacent bone (target structures) 
following implantation of hardware and immediately prior to definitive 
closure. If wounds are left open, the investigational product will be applied 
immediately prior to definitive closure. The minimum amount of MBN-101 
required to achieve a thin coat of the relevant target structures within the 
infected osteosynthesis site will be used. 
Patients will be randomized 3:1 (active:control) to three successive doses 
(0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up 
to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent). Enrollment to the 
next dose cohort will not commence until an evaluation by the Data Review 
Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort. 
PK assessments will be performed predose and at nominal 1, 6, 12, 24, 36, 48 
(Day 2), 60, 72 (Day 3), 96 (Day 4), and 336 (Day 14; Week 2) hours after 
administration of study drug. 
Patients will undergo study visits at Hour 48 and Weeks 2, 6, 12, and 24. All 
patients will be followed for a total of 24 weeks after surgery. 
Study Population: 
Inclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “YES” answer (unless not applicable): 
1. Patients who: 
 
have had operative fracture fixation of the upper extremity 
(AO/OTA class 15, 11-13, 21-23), lower extremity (AO/OTA class 
31-34, 41-44, 81, 82) or pelvis (61, 62), or have undergone 
arthrodesis 
 
are diagnosed with an apparent fracture site infection and have at 
least one of the following: 
 
Elevated ESR above the upper limit of normal 
 
Elevated CRP above the upper limit of normal 
 
Draining wound / sinus tract 
 
Positive culture from site of prior surgery by aspirate or other 
modality 
 
Local erythema or induration at the site of prior surgery 
 
Exposed hardware 
 
Periosteal reaction on x-ray 
 
Loose or broken hardware  
 
require revision surgery with or without removal and replacement of 
existing hardware 
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2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed 
and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as 
per institution’s standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after 
revision surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile 
or at least 2 years postmenopausal, must agree to use one of the 
following forms of contraception from screening through the Week 24 
visit: hormonal (oral, implant, or injection) begun >30 days prior to 
screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications 
and they must ensure their female sexual partner complies with the 
contraception requirements:  
 
Be sexually abstinent from Baseline through Week 24  
 
Be > 6 months post-vasectomy  
 
Agree to use a condom with spermicide from Baseline through 
Week 24 
7. Have read and signed the Informed Consent Form (ICF) after the nature 
of the study has been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of 
personal health information in accordance with Health Insurance 
Portability and Accountability Act (HIPAA) 
Exclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “NO” answer (unless not applicable): 
1. Patients who are no longer hardware dependent or are definitively treated 
for their infection by hardware removal without replacement 
2. Patients with multiple, non-contiguous fracture site infections 
3. Pathologic fracture (not including osteoporosis)  
4. Patient requires immunosuppressive therapy (Topical or inhaled 
corticosteroids are permitted) 
5. Serum creatinine, ALT, AST or Alkaline Phosphatase >1.5 times the 
upper limit of the normal range of the local testing laboratory 
6. Absolute neutrophil count <1000 
7. Patients without definitive soft-tissue coverage over the surgical site at 
time of study product administration 
8. Any condition that has required treatment with any other bismuth 
containing compound within the last 2 weeks (i.e., Kaopectate or 
Pepto-Bismol) 
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9. Participation in an investigational trial to evaluate pharmaceuticals or 
biologics within the past 3 months 
10. Individuals undergoing surgical treatment for more than one infected 
fracture 
11. Known allergy to metals or materials comprising the orthopedic 
hardware, bismuth and/or MBN-101 excipients (methylcellulose, 
Tween 80 (polysorbate 80)) 
12. Patients who are pregnant, lactating, or female patients who have a 
positive serum hCG as determined by laboratory testing 
13. Immunocompromised due to illness or organ transplant 
14. History of chronic or recurrent infections (≥ 3 infections at the same site 
within 12 months) other than the index infected osteosynthesis site 
15. History of any type of cancer (excluding non-melanomatous localized 
skin cancer or completely excised and cured carcinoma-in-situ of uterine 
cervix) 
16. Poorly controlled diabetes mellitus (hemoglobin A1c > 9.0% for 
≥ 6 months despite management by a physician) 
17. History of medical noncompliance 
18. Other medical conditions which, in the opinion of the Principal 
Investigator, would jeopardize the safety of the study subject or impact 
the validity of the study results. 
19. Current incarceration 
Investigational 
Product, Dose and 
Mode of 
Administration: 
MBN-101: A suspension of 0.025, 0.075, or 0.25 mg/mL (w:v) BisEDT 
powder in 3% methylcellulose / 0.5% Tween 80 / 10 mM sodium chloride / 
10 mM sodium phosphate, pH 7.4 (up to 8 mL dose volume) applied directly 
to structures within infected osteosynthesis sites during revision surgery with 
or without hardware removal and replacement as an adjunct to standard care 
systemic antimicrobial therapy. 
Reference Therapy, 
Dose and Mode of 
Administration: 
MBN-101 diluent (placebo): 3% methylcellulose / 0.5% Tween 80 / 
10 mM sodium chloride / 10 mM sodium phosphate, pH 7.4 (up to 8 mL dose 
volume) applied directly to structures within infected osteosynthesis sites 
during revision surgery with or without hardware removal and replacement 
as an adjunct to standard care systemic antimicrobial therapy. 
Study Duration 
24 weeks 
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Criteria for Evaluation: 
Efficacy Endpoints 
 
Proportion of treatment failures. A treatment failure is defined as a 
subject with non-healing or worsening status of their surgical site 
requiring serious intervention by Week 24. 
 
Cumulative number of serious interventions (as defined in Section 
12.6.2) at Week 24. 
 
Time to first serious intervention, time to readmission and time to 
reoperation, exclusive of serious interventions, readmissions, and 
reoperations associated with a healed fracture site. 
 
Number of subjects undergoing removal of stabilizing orthopedic 
hardware due to a healed fracture site by Week 24. 
 
Time to removal of orthopedic hardware due to a healed fracture site. 
 
Incidence and intensity of surgical site signs and symptoms, including 
local erythema, induration, drainage and degree of healing. 
 
Change from baseline in patient-reported outcomes at each post baseline 
time point. Patient-reported outcomes will include Veterans Rand 12 
Item Health Survey (VR-12) and Short Musculoskeletal Function 
Assessment (SMFA). 
 
Surgical site pain score and change from baseline in pain score at each 
post baseline time point. Pain intensity at the surgical site will be 
assessed by Visual Analog Scale (VAS, 0-10 scale). 
 
Findings of microbiology evaluations at the surgical site. Microbiologic 
success is assessed by clearance of infection. 
 
Findings of radiographic evaluations at the surgical site. Radiographic 
success is assessed by healing on radiologic examination. 
 
Changes in serologic markers CRP and ESR at each post baseline time 
point. 
Safety Endpoints 
 
Treatment-emergent adverse events. 
 
Treatment-emergent serious adverse events. 
 
Changes in clinical laboratory tests (clinical chemistry, hematology, and 
urinalysis). 
 
Changes in vital signs (blood pressure, pulse, respiratory rate and body 
temperature). 
 
Changes in physical exams. 
 
Clinical findings of 12-lead electrocardiograms. 
 
Change in microbiology status 
Pharmacokinetic 
Endpoints 
 
Whole blood concentrations of Bismuth (Bi) will be measured after 
administration of single escalating doses of MBN-101 (bismuth as a 
surrogate for BisEDT) and will be used to calculate pharmacokinetic 
parameters (i.e., Tmax, Cmax, AUC0-t, AUC0- ∞, T1/2, CL/F, Vz/F). 
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Statistical Methods: 
Statistical Analysis 
Consideration: 
The study sample of size of 24 subjects was chosen empirically for the 
purpose of the study without considering any formal statistical hypothesis 
testing. 
The safety analysis set will include all subjects who are randomized and 
receive any study drug; the efficacy analysis set will include all randomized 
subject with at least one post treatment assessment. Pharmacokinetic analysis 
set will include all subjects who have sufficient plasma samples to allow for 
calculation of pharmacokinetic parameters.  
All safety and efficacy endpoints will be tabulated with descriptive statistics; 
data from all placebo subjects (2 per cohort; 6 subjects in total) will be 
pooled. Data from BisEDT treated subjects will be presented by dose 
(6 subjects per dose) and combined (a total of 18 subjects). If data permits, 
differences between the treatment groups and 95% confidence intervals for 
the difference will be presented. 
If data permit, exploratory dose-response analyses will be performed for 
selected efficacy and safety endpoints.  
The primary analyses of efficacy and safety endpoints will be based on the 
actual treatment received in the event that the received treatment is not the 
assigned treatment; however, ‘as assigned’ sensitivity analyses are planned to 
evaluate the robustness of the efficacy data. 
 
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SPONSOR CONTACT INFORMATION 
Medical Monitor 
Name: 
Brian Murphy, MD 
Sr. Medical Director, Medpace Infectious Diseases 
Office Phone Number: 
513-579-9911, ext. 12416 
Mobile Phone Number: 
859-619-0037 
E-mail: 
b.murphy1@medpace.com 
Other Appropriate Trial Contact Personnel 
Name 
Tracy Robertson 
Clinical Trial Manager, Medpace 
Office Phone Number 
513-579-9911, ext. 12140 
Mobile Phone Number 
859-512-5183 
Fax 
513-579-0444 
E-mail: 
t.robertson@medpace.com 
Medpace Clinical Safety:  
SAE hotline: 
866-336-0930 or 
800-730-5779, ext. 2999 
Facsimile: 
866-336-5320 
E-mail: 
medpace-safetynotification@medpace.com 
 
If any Sponsor contact information needs to be changed during the course of the study, this will 
be done by the Sponsor, with written notification to the Investigator, and will not require a 
protocol amendment. 
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LIST OF ABBREVIATIONS 
AE 
Adverse event 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase (Serum glutamic pyruvic transaminase [SGPT]) 
AO/OTA 
Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association 
AST 
Aspartate aminotransferase (Serum glutamic oxaloacetic transaminase [SGOT]) 
AUC0-∞ 
Area under the curve from time 0 to infinity 
AUC0-t 
Area under the curve from time 0 to the time of the last measurable concentration 
Bi 
Bismuth, used as a surrogate in concentration and PK analyses after MBN-101 
administration 
BisEDT 
Bismuth-1,2-ethanedithiol 
BMI 
Body mass index 
BUN 
Blood urea nitrogen 
CFR 
Code of Federal Regulations 
CK 
Creatinine kinase 
CL/F 
Apparent clearance after extravascular administration  
CLSI 
Clinical and Laboratory Standards Institute 
Cm 
Centimeter 
Cmax 
Maximum observed concentration 
CRF 
Case report form 
CRP 
C-reactive protein 
DFU 
Directions for Use 
DOD 
Department of Defense 
DRC 
Data Review Committee 
ECG 
Electrocardiogram 
ESBL 
Extended spectrum beta lactamase 
ESR 
Erythrocyte sedimentation rate 
FDA 
U.S. Food and Drug Administration 
GCP 
Good Clinical Practice 
GGT 
Gamma glutamyl transferase 
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hCG 
Human chorionic gonadotropin 
HIPAA 
Health Insurance Portability and Accountability Act 
ICF 
Informed Consent Form  
ICH 
International Conference on Harmonization  
ICP-MS 
Inductively coupled plasma mass spectrometry 
IHMA 
International Health Management Associates, Inc. 
IRB 
Institutional Review Board  
ITT 
Intent to treat 
IUD 
Intrauterine device 
IV 
Intravenous 
IWRS 
Interactive Web Response System 
Kg 
Kilogram 
MBN-101 
Bismuth-1,2-ethanedithiol (BisEDT) suspension 
MC 
Methylcellulose 
MCS 
Mental health domain score 
MCV 
Mean corpuscular volume 
MDR 
Multidrug Resistant 
MedDRA 
Medical Dictionary for Regulatory Activities 
mg 
milligram 
mg/mL 
Milligrams per milliliter 
MIC 
Minimal inhibitory concentration 
mITT 
Modified intent to treat 
mL 
Milliliter 
mm 
Millimeter 
mM 
Millimolar 
MRSA 
Methicillin resistant Staphylococcus aureus 
MRSE 
Methicillin resistant Staphylococcus epidermidis 
MSSA 
Methicillin-sensitive Staphylococcus aureus 
NCA 
Non-compartmental (PK) analysis 
ng/mL 
Nanograms per milliliter 
OR 
Operating room 
ORP 
Office of Research Protections 
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PCS 
Physical health domain score 
PI 
Principal investigator 
PK 
Pharmacokinetics 
PT 
Prothrombin time 
PTT 
Partial thromboplastin time 
QIDP 
Qualified Infectious Disease Product 
RBC 
Red blood cells 
SAE 
Serious Adverse Event 
SAE CRF 
Serious Adverse Event Case Report Form 
SAP 
Statistical Analysis Plan 
SGOT 
Serum glutamic oxaloacetic transaminase 
SGPT 
Serum glutamic pyruvic transaminase 
SMFA 
Short Musculoskeletal Function Assessment 
SOC 
System organ class 
SOP 
Standard Operating Procedure 
T1/2 
Apparent half-life after extravascular administration 
TEAE 
Treatment-emergent adverse event 
Tmax 
Time of the maximal observed concentration 
USAMRMC US Army Medical Research and Materiel Command 
VAS 
Visual Analog Scale 
VR-12 
Veterans Rand 12 Item Health Survey 
Vz/F 
Apparent volume of distribution after extravascular administration 
w/v 
Weight:volume 
w:w 
Weight:weight 
WBC 
White blood cells 
 
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TABLE OF CONTENTS 
Grant Support .................................................................................................................................. 2 
Investigator Agreement ................................................................................................................... 3 
Protocol Synopsis............................................................................................................................ 4 
Sponsor Contact Information ........................................................................................................ 10 
List of Abbreviations .................................................................................................................... 11 
1 
INTRODUCTION ................................................................................................................18 
1.1 
Clinical Problem .......................................................................................................18 
1.2 
Investigational Therapy ............................................................................................19 
1.3 
Value of MBN-101 for the Treatment of the Clinical Problem ................................20 
2 
OBJECTIVES .......................................................................................................................21 
2.1 
Primary ......................................................................................................................21 
2.2 
Secondary ..................................................................................................................21 
3 
INVESTIGATIONAL PLAN ...............................................................................................22 
3.1 
Study Description......................................................................................................22 
3.2 
Number of Subjects...................................................................................................23 
3.3 
Number of Sites ........................................................................................................23 
3.4 
Clinical Trial Material ...............................................................................................23 
3.4.1 
MBN-101 .....................................................................................................23 
3.4.2 
Placebo (MBN-101 diluent) ........................................................................23 
3.5 
Dose ..........................................................................................................................24 
4 
STUDY POPULATION .......................................................................................................25 
4.1 
Inclusion Criteria ......................................................................................................25 
4.2 
Exclusion Criteria .....................................................................................................26 
5 
SUBJECT ENROLLMENT .................................................................................................27 
5.1 
Medical History ........................................................................................................27 
5.2 
Physical Exam ...........................................................................................................27 
5.3 
Studies .......................................................................................................................27 
5.4 
Laboratory Tests at Screening Visit ..........................................................................27 
6 
STUDY PROCEDURES ......................................................................................................28 
6.1 
Description of Study Procedures ..............................................................................28 
6.1.1 
Medical History ...........................................................................................28 
6.1.2 
Physical Exams ............................................................................................28 
6.1.3 
Vital Signs ...................................................................................................28 
6.1.4 
12-lead ECG ................................................................................................28 
6.1.5 
Laboratory Tests ..........................................................................................28 
6.1.6 
BisEDT (MBN-101) Blood Levels .............................................................29 
6.1.7 
Pain Assessments ........................................................................................29 
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6.1.8 
Patient Reported Outcomes .........................................................................29 
6.1.9 
Microbiology ...............................................................................................29 
6.1.9.1 
Specimen Collection ...................................................................29 
6.1.9.2 
Specimen Processing: Local Laboratory ....................................29 
6.1.9.3 
Specimen Processing: IHMA (Central Laboratory) ...................30 
6.1.9.4 
Integration of Local Site Laboratory and Central Laboratory 
Primary Isolation and Identification Results ..............................30 
6.1.10 Radiographic Evaluation .............................................................................31 
6.1.11 Surgical Site Signs and Symptoms Evaluation ...........................................31 
6.2 
Screening and Baseline Assessments ........................................................................31 
6.3 
Randomization Procedure .........................................................................................31 
6.4 
Unblinding Procedure ...............................................................................................32 
6.5 
Investigational Product Administration ....................................................................32 
6.5.1 
Surgical Site Identification ..........................................................................32 
6.5.2 
Study Drug Administration .........................................................................32 
6.6 
Study Assessments ....................................................................................................35 
6.7 
Safety Monitoring .....................................................................................................35 
6.8 
Study Monitoring ......................................................................................................35 
6.9 
Patient Withdrawals ..................................................................................................35 
6.10 
Individual Patient Stopping Rules ............................................................................35 
6.11 
Study Stopping Rules ................................................................................................35 
7 
CONCOMITANT MEDICATIONS ....................................................................................36 
8 
STUDY ENDPOINTS ..........................................................................................................37 
8.1 
Safety Endpoints .......................................................................................................37 
8.2 
Efficacy Endpoints ....................................................................................................37 
8.3 
Pharmacokinetic Endpoint ........................................................................................38 
8.3.1 
Sample Collection and Handling .................................................................38 
8.3.2 
Assay Methodology .....................................................................................38 
8.3.3 
PK Analysis .................................................................................................38 
9 
ADVERSE EVENTS ............................................................................................................39 
9.1 
Reporting and Following Adverse Events ................................................................39 
9.2 
Severity .....................................................................................................................40 
9.3 
Relationship to Clinical Trial Material .....................................................................40 
9.4 
Serious Adverse Events ............................................................................................41 
9.4.1 
Definition .....................................................................................................41 
9.4.2 
Reporting .....................................................................................................41 
9.5 
Pregnancies ...............................................................................................................42 
9.6 
Data Review Committee (DRC) ...............................................................................42 
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10 
INVESTIGATIONAL PRODUCT MANAGEMENT .........................................................43 
10.1 
Study Drug ................................................................................................................43 
10.2 
Study Drug Packaging and Labeling ........................................................................44 
10.3 
Study Drug Storage ...................................................................................................44 
10.4 
Study Drug Accountability .......................................................................................44 
10.5 
Study Drug Handling and Disposal ..........................................................................44 
11 
GENERAL CONSIDERATIONS ........................................................................................45 
11.1 
Basic Principles .........................................................................................................45 
11.2 
Institutional Review Board .......................................................................................45 
11.3 
Informed Consent......................................................................................................45 
11.4 
Study Termination ....................................................................................................46 
11.5 
Regulatory Documentation .......................................................................................46 
11.6 
Study Documentation................................................................................................46 
11.7 
Data Handling and Record Keeping .........................................................................47 
11.8 
Use of Information and Publication ..........................................................................47 
11.9 
Independent Medical Monitor ...................................................................................48 
12 
STATISTICAL ANALYSIS METHODOLOGY ................................................................49 
12.1 
Efficacy Endpoints ....................................................................................................49 
12.2 
Safety Endpoints .......................................................................................................50 
12.3 
Sample Size Considerations ......................................................................................50 
12.4 
Analysis Datasets ......................................................................................................51 
12.5 
Disposition and Study Population Characteristics ....................................................51 
12.6 
Efficacy Analysis ......................................................................................................52 
12.6.1 Treatment Failure ........................................................................................52 
12.6.2 Incidence of Serious Interventions ..............................................................52 
12.6.3 Time to First Serious Interventions .............................................................53 
12.6.4 Subjects Undergoing Removal of Stabilizing Orthopedic Hardware .........53 
12.6.5 Surgical Site Signs and Symptoms ..............................................................53 
12.6.6 Patient-Report Outcomes ............................................................................53 
12.6.6.1 The Veterans RAND 12 Item Health Survey (VR-12) 
Questionnaire ..............................................................................53 
12.6.6.2 The Short Musculoskeletal Function Assessment 
Questionnaire (SMFA) ...............................................................53 
12.6.7 Pain Assessments ........................................................................................54 
12.6.8 Microbiology ...............................................................................................54 
12.6.9 Radiographic Evaluation .............................................................................55 
12.6.10 Serologic Markers .......................................................................................55 
12.6.11 Subgroup Analyses for Efficacy Endpoints ................................................55 
12.6.12 Sensitivity Analyses for Efficacy Endpoints ...............................................55 
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12.7 
Safety Analysis .........................................................................................................56 
12.7.1 Study Drug Exposure and Concentrations ..................................................56 
12.7.2 Adverse Events ............................................................................................56 
12.7.3 Clinical Laboratory Tests ............................................................................56 
12.7.4 12-lead ECG ................................................................................................56 
12.7.5 Vital Sign Measurements ............................................................................57 
12.7.6 Physical Examinations ................................................................................57 
12.7.7 Subgroup Analyses for Safety Endpoints ....................................................57 
12.8 
PK Analysis ..............................................................................................................57 
12.9 
Interim Evaluation ....................................................................................................57 
13 
REFERENCES .....................................................................................................................58 
14 
APPENDICES ......................................................................................................................61 
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1 INTRODUCTION 
1.1 Clinical Problem 
Postoperative orthopedic infections, particularly antibiotic-resistant infections, present a serious 
clinical challenge to surgeons and other treating physicians, since these infections involve 
foreign materials (stabilizing orthopedic hardware) which are frequently associated with 
persistent microbial biofilms (Hetrick, 2006). Surgical intervention, including irrigation, 
debridement and potential replacement of orthopedic hardware, combined with a prolonged 
course of systemic antibiotics, is the standard of care for postoperative infections (Schmidt, 
2000; Patzakis, 2005). However, outcomes associated with these infections are often poor, 
including chronic/recurrent infections, repeated hospitalizations, repeated surgeries, multiple 
courses of systemic antibiotic treatment, loss of function, disability, amputation and death 
(Berkes, 2010). 
Systemic antibiotics are poorly efficacious in the treatment of heavily contaminated or infected 
wounds (Zalavras, 2003; Robson, 1997) and often antibiotics “…have practical and potential 
value only if a therapeutic blood level or, more importantly, tissue level is achieved within the 
first 4 hours after wounding” (Robson, 1999), i.e., before biofilm formation. The ‘contest’ 
between bacteria and host tissues with respect to speed of colonization of foreign objects such as 
orthopedic medical devices has been described as the “race for the surface’ (Gristina, 1988). 
Bacteria are able to adhere to foreign, implanted objects almost immediately, facilitating rapid 
formation of microbial biofilms which drastically increase the resistance of wound-associated 
bacteria and contribute significantly to persistence and virulence of the infection (Parra-Ruiz, 
2012; Gristina, 1994). Such biofilms can serve as quiescent reservoirs of adherent, antibiotic-
tolerant or antibiotic-resistant bacteria within the wound, or as foci of active infections, which 
helps to explain the chronic and/or recurrent nature of many device-related infections. In 
addition, biofilms are hypermutable (Ciofu, 2011), increasing the likelihood of developing 
genetically-based antibiotic resistance. Finally, biofilms serve as environments in which bacteria 
can exchange genetic material encoding antibiotic resistance genes (Ghigo, 2001). Recent studies 
have shown that the most highly multidrug resistant (MDR) bacteria are also the strongest 
biofilm-forming bacteria (Kwon, 2008), and similarly, that invasive MDR bacteria are usually 
biofilm-forming bacteria (Reiter, 2011). 
The high incidence of postoperative orthopedic device-related infections, as well as the 
shortcomings of the standard of care treatment in resolving those infections, particularly 
considering the increasing prevalence of antibiotic-resistant pathogens, has resulted in an 
expanding unmet need for safe, innovative, new and effective therapies to reduce the infectious 
risks and consequences of these infections, which increasingly involve antibiotic- resistant 
strains (Gessman, 2012; Morris, 2013; Tosh, 2012). Antibiotic resistance adds significantly to 
the challenge of successfully resolving these orthopedic infections (Ferry, 2010; Salgado, 2007). 
For example, infection treatment failures are nine times more frequent in orthopedic patients 
with MRSA infections than methicillin-sensitive S. aureus (MSSA) infections (Salgado, 2007).  
Development of local therapies that eradicate established biofilms or prevent the formation of 
biofilms (as a new target) is an innovative new clinical strategy, particularly considering the 
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shortcomings of systemically administered antibiotics for treatment of wound infections. For 
example, several groups have investigated the direct, local application of vancomycin powder on 
the surgical wound in combination with systemic prophylaxis to prevent or treat infection. The 
outcomes of these studies have been mixed, with some groups reporting a reduced infection rate 
and/or a reduction in patient treatment costs (Heller, 2013; Godil, 2013) and others reporting no 
benefit (Tubaki, 2013; Martin, 2013). Antibiotic-loaded bone cement containing tobramycin, 
gentamicin, or vancomycin/tobramycin or other antibiotic combinations have been investigated 
for their ability to reduce infection rates and /or reduce costs when applied locally in a variety of 
orthopedic surgical procedures (Cummins, 2009; Nowinski, 2012; Selhi, 2012). Evidence 
suggests that local therapies may reduce implant related surgical site infections. 
1.2 Investigational Therapy 
MBN-101 [Bismuth-1,2-ethanedithiol (BisEDT) suspension] represents the first drug product 
from a new class of antimicrobial agents with apparently unique mechanisms of action. In 
nonclinical models, BisEDT has been shown to be effective against a broad-spectrum of 
orthopedic device-associated bacteria including antibiotic-resistant strains. 
BisEDT has several characteristics especially suited to the treatment of postoperative orthopedic 
infections: 
a) Broad spectrum antimicrobial activity against the most critically important antibiotic-
resistant bacteria, including MRSA, MRSE, antibiotic-resistant Pseudomonas 
aeruginosa, ESBL-positive Klebsiella pneumoniae, and antibiotic-resistant Enterobacter 
species. 
b) Apparently unique mechanisms of action. 
c) Anti-biofilm capabilities. 
d) Extremely low spontaneous mutation frequency, superior to many conventional 
antibiotics. 
e) Efficacy against both aerobic and anaerobic bacteria. 
f) Demonstrated lack of interference with the activity of a wide range of antibiotics. 
g) Enhanced activity in combination with specific antibiotics; in some cases, synergy has 
been demonstrated in vitro and in vivo. 
h) Maintenance of antimicrobial activity in the presence of excessive protein. 
i) A favorable safety and tolerability profile in nonclinical toxicology studies in a variety of 
species, including absence of effect on wound healing or bone repair 
j) A favorable safety and tolerability profile in a clinical Phase 1 study evaluating topical 
administration. 
Based in part on these characteristics, BisEDT has been granted Qualified Infectious Disease 
Product (QIDP) designation by the FDA for the local, intra-operative treatment of resistant post-
surgical orthopedic implant infections. 
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1.3 Value of MBN-101 for the Treatment of the Clinical Problem  
The broad-spectrum antimicrobial, anti-biofilm activity of BisEDT, its activity against relevant 
antibiotic-resistant pathogens, and its ability to enhance the activity of certain other antibiotics 
are properties that will promote more rapid and/or more complete eradication of infection, and 
reduce infectious risks to patients. With comparatively elevated rates of postoperative infection 
associated with repair of traumatic orthopedic wounds, the development of a new and innovative 
treatment strategy to complement the current standard of care would therefore be expected to 
result in a substantial reduction in mortality, amputation, morbidity, and disability, along with a 
reduction in patient treatment costs. 
MBN-101 provides important potential advantages over current standard of care treatment for 
orthopedic infections. Direct, local contact of MBN-101 with infected target tissue and 
contaminated device surfaces immediately delivers a therapeutically active dose of BisEDT to 
the site of infection. Combined antimicrobial and anti-biofilm effects are achieved with minimal 
systemic exposure. Systemic antibiotics administered alone are frequently ineffective, in part 
because altered perfusion at the surgical wound site hinders effective and timely delivery of 
systemic antibiotics, making it difficult to reach therapeutic antibiotic levels at wound 
tissues/surfaces. The combined effect of IV administered antibiotics, which already serve as a 
pillar of the current standard of care for orthopedic device-related infections, along with the local 
administration of MBN-101, is expected to eradicate bacteria from postoperative orthopedic 
wounds, and will ultimately also serve to reduce the likelihood of development of antibiotic-
resistant bacteria. By reducing the time to resolution of infection and improving the ability of 
current antibiotic therapies to effectively control and eliminate post-surgical orthopedic device-
related infections, MBN-101 will contribute to reductions in the number of additional serious 
interventions needed to resolve infections including reduction in repeat surgeries, additional 
rounds of systemic antibiotics, patient hospitalization time, morbidity and mortality in both 
civilian and military populations. 
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2 OBJECTIVES 
2.1 Primary 
To evaluate the safety and tolerability of single escalating doses of locally administered 
MBN-101 or placebo as adjunct to standard of care antimicrobial and surgical therapy. 
2.2 Secondary 
 To evaluate the clinical activity of single escalating doses of locally administered MBN-101. 
 To evaluate the pharmacokinetics of single escalating doses of locally administered 
MBN-101. 
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3 INVESTIGATIONAL PLAN 
3.1 Study Description 
This is a randomized, single-blind, placebo-controlled multi-center study to assess the safety and 
tolerability of escalating doses of MBN-101 applied directly to target structures within infected 
osteosynthesis sites during revision surgery with or without hardware removal and replacement 
for patients diagnosed with an apparent fracture site infection. Three successive cohorts of 8 
patients will be enrolled in this trial. Consecutive patients from each of the study sites will be 
screened for potential participation as they present to the orthopedic service for clinical care for 
their postoperative infections. After signing an Informed Consent Form (ICF), subjects will 
complete screening procedures. Patients meeting all eligibility criteria on screening will be 
offered participation in the study. Patients accepting participation in the study will be 
randomized 3:1 (active:control) to three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of 
MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent). 
Enrollment to the next dose cohort will not commence until an evaluation by the Data Review 
Committee (DRC) of all available safety data on all patients through Week 6 of study supports 
escalation to the next cohort. The DRC will monitor all safety data in an ongoing manner from 
all patients enrolled onto this study. 
Following baseline evaluation, patients will receive standard of care treatment for their post-
operative fracture site infection that includes systemic antibacterial treatment per institutional 
standard of care guidelines and revision surgery with or without hardware removal and 
replacement as indicated. Multiple debridements, soft tissue transfer, and revision fixation 
procedures may be performed prior to definitive closure. A single application of the 
investigational product, MBN-101 or placebo, applied intraoperatively directly to target 
structures within infected osteosynthesis sites, will be performed following the final irrigation 
and debridement procedure and immediately prior to definitive closure. In cases where original 
hardware is retained, the investigational product will be sparingly applied to all accessible 
surfaces of hardware and adjacent bone. In cases where hardware is replaced or in cases of two-
stage procedures, MBN-101 will be applied to all accessible surfaces of hardware and adjacent 
bone (target structures) following implantation of hardware and immediately prior to definitive 
closure. The volume applied will be determined by the surgeon’s assessment of the size (in cm2) 
of the target area, and guided by the Table in Section 6.5.2. If wounds are left open, the 
investigational product will be applied immediately prior to definitive closure. The minimum 
amount of MBN-101 required to achieve a thin coat of the relevant target structures within the 
infected osteosynthesis site will be used (see Section 6.5.2). 
All patients will receive standard postoperative care per institutional guidelines, and will be 
discharged from the hospital in accordance with local standards. Patients will undergo study 
visits at Hour 48 and Weeks 2, 6, 12, and 24. All patients will be followed for a minimum of 
24 weeks after surgery. 
See Appendix 1 for a Schedule of Activities. 
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3.2 Number of Subjects 
Twenty-four adult male or female patients meeting protocol-specified eligibility criteria may 
participate in the study, with the objective of having a total of 6 patients per dose level in the 
MBN-101-treated group and 6 patients in a pooled placebo-treated group. Patients who are 
randomized but do not receive study drug may be replaced. 
3.3 Number of Sites 
Up to eight U.S. study sites are anticipated to enroll an adequate number of eligible patients. 
 
3.4 Clinical Trial Material 
Patients will be randomized 3:1 (active:control) to three successive doses (0.025, 0.075, or 
0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 2.0 mg, respectively) 
or placebo (diluent). Enrollment to the next dose cohort will not commence until an evaluation 
by the Data Review Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort.  
3.4.1 
MBN-101 
MBN-101 is Bismuth-1,2-ethanedithiol (BisEDT) suspension (0.025, 0.075, or 0.25 mg/mL, 
w:v) in diluent (3% methylcellulose / 0.5% Tween 80 / 10mM sodium chloride / 10 mM sodium 
phosphate, pH 7.4). 
 
 
Structural Formula 
Molecular Formula 
C6H12S6Bi2 
Molecular Weight 
694.51 g/mol 
Stereochemistry/Chirality 
BisEDT has no chiral centers. 
 
3.4.2 
Placebo (MBN-101 diluent) 
Placebo is MBN-101 diluent comprised of 3% methylcellulose / 0.5% Tween 80 / 10mM sodium 
chloride / 10 mM sodium phosphate, pH 7.4. 
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3.5 Dose 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
Investigational product kits (MBN-101 and placebo) configured for each dose cohort will be 
provided and will contain the supplies necessary for preparation of the specified concentrations 
of MBN-101 or placebo for administration to each patient. 
Additionally, each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the Stock Formulation and Diluent 
provided in the Drug Product Kit according to the Directions for Use (DFU) provided. The 
Treatment Dose will be provided to the surgeon in a vial from which an 8 mL volume will be 
drawn up in the operating room into a sterile 10 mL syringe. Surgeons will be instructed to use 
sufficient volume (up to the full 8 mL provided for the largest exposed target areas) to sparingly 
coat the bone at the site of infection, the exposed surfaces of any retained hardware, and the 
surfaces of any new hardware to be implanted. With dose volume determined according to 
Section 6.5.2, the volume of MBN-101 required to achieve a thin coat of the relevant structures 
within the infected osteosynthesis site will be applied. Following application, OR personnel will 
record in the CRF the actual volume (in tenths of milliliters) of any unapplied Treatment Dose 
remaining in the syringe. 
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4 STUDY POPULATION 
The study population will include 24 male or female adults who meet all of the study entry 
requirements. 
4.1 Inclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “YES” answer 
(unless not applicable): 
1. Patients who: 
 have had operative fracture fixation of the upper extremity (AO/OTA class 15, 11-13, 
21-23), lower extremity (AO/OTA class 31-34, 41-44, 81, 82) or pelvis (61, 62), or 
have undergone arthrodesis 
 are diagnosed with an apparent fracture site infection and have at least one of the 
following: 
 Elevated ESR above the upper limit of normal 
 Elevated CRP above the upper limit of normal 
 Draining wound / sinus tract 
 Positive culture from site of prior surgery by aspirate or other modality 
 Local erythema or induration at the site of prior surgery 
 Exposed hardware 
 Periosteal reaction on x-ray 
 Loose or broken hardware  
 require revision surgery with or without removal and replacement of existing hardware 
2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as per institution’s 
standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after revision surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile or at least 
2 years postmenopausal, must agree to use one of the following forms of contraception 
from screening through the Week 24 visit: hormonal (oral, implant, or injection) begun 
>30 days prior to screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications and they must 
ensure their female sexual partner complies with the contraception requirements:  
 Be sexually abstinent from Baseline through Week 24  
 Be > 6 months post-vasectomy  
 Agree to use a condom with spermicide from Baseline through Week 24 
7. Have read and signed the Informed Consent Form (ICF) after the nature of the study has 
been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of personal health 
information in accordance with Health Insurance Portability and Accountability Act 
(HIPAA) 
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4.2 Exclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “NO” answer 
(unless not applicable): 
1. Patients who are no longer hardware dependent or are definitively treated for their 
infection by hardware removal 
2. Patients with multiple, non-contiguous fracture site infections 
3. Pathologic fracture (not including osteoporosis)  
4. Patient requires immunosuppressive therapy (Topical or inhaled corticosteroids are 
permitted) 
5. Serum creatinine, ALT, AST or Alkaline Phosphatase >1.5 times the upper limit of the 
normal range of the local testing laboratory 
6. Absolute neutrophil count <1000 
7. Patients without definitive soft-tissue coverage over the surgical site at time of study 
product administration 
8. Any condition that has required treatment with any other bismuth containing compound 
within the last 2 weeks (i.e., Kaopectate or Pepto-Bismol) 
9. Participation in an investigational trial to evaluate pharmaceuticals or biologics within the 
past 3 months 
10. Individuals undergoing surgical treatment for more than one infected fracture 
11. Known allergy to metals or materials comprising the orthopedic hardware, bismuth 
and/or MBN-101 excipients (methylcellulose, Tween 80 (polysorbate 80)) 
12. Patients who are pregnant, lactating, or female patients who have a positive serum hCG 
as determined by laboratory testing 
13. Immunocompromised due to illness or organ transplant 
14. History of chronic or recurrent infections (≥ 3 infections at the same site within 
12 months) other than the index infected osteosynthesis site 
15. History of any type of cancer (excluding non-melanomatous localized skin cancer or 
completely excised and cured carcinoma-in-situ of uterine cervix) 
16. Poorly controlled diabetes mellitus (hemoglobin A1c > 9.0% for ≥ 6 months despite 
management by a physician) 
17. History of medical noncompliance 
18. Other medical conditions which, in the opinion of the Principal Investigator, would 
jeopardize the safety of the study subject or impact the validity of the study results. 
19. Current incarceration  
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5 SUBJECT ENROLLMENT 
Potential patients will undergo screening medical history and physical examination. If they are 
deemed appropriate candidates for study, they will be asked to provide appropriate informed 
consent. After informed consent is signed additional baseline evaluation will be performed, 
including but not limited to clinical laboratory assessment, radiographic evaluation, 
electrocardiogram (ECG) and pregnancy test if applicable. Only patients with an acceptable 
medical history and physical exam, ECG without clinically significant abnormalities, and 
laboratory results within acceptable limits will be randomized in the study. Randomization will 
occur using an IWRS system immediately after a patient has met all study entry criteria. 
5.1 Medical History 
Medical history and demographic data, including gender, date of birth, ethnicity, and race will be 
recorded. 
5.2 Physical Exam 
Each patient will receive a physical examination (head, ears, eyes, nose, throat, chest, heart, 
abdomen, and skin) including vital signs, weight (kg), and height (cm). Each patient will also 
receive a detailed evaluation of the index fracture site and involved extremity. 
5.3 Studies 
Following signing of the informed consent form, each patient will undergo all screening 
evaluations as provided in the Table of Study Events. These evaluations should be completed no 
more than 2 weeks prior to surgery date; after a screened subject is confirmed to be eligible for 
the study, this qualified subject will be randomized prior to surgery to receive the investigational 
product. 
5.4 Laboratory Tests at Screening Visit 
Hematology White blood cells (WBC), red blood cells (RBC), hemoglobin, hematocrit, platelet count, 
MCV, absolute neutrophils, absolute lymphocytes, absolute monocytes, absolute 
eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, blood urea nitrogen (BUN), glucose, 
creatinine, total protein, albumin, total bilirubin, direct bilirubin, alkaline phosphatase 
(ALP), AST (SGOT), ALT (SGPT), GGT, creatinine kinase (CK), calcium, magnesium, 
Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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6 STUDY PROCEDURES 
See the Table of Study Events outlining study procedures in Appendix 1. For the study site visit 
at Week 2, a visit window of + 4 days will be allowed; for study site visits Weeks 6 – 24, a visit 
window of ± 8 days will be allowed. 
6.1 Description of Study Procedures 
6.1.1 
Medical History 
A comprehensive medical history will be taken on all patients at Screening, including but not 
limited to past medical history, past surgical history, current medications, allergic history and 
psychosocial history. 
6.1.2 
Physical Exams 
A comprehensive physical examination will be performed on all patients at Screening, including 
assessments of height, weight, head, ears, eyes, nose, throat, chest, heart, abdomen, and skin. 
Interval physical exams will be performed at all subsequent study visits according to the 
schedule in Appendix 1 and will focus on the surgical site, with assessments of local erythema, 
induration, drainage and degree of healing. 
6.1.3 
Vital Signs 
Vital signs include blood pressure, pulse, respiratory rate and body temperature; vital signs will 
be assessed according to the schedule in Appendix 1. 
6.1.4 
12-lead ECG 
Testing will be conducted at screening, baseline, and 48 hours. The ECG trace will be stored at 
the investigational sites as source document; clinical interpretation, including normal, abnormal 
but not clinically significant, and abnormal and clinically significant, will be determined by the 
investigator and reported on the CRFs.  
6.1.5 
Laboratory Tests 
All clinical laboratory tests will be performed by the local clinical site laboratory. 
Blood and urine will be collected for hematology, serology, serum chemistry, urinalysis, and 
pregnancy testing (as indicated) according to the schedule in Appendix 1. 
Hematology WBC, RBC, hemoglobin, hematocrit, platelet count, MCV, absolute neutrophils, absolute 
lymphocytes, absolute monocytes, absolute eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, BUN, glucose, creatinine, total protein, 
albumin, total bilirubin, direct bilirubin, alkaline phosphatase (ALP), AST (SGOT), ALT 
(SGPT), GGT, creatinine kinase (CK), calcium, magnesium, Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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6.1.6 
BisEDT (MBN-101) Blood Levels 
BisEDT levels in whole blood after MBN-101 administration will be assessed with a qualified 
Inductively Coupled Plasma Mass Spectrometry (ICP-MS) assay method using bismuth as a 
surrogate for BisEDT according to the schedule in Appendix 1. 
6.1.7 
Pain Assessments 
Pain related specifically to the surgical site (Surgical Site Pain Score) will be assessed via a 
Visual Analog Scale (VAS, 0-10 scale, where 0=no pain at all and 10 =the worst possible pain) 
utilizing a 24 hour recall at screening, baseline, Hour 48 and Weeks 2, 6, 12, and 24. 
6.1.8 
Patient Reported Outcomes 
Patient-reported outcomes will be collected using the Veterans Rand 12 Item Health Survey 
(VR-12) and Short Musculoskeletal Function Assessment (SMFA) according to the schedule in 
Appendix 1. 
6.1.9 
Microbiology 
The microbiology of the index site will be assessed at baseline and at the time of any subsequent 
surgical procedure at the index site. The presence of viable microorganisms will be determined 
by standard microbiological culture methods and include speciation and antimicrobial 
susceptibility testing of any bacterial isolates found (see flowchart, Appendix 2). 
6.1.9.1 Specimen Collection 
Samples collected will include at least one tissue site (bone when possible; eraser head size, 
suitable for dividing into two samples) from the fracture site (if accessed) or involved tissue 
adjacent to the implant(s), two swabs of the peri-implant deep tissue, and two swabs of the 
superficial tissue/wound closure site. One set of specimens (i.e. 1 tissue specimen, 1 deep swab, 
1 superficial swab) will be placed into local site transport vessels. The duplicate set of samples 
will be placed into transport vessels provided by the central laboratory (International Health 
Management Associates, Inc.; IHMA). One set of specimens will be delivered to the local site 
microbiology laboratory using the standard storage and transport procedures employed at each 
site. The duplicate set of specimens will be transported to IHMA. The details regarding specimen 
packaging, transport, and processing will be described in the central laboratory study manual that 
will be provided to each study site. 
6.1.9.2 Specimen Processing: Local Laboratory 
The tissue site sample and swabs will be analyzed immediately in the local laboratory for the 
presence of infectious pathogens by Gram stain and microbiological culture for both aerobic and 
anaerobic bacteria. The specimens will be processed (primary isolation, identification to species 
level and susceptibility testing) per the standard methods of each local site microbiology 
laboratory. Following isolation and identification of each microorganism, the susceptibility of 
each to one or more standard antibacterial agents (but not including MBN-101), as specified by 
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the surgeon or per local site standard procedures, will be determined. It is recognized that the 
local site laboratory may be using one of a variety of susceptibility test methods, and therefore, 
the susceptibility result may be reported as a specific Minimal Inhibitory Concentration (MIC) 
value or as a categorical result (i.e. Susceptible, Intermediate or Resistant). Susceptibility to 
MBN-101 will not be determined at the local site laboratory; the susceptibility results determined 
locally are for the use of the surgeon in the care of the patient. All Gram stain and microbiology 
results from the local site laboratory will be recorded on the CRF. 
6.1.9.3 Specimen Processing: IHMA (Central Laboratory) 
The tissue site sample and swabs will be analyzed immediately in the central laboratory for the 
presence of infectious pathogens by microbiological culture for both aerobic and anaerobic 
bacteria. The specimens will be processed (primary isolation, identification to species level, and 
susceptibility testing) per the central laboratory methods, as described in the central laboratory 
study manual. 
Following identification, the susceptibility of the isolates to MBN-101 and comparator agents 
will be determined using either the reference broth microdilution method (for aerobic/facultative 
bacteria) or the reference agar dilution method (for anaerobic bacteria) as detailed by the Clinical 
and Laboratory Standards Institute (CLSI). Susceptibility tests for aerobic/facultative bacteria 
will be quality-controlled as detailed by CLSI using reference quality control strains and 
previously-established ranges for MBN-101 and comparators. Susceptibility tests for anaerobic 
bacteria will also include CLSI reference quality control strains, however, since quality control 
ranges for anaerobic bacteria are not yet established, the MIC values for the quality control 
strains will be collected then retrospectively compared to the quality control ranges once they are 
available.  Susceptibility testing will be conducted with batches of study isolates as each study 
cohort is completed. Patient and specimen identifier and microbiology results will be recorded in 
the database. The bacterial isolates recovered from the specimens will be propagated and 
archived at the central laboratory. 
6.1.9.4 Integration of Local Site Laboratory and Central Laboratory Primary Isolation and 
Identification Results 
There may be instances where the organism(s) isolated from a given specimen may be different 
at the local site laboratory and the central laboratory. In this instance, the central laboratory will 
first confirm the identification of the archived isolate. If the identification is confirmed, the 
pathogens present in the specimen will be defined as the total number of pathogens recovered by 
the local site laboratory and the central laboratory. For example, if the local site laboratory were 
to recover S. aureus and the central laboratory recovered S. aureus and P. acnes, the specimen 
would be defined as containing both S. aureus and P. acnes following merger of the data. 
It is possible that local site laboratory may perform susceptibility tests with agents that are also 
present in the central laboratory test panel. The MIC value (and interpretation) provided by the 
central laboratory supersedes the local site determination for the purposes of clinical trial data 
analysis and inclusion in the Clinical Study Report. The local site susceptibility test results are 
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for use by the surgeon in the local care of the patient; however, these data will also be captured 
in the study database. 
6.1.10 
Radiographic Evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6, 12, and 24. Radiographs 
(at least two orthogonal views) will be reviewed for union, interval callus formation, loss or 
change in reduction, and hardware failure. 
6.1.11 
Surgical Site Signs and Symptoms Evaluation 
The following signs and symptoms of the surgical site will be evaluated: 
 
local erythema extending beyond suture material or staples 
 
induration  
 
drainage from surgical incision 
 
degree of healing of the surgical incision 
Patients with non-healing or worsening status of their surgical site may be considered for 
additional standard of care treatment, but should be encouraged to remain in the study in order to 
complete study evaluations. In case additional treatment is given, the start/stop dates and dose 
regimen of the new treatment will be recorded on the CRFs. 
6.2 Screening and Baseline Assessments 
Patients who meet initial screening criteria by medical history and physical exam will be offered 
participation on study. If the patient agrees to participate, they will be asked to provide written 
informed consent, after which additional evaluation may be performed, including but not limited 
to clinical laboratory assessments, electrocardiogram (ECG), radiographic evaluation and 
pregnancy test if applicable. Only patients with an acceptable medical history and physical exam, 
ECG without clinically significant abnormalities, and laboratory results within acceptable limits 
will be randomized in the study prior to surgery. 
6.3 Randomization Procedure 
Subjects will be randomized in a 3:1 (active:placebo) ratio up to 24 hours prior to surgery via a 
central randomization scheme. The central randomization will be accomplished using an IWRS 
system linked to study drug treatment kits securely stored under appropriate conditions at the 
study site pharmacy. The randomization number assigned to a subject will be captured on the 
CRF. The specific study drug treatment kit will be utilized by the study pharmacist or other 
qualified individual to perform the appropriate dilution of drug product under sterile conditions 
into a vial to be transported to the operating room. Verification of study patient and study drug 
treatment kit will take place in the operating room prior to treatment with the investigational 
product. The appropriately diluted drug product must be administered within 8 hours of 
preparation. 
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6.4 Unblinding Procedure 
This study is a single blind study; however, knowledge of treatment assignment should remain 
limited to those directly involved with the patient’s surgical procedure and other individuals on a 
need to know basis. In order to provide unblinding data in an emergency in the absence of an 
individual privy to treatment assignment, sites will be provided with a numbered unblinding 
envelope corresponding to each numbered test kit the site is delivered. These envelopes will be 
securely stored in the pharmacy. The unblinding envelope specifies the treatment group of the kit 
and should only be opened when absolutely necessary. For treatment of adverse events, it should 
be assumed that the patient has received study drug, thus avoiding the need to unblind the 
patient. However, in the event the Investigator determines the randomization assignment 
information is required to treat the patient for an adverse event, the Medical Monitor should be 
contacted. If the Medical Monitor cannot be reached, the blind may be broken by opening the 
envelope. The site should document the unblinding process in the patient’s source documents. 
6.5 Investigational Product Administration 
6.5.1 
Surgical Site Identification 
Individuals undergoing surgical treatment for more than one infected fracture are excluded from 
participation in this study. 
6.5.2 
Study Drug Administration 
On the day of surgery, randomized subjects will receive the investigational product during their 
surgical procedure. Investigational product is only administered during the surgical procedure by 
the operating surgeon; therefore, 100% compliance with investigational product administration is 
assured. The operating surgeon will record the approximate surface area of the surgical site as 
well as the amount and location of investigational product administration in the operative note 
and on the CRF. All other details of the surgical procedure will be recorded in the operative note. 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 18 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
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5. Alcohol wipes 
6. One pre-printed "Diluted MBN-101 Drug Product" label 
7. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose”) 
Additionally, each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the MBN-101 Stock Formulation and 
Diluent provided in the Drug Product Kit according to the DFU provided. The Treatment Dose 
will be provided to the surgeon in a vial from which an 8 mL volume will be drawn up in the 
operating room into a sterile 10 mL syringe. Surgeons will be instructed to use sufficient volume 
(up to the full 8 mL provided) to sparingly coat the bone at the site of infection, the exposed 
surfaces of any retained hardware, and the surfaces of any new hardware to be implanted. 
Following application, OR personnel will record in the CRF the actual volume (in tenths of 
milliliters) of any unapplied Treatment Dose remaining in the syringe. 
Application to retained hardware:  Access to infected wound surfaces and implanted orthopedic 
hardware will be provided by surgical intervention. The surgeon will use a 10 mL syringe to 
apply, followed by a gloved finger to spread, a thin layer of the investigational product directly 
onto all accessible surfaces of the orthopedic hardware, as well as surrounding bone. Other 
wound surfaces will not be coated, resulting in administration of the investigational product to 
only a limited area of the wound. 
Application to new hardware:  In cases where hardware is replaced or in cases of two-stage 
procedures, MBN-101 will be applied to all accessible surfaces of hardware and adjacent bone 
(target structures) following implantation of hardware and immediately prior to definitive 
closure. Other wound surfaces will not be coated, resulting in administration of the 
investigational product to only a limited area of the wound. 
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In all cases, the minimum amount of MBN-101 required to coat the relevant structures within the 
infected osteosynthesis site should be used. The suspension should be applied in a thin layer to 
cover all affected areas of bone as well as any exposed hardware. Direct application to muscle 
and other soft tissues should be avoided. The approximate area of the osteosynthesis site should 
be calculated based on the length of exposed bone multiplied by the width of bone exposed; the 
surface area of the hardware should be added to this value to derive the approximate area of the 
osteosynthesis site. Recommended maximum volumes of MBN-101 for various areas of the 
osteosynthesis site are provided in the table below. 
Area of Osteosynthesis Site 
Recommended Volume of MBN-101 
25 cm2 
0.5 mL 
50 cm2 
1.0 mL 
75 cm2 
1.5 mL 
100 cm2 
2.0 mL 
125 cm2 
2.5 mL 
150 cm2 
3.0 mL 
175 cm2 
3.5 mL 
200 cm2 
4.0 mL 
225 cm2 
4.5 mL 
250 cm2 
5.0 mL 
275 cm2 
5.5 mL 
300 cm2 
6.0 mL 
325 cm2 
6.5 mL 
350 cm2 
7.0 mL 
375 cm2 
7.5 mL 
400 cm2 
8.0 mL 
 
The table shows the specified volume of MBN-101 to be applied based on the area (in cm2) of 
the target infected osteosynthesis site. By following these application requirements, the 
administered doses will be: 
 Cohort 1: 0.025 mg/mL MBN-101 = 0.5 µg/cm2 
 Cohort 2: 0.075 mg/mL MBN-101 = 1.5 µg/cm2 
 Cohort 3: 0.250 mg/mL MBN-101 = 5.0 µg/cm2 
The use of drains and vacuum assisted closure devices at the site of hardware will be allowed per 
surgeon preference. The drainage volume over the first 24 hours or prior to discontinuation of the 
drain will be recorded in the eCRF. 
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6.6 Study Assessments 
Each patient enrolled in the study will have an assessment at 48 hours following surgery and at 
Weeks 2, 6, 12, and 24. Study assessments will be performed according to Section 6.1 and 
Appendix 1. The Week 24 assessment will be the final assessment for adverse events. Any 
adverse events ongoing at the Week 24 assessment will be followed until resolution of the event 
or stabilization of the condition. 
6.7 Safety Monitoring 
Patients will be instructed to inform the Investigator and/or a member of the study staff of any 
adverse events that occur at any time during the study. Patients will be asked a general health 
question at each clinic visit to identify changes in the state of their health since their last study 
visit. 
6.8 Study Monitoring 
The Sponsor or the Sponsor’s designee will provide training on the protocol for the study site 
personnel prior to giving the site permission to begin enrollment. Once the enrollment and 
dosing phases of the study have begun, the Sponsor or the Sponsor’s designee will visit the site 
to monitor the clinical conduct of the trial, the adequacy of study documentation and compliance 
with safety reporting. Clinical site monitoring will continue on a periodic basis until the site has 
been closed or all patients at the site have completed the study. The frequency of monitoring 
visits may vary depending on enrollment at the study site. 
6.9 Patient Withdrawals 
Patients will be free to withdraw at any time for any reason, or they may be withdrawn if 
necessary to protect their health and safety or the integrity of the study. Any patient that is 
randomized but not treated will be replaced. The final report will include reasons for 
withdrawals. As this study involves a single administration of study drug, significant patient 
withdrawals are not anticipated. 
All efforts should be made to have subjects complete the Week 24 (end of study) procedures 
prior to withdrawal from the study. 
6.10 Individual Patient Stopping Rules 
Patients who develop adverse events at any time during the study will be treated appropriately 
according to standard of care. Adverse events will be assessed and followed as described in 
Section 9. As this is a single dose study with the investigational product applied directly into a 
surgical site, specific stopping rules for individual patients have not been established. 
6.11 Study Stopping Rules 
Patient enrollment on study will be stopped if the number of individual patients experiencing 
possibly-related or probably-related adverse events > Grade 2 exceeds 2 in any dose cohort or if 
there is any death on study. Should the study stopping rules be invoked, all safety data on all 
patients will be assembled for review by the Data Review Committee (DRC). The study will not 
resume until this information has been reviewed by the DRC and the Sponsor, discussed with the 
FDA, and concurrence reached with the FDA as to the resumption of the study. 
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7 CONCOMITANT MEDICATIONS 
All patients will receive their usual concomitant medications for any underlying medical 
conditions without interruption. Efforts should be made to maintain all concomitant medications 
at a stable dose for the duration of the 24 week study. Patients will also receive standard of care 
treatment for their postoperative fracture site infection that includes systemic antibacterial 
treatment per prevailing standard of care guidelines (i.e., national, institutional, or physician 
preference) and other indicated postoperative medications, including pain medications. All 
concomitant medications will be recorded in the CRF. Pain medication usage, including 
medication, dose, route, day and time of administration, will be recorded on a separate CRF. Use 
of any other bismuth-containing compounds is prohibited from Screening through Week 4. 
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8 STUDY ENDPOINTS 
8.1 Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
 Treatment-emergent adverse events. 
 Treatment-emergent serious adverse events. 
 Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
 Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
 Changes in physical exams. 
 Clinical findings of 12-lead electrocardiograms. 
 Change in microbiology status. 
8.2 Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
 Proportion of treatment failures. A treatment failure defined as a subject with non-healing 
or worsening status of their surgical site requiring serious intervention by Week 24. 
 Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 24. 
 Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed fracture 
site. 
 Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed fracture site by Week 24. 
 Time to removal of orthopedic hardware due to a healed fracture site. 
 Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
 Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
 Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale 
(VAS, 0-10 scale). 
 Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
 Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination.  
 Change in serologic markers CRP and ESR at each post baseline time point. 
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8.3 Pharmacokinetic Endpoint 
8.3.1 
Sample Collection and Handling 
Blood samples will be obtained to measure blood concentrations of Bismuth (Bi) as a surrogate 
for BisEDT. A pre-dose sample will be collected prior to administration of the investigational 
product. Blood will be drawn for PK samples at nominal 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 
(Day 3), 96 (Day 4), and 336 (Day 14) hr after application of MBN-101 to the surgical site. 
Documentation stating the exact time of blood sampling (4 mL per timepoint) in relation to the 
time of study drug administration will be collected and provided. 
Primary and back-up blood samples will be stored at -70°C.  
8.3.2 
Assay Methodology 
Bismuth (Bi) levels, a surrogate for BisEDT, will be assayed in whole blood using a validated 
inductively coupled plasma mass spectrometry (ICP-MS) assay performed by Medpace 
Bioanalytical Laboratories (Cincinnati, Ohio). The samples are prepared for analysis by 
digestion with nitric acid and H2O2 for 2 hours, followed by centrifugation and dilution in water 
with subsequent quantitation of Bi by ICP-MS analysis. 
A detailed method description, including validation, calibration and quality assurance 
procedures, will be included in the analytical report which will be part of the Final Study Report. 
8.3.3 
PK Analysis 
Bismuth (Bi) concentration data will be analyzed by noncompartmental analysis (NCA) with 
Phoenix™ WinNonlin® Version 6.4 or higher, using an extravascular administration model and 
actual sampling times. Interim analyses may use nominal sampling times. The following PK 
parameters will be derived from blood concentrations of Bi using extravascular 
noncompartmental PK analysis (as feasible): 
Tmax 
Time to maximum observed concentrations of Bi 
Cmax 
Maximum observed concentrations of Bi 
AUC0-t Area under the Bi concentration vs time curve from time zero to the time of the last 
measurable concentration. 
AUC0-∞ Area under the Bi concentration vs time curve from time zero and extrapolated to 
infinity. 
T1/2 
The apparent half-life of Bi after extravascular administration of BisEDT 
CL/F 
Apparent clearance after extravascular administration of BisEDT 
Vz/F 
Apparent volume of distribution after extravascular administration of BisEDT 
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9 ADVERSE EVENTS 
An adverse event is an undesirable medical occurrence (sign, symptom, or diagnosis) or 
worsening of a pre-existing medical condition (e.g., diabetes) that occurs after initiation of the 
investigational study whether or not it is considered to be related to the investigational product. 
A worsening of an existing medical condition is one that was present at Day 1 (e.g., diabetes) 
and became more severe, more frequent, or increased in duration during investigational product 
treatment. Clinically relevant abnormal results of diagnostic procedures including abnormal 
laboratory findings (e.g., requiring unscheduled diagnostic procedures or treatment measures, or 
resulting in withdrawal from the study) are considered to be AEs. 
All adverse events (AEs) will be recorded throughout the study, beginning when the subject 
signs the Informed Consent Form. 
A treatment-emergent adverse event (TEAE) is defined as any AE starting after the first dose of 
the investigational agent or placebo is administered. If the AE is present prior to the 
administration of the first dose of the investigational agent or placebo but increases in severity, it 
will also be considered a TEAE. 
Treatment-emergent adverse events will be recorded beginning with the first exposure to 
investigational product and continuing until the subject is discharged from the study due to 
completion or early termination. 
Adverse events will be categorized as local adverse events and as systemic adverse events. 
The Principal Investigator, or medically qualified designee, must completely and promptly 
record each AE on the appropriate CRF. The Principal Investigator should attempt, if possible, to 
establish a diagnosis based on the presenting signs and symptoms. In such cases, the diagnosis 
should be documented as the AE and not the individual sign/symptom. If a clear diagnosis 
cannot be established, each sign and symptom must be recorded individually. Once a diagnosis is 
established, the CRFs should be updated with the final diagnosis. 
Any adverse event ongoing at the time of study completion will be recorded and followed-up 
according to the safety procedures described in the following sections. 
9.1 Reporting and Following Adverse Events 
All AEs encountered during the study will be reported on the AE page of the CRF in a timely 
manner. All AEs should be followed in accordance with good medical practice until resolved or 
fully characterized. 
Serious adverse events: Section 9.4 presents the definition and reporting obligations for Serious 
Adverse Events (SAEs). After the initial report, a follow-up SAE Report Form should be filled 
out and sent to Medpace Clinical Safety within 24 hours. Updates are to be provided by the site 
as soon as relevant information (especially regarding outcome) is available. 
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9.2 Severity 
The Investigator must indicate the severity of the adverse event in the description of the adverse 
event. A severity category of mild, moderate, or severe, as defined below, should be determined 
and entered on the Adverse Events page of the Case Report Form (CRF). 
 
Mild (Grade 1): Transient or mild symptoms; no limitation in activity; no intervention 
required. The AE does not interfere with the participant’s baseline functioning level. It 
may be an annoyance. 
 
Moderate (Grade 2): Symptom results in mild to moderate limitation in activity; no or 
minimal intervention required. The AE produces some impairment of baseline 
functioning, but it is not hazardous to health. It is uncomfortable or an embarrassment. 
 Severe (Grade 3): Symptom results in significant limitation in activity; medical 
intervention may be required. The AE produces significant impairment of functioning or 
incapacitation. 
 Potentially Life-Threatening (Grade 4): Symptoms cause inability to perform basic self-
care functions immediately necessary to sustain life or require medical or operative 
intervention to prevent permanent impairment, persistent disability or death. 
9.3 Relationship to Clinical Trial Material 
The Investigator must document their opinion of the relationship of the event to the 
investigational product as follows: 
 
NONE: The event can be readily explained by the subject’s underlying medical condition, 
a concomitant therapy or other cause and the Investigator believes no relationship exists 
between the event and the investigational product. In this case, the Investigator should 
document the condition, concurrent/underlying illness, medication, study procedure or 
other cause they believe to be the cause of the adverse event. 
 
UNLIKELY: The event does not follow a reasonable temporal sequence from 
administration of the investigational product nor does the event follow a known or expected 
response pattern to the investigational product and may have another cause. In this case, 
the Investigator should document the condition, concurrent/underlying illness, medication, 
study procedure or cause they believe may have contributed to the adverse event. 
 
POSSIBLE: The subject’s condition, concurrent/underlying illness, medication, or study 
procedures cannot explain the event, and there is a plausible temporal relationship 
between the event and the investigational product administration. 
 PROBABLE: The temporal relationship between the administration of the investigational 
product and the adverse event strongly suggests a relationship, and/or the adverse event 
cannot be reasonably explained by another condition, concurrent/underlying illness, 
medication, study procedure or other cause, or the adverse event abates with 
discontinuation of the investigational product, and recurs with re-administration. 
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9.4 Serious Adverse Events 
To report SAEs in a timely manner, monitor subject care, and to fulfill regulatory requirements, 
SAEs (regardless of their relationship to the investigational product) must be reported to 
Medpace Clinical Safety within 24 hours of knowledge of the event by the Investigator or 
members of the study staff.  
9.4.1 
Definition 
SAEs are defined as those adverse events that meet any of the following criteria: 
 
Life threatening, that is, any event that, in the opinion of the Investigator, poses an 
immediate risk of death from that event 
 
Results in death 
 
Results in or prolongs hospitalization 
 
Results in persistent or significant disability/incapacity 
 
Results in congenital anomaly/birth defect 
In addition, events which may not meet these criteria, but, in the opinion of the Investigator, are 
very unusual, potentially serious, or require medical or surgical intervention to prevent one of the 
outcomes listed above, should also be reported in the same manner as events which meet the 
serious adverse event criteria.  
9.4.2 
Reporting 
Serious AEs require immediate reporting (within 24 hours of the site’s knowledge of the event) 
to Medpace Clinical Safety whether or not the Investigator believes that the experience is related 
to the investigational product. A completed SAE CRF signed by the Investigator must be faxed 
to Medpace Clinical Safety. Criteria for documenting the relationship to study product and 
severity will be the same as those previously described in Sections 9.2 and 9.3. 
SAEs must also be reported by the study site to the responsible IRB immediately. The 
Investigator is responsible for complying with the local IRB regulations regarding the reporting 
of AEs. 
Reporting of a suspected SAE should not be delayed in order to obtain additional information. 
Any additional information, if collected, can be reported as a follow-up to the initial report. Any 
SAE that occurs at any time during the study, whether or not related to the investigational 
product, must be reported to Medpace Clinical Safety.  
All possibly- and probably-related serious adverse events must be followed until the outcome is 
known or the event is otherwise explained. All serious adverse events that are not resolved at the 
end of the study are to be followed until resolution, the condition stabilizes, the event is 
otherwise explained, or the subject is lost to follow-up.  
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9.5 Pregnancies 
Pregnancies occurring after the first dose of investigational product are considered immediately 
reportable events. While not considered a serious adverse event unless a serious criterion is met, 
pregnancies occurring in subjects enrolled on the study must be reported and followed to 
outcome. The investigator should complete the pregnancy report form and fax it to Medpace 
Clinical Safety within one working day of knowledge of the pregnancy. Following delivery or 
termination of pregnancy, the follow-up pregnancy report form should be completed and 
submitted via fax to Medpace Clinical Safety. Spontaneous abortions should always be reported 
as SAEs. Follow-up information regarding the outcome of the pregnancy and any postnatal 
sequelae in the infant will be required. 
9.6 Data Review Committee (DRC) 
An independent Data Review Committee will be established to review unblinded clinical trial 
data prior to dose escalation and on an as-needed basis. A statistician, serving as a non-voting 
member to the DRC, will provide data preparation support to the DRC. A sponsor representative 
will also serve as a non-voting member of the DRC to facilitate sponsor internal planning. 
The primary role of the DRC will be to assess unblinded safety data on all patients in a dose 
cohort completing the Week 6 visit, and to determine whether dose escalation should occur. The 
DRC may recommend dose escalation, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
The DRC will also be asked to assess unblinded safety data on an as-needed basis. The Chair of 
the DRC will be informed by Microbion Corporation of the potential need for ad hoc meetings 
and will coordinate any ad hoc meeting with the remainder of the DRC members. The DRC may 
recommend no modifications to the study, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
A formal DRC Charter will be prepared and finalized prior to study enrollment. The DRC will 
meet prior to initiation of the clinical trial in order to review, revise and reach concurrence on the 
content of a DRC charter. The draft charter will be provided by Microbion Corporation to the 
DRC prior to the initial meeting. 
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10 INVESTIGATIONAL PRODUCT MANAGEMENT 
10.1 Study Drug 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied.  
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 18 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
5. Alcohol wipes 
6. One pre-printed "Diluted MBN-101 Drug Product" label 
7. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose” 
Additionally, each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
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10.2 Study Drug Packaging and Labeling 
All shipments of the investigational product will be accompanied by an inventory form. The 
contents of the shipments should be inventoried immediately upon receipt and confirmation of 
inventory shall be performed according to instructions provided by the clinical supplies 
distributor. 
The following information will be provided with each shipment of study drug: Sponsor name and 
contact information (telephone number), study protocol number, description of the contents of 
the container, conditions for storage, and a statement regarding the investigational (clinical trial) 
use of the study drug.  
Each package unit of the investigational product will be labeled with the following information: 
Sponsor name, study protocol number, description of the contents, a statement regarding the 
investigational (clinical trial) use of the study drug, and a packaging lot number.  
10.3 Study Drug Storage 
The investigational product should be kept in a limited-access area at 15-30 degrees C at the 
study site.  
10.4 Study Drug Accountability 
It is the responsibility of the Principal Investigator or his/her designee at each site to ensure that 
all investigational product quantities received at the site will be inventoried and reconciled 
throughout the study and the result recorded on the drug accountability form maintained in the 
study file. 
10.5 Study Drug Handling and Disposal 
Only qualified study personnel familiar with procedures that minimize undue exposure to 
themselves and to the environment should undertake the handling of pharmaceutical agents. 
The study monitor will verify that the disposition of all investigational materials at the trial site is 
in accordance with Sponsor specifications and applicable regulatory requirements. Requirements 
for disposition of used, unused, damaged/quarantined, and expired investigational materials will 
be provided to applicable site personnel. The study monitor will confirm associated 
documentation is filed in the Investigator site file and copies retrieved for the Sponsor or 
Sponsor-designee Investigator File. 
Used, damaged, and expired investigational materials will be destroyed as directed by the Study 
Monitoring Plan. Specific instructions of on-site destruction, return of materials to a 3rd party 
vendor, or any other mechanism of removal of the investigational materials from the site will be 
detailed in the Study Monitoring Plan. 
The study monitor will not take possession of investigational materials. Any deviations from this 
process must be approved in advance by the Sponsor or Sponsor-designee.  
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11 GENERAL CONSIDERATIONS 
11.1 Basic Principles 
This research will be carried out in accordance with the clinical research guidelines established 
by the Basic Principles defined in the U.S. 21 CFR Parts 50, 56, and 312, the principles 
enunciated in the Declaration of Helsinki concerning medical research in humans (“Ethical 
Principles for Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 
1975, Venice 1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, 
Washington 2002 and Tokyo 2004), and the Good Clinical Practice (GCP) guidelines of the 
International Conference on Harmonization (ICH) of the Technical Requirements for 
Registration of Pharmaceuticals for Human Use, ICH E6 (May 1996). 
11.2 Institutional Review Board 
Prior to initiation of any study procedures, the Clinical Study Protocol, Informed Consent Form, 
and Product Information will be submitted to the IRB for review and approval. In addition, any 
amendments to the protocol or informed consent document will be reviewed and approved (if 
necessary) by the IRB. The Principal Investigator (PI) at each clinical site assumes responsibility 
for ensuring that the protocol is submitted to the IRB for any required periodic review. The PI 
must receive a letter documenting the IRB approval at the clinical site prior to the initiation of 
the study. Any subsequent IRB correspondence must also be submitted to the investigator. The 
Investigator is responsible for providing the appropriate reports to the reviewing IRB during the 
course of the clinical study. This will include the following: 
 Informing the IRB of the study progress periodically as required, but at least annually 
 Reporting any unanticipated adverse product per IRB Policies & Procedures 
 Reporting any deviations from the clinical protocol to protect the life or well-being of a 
subject in the case of an emergency within 5 working days after the emergency occurred 
 Providing any other reports requested by the IRB 
After the final visit of the last subject, a final report will be sent to the IRB per their Policies & 
Procedures that includes a summary of the results of the study by the PI. 
The IRB must be constituted and operate in accordance with the principles and requirements 
described in the U.S. Code of Federal Regulations (21 CFR Part 56). 
11.3 Informed Consent 
The purpose of the study, the procedures to be carried out and the potential hazards will be 
described to the subjects in non-technical terms. Subjects will be required to read and sign a 
consent form summarizing the discussion prior to enrollment, and will be assured that they may 
withdraw from the study at any time without jeopardizing their medical care. 
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11.4 Study Termination 
The Investigator reserves the right to terminate the study in the interest of subject safety and 
welfare. The Sponsor reserves the right to terminate the study at any time for administrative 
reasons. 
11.5 Regulatory Documentation 
Documents that must be provided to the Sponsor prior to study drug shipment are as follows: 
 Up-to-date curriculum vitae for each investigator and sub-investigator 
 Signed and dated Investigator Agreement 
 Applicable local regulatory documentation (e.g., FDA 1572 Form) 
 A copy of the formal written notification to the investigator regarding approval of the 
protocol by an IRB that is in compliance with regulatory guidelines. The written 
notification is to be signed by the chairman or authorized designee and must identify the 
specific protocol. In cases where an IRB member has a known conflict of interest, 
abstention of that individual from voting should be documented; an investigator 
(or sub-investigator) may be a member of the IRB, but may not vote on any research in 
which he or she is involved. 
 Name and address of the IRB with a statement that it is organized and operates according 
to GCP and the applicable laws and regulations, and a current list of the IRB members. 
If accompanied by a letter of explanation from the IRB, a general statement may be 
substituted for this list. 
 A copy of the IRB approved informed consent form and other adjunctive materials 
(e.g., advertising) to be used in the study, including written documentation of IRB 
approval of these items. 
 Name and address of any local laboratory conducting tests for the study, a dated copy of 
the laboratory reference values for tests to be performed during the study and a copy of 
the certification or other documentation establishing adequacy of the facility. 
 Required financial agreement. 
In addition to the documents required prior to the study, other documentation may be required 
during the course of the study. 
11.6 Study Documentation 
All documents pertaining to the study, including a copy of the approved protocol, copy of the 
Informed Consent Form, and case report forms, will be retained in the permanent archives of the 
study site. These will be available for inspection at any time by the Sponsor or the U.S. Food and 
Drug Administration (FDA). 
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11.7 Data Handling and Record Keeping 
As electronic trial data handling and/or remote electronic trial data systems will be used, 
Microbion and/or its designee will: 
 Ensure and document that the electronic data processing system(s) conforms to the 
Sponsor’s established requirements for completeness, accuracy, reliability, and consistent 
intended performance 
 Maintain SOPs for using these systems 
 Ensure that the systems are designed to permit data changes in such a way that the data 
changes are documented and that there is no deletion of entered data (i.e., maintain an 
audit trail, data trail, edit trail) 
 Maintain a security system that prevents unauthorized access to the data 
 Maintain a list of the individuals who are authorized to make data changes 
 Maintain adequate backup of the data 
 Safeguard the blinding, if any (e.g., maintain the blinding during data entry and 
processing) 
Moreover: 
 An unambiguous subject identification code will be used that will allow identification of 
all the data reported for each subject 
 Microbion and/or its designee will retain all of the Sponsor-specific essential documents 
pertaining to the trial in conformance with the applicable regulatory requirement(s) of the 
country(ies) where the product is approved and/or where it intends to apply for approval  
 Specific essential documents will be retained until at least 2 years after the last approval 
of a marketing application in an ICH region and until there are no pending or 
contemplated marketing applications in an ICH region or at least 2 years have elapsed 
since the formal discontinuation of clinical development of the investigational product. 
These documents should be retained for a longer period, however, if required by the 
applicable regulatory requirement(s) or if needed by the Sponsor. 
 Microbion and/or its designee will inform the investigator(s)/institution(s) in writing of 
the need for record retention and should notify the investigator(s)/institution(s) in writing 
when the trial related records are no longer needed 
11.8 Use of Information and Publication 
All information concerning BisEDT, MBN-101, MBN-101 diluent, Microbion operations, patent 
applications, formulas, manufacturing processes, basic scientific data, and formulation 
information, supplied by the Sponsor to the investigator and not previously published, is 
considered confidential and remains the sole property of Microbion Corporation. The 
investigator agrees to use this information only to accomplish this study and will not use it for 
other purposes without the Sponsor’s written consent. 
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The investigator understands that the information developed in the clinical study will be used by 
Microbion in connection with the continued development of MBN-101 and BisEDT, and thus 
may be disclosed as required to other clinical investigators or government regulatory agencies. 
To permit the information derived from the clinical studies to be used, the investigator is 
obligated to provide the Sponsor with all data obtained in the study. 
Any publication or other public presentation of results from this study requires prior review and 
written approval of Microbion Corporation. Draft abstracts, manuscripts, and materials for 
presentation at scientific meetings should be provided to the Sponsor at least 30 working days 
prior to abstract or other relevant submission deadlines. Authorship of publications resulting 
from this study will be based on generally accepted criteria for major medical journals. 
11.9 Independent Medical Monitor 
In accordance with US Army Medical Research and Materiel Command (USAMRMC) and 
Department of Defense (DOD) requirements, an independent medical monitor will be identified. 
The independent medical monitor should be physicians, dentists, psychologists, nurses, or other 
healthcare providers capable of overseeing the progress of research protocols, especially issues 
of individual volunteer management and safety. The medical monitor must be independent of the 
investigative team and possess sufficient educational and professional experience to serve as the 
volunteer advocate. Depending on the nature of the study, the medical monitor may be assigned 
to assess one or more of the following phases of research project: volunteer recruitment, 
volunteer enrollment, data collection, or data storage and analysis. The medical monitor provides 
an independent evaluation of serious adverse events and unanticipated problems involving risk to 
subjects or others to the IRB and the Office of Research Protections (ORP). The medical monitor 
may be assigned to discuss research progress with the PI, interview volunteers, consult on 
individual cases, or evaluate adverse event reports. The medical monitor must promptly report 
discrepancies or problems to the IRB and the ORP. They shall have the authority to stop a 
research study in progress, remove individual volunteers from a study, and take whatever steps 
are necessary to protect the safety and well-being of research volunteers until the IRB can assess 
the medical monitor report. 
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12 STATISTICAL ANALYSIS METHODOLOGY 
A formal statistical analysis plan (SAP) will be prepared and finalized before database lock for 
the final analysis for the study report. The SAP will provide details regarding the definition of 
analysis subjects (populations), analysis variables and analysis methodology to meet all study 
objectives. 
The principle and key elements of the SAP are provided as follows: 
In general, safety and efficacy data will be summarized with descriptive statistics, including 
means, standard deviations, medians, minimums and maximums for continuous variables, the 
number of subjects and percent in each category for categorical variables.  
Data from all subjects randomized and treated with placebo in each cohort will be pooled for the 
analysis; data from the subjects randomized and treated with MBN-101 will be presented by dose 
as well as combined.  
Data from each individual will be tabulated as appropriate. Efficacy and safety endpoints will be 
tabulated by treatment group and time point.  
12.1 Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
 Proportion of treatment failures. A treatment failure is defined as a subject with 
non-healing or worsening status of their surgical site requiring serious intervention by 
Week 24. 
Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 24. 
 Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed fracture 
site.  
 Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed fracture site by Week 24. 
 Time to removal of orthopedic hardware due to a healed fracture site. 
 Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
 Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
 Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale (VAS, 
0-10 scale).  
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 Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
 Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination. 
 Changes in serologic markers CRP and ESR at each post baseline time point. 
12.2 Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
 Treatment-emergent adverse events. 
 Treatment-emergent serious adverse events. 
 Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
 Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
 Changes in physical exams. 
 Clinical findings of 12-lead electrocardiograms. 
 Change in microbiology status. 
12.3 Sample Size Considerations 
Sample size for this study was chosen empirically for the purpose of the study without any 
formal statistical hypothesis to be tested. 
Six subjects will receive active drug in each dose cohort. With 6 subjects receiving active drug, 
the probability of observing at least one of 6 subjects in a dose cohort exhibiting an AE of a 
specific type is 95% if the true background incidence rate for that event-type were approximately 
0.385 or greater. Hence, if an AE of a specific type is not observed in the study in a sample size 
of 6 subjects receiving active study drug at a given dose, one would “rule-out” this AE as having 
an incidence rate of more than 0.385 with 95% confidence. 
Similarly, if a rare event of interest is not reported in the 18 subjects treated with the active study 
drug, one could conclude that the rate of the event would be 0.153 or less with 95% confidence. 
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12.4 Analysis Datasets 
The following analysis datasets will be identified for the purpose of analysis:  
Screened Subjects: All subjects who signed informed consent for the study will be included in 
the Screened Subjects analysis set. 
Randomized Subjects: All subjects who were randomized in the study will be included in the 
Randomized Subjects analysis set. A randomized subject may or may not be treated with the 
assigned study drug. This is the classic Intent-to-Treat (ITT) analysis set. 
Treated Subjects: All subjects who received any amount of study drug (active or placebo) will be 
included in the Treated Subjects analysis set. All treated subject will be included in the safety 
analysis. This analysis set is also referenced as the Safety Analysis Set. 
Modified Intent-to-Treat (mITT) Subjects: the ITT subjects who received any amount of study 
(active or placebo) and have at least one post-treatment assessment will be included in the mITT 
analysis set. The mITT analysis set is the primary dataset for efficacy analysis. 
PK Concentration Subjects (i.e., PK Concentration Population): The PK Concentration 
Population will include all subjects with any measurable bismuth blood concentrations. 
PK Evaluable Subjects (i.e., PK Evaluable Population): The PK Evaluable Population will 
include all subjects providing sufficient measurable bismuth blood concentrations to facilitate 
determination of PK parameters. 
In the event that a subject received study drug treatment that is not the assigned/randomized 
treatment group, the subject has a major protocol deviation. The subject, however, will be 
included in the analysis for safety and efficacy in the actual treatment group received.  
Subjects randomized but not treated for any reason will be included in the disposition tabulation 
and will be excluded from the safety and efficacy analysis.  
12.5 Disposition and Study Population Characteristics 
Disposition summaries will be prepared to include number and percent of subjects screened, 
randomized, treated, subjects that completed the study and reason for discontinuation. Reason for 
screening failure will also be tabulated.  
Subject characteristics summaries will include demographics (age, gender, race, and ethnicity), 
baseline characteristics (weight, height, BMI), surgery site characteristics (type of injuries, type 
of fraction fixation, surgical site location), microbiology analysis results, time from previous 
surgery to study enrollment, and type of previous treatment), current surgery characteristics 
(area of the osteosynthesis site, with or without hardware replacement, etc.), and medical history.  
Disposition summary will be based on randomized treatment group (i.e., planned treatment) 
whereas the baseline characteristics summaries will be based on the actual treatment group.  
Subjects with protocol deviations will be identified. The nature of the deviation and potential 
impact on the deviation on study outcome will also be assessed.  
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12.6 Efficacy Analysis 
12.6.1 
Treatment Failure 
A treatment failure is defined as a subject with non-healing or worsening status of their surgical 
site requiring serious intervention by Week 24. 
The number of subjects meeting treatment failure criteria during the study will be tabulated by 
treatment group. If data permit, the difference in proportion of treatment failures between the 
groups and the corresponding 95% confidence intervals for the difference will be presented. 
Fisher’s exact test may be used to test the difference between the groups; difference in rates and 
95% confidence intervals for the relative risk will be derived. Dose-response assessment may be 
performed. 
12.6.2 
Incidence of Serious Interventions  
All interventions meeting the following criteria are serious interventions: 
 Initiation of antibiotic treatment in patient not previously on antibiotics 
 Change in the route of antibiotic administration from oral to intravenous for escalation of 
treatment 
 Change in the type or dosage of antibiotic drug for escalation of treatment 
 Readmission (exclusive of readmissions associated with a healed fracture site) 
 Reoperation (exclusive of reoperations associated with a healed fracture site) 
The number of subjects with at least one serious intervention (exclusive of serious interventions, 
readmissions, and reoperations associated with a healed fracture site) and total number of serious 
interventions will be tabulated for the following periods:  
 duration of the study;  
 within the first 4 weeks after the surgery; 
 from week 4 to week 8 
 from week 8 to week 12  
 from week 12 to week 24 
The difference between the placebo arm and the active arms will be evaluated as follows if data 
permits: Fisher’s exact test may be used to test the difference between the groups; difference in 
rates and 95% confidence intervals for the relative risk will be derived.  
Similar summaries will be prepared for incidence of re-admission and incidence of re-operation. 
Time elapsed between the initial hospital discharge to hospital readmission and between the 
operations will be derived and tabulated.  
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12.6.3 
Time to First Serious Interventions  
Time to the first serious intervention exclusive of serious interventions, readmissions, and 
reoperations associated with a healed fracture site will be derived. Time to first serious 
intervention will be calculated as the number of study days from the study surgery date to the 
event onset date plus 1. Subjects who do not have any serious intervention will be censored to 
the last observation date. 
No formal inferential statistics will be carried out for this endpoint. 
12.6.4 
Subjects Undergoing Removal of Stabilizing Orthopedic Hardware 
The number of subjects undergoing removal of hardware due to a healed fracture site and the 
time to removal of hardware due to a healed fracture site will be derived. Time to removal of 
hardware will be calculated as the number of study days from the study surgery date to the event 
date plus 1.  
12.6.5 
Surgical Site Signs and Symptoms 
The surgical site will be examined for local erythema, induration, drainage and degree of 
healing. 
Subjects with non-healing or worsening status of their surgical sites will be tabulated. 
12.6.6 
Patient-Report Outcomes 
12.6.6.1 The Veterans RAND 12 Item Health Survey (VR-12) Questionnaire  
The Veterans RAND 12 Item Health Survey (VR-12) is a brief, generic, multi-use, self-
administered health survey comprised of 12 items. The instrument is primarily used to measure 
health related quality of life, to estimate disease burden and to evaluate disease-specific 
benchmarks with other populations. The 12 items in the questionnaire correspond to eight 
principal physical and mental health domains including general health perceptions; physical 
functioning; role limitations due to physical and emotional problems; bodily pain; energy-
fatigue, social functioning and mental health (Selim, 2009; Veterans Affairs website, 2014). 
VR-12 total score, physical health domain score (PCS), and mental health domain score (MCS) 
will be tabulated by visit; change from baseline in total score, physical health domain score and 
mental health domain score will also be derived and tabulated.  
12.6.6.2 The Short Musculoskeletal Function Assessment Questionnaire (SMFA) 
The 46-item SMFA questionnaire comprises two parts: the dysfunction index with 34 items and 
the bother index with 12 items. The dysfunction index assesses the patient’s perceptions of the 
amount of difficulty they have in the performance of certain functions (25 items) and how often 
the patients have difficulty when performing certain functions (9 items). The dysfunction items 
are grouped into four categories: daily activities, emotional status, function of the arm and hand, 
and mobility. Each item has a 5-point response format (1 point for good function and 5 points for 
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poor function). The bother index asks the patients to assess how much they are bothered by 
problems in various areas of life (e.g., recreation, work, sleep and rest). These items also have a 
5-point response format (1 point for not at all bothered and 5 points for extremely bothered). 
The scores of the dysfunction and the bother indices are calculated by summing up the responses 
to the items and then transforming the scores according to the formula: (actual raw score - lowest 
possible raw score)/(possible range of raw score) ×100. 
This transformation formula gives the final scores, which ranged from 0 to 100. The higher 
scores indicate poorer function. In the case of the dysfunction index, unanswered items in a 
category are replaced by the individual’s mean score for that category, as long as more than 
50 per cent of the items in that category have been answered. Substitution with the mean is not 
appropriate for the bother index as each item addresses a unique area of function (Swiontkowski, 
1999; Short Musculoskeletal Function Assessment Injury and Arthritis Survey, 
www.grossortho.com/forms/injury.pdf). 
SMFA results and change from baseline will be summarized by visit and treatment group with 
descriptive statistics. 
12.6.7 
Pain Assessments 
Surgical site pain score utilizing a 24 hour recall will be assessed via Visual Analog Scale (VAS) 
(Burckhardt, 2003; Brokelman, 2012; Briggs, 1999) at baseline, and Weeks 2, 6, 12, and 24. 
Change in pain from baseline will be derived; observed pain score and change from baseline will 
be tabulated by visit and treatment group. 
12.6.8 
Microbiology 
Microbiology will be assessed at baseline and at the time of any subsequent surgical procedure at 
the index site. The presence of viable microorganisms will be determined by standard 
microbiological culture methods and include speciation and antimicrobial susceptibility testing 
of any bacterial isolates found (see flowchart, Appendix 2). Samples collected will include at 
least one tissue site (eraser head size; suitable for dividing into two samples) from the fracture 
site (if accessed) or involved tissue adjacent to the implant(s), two swabs of the infected 
hardware (in situ or ex vivo), two swabs of the deep infection site, and two swabs of the 
superficial tissue/wound closure site when possible. Duplicate specimens will be transported 
aerobically and anaerobically, respectively. Specimens will be processed by the local laboratory 
and the central laboratory as presented in Sections 6.1.9.3 and 6.1.9.2. 
Microorganisms isolated from each assessment will be listed. This information may also be used 
to identify potential subgroups. 
Microbiological success is assessed by clearance of infection. The proportion of subjects that 
meet the treatment success criteria per microbiologic evaluations will be identified and tabulated 
by each treatment group. 
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12.6.9 
Radiographic Evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6, 12, and 24. 
Radiographic success is assessed by healing on radiographic examination. The proportion of 
subjects that met the treatment success criteria per radiographic examination will be identified 
and tabulated by each treatment group. 
12.6.10 Serologic Markers 
Serology markers CRP and ESR will be assessed at baseline and Weeks 2, 6, 12, and 24. 
Serology markers CRP and ESR have been used together with clinical signs and symptoms for 
periprosthetic infection diagnosis. The values for each serologic marker and the number of 
subjects with normal or abnormal serologic marker values at each visit will be tabulated by 
treatment group.  
12.6.11 Subgroup Analyses for Efficacy Endpoints 
If data permit, the following potential covariates will be identified and subgroup analysis may be 
performed for those subgroups. 
1. 
Area of the osteosynthesis site 
2. 
Method of fracture fixation 
3. 
Type of infection (per identified microorganism) 
4. 
Anatomic location of the surgery site 
5. 
Hardware retention status (retained vs. exchanged) 
6. 
Influence of host factors 
7. 
Method of wound closure / wound management 
12.6.12 Sensitivity Analyses for Efficacy Endpoints 
The primary efficacy analysis set (mITT) will included all randomized subjects who received 
any amount of study drug and have at least one post-treatment assessment. In addition, in the 
event that a subject received treatment that is different from the assigned treatment, the subject 
will be included in the actual treatment received in the mITT analysis. 
An ‘as assigned’ analysis will be performed on the mITT subjects as a sensitivity analysis for the 
primary efficacy endpoint. In this analysis, subjects who received a treatment that is not the 
assigned treatment will be included in the ‘assigned’ treatment group for this analysis. 
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12.7 Safety Analysis 
12.7.1 
Study Drug Exposure and Concentrations 
Study drug exposure will be presented by treatment group. Descriptive statistics will be provided 
without any formal inferential statistics.  
12.7.2 
Adverse Events 
The Medical Dictionary for Regulatory Activities (MedDRA Version 16 or higher) will be used 
to classify all AEs with respect to system organ class (SOC) and preferred term. Summary of 
adverse events will include: 
1. Treatment emergent adverse events by SOC, preferred term, and intensity 
2. Treatment emergent adverse events by SOC, preferred term, and relationship to study 
drug  
3. All AEs leading to study discontinuation by SOC and preferred term 
4. All serious adverse events by SOC and preferred term 
Summary tables will provide total number of events and number of subjects with the event. 
The incidence and intensity of each pre-specified local AEs will be tabulated by visit and 
treatment groups. 
12.7.3 
Clinical Laboratory Tests 
Laboratory includes hematology, serology, serum chemistry, and urinalysis; laboratory collected 
prior to surgery will be the baseline laboratory. The study will utilize local lab for all clinical 
laboratory testing. Laboratory data will be tabulated based on the following result class. 
 Normal: result is within the local lab normal range 
 Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each lab test without formal inferential statistics. If data permits shift 
in result class from baseline to post baseline may also be tabulated. 
12.7.4 
12-lead ECG 
ECG findings at each time point will be tabulated by treatment group without inferential 
statistics. 
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12.7.5 
Vital Sign Measurements 
Vital signs collected immediately prior to receiving study drug will be the baseline vital signs. 
Observed vital sign values and change from baseline in vital signs at each visit will be 
summarized without formal statistical testing. 
Vital sign result may also be tabulated based on the following result class. 
 Normal: result is within the normal range 
 Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each vital sign. 
12.7.6 
Physical Examinations  
Findings of physical examinations will be tabulated by treatment groups without inferential 
statistics. 
12.7.7 
Subgroup Analyses for Safety Endpoints 
No subgroup analysis is planned for safety endpoints. 
12.8 PK Analysis 
Blood bismuth concentration vs. time profiles after administration of MBN-101 will be 
summarized for each nominal sampling time point and by dose group using descriptive statistics 
generated by WinNonlin. The NCA PK parameters (AUC0-t, AUC0-inf, Tmax, Cmax, T1/2, CL/F, 
Vz/F) will also be summarized with descriptive statistics (generated by WinNonlin) for each dose 
group as well as for all treated subjects in the PK Evaluable Population. 
If data permit, the correlation between Bismuth concentration and efficacy and/or safety 
endpoints may be explored. 
12.9 Interim Evaluation 
Interim analyses are planned for this study for the purpose of DRC. The purpose of the interim 
analysis is to allow the DRC to review the data and to make recommendation to the Sponsor on 
whether or not the next cohort of the subjects should be studied as planned.  
An analysis plan for the DRC will be prepared as an appendix of the DRC charter. The scope of 
the interim analyses for the DRC will be defined in this analysis plan. 
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13 REFERENCES 
1. Berkes M, Obremskey WT, Scannell B, Ellington JK, Hymes RA, Bosse M. Maintenance of 
hardware after early postoperative infection following fracture internal fixation. J Bone Joint 
Surg Am. 2010;92(4):823-28. 
2. Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and verbal rating 
scales for the assessment of post-operative pain in orthopedic patients. J Pain Symptom 
Manage. 1999:18(6);438-46. 
3. Brokelman RBG, Haverkamp D, van Loon C, Hol A, van Kampen A, Veth R. The validation 
of the visual analogue scale for patient satisfaction after total hip arthroplasty. Eur Orthop 
Traumatol. 2012;3(2):101–5. doi:10.1007/s12570-012-0100-3. PMCID: PMC3389603. 
4. Burckhardt CS, Jones KD. Adult measures of pain: The McGill Pain Questionnaire (MPQ), 
Rheumatoid Arthritis Pain Scale (RAPS), Short-Form McGill Pain Questionnaire (SF-MPQ), 
Verbal Descriptive Scale (VDS), Visual Analog Scale (VAS), and West Haven-Yale 
Multidisciplinary Pain Inventory (WHYMPI). Arthritis Rheum. 2003;49;S96-104. 
5. Ciofu O, Tolker-Nielson T. Antibiotic Tolerance and Resistance in Biofilms. In: Bjarnsholt 
T, Jensen PØ, Moser C, Høiby N, editors. Biofilm Infections. New York: Springer; 2011. 
pp 215-29. doi: 10.1007/978-1-4419-6084-9_13. 
6. Cummins JS, Tomek IM, Kantor SR, Furnes O, Engesaeter LB, Finlayson SR. 
Cost‑effectiveness of antibiotic-impregnated bone cement used in primary total hip 
arthroplasty. J Bone Joint Surg Am. 2009;91(3):634-41. PubMed PMID: 19255224. 
doi:10.2106/JBJS.G.01029. 
7. Ferry T, Uckay I, Vaudaux P, Francois P, Schrenzel J, Harbarth S. Laurent F, Bernard L, 
Vandenesch F, Etienne J, Hoffmeyer P, Lew D. Risk factors for treatment failure in 
orthopedic device-related methicillin-resistant Staphylococcus aureus infection. Eur J Clin 
Microbiol Infect Dis. 2010;29(2):171-80. 
8. Gessmann J, Kammler J, Schildhauer TA, Kaminski A. MRSA colonisation in patients with 
proximal femur fractures in a German trauma centre: incidence, infection rates and outcomes. 
Langenbecks Arch Surg. 2012;397(1):117-23. 
9. Ghigo J-M. Natural conjugative plasmids induce bacterial biofilm development. Nature. 
2001;412(26):442-5. 
10. Godil SS, Parker SL, O'Neill KR, Devin CJ, McGirt MJ. Comparative effectiveness and cost-
benefit analysis of local application of vancomycin powder in posterior spinal fusion for 
spine trauma: clinical article. J Neurosurg Spine. 2013;19(3):331-5. 
11. Gristina AG, Naylor P, Myrvik Q. Infections from biomaterials and implants: a race for the 
surface. Medical Progress Through Technology. 1988;14:205-24. 
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12. Gristina AG, Shibata Y, Giridhar G, Kreger A, Myrvik QN. The glycocalyx, biofilm, 
microbes, and resistant infection. Semin Arthroplasty. 1994;5(4):160-70. 
13. Heller A, McIff TE, Lai SM, Burton DC. Intrawound vancomycin powder decreases 
Staphylococcal surgical site infections following posterior instrumented spinal arthrodesis. 
J Spinal Disord Tech. Epub ahead of print 2013. PubMed PMID: 24189484. 
14. Hetrick EM, Schoenfisch MH. Reducing implant-related infections: active release strategies. 
Chem Soc Rev. 2006;35(9):780-9. 
15. Kwon A, Park G, Ryu S, Lim D, Lim D, Choi C, Park Y, Lim Y. Higher biofilm formation in 
multidrug-resistant clinical isolates of Staphylococcus aureus. Int J Antimicrob Ag. 
2008;32:68-72. 
16. Martin JR, Adogwa O, Brown CR, Bagley CA, Richardson WJ, Lad SP, Kuchibhatla M, 
Gottfried ON. Experience with intrawound vancomycin powder for spinal deformity surgery. 
Spine (Phila Pa 1976). Epub ahead of print 2013. PubMed PMID: 24158179. 
17. Morris BJ, Unger RZ, Archer KR, Mathis SL, Perdue AM, Obremskey WT. Risk factors of 
infection after ORIF of bichondylar tibial plateau fractures. J Orthop Trauma. 
2013;27(9):e196-e200. 
18. Nowinski RJ, Gillespie, RJ, Shishani Y, Cohen B, Walch G, Gobezie R. Antibiotic-loaded 
bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a 
retrospective, cohort study of 501 shoulders. J Shoulder and Elbow Surgery. 
2012;21(3):324-8. doi: 10.1016/j/jse.2011.08.072. 
19. Parra-Ruiz J, Vidaillac C, Rybak MJ.Macrolides and staphylococcal biofilms. Rev Esp 
Quimioter. 2012;25(1):10-16. 
20. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the 
tibia: current management concepts. Journal of the American Academy of Orthopaedic 
Surgeons. 2005;13(6):417-27. 
21. Reiter K, Da Silva Paim TG, De Oliveira CF, D’Azevedo PA. High biofilm production by 
invasive multiresistant staphylococci. Acta Pathologica Microbiologica et Immunologica 
Scandinavia. 2011;119:776-81. 
22. Robson MC. Wound infection. A failure of wound healing caused by an imbalance of 
bacteria. Surg Clin North Am. 1997;77(3):637-50. 
23. Robson MC. Award recipient address: Lessons gleaned from the sport of wound watching. 
Wound Repair Regen. 1999;7(1):2-6. 
24. Salgado CD, Dash S, Cantey JR, Marculescu CE. Higher risk of failure of methicillin-
resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res. 
2007;461:48-53. 
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25. Schmidt AH, Swiontkowski MF. Pathophysiology of infections after internal fixation of 
fractures. Journal of the American Academy of Orthopaedic Surgeons. 2000;8(5):285-91. 
26. Selhi HS, Mahindra R, Yamin M, Jain D, De Long WG, Singh J. Outcomes in patients with 
an infected nonunion of the long bones treated with a reinforced antibiotic cement rod. 
J Orthop Trauma. 2012;26(3):184-8. 
27. Selim AJ, Rogers W, Fleishman JA, Qian SX, Fincke BG, Rothendler JA, Kazis LE. 
Updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12). 
Qual Life Res. 2009;18(1):43-52. doi: 10.1007/s11136-008-9418-2. Epub 2008 Dec 3. 
28. Short Musculokeletal Function Assessment Injury and Arthritis Survey; 
http://www.grossortho.com/forms/injury.pdf, accessed 05-16-2014. 
29. Swiontkowski MF, Engelberg R, Martin DP, Angel J. Short musculoskeletal function 
assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am. 
1999;81(9):1245-60. 
30. Tosh PK, McDonald LC. Infection control in the multidrug-resistant era: tending the human 
microbiome. Clin Infect Dis. 2012;54(5);707-13. 
31. Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic only versus 
local intrawound vancomycin antibiotic powder application in addition to intravenous 
antibiotics on postoperative infection in spine surgery in 907 patients. Spine (Phila Pa 1976), 
2013;38(25):2149-55. doi:10.1097/BRS.0000000000000015. PubMed PMID: 24048091. 
32. U.S. Department of Veterans Affairs [internet]. Washington: U.S. Department of Veterans 
Affairs; last updated 21 January 2014. Health Economics Resource Center: Cost-Effective 
Analysis. Available from: http://www.herc.research.va.gov/include/page.asp?id=cost-
effectiveness-analysis#vr36. 
33. Zalavras CG Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop 
Surg. 2003;11(3):212-9. 
 
 
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14 APPENDICES 
Appendix 1: 
Table of Study Events ............................................................................................62 
Appendix 2: 
Flowchart for Microbiological Specimen Processing ............................................63 
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Appendix 1: Table of Study Events 
 
 
Procedure 
Screening 
Baseline/ 
Day of Surgery 
Hour 48- 60 
Hour 72 
Hour 96 
Week 2 
Week 6 
Week 12 
Week 24, EOT 
Early Term / 
Tx Failure 
Day 1 
Day 2 
Day 3 
Day 4 
Day 14 
±4 days 
Day 42 
±8 days 
Day 84 
±8 days 
Day 168 
±8 days 
Review of eligibility criteria 
X 
X 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
Surgery/Administration of the 
Investigational Product 
 
X 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
 
 
 
 
Interval physical exam 
 
X 
X 
 
 
X 
X 
X 
X 
X 
Hematology 
X 
 
X 
 
 
 
X 
X 
X 
X 
Serology 
 
X 
 
 
 
X 
X 
X 
X 
X 
Serum chemistry 
X 
 
X 
 
 
 
X 
X 
X 
X 
Urinalysis 
X 
 
X 
 
 
 
X 
X 
X 
X 
Pregnancy test 
X 
X 
 
 
 
 
 
 
X 
X 
BisEDT Blood levels1 
 
X 
X 
X 
X 
X 
 
 
 
 
12-lead ECG 
X 
X 
X 
 
 
 
 
 
X 
X 
Vital signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Patient-reported outcomes2 
X 
 
 
 
 
X 
X 
X 
X 
X 
Surgical site signs and symptoms 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Surgical site pain score 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Microbiology 
 
X 
(X)3 
 
 
(X) 
(X) 
(X) 
(X) 
(X) 
Radiographic evaluation 
 
X 
 
 
 
X 
X 
X 
X 
X 
Concomitant medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
1 PK blood samples will be collected pre-dose and at nominal 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 (Day 3), 96 (Day 4) and 336 (Day 14; Week 2) hours after administration of the 
investigational product 
2 Patient-reported outcomes include the Veterans Rand 12 Item Health Survey (VR-12) and Short Musculoskeletal Function Assessment (SMFA) 
3 Microbiology will be performed at any time that a new surgical intervention is required. 
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Appendix 2: Flowchart for Microbiological Specimen Processing 
 
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PROTOCOL AMENDMENT FORM 
DATE: 05/09/16 
AMENDMENT NUMBER: 03 
PROTOCOL NUMBER: MBN-101-201 (Version 3) 
 
SPONSOR: Microbion Corporation 
 
PROTOCOL TITLE: A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week Escalating Dose 
Study to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally Applied 
MBN-101 to Infected Osteosynthesis Sites 
 
REASON(S) FOR CHANGE(S): Revise protocol with administrative changes and updated methodologies. 
Modified eligibility criteria to increase enrollment rate. 
 
CHANGE(S): 
Note – All changes refer to page numbers in the clean Version 3.0 
 
Location 
From 
To 
Comment 
Header 
Version 2.1, 
Issue Date 29 December 2015 
Version 3.0, 
Issue Date 05 May 2016 
Update version 
Page 1 
Version 2.1 
Issue Date: 29 December 2015 
 
Replaces Version 2.0 
Dated 08 October 2015 
Version 3.0, 
Issue Date 05 May 2016 
 
Replaces Version 2.1 
Dated 29 December 2015 
Update version 
Page 1 
Version: 2.1 
Version: 3.0 
Update version 
Pages 
4, 23 
Number of Sites 
 
 
Increase enrollment rate 
3-4 
Up to eight 
Pages 
4, 22 
Study Design and Methodology 
 
Increase enrollment rate 
 
This is a randomized, single-blind, 
… with an apparent fracture site 
infection within one year of the last 
surgical intervention.  
This is a randomized, single-blind, 
… with an apparent fracture site 
infection. 
Pages 
5, 25 
Inclusion Criteria 
 
Increase enrollment rate 
 
are diagnosed with an apparent 
fracture site infection within 
one year of their last surgical 
intervention and have at least 
one of the following: 
 
are diagnosed with an apparent 
fracture site infection and have 
at least one of the following: 
Pages 
6, 26 
Exclusion Criteria 
Increase enrollment rate 
deleted 
2. Greater than one year time lapse from last operative procedure 
3. Patients with a previous revision surgery at the site 
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PROTOCOL AMENDMENT FORM 
DATE: 05/09/16 
AMENDMENT NUMBER: 03 
PROTOCOL NUMBER: MBN-101-201 (Version 3) 
Location 
From 
To 
Comment 
Page 38 
8.3.2 Assay Methodology 
 
Update methodology 
 
The samples are prepared for 
analysis by digestion with 2% nitric 
acid and H2O2, followed by 
centrifugation and dilution with 
water into 2% Tetramethyl 
Ammonium Hydroxide (TMAH) 
with 0.02% Triton X-100, and 
subsequent quantitation of Bi by 
ICP-MS analysis. 
The samples are prepared for 
analysis by digestion with nitric 
acid and H2O2 for 2 hours, followed 
by centrifugation and dilution in 
water with subsequent quantitation 
of Bi by ICP-MS analysis. 
Page 38 
8.3.3 PK Analysis 
 
Update methodology 
Bismuth (Bi) concentration data 
will be analyzed by 
noncompartmental analysis (NCA) 
with Phoenix™ WinNonlin® 
Version 6.3 or higher, using an 
extravascular administration model 
and actual sampling times. The 
following PK parameters will be 
derived from blood concentrations 
of Bi using extravascular 
noncompartmental PK analysis: 
Bismuth (Bi) concentration data 
will be analyzed by 
noncompartmental analysis (NCA) 
with Phoenix™ WinNonlin® 
Version 6.4 or higher, using an 
extravascular administration model 
and actual sampling times. Interim 
analyses may use nominal 
sampling times. The following PK 
parameters will be derived from 
blood concentrations of Bi using 
extravascular noncompartmental 
PK analysis (as feasible): 
Page 50 
12.1 Efficacy Endpoints and 
12.2 Safety Endpoints 
 
Correct placement of last 
efficacy endpoint and 
section heading for safety 
endpoints. 
12.2 Changes in serologic markers 
CRP and ESR at each post baseline 
time point. Safety Endpoints 
 
Changes in serologic markers 
CRP and ESR at each post 
baseline time point. 
 
12.2 Safety Endpoints 
 
Page 63 
Appendix 2: Flowchart for 
Microbiological Specimen 
Processing 
 
Correct description of 
specimen for deep swab to 
be consistent with 
description in 6.1.9.1 
Specimen Collection 
Swabs (Deep) 
(2) Superficial tissue / 
wound closure site 
Swabs (Deep) 
(2) Peri-implant deep tissue 
 
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1 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 
24-week Escalating Dose Study to Assess the Safety, Tolerability 
and Clinical Activity of 3 Concentrations of Locally Applied MBN-101 
to Infected Osteosynthesis Sites 
PROTOCOL NUMBER: MBN-101-201 
Version 3.0 Issue Date: 05 May 2016 
Replaces Version 2.1 Dated 29 December 2015 
Regulatory Sponsor: 
Microbion Corporation 
1102 West Babcock, Suite B 
Bozeman MT 59715 
Version: 3.0 
Microbion Corporation 
 
Reviewed and Approved by: 
 
 
 
05 May 2016 
Dr. Brett Baker 
Microbion Corporation 
President and Chief Scientific Officer 
 
Date 
Confidentiality 
This document is the confidential property of Microbion Corporation. 
No part of it may be reproduced, published, or transmitted by other persons 
without written permission of Microbion Corporation. 
 
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GRANT SUPPORT 
This Phase 2a clinical study is supported in part by a $2.5 million grant awarded through the 
"Defense Medical Research and Development Program (DMRDP) Military Infectious Diseases 
Clinical Trial Award, W81XWH-12-DMRDP-MID-CTA". The grant award number is 
W81XWH-12-2-0100.  
The Awardee is the University of Pennsylvania, and the Principal Investigator (PI) for this grant 
award is Dr. Samir Mehta, Chief, Division of Orthopaedic Trauma, and Assistant Professor of 
Orthopaedic Surgery at the Hospital of the University of Pennsylvania. Dr. Mehta is also serving 
as the clinical PI for the University of Pennsylvania orthopaedic trauma clinical site. 
Participating as a Co-Investigator in this grant award is Dr. Saam Morshed, attending 
orthopaedic trauma surgeon and Director of the Clinical Research Center at the University of 
California San Francisco (UCSF) and the San Francisco General Hospital Orthopaedic Trauma 
Institute (OTI). Dr. Morshed will also serve as the clinical PI for the UCSF orthopaedic trauma 
clinical site.  
The Program Sponsor, Microbion Corporation, is represented by Dr. Brett Baker, President and 
Chief Scientific Officer. 
 
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INVESTIGATOR AGREEMENT 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week Escalating Dose Study 
to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally 
Applied MBN-101 to Infected Osteosynthesis Sites 
I have read the protocol and agree that it contains all necessary details for carrying out the study 
as described. I will conduct this protocol as outlined therein and will make all reasonable efforts 
to complete the study within the designated time. 
I will provide copies of the protocol and access to all information furnished by Microbion 
Corporation to study personnel under my supervision. I will discuss this material with them to 
ensure that they are fully informed about the drug and the study. 
I understand that the study may be terminated or enrollment suspended at any time by Microbion 
Corporation with or without cause, or by me, if it becomes necessary to protect the best interests 
of the study subjects. 
I agree to conduct this study in accordance with the requirements of this protocol and in 
accordance with the following: 
 Good Clinical Practice: Consolidated Guideline International Conference on Harmonisation 
of Technical Requirements for the Registration of Pharmaceuticals for Human Use, ICH E6 
(May 1996) 
 United States (U.S.) Code of Federal Regulations (CFR) associated with clinical studies 
(21 CFR parts 50, 56, 312) 
 Declaration of Helsinki, concerning medical research in humans (“Ethical Principles for 
Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 1975, Venice 
1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, Washington 
2002 and Tokyo 2004). 
 
  
Investigator’s Printed Name 
  
Investigator’s Signature 
 Date 
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PROTOCOL SYNOPSIS 
Protocol Number 
MBN-101-201 
Title 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week 
Escalating Dose Study to Assess the Safety, Tolerability and Clinical 
Activity of 3 Concentrations of Locally Applied MBN-101 to Infected 
Osteosynthesis Sites 
Regulatory Sponsor 
Microbion Corporation, 1102 West Babcock, Suite B, Bozeman MT 59715 
Name of 
Investigational 
Product 
MBN-101 
Phase 
2a 
Investigators/Study 
Centers 
Up to eight Study Centers in the United States  
Objectives: 
Primary Objective 
To evaluate the safety and tolerability of single escalating doses of locally 
administered MBN-101 or placebo as adjunct to standard of care 
antimicrobial and surgical therapy 
Secondary Objectives  
To evaluate the clinical activity of single escalating doses of locally 
administered MBN-101 
 
To evaluate the pharmacokinetics of single escalating doses of locally 
administered MBN-101 
Number of Subjects 
36 
Study Design and 
Methodology 
This is a randomized, single-blind, placebo-controlled, multi-center study to 
assess the safety and tolerability of single escalating doses of MBN-101 
applied directly to target structures within infected osteosynthesis sites during 
revision surgery with or without hardware removal and replacement for 
patients diagnosed with an apparent fracture site infection. Three successive 
cohorts of 12 patients will be enrolled in this trial. Consecutive patients from 
each of the study sites will be screened for potential participation as they 
present to the orthopedic service for clinical care for their postoperative 
infections. Patients meeting eligibility criteria on screening will be offered 
participation in the study. 
Following baseline evaluation, patients will receive standard of care 
treatment for their postoperative fracture site infection that includes systemic 
antibacterial treatment per institutional standard of care guidelines and 
revision surgery with or without hardware removal and replacement as 
indicated. A single application of MBN-101 or placebo, applied 
intraoperatively directly to target structures within infected osteosynthesis 
sites, will be performed following the final irrigation and debridement 
procedure and immediately prior to definitive closure. In cases where original 
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hardware is retained, MBN-101 will be applied to all accessible surfaces of 
hardware and adjacent bone (target structures). In cases where hardware is 
replaced or in cases of two-stage procedures, MBN-101 will be applied to all 
accessible surfaces of hardware and adjacent bone (target structures) 
following implantation of hardware and immediately prior to definitive 
closure. If wounds are left open, the investigational product will be applied 
immediately prior to definitive closure. The minimum amount of MBN-101 
required to achieve a thin coat of the relevant target structures within the 
infected osteosynthesis site will be used. 
Patients will be randomized 3:1 (active:control) to three successive doses 
(0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up 
to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent). Enrollment to the 
next dose cohort will not commence until an evaluation by the Data Review 
Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort. 
PK assessments will be performed predose and at nominal 1, 6, 12, 24, 36, 48 
(Day 2), 60, 72 (Day 3), 96 (Day 4), and 336 (Day 14; Week 2) hours after 
administration of study drug. 
Patients will undergo study visits at Hour 48 and Weeks 2, 6, 12, and 24. All 
patients will be followed for a total of 24 weeks after surgery. 
Study Population: 
Inclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “YES” answer (unless not applicable): 
1. Patients who: 
 
have had operative fracture fixation of the upper extremity 
(AO/OTA class 15, 11-13, 21-23), lower extremity (AO/OTA class 
31-34, 41-44, 81, 82) or pelvis (61, 62), or have undergone 
arthrodesis 
 
are diagnosed with an apparent fracture site infection and have at 
least one of the following: 
 
Elevated ESR above the upper limit of normal 
 
Elevated CRP above the upper limit of normal 
 
Draining wound / sinus tract 
 
Positive culture from site of prior surgery by aspirate or other 
modality 
 
Local erythema or induration at the site of prior surgery 
 
Exposed hardware 
 
Periosteal reaction on x-ray 
 
Loose or broken hardware  
 
require revision surgery with or without removal and replacement of 
existing hardware 
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2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed 
and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as 
per institution’s standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after 
revision surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile 
or at least 2 years postmenopausal, must agree to use one of the 
following forms of contraception from screening through the Week 24 
visit: hormonal (oral, implant, or injection) begun >30 days prior to 
screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications 
and they must ensure their female sexual partner complies with the 
contraception requirements:  
 
Be sexually abstinent from Baseline through Week 24  
 
Be > 6 months post-vasectomy  
 
Agree to use a condom with spermicide from Baseline through 
Week 24 
7. Have read and signed the Informed Consent Form (ICF) after the nature 
of the study has been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of 
personal health information in accordance with Health Insurance 
Portability and Accountability Act (HIPAA) 
Exclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “NO” answer (unless not applicable): 
1. Patients who are no longer hardware dependent or are definitively treated 
for their infection by hardware removal without replacement 
2. Patients with multiple, non-contiguous fracture site infections 
3. Pathologic fracture (not including osteoporosis)  
4. Patient requires immunosuppressive therapy (Topical or inhaled 
corticosteroids are permitted) 
5. Serum creatinine, ALT, AST or Alkaline Phosphatase >1.5 times the 
upper limit of the normal range of the local testing laboratory 
6. Absolute neutrophil count <1000 
7. Patients without definitive soft-tissue coverage over the surgical site at 
time of study product administration 
8. Any condition that has required treatment with any other bismuth 
containing compound within the last 2 weeks (i.e., Kaopectate or 
Pepto-Bismol) 
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9. Participation in an investigational trial to evaluate pharmaceuticals or 
biologics within the past 3 months 
10. Individuals undergoing surgical treatment for more than one infected 
fracture 
11. Known allergy to metals or materials comprising the orthopedic 
hardware, bismuth and/or MBN-101 excipients (methylcellulose, 
Tween 80 (polysorbate 80)) 
12. Patients who are pregnant, lactating, or female patients who have a 
positive serum hCG as determined by laboratory testing 
13. Immunocompromised due to illness or organ transplant 
14. History of chronic or recurrent infections (≥ 3 infections at the same site 
within 12 months) other than the index infected osteosynthesis site 
15. History of any type of cancer (excluding non-melanomatous localized 
skin cancer or completely excised and cured carcinoma-in-situ of uterine 
cervix) 
16. Poorly controlled diabetes mellitus (hemoglobin A1c > 9.0% for 
≥ 6  months despite management by a physician) 
17. History of medical noncompliance 
18. Other medical conditions which, in the opinion of the Principal 
Investigator, would jeopardize the safety of the study subject or impact 
the validity of the study results. 
19. Current incarceration 
Investigational 
Product, Dose and 
Mode of 
Administration: 
MBN-101: A suspension of 0.025, 0.075, or 0.25 mg/mL (w:v) BisEDT 
powder in 3% methylcellulose / 0.5% Tween 80 / 10 mM sodium chloride / 
10 mM sodium phosphate, pH 7.4 (up to 8 mL dose volume) applied directly 
to structures within infected osteosynthesis sites during revision surgery with 
or without hardware removal and replacement as an adjunct to standard care 
systemic antimicrobial therapy. 
Reference Therapy, 
Dose and Mode of 
Administration: 
MBN-101 diluent (placebo): 3% methylcellulose / 0.5% Tween 80 / 
10 mM sodium chloride / 10 mM sodium phosphate, pH 7.4 (up to 8 mL dose 
volume) applied directly to structures within infected osteosynthesis sites 
during revision surgery with or without hardware removal and replacement 
as an adjunct to standard care systemic antimicrobial therapy. 
Study Duration 
24 weeks 
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Criteria for Evaluation: 
Efficacy Endpoints 
 
Proportion of treatment failures. A treatment failure is defined as a 
subject with non-healing or worsening status of their surgical site 
requiring serious intervention by Week 24. 
 
Cumulative number of serious interventions (as defined in Section 
12.6.2) at Week 24. 
 
Time to first serious intervention, time to readmission and time to 
reoperation, exclusive of serious interventions, readmissions, and 
reoperations associated with a healed fracture site. 
 
Number of subjects undergoing removal of stabilizing orthopedic 
hardware due to a healed fracture site by Week 24. 
 
Time to removal of orthopedic hardware due to a healed fracture site. 
 
Incidence and intensity of surgical site signs and symptoms, including 
local erythema, induration, drainage and degree of healing. 
 
Change from baseline in patient-reported outcomes at each post baseline 
time point. Patient-reported outcomes will include Veterans Rand 12 
Item Health Survey (VR-12) and Short Musculoskeletal Function 
Assessment (SMFA). 
 
Surgical site pain score and change from baseline in pain score at each 
post baseline time point. Pain intensity at the surgical site will be 
assessed by Visual Analog Scale (VAS, 0-10 scale). 
 
Findings of microbiology evaluations at the surgical site. Microbiologic 
success is assessed by clearance of infection. 
 
Findings of radiographic evaluations at the surgical site. Radiographic 
success is assessed by healing on radiologic examination. 
 
Changes in serologic markers CRP and ESR at each post baseline time 
point. 
Safety Endpoints 
 
Treatment-emergent adverse events. 
 
Treatment-emergent serious adverse events. 
 
Changes in clinical laboratory tests (clinical chemistry, hematology, and 
urinalysis). 
 
Changes in vital signs (blood pressure, pulse, respiratory rate and body 
temperature). 
 
Changes in physical exams. 
 
Clinical findings of 12-lead electrocardiograms. 
 
Change in microbiology status 
Pharmacokinetic 
Endpoints 
 
Whole blood concentrations of Bismuth (Bi) will be measured after 
administration of single escalating doses of MBN-101 (bismuth as a 
surrogate for BisEDT) and will be used to calculate pharmacokinetic 
parameters (i.e., Tmax, Cmax, AUC0-t, AUC0- ∞, T1/2, CL/F, Vz/F). 
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Statistical Methods: 
Statistical Analysis 
Consideration: 
The study sample of size of 36 subjects was chosen empirically for the 
purpose of the study without considering any formal statistical hypothesis 
testing. 
The safety analysis set will include all subjects who are randomized and 
receive any study drug; the efficacy analysis set will include all randomized 
subject with at least one post treatment assessment. Pharmacokinetic analysis 
set will include all subjects who have sufficient plasma samples to allow for 
calculation of pharmacokinetic parameters.  
All safety and efficacy endpoints will be tabulated with descriptive statistics; 
data from all placebo subjects (3 per cohort; 9 subjects in total) will be 
pooled. Data from BisEDT treated subjects will be presented by dose 
(9 subjects per dose) and combined (a total of 27 subjects). If data permits, 
differences between the treatment groups and 95% confidence intervals for 
the difference will be presented. 
If data permit, exploratory dose-response analyses will be performed for 
selected efficacy and safety endpoints.  
The primary analyses of efficacy and safety endpoints will be based on the 
actual treatment received in the event that the received treatment is not the 
assigned treatment; however, ‘as assigned’ sensitivity analyses are planned to 
evaluate the robustness of the efficacy data. 
 
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SPONSOR CONTACT INFORMATION 
Medical Monitor 
Name: 
Brian Murphy, MD 
Sr. Medical Director, Medpace Infectious Diseases 
Office Phone Number: 
513-579-9911, ext. 2416 
Mobile Phone Number: 
859-619-0037 
E-mail: 
b.murphy1@medpace.com 
Other Appropriate Trial Contact Personnel 
Name 
Ronnie McAdams 
Clinical Trial Manager, Associate Director, Medpace 
Office Phone Number 
513-579-9911, ext. 2845 
Mobile Phone Number 
513-394-0516 
Fax 
513-579-0444 
E-mail: 
r.mcadams@medpace.com 
Medpace Clinical Safety:  
SAE hotline: 
800-730-5779, ext. 2999 
Facsimile: 
866-336-5320 
E-mail: 
medpace-safetynotification@medpace.com 
 
If any Sponsor contact information needs to be changed during the course of the study, this will 
be done by the Sponsor, with written notification to the Investigator, and will not require a 
protocol amendment. 
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LIST OF ABBREVIATIONS 
AE 
Adverse event 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase (Serum glutamic pyruvic transaminase [SGPT]) 
AO/OTA 
Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association 
AST 
Aspartate aminotransferase (Serum glutamic oxaloacetic transaminase [SGOT]) 
AUC0-∞ 
Area under the curve from time 0 to infinity 
AUC0-t 
Area under the curve from time 0 to the time of the last measurable concentration 
Bi 
Bismuth, used as a surrogate in concentration and PK analyses after MBN-101 
administration 
BisEDT 
Bismuth-1,2-ethanedithiol 
BMI 
Body mass index 
BUN 
Blood urea nitrogen 
CFR 
Code of Federal Regulations 
CK 
Creatinine kinase 
CL/F 
Apparent clearance after extravascular administration  
CLSI 
Clinical and Laboratory Standards Institute 
Cm 
Centimeter 
Cmax 
Maximum observed concentration 
CRF 
Case report form 
CRP 
C-reactive protein 
DFU 
Directions for Use 
DOD 
Department of Defense 
DRC 
Data Review Committee 
ECG 
Electrocardiogram 
ESBL 
Extended spectrum beta lactamase 
ESR 
Erythrocyte sedimentation rate 
FDA 
U.S. Food and Drug Administration 
GCP 
Good Clinical Practice 
GGT 
Gamma glutamyl transferase 
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hCG 
Human chorionic gonadotropin 
HIPAA 
Health Insurance Portability and Accountability Act 
ICF 
Informed Consent Form  
ICH 
International Conference on Harmonization  
ICP-MS 
Inductively coupled plasma mass spectrometry 
IHMA 
International Health Management Associates, Inc. 
IRB 
Institutional Review Board  
ITT 
Intent to treat 
IUD 
Intrauterine device 
IV 
Intravenous 
IVRS 
Interactive Voice Response System 
Kg 
Kilogram 
MBN-101 
Bismuth-1,2-ethanedithiol (BisEDT) suspension 
MC 
Methylcellulose 
MCS 
Mental health domain score 
MCV 
Mean corpuscular volume 
MDR 
Multidrug Resistant 
MedDRA 
Medical Dictionary for Regulatory Activities 
mg 
milligram 
mg/mL 
Milligrams per milliliter 
MIC 
Minimal inhibitory concentration 
mITT 
Modified intent to treat 
mL 
Milliliter 
mm 
Millimeter 
mM 
Millimolar 
MRSA 
Methicillin resistant Staphylococcus aureus 
MRSE 
Methicillin resistant Staphylococcus epidermidis 
MSSA 
Methicillin-sensitive Staphylococcus aureus 
NCA 
Non-compartmental (PK) analysis 
ng/mL 
Nanograms per milliliter 
OR 
Operating room 
ORP 
Office of Research Protections 
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PCS 
Physical health domain score 
PI 
Principal investigator 
PK 
Pharmacokinetics 
PT 
Prothrombin time 
PTT 
Partial thromboplastin time 
QIDP 
Qualified Infectious Disease Product 
RBC 
Red blood cells 
SAE 
Serious Adverse Event 
SAE CRF 
Serious Adverse Event Case Report Form 
SAP 
Statistical Analysis Plan 
SGOT 
Serum glutamic oxaloacetic transaminase 
SGPT 
Serum glutamic pyruvic transaminase 
SMFA 
Short Musculoskeletal Function Assessment 
SOC 
System organ class 
SOP 
Standard Operating Procedure 
T1/2 
Apparent half-life after extravascular administration 
TEAE 
Treatment-emergent adverse event 
Tmax 
Time of the maximal observed concentration 
USAMRMC US Army Medical Research and Materiel Command 
VAS 
Visual Analog Scale 
VR-12 
Veterans Rand 12 Item Health Survey 
Vz/F 
Apparent volume of distribution after extravascular administration 
w/v 
Weight:volume 
w:w 
Weight:weight 
WBC 
White blood cells 
 
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TABLE OF CONTENTS 
Grant Support .................................................................................................................................. 2 
Investigator Agreement ................................................................................................................... 3 
Protocol Synopsis............................................................................................................................ 4 
Sponsor Contact Information ........................................................................................................ 10 
List of Abbreviations .................................................................................................................... 11 
1 
INTRODUCTION ................................................................................................................18 
1.1 
Clinical Problem .......................................................................................................18 
1.2 
Investigational Therapy ............................................................................................19 
1.3 
Value of MBN-101 for the Treatment of the Clinical Problem ................................20 
2 
OBJECTIVES .......................................................................................................................21 
2.1 
Primary ......................................................................................................................21 
2.2 
Secondary ..................................................................................................................21 
3 
INVESTIGATIONAL PLAN ...............................................................................................22 
3.1 
Study Description......................................................................................................22 
3.2 
Number of Subjects...................................................................................................23 
3.3 
Number of Sites ........................................................................................................23 
3.4 
Clinical Trial Material ...............................................................................................23 
3.4.1 
MBN-101 .....................................................................................................23 
3.4.2 
Placebo (MBN-101 diluent) ........................................................................23 
3.5 
Dose ..........................................................................................................................24 
4 
STUDY POPULATION .......................................................................................................25 
4.1 
Inclusion Criteria ......................................................................................................25 
4.2 
Exclusion Criteria .....................................................................................................26 
5 
SUBJECT ENROLLMENT .................................................................................................27 
5.1 
Medical History ........................................................................................................27 
5.2 
Physical Exam ...........................................................................................................27 
5.3 
Studies .......................................................................................................................27 
5.4 
Laboratory Tests at Screening Visit ..........................................................................27 
6 
STUDY PROCEDURES ......................................................................................................28 
6.1 
Description of Study Procedures ..............................................................................28 
6.1.1 
Medical History ...........................................................................................28 
6.1.2 
Physical Exams ............................................................................................28 
6.1.3 
Vital Signs ...................................................................................................28 
6.1.4 
12-lead ECG ................................................................................................28 
6.1.5 
Laboratory Tests ..........................................................................................28 
6.1.6 
BisEDT (MBN-101) Blood Levels .............................................................29 
6.1.7 
Pain Assessments ........................................................................................29 
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6.1.8 
Patient Reported Outcomes .........................................................................29 
6.1.9 
Microbiology ...............................................................................................29 
6.1.9.1 
Specimen Collection ...................................................................29 
6.1.9.2 
Specimen Processing: Local Laboratory ....................................29 
6.1.9.3 
Specimen Processing: IHMA (Central Laboratory) ...................30 
6.1.9.4 
Integration of Local Site Laboratory and Central Laboratory 
Primary Isolation and Identification Results ..............................30 
6.1.10 Radiographic Evaluation .............................................................................31 
6.1.11 Surgical Site Signs and Symptoms Evaluation ...........................................31 
6.2 
Screening and Baseline Assessments ........................................................................31 
6.3 
Randomization Procedure .........................................................................................31 
6.4 
Unblinding Procedure ...............................................................................................32 
6.5 
Investigational Product Administration ....................................................................32 
6.5.1 
Surgical Site Identification ..........................................................................32 
6.5.2 
Study Drug Administration .........................................................................32 
6.6 
Study Assessments ....................................................................................................35 
6.7 
Safety Monitoring .....................................................................................................35 
6.8 
Study Monitoring ......................................................................................................35 
6.9 
Patient Withdrawals ..................................................................................................35 
6.10 
Individual Patient Stopping Rules ............................................................................35 
6.11 
Study Stopping Rules ................................................................................................35 
7 
CONCOMITANT MEDICATIONS ....................................................................................36 
8 
STUDY ENDPOINTS ..........................................................................................................37 
8.1 
Safety Endpoints .......................................................................................................37 
8.2 
Efficacy Endpoints ....................................................................................................37 
8.3 
Pharmacokinetic Endpoint ........................................................................................38 
8.3.1 
Sample Collection and Handling .................................................................38 
8.3.2 
Assay Methodology .....................................................................................38 
8.3.3 
PK Analysis .................................................................................................38 
9 
ADVERSE EVENTS ............................................................................................................39 
9.1 
Reporting and Following Adverse Events ................................................................39 
9.2 
Severity .....................................................................................................................40 
9.3 
Relationship to Clinical Trial Material .....................................................................40 
9.4 
Serious Adverse Events ............................................................................................41 
9.4.1 
Definition .....................................................................................................41 
9.4.2 
Reporting .....................................................................................................41 
9.5 
Pregnancies ...............................................................................................................42 
9.6 
Data Review Committee (DRC) ...............................................................................42 
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10 
INVESTIGATIONAL PRODUCT MANAGEMENT .........................................................43 
10.1 
Study Drug ................................................................................................................43 
10.2 
Study Drug Packaging and Labeling ........................................................................44 
10.3 
Study Drug Storage ...................................................................................................44 
10.4 
Study Drug Accountability .......................................................................................44 
10.5 
Study Drug Handling and Disposal ..........................................................................44 
11 
GENERAL CONSIDERATIONS ........................................................................................45 
11.1 
Basic Principles .........................................................................................................45 
11.2 
Institutional Review Board .......................................................................................45 
11.3 
Informed Consent......................................................................................................45 
11.4 
Study Termination ....................................................................................................46 
11.5 
Regulatory Documentation .......................................................................................46 
11.6 
Study Documentation................................................................................................46 
11.7 
Data Handling and Record Keeping .........................................................................47 
11.8 
Use of Information and Publication ..........................................................................47 
11.9 
Independent Medical Monitor ...................................................................................48 
12 
STATISTICAL ANALYSIS METHODOLOGY ................................................................49 
12.1 
Efficacy Endpoints ....................................................................................................49 
12.2 
Safety Endpoints .......................................................................................................50 
12.3 
Sample Size Considerations ......................................................................................50 
12.4 
Analysis Datasets ......................................................................................................51 
12.5 
Disposition and Study Population Characteristics ....................................................51 
12.6 
Efficacy Analysis ......................................................................................................52 
12.6.1 Treatment Failure ........................................................................................52 
12.6.2 Incidence of Serious Interventions ..............................................................52 
12.6.3 Time to First Serious Interventions .............................................................53 
12.6.4 Subjects Undergoing Removal of Stabilizing Orthopedic Hardware .........53 
12.6.5 Surgical Site Signs and Symptoms ..............................................................53 
12.6.6 Patient-Report Outcomes ............................................................................53 
12.6.6.1 The Veterans RAND 12 Item Health Survey (VR-12) 
Questionnaire ..............................................................................53 
12.6.6.2 The Short Musculoskeletal Function Assessment 
Questionnaire (SMFA) ...............................................................53 
12.6.7 Pain Assessments ........................................................................................54 
12.6.8 Microbiology ...............................................................................................54 
12.6.9 Radiographic Evaluation .............................................................................55 
12.6.10 Serologic Markers .......................................................................................55 
12.6.11 Subgroup Analyses for Efficacy Endpoints ................................................55 
12.6.12 Sensitivity Analyses for Efficacy Endpoints ...............................................55 
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12.7 
Safety Analysis .........................................................................................................56 
12.7.1 Study Drug Exposure and Concentrations ..................................................56 
12.7.2 Adverse Events ............................................................................................56 
12.7.3 Clinical Laboratory Tests ............................................................................56 
12.7.4 12-lead ECG ................................................................................................56 
12.7.5 Vital Sign Measurements ............................................................................57 
12.7.6 Physical Examinations ................................................................................57 
12.7.7 Subgroup Analyses for Safety Endpoints ....................................................57 
12.8 
PK Analysis ..............................................................................................................57 
12.9 
Interim Evaluation ....................................................................................................57 
13 
REFERENCES .....................................................................................................................58 
14 
APPENDICES ......................................................................................................................61 
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1 INTRODUCTION 
1.1 Clinical Problem 
Postoperative orthopedic infections, particularly antibiotic-resistant infections, present a serious 
clinical challenge to surgeons and other treating physicians, since these infections involve 
foreign materials (stabilizing orthopedic hardware) which are frequently associated with 
persistent microbial biofilms (Hetrick, 2006). Surgical intervention, including irrigation, 
debridement and potential replacement of orthopedic hardware, combined with a prolonged 
course of systemic antibiotics, is the standard of care for postoperative infections (Schmidt, 
2000; Patzakis, 2005). However, outcomes associated with these infections are often poor, 
including chronic/recurrent infections, repeated hospitalizations, repeated surgeries, multiple 
courses of systemic antibiotic treatment, loss of function, disability, amputation and death 
(Berkes, 2010). 
Systemic antibiotics are poorly efficacious in the treatment of heavily contaminated or infected 
wounds (Zalavras, 2003; Robson, 1997) and often antibiotics “…have practical and potential 
value only if a therapeutic blood level or, more importantly, tissue level is achieved within the 
first 4 hours after wounding” (Robson, 1999), i.e., before biofilm formation. The ‘contest’ 
between bacteria and host tissues with respect to speed of colonization of foreign objects such as 
orthopedic medical devices has been described as the “race for the surface’ (Gristina, 1988). 
Bacteria are able to adhere to foreign, implanted objects almost immediately, facilitating rapid 
formation of microbial biofilms which drastically increase the resistance of wound-associated 
bacteria and contribute significantly to persistence and virulence of the infection (Parra-Ruiz, 
2012; Gristina, 1994). Such biofilms can serve as quiescent reservoirs of adherent, antibiotic-
tolerant or antibiotic-resistant bacteria within the wound, or as foci of active infections, which 
helps to explain the chronic and/or recurrent nature of many device-related infections. In 
addition, biofilms are hypermutable (Ciofu, 2011), increasing the likelihood of developing 
genetically-based antibiotic resistance. Finally, biofilms serve as environments in which bacteria 
can exchange genetic material encoding antibiotic resistance genes (Ghigo, 2001). Recent studies 
have shown that the most highly multidrug resistant (MDR) bacteria are also the strongest 
biofilm-forming bacteria (Kwon, 2008), and similarly, that invasive MDR bacteria are usually 
biofilm-forming bacteria (Reiter, 2011). 
The high incidence of postoperative orthopedic device-related infections, as well as the 
shortcomings of the standard of care treatment in resolving those infections, particularly 
considering the increasing prevalence of antibiotic-resistant pathogens, has resulted in an 
expanding unmet need for safe, innovative, new and effective therapies to reduce the infectious 
risks and consequences of these infections, which increasingly involve antibiotic- resistant 
strains (Gessman, 2012; Morris, 2013; Tosh, 2012). Antibiotic resistance adds significantly to 
the challenge of successfully resolving these orthopedic infections (Ferry, 2010; Salgado, 2007). 
For example, infection treatment failures are nine times more frequent in orthopedic patients 
with MRSA infections than methicillin-sensitive S. aureus (MSSA) infections (Salgado, 2007).  
Development of local therapies that eradicate established biofilms or prevent the formation of 
biofilms (as a new target) is an innovative new clinical strategy, particularly considering the 
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shortcomings of systemically administered antibiotics for treatment of wound infections. For 
example, several groups have investigated the direct, local application of vancomycin powder on 
the surgical wound in combination with systemic prophylaxis to prevent or treat infection. The 
outcomes of these studies have been mixed, with some groups reporting a reduced infection rate 
and/or a reduction in patient treatment costs (Heller, 2013; Godil, 2013) and others reporting no 
benefit (Tubaki, 2013; Martin, 2013). Antibiotic-loaded bone cement containing tobramycin, 
gentamicin, or vancomycin/tobramycin or other antibiotic combinations have been investigated 
for their ability to reduce infection rates and /or reduce costs when applied locally in a variety of 
orthopedic surgical procedures (Cummins, 2009; Nowinski, 2012; Selhi, 2012). Evidence 
suggests that local therapies may reduce implant related surgical site infections. 
1.2 Investigational Therapy 
MBN-101 [Bismuth-1,2-ethanedithiol (BisEDT) suspension] represents the first drug product 
from a new class of antimicrobial agents with apparently unique mechanisms of action. In 
nonclinical models, BisEDT has been shown to be effective against a broad-spectrum of 
orthopedic device-associated bacteria including antibiotic-resistant strains. 
BisEDT has several characteristics especially suited to the treatment of postoperative orthopedic 
infections: 
a) Broad spectrum antimicrobial activity against the most critically important antibiotic-
resistant bacteria, including MRSA, MRSE, antibiotic-resistant Pseudomonas 
aeruginosa, ESBL-positive Klebsiella pneumoniae, and antibiotic-resistant Enterobacter 
species. 
b) Apparently unique mechanisms of action. 
c) Anti-biofilm capabilities. 
d) Extremely low spontaneous mutation frequency, superior to many conventional 
antibiotics. 
e) Efficacy against both aerobic and anaerobic bacteria. 
f) Demonstrated lack of interference with the activity of a wide range of antibiotics. 
g) Enhanced activity in combination with specific antibiotics; in some cases synergy, has 
been demonstrated in vitro and in vivo. 
h) Maintenance of antimicrobial activity in the presence of excessive protein. 
i) A favorable safety and tolerability profile in nonclinical toxicology studies in a variety of 
species, including absence of effect on wound healing or bone repair 
j) A favorable safety and tolerability profile in a clinical Phase 1 study evaluating topical 
administration. 
Based in part on these characteristics, BisEDT has been granted Qualified Infectious Disease 
Product (QIDP) designation by the FDA for the local, intra-operative treatment of resistant post-
surgical orthopedic implant infections. 
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1.3 Value of MBN-101 for the Treatment of the Clinical Problem  
The broad-spectrum antimicrobial, anti-biofilm activity of BisEDT, its activity against relevant 
antibiotic-resistant pathogens, and its ability to enhance the activity of certain other antibiotics 
are properties that will promote more rapid and/or more complete eradication of infection, and 
reduce infectious risks to patients. With comparatively elevated rates of postoperative infection 
associated with repair of traumatic orthopedic wounds, the development of a new and innovative 
treatment strategy to complement the current standard of care would therefore be expected to 
result in a substantial reduction in mortality, amputation, morbidity, and disability, along with a 
reduction in patient treatment costs. 
MBN-101 provides important potential advantages over current standard of care treatment for 
orthopedic infections. Direct, local contact of MBN-101 with infected target tissue and 
contaminated device surfaces immediately delivers a therapeutically active dose of BisEDT to 
the site of infection. Combined antimicrobial and anti-biofilm effects are achieved with minimal 
systemic exposure. Systemic antibiotics administered alone are frequently ineffective, in part 
because altered perfusion at the surgical wound site hinders effective and timely delivery of 
systemic antibiotics, making it difficult to reach therapeutic antibiotic levels at wound 
tissues/surfaces. The combined effect of IV administered antibiotics, which already serve as a 
pillar of the current standard of care for orthopedic device-related infections, along with the local 
administration of MBN-101, is expected to eradicate bacteria from postoperative orthopedic 
wounds, and will ultimately also serve to reduce the likelihood of development of antibiotic-
resistant bacteria. By reducing the time to resolution of infection and improving the ability of 
current antibiotic therapies to effectively control and eliminate post-surgical orthopedic device-
related infections, MBN-101 will contribute to reductions in the number of additional serious 
interventions needed to resolve infections including reduction in repeat surgeries, additional 
rounds of systemic antibiotics, patient hospitalization time, morbidity and mortality in both 
civilian and military populations. 
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2 OBJECTIVES 
2.1 Primary 
To evaluate the safety and tolerability of single escalating doses of locally administered 
MBN-101 or placebo as adjunct to standard of care antimicrobial and surgical therapy. 
2.2 Secondary 
 To evaluate the clinical activity of single escalating doses of locally administered MBN-101. 
 To evaluate the pharmacokinetics of single escalating doses of locally administered 
MBN-101. 
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3 INVESTIGATIONAL PLAN 
3.1 Study Description 
This is a randomized, single-blind, placebo-controlled multi-center study to assess the safety and 
tolerability of escalating doses of MBN-101 applied directly to target structures within infected 
osteosynthesis sites during revision surgery with or without hardware removal and replacement 
for patients diagnosed with an apparent fracture site infection. Three successive cohorts of 12 
patients will be enrolled in this trial. Consecutive patients from each of the study sites will be 
screened for potential participation as they present to the orthopedic service for clinical care for 
their postoperative infections. After signing an Informed Consent Form (ICF), subjects will 
complete screening procedures. Patients meeting all eligibility criteria on screening will be 
offered participation in the study. Patients accepting participation in the study will be 
randomized 3:1 (active:control) to three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of 
MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent). 
Enrollment to the next dose cohort will not commence until an evaluation by the Data Review 
Committee (DRC) of all available safety data on all patients through Week 6 of study supports 
escalation to the next cohort. The DRC will monitor all safety data in an ongoing manner from 
all patients enrolled onto this study. 
Following baseline evaluation, patients will receive standard of care treatment for their post-
operative fracture site infection that includes systemic antibacterial treatment per institutional 
standard of care guidelines and revision surgery with or without hardware removal and 
replacement as indicated. Multiple debridements, soft tissue transfer, and revision fixation 
procedures may be performed prior to definitive closure. A single application of the 
investigational product, MBN-101 or placebo, applied intraoperatively directly to target 
structures within infected osteosynthesis sites, will be performed following the final irrigation 
and debridement procedure and immediately prior to definitive closure. In cases where original 
hardware is retained, the investigational product will be sparingly applied to all accessible 
surfaces of hardware and adjacent bone. In cases where hardware is replaced or in cases of two-
stage procedures, MBN-101 will be applied to all accessible surfaces of hardware and adjacent 
bone (target structures) following implantation of hardware and immediately prior to definitive 
closure. The volume applied will be determined by the surgeon’s assessment of the size (in cm2) 
of the target area, and guided by the Table in Section 6.5.2. If wounds are left open, the 
investigational product will be applied immediately prior to definitive closure. The minimum 
amount of MBN-101 required to achieve a thin coat of the relevant target structures within the 
infected osteosynthesis site will be used (see Section 6.5.2). 
All patients will receive standard postoperative care per institutional guidelines, and will be 
discharged from the hospital in accordance with local standards. Patients will undergo study 
visits at Hour 48 and Weeks 2, 6, 12, and 24. All patients will be followed for a minimum of 
24 weeks after surgery. 
See Appendix 1 for a Schedule of Activities. 
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3.2 Number of Subjects 
Thirty-six adult male or female patients meeting protocol-specified eligibility criteria may 
participate in the study, with the objective of having a total of 9 patients per dose level in the 
MBN-101-treated group and 9 patients in a pooled placebo-treated group. Patients who are 
randomized but do not receive study drug may be replaced. 
3.3 Number of Sites 
Up to eight U.S. study sites are anticipated to enroll an adequate number of eligible patients. 
 
3.4 Clinical Trial Material 
Patients will be randomized 3:1 (active:control) to three successive doses (0.025, 0.075, or 
0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 2.0 mg, respectively) 
or placebo (diluent). Enrollment to the next dose cohort will not commence until an evaluation 
by the Data Review Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort.  
3.4.1 
MBN-101 
MBN-101 is Bismuth-1,2-ethanedithiol (BisEDT) suspension (0.025, 0.075, or 0.25 mg/mL, 
w:v) in diluent (3% methylcellulose / 0.5% Tween 80 / 10mM sodium chloride / 10 mM sodium 
phosphate, pH 7.4). 
 
 
Structural Formula 
Molecular Formula 
C6H12S6Bi2 
Molecular Weight 
694.51 g/mol 
Stereochemistry/Chirality 
BisEDT has no chiral centers. 
 
3.4.2 
Placebo (MBN-101 diluent) 
Placebo is MBN-101 diluent comprised of 3% methylcellulose / 0.5% Tween 80 / 10mM sodium 
chloride / 10 mM sodium phosphate, pH 7.4. 
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3.5 Dose 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
Investigational product kits (MBN-101 and placebo) configured for each dose cohort will be 
provided and will contain the supplies necessary for preparation of the specified concentrations 
of MBN-101 or placebo for administration to each patient. 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the Stock Formulation and Diluent 
provided in the Drug Product Kit according to the Directions for Use (DFU) provided. The 
Treatment Dose will be provided to the surgeon in a vial from which an 8 mL volume will be 
drawn up in the operating room into a sterile 10 mL syringe. Surgeons will be instructed to use 
sufficient volume (up to the full 8 mL provided for the largest exposed target areas) to sparingly 
coat the bone at the site of infection, the exposed surfaces of any retained hardware, and the 
surfaces of any new hardware to be implanted. With dose volume determined according to 
Section 6.5.2, the volume of MBN-101 required to achieve a thin coat of the relevant structures 
within the infected osteosynthesis site will be applied. Following application, OR personnel will 
record in the CRF the actual volume (in tenths of milliliters) of any unapplied Treatment Dose 
remaining in the syringe. 
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4 STUDY POPULATION 
The study population will include 36 male or female adults who meet all of the study entry 
requirements. 
4.1 Inclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “YES” answer 
(unless not applicable): 
1. Patients who: 
 have had operative fracture fixation of the upper extremity (AO/OTA class 15, 11-13, 
21-23), lower extremity (AO/OTA class 31-34, 41-44, 81, 82) or pelvis (61, 62), or 
have undergone arthrodesis 
 are diagnosed with an apparent fracture site infection and have at least one of the 
following: 
 Elevated ESR above the upper limit of normal 
 Elevated CRP above the upper limit of normal 
 Draining wound / sinus tract 
 Positive culture from site of prior surgery by aspirate or other modality 
 Local erythema or induration at the site of prior surgery 
 Exposed hardware 
 Periosteal reaction on x-ray 
 Loose or broken hardware  
 require revision surgery with or without removal and replacement of existing hardware 
2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as per institution’s 
standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after revision surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile or at least 
2 years postmenopausal, must agree to use one of the following forms of contraception 
from screening through the Week 24 visit: hormonal (oral, implant, or injection) begun 
>30 days prior to screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications and they must 
ensure their female sexual partner complies with the contraception requirements:  
 Be sexually abstinent from Baseline through Week 24  
 Be > 6 months post-vasectomy  
 Agree to use a condom with spermicide from Baseline through Week 24 
7. Have read and signed the Informed Consent Form (ICF) after the nature of the study has 
been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of personal health 
information in accordance with Health Insurance Portability and Accountability Act 
(HIPAA) 
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4.2 Exclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “NO” answer 
(unless not applicable): 
1. Patients who are no longer hardware dependent or are definitively treated for their 
infection by hardware removal 
2. Patients with multiple, non-contiguous fracture site infections 
3. Pathologic fracture (not including osteoporosis)  
4. Patient requires immunosuppressive therapy (Topical or inhaled corticosteroids are 
permitted) 
5. Serum creatinine, ALT, AST or Alkaline Phosphatase >1.5 times the upper limit of the 
normal range of the local testing laboratory 
6. Absolute neutrophil count <1000 
7. Patients without definitive soft-tissue coverage over the surgical site at time of study 
product administration 
8. Any condition that has required treatment with any other bismuth containing compound 
within the last 2 weeks (i.e., Kaopectate or Pepto-Bismol) 
9. Participation in an investigational trial to evaluate pharmaceuticals or biologics within the 
past 3 months 
10. Individuals undergoing surgical treatment for more than one infected fracture 
11. Known allergy to metals or materials comprising the orthopedic hardware, bismuth 
and/or MBN-101 excipients (methylcellulose, Tween 80 (polysorbate 80)) 
12. Patients who are pregnant, lactating, or female patients who have a positive serum hCG 
as determined by laboratory testing 
13. Immunocompromised due to illness or organ transplant 
14. History of chronic or recurrent infections (≥ 3 infections at the same site within 
12 months) other than the index infected osteosynthesis site 
15. History of any type of cancer (excluding non-melanomatous localized skin cancer or 
completely excised and cured carcinoma-in-situ of uterine cervix) 
16. Poorly controlled diabetes mellitus (hemoglobin A1c > 9.0% for ≥ 6 months despite 
management by a physician) 
17. History of medical noncompliance 
18. Other medical conditions which, in the opinion of the Principal Investigator, would 
jeopardize the safety of the study subject or impact the validity of the study results. 
19. Current incarceration  
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5 SUBJECT ENROLLMENT 
Potential patients will undergo screening medical history and physical examination. If they are 
deemed appropriate candidates for study, they will be asked to provide appropriate informed 
consent. After informed consent is signed additional baseline evaluation will be performed, 
including but not limited to clinical laboratory assessment, radiographic evaluation, 
electrocardiogram (ECG) and pregnancy test if applicable. Only patients with an acceptable 
medical history and physical exam, ECG without clinically significant abnormalities, and 
laboratory results within acceptable limits will be randomized in the study. Randomization will 
occur using an IVRS system immediately after a patient has met all study entry criteria. 
5.1 Medical History 
Medical history and demographic data, including gender, date of birth, ethnicity, and race will be 
recorded. 
5.2 Physical Exam 
Each patient will receive a physical examination (head, ears, eyes, nose, throat, chest, heart, 
abdomen, and skin) including vital signs, weight (kg), and height (cm). Each patient will also 
receive a detailed evaluation of the index fracture site and involved extremity. 
5.3 Studies 
Following signing of the informed consent form, each patient will undergo all screening 
evaluations as provided in the Table of Study Events. These evaluations should be completed no 
more than 2 weeks prior to surgery date; after a screened subject is confirmed to be eligible for 
the study, this qualified subject will be randomized prior to surgery to receive the investigational 
product. 
5.4 Laboratory Tests at Screening Visit 
Hematology White blood cells (WBC), red blood cells (RBC), hemoglobin, hematocrit, platelet count, 
MCV, absolute neutrophils, absolute lymphocytes, absolute monocytes, absolute 
eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, blood urea nitrogen (BUN), glucose, 
creatinine, total protein, albumin, total bilirubin, direct bilirubin, alkaline phosphatase 
(ALP), AST (SGOT), ALT (SGPT), GGT, creatinine kinase (CK), calcium, magnesium, 
Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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6 STUDY PROCEDURES 
See the Table of Study Events outlining study procedures in Appendix 1. For the study site visit 
at Week 2, a visit window of + 4 days will be allowed; for study site visits Weeks 6 – 24, a visit 
window of ± 8 days will be allowed. 
6.1 Description of Study Procedures 
6.1.1 
Medical History 
A comprehensive medical history will be taken on all patients at Screening, including but not 
limited to past medical history, past surgical history, current medications, allergic history and 
psychosocial history. 
6.1.2 
Physical Exams 
A comprehensive physical examination will be performed on all patients at Screening, including 
assessments of height, weight, head, ears, eyes, nose, throat, chest, heart, abdomen, and skin. 
Interval physical exams will be performed at all subsequent study visits according to the 
schedule in Appendix 1 and will focus on the surgical site, with assessments of local erythema, 
induration, drainage and degree of healing. 
6.1.3 
Vital Signs 
Vital signs include blood pressure, pulse, respiratory rate and body temperature; vital signs will 
be assessed according to the schedule in Appendix 1. 
6.1.4 
12-lead ECG 
Testing will be conducted at screening, baseline, and 48 hours. The ECG trace will be stored at 
the investigational sites as source document; clinical interpretation, including normal, abnormal 
but not clinically significant, and abnormal and clinically significant, will be determined by the 
investigator and reported on the CRFs.  
6.1.5 
Laboratory Tests 
All clinical laboratory tests will be performed by the local clinical site laboratory. 
Blood and urine will be collected for hematology, serology, serum chemistry, urinalysis, and 
pregnancy testing (as indicated) according to the schedule in Appendix 1. 
Hematology WBC, RBC, hemoglobin, hematocrit, platelet count, MCV, absolute neutrophils, absolute 
lymphocytes, absolute monocytes, absolute eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, BUN, glucose, creatinine, total protein, 
albumin, total bilirubin, direct bilirubin, alkaline phosphatase (ALP), AST (SGOT), ALT 
(SGPT), GGT, creatinine kinase (CK), calcium, magnesium, Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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6.1.6 
BisEDT (MBN-101) Blood Levels 
BisEDT levels in whole blood after MBN-101 administration will be assessed with a qualified 
Inductively Coupled Plasma Mass Spectrometry (ICP-MS) assay method using bismuth as a 
surrogate for BisEDT according to the schedule in Appendix 1. 
6.1.7 
Pain Assessments 
Pain related specifically to the surgical site (Surgical Site Pain Score) will be assessed via a 
Visual Analog Scale (VAS, 0-10 scale, where 0=no pain at all and 10 =the worst possible pain) 
utilizing a 24 hour recall at screening, baseline, Hour 48 and Weeks 2, 6, 12, and 24. 
6.1.8 
Patient Reported Outcomes 
Patient-reported outcomes will be collected using the Veterans Rand 12 Item Health Survey 
(VR-12) and Short Musculoskeletal Function Assessment (SMFA) according to the schedule in 
Appendix 1. 
6.1.9 
Microbiology 
The microbiology of the index site will be assessed at baseline and at the time of any subsequent 
surgical procedure at the index site. The presence of viable microorganisms will be determined 
by standard microbiological culture methods and include speciation and antimicrobial 
susceptibility testing of any bacterial isolates found (see flowchart, Appendix 2). 
6.1.9.1 Specimen Collection 
Samples collected will include at least one tissue site (bone when possible; eraser head size, 
suitable for dividing into two samples) from the fracture site (if accessed) or involved tissue 
adjacent to the implant(s), two swabs of the peri-implant deep tissue, and two swabs of the 
superficial tissue/wound closure site. One set of specimens (i.e. 1 tissue specimen, 1 deep swab, 
1 superficial swab) will be placed into local site transport vessels. The duplicate set of samples 
will be placed into transport vessels provided by the central laboratory (International Health 
Management Associates, Inc.; IHMA). One set of specimens will be delivered to the local site 
microbiology laboratory using the standard storage and transport procedures employed at each 
site. The duplicate set of specimens will be transported to IHMA. The details regarding specimen 
packaging, transport, and processing will be described in the central laboratory study manual that 
will be provided to each study site. 
6.1.9.2 Specimen Processing: Local Laboratory 
The tissue site sample and swabs will be analyzed immediately in the local laboratory for the 
presence of infectious pathogens by Gram stain and microbiological culture for both aerobic and 
anaerobic bacteria. The specimens will be processed (primary isolation, identification to species 
level and susceptibility testing) per the standard methods of each local site microbiology 
laboratory. Following isolation and identification of each microorganism, the susceptibility of 
each to one or more standard antibacterial agents (but not including MBN-101), as specified by 
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the surgeon or per local site standard procedures, will be determined. It is recognized that the 
local site laboratory may be using one of a variety of susceptibility test methods, and therefore, 
the susceptibility result may be reported as a specific Minimal Inhibitory Concentration (MIC) 
value or as a categorical result (i.e. Susceptible, Intermediate or Resistant). Susceptibility to 
MBN-101 will not be determined at the local site laboratory; the susceptibility results determined 
locally are for the use of the surgeon in the care of the patient. All Gram stain and microbiology 
results from the local site laboratory will be recorded on the CRF. 
6.1.9.3 Specimen Processing: IHMA (Central Laboratory) 
The tissue site sample and swabs will be analyzed immediately in the central laboratory for the 
presence of infectious pathogens by microbiological culture for both aerobic and anaerobic 
bacteria. The specimens will be processed (primary isolation, identification to species level, and 
susceptibility testing) per the central laboratory methods, as described in the central laboratory 
study manual. 
Following identification, the susceptibility of the isolates to MBN-101 and comparator agents 
will be determined using either the reference broth microdilution method (for aerobic/facultative 
bacteria) or the reference agar dilution method (for anaerobic bacteria) as detailed by the Clinical 
and Laboratory Standards Institute (CLSI). Susceptibility tests for aerobic/facultative bacteria 
will be quality-controlled as detailed by CLSI using reference quality control strains and 
previously-established ranges for MBN-101 and comparators. Susceptibility tests for anaerobic 
bacteria will also include CLSI reference quality control strains, however, since quality control 
ranges for anaerobic bacteria are not yet established, the MIC values for the quality control 
strains will be collected then retrospectively compared to the quality control ranges once they are 
available.  Susceptibility testing will be conducted with batches of study isolates as each study 
cohort is completed. Patient and specimen identifier and microbiology results will be recorded in 
the database. The bacterial isolates recovered from the specimens will be propagated and 
archived at the central laboratory. 
6.1.9.4 Integration of Local Site Laboratory and Central Laboratory Primary Isolation and 
Identification Results 
There may be instances where the organism(s) isolated from a given specimen may be different 
at the local site laboratory and the central laboratory. In this instance, the central laboratory will 
first confirm the identification of the archived isolate. If the identification is confirmed, the 
pathogens present in the specimen will be defined as the total number of pathogens recovered by 
the local site laboratory and the central laboratory. For example, if the local site laboratory were 
to recover S. aureus and the central laboratory recovered S. aureus and P. acnes, the specimen 
would be defined as containing both S. aureus and P. acnes following merger of the data. 
It is possible that local site laboratory may perform susceptibility tests with agents that are also 
present in the central laboratory test panel. The MIC value (and interpretation) provided by the 
central laboratory supersedes the local site determination for the purposes of clinical trial data 
analysis and inclusion in the Clinical Study Report. The local site susceptibility test results are 
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for use by the surgeon in the local care of the patient; however, these data will also be captured 
in the study database. 
6.1.10 
Radiographic Evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6, 12, and 24. Radiographs 
(at least two orthogonal views) will be reviewed for union, interval callus formation, loss or 
change in reduction, and hardware failure. 
6.1.11 
Surgical Site Signs and Symptoms Evaluation 
The following signs and symptoms of the surgical site will be evaluated: 
 
local erythema extending beyond suture material or staples 
 
induration  
 
drainage from surgical incision 
 
degree of healing of the surgical incision 
Patients with non-healing or worsening status of their surgical site may be considered for 
additional standard of care treatment, but should be encouraged to remain in the study in order to 
complete study evaluations. In case additional treatment is given, the start/stop dates and dose 
regimen of the new treatment will be recorded on the CRFs. 
6.2 Screening and Baseline Assessments 
Patients who meet initial screening criteria by medical history and physical exam will be offered 
participation on study. If the patient agrees to participate, they will be asked to provide written 
informed consent, after which additional evaluation may be performed, including but not limited 
to clinical laboratory assessments, electrocardiogram (ECG), radiographic evaluation and 
pregnancy test if applicable. Only patients with an acceptable medical history and physical exam, 
ECG without clinically significant abnormalities, and laboratory results within acceptable limits 
will be randomized in the study prior to surgery. 
6.3 Randomization Procedure 
Subjects will be randomized in a 3:1 (active:placebo) ratio up to 24 hours prior to surgery via a 
central randomization scheme. The central randomization will be accomplished using an IVRS 
system linked to study drug treatment kits securely stored under appropriate conditions at the 
study site pharmacy. The randomization number assigned to a subject will be captured on the 
CRF. The specific study drug treatment kit will be utilized by the study pharmacist or other 
qualified individual to perform the appropriate dilution of drug product under sterile conditions 
into a vial to be transported to the operating room. Verification of study patient and study drug 
treatment kit will take place in the operating room prior to treatment with the investigational 
product. The appropriately diluted drug product must be administered within 8 hours of 
preparation. 
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6.4 Unblinding Procedure 
This study is a single blind study; however, knowledge of treatment assignment should remain 
limited to those directly involved with the patient’s surgical procedure and other individuals on a 
need to know basis. In order to provide unblinding data in an emergency in the absence of an 
individual privy to treatment assignment, sites will be provided with a numbered unblinding 
envelope corresponding to each numbered test kit the site is delivered. These envelopes will be 
securely stored in the pharmacy. The unblinding envelope specifies the treatment group of the kit 
and should only be opened when absolutely necessary. For treatment of adverse events, it should 
be assumed that the patient has received study drug, thus avoiding the need to unblind the 
patient. However, in the event the Investigator determines the randomization assignment 
information is required to treat the patient for an adverse event, the Medical Monitor should be 
contacted. If the Medical Monitor cannot be reached, the blind may be broken by opening the 
envelope. The site should document the unblinding process in the patient’s source documents. 
6.5 Investigational Product Administration 
6.5.1 
Surgical Site Identification 
Individuals undergoing surgical treatment for more than one infected fracture are excluded from 
participation in this study. 
6.5.2 
Study Drug Administration 
On the day of surgery, randomized subjects will receive the investigational product during their 
surgical procedure. Investigational product is only administered during the surgical procedure by 
the operating surgeon; therefore, 100% compliance with investigational product administration is 
assured. The operating surgeon will record the approximate surface area of the surgical site as 
well as the amount and location of investigational product administration in the operative note 
and on the CRF. All other details of the surgical procedure will be recorded in the operative note. 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 18 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
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5. Alcohol wipes 
6. One pre-printed "Diluted MBN-101 Drug Product" label 
7. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose”) 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the MBN-101 Stock Formulation and 
Diluent provided in the Drug Product Kit according to the DFU provided. The Treatment Dose 
will be provided to the surgeon in a vial from which an 8 mL volume will be drawn up in the 
operating room into a sterile 10 mL syringe. Surgeons will be instructed to use sufficient volume 
(up to the full 8 mL provided) to sparingly coat the bone at the site of infection, the exposed 
surfaces of any retained hardware, and the surfaces of any new hardware to be implanted. 
Following application, OR personnel will record in the CRF the actual volume (in tenths of 
milliliters) of any unapplied Treatment Dose remaining in the syringe. 
Application to retained hardware:  Access to infected wound surfaces and implanted orthopedic 
hardware will be provided by surgical intervention. The surgeon will use a 10 mL syringe to 
apply, followed by a gloved finger to spread, a thin layer of the investigational product directly 
onto all accessible surfaces of the orthopedic hardware, as well as surrounding bone. Other 
wound surfaces will not be coated, resulting in administration of the investigational product to 
only a limited area of the wound. 
Application to new hardware:  In cases where hardware is replaced or in cases of two-stage 
procedures, MBN-101 will be applied to all accessible surfaces of hardware and adjacent bone 
(target structures) following implantation of hardware and immediately prior to definitive 
closure. Other wound surfaces will not be coated, resulting in administration of the 
investigational product to only a limited area of the wound. 
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In all cases, the minimum amount of MBN-101 required to coat the relevant structures within the 
infected osteosynthesis site should be used. The suspension should be applied in a thin layer to 
cover all affected areas of bone as well as any exposed hardware. Direct application to muscle 
and other soft tissues should be avoided. The approximate area of the osteosynthesis site should 
be calculated based on the length of exposed bone multiplied by the width of bone exposed; the 
surface area of the hardware should be added to this value to derive the approximate area of the 
osteosynthesis site. Recommended maximum volumes of MBN-101 for various areas of the 
osteosynthesis site are provided in the table below. 
Area of Osteosynthesis Site 
Recommended Volume of MBN-101 
25 cm2 
0.5 mL 
50 cm2 
1.0 mL 
75 cm2 
1.5 mL 
100 cm2 
2.0 mL 
125 cm2 
2.5 mL 
150 cm2 
3.0 mL 
175 cm2 
3.5 mL 
200 cm2 
4.0 mL 
225 cm2 
4.5 mL 
250 cm2 
5.0 mL 
275 cm2 
5.5 mL 
300 cm2 
6.0 mL 
325 cm2 
6.5 mL 
350 cm2 
7.0 mL 
375 cm2 
7.5 mL 
400 cm2 
8.0 mL 
 
The table shows the specified volume of MBN-101 to be applied based on the area (in cm2) of 
the target infected osteosynthesis site. By following these application requirements, the 
administered doses will be: 
 Cohort 1: 0.025 mg/mL MBN-101 = 0.5 µg/cm2 
 Cohort 2: 0.075 mg/mL MBN-101 = 1.5 µg/cm2 
 Cohort 3: 0.250 mg/mL MBN-101 = 5.0 µg/cm2 
The use of drains and vacuum assisted closure devices at the site of hardware will be allowed per 
surgeon preference. The drainage volume over the first 24 hours or prior to discontinuation of the 
drain will be recorded in the eCRF. 
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6.6 Study Assessments 
Each patient enrolled in the study will have an assessment at 48 hours following surgery and at 
Weeks 2, 6, 12, and 24. Study assessments will be performed according to Section 6.1 and 
Appendix 1. The Week 24 assessment will be the final assessment for adverse events. Any 
adverse events ongoing at the Week 24 assessment will be followed until resolution of the event 
or stabilization of the condition. 
6.7 Safety Monitoring 
Patients will be instructed to inform the Investigator and/or a member of the study staff of any 
adverse events that occur at any time during the study. Patients will be asked a general health 
question at each clinic visit to identify changes in the state of their health since their last study 
visit. 
6.8 Study Monitoring 
The Sponsor or the Sponsor’s designee will provide training on the protocol for the study site 
personnel prior to giving the site permission to begin enrollment. Once the enrollment and 
dosing phases of the study have begun, the Sponsor or the Sponsor’s designee will visit the site 
to monitor the clinical conduct of the trial, the adequacy of study documentation and compliance 
with safety reporting. Clinical site monitoring will continue on a periodic basis until the site has 
been closed or all patients at the site have completed the study. The frequency of monitoring 
visits may vary depending on enrollment at the study site. 
6.9 Patient Withdrawals 
Patients will be free to withdraw at any time for any reason, or they may be withdrawn if 
necessary to protect their health and safety or the integrity of the study. Any patient that is 
randomized but not treated will be replaced. The final report will include reasons for 
withdrawals. As this study involves a single administration of study drug, significant patient 
withdrawals are not anticipated. 
All efforts should be made to have subjects complete the Week 24 (end of study) procedures 
prior to withdrawal from the study. 
6.10 Individual Patient Stopping Rules 
Patients who develop adverse events at any time during the study will be treated appropriately 
according to standard of care. Adverse events will be assessed and followed as described in 
Section 9. As this is a single dose study with the investigational product applied directly into a 
surgical site, specific stopping rules for individual patients have not been established. 
6.11 Study Stopping Rules 
Patient enrollment on study will be stopped if the number of individual patients experiencing 
possibly-related or probably-related adverse events > Grade 2 exceeds 2 in any dose cohort or if 
there is any death on study. Should the study stopping rules be invoked, all safety data on all 
patients will be assembled for review by the Data Review Committee (DRC). The study will not 
resume until this information has been reviewed by the DRC and the Sponsor, discussed with the 
FDA, and concurrence reached with the FDA as to the resumption of the study. 
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7 CONCOMITANT MEDICATIONS 
All patients will received their usual concomitant medications for any underlying medical 
conditions without interruption. Efforts should be made to maintain all concomitant medications 
at a stable dose for the duration of the 24 week study. Patients will also receive standard of care 
treatment for their postoperative fracture site infection that includes systemic antibacterial 
treatment per prevailing standard of care guidelines (i.e., national, institutional, or physician 
preference) and other indicated postoperative medications, including pain medications. All 
concomitant medications will be recorded in the CRF. Pain medication usage, including 
medication, dose, route, day and time of administration, will be recorded on a separate CRF. Use 
of any other bismuth-containing compounds is prohibited from Screening through Week 4. 
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8 STUDY ENDPOINTS 
8.1 Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
 Treatment-emergent adverse events. 
 Treatment-emergent serious adverse events. 
 Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
 Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
 Changes in physical exams. 
 Clinical findings of 12-lead electrocardiograms. 
 Change in microbiology status. 
8.2 Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
 Proportion of treatment failures. A treatment failure defined as a subject with non-healing 
or worsening status of their surgical site requiring serious intervention by Week 24. 
 Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 24. 
 Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed fracture 
site. 
 Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed fracture site by Week 24. 
 Time to removal of orthopedic hardware due to a healed fracture site. 
 Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
 Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
 Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale 
(VAS, 0-10 scale). 
 Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
 Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination.  
 Change in serologic markers CRP and ESR at each post baseline time point. 
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8.3 Pharmacokinetic Endpoint 
8.3.1 
Sample Collection and Handling 
Blood samples will be obtained to measure blood concentrations of Bismuth (Bi) as a surrogate 
for BisEDT. A pre-dose sample will be collected prior to administration of the investigational 
product. Blood will be drawn for PK samples at nominal 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 (Day 
3), 96 (Day 4), and 336 (Day 14) hr after application of MBN-101 to the surgical site. 
Documentation stating the exact time of blood sampling (4 mL per timepoint) in relation to the 
time of study drug administration will be collected and provided. 
Primary and back-up blood samples will be stored at -70°C.  
8.3.2 
Assay Methodology 
Bismuth (Bi) levels, a surrogate for BisEDT, will be assayed in whole blood using a validated 
inductively coupled plasma mass spectrometry (ICP-MS) assay performed by Medpace 
Bioanalytical Laboratories (Cincinnati, Ohio). The samples are prepared for analysis by 
digestion with nitric acid and H2O2 for 2 hours, followed by centrifugation and dilution in water 
with subsequent quantitation of Bi by ICP-MS analysis. 
A detailed method description, including validation, calibration and quality assurance 
procedures, will be included in the analytical report which will be part of the Final Study Report. 
8.3.3 
PK Analysis 
Bismuth (Bi) concentration data will be analyzed by noncompartmental analysis (NCA) with 
Phoenix™ WinNonlin® Version 6.4 or higher, using an extravascular administration model and 
actual sampling times. Interim analyses may use nominal sampling times. The following PK 
parameters will be derived from blood concentrations of Bi using extravascular 
noncompartmental PK analysis (as feasible): 
Tmax 
Time to maximum observed concentrations of Bi 
Cmax 
Maximum observed concentrations of Bi 
AUC0-t Area under the Bi concentration vs time curve from time zero to the time of the last 
measurable concentration. 
AUC0-∞ Area under the Bi concentration vs time curve from time zero and extrapolated to 
infinity. 
T1/2 
The apparent half-life of Bi after extravascular administration of BisEDT 
CL/F 
Apparent clearance after extravascular administration of BisEDT 
Vz/F 
Apparent volume of distribution after extravascular administration of BisEDT 
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9 ADVERSE EVENTS 
An adverse event is an undesirable medical occurrence (sign, symptom, or diagnosis) or 
worsening of a pre-existing medical condition (e.g., diabetes) that occurs after initiation of the 
investigational study whether or not it is considered to be related to the investigational product. 
A worsening of an existing medical condition is one that was present at Day 1 (e.g., diabetes) 
and became more severe, more frequent, or increased in duration during investigational product 
treatment. Clinically relevant abnormal results of diagnostic procedures including abnormal 
laboratory findings (e.g., requiring unscheduled diagnostic procedures or treatment measures, or 
resulting in withdrawal from the study) are considered to be AEs. 
All adverse events (AEs) will be recorded throughout the study, beginning when the subject 
signs the Informed Consent Form. 
A treatment-emergent adverse event (TEAE) is defined as any AE starting after the first dose of 
the investigational agent or placebo is administered. If the AE is present prior to the 
administration of the first dose of the investigational agent or placebo but increases in severity, it 
will also be considered a TEAE. 
Treatment-emergent adverse events will be recorded beginning with the first exposure to 
investigational product and continuing until the subject is discharged from the study due to 
completion or early termination. 
Adverse events will be categorized as local adverse events and as systemic adverse events. 
The Principal Investigator, or medically qualified designee, must completely and promptly 
record each AE on the appropriate CRF. The Principal Investigator should attempt, if possible, to 
establish a diagnosis based on the presenting signs and symptoms. In such cases, the diagnosis 
should be documented as the AE and not the individual sign/symptom. If a clear diagnosis 
cannot be established, each sign and symptom must be recorded individually. Once a diagnosis is 
established, the CRFs should be updated with the final diagnosis. 
Any adverse event ongoing at the time of study completion will be recorded and followed-up 
according to the safety procedures described in the following sections. 
9.1 Reporting and Following Adverse Events 
All AEs encountered during the study will be reported on the AE page of the CRF in a timely 
manner. All AEs should be followed in accordance with good medical practice until resolved or 
fully characterized. 
Serious adverse events: Section 9.4 presents the definition and reporting obligations for Serious 
Adverse Events (SAEs). After the initial report, a follow-up SAE Report Form should be filled 
out and sent to Medpace Clinical Safety within 24 hours. Updates are to be provided by the site 
as soon as relevant information (especially regarding outcome) is available. 
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9.2 Severity 
The Investigator must indicate the severity of the adverse event in the description of the adverse 
event. A severity category of mild, moderate, or severe, as defined below, should be determined 
and entered on the Adverse Events page of the Case Report Form (CRF). 
 
Mild (Grade 1): Transient or mild symptoms; no limitation in activity; no intervention 
required. The AE does not interfere with the participant’s baseline functioning level. It 
may be an annoyance. 
 
Moderate (Grade 2): Symptom results in mild to moderate limitation in activity; no or 
minimal intervention required. The AE produces some impairment of baseline 
functioning, but it is not hazardous to health. It is uncomfortable or an embarrassment. 
 Severe (Grade 3): Symptom results in significant limitation in activity; medical 
intervention may be required. The AE produces significant impairment of functioning or 
incapacitation. 
 Potentially Life-Threatening (Grade 4): Symptoms cause inability to perform basic self-
care functions immediately necessary to sustain life or require medical or operative 
intervention to prevent permanent impairment, persistent disability or death. 
9.3 Relationship to Clinical Trial Material 
The Investigator must document their opinion of the relationship of the event to the 
investigational product as follows: 
 
NONE: The event can be readily explained by the subject’s underlying medical condition, 
a concomitant therapy or other cause and the Investigator believes no relationship exists 
between the event and the investigational product. In this case, the Investigator should 
document the condition, concurrent/underlying illness, medication, study procedure or 
other cause they believe to be the cause of the adverse event. 
 
UNLIKELY: The event does not follow a reasonable temporal sequence from 
administration of the investigational product nor does the event follow a known or expected 
response pattern to the investigational product and may have another cause. In this case, 
the Investigator should document the condition, concurrent/underlying illness, medication, 
study procedure or cause they believe may have contributed to the adverse event. 
 
POSSIBLE: The subject’s condition, concurrent/underlying illness, medication, or study 
procedures cannot explain the event, and there is a plausible temporal relationship 
between the event and the investigational product administration. 
 PROBABLE: The temporal relationship between the administration of the investigational 
product and the adverse event strongly suggests a relationship, and/or the adverse event 
cannot be reasonably explained by another condition, concurrent/underlying illness, 
medication, study procedure or other cause, or the adverse event abates with 
discontinuation of the investigational product, and recurs with re-administration. 
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9.4 Serious Adverse Events 
To report SAEs in a timely manner, monitor subject care, and to fulfill regulatory requirements, 
SAEs (regardless of their relationship to the investigational product) must be reported to 
Medpace Clinical Safety within 24 hours of knowledge of the event by the Investigator or 
members of the study staff.  
9.4.1 
Definition 
SAEs are defined as those adverse events that meet any of the following criteria: 
 
Life threatening, that is, any event that, in the opinion of the Investigator, poses an 
immediate risk of death from that event 
 
Results in death 
 
Results in or prolongs hospitalization 
 
Results in persistent or significant disability/incapacity 
 
Results in congenital anomaly/birth defect 
In addition, events which may not meet these criteria, but, in the opinion of the Investigator, are 
very unusual, potentially serious, or require medical or surgical intervention to prevent one of the 
outcomes listed above, should also be reported in the same manner as events which meet the 
serious adverse event criteria.  
9.4.2 
Reporting 
Serious AEs require immediate reporting (within 24 hours of the site’s knowledge of the event) 
to Medpace Clinical Safety whether or not the Investigator believes that the experience is related 
to the investigational product. A completed SAE CRF signed by the Investigator must be faxed 
to Medpace Clinical Safety. Criteria for documenting the relationship to study product and 
severity will be the same as those previously described in Sections 9.2 and 9.3. 
SAEs must also be reported by the study site to the responsible IRB immediately. The 
Investigator is responsible for complying with the local IRB regulations regarding the reporting 
of AEs. 
Reporting of a suspected SAE should not be delayed in order to obtain additional information. 
Any additional information, if collected, can be reported as a follow-up to the initial report. Any 
SAE that occurs at any time during the study, whether or not related to the investigational 
product, must be reported to Medpace Clinical Safety.  
All possibly- and probably-related serious adverse events must be followed until the outcome is 
known or the event is otherwise explained. All serious adverse events that are not resolved at the 
end of the study are to be followed until resolution, the condition stabilizes, the event is 
otherwise explained, or the subject is lost to follow-up.  
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9.5 Pregnancies 
Pregnancies occurring after the first dose of investigational product are considered immediately 
reportable events. While not considered a serious adverse event unless a serious criterion is met, 
pregnancies occurring in subjects enrolled on the study must be reported and followed to 
outcome. The investigator should complete the pregnancy report form and fax it to Medpace 
Clinical Safety within one working day of knowledge of the pregnancy. Following delivery or 
termination of pregnancy, the follow-up pregnancy report form should be completed and 
submitted via fax to Medpace Clinical Safety. Spontaneous abortions should always be reported 
as SAEs. Follow-up information regarding the outcome of the pregnancy and any postnatal 
sequelae in the infant will be required. 
9.6 Data Review Committee (DRC) 
An independent Data Review Committee will be established to review unblinded clinical trial 
data prior to dose escalation and on an as-needed basis. A statistician, serving as a non-voting 
member to the DRC, will provide data preparation support to the DRC. A sponsor representative 
will also serve as a non-voting member of the DRC to facilitate sponsor internal planning. 
The primary role of the DRC will be to assess unblinded safety data on all patients in a dose 
cohort completing the Week 6 visit, and to determine whether dose escalation should occur. The 
DRC may recommend dose escalation, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
The DRC will also be asked to assess unblinded safety data on an as-needed basis. The Chair of 
the DRC will be informed by Microbion Corporation of the potential need for ad hoc meetings 
and will coordinate any ad hoc meeting with the remainder of the DRC members. The DRC may 
recommend no modifications to the study, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
A formal DRC Charter will be prepared and finalized prior to study enrollment. The DRC will 
meet prior to initiation of the clinical trial in order to review, revise and reach concurrence on the 
content of a DRC charter. The draft charter will be provided by Microbion Corporation to the 
DRC prior to the initial meeting. 
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10 INVESTIGATIONAL PRODUCT MANAGEMENT 
10.1 Study Drug 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied.  
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 18 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
5. Alcohol wipes 
6. One pre-printed "Diluted MBN-101 Drug Product" label 
7. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose” 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
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10.2 Study Drug Packaging and Labeling 
All shipments of the investigational product will be accompanied by an inventory form. The 
contents of the shipments should be inventoried immediately upon receipt and confirmation of 
inventory shall be performed according to instructions provided by the clinical supplies 
distributor. 
The following information will be provided with each shipment of study drug: Sponsor name and 
contact information (telephone number), study protocol number, description of the contents of 
the container, conditions for storage, and a statement regarding the investigational (clinical trial) 
use of the study drug.  
Each package unit of the investigational product will be labeled with the following information: 
Sponsor name, study protocol number, description of the contents, a statement regarding the 
investigational (clinical trial) use of the study drug, and a packaging lot number.  
10.3 Study Drug Storage 
The investigational product should be kept in a limited-access area at 15-30 degrees C at the 
study site.  
10.4 Study Drug Accountability 
It is the responsibility of the Principal Investigator or his/her designee at each site to ensure that 
all investigational product quantities received at the site will be inventoried and reconciled 
throughout the study and the result recorded on the drug accountability form maintained in the 
study file. 
10.5 Study Drug Handling and Disposal 
Only qualified study personnel familiar with procedures that minimize undue exposure to 
themselves and to the environment should undertake the handling of pharmaceutical agents. 
The study monitor will verify that the disposition of all investigational materials at the trial site is 
in accordance with Sponsor specifications and applicable regulatory requirements. Requirements 
for disposition of used, unused, damaged/quarantined, and expired investigational materials will 
be provided to applicable site personnel. The study monitor will confirm associated 
documentation is filed in the Investigator site file and copies retrieved for the Sponsor or 
Sponsor-designee Investigator File. 
Used, damaged, and expired investigational materials will be destroyed as directed by the Study 
Monitoring Plan. Specific instructions of on-site destruction, return of materials to a 3rd party 
vendor, or any other mechanism of removal of the investigational materials from the site will be 
detailed in the Study Monitoring Plan. 
The study monitor will not take possession of investigational materials. Any deviations from this 
process must be approved in advance by the Sponsor or Sponsor-designee.  
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11 GENERAL CONSIDERATIONS 
11.1 Basic Principles 
This research will be carried out in accordance with the clinical research guidelines established 
by the Basic Principles defined in the U.S. 21 CFR Parts 50, 56, and 312, the principles 
enunciated in the Declaration of Helsinki concerning medical research in humans (“Ethical 
Principles for Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 
1975, Venice 1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, 
Washington 2002 and Tokyo 2004), and the Good Clinical Practice (GCP) guidelines of the 
International Conference on Harmonization (ICH) of the Technical Requirements for 
Registration of Pharmaceuticals for Human Use, ICH E6 (May 1996). 
11.2 Institutional Review Board 
Prior to initiation of any study procedures, the Clinical Study Protocol, Informed Consent Form, 
and Product Information will be submitted to the IRB for review and approval. In addition, any 
amendments to the protocol or informed consent document will be reviewed and approved (if 
necessary) by the IRB. The Principal Investigator (PI) at each clinical site assumes responsibility 
for ensuring that the protocol is submitted to the IRB for any required periodic review. The PI 
must receive a letter documenting the IRB approval at the clinical site prior to the initiation of 
the study. Any subsequent IRB correspondence must also be submitted to the investigator. The 
Investigator is responsible for providing the appropriate reports to the reviewing IRB during the 
course of the clinical study. This will include the following: 
 Informing the IRB of the study progress periodically as required, but at least annually 
 Reporting any unanticipated adverse product per IRB Policies & Procedures 
 Reporting any deviations from the clinical protocol to protect the life or well-being of a 
subject in the case of an emergency within 5 working days after the emergency occurred 
 Providing any other reports requested by the IRB 
After the final visit of the last subject, a final report will be sent to the IRB per their Policies & 
Procedures that includes a summary of the results of the study by the PI. 
The IRB must be constituted and operate in accordance with the principles and requirements 
described in the U.S. Code of Federal Regulations (21 CFR Part 56). 
11.3 Informed Consent 
The purpose of the study, the procedures to be carried out and the potential hazards will be 
described to the subjects in non-technical terms. Subjects will be required to read and sign a 
consent form summarizing the discussion prior to enrollment, and will be assured that they may 
withdraw from the study at any time without jeopardizing their medical care. 
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11.4 Study Termination 
The Investigator reserves the right to terminate the study in the interest of subject safety and 
welfare. The Sponsor reserves the right to terminate the study at any time for administrative 
reasons. 
11.5 Regulatory Documentation 
Documents that must be provided to the Sponsor prior to study drug shipment are as follows: 
 Up-to-date curriculum vitae for each investigator and sub-investigator 
 Signed and dated Investigator Agreement 
 Applicable local regulatory documentation (e.g., FDA 1572 Form) 
 A copy of the formal written notification to the investigator regarding approval of the 
protocol by an IRB that is in compliance with regulatory guidelines. The written 
notification is to be signed by the chairman or authorized designee and must identify the 
specific protocol. In cases where an IRB member has a known conflict of interest, 
abstention of that individual from voting should be documented; an investigator 
(or sub-investigator) may be a member of the IRB, but may not vote on any research in 
which he or she is involved. 
 Name and address of the IRB with a statement that it is organized and operates according 
to GCP and the applicable laws and regulations, and a current list of the IRB members. 
If accompanied by a letter of explanation from the IRB, a general statement may be 
substituted for this list. 
 A copy of the IRB approved informed consent form and other adjunctive materials 
(e.g., advertising) to be used in the study, including written documentation of IRB 
approval of these items. 
 Name and address of any local laboratory conducting tests for the study, a dated copy of 
the laboratory reference values for tests to be performed during the study and a copy of 
the certification or other documentation establishing adequacy of the facility. 
 Required financial agreement. 
In addition to the documents required prior to the study, other documentation may be required 
during the course of the study. 
11.6 Study Documentation 
All documents pertaining to the study, including a copy of the approved protocol, copy of the 
Informed Consent Form, and case report forms, will be retained in the permanent archives of the 
study site. These will be available for inspection at any time by the Sponsor or the U.S. Food and 
Drug Administration (FDA). 
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11.7 Data Handling and Record Keeping 
As electronic trial data handling and/or remote electronic trial data systems will be used, 
Microbion and/or its designee will: 
 Ensure and document that the electronic data processing system(s) conforms to the 
Sponsor’s established requirements for completeness, accuracy, reliability, and consistent 
intended performance 
 Maintain SOPs for using these systems 
 Ensure that the systems are designed to permit data changes in such a way that the data 
changes are documented and that there is no deletion of entered data (i.e., maintain an 
audit trail, data trail, edit trail) 
 Maintain a security system that prevents unauthorized access to the data 
 Maintain a list of the individuals who are authorized to make data changes 
 Maintain adequate backup of the data 
 Safeguard the blinding, if any (e.g., maintain the blinding during data entry and 
processing) 
Moreover: 
 An unambiguous subject identification code will be used that will allow identification of 
all the data reported for each subject 
 Microbion and/or its designee will retain all of the Sponsor-specific essential documents 
pertaining to the trial in conformance with the applicable regulatory requirement(s) of the 
country(ies) where the product is approved and/or where it intends to apply for approval  
 Specific essential documents will be retained until at least 2 years after the last approval 
of a marketing application in an ICH region and until there are no pending or 
contemplated marketing applications in an ICH region or at least 2 years have elapsed 
since the formal discontinuation of clinical development of the investigational product. 
These documents should be retained for a longer period, however, if required by the 
applicable regulatory requirement(s) or if needed by the Sponsor. 
 Microbion and/or its designee will inform the investigator(s)/institution(s) in writing of 
the need for record retention and should notify the investigator(s)/institution(s) in writing 
when the trial related records are no longer needed 
11.8 Use of Information and Publication 
All information concerning BisEDT, MBN-101, MBN-101 diluent, Microbion operations, patent 
applications, formulas, manufacturing processes, basic scientific data, and formulation 
information, supplied by the Sponsor to the investigator and not previously published, is 
considered confidential and remains the sole property of Microbion Corporation. The 
investigator agrees to use this information only to accomplish this study and will not use it for 
other purposes without the Sponsor’s written consent. 
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The investigator understands that the information developed in the clinical study will be used by 
Microbion in connection with the continued development of MBN-101 and BisEDT, and thus 
may be disclosed as required to other clinical investigators or government regulatory agencies. 
To permit the information derived from the clinical studies to be used, the investigator is 
obligated to provide the Sponsor with all data obtained in the study. 
Any publication or other public presentation of results from this study requires prior review and 
written approval of Microbion Corporation. Draft abstracts, manuscripts, and materials for 
presentation at scientific meetings should be provided to the Sponsor at least 30 working days 
prior to abstract or other relevant submission deadlines. Authorship of publications resulting 
from this study will be based on generally accepted criteria for major medical journals. 
11.9 Independent Medical Monitor 
In accordance with US Army Medical Research and Materiel Command (USAMRMC) and 
Department of Defense (DOD) requirements, an independent medical monitor will be identified. 
The independent medical monitor should be physicians, dentists, psychologists, nurses, or other 
healthcare providers capable of overseeing the progress of research protocols, especially issues 
of individual volunteer management and safety. The medical monitor must be independent of the 
investigative team and possess sufficient educational and professional experience to serve as the 
volunteer advocate. Depending on the nature of the study, the medical monitor may be assigned 
to assess one or more of the following phases of research project: volunteer recruitment, 
volunteer enrollment, data collection, or data storage and analysis. The medical monitor provides 
an independent evaluation of serious adverse events and unanticipated problems involving risk to 
subjects or others to the IRB and the Office of Research Protections (ORP). The medical monitor 
may be assigned to discuss research progress with the PI, interview volunteers, consult on 
individual cases, or evaluate adverse event reports. The medical monitor must promptly report 
discrepancies or problems to the IRB and the ORP. They shall have the authority to stop a 
research study in progress, remove individual volunteers from a study, and take whatever steps 
are necessary to protect the safety and well-being of research volunteers until the IRB can assess 
the medical monitor report. 
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12 STATISTICAL ANALYSIS METHODOLOGY 
A formal statistical analysis plan (SAP) will be prepared and finalized before database lock for 
the final analysis for the study report. The SAP will provide details regarding the definition of 
analysis subjects (populations), analysis variables and analysis methodology to meet all study 
objectives. 
The principle and key elements of the SAP are provided as follows: 
In general, safety and efficacy data will be summarized with descriptive statistics, including 
means, standard deviations, medians, minimums and maximums for continuous variables, the 
number of subjects and percent in each category for categorical variables.  
Data from all subjects randomized and treated with placebo in each cohort will be pooled for the 
analysis; data from the subjects randomized and treated with MBN-101 will be presented by dose 
as well as combined.  
Data from each individual will be tabulated as appropriate. Efficacy and safety endpoints will be 
tabulated by treatment group and time point.  
12.1 Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
 Proportion of treatment failures. A treatment failure is defined as a subject with 
non-healing or worsening status of their surgical site requiring serious intervention by 
Week 24. 
Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 24. 
 Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed fracture 
site.  
 Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed fracture site by Week 24. 
 Time to removal of orthopedic hardware due to a healed fracture site. 
 Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
 Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
 Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale (VAS, 
0-10 scale).  
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 Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
 Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination. 
 Changes in serologic markers CRP and ESR at each post baseline time point. 
12.2 Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
 Treatment-emergent adverse events. 
 Treatment-emergent serious adverse events. 
 Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
 Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
 Changes in physical exams. 
 Clinical findings of 12-lead electrocardiograms. 
 Change in microbiology status. 
12.3 Sample Size Considerations 
Sample size for this study was chosen empirically for the purpose of the study without any 
formal statistical hypothesis to be tested. 
Nine subjects will receive active drug in each dose cohort. With 9 subjects receiving active drug, 
the probability of observing at least one of 9 subjects in a dose cohort exhibiting an AE of a 
specific type is 95% if the true background incidence rate for that event-type were approximately 
0.283 or greater. Hence, if an AE of a specific type is not observed in the study in a sample size 
of 9 subjects receiving active study drug at a given dose, one would “rule-out” this AE as having 
an incidence rate of more than 0.283 with 95% confidence. 
Similarly, if a rare event of interest is not reported in the 27 subjects treated with the active study 
drug, one could conclude that the rate of the event would be 0.105 or less with 95% confidence. 
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12.4 Analysis Datasets 
The following analysis datasets will be identified for the purpose of analysis:  
Screened Subjects: All subjects who signed informed consent for the study will be included in 
the Screened Subjects analysis set. 
Randomized Subjects: All subjects who were randomized in the study will be included in the 
Randomized Subjects analysis set. A randomized subject may or may not be treated with the 
assigned study drug. This is the classic Intent-to-Treat (ITT) analysis set. 
Treated Subjects: All subjects who received any amount of study drug (active or placebo) will be 
included in the Treated Subjects analysis set. All treated subject will be included in the safety 
analysis. This analysis set is also referenced as the Safety Analysis Set. 
Modified Intent-to-Treat (mITT) Subjects: the ITT subjects who received any amount of study 
(active or placebo) and have at least one post-treatment assessment will be included in the mITT 
analysis set. The mITT analysis set is the primary dataset for efficacy analysis. 
PK Concentration Subjects (i.e., PK Concentration Population): The PK Concentration 
Population will include all subjects with any measurable bismuth blood concentrations. 
PK Evaluable Subjects (i.e., PK Evaluable Population): The PK Evaluable Population will 
include all subjects providing sufficient measurable bismuth blood concentrations to facilitate 
determination of PK parameters. 
In the event that a subject received study drug treatment that is not the assigned/randomized 
treatment group, the subject has a major protocol deviation. The subject, however, will be 
included in the analysis for safety and efficacy in the actual treatment group received.  
Subjects randomized but not treated for any reason will be included in the disposition tabulation 
and will be excluded from the safety and efficacy analysis.  
12.5 Disposition and Study Population Characteristics 
Disposition summaries will be prepared to include number and percent of subjects screened, 
randomized, treated, subjects that completed the study and reason for discontinuation. Reason for 
screening failure will also be tabulated.  
Subject characteristics summaries will include demographics (age, gender, race, and ethnicity), 
baseline characteristics (weight, height, BMI), surgery site characteristics (type of injuries, type 
of fraction fixation, surgical site location), microbiology analysis results, time from previous 
surgery to study enrollment, and type of previous treatment), current surgery characteristics 
(area of the osteosynthesis site, with or without hardware replacement, etc.), and medical history.  
Disposition summary will be based on randomized treatment group (i.e., planned treatment) 
whereas the baseline characteristics summaries will be based on the actual treatment group.  
Subjects with protocol deviations will be identified. The nature of the deviation and potential 
impact on the deviation on study outcome will also be assessed.  
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12.6 Efficacy Analysis 
12.6.1 
Treatment Failure 
A treatment failure is defined as a subject with non-healing or worsening status of their surgical 
site requiring serious intervention by Week 24. 
The number of subjects meeting treatment failure criteria during the study will be tabulated by 
treatment group. If data permit, the difference in proportion of treatment failures between the 
groups and the corresponding 95% confidence intervals for the difference will be presented. 
Fisher’s exact test may be used to test the difference between the groups; difference in rates and 
95% confidence intervals for the relative risk will be derived. Dose-response assessment may be 
performed. 
12.6.2 
Incidence of Serious Interventions  
All interventions meeting the following criteria are serious interventions: 
 Initiation of antibiotic treatment in patient not previously on antibiotics 
 Change in the route of antibiotic administration from oral to intravenous for escalation of 
treatment 
 Change in the type or dosage of antibiotic drug for escalation of treatment 
 Readmission (exclusive of readmissions associated with a healed fracture site) 
 Reoperation (exclusive of reoperations associated with a healed fracture site) 
The number of subjects with at least one serious intervention (exclusive of serious interventions, 
readmissions, and reoperations associated with a healed fracture site) and total number of serious 
interventions will be tabulated for the following periods:  
 duration of the study;  
 within the first 4 weeks after the surgery; 
 from week 4 to week 8 
 from week 8 to week 12  
 from week 12 to week 24 
The difference between the placebo arm and the active arms will be evaluated as follows if data 
permits: Fisher’s exact test may be used to test the difference between the groups; difference in 
rates and 95% confidence intervals for the relative risk will be derived.  
Similar summaries will be prepared for incidence of re-admission and incidence of re-operation. 
Time elapsed between the initial hospital discharge to hospital readmission and between the 
operations will be derived and tabulated.  
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12.6.3 
Time to First Serious Interventions  
Time to the first serious intervention exclusive of serious interventions, readmissions, and 
reoperations associated with a healed fracture site will be derived. Time to first serious 
intervention will be calculated as the number of study days from the study surgery date to the 
event onset date plus 1. Subjects who do not have any serious intervention will be censored to 
the last observation date. 
No formal inferential statistics will be carried out for this endpoint. 
12.6.4 
Subjects Undergoing Removal of Stabilizing Orthopedic Hardware 
The number of subjects undergoing removal of hardware due to a healed fracture site and the 
time to removal of hardware due to a healed fracture site will be derived. Time to removal of 
hardware will be calculated as the number of study days from the study surgery date to the event 
date plus 1.  
12.6.5 
Surgical Site Signs and Symptoms 
The surgical site will be examined for local erythema, induration, drainage and degree of 
healing. 
Subjects with non-healing or worsening status of their surgical sites will be tabulated. 
12.6.6 
Patient-Report Outcomes 
12.6.6.1 The Veterans RAND 12 Item Health Survey (VR-12) Questionnaire  
The Veterans RAND 12 Item Health Survey (VR-12) is a brief, generic, multi-use, self-
administered health survey comprised of 12 items. The instrument is primarily used to measure 
health related quality of life, to estimate disease burden and to evaluate disease-specific 
benchmarks with other populations. The 12 items in the questionnaire correspond to eight 
principal physical and mental health domains including general health perceptions; physical 
functioning; role limitations due to physical and emotional problems; bodily pain; energy-
fatigue, social functioning and mental health (Selim, 2009; Veterans Affairs website, 2014). 
VR-12 total score, physical health domain score (PCS), and mental health domain score (MCS) 
will be tabulated by visit; change from baseline in total score, physical health domain score and 
mental health domain score will also be derived and tabulated.  
12.6.6.2 The Short Musculoskeletal Function Assessment Questionnaire (SMFA) 
The 46-item SMFA questionnaire comprises two parts: the dysfunction index with 34 items and 
the bother index with 12 items. The dysfunction index assesses the patients perceptions of the 
amount of difficulty they have in the performance of certain functions (25 items) and how often 
the patients have difficulty when performing certain functions (9 items). The dysfunction items 
are grouped into four categories: daily activities, emotional status, function of the arm and hand, 
and mobility. Each item has a 5-point response format (1 point for good function and 5 points for 
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poor function). The bother index asks the patients to assess how much they are bothered by 
problems in various areas of life (e.g., recreation, work, sleep and rest). These items also have a 
5-point response format (1 point for not at all bothered and 5 points for extremely bothered). 
The scores of the dysfunction and the bother indices are calculated by summing up the responses 
to the items and then transforming the scores according to the formula: (actual raw score - lowest 
possible raw score)/(possible range of raw score) ×100. 
This transformation formula gives the final scores, which ranged from 0 to 100. The higher 
scores indicate poorer function. In the case of the dysfunction index, unanswered items in a 
category are replaced by the individual’s mean score for that category, as long as more than 
50 per cent of the items in that category have been answered. Substitution with the mean is not 
appropriate for the bother index as each item addresses a unique area of function (Swiontkowski, 
1999; Short Musculoskeletal Function Assessment Injury and Arthritis Survey, 
www.grossortho.com/forms/injury.pdf). 
SMFA results and change from baseline will be summarized by visit and treatment group with 
descriptive statistics. 
12.6.7 
Pain Assessments 
Surgical site pain score utilizing a 24 hour recall will be assessed via Visual Analog Scale (VAS) 
(Burckhardt, 2003; Brokelman, 2012; Briggs, 1999) at baseline, and Weeks 2, 6, 12, and 24. 
Change in pain from baseline will be derived; observed pain score and change from baseline will 
be tabulated by visit and treatment group. 
12.6.8 
Microbiology 
Microbiology will be assessed at baseline and at the time of any subsequent surgical procedure at 
the index site. The presence of viable microorganisms will be determined by standard 
microbiological culture methods and include speciation and antimicrobial susceptibility testing 
of any bacterial isolates found (see flowchart, Appendix 2). Samples collected will include at 
least one tissue site (eraser head size; suitable for dividing into two samples) from the fracture 
site (if accessed) or involved tissue adjacent to the implant(s), two swabs of the infected 
hardware (in situ or ex vivo), two swabs of the deep infection site, and two swabs of the 
superficial tissue/wound closure site when possible. Duplicate specimens will be transported 
aerobically and anaerobically, respectively. Specimens will be processed by the local laboratory 
and the central laboratory as presented in Sections 6.1.9.3 and 6.1.9.2. 
Microorganisms isolated from each assessment will be listed. This information may also be used 
to identify potential subgroups. 
Microbiological success is assessed by clearance of infection. The proportion of subjects that 
meet the treatment success criteria per microbiologic evaluations will be identified and tabulated 
by each treatment group. 
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12.6.9 
Radiographic Evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6, 12, and 24. 
Radiographic success is assessed by healing on radiographic examination. The proportion of 
subjects that met the treatment success criteria per radiographic examination will be identified 
and tabulated by each treatment group. 
12.6.10 Serologic Markers 
Serology markers CRP and ESR will be assessed at baseline and Weeks 2, 6, 12, and 24. 
Serology markers CRP and ESR have been used together with clinical signs and symptoms for 
periprosthetic infection diagnosis. The values for each serologic marker and the number of 
subjects with normal or abnormal serologic marker values at each visit will be tabulated by 
treatment group.  
12.6.11 Subgroup Analyses for Efficacy Endpoints 
If data permit, the following potential covariates will be identified and subgroup analysis may be 
performed for those subgroups. 
1. 
Area of the osteosynthesis site 
2. 
Method of fracture fixation 
3. 
Type of infection (per identified microorganism) 
4. 
Anatomic location of the surgery site 
5. 
Hardware retention status (retained vs. exchanged) 
6. 
Influence of host factors 
7. 
Method of wound closure / wound management 
12.6.12 Sensitivity Analyses for Efficacy Endpoints 
The primary efficacy analysis set (mITT) will included all randomized subjects who received 
any amount of study drug and have at least one post-treatment assessment. In addition, in the 
event that a subject received treatment that is different from the assigned treatment, the subject 
will be included in the actual treatment received in the mITT analysis. 
An ‘as assigned’ analysis will be performed on the mITT subjects as a sensitivity analysis for the 
primary efficacy endpoint. In this analysis, subjects who received a treatment that is not the 
assigned treatment will be included in the ‘assigned’ treatment group for this analysis. 
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12.7 Safety Analysis 
12.7.1 
Study Drug Exposure and Concentrations 
Study drug exposure will be presented by treatment group. Descriptive statistics will be provided 
without any formal inferential statistics.  
12.7.2 
Adverse Events 
The Medical Dictionary for Regulatory Activities (MedDRA Version 16 or higher) will be used 
to classify all AEs with respect to system organ class (SOC) and preferred term. Summary of 
adverse events will include: 
1. Treatment emergent adverse events by SOC, preferred term, and intensity 
2. Treatment emergent adverse events by SOC, preferred term, and relationship to study 
drug  
3. All AEs leading to study discontinuation by SOC and preferred term 
4. All serious adverse events by SOC and preferred term 
Summary tables will provide total number of events and number of subjects with the event. 
The incidence and intensity of each pre-specified local AEs will be tabulated by visit and 
treatment groups. 
12.7.3 
Clinical Laboratory Tests 
Laboratory includes hematology, serology, serum chemistry, and urinalysis; laboratory collected 
prior to surgery will be the baseline laboratory. The study will utilize local lab for all clinical 
laboratory testing. Laboratory data will be tabulated based on the following result class. 
 Normal: result is within the local lab normal range 
 Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each lab test without formal inferential statistics. If data permits shift 
in result class from baseline to post baseline may also be tabulated. 
12.7.4 
12-lead ECG 
ECG findings at each time point will be tabulated by treatment group without inferential 
statistics. 
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12.7.5 
Vital Sign Measurements 
Vital signs collected immediately prior to receiving study drug will be the baseline vital signs. 
Observed vital sign values and change from baseline in vital signs at each visit will be 
summarized without formal statistical testing. 
Vital sign result may also be tabulated based on the following result class. 
 Normal: result is within the normal range 
 Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each vital sign. 
12.7.6 
Physical Examinations  
Findings of physical examinations will be tabulated by treatment groups without inferential 
statistics. 
12.7.7 
Subgroup Analyses for Safety Endpoints 
No subgroup analysis is planned for safety endpoints. 
12.8 PK Analysis 
Blood bismuth concentration vs. time profiles after administration of MBN-101 will be 
summarized for each nominal sampling time point and by dose group using descriptive statistics 
generated by WinNonlin. The NCA PK parameters (AUC0-t, AUC0-inf, Tmax, Cmax, T1/2, CL/F, 
Vz/F) will also be summarized with descriptive statistics (generated by WinNonlin) for each dose 
group as well as for all treated subjects in the PK Evaluable Population. 
If data permit, the correlation between Bismuth concentration and efficacy and/or safety 
endpoints may be explored. 
12.9 Interim Evaluation 
Interim analyses are planned for this study for the purpose of DRC. The purpose of the interim 
analysis is to allow the DRC to review the data and to make recommendation to the Sponsor on 
whether or not the next cohort of the subjects should be studied as planned.  
An analysis plan for the DRC will be prepared as an appendix of the DRC charter. The scope of 
the interim analyses for the DRC will be defined in this analysis plan. 
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13 REFERENCES 
1. Berkes M, Obremskey WT, Scannell B, Ellington JK, Hymes RA, Bosse M. Maintenance of 
hardware after early postoperative infection following fracture internal fixation. J Bone Joint 
Surg Am. 2010;92(4):823-28. 
2. Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and verbal rating 
scales for the assessment of post-operative pain in orthopedic patients. J Pain Symptom 
Manage. 1999:18(6);438-46. 
3. Brokelman RBG, Haverkamp D, van Loon C, Hol A, van Kampen A, Veth R. The validation 
of the visual analogue scale for patient satisfaction after total hip arthroplasty. Eur Orthop 
Traumatol. 2012;3(2):101–5. doi:10.1007/s12570-012-0100-3. PMCID: PMC3389603. 
4. Burckhardt CS, Jones KD. Adult measures of pain: The McGill Pain Questionnaire (MPQ), 
Rheumatoid Arthritis Pain Scale (RAPS), Short-Form McGill Pain Questionnaire (SF-MPQ), 
Verbal Descriptive Scale (VDS), Visual Analog Scale (VAS), and West Haven-Yale 
Multidisciplinary Pain Inventory (WHYMPI). Arthritis Rheum. 2003;49;S96-104. 
5. Ciofu O, Tolker-Nielson T. Antibiotic Tolerance and Resistance in Biofilms. In: Bjarnsholt 
T, Jensen PØ, Moser C, Høiby N, editors. Biofilm Infections. New York: Springer; 2011. 
pp 215-29. doi: 10.1007/978-1-4419-6084-9_13. 
6. Cummins JS, Tomek IM, Kantor SR, Furnes O, Engesaeter LB, Finlayson SR. 
Cost‑effectiveness of antibiotic-impregnated bone cement used in primary total hip 
arthroplasty. J Bone Joint Surg Am. 2009;91(3):634-41. PubMed PMID: 19255224. 
doi:10.2106/JBJS.G.01029. 
7. Ferry T, Uckay I, Vaudaux P, Francois P, Schrenzel J, Harbarth S. Laurent F, Bernard L, 
Vandenesch F, Etienne J, Hoffmeyer P, Lew D. Risk factors for treatment failure in 
orthopedic device-related methicillin-resistant Staphylococcus aureus infection. Eur J Clin 
Microbiol Infect Dis. 2010;29(2):171-80. 
8. Gessmann J, Kammler J, Schildhauer TA, Kaminski A. MRSA colonisation in patients with 
proximal femur fractures in a German trauma centre: incidence, infection rates and outcomes. 
Langenbecks Arch Surg. 2012;397(1):117-23. 
9. Ghigo J-M. Natural conjugative plasmids induce bacterial biofilm development. Nature. 
2001;412(26):442-5. 
10. Godil SS, Parker SL, O'Neill KR, Devin CJ, McGirt MJ. Comparative effectiveness and cost-
benefit analysis of local application of vancomycin powder in posterior spinal fusion for 
spine trauma: clinical article. J Neurosurg Spine. 2013;19(3):331-5. 
11. Gristina AG, Naylor P, Myrvik Q. Infections from biomaterials and implants: a race for the 
surface. Medical Progress Through Technology. 1988;14:205-24. 
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12. Gristina AG, Shibata Y, Giridhar G, Kreger A, Myrvik QN. The glycocalyx, biofilm, 
microbes, and resistant infection. Semin Arthroplasty. 1994;5(4):160-70. 
13. Heller A, McIff TE, Lai SM, Burton DC. Intrawound vancomycin powder decreases 
Staphylococcal surgical site infections following posterior instrumented spinal arthrodesis. 
J Spinal Disord Tech. Epub ahead of print 2013. PubMed PMID: 24189484. 
14. Hetrick EM, Schoenfisch MH. Reducing implant-related infections: active release strategies. 
Chem Soc Rev. 2006;35(9):780-9. 
15. Kwon A, Park G, Ryu S, Lim D, Lim D, Choi C, Park Y, Lim Y. Higher biofilm formation in 
multidrug-resistant clinical isolates of Staphylococcus aureus. Int J Antimicrob Ag. 
2008;32:68-72. 
16. Martin JR, Adogwa O, Brown CR, Bagley CA, Richardson WJ, Lad SP, Kuchibhatla M, 
Gottfried ON. Experience with intrawound vancomycin powder for spinal deformity surgery. 
Spine (Phila Pa 1976). Epub ahead of print 2013. PubMed PMID: 24158179. 
17. Morris BJ, Unger RZ, Archer KR, Mathis SL, Perdue AM, Obremskey WT. Risk factors of 
infection after ORIF of bichondylar tibial plateau fractures. J Orthop Trauma. 
2013;27(9):e196-e200. 
18. Nowinski RJ, Gillespie, RJ, Shishani Y, Cohen B, Walch G, Gobezie R. Antibiotic-loaded 
bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a 
retrospective, cohort study of 501 shoulders. J Shoulder and Elbow Surgery. 
2012;21(3):324-8. doi: 10.1016/j/jse.2011.08.072. 
19. Parra-Ruiz J, Vidaillac C, Rybak MJ.Macrolides and staphylococcal biofilms. Rev Esp 
Quimioter. 2012;25(1):10-16. 
20. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the 
tibia: current management concepts. Journal of the American Academy of Orthopaedic 
Surgeons. 2005;13(6):417-27. 
21. Reiter K, Da Silva Paim TG, De Oliveira CF, D’Azevedo PA. High biofilm production by 
invasive multiresistant staphylococci. Acta Pathologica Microbiologica et Immunologica 
Scandinavia. 2011;119:776-81. 
22. Robson MC. Wound infection. A failure of wound healing caused by an imbalance of 
bacteria. Surg Clin North Am. 1997;77(3):637-50. 
23. Robson MC. Award recipient address: Lessons gleaned from the sport of wound watching. 
Wound Repair Regen. 1999;7(1):2-6. 
24. Salgado CD, Dash S, Cantey JR, Marculescu CE. Higher risk of failure of methicillin-
resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res. 
2007;461:48-53. 
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25. Schmidt AH, Swiontkowski MF. Pathophysiology of infections after internal fixation of 
fractures. Journal of the American Academy of Orthopaedic Surgeons. 2000;8(5):285-91. 
26. Selhi HS, Mahindra R, Yamin M, Jain D, De Long WG, Singh J. Outcomes in patients with 
an infected nonunion of the long bones treated with a reinforced antibiotic cement rod. 
J Orthop Trauma. 2012;26(3):184-8. 
27. Selim AJ, Rogers W, Fleishman JA, Qian SX, Fincke BG, Rothendler JA, Kazis LE. 
Updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12). 
Qual Life Res. 2009;18(1):43-52. doi: 10.1007/s11136-008-9418-2. Epub 2008 Dec 3. 
28. Short Musculokeletal Function Assessment Injury and Arthritis Survey; 
http://www.grossortho.com/forms/injury.pdf, accessed 05-16-2014. 
29. Swiontkowski MF, Engelberg R, Martin DP, Angel J. Short musculoskeletal function 
assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am. 
1999;81(9):1245-60. 
30. Tosh PK, McDonald LC. Infection control in the multidrug-resistant era: tending the human 
microbiome. Clin Infect Dis. 2012;54(5);707-13. 
31. Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic only versus 
local intrawound vancomycin antibiotic powder application in addition to intravenous 
antibiotics on postoperative infection in spine surgery in 907 patients. Spine (Phila Pa 1976), 
2013;38(25):2149-55. doi:10.1097/BRS.0000000000000015. PubMed PMID: 24048091. 
32. U.S. Department of Veterans Affairs [internet]. Washington: U.S. Department of Veterans 
Affairs; last updated 21 January 2014. Health Economics Resource Center: Cost-Effective 
Analysis. Available from: http://www.herc.research.va.gov/include/page.asp?id=cost-
effectiveness-analysis#vr36. 
33. Zalavras CG Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop 
Surg. 2003;11(3):212-9. 
 
 
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14 APPENDICES 
Appendix 1: 
Table of Study Events ............................................................................................62 
Appendix 2: 
Flowchart for Microbiological Specimen Processing ............................................63 
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Appendix 1: Table of Study Events 
 
 
Procedure 
Screening 
Baseline/ 
Day of Surgery 
Hour 48- 60 
Hour 72 
Hour 96 
Week 2 
Week 6 
Week 12 
Week 24, EOT 
Early Term / 
Tx Failure 
Day 1 
Day 2 
Day 3 
Day 4 
Day 14 
±4 days 
Day 42 
±8 days 
Day 84 
±8 days 
Day 168 
±8 days 
Review of eligibility criteria 
X 
X 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
Surgery/Administration of the 
Investigational Product 
 
X 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
 
 
 
 
Interval physical exam 
 
X 
X 
 
 
X 
X 
X 
X 
X 
Hematology 
X 
 
X 
 
 
 
X 
X 
X 
X 
Serology 
 
X 
 
 
 
X 
X 
X 
X 
X 
Serum chemistry 
X 
 
X 
 
 
 
X 
X 
X 
X 
Urinalysis 
X 
 
X 
 
 
 
X 
X 
X 
X 
Pregnancy test 
X 
X 
 
 
 
 
 
 
X 
X 
BisEDT Blood levels1 
 
X 
X 
X 
X 
X 
 
 
 
 
12-lead ECG 
X 
X 
X 
 
 
 
 
 
X 
X 
Vital signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Patient-reported outcomes2 
X 
 
 
 
 
X 
X 
X 
X 
X 
Surgical site signs and symptoms 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Surgical site pain score 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Microbiology 
 
X 
(X)3 
 
 
(X) 
(X) 
(X) 
(X) 
(X) 
Radiographic evaluation 
 
X 
 
 
 
X 
X 
X 
X 
X 
Concomitant medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
1 PK blood samples will be collected pre-dose and at nominal 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 (Day 3), 96 (Day 4) and 336 (Day 14; Week 2) hours after administration of the 
investigational product 
2 Patient-reported outcomes include the Veterans Rand 12 Item Health Survey (VR-12) and Short Musculoskeletal Function Assessment (SMFA) 
3 Microbiology will be performed at any time that a new surgical intervention is required. 
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Appendix 2: Flowchart for Microbiological Specimen Processing 
 
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PROTOCOL AMENDMENT FORM 
DATE: 12/29/15 
AMENDMENT NUMBER: 02 
PROTOCOL NUMBER: MBN-101-201 (Version 2.1) 
 
 
SPONSOR: Microbion Corporation 
 
PROTOCOL TITLE: A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week Escalating Dose 
Study to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally Applied MBN-101 
to Infected Osteosynthesis Sites 
 
REASON(S) FOR CHANGE(S): Revise protocol with administrative changes and updated methodologies. 
 
CHANGE(S): 
Note – All changes refer to page numbers in the Clean Version 2.1 
 
Location 
From 
To 
Comment 
Header 
Version 2.0, 
Issue Date 08 October 2015 
Version 2.1, 
Issue Date 29 December 2015 
Update version 
Page 1 
Version 2.0 
Issue Date: 08 October 2015 
 
Replaces Version 1.0 
Dated 06 May 2015 
Version 2.1 
Issue Date: 29 December 2015 
 
Replaces Version 2.0 
Dated 08 October 2015 
Update version 
Page 1 
Version: 2.0 
Version: 2.1 
Update version 
Page 8, 
Page 37 
and 
Page 49 
Protocol Synopsis – Criteria for 
Evaluation: Efficacy Endpoints 
 
Cite updated VAS scale 
template 
Surgical site pain score and change 
from baseline in pain score at each 
post baseline time point. Pain 
intensity at the surgical site will be 
assessed by Visual Analog Scale 
(VAS, 0-100 mm). 
Surgical site pain score and change 
from baseline in pain score at each 
post baseline time point. Pain 
intensity at the surgical site will be 
assessed by Visual Analog Scale 
(VAS, 0-10 scale). 
 
Page 10 
Other Appropriate Trial Contact Personnel 
Administrative change 
 
deleted 
 
 
 
Name 
Markus Heep, MD 
 
Medical Director Infectious Diseases 
 
Medpace Germany GmbH 
 
Office Phone Number 
+49 174 190 6865 
E-mail: 
M.Heep@Medpace.com 
 
 
 
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PROTOCOL AMENDMENT FORM 
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AMENDMENT NUMBER: 02 
PROTOCOL NUMBER: MBN-101-201 (Version 2.1) 
 
 
Location 
From 
To 
Comment 
Page 29 
6.1.7 Pain Assessments 
 
 
 
Pain related specifically to the 
surgical site (Surgical Site Pain 
Score) will be assessed via a Visual 
Analog Scale (VAS, 0-100 mm, 
where 0=no pain at all and 
100 =the worst possible pain) 
utilizing a 24 hour recall at 
screening, baseline, Hour 48 and 
Weeks 2, 6, 12, and 24. 
Pain related specifically to the 
surgical site (Surgical Site Pain 
Score) will be assessed via a Visual 
Analog Scale (VAS, 0-10 scale, 
where 0=no pain at all and 
10 =the worst possible pain) 
utilizing a 24 hour recall at 
screening, baseline, Hour 48 and 
Weeks 2, 6, 12, and 24. 
Cite updated VAS scale 
template 
Page 30 
6.1.9.3 Specimen Processing: 
IHMA (Central Laboratory) 
 
 
 
The tissue site sample and swabs 
will be analyzed immediately in the 
central laboratory for the presence 
of infectious pathogens by Gram 
stain and microbiological culture 
for both aerobic and anaerobic 
bacteria. 
The tissue site sample and swabs 
will be analyzed immediately in the 
central laboratory for the presence 
of infectious pathogens by 
microbiological culture for both 
aerobic and anaerobic bacteria. 
Delete Central Laboratory 
Gram Stain, since only 
Local Laboratory Gram 
Stain will be performed 
and utilized for patient care 
 
Susceptibility tests will be quality-
controlled as detailed by CLSI 
using reference quality control 
strains and previously-established 
ranges for MBN-101 and 
comparators. 
Susceptibility tests for 
aerobic/facultative bacteria will be 
quality-controlled as detailed by 
CLSI using reference quality 
control strains and previously-
established ranges for MBN-101 
and comparators. Susceptibility 
tests for anaerobic bacteria will 
also include CLSI reference quality 
control strains, however, since 
quality control ranges for anaerobic 
bacteria are not yet established, the 
MIC values for the quality control 
strains will be collected then 
retrospectively compared to the 
quality control ranges once they are 
available. 
Cite updated testing 
strategy 
Page 38 
8.3.1 Sample Collection and 
Handling 
 
 
 
Documentation stating the exact 
time of blood sampling (5 mL per 
timepoint) in relation to the time of 
study drug administration will be 
collected and provided. 
Documentation stating the exact 
time of blood sampling (4 mL per 
timepoint) in relation to the time of 
study drug administration will be 
collected and provided. 
Cite correct tube size 
 
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PROTOCOL AMENDMENT FORM 
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AMENDMENT NUMBER: 02 
PROTOCOL NUMBER: MBN-101-201 (Version 2.1) 
 
 
Location 
From 
To 
Comment 
Page 38 
8.3.2 Assay Methodology 
 
 
 
The samples are prepared for 
analysis by digestion with 2% nitric 
acid followed by dilution into 2% 
Tetramethyl Ammonium 
Hydroxide (TMAH) with 0.02% 
Triton X-100, and subsequent 
quantitation of Bi by ICP-MS 
analysis. 
The samples are prepared for 
analysis by digestion with 2% nitric 
acid and H2O2, followed by 
centrifugation and dilution with 
water into 2% Tetramethyl 
Ammonium Hydroxide (TMAH) 
with 0.02% Triton X-100, and 
subsequent quantitation of Bi by 
ICP-MS analysis. 
Cite updated methodology 
 
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1 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 
24-week Escalating Dose Study to Assess the Safety, Tolerability 
and Clinical Activity of 3 Concentrations of Locally Applied MBN-101 
to Infected Osteosynthesis Sites 
PROTOCOL NUMBER: MBN-101-201 
Version 2.1 Issue Date: 29 December 2015 
Replaces Version 2.0 Dated 08 October 2015 
Regulatory Sponsor: 
Microbion Corporation 
1102 West Babcock, Suite B 
Bozeman MT 59715 
Version: 2.1 
Microbion Corporation 
 
Reviewed and Approved by: 
 
 
 
29 December2015 
Dr. Brett Baker 
Microbion Corporation 
President and Chief Scientific Officer 
 
Date 
Confidentiality 
This document is the confidential property of Microbion Corporation. 
No part of it may be reproduced, published, or transmitted by other persons 
without written permission of Microbion Corporation. 
 
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GRANT SUPPORT 
This Phase 2a clinical study is supported in part by a $2.5 million grant awarded through the 
"Defense Medical Research and Development Program (DMRDP) Military Infectious Diseases 
Clinical Trial Award, W81XWH-12-DMRDP-MID-CTA". The grant award number is 
W81XWH-12-2-0100.  
The Awardee is the University of Pennsylvania, and the Principal Investigator (PI) for this grant 
award is Dr. Samir Mehta, Chief, Division of Orthopaedic Trauma, and Assistant Professor of 
Orthopaedic Surgery at the Hospital of the University of Pennsylvania. Dr. Mehta is also serving 
as the clinical PI for the University of Pennsylvania orthopaedic trauma clinical site. 
Participating as a Co-Investigator in this grant award is Dr. Saam Morshed, attending 
orthopaedic trauma surgeon and Director of the Clinical Research Center at the University of 
California San Francisco (UCSF) and the San Francisco General Hospital Orthopaedic Trauma 
Institute (OTI). Dr. Morshed will also serve as the clinical PI for the UCSF orthopaedic trauma 
clinical site.  
The Program Sponsor, Microbion Corporation, is represented by Dr. Brett Baker, President and 
Chief Scientific Officer. 
 
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INVESTIGATOR AGREEMENT 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week Escalating Dose Study 
to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally 
Applied MBN-101 to Infected Osteosynthesis Sites 
I have read the protocol and agree that it contains all necessary details for carrying out the study 
as described. I will conduct this protocol as outlined therein and will make all reasonable efforts 
to complete the study within the designated time. 
I will provide copies of the protocol and access to all information furnished by Microbion 
Corporation to study personnel under my supervision. I will discuss this material with them to 
ensure that they are fully informed about the drug and the study. 
I understand that the study may be terminated or enrollment suspended at any time by Microbion 
Corporation with or without cause, or by me, if it becomes necessary to protect the best interests 
of the study subjects. 
I agree to conduct this study in accordance with the requirements of this protocol and in 
accordance with the following: 
 Good Clinical Practice: Consolidated Guideline International Conference on Harmonisation 
of Technical Requirements for the Registration of Pharmaceuticals for Human Use, ICH E6 
(May 1996) 
 United States (U.S.) Code of Federal Regulations (CFR) associated with clinical studies 
(21 CFR parts 50, 56, 312) 
 Declaration of Helsinki, concerning medical research in humans (“Ethical Principles for 
Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 1975, Venice 
1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, Washington 
2002 and Tokyo 2004). 
 
  
Investigator’s Printed Name 
  
Investigator’s Signature 
 Date 
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PROTOCOL SYNOPSIS 
Protocol Number 
MBN-101-201 
Title 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week 
Escalating Dose Study to Assess the Safety, Tolerability and Clinical 
Activity of 3 Concentrations of Locally Applied MBN-101 to Infected 
Osteosynthesis Sites 
Regulatory Sponsor 
Microbion Corporation, 1102 West Babcock, Suite B, Bozeman MT 59715 
Name of 
Investigational 
Product 
MBN-101 
Phase 
2a 
Investigators/Study 
Centers 
3-4 Study Centers in the United States  
Objectives: 
Primary Objective 
To evaluate the safety and tolerability of single escalating doses of locally 
administered MBN-101 or placebo as adjunct to standard of care 
antimicrobial and surgical therapy 
Secondary Objectives  
To evaluate the clinical activity of single escalating doses of locally 
administered MBN-101 
 
To evaluate the pharmacokinetics of single escalating doses of locally 
administered MBN-101 
Number of Subjects 
36 
Study Design and 
Methodology 
This is a randomized, single-blind, placebo-controlled, multi-center study to 
assess the safety and tolerability of single escalating doses of MBN-101 
applied directly to target structures within infected osteosynthesis sites during 
revision surgery with or without hardware removal and replacement for 
patients diagnosed with an apparent fracture site infection within one year of 
the last surgical intervention. Three successive cohorts of 12 patients will be 
enrolled in this trial. Consecutive patients from each of the study sites will be 
screened for potential participation as they present to the orthopedic service 
for clinical care for their postoperative infections. Patients meeting eligibility 
criteria on screening will be offered participation in the study. 
Following baseline evaluation, patients will receive standard of care 
treatment for their postoperative fracture site infection that includes systemic 
antibacterial treatment per institutional standard of care guidelines and 
revision surgery with or without hardware removal and replacement as 
indicated. A single application of MBN-101 or placebo, applied 
intraoperatively directly to target structures within infected osteosynthesis 
sites, will be performed following the final irrigation and debridement 
procedure and immediately prior to definitive closure. In cases where original 
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hardware is retained, MBN-101 will be applied to all accessible surfaces of 
hardware and adjacent bone (target structures). In cases where hardware is 
replaced or in cases of two-stage procedures, MBN-101 will be applied to all 
accessible surfaces of hardware and adjacent bone (target structures) 
following implantation of hardware and immediately prior to definitive 
closure. If wounds are left open, the investigational product will be applied 
immediately prior to definitive closure. The minimum amount of MBN-101 
required to achieve a thin coat of the relevant target structures within the 
infected osteosynthesis site will be used. 
Patients will be randomized 3:1 (active:control) to three successive doses 
(0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up 
to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent). Enrollment to the 
next dose cohort will not commence until an evaluation by the Data Review 
Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort. 
PK assessments will be performed predose and at nominal 1, 6, 12, 24, 36, 48 
(Day 2), 60, 72 (Day 3), 96 (Day 4), and 336 (Day 14; Week 2) hours after 
administration of study drug. 
Patients will undergo study visits at Hour 48 and Weeks 2, 6, 12, and 24. All 
patients will be followed for a total of 24 weeks after surgery. 
Study Population: 
Inclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “YES” answer (unless not applicable): 
1. Patients who: 
 
have had operative fracture fixation of the upper extremity 
(AO/OTA class 15, 11-13, 21-23), lower extremity (AO/OTA class 
31-34, 41-44, 81, 82) or pelvis (61, 62), or have undergone 
arthrodesis 
 
are diagnosed with an apparent fracture site infection within one year 
of their last surgical intervention and have at least one of the 
following: 
 
Elevated ESR above the upper limit of normal 
 
Elevated CRP above the upper limit of normal 
 
Draining wound / sinus tract 
 
Positive culture from site of prior surgery by aspirate or other 
modality 
 
Local erythema or induration at the site of prior surgery 
 
Exposed hardware 
 
Periosteal reaction on x-ray 
 
Loose or broken hardware  
 
require revision surgery with or without removal and replacement of 
existing hardware 
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2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed 
and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as 
per institution’s standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after 
revision surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile 
or at least 2 years postmenopausal, must agree to use one of the 
following forms of contraception from screening through the Week 24 
visit: hormonal (oral, implant, or injection) begun >30 days prior to 
screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications 
and they must ensure their female sexual partner complies with the 
contraception requirements:  
 
Be sexually abstinent from Baseline through Week 24  
 
Be > 6 months post-vasectomy  
 
Agree to use a condom with spermicide from Baseline through 
Week 24 
7. Have read and signed the Informed Consent Form (ICF) after the nature 
of the study has been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of 
personal health information in accordance with Health Insurance 
Portability and Accountability Act (HIPAA) 
Exclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “NO” answer (unless not applicable): 
1. Patients who are no longer hardware dependent or are definitively treated 
for their infection by hardware removal without replacement 
2. Greater than one year time lapse from last operative procedure 
3. Patients with a previous revision surgery at the site 
4. Patients with multiple, non-contiguous fracture site infections 
5. Pathologic fracture (not including osteoporosis)  
6. Patient requires immunosuppressive therapy (Topical or inhaled 
corticosteroids are permitted) 
7. Serum creatinine, ALT, AST or Alkaline Phosphatase >1.5 times the 
upper limit of the normal range of the local testing laboratory 
8. Absolute neutrophil count <1000 
9. Patients without definitive soft-tissue coverage over the surgical site at 
time of study product administration 
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10. Any condition that has required treatment with any other bismuth 
containing compound within the last 2 weeks (i.e., Kaopectate or 
Pepto-Bismol) 
11. Participation in an investigational trial to evaluate pharmaceuticals or 
biologics within the past 3 months 
12. Individuals undergoing surgical treatment for more than one infected 
fracture 
13. Known allergy to metals or materials comprising the orthopedic 
hardware, bismuth and/or MBN-101 excipients (methylcellulose, 
Tween 80 (polysorbate 80)) 
14. Patients who are pregnant, lactating, or female patients who have a 
positive serum hCG as determined by laboratory testing 
15. Immunocompromised due to illness or organ transplant 
16. History of chronic or recurrent infections (≥ 3 infections at the same site 
within 12 months) other than the index infected osteosynthesis site 
17. History of any type of cancer (excluding non-melanomatous localized 
skin cancer or completely excised and cured carcinoma-in-situ of uterine 
cervix) 
18. Poorly controlled diabetes mellitus (hemoglobin A1c > 9.0% for 
≥ 6  months despite management by a physician) 
19. History of medical noncompliance 
20. Other medical conditions which, in the opinion of the Principal 
Investigator, would jeopardize the safety of the study subject or impact 
the validity of the study results. 
21. Current incarceration 
Investigational 
Product, Dose and 
Mode of 
Administration: 
MBN-101: A suspension of 0.025, 0.075, or 0.25 mg/mL (w:v) BisEDT 
powder in 3% methylcellulose / 0.5% Tween 80 / 10 mM sodium chloride / 
10 mM sodium phosphate, pH 7.4 (up to 8 mL dose volume) applied directly 
to structures within infected osteosynthesis sites during revision surgery with 
or without hardware removal and replacement as an adjunct to standard care 
systemic antimicrobial therapy. 
Reference Therapy, 
Dose and Mode of 
Administration: 
MBN-101 diluent (placebo): 3% methylcellulose / 0.5% Tween 80 / 
10 mM sodium chloride / 10 mM sodium phosphate, pH 7.4 (up to 8 mL dose 
volume) applied directly to structures within infected osteosynthesis sites 
during revision surgery with or without hardware removal and replacement 
as an adjunct to standard care systemic antimicrobial therapy. 
Study Duration 
24 weeks 
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Criteria for Evaluation: 
Efficacy Endpoints 
 
Proportion of treatment failures. A treatment failure is defined as a 
subject with non-healing or worsening status of their surgical site 
requiring serious intervention by Week 24. 
 
Cumulative number of serious interventions (as defined in Section 
12.6.2) at Week 24. 
 
Time to first serious intervention, time to readmission and time to 
reoperation, exclusive of serious interventions, readmissions, and 
reoperations associated with a healed fracture site. 
 
Number of subjects undergoing removal of stabilizing orthopedic 
hardware due to a healed fracture site by Week 24. 
 
Time to removal of orthopedic hardware due to a healed fracture site. 
 
Incidence and intensity of surgical site signs and symptoms, including 
local erythema, induration, drainage and degree of healing. 
 
Change from baseline in patient-reported outcomes at each post baseline 
time point. Patient-reported outcomes will include Veterans Rand 12 
Item Health Survey (VR-12) and Short Musculoskeletal Function 
Assessment (SMFA). 
 
Surgical site pain score and change from baseline in pain score at each 
post baseline time point. Pain intensity at the surgical site will be 
assessed by Visual Analog Scale (VAS, 0-10 scale). 
 
Findings of microbiology evaluations at the surgical site. Microbiologic 
success is assessed by clearance of infection. 
 
Findings of radiographic evaluations at the surgical site. Radiographic 
success is assessed by healing on radiologic examination. 
 
Changes in serologic markers CRP and ESR at each post baseline time 
point. 
Safety Endpoints 
 
Treatment-emergent adverse events. 
 
Treatment-emergent serious adverse events. 
 
Changes in clinical laboratory tests (clinical chemistry, hematology, and 
urinalysis). 
 
Changes in vital signs (blood pressure, pulse, respiratory rate and body 
temperature). 
 
Changes in physical exams. 
 
Clinical findings of 12-lead electrocardiograms. 
 
Change in microbiology status 
Pharmacokinetic 
Endpoints 
 
Whole blood concentrations of Bismuth (Bi) will be measured after 
administration of single escalating doses of MBN-101 (bismuth as a 
surrogate for BisEDT) and will be used to calculate pharmacokinetic 
parameters (i.e., Tmax, Cmax, AUC0-t, AUC0- ∞, T1/2, CL/F, Vz/F). 
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Statistical Methods: 
Statistical Analysis 
Consideration: 
The study sample of size of 36 subjects was chosen empirically for the 
purpose of the study without considering any formal statistical hypothesis 
testing. 
The safety analysis set will include all subjects who are randomized and 
receive any study drug; the efficacy analysis set will include all randomized 
subject with at least one post treatment assessment. Pharmacokinetic analysis 
set will include all subjects who have sufficient plasma samples to allow for 
calculation of pharmacokinetic parameters.  
All safety and efficacy endpoints will be tabulated with descriptive statistics; 
data from all placebo subjects (3 per cohort; 9 subjects in total) will be 
pooled. Data from BisEDT treated subjects will be presented by dose 
(9 subjects per dose) and combined (a total of 27 subjects). If data permits, 
differences between the treatment groups and 95% confidence intervals for 
the difference will be presented. 
If data permit, exploratory dose-response analyses will be performed for 
selected efficacy and safety endpoints.  
The primary analyses of efficacy and safety endpoints will be based on the 
actual treatment received in the event that the received treatment is not the 
assigned treatment; however, ‘as assigned’ sensitivity analyses are planned to 
evaluate the robustness of the efficacy data. 
 
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SPONSOR CONTACT INFORMATION 
Medical Monitor 
Name: 
Brian Murphy, MD 
Sr. Medical Director, Medpace Infectious Diseases 
Office Phone Number: 
513-579-9911, ext. 2416 
Mobile Phone Number: 
859-619-0037 
E-mail: 
b.murphy1@medpace.com 
Other Appropriate Trial Contact Personnel 
Name 
Ronnie McAdams 
Clinical Trial Manager, Associate Director, Medpace 
Office Phone Number 
513-579-9911, ext. 2845 
Mobile Phone Number 
513-394-0516 
Fax 
513-579-0444 
E-mail: 
r.mcadams@medpace.com 
Medpace Clinical Safety:  
SAE hotline: 
800-730-5779, ext. 2999 
Facsimile: 
866-336-5320 
E-mail: 
medpace-safetynotification@medpace.com 
 
If any Sponsor contact information needs to be changed during the course of the study, this will 
be done by the Sponsor, with written notification to the Investigator, and will not require a 
protocol amendment. 
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LIST OF ABBREVIATIONS 
AE 
Adverse event 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase (Serum glutamic pyruvic transaminase [SGPT]) 
AO/OTA 
Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association 
AST 
Aspartate aminotransferase (Serum glutamic oxaloacetic transaminase [SGOT]) 
AUC0-∞ 
Area under the curve from time 0 to infinity 
AUC0-t 
Area under the curve from time 0 to the time of the last measurable concentration 
Bi 
Bismuth, used as a surrogate in concentration and PK analyses after MBN-101 
administration 
BisEDT 
Bismuth-1,2-ethanedithiol 
BMI 
Body mass index 
BUN 
Blood urea nitrogen 
CFR 
Code of Federal Regulations 
CK 
Creatinine kinase 
CL/F 
Apparent clearance after extravascular administration  
CLSI 
Clinical and Laboratory Standards Institute 
Cm 
Centimeter 
Cmax 
Maximum observed concentration 
CRF 
Case report form 
CRP 
C-reactive protein 
DFU 
Directions for Use 
DOD 
Department of Defense 
DRC 
Data Review Committee 
ECG 
Electrocardiogram 
ESBL 
Extended spectrum beta lactamase 
ESR 
Erythrocyte sedimentation rate 
FDA 
U.S. Food and Drug Administration 
GCP 
Good Clinical Practice 
GGT 
Gamma glutamyl transferase 
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hCG 
Human chorionic gonadotropin 
HIPAA 
Health Insurance Portability and Accountability Act 
ICF 
Informed Consent Form  
ICH 
International Conference on Harmonization  
ICP-MS 
Inductively coupled plasma mass spectrometry 
IHMA 
International Health Management Associates, Inc. 
IRB 
Institutional Review Board  
ITT 
Intent to treat 
IUD 
Intrauterine device 
IV 
Intravenous 
IVRS 
Interactive Voice Response System 
Kg 
Kilogram 
MBN-101 
Bismuth-1,2-ethanedithiol (BisEDT) suspension 
MC 
Methylcellulose 
MCS 
Mental health domain score 
MCV 
Mean corpuscular volume 
MDR 
Multidrug Resistant 
MedDRA 
Medical Dictionary for Regulatory Activities 
mg 
milligram 
mg/mL 
Milligrams per milliliter 
MIC 
Minimal inhibitory concentration 
mITT 
Modified intent to treat 
mL 
Milliliter 
mm 
Millimeter 
mM 
Millimolar 
MRSA 
Methicillin resistant Staphylococcus aureus 
MRSE 
Methicillin resistant Staphylococcus epidermidis 
MSSA 
Methicillin-sensitive Staphylococcus aureus 
NCA 
Non-compartmental (PK) analysis 
ng/mL 
Nanograms per milliliter 
OR 
Operating room 
ORP 
Office of Research Protections 
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PCS 
Physical health domain score 
PI 
Principal investigator 
PK 
Pharmacokinetics 
PT 
Prothrombin time 
PTT 
Partial thromboplastin time 
QIDP 
Qualified Infectious Disease Product 
RBC 
Red blood cells 
SAE 
Serious Adverse Event 
SAE CRF 
Serious Adverse Event Case Report Form 
SAP 
Statistical Analysis Plan 
SGOT 
Serum glutamic oxaloacetic transaminase 
SGPT 
Serum glutamic pyruvic transaminase 
SMFA 
Short Musculoskeletal Function Assessment 
SOC 
System organ class 
SOP 
Standard Operating Procedure 
T1/2 
Apparent half-life after extravascular administration 
TEAE 
Treatment-emergent adverse event 
Tmax 
Time of the maximal observed concentration 
USAMRMC US Army Medical Research and Materiel Command 
VAS 
Visual Analog Scale 
VR-12 
Veterans Rand 12 Item Health Survey 
Vz/F 
Apparent volume of distribution after extravascular administration 
w/v 
Weight:volume 
w:w 
Weight:weight 
WBC 
White blood cells 
 
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TABLE OF CONTENTS 
Grant Support .................................................................................................................................. 2 
Investigator Agreement ................................................................................................................... 3 
Protocol Synopsis............................................................................................................................ 4 
Sponsor Contact Information ........................................................................................................ 10 
List of Abbreviations .................................................................................................................... 11 
1 
INTRODUCTION ................................................................................................................18 
1.1 
Clinical Problem .......................................................................................................18 
1.2 
Investigational Therapy ............................................................................................19 
1.3 
Value of MBN-101 for the Treatment of the Clinical Problem ................................20 
2 
OBJECTIVES .......................................................................................................................21 
2.1 
Primary ......................................................................................................................21 
2.2 
Secondary ..................................................................................................................21 
3 
INVESTIGATIONAL PLAN ...............................................................................................22 
3.1 
Study Description......................................................................................................22 
3.2 
Number of Subjects...................................................................................................23 
3.3 
Number of Sites ........................................................................................................23 
3.4 
Clinical Trial Material...............................................................................................23 
3.4.1 
MBN-101 .....................................................................................................23 
3.4.2 
Placebo (MBN-101 diluent) ........................................................................23 
3.5 
Dose ..........................................................................................................................24 
4 
STUDY POPULATION .......................................................................................................25 
4.1 
Inclusion Criteria ......................................................................................................25 
4.2 
Exclusion Criteria .....................................................................................................26 
5 
SUBJECT ENROLLMENT .................................................................................................27 
5.1 
Medical History ........................................................................................................27 
5.2 
Physical Exam ...........................................................................................................27 
5.3 
Studies .......................................................................................................................27 
5.4 
Laboratory Tests at Screening Visit ..........................................................................27 
6 
STUDY PROCEDURES ......................................................................................................28 
6.1 
Description of Study Procedures ..............................................................................28 
6.1.1 
Medical History ...........................................................................................28 
6.1.2 
Physical Exams ............................................................................................28 
6.1.3 
Vital Signs ...................................................................................................28 
6.1.4 
12-lead ECG ................................................................................................28 
6.1.5 
Laboratory Tests ..........................................................................................28 
6.1.6 
BisEDT (MBN-101) Blood Levels .............................................................29 
6.1.7 
Pain Assessments ........................................................................................29 
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6.1.8 
Patient Reported Outcomes .........................................................................29 
6.1.9 
Microbiology ...............................................................................................29 
6.1.9.1 
Specimen Collection ...................................................................29 
6.1.9.2 
Specimen Processing: Local Laboratory ....................................29 
6.1.9.3 
Specimen Processing: IHMA (Central Laboratory) ...................30 
6.1.9.4 
Integration of Local Site Laboratory and Central Laboratory 
Primary Isolation and Identification Results ..............................30 
6.1.10 Radiographic Evaluation .............................................................................31 
6.1.11 Surgical Site Signs and Symptoms Evaluation ...........................................31 
6.2 
Screening and Baseline Assessments........................................................................31 
6.3 
Randomization Procedure .........................................................................................31 
6.4 
Unblinding Procedure ...............................................................................................32 
6.5 
Investigational Product Administration ....................................................................32 
6.5.1 
Surgical Site Identification ..........................................................................32 
6.5.2 
Study Drug Administration .........................................................................32 
6.6 
Study Assessments ....................................................................................................35 
6.7 
Safety Monitoring .....................................................................................................35 
6.8 
Study Monitoring ......................................................................................................35 
6.9 
Patient Withdrawals ..................................................................................................35 
6.10 
Individual Patient Stopping Rules ............................................................................35 
6.11 
Study Stopping Rules ................................................................................................35 
7 
CONCOMITANT MEDICATIONS ....................................................................................36 
8 
STUDY ENDPOINTS ..........................................................................................................37 
8.1 
Safety Endpoints .......................................................................................................37 
8.2 
Efficacy Endpoints ....................................................................................................37 
8.3 
Pharmacokinetic Endpoint ........................................................................................38 
8.3.1 
Sample Collection and Handling .................................................................38 
8.3.2 
Assay Methodology .....................................................................................38 
8.3.3 
PK Analysis .................................................................................................38 
9 
ADVERSE EVENTS ............................................................................................................39 
9.1 
Reporting and Following Adverse Events ................................................................39 
9.2 
Severity .....................................................................................................................40 
9.3 
Relationship to Clinical Trial Material .....................................................................40 
9.4 
Serious Adverse Events ............................................................................................41 
9.4.1 
Definition .....................................................................................................41 
9.4.2 
Reporting .....................................................................................................41 
9.5 
Pregnancies ...............................................................................................................42 
9.6 
Data Review Committee (DRC) ...............................................................................42 
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10 
INVESTIGATIONAL PRODUCT MANAGEMENT .........................................................43 
10.1 
Study Drug ................................................................................................................43 
10.2 
Study Drug Packaging and Labeling ........................................................................44 
10.3 
Study Drug Storage ...................................................................................................44 
10.4 
Study Drug Accountability .......................................................................................44 
10.5 
Study Drug Handling and Disposal ..........................................................................44 
11 
GENERAL CONSIDERATIONS ........................................................................................45 
11.1 
Basic Principles .........................................................................................................45 
11.2 
Institutional Review Board .......................................................................................45 
11.3 
Informed Consent......................................................................................................45 
11.4 
Study Termination ....................................................................................................46 
11.5 
Regulatory Documentation .......................................................................................46 
11.6 
Study Documentation................................................................................................46 
11.7 
Data Handling and Record Keeping .........................................................................47 
11.8 
Use of Information and Publication ..........................................................................47 
11.9 
Independent Medical Monitor...................................................................................48 
12 
STATISTICAL ANALYSIS METHODOLOGY ................................................................49 
12.1 
Efficacy Endpoints ....................................................................................................49 
12.2 
Changes in serologic markers CRP and ESR at each post baseline time 
point.Safety Endpoints ..............................................................................................50 
12.3 
Sample Size Considerations ......................................................................................50 
12.4 
Analysis Datasets ......................................................................................................51 
12.5 
Disposition and Study Population Characteristics ....................................................51 
12.6 
Efficacy Analysis ......................................................................................................52 
12.6.1 Treatment Failure ........................................................................................52 
12.6.2 Incidence of Serious Interventions ..............................................................52 
12.6.3 Time to First Serious Interventions .............................................................53 
12.6.4 Subjects Undergoing Removal of Stabilizing Orthopedic Hardware .........53 
12.6.5 Surgical Site Signs and Symptoms ..............................................................53 
12.6.6 Patient-Report Outcomes ............................................................................53 
12.6.6.1 The Veterans RAND 12 Item Health Survey (VR-12) 
Questionnaire ..............................................................................53 
12.6.6.2 The Short Musculoskeletal Function Assessment 
Questionnaire (SMFA) ...............................................................53 
12.6.7 Pain Assessments ........................................................................................54 
12.6.8 Microbiology ...............................................................................................54 
12.6.9 Radiographic evaluation ..............................................................................55 
12.6.10 Serologic Markers .......................................................................................55 
12.6.11 Subgroup Analyses for Efficacy Endpoints ................................................55 
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12.6.12 Sensitivity Analyses for Efficacy Endpoints ...............................................55 
12.7 
Safety Analysis .........................................................................................................56 
12.7.1 Study Drug Exposure and Concentrations ..................................................56 
12.7.2 Adverse Events ............................................................................................56 
12.7.3 Clinical Laboratory Tests ............................................................................56 
12.7.4 12-lead ECG ................................................................................................56 
12.7.5 Vital Sign Measurements ............................................................................57 
12.7.6 Physical Examinations ................................................................................57 
12.7.7 Subgroup Analyses for Safety Endpoints ....................................................57 
12.8 
PK Analysis ..............................................................................................................57 
12.9 
Interim Evaluation ....................................................................................................57 
13 
REFERENCES .....................................................................................................................58 
14 
APPENDICES ......................................................................................................................61 
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1 INTRODUCTION 
1.1 Clinical Problem 
Postoperative orthopedic infections, particularly antibiotic-resistant infections, present a serious 
clinical challenge to surgeons and other treating physicians, since these infections involve 
foreign materials (stabilizing orthopedic hardware) which are frequently associated with 
persistent microbial biofilms (Hetrick, 2006). Surgical intervention, including irrigation, 
debridement and potential replacement of orthopedic hardware, combined with a prolonged 
course of systemic antibiotics, is the standard of care for postoperative infections (Schmidt, 
2000; Patzakis, 2005). However, outcomes associated with these infections are often poor, 
including chronic/recurrent infections, repeated hospitalizations, repeated surgeries, multiple 
courses of systemic antibiotic treatment, loss of function, disability, amputation and death 
(Berkes, 2010). 
Systemic antibiotics are poorly efficacious in the treatment of heavily contaminated or infected 
wounds (Zalavras, 2003; Robson, 1997) and often antibiotics “…have practical and potential 
value only if a therapeutic blood level or, more importantly, tissue level is achieved within the 
first 4 hours after wounding” (Robson, 1999), i.e., before biofilm formation. The ‘contest’ 
between bacteria and host tissues with respect to speed of colonization of foreign objects such as 
orthopedic medical devices has been described as the “race for the surface’ (Gristina, 1988). 
Bacteria are able to adhere to foreign, implanted objects almost immediately, facilitating rapid 
formation of microbial biofilms which drastically increase the resistance of wound-associated 
bacteria and contribute significantly to persistence and virulence of the infection (Parra-Ruiz, 
2012; Gristina, 1994). Such biofilms can serve as quiescent reservoirs of adherent, antibiotic-
tolerant or antibiotic-resistant bacteria within the wound, or as foci of active infections, which 
helps to explain the chronic and/or recurrent nature of many device-related infections. In 
addition, biofilms are hypermutable (Ciofu, 2011), increasing the likelihood of developing 
genetically-based antibiotic resistance. Finally, biofilms serve as environments in which bacteria 
can exchange genetic material encoding antibiotic resistance genes (Ghigo, 2001). Recent studies 
have shown that the most highly multidrug resistant (MDR) bacteria are also the strongest 
biofilm-forming bacteria (Kwon, 2008), and similarly, that invasive MDR bacteria are usually 
biofilm-forming bacteria (Reiter, 2011). 
The high incidence of postoperative orthopedic device-related infections, as well as the 
shortcomings of the standard of care treatment in resolving those infections, particularly 
considering the increasing prevalence of antibiotic-resistant pathogens, has resulted in an 
expanding unmet need for safe, innovative, new and effective therapies to reduce the infectious 
risks and consequences of these infections, which increasingly involve antibiotic- resistant 
strains (Gessman, 2012; Morris, 2013; Tosh, 2012). Antibiotic resistance adds significantly to 
the challenge of successfully resolving these orthopedic infections (Ferry, 2010; Salgado, 2007). 
For example, infection treatment failures are nine times more frequent in orthopedic patients 
with MRSA infections than methicillin-sensitive S. aureus (MSSA) infections (Salgado, 2007).  
Development of local therapies that eradicate established biofilms or prevent the formation of 
biofilms (as a new target) is an innovative new clinical strategy, particularly considering the 
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shortcomings of systemically administered antibiotics for treatment of wound infections. For 
example, several groups have investigated the direct, local application of vancomycin powder on 
the surgical wound in combination with systemic prophylaxis to prevent or treat infection. The 
outcomes of these studies have been mixed, with some groups reporting a reduced infection rate 
and/or a reduction in patient treatment costs (Heller, 2013; Godil, 2013) and others reporting no 
benefit (Tubaki, 2013; Martin, 2013). Antibiotic-loaded bone cement containing tobramycin, 
gentamicin, or vancomycin/tobramycin or other antibiotic combinations have been investigated 
for their ability to reduce infection rates and /or reduce costs when applied locally in a variety of 
orthopedic surgical procedures (Cummins, 2009; Nowinski, 2012; Selhi, 2012). Evidence 
suggests that local therapies may reduce implant related surgical site infections. 
1.2 Investigational Therapy 
MBN-101 [Bismuth-1,2-ethanedithiol (BisEDT) suspension] represents the first drug product 
from a new class of antimicrobial agents with apparently unique mechanisms of action. In 
nonclinical models, BisEDT has been shown to be effective against a broad-spectrum of 
orthopedic device-associated bacteria including antibiotic-resistant strains. 
BisEDT has several characteristics especially suited to the treatment of postoperative orthopedic 
infections: 
a) Broad spectrum antimicrobial activity against the most critically important antibiotic-
resistant bacteria, including MRSA, MRSE, antibiotic-resistant Pseudomonas 
aeruginosa, ESBL-positive Klebsiella pneumoniae, and antibiotic-resistant Enterobacter 
species. 
b) Apparently unique mechanisms of action. 
c) Anti-biofilm capabilities. 
d) Extremely low spontaneous mutation frequency, superior to many conventional 
antibiotics. 
e) Efficacy against both aerobic and anaerobic bacteria. 
f) Demonstrated lack of interference with the activity of a wide range of antibiotics. 
g) Enhanced activity in combination with specific antibiotics; in some cases synergy, has 
been demonstrated in vitro and in vivo. 
h) Maintenance of antimicrobial activity in the presence of excessive protein. 
i) A favorable safety and tolerability profile in nonclinical toxicology studies in a variety of 
species, including absence of effect on wound healing or bone repair 
j) A favorable safety and tolerability profile in a clinical Phase 1 study evaluating topical 
administration. 
Based in part on these characteristics, BisEDT has been granted Qualified Infectious Disease 
Product (QIDP) designation by the FDA for the local, intra-operative treatment of resistant post-
surgical orthopedic implant infections. 
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1.3 Value of MBN-101 for the Treatment of the Clinical Problem  
The broad-spectrum antimicrobial, anti-biofilm activity of BisEDT, its activity against relevant 
antibiotic-resistant pathogens, and its ability to enhance the activity of certain other antibiotics 
are properties that will promote more rapid and/or more complete eradication of infection, and 
reduce infectious risks to patients. With comparatively elevated rates of postoperative infection 
associated with repair of traumatic orthopedic wounds, the development of a new and innovative 
treatment strategy to complement the current standard of care would therefore be expected to 
result in a substantial reduction in mortality, amputation, morbidity, and disability, along with a 
reduction in patient treatment costs. 
MBN-101 provides important potential advantages over current standard of care treatment for 
orthopedic infections. Direct, local contact of MBN-101 with infected target tissue and 
contaminated device surfaces immediately delivers a therapeutically active dose of BisEDT to 
the site of infection. Combined antimicrobial and anti-biofilm effects are achieved with minimal 
systemic exposure. Systemic antibiotics administered alone are frequently ineffective, in part 
because altered perfusion at the surgical wound site hinders effective and timely delivery of 
systemic antibiotics, making it difficult to reach therapeutic antibiotic levels at wound 
tissues/surfaces. The combined effect of IV administered antibiotics, which already serve as a 
pillar of the current standard of care for orthopedic device-related infections, along with the local 
administration of MBN-101, is expected to eradicate bacteria from postoperative orthopedic 
wounds, and will ultimately also serve to reduce the likelihood of development of antibiotic-
resistant bacteria. By reducing the time to resolution of infection and improving the ability of 
current antibiotic therapies to effectively control and eliminate post-surgical orthopedic device-
related infections, MBN-101 will contribute to reductions in the number of additional serious 
interventions needed to resolve infections including reduction in repeat surgeries, additional 
rounds of systemic antibiotics, patient hospitalization time, morbidity and mortality in both 
civilian and military populations. 
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2 OBJECTIVES 
2.1 Primary 
To evaluate the safety and tolerability of single escalating doses of locally administered 
MBN-101 or placebo as adjunct to standard of care antimicrobial and surgical therapy. 
2.2 Secondary 
 To evaluate the clinical activity of single escalating doses of locally administered MBN-101. 
 To evaluate the pharmacokinetics of single escalating doses of locally administered 
MBN-101. 
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3 INVESTIGATIONAL PLAN 
3.1 Study Description 
This is a randomized, single-blind, placebo-controlled multi-center study to assess the safety and 
tolerability of escalating doses of MBN-101 applied directly to target structures within infected 
osteosynthesis sites during revision surgery with or without hardware removal and replacement 
for patients diagnosed with an apparent fracture site infection within one year of the last surgical 
intervention. Three successive cohorts of 12 patients will be enrolled in this trial. Consecutive 
patients from each of the study sites will be screened for potential participation as they present to 
the orthopedic service for clinical care for their postoperative infections. After signing an 
Informed Consent Form (ICF), subjects will complete screening procedures. Patients meeting all 
eligibility criteria on screening will be offered participation in the study. Patients accepting 
participation in the study will be randomized 3:1 (active:control) to three successive doses 
(0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 
2.0 mg, respectively) or placebo (diluent). Enrollment to the next dose cohort will not commence 
until an evaluation by the Data Review Committee (DRC) of all available safety data on all 
patients through Week 6 of study supports escalation to the next cohort. The DRC will monitor 
all safety data in an ongoing manner from all patients enrolled onto this study. 
Following baseline evaluation, patients will receive standard of care treatment for their post-
operative fracture site infection that includes systemic antibacterial treatment per institutional 
standard of care guidelines and revision surgery with or without hardware removal and 
replacement as indicated. Multiple debridements, soft tissue transfer, and revision fixation 
procedures may be performed prior to definitive closure. A single application of the 
investigational product, MBN-101 or placebo, applied intraoperatively directly to target 
structures within infected osteosynthesis sites, will be performed following the final irrigation 
and debridement procedure and immediately prior to definitive closure. In cases where original 
hardware is retained, the investigational product will be sparingly applied to all accessible 
surfaces of hardware and adjacent bone. In cases where hardware is replaced or in cases of two-
stage procedures, MBN-101 will be applied to all accessible surfaces of hardware and adjacent 
bone (target structures) following implantation of hardware and immediately prior to definitive 
closure. The volume applied will be determined by the surgeon’s assessment of the size (in cm2) 
of the target area, and guided by the Table in Section 6.5.2. If wounds are left open, the 
investigational product will be applied immediately prior to definitive closure. The minimum 
amount of MBN-101 required to achieve a thin coat of the relevant target structures within the 
infected osteosynthesis site will be used (see Section 6.5.2). 
All patients will receive standard postoperative care per institutional guidelines, and will be 
discharged from the hospital in accordance with local standards. Patients will undergo study 
visits at Hour 48 and Weeks 2, 6, 12, and 24. All patients will be followed for a minimum of 
24 weeks after surgery. 
See Appendix 1 for a Schedule of Activities. 
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3.2 Number of Subjects 
Thirty-six adult male or female patients meeting protocol-specified eligibility criteria may 
participate in the study, with the objective of having a total of 9 patients per dose level in the 
MBN-101-treated group and 9 patients in a pooled placebo-treated group. Patients who are 
randomized but do not receive study drug may be replaced. 
3.3 Number of Sites 
Three or four U.S. study sites are anticipated to enroll an adequate number of eligible patients. 
 
3.4 Clinical Trial Material 
Patients will be randomized 3:1 (active:control) to three successive doses (0.025, 0.075, or 
0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 2.0 mg, respectively) 
or placebo (diluent). Enrollment to the next dose cohort will not commence until an evaluation 
by the Data Review Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort.  
3.4.1 MBN-101 
MBN-101 is Bismuth-1,2-ethanedithiol (BisEDT) suspension (0.025, 0.075, or 0.25 mg/mL, 
w:v) in diluent (3% methylcellulose / 0.5% Tween 80 / 10mM sodium chloride / 10 mM sodium 
phosphate, pH 7.4). 
 
 
Structural Formula 
Molecular Formula 
C6H12S6Bi2 
Molecular Weight 
694.51 g/mol 
Stereochemistry/Chirality 
BisEDT has no chiral centers. 
 
3.4.2 Placebo (MBN-101 diluent) 
Placebo is MBN-101 diluent comprised of 3% methylcellulose / 0.5% Tween 80 / 10mM sodium 
chloride / 10 mM sodium phosphate, pH 7.4. 
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3.5 Dose 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
Investigational product kits (MBN-101 and placebo) configured for each dose cohort will be 
provided and will contain the supplies necessary for preparation of the specified concentrations 
of MBN-101 or placebo for administration to each patient. 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the Stock Formulation and Diluent 
provided in the Drug Product Kit according to the Directions for Use (DFU) provided. The 
Treatment Dose will be provided to the surgeon in a vial from which an 8 mL volume will be 
drawn up in the operating room into a sterile 10 mL syringe. Surgeons will be instructed to use 
sufficient volume (up to the full 8 mL provided for the largest exposed target areas) to sparingly 
coat the bone at the site of infection, the exposed surfaces of any retained hardware, and the 
surfaces of any new hardware to be implanted. With dose volume determined according to 
Section 6.5.2, the volume of MBN-101 required to achieve a thin coat of the relevant structures 
within the infected osteosynthesis site will be applied. Following application, OR personnel will 
record in the CRF the actual volume (in tenths of milliliters) of any unapplied Treatment Dose 
remaining in the syringe. 
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4 STUDY POPULATION 
The study population will include 36 male or female adults who meet all of the study entry 
requirements. 
4.1 Inclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “YES” answer 
(unless not applicable): 
1. Patients who: 
 have had operative fracture fixation of the upper extremity (AO/OTA class 15, 11-13, 
21-23), lower extremity (AO/OTA class 31-34, 41-44, 81, 82) or pelvis (61, 62), or 
have undergone arthrodesis 
 are diagnosed with an apparent fracture site infection within one year of their last 
surgical intervention and have at least one of the following: 
 Elevated ESR above the upper limit of normal 
 Elevated CRP above the upper limit of normal 
 Draining wound / sinus tract 
 Positive culture from site of prior surgery by aspirate or other modality 
 Local erythema or induration at the site of prior surgery 
 Exposed hardware 
 Periosteal reaction on x-ray 
 Loose or broken hardware  
 require revision surgery with or without removal and replacement of existing hardware 
2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as per institution’s 
standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after revision surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile or at least 
2 years postmenopausal, must agree to use one of the following forms of contraception 
from screening through the Week 24 visit: hormonal (oral, implant, or injection) begun 
>30 days prior to screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications and they must 
ensure their female sexual partner complies with the contraception requirements:  
 Be sexually abstinent from Baseline through Week 24  
 Be > 6 months post-vasectomy  
 Agree to use a condom with spermicide from Baseline through Week 24 
7. Have read and signed the Informed Consent Form (ICF) after the nature of the study has 
been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of personal health 
information in accordance with Health Insurance Portability and Accountability Act 
(HIPAA) 
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4.2 Exclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “NO” answer 
(unless not applicable): 
1. Patients who are no longer hardware dependent or are definitively treated for their 
infection by hardware removal 
2. Greater than one year time lapse from last operative procedure 
3. Patients with a previous revision surgery at the site 
4. Patients with multiple, non-contiguous fracture site infections 
5. Pathologic fracture (not including osteoporosis)  
6. Patient requires immunosuppressive therapy (Topical or inhaled corticosteroids are 
permitted) 
7. Serum creatinine, ALT, AST or Alkaline Phosphatase >1.5 times the upper limit of the 
normal range of the local testing laboratory 
8. Absolute neutrophil count <1000 
9. Patients without definitive soft-tissue coverage over the surgical site at time of study 
product administration 
10. Any condition that has required treatment with any other bismuth containing compound 
within the last 2 weeks (i.e., Kaopectate or Pepto-Bismol) 
11. Participation in an investigational trial to evaluate pharmaceuticals or biologics within the 
past 3 months 
12. Individuals undergoing surgical treatment for more than one infected fracture 
13. Known allergy to metals or materials comprising the orthopedic hardware, bismuth 
and/or MBN-101 excipients (methylcellulose, Tween 80 (polysorbate 80)) 
14. Patients who are pregnant, lactating, or female patients who have a positive serum hCG 
as determined by laboratory testing 
15. Immunocompromised due to illness or organ transplant 
16. History of chronic or recurrent infections (≥ 3 infections at the same site within 
12 months) other than the index infected osteosynthesis site 
17. History of any type of cancer (excluding non-melanomatous localized skin cancer or 
completely excised and cured carcinoma-in-situ of uterine cervix) 
18. Poorly controlled diabetes mellitus (hemoglobin A1c > 9.0% for ≥ 6 months despite 
management by a physician) 
19. History of medical noncompliance 
20. Other medical conditions which, in the opinion of the Principal Investigator, would 
jeopardize the safety of the study subject or impact the validity of the study results. 
21. Current incarceration  
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5 SUBJECT ENROLLMENT 
Potential patients will undergo screening medical history and physical examination. If they are 
deemed appropriate candidates for study, they will be asked to provide appropriate informed 
consent. After informed consent is signed additional baseline evaluation will be performed, 
including but not limited to clinical laboratory assessment, radiographic evaluation, 
electrocardiogram (ECG) and pregnancy test if applicable. Only patients with an acceptable 
medical history and physical exam, ECG without clinically significant abnormalities, and 
laboratory results within acceptable limits will be randomized in the study. Randomization will 
occur using an IVRS system immediately after a patient has met all study entry criteria. 
5.1 Medical History 
Medical history and demographic data, including gender, date of birth, ethnicity, and race will be 
recorded. 
5.2 Physical Exam 
Each patient will receive a physical examination (head, ears, eyes, nose, throat, chest, heart, 
abdomen, and skin) including vital signs, weight (kg), and height (cm). Each patient will also 
receive a detailed evaluation of the index fracture site and involved extremity. 
5.3 Studies 
Following signing of the informed consent form, each patient will undergo all screening 
evaluations as provided in the Table of Study Events. These evaluations should be completed no 
more than 2 weeks prior to surgery date; after a screened subject is confirmed to be eligible for 
the study, this qualified subject will be randomized prior to surgery to receive the investigational 
product. 
5.4 Laboratory Tests at Screening Visit 
Hematology White blood cells (WBC), red blood cells (RBC), hemoglobin, hematocrit, platelet count, 
MCV, absolute neutrophils, absolute lymphocytes, absolute monocytes, absolute 
eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, blood urea nitrogen (BUN), glucose, 
creatinine, total protein, albumin, total bilirubin, direct bilirubin, alkaline phosphatase 
(ALP), AST (SGOT), ALT (SGPT), GGT, creatinine kinase (CK), calcium, magnesium, 
Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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6 STUDY PROCEDURES 
See the Table of Study Events outlining study procedures in Appendix 1. For the study site visit 
at Week 2, a visit window of + 4 days will be allowed; for study site visits Weeks 6 – 24, a visit 
window of ± 8 days will be allowed. 
6.1 Description of Study Procedures 
6.1.1 Medical History 
A comprehensive medical history will be taken on all patients at Screening, including but not 
limited to past medical history, past surgical history, current medications, allergic history and 
psychosocial history. 
6.1.2 Physical Exams 
A comprehensive physical examination will be performed on all patients at Screening, including 
assessments of height, weight, head, ears, eyes, nose, throat, chest, heart, abdomen, and skin. 
Interval physical exams will be performed at all subsequent study visits according to the 
schedule in Appendix 1 and will focus on the surgical site, with assessments of local erythema, 
induration, drainage and degree of healing. 
6.1.3 Vital Signs 
Vital signs include blood pressure, pulse, respiratory rate and body temperature; vital signs will 
be assessed according to the schedule in Appendix 1. 
6.1.4 12-lead ECG 
Testing will be conducted at screening, baseline, and 48 hours. The ECG trace will be stored at 
the investigational sites as source document; clinical interpretation, including normal, abnormal 
but not clinically significant, and abnormal and clinically significant, will be determined by the 
investigator and reported on the CRFs.  
6.1.5 Laboratory Tests 
All clinical laboratory tests will be performed by the local clinical site laboratory. 
Blood and urine will be collected for hematology, serology, serum chemistry, urinalysis, and 
pregnancy testing (as indicated) according to the schedule in Appendix 1. 
Hematology WBC, RBC, hemoglobin, hematocrit, platelet count, MCV, absolute neutrophils, absolute 
lymphocytes, absolute monocytes, absolute eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, BUN, glucose, creatinine, total protein, 
albumin, total bilirubin, direct bilirubin, alkaline phosphatase (ALP), AST (SGOT), ALT 
(SGPT), GGT, creatinine kinase (CK), calcium, magnesium, Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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6.1.6 BisEDT (MBN-101) Blood Levels 
BisEDT levels in whole blood after MBN-101 administration will be assessed with a qualified 
Inductively Coupled Plasma Mass Spectrometry (ICP-MS) assay method using bismuth as a 
surrogate for BisEDT according to the schedule in Appendix 1. 
6.1.7 Pain Assessments 
Pain related specifically to the surgical site (Surgical Site Pain Score) will be assessed via a 
Visual Analog Scale (VAS, 0-10 scale, where 0=no pain at all and 10 =the worst possible pain) 
utilizing a 24 hour recall at screening, baseline, Hour 48 and Weeks 2, 6, 12, and 24. 
6.1.8 Patient Reported Outcomes 
Patient-reported outcomes will be collected using the Veterans Rand 12 Item Health Survey 
(VR-12) and Short Musculoskeletal Function Assessment (SMFA) according to the schedule in 
Appendix 1. 
6.1.9 Microbiology 
The microbiology of the index site will be assessed at baseline and at the time of any subsequent 
surgical procedure at the index site. The presence of viable microorganisms will be determined 
by standard microbiological culture methods and include speciation and antimicrobial 
susceptibility testing of any bacterial isolates found (see flowchart, Appendix 2). 
6.1.9.1 Specimen Collection 
Samples collected will include at least one tissue site (bone when possible; eraser head size, 
suitable for dividing into two samples) from the fracture site (if accessed) or involved tissue 
adjacent to the implant(s), two swabs of the peri-implant deep tissue, and two swabs of the 
superficial tissue/wound closure site. One set of specimens (i.e. 1 tissue specimen, 1 deep swab, 
1 superficial swab) will be placed into local site transport vessels. The duplicate set of samples 
will be placed into transport vessels provided by the central laboratory (International Health 
Management Associates, Inc.; IHMA). One set of specimens will be delivered to the local site 
microbiology laboratory using the standard storage and transport procedures employed at each 
site. The duplicate set of specimens will be transported to IHMA. The details regarding specimen 
packaging, transport, and processing will be described in the central laboratory study manual that 
will be provided to each study site. 
6.1.9.2 Specimen Processing: Local Laboratory 
The tissue site sample and swabs will be analyzed immediately in the local laboratory for the 
presence of infectious pathogens by Gram stain and microbiological culture for both aerobic and 
anaerobic bacteria. The specimens will be processed (primary isolation, identification to species 
level and susceptibility testing) per the standard methods of each local site microbiology 
laboratory. Following isolation and identification of each microorganism, the susceptibility of 
each to one or more standard antibacterial agents (but not including MBN-101), as specified by 
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the surgeon or per local site standard procedures, will be determined. It is recognized that the 
local site laboratory may be using one of a variety of susceptibility test methods, and therefore, 
the susceptibility result may be reported as a specific Minimal Inhibitory Concentration (MIC) 
value or as a categorical result (i.e. Susceptible, Intermediate or Resistant). Susceptibility to 
MBN-101 will not be determined at the local site laboratory; the susceptibility results determined 
locally are for the use of the surgeon in the care of the patient. All Gram stain and microbiology 
results from the local site laboratory will be recorded on the CRF. 
6.1.9.3 Specimen Processing: IHMA (Central Laboratory) 
The tissue site sample and swabs will be analyzed immediately in the central laboratory for the 
presence of infectious pathogens by microbiological culture for both aerobic and anaerobic 
bacteria. The specimens will be processed (primary isolation, identification to species level, and 
susceptibility testing) per the central laboratory methods, as described in the central laboratory 
study manual. 
Following identification, the susceptibility of the isolates to MBN-101 and comparator agents 
will be determined using either the reference broth microdilution method (for aerobic/facultative 
bacteria) or the reference agar dilution method (for anaerobic bacteria) as detailed by the Clinical 
and Laboratory Standards Institute (CLSI). Susceptibility tests for aerobic/facultative bacteria 
will be quality-controlled as detailed by CLSI using reference quality control strains and 
previously-established ranges for MBN-101 and comparators. Susceptibility tests for anaerobic 
bacteria will also include CLSI reference quality control strains, however, since quality control 
ranges for anaerobic bacteria are not yet established, the MIC values for the quality control 
strains will be collected then retrospectively compared to the quality control ranges once they are 
available.  Susceptibility testing will be conducted with batches of study isolates as each study 
cohort is completed. Patient and specimen identifier and microbiology results will be recorded in 
the database. The bacterial isolates recovered from the specimens will be propagated and 
archived at the central laboratory. 
6.1.9.4 Integration of Local Site Laboratory and Central Laboratory Primary Isolation and 
Identification Results 
There may be instances where the organism(s) isolated from a given specimen may be different 
at the local site laboratory and the central laboratory. In this instance, the central laboratory will 
first confirm the identification of the archived isolate. If the identification is confirmed, the 
pathogens present in the specimen will be defined as the total number of pathogens recovered by 
the local site laboratory and the central laboratory. For example, if the local site laboratory were 
to recover S. aureus and the central laboratory recovered S. aureus and P. acnes, the specimen 
would be defined as containing both S. aureus and P. acnes following merger of the data. 
It is possible that local site laboratory may perform susceptibility tests with agents that are also 
present in the central laboratory test panel. The MIC value (and interpretation) provided by the 
central laboratory supersedes the local site determination for the purposes of clinical trial data 
analysis and inclusion in the Clinical Study Report. The local site susceptibility test results are 
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for use by the surgeon in the local care of the patient; however, these data will also be captured 
in the study database. 
6.1.10 Radiographic Evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6, 12, and 24. Radiographs 
(at least two orthogonal views) will be reviewed for union, interval callus formation, loss or 
change in reduction, and hardware failure. 
6.1.11 Surgical Site Signs and Symptoms Evaluation 
The following signs and symptoms of the surgical site will be evaluated: 
 
local erythema extending beyond suture material or staples 
 
induration  
 
drainage from surgical incision 
 
degree of healing of the surgical incision 
Patients with non-healing or worsening status of their surgical site may be considered for 
additional standard of care treatment, but should be encouraged to remain in the study in order to 
complete study evaluations. In case additional treatment is given, the start/stop dates and dose 
regimen of the new treatment will be recorded on the CRFs. 
6.2 Screening and Baseline Assessments 
Patients who meet initial screening criteria by medical history and physical exam will be offered 
participation on study. If the patient agrees to participate, they will be asked to provide written 
informed consent, after which additional evaluation may be performed, including but not limited 
to clinical laboratory assessments, electrocardiogram (ECG), radiographic evaluation and 
pregnancy test if applicable. Only patients with an acceptable medical history and physical exam, 
ECG without clinically significant abnormalities, and laboratory results within acceptable limits 
will be randomized in the study prior to surgery. 
6.3 Randomization Procedure 
Subjects will be randomized in a 3:1 (active:placebo) ratio up to 24 hours prior to surgery via a 
central randomization scheme. The central randomization will be accomplished using an IVRS 
system linked to study drug treatment kits securely stored under appropriate conditions at the 
study site pharmacy. The randomization number assigned to a subject will be captured on the 
CRF. The specific study drug treatment kit will be utilized by the study pharmacist or other 
qualified individual to perform the appropriate dilution of drug product under sterile conditions 
into a vial to be transported to the operating room. Verification of study patient and study drug 
treatment kit will take place in the operating room prior to treatment with the investigational 
product. The appropriately diluted drug product must be administered within 8 hours of 
preparation. 
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6.4 Unblinding Procedure 
This study is a single blind study; however, knowledge of treatment assignment should remain 
limited to those directly involved with the patient’s surgical procedure and other individuals on a 
need to know basis. In order to provide unblinding data in an emergency in the absence of an 
individual privy to treatment assignment, sites will be provided with a numbered unblinding 
envelope corresponding to each numbered test kit the site is delivered. These envelopes will be 
securely stored in the pharmacy. The unblinding envelope specifies the treatment group of the kit 
and should only be opened when absolutely necessary. For treatment of adverse events, it should 
be assumed that the patient has received study drug, thus avoiding the need to unblind the 
patient. However, in the event the Investigator determines the randomization assignment 
information is required to treat the patient for an adverse event, the Medical Monitor should be 
contacted. If the Medical Monitor cannot be reached, the blind may be broken by opening the 
envelope. The site should document the unblinding process in the patient’s source documents. 
6.5 Investigational Product Administration 
6.5.1 Surgical Site Identification 
Individuals undergoing surgical treatment for more than one infected fracture are excluded from 
participation in this study. 
6.5.2 Study Drug Administration 
On the day of surgery, randomized subjects will receive the investigational product during their 
surgical procedure. Investigational product is only administered during the surgical procedure by 
the operating surgeon; therefore, 100% compliance with investigational product administration is 
assured. The operating surgeon will record the approximate surface area of the surgical site as 
well as the amount and location of investigational product administration in the operative note 
and on the CRF. All other details of the surgical procedure will be recorded in the operative note. 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 18 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
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5. Alcohol wipes 
6. One pre-printed "Diluted MBN-101 Drug Product" label 
7. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose”) 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the MBN-101 Stock Formulation and 
Diluent provided in the Drug Product Kit according to the DFU provided. The Treatment Dose 
will be provided to the surgeon in a vial from which an 8 mL volume will be drawn up in the 
operating room into a sterile 10 mL syringe. Surgeons will be instructed to use sufficient volume 
(up to the full 8 mL provided) to sparingly coat the bone at the site of infection, the exposed 
surfaces of any retained hardware, and the surfaces of any new hardware to be implanted. 
Following application, OR personnel will record in the CRF the actual volume (in tenths of 
milliliters) of any unapplied Treatment Dose remaining in the syringe. 
Application to retained hardware:  Access to infected wound surfaces and implanted orthopedic 
hardware will be provided by surgical intervention. The surgeon will use a 10 mL syringe to 
apply, followed by a gloved finger to spread, a thin layer of the investigational product directly 
onto all accessible surfaces of the orthopedic hardware, as well as surrounding bone. Other 
wound surfaces will not be coated, resulting in administration of the investigational product to 
only a limited area of the wound. 
Application to new hardware:  In cases where hardware is replaced or in cases of two-stage 
procedures, MBN-101 will be applied to all accessible surfaces of hardware and adjacent bone 
(target structures) following implantation of hardware and immediately prior to definitive 
closure. Other wound surfaces will not be coated, resulting in administration of the 
investigational product to only a limited area of the wound. 
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In all cases, the minimum amount of MBN-101 required to coat the relevant structures within the 
infected osteosynthesis site should be used. The suspension should be applied in a thin layer to 
cover all affected areas of bone as well as any exposed hardware. Direct application to muscle 
and other soft tissues should be avoided. The approximate area of the osteosynthesis site should 
be calculated based on the length of exposed bone multiplied by the width of bone exposed; the 
surface area of the hardware should be added to this value to derive the approximate area of the 
osteosynthesis site. Recommended maximum volumes of MBN-101 for various areas of the 
osteosynthesis site are provided in the table below. 
Area of Osteosynthesis Site 
Recommended Volume of MBN-101 
25 cm2 
0.5 mL 
50 cm2 
1.0 mL 
75 cm2 
1.5 mL 
100 cm2 
2.0 mL 
125 cm2 
2.5 mL 
150 cm2 
3.0 mL 
175 cm2 
3.5 mL 
200 cm2 
4.0 mL 
225 cm2 
4.5 mL 
250 cm2 
5.0 mL 
275 cm2 
5.5 mL 
300 cm2 
6.0 mL 
325 cm2 
6.5 mL 
350 cm2 
7.0 mL 
375 cm2 
7.5 mL 
400 cm2 
8.0 mL 
 
The table shows the specified volume of MBN-101 to be applied based on the area (in cm2) of 
the target infected osteosynthesis site. By following these application requirements, the 
administered doses will be: 
 Cohort 1: 0.025 mg/mL MBN-101 = 0.5 µg/cm2 
 Cohort 2: 0.075 mg/mL MBN-101 = 1.5 µg/cm2 
 Cohort 3: 0.250 mg/mL MBN-101 = 5.0 µg/cm2 
The use of drains and vacuum assisted closure devices at the site of hardware will be allowed per 
surgeon preference. The drainage volume over the first 24 hours or prior to discontinuation of the 
drain will be recorded in the eCRF. 
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6.6 Study Assessments 
Each patient enrolled in the study will have an assessment at 48 hours following surgery and at 
Weeks 2, 6, 12, and 24. Study assessments will be performed according to Section 6.1 and 
Appendix 1. The Week 24 assessment will be the final assessment for adverse events. Any 
adverse events ongoing at the Week 24 assessment will be followed until resolution of the event 
or stabilization of the condition. 
6.7 Safety Monitoring 
Patients will be instructed to inform the Investigator and/or a member of the study staff of any 
adverse events that occur at any time during the study. Patients will be asked a general health 
question at each clinic visit to identify changes in the state of their health since their last study 
visit. 
6.8 Study Monitoring 
The Sponsor or the Sponsor’s designee will provide training on the protocol for the study site 
personnel prior to giving the site permission to begin enrollment. Once the enrollment and 
dosing phases of the study have begun, the Sponsor or the Sponsor’s designee will visit the site 
to monitor the clinical conduct of the trial, the adequacy of study documentation and compliance 
with safety reporting. Clinical site monitoring will continue on a periodic basis until the site has 
been closed or all patients at the site have completed the study. The frequency of monitoring 
visits may vary depending on enrollment at the study site. 
6.9 Patient Withdrawals 
Patients will be free to withdraw at any time for any reason, or they may be withdrawn if 
necessary to protect their health and safety or the integrity of the study. Any patient that is 
randomized but not treated will be replaced. The final report will include reasons for 
withdrawals. As this study involves a single administration of study drug, significant patient 
withdrawals are not anticipated. 
All efforts should be made to have subjects complete the Week 24 (end of study) procedures 
prior to withdrawal from the study. 
6.10 Individual Patient Stopping Rules 
Patients who develop adverse events at any time during the study will be treated appropriately 
according to standard of care. Adverse events will be assessed and followed as described in 
Section 9. As this is a single dose study with the investigational product applied directly into a 
surgical site, specific stopping rules for individual patients have not been established. 
6.11 Study Stopping Rules 
Patient enrollment on study will be stopped if the number of individual patients experiencing 
possibly-related or probably-related adverse events > Grade 2 exceeds 2 in any dose cohort or if 
there is any death on study. Should the study stopping rules be invoked, all safety data on all 
patients will be assembled for review by the Data Review Committee (DRC). The study will not 
resume until this information has been reviewed by the DRC and the Sponsor, discussed with the 
FDA, and concurrence reached with the FDA as to the resumption of the study. 
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7 CONCOMITANT MEDICATIONS 
All patients will received their usual concomitant medications for any underlying medical 
conditions without interruption. Efforts should be made to maintain all concomitant medications 
at a stable dose for the duration of the 24 week study. Patients will also receive standard of care 
treatment for their postoperative fracture site infection that includes systemic antibacterial 
treatment per prevailing standard of care guidelines (i.e., national, institutional, or physician 
preference) and other indicated postoperative medications, including pain medications. All 
concomitant medications will be recorded in the CRF. Pain medication usage, including 
medication, dose, route, day and time of administration, will be recorded on a separate CRF. Use 
of any other bismuth-containing compounds is prohibited from Screening through Week 4. 
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8 STUDY ENDPOINTS 
8.1 Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
 Treatment-emergent adverse events. 
 Treatment-emergent serious adverse events. 
 Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
 Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
 Changes in physical exams. 
 Clinical findings of 12-lead electrocardiograms. 
 Change in microbiology status. 
8.2 Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
 Proportion of treatment failures. A treatment failure defined as a subject with non-healing 
or worsening status of their surgical site requiring serious intervention by Week 24. 
 Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 24. 
 Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed fracture 
site. 
 Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed fracture site by Week 24. 
 Time to removal of orthopedic hardware due to a healed fracture site. 
 Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
 Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
 Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale 
(VAS, 0-10 scale). 
 Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
 Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination.  
 Change in serologic markers CRP and ESR at each post baseline time point. 
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8.3 Pharmacokinetic Endpoint 
8.3.1 Sample Collection and Handling 
Blood samples will be obtained to measure blood concentrations of Bismuth (Bi) as a surrogate 
for BisEDT. A pre-dose sample will be collected prior to administration of the investigational 
product. Blood will be drawn for PK samples at nominal 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 (Day 
3), 96 (Day 4), and 336 (Day 14) hr after application of MBN-101 to the surgical site. 
Documentation stating the exact time of blood sampling (4 mL per timepoint) in relation to the 
time of study drug administration will be collected and provided. 
Primary and back-up blood samples will be stored at -70°C.  
8.3.2 Assay Methodology 
Bismuth (Bi) levels, a surrogate for BisEDT, will be assayed in whole blood using a validated 
inductively coupled plasma mass spectrometry (ICP-MS) assay performed by Medpace 
Bioanalytical Laboratories (Cincinnati, Ohio). The samples are prepared for analysis by 
digestion with 2% nitric acid and H2O2, followed by centrifugation and dilution with water into 
2% Tetramethyl Ammonium Hydroxide (TMAH) with 0.02% Triton X-100, and subsequent 
quantitation of Bi by ICP-MS analysis. 
A detailed method description, including validation, calibration and quality assurance 
procedures, will be included in the analytical report which will be part of the Final Study Report. 
8.3.3 PK Analysis 
Bismuth (Bi) concentration data will be analyzed by noncompartmental analysis (NCA) with 
Phoenix™ WinNonlin® Version 6.3 or higher, using an extravascular administration model and 
actual sampling times. The following PK parameters will be derived from blood concentrations 
of Bi using extravascular noncompartmental PK analysis: 
Tmax 
Time to maximum observed concentrations of Bi 
Cmax 
Maximum observed concentrations of Bi 
AUC0-t Area under the Bi concentration vs time curve from time zero to the time of the last 
measurable concentration. 
AUC0-∞ Area under the Bi concentration vs time curve from time zero and extrapolated to 
infinity. 
T1/2 
The apparent half-life of Bi after extravascular administration of BisEDT 
CL/F 
Apparent clearance after extravascular administration of BisEDT 
Vz/F 
Apparent volume of distribution after extravascular administration of BisEDT 
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9 ADVERSE EVENTS 
An adverse event is an undesirable medical occurrence (sign, symptom, or diagnosis) or 
worsening of a pre-existing medical condition (e.g., diabetes) that occurs after initiation of the 
investigational study whether or not it is considered to be related to the investigational product. 
A worsening of an existing medical condition is one that was present at Day 1 (e.g., diabetes) 
and became more severe, more frequent, or increased in duration during investigational product 
treatment. Clinically relevant abnormal results of diagnostic procedures including abnormal 
laboratory findings (e.g., requiring unscheduled diagnostic procedures or treatment measures, or 
resulting in withdrawal from the study) are considered to be AEs. 
All adverse events (AEs) will be recorded throughout the study, beginning when the subject 
signs the Informed Consent Form. 
A treatment-emergent adverse event (TEAE) is defined as any AE starting after the first dose of 
the investigational agent or placebo is administered. If the AE is present prior to the 
administration of the first dose of the investigational agent or placebo but increases in severity, it 
will also be considered a TEAE. 
Treatment-emergent adverse events will be recorded beginning with the first exposure to 
investigational product and continuing until the subject is discharged from the study due to 
completion or early termination. 
Adverse events will be categorized as local adverse events and as systemic adverse events. 
The Principal Investigator, or medically qualified designee, must completely and promptly 
record each AE on the appropriate CRF. The Principal Investigator should attempt, if possible, to 
establish a diagnosis based on the presenting signs and symptoms. In such cases, the diagnosis 
should be documented as the AE and not the individual sign/symptom. If a clear diagnosis 
cannot be established, each sign and symptom must be recorded individually. Once a diagnosis is 
established, the CRFs should be updated with the final diagnosis. 
Any adverse event ongoing at the time of study completion will be recorded and followed-up 
according to the safety procedures described in the following sections. 
9.1 Reporting and Following Adverse Events 
All AEs encountered during the study will be reported on the AE page of the CRF in a timely 
manner. All AEs should be followed in accordance with good medical practice until resolved or 
fully characterized. 
Serious adverse events: Section 9.4 presents the definition and reporting obligations for Serious 
Adverse Events (SAEs). After the initial report, a follow-up SAE Report Form should be filled 
out and sent to Medpace Clinical Safety within 24 hours. Updates are to be provided by the site 
as soon as relevant information (especially regarding outcome) is available. 
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9.2 Severity 
The Investigator must indicate the severity of the adverse event in the description of the adverse 
event. A severity category of mild, moderate, or severe, as defined below, should be determined 
and entered on the Adverse Events page of the Case Report Form (CRF). 
 
Mild (Grade 1): Transient or mild symptoms; no limitation in activity; no intervention 
required. The AE does not interfere with the participant’s baseline functioning level. It 
may be an annoyance. 
 
Moderate (Grade 2): Symptom results in mild to moderate limitation in activity; no or 
minimal intervention required. The AE produces some impairment of baseline 
functioning, but it is not hazardous to health. It is uncomfortable or an embarrassment. 
 Severe (Grade 3): Symptom results in significant limitation in activity; medical 
intervention may be required. The AE produces significant impairment of functioning or 
incapacitation. 
 Potentially Life-Threatening (Grade 4): Symptoms cause inability to perform basic self-
care functions immediately necessary to sustain life or require medical or operative 
intervention to prevent permanent impairment, persistent disability or death. 
9.3 Relationship to Clinical Trial Material 
The Investigator must document their opinion of the relationship of the event to the 
investigational product as follows: 
 
NONE: The event can be readily explained by the subject’s underlying medical condition, 
a concomitant therapy or other cause and the Investigator believes no relationship exists 
between the event and the investigational product. In this case, the Investigator should 
document the condition, concurrent/underlying illness, medication, study procedure or 
other cause they believe to be the cause of the adverse event. 
 
UNLIKELY: The event does not follow a reasonable temporal sequence from 
administration of the investigational product nor does the event follow a known or expected 
response pattern to the investigational product and may have another cause. In this case, 
the Investigator should document the condition, concurrent/underlying illness, medication, 
study procedure or cause they believe may have contributed to the adverse event. 
 
POSSIBLE: The subject’s condition, concurrent/underlying illness, medication, or study 
procedures cannot explain the event, and there is a plausible temporal relationship 
between the event and the investigational product administration. 
 PROBABLE: The temporal relationship between the administration of the investigational 
product and the adverse event strongly suggests a relationship, and/or the adverse event 
cannot be reasonably explained by another condition, concurrent/underlying illness, 
medication, study procedure or other cause, or the adverse event abates with 
discontinuation of the investigational product, and recurs with re-administration. 
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9.4 Serious Adverse Events 
To report SAEs in a timely manner, monitor subject care, and to fulfill regulatory requirements, 
SAEs (regardless of their relationship to the investigational product) must be reported to 
Medpace Clinical Safety within 24 hours of knowledge of the event by the Investigator or 
members of the study staff.  
9.4.1 Definition 
SAEs are defined as those adverse events that meet any of the following criteria: 
 
Life threatening, that is, any event that, in the opinion of the Investigator, poses an 
immediate risk of death from that event 
 
Results in death 
 
Results in or prolongs hospitalization 
 
Results in persistent or significant disability/incapacity 
 
Results in congenital anomaly/birth defect 
In addition, events which may not meet these criteria, but, in the opinion of the Investigator, are 
very unusual, potentially serious, or require medical or surgical intervention to prevent one of the 
outcomes listed above, should also be reported in the same manner as events which meet the 
serious adverse event criteria.  
9.4.2 Reporting 
Serious AEs require immediate reporting (within 24 hours of the site’s knowledge of the event) 
to Medpace Clinical Safety whether or not the Investigator believes that the experience is related 
to the investigational product. A completed SAE CRF signed by the Investigator must be faxed 
to Medpace Clinical Safety. Criteria for documenting the relationship to study product and 
severity will be the same as those previously described in Sections 9.2 and 9.3. 
SAEs must also be reported by the study site to the responsible IRB immediately. The 
Investigator is responsible for complying with the local IRB regulations regarding the reporting 
of AEs. 
Reporting of a suspected SAE should not be delayed in order to obtain additional information. 
Any additional information, if collected, can be reported as a follow-up to the initial report. Any 
SAE that occurs at any time during the study, whether or not related to the investigational 
product, must be reported to Medpace Clinical Safety.  
All possibly- and probably-related serious adverse events must be followed until the outcome is 
known or the event is otherwise explained. All serious adverse events that are not resolved at the 
end of the study are to be followed until resolution, the condition stabilizes, the event is 
otherwise explained, or the subject is lost to follow-up.  
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9.5 Pregnancies 
Pregnancies occurring after the first dose of investigational product are considered immediately 
reportable events. While not considered a serious adverse event unless a serious criterion is met, 
pregnancies occurring in subjects enrolled on the study must be reported and followed to 
outcome. The investigator should complete the pregnancy report form and fax it to Medpace 
Clinical Safety within one working day of knowledge of the pregnancy. Following delivery or 
termination of pregnancy, the follow-up pregnancy report form should be completed and 
submitted via fax to Medpace Clinical Safety. Spontaneous abortions should always be reported 
as SAEs. Follow-up information regarding the outcome of the pregnancy and any postnatal 
sequelae in the infant will be required. 
9.6 Data Review Committee (DRC) 
An independent Data Review Committee will be established to review unblinded clinical trial 
data prior to dose escalation and on an as-needed basis. A statistician, serving as a non-voting 
member to the DRC, will provide data preparation support to the DRC. A sponsor representative 
will also serve as a non-voting member of the DRC to facilitate sponsor internal planning. 
The primary role of the DRC will be to assess unblinded safety data on all patients in a dose 
cohort completing the Week 6 visit, and to determine whether dose escalation should occur. The 
DRC may recommend dose escalation, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
The DRC will also be asked to assess unblinded safety data on an as-needed basis. The Chair of 
the DRC will be informed by Microbion Corporation of the potential need for ad hoc meetings 
and will coordinate any ad hoc meeting with the remainder of the DRC members. The DRC may 
recommend no modifications to the study, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
A formal DRC Charter will be prepared and finalized prior to study enrollment. The DRC will 
meet prior to initiation of the clinical trial in order to review, revise and reach concurrence on the 
content of a DRC charter. The draft charter will be provided by Microbion Corporation to the 
DRC prior to the initial meeting. 
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10 INVESTIGATIONAL PRODUCT MANAGEMENT 
10.1 Study Drug 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied.  
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 18 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
5. Alcohol wipes 
6. One pre-printed "Diluted MBN-101 Drug Product" label 
7. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose” 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
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10.2 Study Drug Packaging and Labeling 
All shipments of the investigational product will be accompanied by an inventory form. The 
contents of the shipments should be inventoried immediately upon receipt and confirmation of 
inventory shall be performed according to instructions provided by the clinical supplies 
distributor. 
The following information will be provided with each shipment of study drug: Sponsor name and 
contact information (telephone number), study protocol number, description of the contents of 
the container, conditions for storage, and a statement regarding the investigational (clinical trial) 
use of the study drug.  
Each package unit of the investigational product will be labeled with the following information: 
Sponsor name, study protocol number, description of the contents, a statement regarding the 
investigational (clinical trial) use of the study drug, and a packaging lot number.  
10.3 Study Drug Storage 
The investigational product should be kept in a limited-access area at 15-30 degrees C at the 
study site.  
10.4 Study Drug Accountability 
It is the responsibility of the Principal Investigator or his/her designee at each site to ensure that 
all investigational product quantities received at the site will be inventoried and reconciled 
throughout the study and the result recorded on the drug accountability form maintained in the 
study file. 
10.5 Study Drug Handling and Disposal 
Only qualified study personnel familiar with procedures that minimize undue exposure to 
themselves and to the environment should undertake the handling of pharmaceutical agents. 
The study monitor will verify that the disposition of all investigational materials at the trial site is 
in accordance with Sponsor specifications and applicable regulatory requirements. Requirements 
for disposition of used, unused, damaged/quarantined, and expired investigational materials will 
be provided to applicable site personnel. The study monitor will confirm associated 
documentation is filed in the Investigator site file and copies retrieved for the Sponsor or 
Sponsor-designee Investigator File. 
Used, damaged, and expired investigational materials will be destroyed as directed by the Study 
Monitoring Plan. Specific instructions of on-site destruction, return of materials to a 3rd party 
vendor, or any other mechanism of removal of the investigational materials from the site will be 
detailed in the Study Monitoring Plan. 
The study monitor will not take possession of investigational materials. Any deviations from this 
process must be approved in advance by the Sponsor or Sponsor-designee.  
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11 GENERAL CONSIDERATIONS 
11.1 Basic Principles 
This research will be carried out in accordance with the clinical research guidelines established 
by the Basic Principles defined in the U.S. 21 CFR Parts 50, 56, and 312, the principles 
enunciated in the Declaration of Helsinki concerning medical research in humans (“Ethical 
Principles for Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 
1975, Venice 1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, 
Washington 2002 and Tokyo 2004), and the Good Clinical Practice (GCP) guidelines of the 
International Conference on Harmonization (ICH) of the Technical Requirements for 
Registration of Pharmaceuticals for Human Use, ICH E6 (May 1996). 
11.2 Institutional Review Board 
Prior to initiation of any study procedures, the Clinical Study Protocol, Informed Consent Form, 
and Product Information will be submitted to the IRB for review and approval. In addition, any 
amendments to the protocol or informed consent document will be reviewed and approved (if 
necessary) by the IRB. The Principal Investigator (PI) at each clinical site assumes responsibility 
for ensuring that the protocol is submitted to the IRB for any required periodic review. The PI 
must receive a letter documenting the IRB approval at the clinical site prior to the initiation of 
the study. Any subsequent IRB correspondence must also be submitted to the investigator. The 
Investigator is responsible for providing the appropriate reports to the reviewing IRB during the 
course of the clinical study. This will include the following: 
 Informing the IRB of the study progress periodically as required, but at least annually 
 Reporting any unanticipated adverse product per IRB Policies & Procedures 
 Reporting any deviations from the clinical protocol to protect the life or well-being of a 
subject in the case of an emergency within 5 working days after the emergency occurred 
 Providing any other reports requested by the IRB 
After the final visit of the last subject, a final report will be sent to the IRB per their Policies & 
Procedures that includes a summary of the results of the study by the PI. 
The IRB must be constituted and operate in accordance with the principles and requirements 
described in the U.S. Code of Federal Regulations (21 CFR Part 56). 
11.3 Informed Consent 
The purpose of the study, the procedures to be carried out and the potential hazards will be 
described to the subjects in non-technical terms. Subjects will be required to read and sign a 
consent form summarizing the discussion prior to enrollment, and will be assured that they may 
withdraw from the study at any time without jeopardizing their medical care. 
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11.4 Study Termination 
The Investigator reserves the right to terminate the study in the interest of subject safety and 
welfare. The Sponsor reserves the right to terminate the study at any time for administrative 
reasons. 
11.5 Regulatory Documentation 
Documents that must be provided to the Sponsor prior to study drug shipment are as follows: 
 Up-to-date curriculum vitae for each investigator and sub-investigator 
 Signed and dated Investigator Agreement 
 Applicable local regulatory documentation (e.g., FDA 1572 Form) 
 A copy of the formal written notification to the investigator regarding approval of the 
protocol by an IRB that is in compliance with regulatory guidelines. The written 
notification is to be signed by the chairman or authorized designee and must identify the 
specific protocol. In cases where an IRB member has a known conflict of interest, 
abstention of that individual from voting should be documented; an investigator 
(or sub-investigator) may be a member of the IRB, but may not vote on any research in 
which he or she is involved. 
 Name and address of the IRB with a statement that it is organized and operates according 
to GCP and the applicable laws and regulations, and a current list of the IRB members. 
If accompanied by a letter of explanation from the IRB, a general statement may be 
substituted for this list. 
 A copy of the IRB approved informed consent form and other adjunctive materials 
(e.g., advertising) to be used in the study, including written documentation of IRB 
approval of these items. 
 Name and address of any local laboratory conducting tests for the study, a dated copy of 
the laboratory reference values for tests to be performed during the study and a copy of 
the certification or other documentation establishing adequacy of the facility. 
 Required financial agreement. 
In addition to the documents required prior to the study, other documentation may be required 
during the course of the study. 
11.6 Study Documentation 
All documents pertaining to the study, including a copy of the approved protocol, copy of the 
Informed Consent Form, and case report forms, will be retained in the permanent archives of the 
study site. These will be available for inspection at any time by the Sponsor or the U.S. Food and 
Drug Administration (FDA). 
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11.7 Data Handling and Record Keeping 
As electronic trial data handling and/or remote electronic trial data systems will be used, 
Microbion and/or its designee will: 
 Ensure and document that the electronic data processing system(s) conforms to the 
Sponsor’s established requirements for completeness, accuracy, reliability, and consistent 
intended performance 
 Maintain SOPs for using these systems 
 Ensure that the systems are designed to permit data changes in such a way that the data 
changes are documented and that there is no deletion of entered data (i.e., maintain an 
audit trail, data trail, edit trail) 
 Maintain a security system that prevents unauthorized access to the data 
 Maintain a list of the individuals who are authorized to make data changes 
 Maintain adequate backup of the data 
 Safeguard the blinding, if any (e.g., maintain the blinding during data entry and 
processing) 
Moreover: 
 An unambiguous subject identification code will be used that will allow identification of 
all the data reported for each subject 
 Microbion and/or its designee will retain all of the Sponsor-specific essential documents 
pertaining to the trial in conformance with the applicable regulatory requirement(s) of the 
country(ies) where the product is approved and/or where it intends to apply for approval  
 Specific essential documents will be retained until at least 2 years after the last approval 
of a marketing application in an ICH region and until there are no pending or 
contemplated marketing applications in an ICH region or at least 2 years have elapsed 
since the formal discontinuation of clinical development of the investigational product. 
These documents should be retained for a longer period, however, if required by the 
applicable regulatory requirement(s) or if needed by the Sponsor. 
 Microbion and/or its designee will inform the investigator(s)/institution(s) in writing of 
the need for record retention and should notify the investigator(s)/institution(s) in writing 
when the trial related records are no longer needed 
11.8 Use of Information and Publication 
All information concerning BisEDT, MBN-101, MBN-101 diluent, Microbion operations, patent 
applications, formulas, manufacturing processes, basic scientific data, and formulation 
information, supplied by the Sponsor to the investigator and not previously published, is 
considered confidential and remains the sole property of Microbion Corporation. The 
investigator agrees to use this information only to accomplish this study and will not use it for 
other purposes without the Sponsor’s written consent. 
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The investigator understands that the information developed in the clinical study will be used by 
Microbion in connection with the continued development of MBN-101 and BisEDT, and thus 
may be disclosed as required to other clinical investigators or government regulatory agencies. 
To permit the information derived from the clinical studies to be used, the investigator is 
obligated to provide the Sponsor with all data obtained in the study. 
Any publication or other public presentation of results from this study requires prior review and 
written approval of Microbion Corporation. Draft abstracts, manuscripts, and materials for 
presentation at scientific meetings should be provided to the Sponsor at least 30 working days 
prior to abstract or other relevant submission deadlines. Authorship of publications resulting 
from this study will be based on generally accepted criteria for major medical journals. 
11.9 Independent Medical Monitor 
In accordance with US Army Medical Research and Materiel Command (USAMRMC) and 
Department of Defense (DOD) requirements, an independent medical monitor will be identified. 
The independent medical monitor should be physicians, dentists, psychologists, nurses, or other 
healthcare providers capable of overseeing the progress of research protocols, especially issues 
of individual volunteer management and safety. The medical monitor must be independent of the 
investigative team and possess sufficient educational and professional experience to serve as the 
volunteer advocate. Depending on the nature of the study, the medical monitor may be assigned 
to assess one or more of the following phases of research project: volunteer recruitment, 
volunteer enrollment, data collection, or data storage and analysis. The medical monitor provides 
an independent evaluation of serious adverse events and unanticipated problems involving risk to 
subjects or others to the IRB and the Office of Research Protections (ORP). The medical monitor 
may be assigned to discuss research progress with the PI, interview volunteers, consult on 
individual cases, or evaluate adverse event reports. The medical monitor must promptly report 
discrepancies or problems to the IRB and the ORP. They shall have the authority to stop a 
research study in progress, remove individual volunteers from a study, and take whatever steps 
are necessary to protect the safety and well-being of research volunteers until the IRB can assess 
the medical monitor report. 
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12 STATISTICAL ANALYSIS METHODOLOGY 
A formal statistical analysis plan (SAP) will be prepared and finalized before database lock for 
the final analysis for the study report. The SAP will provide details regarding the definition of 
analysis subjects (populations), analysis variables and analysis methodology to meet all study 
objectives. 
The principle and key elements of the SAP are provided as follows: 
In general, safety and efficacy data will be summarized with descriptive statistics, including 
means, standard deviations, medians, minimums and maximums for continuous variables, the 
number of subjects and percent in each category for categorical variables.  
Data from all subjects randomized and treated with placebo in each cohort will be pooled for the 
analysis; data from the subjects randomized and treated with MBN-101 will be presented by dose 
as well as combined.  
Data from each individual will be tabulated as appropriate. Efficacy and safety endpoints will be 
tabulated by treatment group and time point.  
12.1 Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
 Proportion of treatment failures. A treatment failure is defined as a subject with 
non-healing or worsening status of their surgical site requiring serious intervention by 
Week 24. 
Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 24. 
 Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed fracture 
site.  
 Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed fracture site by Week 24. 
 Time to removal of orthopedic hardware due to a healed fracture site. 
 Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
 Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
 Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale (VAS, 
0-10 scale).  
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 Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
 Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination.  
12.2 Changes in serologic markers CRP and ESR at each post baseline time 
point.Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
 Treatment-emergent adverse events. 
 Treatment-emergent serious adverse events. 
 Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
 Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
 Changes in physical exams. 
 Clinical findings of 12-lead electrocardiograms. 
 Change in microbiology status. 
12.3 Sample Size Considerations 
Sample size for this study was chosen empirically for the purpose of the study without any 
formal statistical hypothesis to be tested. 
Nine subjects will receive active drug in each dose cohort. With 9 subjects receiving active drug, 
the probability of observing at least one of 9 subjects in a dose cohort exhibiting an AE of a 
specific type is 95% if the true background incidence rate for that event-type were approximately 
0.283 or greater. Hence, if an AE of a specific type is not observed in the study in a sample size 
of 9 subjects receiving active study drug at a given dose, one would “rule-out” this AE as having 
an incidence rate of more than 0.283 with 95% confidence. 
Similarly, if a rare event of interest is not reported in the 27 subjects treated with the active study 
drug, one could conclude that the rate of the event would be 0.105 or less with 95% confidence. 
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12.4 Analysis Datasets 
The following analysis datasets will be identified for the purpose of analysis:  
Screened Subjects: All subjects who signed informed consent for the study will be included in 
the Screened Subjects analysis set. 
Randomized Subjects: All subjects who were randomized in the study will be included in the 
Randomized Subjects analysis set. A randomized subject may or may not be treated with the 
assigned study drug. This is the classic Intent-to-Treat (ITT) analysis set. 
Treated Subjects: All subjects who received any amount of study drug (active or placebo) will be 
included in the Treated Subjects analysis set. All treated subject will be included in the safety 
analysis. This analysis set is also referenced as the Safety Analysis Set. 
Modified Intent-to-Treat (mITT) Subjects: the ITT subjects who received any amount of study 
(active or placebo) and have at least one post-treatment assessment will be included in the mITT 
analysis set. The mITT analysis set is the primary dataset for efficacy analysis. 
PK Concentration Subjects (i.e., PK Concentration Population): The PK Concentration 
Population will include all subjects with any measurable bismuth blood concentrations. 
PK Evaluable Subjects (i.e., PK Evaluable Population): The PK Evaluable Population will 
include all subjects providing sufficient measurable bismuth blood concentrations to facilitate 
determination of PK parameters. 
In the event that a subject received study drug treatment that is not the assigned/randomized 
treatment group, the subject has a major protocol deviation. The subject, however, will be 
included in the analysis for safety and efficacy in the actual treatment group received.  
Subjects randomized but not treated for any reason will be included in the disposition tabulation 
and will be excluded from the safety and efficacy analysis.  
12.5 Disposition and Study Population Characteristics 
Disposition summaries will be prepared to include number and percent of subjects screened, 
randomized, treated, subjects that completed the study and reason for discontinuation. Reason for 
screening failure will also be tabulated.  
Subject characteristics summaries will include demographics (age, gender, race, and ethnicity), 
baseline characteristics (weight, height, BMI), surgery site characteristics (type of injuries, type 
of fraction fixation, surgical site location), microbiology analysis results, time from previous 
surgery to study enrollment, and type of previous treatment), current surgery characteristics 
(area of the osteosynthesis site, with or without hardware replacement, etc.), and medical history.  
Disposition summary will be based on randomized treatment group (i.e., planned treatment) 
whereas the baseline characteristics summaries will be based on the actual treatment group.  
Subjects with protocol deviations will be identified. The nature of the deviation and potential 
impact on the deviation on study outcome will also be assessed.  
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12.6 Efficacy Analysis 
12.6.1 Treatment Failure 
A treatment failure is defined as a subject with non-healing or worsening status of their surgical 
site requiring serious intervention by Week 24. 
The number of subjects meeting treatment failure criteria during the study will be tabulated by 
treatment group. If data permit, the difference in proportion of treatment failures between the 
groups and the corresponding 95% confidence intervals for the difference will be presented. 
Fisher’s exact test may be used to test the difference between the groups; difference in rates and 
95% confidence intervals for the relative risk will be derived. Dose-response assessment may be 
performed. 
12.6.2 Incidence of Serious Interventions  
All interventions meeting the following criteria are serious interventions: 
 Initiation of antibiotic treatment in patient not previously on antibiotics 
 Change in the route of antibiotic administration from oral to intravenous for escalation of 
treatment 
 Change in the type or dosage of antibiotic drug for escalation of treatment 
 Readmission (exclusive of readmissions associated with a healed fracture site) 
 Reoperation (exclusive of reoperations associated with a healed fracture site) 
The number of subjects with at least one serious intervention (exclusive of serious interventions, 
readmissions, and reoperations associated with a healed fracture site) and total number of serious 
interventions will be tabulated for the following periods:  
 duration of the study;  
 within the first 4 weeks after the surgery; 
 from week 4 to week 8 
 from week 8 to week 12  
 from week 12 to week 24 
The difference between the placebo arm and the active arms will be evaluated as follows if data 
permits: Fisher’s exact test may be used to test the difference between the groups; difference in 
rates and 95% confidence intervals for the relative risk will be derived.  
Similar summaries will be prepared for incidence of re-admission and incidence of re-operation. 
Time elapsed between the initial hospital discharge to hospital readmission and between the 
operations will be derived and tabulated.  
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12.6.3 Time to First Serious Interventions  
Time to the first serious intervention exclusive of serious interventions, readmissions, and 
reoperations associated with a healed fracture site will be derived. Time to first serious 
intervention will be calculated as the number of study days from the study surgery date to the 
event onset date plus 1. Subjects who do not have any serious intervention will be censored to 
the last observation date. 
No formal inferential statistics will be carried out for this endpoint. 
12.6.4 Subjects Undergoing Removal of Stabilizing Orthopedic Hardware 
The number of subjects undergoing removal of hardware due to a healed fracture site and the 
time to removal of hardware due to a healed fracture site will be derived. Time to removal of 
hardware will be calculated as the number of study days from the study surgery date to the event 
date plus 1.  
12.6.5 Surgical Site Signs and Symptoms 
The surgical site will be examined for local erythema, induration, drainage and degree of 
healing. 
Subjects with non-healing or worsening status of their surgical sites will be tabulated. 
12.6.6 Patient-Report Outcomes 
12.6.6.1 The Veterans RAND 12 Item Health Survey (VR-12) Questionnaire  
The Veterans RAND 12 Item Health Survey (VR-12) is a brief, generic, multi-use, self-
administered health survey comprised of 12 items. The instrument is primarily used to measure 
health related quality of life, to estimate disease burden and to evaluate disease-specific 
benchmarks with other populations. The 12 items in the questionnaire correspond to eight 
principal physical and mental health domains including general health perceptions; physical 
functioning; role limitations due to physical and emotional problems; bodily pain; energy-
fatigue, social functioning and mental health (Selim, 2009; Veterans Affairs website, 2014). 
VR-12 total score, physical health domain score (PCS), and mental health domain score (MCS) 
will be tabulated by visit; change from baseline in total score, physical health domain score and 
mental health domain score will also be derived and tabulated.  
12.6.6.2 The Short Musculoskeletal Function Assessment Questionnaire (SMFA) 
The 46-item SMFA questionnaire comprises two parts: the dysfunction index with 34 items and 
the bother index with 12 items. The dysfunction index assesses the patients perceptions of the 
amount of difficulty they have in the performance of certain functions (25 items) and how often 
the patients have difficulty when performing certain functions (9 items). The dysfunction items 
are grouped into four categories: daily activities, emotional status, function of the arm and hand, 
and mobility. Each item has a 5-point response format (1 point for good function and 5 points for 
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poor function). The bother index asks the patients to assess how much they are bothered by 
problems in various areas of life (e.g., recreation, work, sleep and rest). These items also have a 
5-point response format (1 point for not at all bothered and 5 points for extremely bothered). 
The scores of the dysfunction and the bother indices are calculated by summing up the responses 
to the items and then transforming the scores according to the formula: (actual raw score - lowest 
possible raw score)/(possible range of raw score) ×100. 
This transformation formula gives the final scores, which ranged from 0 to 100. The higher 
scores indicate poorer function. In the case of the dysfunction index, unanswered items in a 
category are replaced by the individual’s mean score for that category, as long as more than 
50 per cent of the items in that category have been answered. Substitution with the mean is not 
appropriate for the bother index as each item addresses a unique area of function (Swiontkowski, 
1999; Short Musculoskeletal Function Assessment Injury and Arthritis Survey, 
www.grossortho.com/forms/injury.pdf). 
SMFA results and change from baseline will be summarized by visit and treatment group with 
descriptive statistics. 
12.6.7 Pain Assessments 
Surgical site pain score utilizing a 24 hour recall will be assessed via Visual Analog Scale (VAS) 
(Burckhardt, 2003; Brokelman, 2012; Briggs, 1999) at baseline, and Weeks 2, 6, 12, and 24. 
Change in pain from baseline will be derived; observed pain score and change from baseline will 
be tabulated by visit and treatment group. 
12.6.8 Microbiology 
Microbiology will be assessed at baseline and at the time of any subsequent surgical procedure at 
the index site. The presence of viable microorganisms will be determined by standard 
microbiological culture methods and include speciation and antimicrobial susceptibility testing 
of any bacterial isolates found (see flowchart, Appendix 2). Samples collected will include at 
least one tissue site (eraser head size; suitable for dividing into two samples) from the fracture 
site (if accessed) or involved tissue adjacent to the implant(s), two swabs of the infected 
hardware (in situ or ex vivo), two swabs of the deep infection site, and two swabs of the 
superficial tissue/wound closure site when possible. Duplicate specimens will be transported 
aerobically and anaerobically, respectively. Specimens will be processed by the local laboratory 
and the central laboratory as presented in Sections 6.1.9.3 and 6.1.9.2. 
Microorganisms isolated from each assessment will be listed. This information may also be used 
to identify potential subgroups. 
Microbiological success is assessed by clearance of infection. The proportion of subjects that 
meet the treatment success criteria per microbiologic evaluations will be identified and tabulated 
by each treatment group. 
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12.6.9 Radiographic evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6, 12, and 24. 
Radiographic success is assessed by healing on radiographic examination. The proportion of 
subjects that met the treatment success criteria per radiographic examination will be identified 
and tabulated by each treatment group. 
12.6.10Serologic Markers 
Serology markers CRP and ESR will be assessed at baseline and Weeks 2, 6, 12, and 24. 
Serology markers CRP and ESR have been used together with clinical signs and symptoms for 
periprosthetic infection diagnosis. The values for each serologic marker and the number of 
subjects with normal or abnormal serologic marker values at each visit will be tabulated by 
treatment group.  
12.6.11Subgroup Analyses for Efficacy Endpoints 
If data permit, the following potential covariates will be identified and subgroup analysis may be 
performed for those subgroups. 
1. 
Area of the osteosynthesis site 
2. 
Method of fracture fixation 
3. 
Type of infection (per identified microorganism) 
4. 
Anatomic location of the surgery site 
5. 
Hardware retention status (retained vs. exchanged) 
6. 
Influence of host factors 
7. 
Method of wound closure / wound management 
12.6.12Sensitivity Analyses for Efficacy Endpoints 
The primary efficacy analysis set (mITT) will included all randomized subjects who received 
any amount of study drug and have at least one post-treatment assessment. In addition, in the 
event that a subject received treatment that is different from the assigned treatment, the subject 
will be included in the actual treatment received in the mITT analysis. 
An ‘as assigned’ analysis will be performed on the mITT subjects as a sensitivity analysis for the 
primary efficacy endpoint. In this analysis, subjects who received a treatment that is not the 
assigned treatment will be included in the ‘assigned’ treatment group for this analysis. 
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12.7 Safety Analysis 
12.7.1 Study Drug Exposure and Concentrations 
Study drug exposure will be presented by treatment group. Descriptive statistics will be provided 
without any formal inferential statistics.  
12.7.2 Adverse Events 
The Medical Dictionary for Regulatory Activities (MedDRA Version 16 or higher) will be used 
to classify all AEs with respect to system organ class (SOC) and preferred term. Summary of 
adverse events will include: 
1. Treatment emergent adverse events by SOC, preferred term, and intensity 
2. Treatment emergent adverse events by SOC, preferred term, and relationship to study 
drug  
3. All AEs leading to study discontinuation by SOC and preferred term 
4. All serious adverse events by SOC and preferred term 
Summary tables will provide total number of events and number of subjects with the event. 
The incidence and intensity of each pre-specified local AEs will be tabulated by visit and 
treatment groups. 
12.7.3 Clinical Laboratory Tests 
Laboratory includes hematology, serology, serum chemistry, and urinalysis; laboratory collected 
prior to surgery will be the baseline laboratory. The study will utilize local lab for all clinical 
laboratory testing. Laboratory data will be tabulated based on the following result class. 
 Normal: result is within the local lab normal range 
 Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each lab test without formal inferential statistics. If data permits shift 
in result class from baseline to post baseline may also be tabulated. 
12.7.4 12-lead ECG 
ECG findings at each time point will be tabulated by treatment group without inferential 
statistics. 
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12.7.5 Vital Sign Measurements 
Vital signs collected immediately prior to receiving study drug will be the baseline vital signs. 
Observed vital sign values and change from baseline in vital signs at each visit will be 
summarized without formal statistical testing. 
Vital sign result may also be tabulated based on the following result class. 
 Normal: result is within the normal range 
 Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each vital sign. 
12.7.6 Physical Examinations  
Findings of physical examinations will be tabulated by treatment groups without inferential 
statistics. 
12.7.7 Subgroup Analyses for Safety Endpoints 
No subgroup analysis is planned for safety endpoints. 
12.8 PK Analysis 
Blood bismuth concentration vs. time profiles after administration of MBN-101 will be 
summarized for each nominal sampling time point and by dose group using descriptive statistics 
generated by WinNonlin. The NCA PK parameters (AUC0-t, AUC0-inf, Tmax, Cmax, T1/2, CL/F, 
Vz/F) will also be summarized with descriptive statistics (generated by WinNonlin) for each dose 
group as well as for all treated subjects in the PK Evaluable Population. 
If data permit, the correlation between Bismuth concentration and efficacy and/or safety 
endpoints may be explored. 
12.9 Interim Evaluation 
Interim analyses are planned for this study for the purpose of DRC. The purpose of the interim 
analysis is to allow the DRC to review the data and to make recommendation to the Sponsor on 
whether or not the next cohort of the subjects should be studied as planned.  
An analysis plan for the DRC will be prepared as an appendix of the DRC charter. The scope of 
the interim analyses for the DRC will be defined in this analysis plan. 
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13 REFERENCES 
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2. Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and verbal rating 
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3. Brokelman RBG, Haverkamp D, van Loon C, Hol A, van Kampen A, Veth R. The validation 
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4. Burckhardt CS, Jones KD. Adult measures of pain: The McGill Pain Questionnaire (MPQ), 
Rheumatoid Arthritis Pain Scale (RAPS), Short-Form McGill Pain Questionnaire (SF-MPQ), 
Verbal Descriptive Scale (VDS), Visual Analog Scale (VAS), and West Haven-Yale 
Multidisciplinary Pain Inventory (WHYMPI). Arthritis Rheum. 2003;49;S96-104. 
5. Ciofu O, Tolker-Nielson T. Antibiotic Tolerance and Resistance in Biofilms. In: Bjarnsholt 
T, Jensen PØ, Moser C, Høiby N, editors. Biofilm Infections. New York: Springer; 2011. 
pp 215-29. doi: 10.1007/978-1-4419-6084-9_13. 
6. Cummins JS, Tomek IM, Kantor SR, Furnes O, Engesaeter LB, Finlayson SR. 
Cost‑ effectiveness of antibiotic-impregnated bone cement used in primary total hip 
arthroplasty. J Bone Joint Surg Am. 2009;91(3):634-41. PubMed PMID: 19255224. 
doi:10.2106/JBJS.G.01029. 
7. Ferry T, Uckay I, Vaudaux P, Francois P, Schrenzel J, Harbarth S. Laurent F, Bernard L, 
Vandenesch F, Etienne J, Hoffmeyer P, Lew D. Risk factors for treatment failure in 
orthopedic device-related methicillin-resistant Staphylococcus aureus infection. Eur J Clin 
Microbiol Infect Dis. 2010;29(2):171-80. 
8. Gessmann J, Kammler J, Schildhauer TA, Kaminski A. MRSA colonisation in patients with 
proximal femur fractures in a German trauma centre: incidence, infection rates and outcomes. 
Langenbecks Arch Surg. 2012;397(1):117-23. 
9. Ghigo J-M. Natural conjugative plasmids induce bacterial biofilm development. Nature. 
2001;412(26):442-5. 
10. Godil SS, Parker SL, O'Neill KR, Devin CJ, McGirt MJ. Comparative effectiveness and cost-
benefit analysis of local application of vancomycin powder in posterior spinal fusion for 
spine trauma: clinical article. J Neurosurg Spine. 2013;19(3):331-5. 
11. Gristina AG, Naylor P, Myrvik Q. Infections from biomaterials and implants: a race for the 
surface. Medical Progress Through Technology. 1988;14:205-24. 
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12. Gristina AG, Shibata Y, Giridhar G, Kreger A, Myrvik QN. The glycocalyx, biofilm, 
microbes, and resistant infection. Semin Arthroplasty. 1994;5(4):160-70. 
13. Heller A, McIff TE, Lai SM, Burton DC. Intrawound vancomycin powder decreases 
Staphylococcal surgical site infections following posterior instrumented spinal arthrodesis. 
J Spinal Disord Tech. Epub ahead of print 2013. PubMed PMID: 24189484. 
14. Hetrick EM, Schoenfisch MH. Reducing implant-related infections: active release strategies. 
Chem Soc Rev. 2006;35(9):780-9. 
15. Kwon A, Park G, Ryu S, Lim D, Lim D, Choi C, Park Y, Lim Y. Higher biofilm formation in 
multidrug-resistant clinical isolates of Staphylococcus aureus. Int J Antimicrob Ag. 
2008;32:68-72. 
16. Martin JR, Adogwa O, Brown CR, Bagley CA, Richardson WJ, Lad SP, Kuchibhatla M, 
Gottfried ON. Experience with intrawound vancomycin powder for spinal deformity surgery. 
Spine (Phila Pa 1976). Epub ahead of print 2013. PubMed PMID: 24158179. 
17. Morris BJ, Unger RZ, Archer KR, Mathis SL, Perdue AM, Obremskey WT. Risk factors of 
infection after ORIF of bichondylar tibial plateau fractures. J Orthop Trauma. 
2013;27(9):e196-e200. 
18. Nowinski RJ, Gillespie, RJ, Shishani Y, Cohen B, Walch G, Gobezie R. Antibiotic-loaded 
bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a 
retrospective, cohort study of 501 shoulders. J Shoulder and Elbow Surgery. 
2012;21(3):324-8. doi: 10.1016/j/jse.2011.08.072. 
19. Parra-Ruiz J, Vidaillac C, Rybak MJ.Macrolides and staphylococcal biofilms. Rev Esp 
Quimioter. 2012;25(1):10-16. 
20. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the 
tibia: current management concepts. Journal of the American Academy of Orthopaedic 
Surgeons. 2005;13(6):417-27. 
21. Reiter K, Da Silva Paim TG, De Oliveira CF, D’Azevedo PA. High biofilm production by 
invasive multiresistant staphylococci. Acta Pathologica Microbiologica et Immunologica 
Scandinavia. 2011;119:776-81. 
22. Robson MC. Wound infection. A failure of wound healing caused by an imbalance of 
bacteria. Surg Clin North Am. 1997;77(3):637-50. 
23. Robson MC. Award recipient address: Lessons gleaned from the sport of wound watching. 
Wound Repair Regen. 1999;7(1):2-6. 
24. Salgado CD, Dash S, Cantey JR, Marculescu CE. Higher risk of failure of methicillin-
resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res. 
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25. Schmidt AH, Swiontkowski MF. Pathophysiology of infections after internal fixation of 
fractures. Journal of the American Academy of Orthopaedic Surgeons. 2000;8(5):285-91. 
26. Selhi HS, Mahindra R, Yamin M, Jain D, De Long WG, Singh J. Outcomes in patients with 
an infected nonunion of the long bones treated with a reinforced antibiotic cement rod. 
J Orthop Trauma. 2012;26(3):184-8. 
27. Selim AJ, Rogers W, Fleishman JA, Qian SX, Fincke BG, Rothendler JA, Kazis LE. 
Updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12). 
Qual Life Res. 2009;18(1):43-52. doi: 10.1007/s11136-008-9418-2. Epub 2008 Dec 3. 
28. Short Musculokeletal Function Assessment Injury and Arthritis Survey; 
http://www.grossortho.com/forms/injury.pdf, accessed 05-16-2014. 
29. Swiontkowski MF, Engelberg R, Martin DP, Angel J. Short musculoskeletal function 
assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am. 
1999;81(9):1245-60. 
30. Tosh PK, McDonald LC. Infection control in the multidrug-resistant era: tending the human 
microbiome. Clin Infect Dis. 2012;54(5);707-13. 
31. Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic only versus 
local intrawound vancomycin antibiotic powder application in addition to intravenous 
antibiotics on postoperative infection in spine surgery in 907 patients. Spine (Phila Pa 1976), 
2013;38(25):2149-55. doi:10.1097/BRS.0000000000000015. PubMed PMID: 24048091. 
32. U.S. Department of Veterans Affairs [internet]. Washington: U.S. Department of Veterans 
Affairs; last updated 21 January 2014. Health Economics Resource Center: Cost-Effective 
Analysis. Available from: http://www.herc.research.va.gov/include/page.asp?id=cost-
effectiveness-analysis#vr36. 
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Surg. 2003;11(3):212-9. 
 
 
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14 APPENDICES 
Appendix 1: 
Table of Study Events ............................................................................................62 
Appendix 2: 
Flowchart for Microbiological Specimen Processing ............................................63 
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Appendix 1: Table of Study Events 
 
 
Procedure 
Screening 
Baseline/ 
Day of Surgery 
Hour 48- 60 
Hour 72 
Hour 96 
Week 2 
Week 6 
Week 12 
Week 24, EOT 
Early Term / 
Tx Failure 
Day 1 
Day 2 
Day 3 
Day 4 
Day 14 
±4 days 
Day 42 
±8 days 
Day 84 
±8 days 
Day 168 
±8 days 
Review of eligibility criteria 
X 
X 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
Surgery/Administration of the 
Investigational Product 
 
X 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
 
 
 
 
Interval physical exam 
 
X 
X 
 
 
X 
X 
X 
X 
X 
Hematology 
X 
 
X 
 
 
 
X 
X 
X 
X 
Serology 
 
X 
 
 
 
X 
X 
X 
X 
X 
Serum chemistry 
X 
 
X 
 
 
 
X 
X 
X 
X 
Urinalysis 
X 
 
X 
 
 
 
X 
X 
X 
X 
Pregnancy test 
X 
X 
 
 
 
 
 
 
X 
X 
BisEDT Blood levels1 
 
X 
X 
X 
X 
X 
 
 
 
 
12-lead ECG 
X 
X 
X 
 
 
 
 
 
X 
X 
Vital signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Patient-reported outcomes2 
X 
 
 
 
 
X 
X 
X 
X 
X 
Surgical site signs and symptoms 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Surgical site pain score 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Microbiology 
 
X 
(X)3 
 
 
(X) 
(X) 
(X) 
(X) 
(X) 
Radiographic evaluation 
 
X 
 
 
 
X 
X 
X 
X 
X 
Concomitant medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
1 PK blood samples will be collected pre-dose and at nominal 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 (Day 3), 96 (Day 4) and 336 (Day 14; Week 2) hours after administration of the 
investigational product 
2 Patient-reported outcomes include the Veterans Rand 12 Item Health Survey (VR-12) and Short Musculoskeletal Function Assessment (SMFA) 
3 Microbiology will be performed at any time that a new surgical intervention is required. 
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Appendix 2: Flowchart for Microbiological Specimen Processing 
 
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PROTOCOL AMENDMENT FORM 
 
DATE:  10/08/15 
AMENDMENT NUMBER:  01 
 
PROTOCOL NUMBER:  MBN-101-201 (Version 2.0) 
 
SPONSOR: Microbion Corporation 
 
PROTOCOL TITLE: A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week Escalating Dose 
Study to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally Applied MBN-101 
to Infected Osteosynthesis Sites 
 
 
REASON(S) FOR CHANGE(S): Changes were implemented to add a citation of grant support, to correct the study 
drug application procedure in cases where hardware is replaced or in cases of two-stage procedures, to clarify 
exclusion criteria #16 and #18, to maintain consistent descriptions of study procedures across sections of the protocol, 
and to correct several administrative and editorial errors from Version 1.0. 
 
CHANGE(S):  
Note – All changes refer to page numbers in the Clean Version 2.0 
Location 
From 
To 
Comment 
Header 
Version 1.0, 
Issue Date 06 May 2015 
Version 2.0, 
Issue Date 05 October 2015 
Update version 
Page 1 
Issue Date: 06 May 2015 
Version 2.0, 
Issue Date: 05 October 2015 
Replaces Version 1.0 
Dated 06 May 2015 
Update version 
Page 1 
Version: 1.0 
Version: 2.0 
Update version 
Page 2 
 
Grant Support: 
This Phase 2a clinical study is 
supported in part by a $2.5 million 
grant awarded through the "Defense 
Medical Research and Development 
Program (DMRDP) Military 
Infectious Diseases Clinical Trial 
Award, W81XWH-12-DMRDP-
MID-CTA". The grant award 
number is W81XWH-12-2-0100.  
The Awardee is the University of 
Pennsylvania, and the Principal 
Investigator (PI) for this grant 
award is Dr. Samir Mehta, Chief, 
Division of Orthopaedic Trauma, 
and Assistant Professor of 
Orthopaedic Surgery at the Hospital 
of the University of Pennsylvania. 
Dr. Mehta is also serving as the 
clinical PI for the University of 
Pennsylvania orthopaedic trauma 
clinical site. 
Added grant support 
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PROTOCOL AMENDMENT FORM 
 
DATE:  10/08/15 
AMENDMENT NUMBER:  01 
 
PROTOCOL NUMBER:  MBN-101-201 (Version 2.0) 
 
Location 
From 
To 
Comment 
Participating as a Co-Investigator in 
this grant award is Dr. Saam 
Morshed, attending orthopaedic 
trauma surgeon and Director of the 
Clinical Research Center at the 
University of California San 
Francisco (UCSF) and the San 
Francisco General Hospital 
Orthopaedic Trauma Institute 
(OTI). Dr. Morshed will also serve 
as the clinical PI for the UCSF 
orthopaedic trauma clinical site. 
The Program Sponsor, Microbion 
Corporation, is represented by Dr. 
Brett Baker, President and Chief 
Scientific Officer. 
Page 5 
In cases where hardware is 
replaced or in cases of two-
stage procedures, MBN-101 
will be applied to all surfaces 
of new hardware immediately 
prior to implantation, and 
following implantation to 
adjacent bone and accessible 
hardware surfaces. 
In cases where hardware is replaced 
or in cases of two-stage procedures, 
MBN-101 will be applied to all 
accessible surfaces of hardware and 
adjacent bone (target structures) 
following implantation of hardware 
and immediately prior to definitive 
closure. 
Correct study drug application 
procedure 
Page 5 
 
nominal 
Administrative change 
Page 7 
 
other than the index infected 
osteosynthesis site 
Clarify Exclusion #16 
Page 7 
 
(hemoglobin A1c > 9.0% for 
≥ 6 months despite management 
by a physician) 
Clarify Exclusion #18 
Page 22 
In cases where hardware is 
replaced or in cases of two-
stage procedures, the 
investigational product will be 
applied to all surfaces of new 
hardware immediately prior to 
implantation, and following 
implantation to adjacent bone 
and accessible hardware 
surfaces. 
In cases where hardware is replaced 
or in cases of two-stage procedures, 
MBN-101 will be applied to all 
accessible surfaces of hardware and 
adjacent bone (target structures) 
following implantation of hardware 
and immediately prior to definitive 
closure. 
Correct study drug application 
procedure 
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PROTOCOL AMENDMENT FORM 
 
DATE:  10/08/15 
AMENDMENT NUMBER:  01 
 
PROTOCOL NUMBER:  MBN-101-201 (Version 2.0) 
 
Location 
From 
To 
Comment 
Page 24 
The Treatment Dose will be 
provided to the surgeon in an 
8 mL volume in a sterile 10 
mL syringe. 
The Treatment Dose will be 
provided to the surgeon in a vial 
from which an 8 mL volume will be 
drawn up in the operating room into 
a sterile 10 mL syringe. 
Correct study drug application 
procedure 
Page 24 
lightly 
sparingly…actual 
Correct study drug application 
procedure 
Page 25 
<75 
<75 
Maintain consistency across 
sections of the protocol 
Page 26 
 
other than the index infected 
osteosynthesis site 
Clarify Exclusion #16 
Page 26 
 
(hemoglobin A1c > 9.0% for 
≥ 6 months despite management 
by a physician) 
Clarify Exclusion #18 
Page 29 
Inc 
Inc. 
Administrative change 
Page 31 
…absence of individual… 
…absence of an individual… 
Administrative change 
Page 32 
 
approximate surface area of the 
surgical site as well as the amount 
and 
Correct study drug application 
procedure 
Page 32 
, including the dimensions and 
approximate surface area of 
the surgical incision, 
 
Correct study drug application 
procedure 
Page 32 
15 gauge 
18 gauge 
Correct study drug application 
procedure 
Page 32 
 
6. One pre-printed "Diluted 
MBN-101 Drug Product" label 
Correct study drug application 
procedure 
Page 33 
Prior to implantation, the 
surgeon will use a gloved 
finger to sparingly coat all 
hardware with a thin layer of 
the investigational product. 
Following surgical 
implantation of the coated 
hardware, a thin layer of the 
investigational product will be 
applied to surrounding bone 
using a gloved finger. 
Administration of the 
investigational product will 
therefore be limited to target 
areas, specifically orthopedic 
In cases where hardware is replaced 
or in cases of two-stage procedures, 
MBN-101 will be applied to all 
accessible surfaces of hardware and 
adjacent bone (target structures) 
following implantation of hardware 
and immediately prior to definitive 
closure. Other wound surfaces will 
not be coated, resulting in 
administration of the investigational 
product to only a limited area of the 
wound. 
Correct study drug application 
procedure 
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PROTOCOL AMENDMENT FORM 
 
DATE:  10/08/15 
AMENDMENT NUMBER:  01 
 
PROTOCOL NUMBER:  MBN-101-201 (Version 2.0) 
 
Location 
From 
To 
Comment 
hardware and the immediately 
adjacent, accessible bone 
(osseous) surfaces. 
Page 34 
•Cohort 1: 25 µg/mL MBN-
101 = 0.5 µg/cm2 
•Cohort 2: 75 µg/mL MBN-
101 = 1.5 µg/cm2 
•Cohort 3: 250 µg/mL MBN-
101 = 5.0 µg/cm2 
•Cohort 1: 0.025 mg/mL MBN-101 
= 0.5 µg/cm2 
•Cohort 2: 0.075 mg/mL MBN-101 
= 1.5 µg/cm2 
•Cohort 3: 0.250 mg/mL MBN-101 
= 5.0 µg/cm2 
Administrative change 
Page 34 
…assayed for BisEDT 
…recorded in the eCRF 
Maintain consistency across 
sections of the protocol 
Page 38 
 
nominal 
Administrative change 
Page 42 
This DRC will include a 
Statistician, an orthopedic 
surgeon and a Medical Safety 
Officer. An independent 
statistician… 
A statistician… 
Maintain consistency across 
sections of the protocol 
Page 42 
 
A sponsor representative will also 
serve as a non-voting member of 
the DRC to facilitate sponsor 
internal planning. 
Administrative change 
Page 43 
15 gauge 
18 gauge 
Correct study drug application 
procedure 
Page 43 
 
6. One pre-printed "Diluted 
MBN-101 Drug Product" label 
Correct study drug application 
procedure 
Page 47 
Microbion 
Microbion and/or its designee 
Administrative change 
Page 47 
 
Moreover: 
Administrative change 
Page 48 
monitors 
monitor 
Administrative change 
Page 48 
Medical monitors… 
The medical monitor… 
Administrative change 
Page 62 
+2 days 
+4 days 
Maintain consistency across 
sections of the protocol 
Page 62 
28 
42 
Correction to Week 6 Visit 
Page 62 
 
Added “X” for Concomitant 
medications Days 3 and 4 
Maintain consistency across 
sections of the protocol 
Page 62 
 
Added “X” for Adverse events 
Days 3 and 4 
Maintain consistency across 
sections of the protocol 
Page 62 
 
nominal 
Administrative change 
 
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1 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 
24-week Escalating Dose Study to Assess the Safety, Tolerability 
and Clinical Activity of 3 Concentrations of Locally Applied MBN-101 
to Infected Osteosynthesis Sites 
PROTOCOL NUMBER: MBN-101-201 
Version 2.0 Issue Date: 08 October 2015 
Replaces Version 1.0 Dated 06 May 2015 
Regulatory Sponsor: 
Microbion Corporation 
1102 West Babcock, Suite B 
Bozeman MT 59715 
Version: 2.0 
Microbion Corporation 
 
Reviewed and Approved by: 
 
 
 
08 October 2015 
Dr. Brett Baker 
Microbion Corporation 
President and Chief Scientific Officer 
 
Date 
Confidentiality 
This document is the confidential property of Microbion Corporation. 
No part of it may be reproduced, published, or transmitted by other persons 
without written permission of Microbion Corporation. 
 
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GRANT SUPPORT 
This Phase 2a clinical study is supported in part by a $2.5 million grant awarded through the 
"Defense Medical Research and Development Program (DMRDP) Military Infectious Diseases 
Clinical Trial Award, W81XWH-12-DMRDP-MID-CTA". The grant award number is 
W81XWH-12-2-0100.  
The Awardee is the University of Pennsylvania, and the Principal Investigator (PI) for this grant 
award is Dr. Samir Mehta, Chief, Division of Orthopaedic Trauma, and Assistant Professor of 
Orthopaedic Surgery at the Hospital of the University of Pennsylvania. Dr. Mehta is also serving 
as the clinical PI for the University of Pennsylvania orthopaedic trauma clinical site. 
Participating as a Co-Investigator in this grant award is Dr. Saam Morshed, attending 
orthopaedic trauma surgeon and Director of the Clinical Research Center at the University of 
California San Francisco (UCSF) and the San Francisco General Hospital Orthopaedic Trauma 
Institute (OTI). Dr. Morshed will also serve as the clinical PI for the UCSF orthopaedic trauma 
clinical site.  
The Program Sponsor, Microbion Corporation, is represented by Dr. Brett Baker, President and 
Chief Scientific Officer. 
 
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INVESTIGATOR AGREEMENT 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week Escalating Dose Study 
to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally Applied 
MBN-101 to Infected Osteosynthesis Sites 
I have read the protocol and agree that it contains all necessary details for carrying out the study 
as described. I will conduct this protocol as outlined therein and will make all reasonable efforts 
to complete the study within the designated time. 
I will provide copies of the protocol and access to all information furnished by Microbion 
Corporation to study personnel under my supervision. I will discuss this material with them to 
ensure that they are fully informed about the drug and the study. 
I understand that the study may be terminated or enrollment suspended at any time by Microbion 
Corporation with or without cause, or by me, if it becomes necessary to protect the best interests 
of the study subjects. 
I agree to conduct this study in accordance with the requirements of this protocol and in 
accordance with the following: 
• Good Clinical Practice: Consolidated Guideline International Conference on Harmonisation 
of Technical Requirements for the Registration of Pharmaceuticals for Human Use, ICH E6 
(May 1996) 
• United States (U.S.) Code of Federal Regulations (CFR) associated with clinical studies 
(21 CFR parts 50, 56, 312) 
• Declaration of Helsinki, concerning medical research in humans (“Ethical Principles for 
Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 1975, Venice 
1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, Washington 
2002 and Tokyo 2004). 
 
  
Investigator’s Printed Name 
  
Investigator’s Signature 
 Date 
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PROTOCOL SYNOPSIS 
Protocol Number 
MBN-101-201 
Title 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week 
Escalating Dose Study to Assess the Safety, Tolerability and Clinical 
Activity of 3 Concentrations of Locally Applied MBN-101 to Infected 
Osteosynthesis Sites 
Regulatory Sponsor 
Microbion Corporation, 1102 West Babcock, Suite B, Bozeman MT 59715 
Name of 
Investigational 
Product 
MBN-101 
Phase 
2a 
Investigators/Study 
Centers 
3-4 Study Centers in the United States  
Objectives: 
Primary Objective 
To evaluate the safety and tolerability of single escalating doses of locally 
administered MBN-101 or placebo as adjunct to standard of care 
antimicrobial and surgical therapy 
Secondary Objectives • 
To evaluate the clinical activity of single escalating doses of locally 
administered MBN-101 
• 
To evaluate the pharmacokinetics of single escalating doses of locally 
administered MBN-101 
Number of Subjects 
36 
Study Design and 
Methodology 
This is a randomized, single-blind, placebo-controlled, multi-center study to 
assess the safety and tolerability of single escalating doses of MBN-101 
applied directly to target structures within infected osteosynthesis sites during 
revision surgery with or without hardware removal and replacement for 
patients diagnosed with an apparent fracture site infection within one year of 
the last surgical intervention. Three successive cohorts of 12 patients will be 
enrolled in this trial. Consecutive patients from each of the study sites will be 
screened for potential participation as they present to the orthopedic service 
for clinical care for their postoperative infections. Patients meeting eligibility 
criteria on screening will be offered participation in the study. 
Following baseline evaluation, patients will receive standard of care 
treatment for their postoperative fracture site infection that includes systemic 
antibacterial treatment per institutional standard of care guidelines and 
revision surgery with or without hardware removal and replacement as 
indicated. A single application of MBN-101 or placebo, applied 
intraoperatively directly to target structures within infected osteosynthesis 
sites, will be performed following the final irrigation and debridement 
procedure and immediately prior to definitive closure. In cases where original 
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hardware is retained, MBN-101 will be applied to all accessible surfaces of 
hardware and adjacent bone (target structures). In cases where hardware is 
replaced or in cases of two-stage procedures, MBN-101 will be applied to all 
accessible surfaces of hardware and adjacent bone (target structures) 
following implantation of hardware and immediately prior to definitive 
closure. If wounds are left open, the investigational product will be applied 
immediately prior to definitive closure. The minimum amount of MBN-101 
required to achieve a thin coat of the relevant target structures within the 
infected osteosynthesis site will be used. 
Patients will be randomized 3:1 (active:control) to three successive doses 
(0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up 
to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent). Enrollment to the 
next dose cohort will not commence until an evaluation by the Data Review 
Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort. 
PK assessments will be performed predose and at nominal 1, 6, 12, 24, 36, 48 
(Day 2), 60, 72 (Day 3), 96 (Day 4), and 336 (Day 14; Week 2) hours after 
administration of study drug. 
Patients will undergo study visits at Hour 48 and Weeks 2, 6, 12, and 24. All 
patients will be followed for a total of 24 weeks after surgery. 
Study Population: 
Inclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “YES” answer (unless not applicable): 
1. Patients who: 
• 
have had operative fracture fixation of the upper extremity 
(AO/OTA class 15, 11-13, 21-23), lower extremity (AO/OTA class 
31-34, 41-44, 81, 82) or pelvis (61, 62), or have undergone 
arthrodesis 
• 
are diagnosed with an apparent fracture site infection within one year 
of their last surgical intervention and have at least one of the 
following: 
− 
Elevated ESR above the upper limit of normal 
− 
Elevated CRP above the upper limit of normal 
− 
Draining wound / sinus tract 
− 
Positive culture from site of prior surgery by aspirate or other 
modality 
− 
Local erythema or induration at the site of prior surgery 
− 
Exposed hardware 
− 
Periosteal reaction on x-ray 
− 
Loose or broken hardware  
• 
require revision surgery with or without removal and replacement of 
existing hardware 
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2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed 
and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as 
per institution’s standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after 
revision surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile 
or at least 2 years postmenopausal, must agree to use one of the 
following forms of contraception from screening through the Week 24 
visit: hormonal (oral, implant, or injection) begun >30 days prior to 
screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications 
and they must ensure their female sexual partner complies with the 
contraception requirements:  
• 
Be sexually abstinent from Baseline through Week 24  
• 
Be > 6 months post-vasectomy  
• 
Agree to use a condom with spermicide from Baseline through 
Week 24 
7. Have read and signed the Informed Consent Form (ICF) after the nature 
of the study has been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of 
personal health information in accordance with Health Insurance 
Portability and Accountability Act (HIPAA) 
Exclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “NO” answer (unless not applicable): 
1. Patients who are no longer hardware dependent or are definitively treated 
for their infection by hardware removal without replacement 
2. Greater than one year time lapse from last operative procedure 
3. Patients with a previous revision surgery at the site 
4. Patients with multiple, non-contiguous fracture site infections 
5. Pathologic fracture (not including osteoporosis)  
6. Patient requires immunosuppressive therapy (Topical or inhaled 
corticosteroids are permitted) 
7. Serum creatinine, ALT, AST or Alkaline Phosphatase >1.5 times the 
upper limit of the normal range of the local testing laboratory 
8. Absolute neutrophil count <1000 
9. Patients without definitive soft-tissue coverage over the surgical site at 
time of study product administration 
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10. Any condition that has required treatment with any other bismuth 
containing compound within the last 2 weeks (i.e., Kaopectate or 
Pepto-Bismol) 
11. Participation in an investigational trial to evaluate pharmaceuticals or 
biologics within the past 3 months 
12. Individuals undergoing surgical treatment for more than one infected 
fracture 
13. Known allergy to metals or materials comprising the orthopedic 
hardware, bismuth and/or MBN-101 excipients (methylcellulose, 
Tween 80 (polysorbate 80)) 
14. Patients who are pregnant, lactating, or female patients who have a 
positive serum hCG as determined by laboratory testing 
15. Immunocompromised due to illness or organ transplant 
16. History of chronic or recurrent infections (≥ 3 infections at the same site 
within 12 months) other than the index infected osteosynthesis site 
17. History of any type of cancer (excluding non-melanomatous localized 
skin cancer or completely excised and cured carcinoma-in-situ of uterine 
cervix) 
18. Poorly controlled diabetes mellitus (hemoglobin A1c > 9.0% for 
≥ 6  months despite management by a physician) 
19. History of medical noncompliance 
20. Other medical conditions which, in the opinion of the Principal 
Investigator, would jeopardize the safety of the study subject or impact 
the validity of the study results. 
21. Current incarceration 
Investigational 
Product, Dose and 
Mode of 
Administration: 
MBN-101: A suspension of 0.025, 0.075, or 0.25 mg/mL (w:v) BisEDT 
powder in 3% methylcellulose / 0.5% Tween 80 / 10 mM sodium chloride / 
10 mM sodium phosphate, pH 7.4 (up to 8 mL dose volume) applied directly 
to structures within infected osteosynthesis sites during revision surgery with 
or without hardware removal and replacement as an adjunct to standard care 
systemic antimicrobial therapy. 
Reference Therapy, 
Dose and Mode of 
Administration: 
MBN-101 diluent (placebo): 3% methylcellulose / 0.5% Tween 80 / 
10 mM sodium chloride / 10 mM sodium phosphate, pH 7.4 (up to 8 mL dose 
volume) applied directly to structures within infected osteosynthesis sites 
during revision surgery with or without hardware removal and replacement 
as an adjunct to standard care systemic antimicrobial therapy. 
Study Duration 
24 weeks 
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Criteria for Evaluation: 
Efficacy Endpoints 
• 
Proportion of treatment failures. A treatment failure is defined as a 
subject with non-healing or worsening status of their surgical site 
requiring serious intervention by Week 24. 
• 
Cumulative number of serious interventions (as defined in Section 
12.6.2) at Week 24. 
• 
Time to first serious intervention, time to readmission and time to 
reoperation, exclusive of serious interventions, readmissions, and 
reoperations associated with a healed fracture site. 
• 
Number of subjects undergoing removal of stabilizing orthopedic 
hardware due to a healed fracture site by Week 24. 
• 
Time to removal of orthopedic hardware due to a healed fracture site. 
• 
Incidence and intensity of surgical site signs and symptoms, including 
local erythema, induration, drainage and degree of healing. 
• 
Change from baseline in patient-reported outcomes at each post baseline 
time point. Patient-reported outcomes will include Veterans Rand 12 
Item Health Survey (VR-12) and Short Musculoskeletal Function 
Assessment (SMFA). 
• 
Surgical site pain score and change from baseline in pain score at each 
post baseline time point. Pain intensity at the surgical site will be 
assessed by Visual Analog Scale (VAS, 0-100 mm). 
• 
Findings of microbiology evaluations at the surgical site. Microbiologic 
success is assessed by clearance of infection. 
• 
Findings of radiographic evaluations at the surgical site. Radiographic 
success is assessed by healing on radiologic examination. 
• 
Changes in serologic markers CRP and ESR at each post baseline time 
point. 
Safety Endpoints 
• 
Treatment-emergent adverse events. 
• 
Treatment-emergent serious adverse events. 
• 
Changes in clinical laboratory tests (clinical chemistry, hematology, and 
urinalysis). 
• 
Changes in vital signs (blood pressure, pulse, respiratory rate and body 
temperature). 
• 
Changes in physical exams. 
• 
Clinical findings of 12-lead electrocardiograms. 
• 
Change in microbiology status 
Pharmacokinetic 
Endpoints 
• 
Whole blood concentrations of Bismuth (Bi) will be measured after 
administration of single escalating doses of MBN-101 (bismuth as a 
surrogate for BisEDT) and will be used to calculate pharmacokinetic 
parameters (i.e., Tmax, Cmax, AUC0-t, AUC0- ∞, T1/2, CL/F, Vz/F). 
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Statistical Methods: 
Statistical Analysis 
Consideration: 
The study sample of size of 36 subjects was chosen empirically for the 
purpose of the study without considering any formal statistical hypothesis 
testing. 
The safety analysis set will include all subjects who are randomized and 
receive any study drug; the efficacy analysis set will include all randomized 
subject with at least one post treatment assessment. Pharmacokinetic analysis 
set will include all subjects who have sufficient plasma samples to allow for 
calculation of pharmacokinetic parameters.  
All safety and efficacy endpoints will be tabulated with descriptive statistics; 
data from all placebo subjects (3 per cohort; 9 subjects in total) will be 
pooled. Data from BisEDT treated subjects will be presented by dose 
(9 subjects per dose) and combined (a total of 27 subjects). If data permits, 
differences between the treatment groups and 95% confidence intervals for 
the difference will be presented. 
If data permit, exploratory dose-response analyses will be performed for 
selected efficacy and safety endpoints.  
The primary analyses of efficacy and safety endpoints will be based on the 
actual treatment received in the event that the received treatment is not the 
assigned treatment; however, ‘as assigned’ sensitivity analyses are planned to 
evaluate the robustness of the efficacy data. 
 
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SPONSOR CONTACT INFORMATION 
Medical Monitor 
Name: 
Brian Murphy, MD 
Sr. Medical Director, Medpace Infectious Diseases 
Office Phone Number: 
513-579-9911, ext. 2416 
Mobile Phone Number: 
859-619-0037 
E-mail: 
b.murphy1@medpace.com 
Other Appropriate Trial Contact Personnel 
Name 
Ronnie McAdams 
Clinical Trial Manager, Associate Director, Medpace 
Office Phone Number 
513-579-9911, ext. 2845 
Mobile Phone Number 
513-394-0516 
Fax 
513-579-0444 
E-mail: 
r.mcadams@medpace.com 
Name 
Markus Heep, MD 
Medical Director Infectious Diseases 
Medpace Germany GmbH 
Office Phone Number 
+49 174 190 6865 
E-mail: 
M.Heep@Medpace.com 
24 Hour Emergency Contact Information 
Medpace Clinical Safety: 
 
SAE hotline: 
800-730-5779, ext. 2999 
Facsimile: 
866-336-5320 
E-mail: 
medpace-safetynotification@medpace.com 
 
If any Sponsor contact information needs to be changed during the course of the study, this will 
be done by the Sponsor, with written notification to the Investigator, and will not require a 
protocol amendment. 
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LIST OF ABBREVIATIONS 
AE 
Adverse event 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase (Serum glutamic pyruvic transaminase [SGPT]) 
AO/OTA 
Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association 
AST 
Aspartate aminotransferase (Serum glutamic oxaloacetic transaminase [SGOT]) 
AUC0-∞ 
Area under the curve from time 0 to infinity 
AUC0-t 
Area under the curve from time 0 to the time of the last measurable concentration 
Bi 
Bismuth, used as a surrogate in concentration and PK analyses after MBN-101 
administration 
BisEDT 
Bismuth-1,2-ethanedithiol 
BMI 
Body mass index 
BUN 
Blood urea nitrogen 
CFR 
Code of Federal Regulations 
CK 
Creatinine kinase 
CL/F 
Apparent clearance after extravascular administration  
CLSI 
Clinical and Laboratory Standards Institute 
Cm 
Centimeter 
Cmax 
Maximum observed concentration 
CRF 
Case report form 
CRP 
C-reactive protein 
DFU 
Directions for Use 
DOD 
Department of Defense 
DRC 
Data Review Committee 
ECG 
Electrocardiogram 
ESBL 
Extended spectrum beta lactamase 
ESR 
Erythrocyte sedimentation rate 
FDA 
U.S. Food and Drug Administration 
GCP 
Good Clinical Practice 
GGT 
Gamma glutamyl transferase 
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hCG 
Human chorionic gonadotropin 
HIPAA 
Health Insurance Portability and Accountability Act 
ICF 
Informed Consent Form  
ICH 
International Conference on Harmonization  
ICP-MS 
Inductively coupled plasma mass spectrometry 
IHMA 
International Health Management Associates, Inc. 
IRB 
Institutional Review Board  
ITT 
Intent to treat 
IUD 
Intrauterine device 
IV 
Intravenous 
IVRS 
Interactive Voice Response System 
Kg 
Kilogram 
MBN-101 
Bismuth-1,2-ethanedithiol (BisEDT) suspension 
MC 
Methylcellulose 
MCS 
Mental health domain score 
MCV 
Mean corpuscular volume 
MDR 
Multidrug Resistant 
MedDRA 
Medical Dictionary for Regulatory Activities 
mg 
milligram 
mg/mL 
Milligrams per milliliter 
MIC 
Minimal inhibitory concentration 
mITT 
Modified intent to treat 
mL 
Milliliter 
mm 
Millimeter 
mM 
Millimolar 
MRSA 
Methicillin resistant Staphylococcus aureus 
MRSE 
Methicillin resistant Staphylococcus epidermidis 
MSSA 
Methicillin-sensitive Staphylococcus aureus 
NCA 
Non-compartmental (PK) analysis 
ng/mL 
Nanograms per milliliter 
OR 
Operating room 
ORP 
Office of Research Protections 
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PCS 
Physical health domain score 
PI 
Principal investigator 
PK 
Pharmacokinetics 
PT 
Prothrombin time 
PTT 
Partial thromboplastin time 
QIDP 
Qualified Infectious Disease Product 
RBC 
Red blood cells 
SAE 
Serious Adverse Event 
SAE CRF 
Serious Adverse Event Case Report Form 
SAP 
Statistical Analysis Plan 
SGOT 
Serum glutamic oxaloacetic transaminase 
SGPT 
Serum glutamic pyruvic transaminase 
SMFA 
Short Musculoskeletal Function Assessment 
SOC 
System organ class 
SOP 
Standard Operating Procedure 
T1/2 
Apparent half-life after extravascular administration 
TEAE 
Treatment-emergent adverse event 
Tmax 
Time of the maximal observed concentration 
USAMRMC US Army Medical Research and Materiel Command 
VAS 
Visual Analog Scale 
VR-12 
Veterans Rand 12 Item Health Survey 
Vz/F 
Apparent volume of distribution after extravascular administration 
w/v 
Weight:volume 
w:w 
Weight:weight 
WBC 
White blood cells 
 
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TABLE OF CONTENTS 
Grant Support .................................................................................................................................. 2 
Investigator Agreement ................................................................................................................... 3 
Protocol Synopsis............................................................................................................................ 4 
Sponsor Contact Information ........................................................................................................ 10 
List of Abbreviations .................................................................................................................... 11 
 
INTRODUCTION ................................................................................................................18 
1.1 
Clinical Problem .......................................................................................................18 
1.2 
Investigational Therapy ............................................................................................19 
1.3 
Value of MBN-101 for the Treatment of the Clinical Problem ................................20 
 
OBJECTIVES .......................................................................................................................21 
2.1 
Primary ......................................................................................................................21 
2.2 
Secondary ..................................................................................................................21 
 
INVESTIGATIONAL PLAN ...............................................................................................22 
3.1 
Study Description......................................................................................................22 
3.2 
Number of Subjects...................................................................................................23 
3.3 
Number of Sites ........................................................................................................23 
3.4 
Clinical Trial Material...............................................................................................23 
3.4.1 
MBN-101 .....................................................................................................23 
3.4.2 
Placebo (MBN-101 diluent) ........................................................................23 
3.5 
Dose ..........................................................................................................................24 
 
STUDY POPULATION .......................................................................................................25 
4.1 
Inclusion Criteria ......................................................................................................25 
4.2 
Exclusion Criteria .....................................................................................................26 
 
SUBJECT ENROLLMENT .................................................................................................27 
5.1 
Medical History ........................................................................................................27 
5.2 
Physical Exam ...........................................................................................................27 
5.3 
Studies .......................................................................................................................27 
5.4 
Laboratory Tests at Screening Visit ..........................................................................27 
 
STUDY PROCEDURES ......................................................................................................28 
6.1 
Description of Study Procedures ..............................................................................28 
6.1.1 
Medical History ...........................................................................................28 
6.1.2 
Physical Exams ............................................................................................28 
6.1.3 
Vital Signs ...................................................................................................28 
6.1.4 
12-lead ECG ................................................................................................28 
6.1.5 
Laboratory Tests ..........................................................................................28 
6.1.6 
BisEDT (MBN-101) Blood Levels .............................................................29 
6.1.7 
Pain Assessments ........................................................................................29 
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6.1.8 
Patient Reported Outcomes .........................................................................29 
6.1.9 
Microbiology ...............................................................................................29 
6.1.9.1 
Specimen Collection ...................................................................29 
6.1.9.2 
Specimen Processing: Local Laboratory ....................................29 
6.1.9.3 
Specimen Processing: IHMA (Central Laboratory) ...................30 
6.1.9.4 
Integration of Local Site Laboratory and Central Laboratory 
Primary Isolation and Identification Results ..............................30 
6.1.10 Radiographic Evaluation .............................................................................31 
6.1.11 Surgical Site Signs and Symptoms Evaluation ...........................................31 
6.2 
Screening and Baseline Assessments........................................................................31 
6.3 
Randomization Procedure .........................................................................................31 
6.4 
Unblinding Procedure ...............................................................................................31 
6.5 
Investigational Product Administration ....................................................................32 
6.5.1 
Surgical Site Identification ..........................................................................32 
6.5.2 
Study Drug Administration .........................................................................32 
6.6 
Study Assessments ....................................................................................................35 
6.7 
Safety Monitoring .....................................................................................................35 
6.8 
Study Monitoring ......................................................................................................35 
6.9 
Patient Withdrawals ..................................................................................................35 
6.10 
Individual Patient Stopping Rules ............................................................................35 
6.11 
Study Stopping Rules ................................................................................................35 
 
CONCOMITANT MEDICATIONS ....................................................................................36 
 
STUDY ENDPOINTS ..........................................................................................................37 
8.1 
Safety Endpoints .......................................................................................................37 
8.2 
Efficacy Endpoints ....................................................................................................37 
8.3 
Pharmacokinetic Endpoint ........................................................................................38 
8.3.1 
Sample Collection and Handling .................................................................38 
8.3.2 
Assay Methodology .....................................................................................38 
8.3.3 
PK Analysis .................................................................................................38 
 
ADVERSE EVENTS ............................................................................................................39 
9.1 
Reporting and Following Adverse Events ................................................................39 
9.2 
Severity .....................................................................................................................40 
9.3 
Relationship to Clinical Trial Material .....................................................................40 
9.4 
Serious Adverse Events ............................................................................................41 
9.4.1 
Definition .....................................................................................................41 
9.4.2 
Reporting .....................................................................................................41 
9.5 
Pregnancies ...............................................................................................................42 
9.6 
Data Review Committee (DRC) ...............................................................................42 
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INVESTIGATIONAL PRODUCT MANAGEMENT .........................................................43 
10.1 
Study Drug ................................................................................................................43 
10.2 
Study Drug Packaging and Labeling ........................................................................44 
10.3 
Study Drug Storage ...................................................................................................44 
10.4 
Study Drug Accountability .......................................................................................44 
10.5 
Study Drug Handling and Disposal ..........................................................................44 
 
GENERAL CONSIDERATIONS ........................................................................................45 
11.1 
Basic Principles .........................................................................................................45 
11.2 
Institutional Review Board .......................................................................................45 
11.3 
Informed Consent......................................................................................................45 
11.4 
Study Termination ....................................................................................................46 
11.5 
Regulatory Documentation .......................................................................................46 
11.6 
Study Documentation................................................................................................46 
11.7 
Data Handling and Record Keeping .........................................................................47 
11.8 
Use of Information and Publication ..........................................................................47 
11.9 
Independent Medical Monitor...................................................................................48 
 
STATISTICAL ANALYSIS METHODOLOGY ................................................................49 
12.1 
Efficacy Endpoints ....................................................................................................49 
12.2 
Changes in serologic markers CRP and ESR at each post baseline time 
point.Safety Endpoints ..............................................................................................50 
12.3 
Sample Size Considerations ......................................................................................50 
12.4 
Analysis Datasets ......................................................................................................51 
12.5 
Disposition and Study Population Characteristics ....................................................51 
12.6 
Efficacy Analysis ......................................................................................................52 
12.6.1 Treatment Failure ........................................................................................52 
12.6.2 Incidence of Serious Interventions ..............................................................52 
12.6.3 Time to First Serious Interventions .............................................................53 
12.6.4 Subjects Undergoing Removal of Stabilizing Orthopedic Hardware .........53 
12.6.5 Surgical Site Signs and Symptoms ..............................................................53 
12.6.6 Patient-Report Outcomes ............................................................................53 
12.6.6.1 The Veterans RAND 12 Item Health Survey (VR-12) 
Questionnaire ..............................................................................53 
12.6.6.2 The Short Musculoskeletal Function Assessment 
Questionnaire (SMFA) ...............................................................53 
12.6.7 Pain Assessments ........................................................................................54 
12.6.8 Microbiology ...............................................................................................54 
12.6.9 Radiographic evaluation ..............................................................................55 
12.6.10 Serologic Markers .......................................................................................55 
12.6.11 Subgroup Analyses for Efficacy Endpoints ................................................55 
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12.6.12 Sensitivity Analyses for Efficacy Endpoints ...............................................55 
12.7 
Safety Analysis .........................................................................................................56 
12.7.1 Study Drug Exposure and Concentrations ..................................................56 
12.7.2 Adverse Events ............................................................................................56 
12.7.3 Clinical Laboratory Tests ............................................................................56 
12.7.4 12-lead ECG ................................................................................................56 
12.7.5 Vital Sign Measurements ............................................................................57 
12.7.6 Physical Examinations ................................................................................57 
12.7.7 Subgroup Analyses for Safety Endpoints ....................................................57 
12.8 
PK Analysis ..............................................................................................................57 
12.9 
Interim Evaluation ....................................................................................................57 
 
REFERENCES .....................................................................................................................58 
 
APPENDICES ......................................................................................................................61 
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INTRODUCTION 
1.1 
Clinical Problem 
Postoperative orthopedic infections, particularly antibiotic-resistant infections, present a serious 
clinical challenge to surgeons and other treating physicians, since these infections involve 
foreign materials (stabilizing orthopedic hardware) which are frequently associated with 
persistent microbial biofilms (Hetrick, 2006). Surgical intervention, including irrigation, 
debridement and potential replacement of orthopedic hardware, combined with a prolonged 
course of systemic antibiotics, is the standard of care for postoperative infections (Schmidt, 
2000; Patzakis, 2005). However, outcomes associated with these infections are often poor, 
including chronic/recurrent infections, repeated hospitalizations, repeated surgeries, multiple 
courses of systemic antibiotic treatment, loss of function, disability, amputation and death 
(Berkes, 2010). 
Systemic antibiotics are poorly efficacious in the treatment of heavily contaminated or infected 
wounds (Zalavras, 2003; Robson, 1997) and often antibiotics “…have practical and potential 
value only if a therapeutic blood level or, more importantly, tissue level is achieved within the 
first 4 hours after wounding” (Robson, 1999), i.e., before biofilm formation. The ‘contest’ 
between bacteria and host tissues with respect to speed of colonization of foreign objects such as 
orthopedic medical devices has been described as the “race for the surface’ (Gristina, 1988). 
Bacteria are able to adhere to foreign, implanted objects almost immediately, facilitating rapid 
formation of microbial biofilms which drastically increase the resistance of wound-associated 
bacteria and contribute significantly to persistence and virulence of the infection (Parra-Ruiz, 
2012; Gristina, 1994). Such biofilms can serve as quiescent reservoirs of adherent, antibiotic-
tolerant or antibiotic-resistant bacteria within the wound, or as foci of active infections, which 
helps to explain the chronic and/or recurrent nature of many device-related infections. In 
addition, biofilms are hypermutable (Ciofu, 2011), increasing the likelihood of developing 
genetically-based antibiotic resistance. Finally, biofilms serve as environments in which bacteria 
can exchange genetic material encoding antibiotic resistance genes (Ghigo, 2001). Recent studies 
have shown that the most highly multidrug resistant (MDR) bacteria are also the strongest 
biofilm-forming bacteria (Kwon, 2008), and similarly, that invasive MDR bacteria are usually 
biofilm-forming bacteria (Reiter, 2011). 
The high incidence of postoperative orthopedic device-related infections, as well as the 
shortcomings of the standard of care treatment in resolving those infections, particularly 
considering the increasing prevalence of antibiotic-resistant pathogens, has resulted in an 
expanding unmet need for safe, innovative, new and effective therapies to reduce the infectious 
risks and consequences of these infections, which increasingly involve antibiotic- resistant 
strains (Gessman, 2012; Morris, 2013; Tosh, 2012). Antibiotic resistance adds significantly to 
the challenge of successfully resolving these orthopedic infections (Ferry, 2010; Salgado, 2007). 
For example, infection treatment failures are nine times more frequent in orthopedic patients 
with MRSA infections than methicillin-sensitive S. aureus (MSSA) infections (Salgado, 2007).  
Development of local therapies that eradicate established biofilms or prevent the formation of 
biofilms (as a new target) is an innovative new clinical strategy, particularly considering the 
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shortcomings of systemically administered antibiotics for treatment of wound infections. For 
example, several groups have investigated the direct, local application of vancomycin powder on 
the surgical wound in combination with systemic prophylaxis to prevent or treat infection. The 
outcomes of these studies have been mixed, with some groups reporting a reduced infection rate 
and/or a reduction in patient treatment costs (Heller, 2013; Godil, 2013) and others reporting no 
benefit (Tubaki, 2013; Martin, 2013). Antibiotic-loaded bone cement containing tobramycin, 
gentamicin, or vancomycin/tobramycin or other antibiotic combinations have been investigated 
for their ability to reduce infection rates and /or reduce costs when applied locally in a variety of 
orthopedic surgical procedures (Cummins, 2009; Nowinski, 2012; Selhi, 2012). Evidence 
suggests that local therapies may reduce implant related surgical site infections. 
1.2 
Investigational Therapy 
MBN-101 [Bismuth-1,2-ethanedithiol (BisEDT) suspension] represents the first drug product 
from a new class of antimicrobial agents with apparently unique mechanisms of action. In 
nonclinical models, BisEDT has been shown to be effective against a broad-spectrum of 
orthopedic device-associated bacteria including antibiotic-resistant strains. 
BisEDT has several characteristics especially suited to the treatment of postoperative orthopedic 
infections: 
a) Broad spectrum antimicrobial activity against the most critically important antibiotic-
resistant bacteria, including MRSA, MRSE, antibiotic-resistant Pseudomonas 
aeruginosa, ESBL-positive Klebsiella pneumoniae, and antibiotic-resistant Enterobacter 
species. 
b) Apparently unique mechanisms of action. 
c) Anti-biofilm capabilities. 
d) Extremely low spontaneous mutation frequency, superior to many conventional 
antibiotics. 
e) Efficacy against both aerobic and anaerobic bacteria. 
f) Demonstrated lack of interference with the activity of a wide range of antibiotics. 
g) Enhanced activity in combination with specific antibiotics; in some cases synergy, has 
been demonstrated in vitro and in vivo. 
h) Maintenance of antimicrobial activity in the presence of excessive protein. 
i) A favorable safety and tolerability profile in nonclinical toxicology studies in a variety of 
species, including absence of effect on wound healing or bone repair 
j) A favorable safety and tolerability profile in a clinical Phase 1 study evaluating topical 
administration. 
Based in part on these characteristics, BisEDT has been granted Qualified Infectious Disease 
Product (QIDP) designation by the FDA for the local, intra-operative treatment of resistant post-
surgical orthopedic implant infections. 
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1.3 
Value of MBN-101 for the Treatment of the Clinical Problem  
The broad-spectrum antimicrobial, anti-biofilm activity of BisEDT, its activity against relevant 
antibiotic-resistant pathogens, and its ability to enhance the activity of certain other antibiotics 
are properties that will promote more rapid and/or more complete eradication of infection, and 
reduce infectious risks to patients. With comparatively elevated rates of postoperative infection 
associated with repair of traumatic orthopedic wounds, the development of a new and innovative 
treatment strategy to complement the current standard of care would therefore be expected to 
result in a substantial reduction in mortality, amputation, morbidity, and disability, along with a 
reduction in patient treatment costs. 
MBN-101 provides important potential advantages over current standard of care treatment for 
orthopedic infections. Direct, local contact of MBN-101 with infected target tissue and 
contaminated device surfaces immediately delivers a therapeutically active dose of BisEDT to 
the site of infection. Combined antimicrobial and anti-biofilm effects are achieved with minimal 
systemic exposure. Systemic antibiotics administered alone are frequently ineffective, in part 
because altered perfusion at the surgical wound site hinders effective and timely delivery of 
systemic antibiotics, making it difficult to reach therapeutic antibiotic levels at wound 
tissues/surfaces. The combined effect of IV administered antibiotics, which already serve as a 
pillar of the current standard of care for orthopedic device-related infections, along with the local 
administration of MBN-101, is expected to eradicate bacteria from postoperative orthopedic 
wounds, and will ultimately also serve to reduce the likelihood of development of antibiotic-
resistant bacteria. By reducing the time to resolution of infection and improving the ability of 
current antibiotic therapies to effectively control and eliminate post-surgical orthopedic device-
related infections, MBN-101 will contribute to reductions in the number of additional serious 
interventions needed to resolve infections including reduction in repeat surgeries, additional 
rounds of systemic antibiotics, patient hospitalization time, morbidity and mortality in both 
civilian and military populations. 
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OBJECTIVES 
2.1 
Primary 
To evaluate the safety and tolerability of single escalating doses of locally administered 
MBN-101 or placebo as adjunct to standard of care antimicrobial and surgical therapy. 
2.2 
Secondary 
• To evaluate the clinical activity of single escalating doses of locally administered MBN-101. 
• To evaluate the pharmacokinetics of single escalating doses of locally administered 
MBN-101. 
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INVESTIGATIONAL PLAN 
3.1 
Study Description 
This is a randomized, single-blind, placebo-controlled multi-center study to assess the safety and 
tolerability of escalating doses of MBN-101 applied directly to target structures within infected 
osteosynthesis sites during revision surgery with or without hardware removal and replacement 
for patients diagnosed with an apparent fracture site infection within one year of the last surgical 
intervention. Three successive cohorts of 12 patients will be enrolled in this trial. Consecutive 
patients from each of the study sites will be screened for potential participation as they present to 
the orthopedic service for clinical care for their postoperative infections. After signing an 
Informed Consent Form (ICF), subjects will complete screening procedures. Patients meeting all 
eligibility criteria on screening will be offered participation in the study. Patients accepting 
participation in the study will be randomized 3:1 (active:control) to three successive doses 
(0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 
2.0 mg, respectively) or placebo (diluent). Enrollment to the next dose cohort will not commence 
until an evaluation by the Data Review Committee (DRC) of all available safety data on all 
patients through Week 6 of study supports escalation to the next cohort. The DRC will monitor 
all safety data in an ongoing manner from all patients enrolled onto this study. 
Following baseline evaluation, patients will receive standard of care treatment for their post-
operative fracture site infection that includes systemic antibacterial treatment per institutional 
standard of care guidelines and revision surgery with or without hardware removal and 
replacement as indicated. Multiple debridements, soft tissue transfer, and revision fixation 
procedures may be performed prior to definitive closure. A single application of the 
investigational product, MBN-101 or placebo, applied intraoperatively directly to target 
structures within infected osteosynthesis sites, will be performed following the final irrigation 
and debridement procedure and immediately prior to definitive closure. In cases where original 
hardware is retained, the investigational product will be sparingly applied to all accessible 
surfaces of hardware and adjacent bone. In cases where hardware is replaced or in cases of two-
stage procedures, MBN-101 will be applied to all accessible surfaces of hardware and adjacent 
bone (target structures) following implantation of hardware and immediately prior to definitive 
closure. The volume applied will be determined by the surgeon’s assessment of the size (in cm2) 
of the target area, and guided by the Table in Section 6.5.2. If wounds are left open, the 
investigational product will be applied immediately prior to definitive closure. The minimum 
amount of MBN-101 required to achieve a thin coat of the relevant target structures within the 
infected osteosynthesis site will be used (see Section 6.5.2). 
All patients will receive standard postoperative care per institutional guidelines, and will be 
discharged from the hospital in accordance with local standards. Patients will undergo study 
visits at Hour 48 and Weeks 2, 6, 12, and 24. All patients will be followed for a minimum of 
24 weeks after surgery. 
See Appendix 1 for a Schedule of Activities. 
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3.2 
Number of Subjects 
Thirty-six adult male or female patients meeting protocol-specified eligibility criteria may 
participate in the study, with the objective of having a total of 9 patients per dose level in the 
MBN-101-treated group and 9 patients in a pooled placebo-treated group. Patients who are 
randomized but do not receive study drug may be replaced. 
3.3 
Number of Sites 
Three or four U.S. study sites are anticipated to enroll an adequate number of eligible patients. 
 
3.4 
Clinical Trial Material 
Patients will be randomized 3:1 (active:control) to three successive doses (0.025, 0.075, or 
0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 2.0 mg, respectively) 
or placebo (diluent). Enrollment to the next dose cohort will not commence until an evaluation 
by the Data Review Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort.  
3.4.1 
MBN-101 
MBN-101 is Bismuth-1,2-ethanedithiol (BisEDT) suspension (0.025, 0.075, or 0.25 mg/mL, 
w:v) in diluent (3% methylcellulose / 0.5% Tween 80 / 10mM sodium chloride / 10 mM sodium 
phosphate, pH 7.4). 
 
 
Structural Formula 
Molecular Formula 
C6H12S6Bi2 
Molecular Weight 
694.51 g/mol 
Stereochemistry/Chirality 
BisEDT has no chiral centers. 
 
3.4.2 
Placebo (MBN-101 diluent) 
Placebo is MBN-101 diluent comprised of 3% methylcellulose / 0.5% Tween 80 / 10mM sodium 
chloride / 10 mM sodium phosphate, pH 7.4. 
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3.5 
Dose 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
Investigational product kits (MBN-101 and placebo) configured for each dose cohort will be 
provided and will contain the supplies necessary for preparation of the specified concentrations 
of MBN-101 or placebo for administration to each patient. 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the Stock Formulation and Diluent 
provided in the Drug Product Kit according to the Directions for Use (DFU) provided. The 
Treatment Dose will be provided to the surgeon in a vial from which an 8 mL volume will be 
drawn up in the operating room into a sterile 10 mL syringe. Surgeons will be instructed to use 
sufficient volume (up to the full 8 mL provided for the largest exposed target areas) to sparingly 
coat the bone at the site of infection, the exposed surfaces of any retained hardware, and the 
surfaces of any new hardware to be implanted. With dose volume determined according to 
Section 6.5.2, the volume of MBN-101 required to achieve a thin coat of the relevant structures 
within the infected osteosynthesis site will be applied. Following application, OR personnel will 
record in the CRF the actual volume (in tenths of milliliters) of any unapplied Treatment Dose 
remaining in the syringe. 
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STUDY POPULATION 
The study population will include 36 male or female adults who meet all of the study entry 
requirements. 
4.1 
Inclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “YES” answer 
(unless not applicable): 
1. Patients who: 
• have had operative fracture fixation of the upper extremity (AO/OTA class 15, 11-13, 
21-23), lower extremity (AO/OTA class 31-34, 41-44, 81, 82) or pelvis (61, 62), or 
have undergone arthrodesis 
• are diagnosed with an apparent fracture site infection within one year of their last 
surgical intervention and have at least one of the following: 
− Elevated ESR above the upper limit of normal 
− Elevated CRP above the upper limit of normal 
− Draining wound / sinus tract 
− Positive culture from site of prior surgery by aspirate or other modality 
− Local erythema or induration at the site of prior surgery 
− Exposed hardware 
− Periosteal reaction on x-ray 
− Loose or broken hardware  
• require revision surgery with or without removal and replacement of existing hardware 
2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as per institution’s 
standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after revision surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile or at least 
2 years postmenopausal, must agree to use one of the following forms of contraception 
from screening through the Week 24 visit: hormonal (oral, implant, or injection) begun 
>30 days prior to screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications and they must 
ensure their female sexual partner complies with the contraception requirements:  
• Be sexually abstinent from Baseline through Week 24  
• Be > 6 months post-vasectomy  
• Agree to use a condom with spermicide from Baseline through Week 24 
7. Have read and signed the Informed Consent Form (ICF) after the nature of the study has 
been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of personal health 
information in accordance with Health Insurance Portability and Accountability Act 
(HIPAA) 
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4.2 
Exclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “NO” answer 
(unless not applicable): 
1. Patients who are no longer hardware dependent or are definitively treated for their 
infection by hardware removal 
2. Greater than one year time lapse from last operative procedure 
3. Patients with a previous revision surgery at the site 
4. Patients with multiple, non-contiguous fracture site infections 
5. Pathologic fracture (not including osteoporosis)  
6. Patient requires immunosuppressive therapy (Topical or inhaled corticosteroids are 
permitted) 
7. Serum creatinine, ALT, AST or Alkaline Phosphatase >1.5 times the upper limit of the 
normal range of the local testing laboratory 
8. Absolute neutrophil count <1000 
9. Patients without definitive soft-tissue coverage over the surgical site at time of study 
product administration 
10. Any condition that has required treatment with any other bismuth containing compound 
within the last 2 weeks (i.e., Kaopectate or Pepto-Bismol) 
11. Participation in an investigational trial to evaluate pharmaceuticals or biologics within the 
past 3 months 
12. Individuals undergoing surgical treatment for more than one infected fracture 
13. Known allergy to metals or materials comprising the orthopedic hardware, bismuth 
and/or MBN-101 excipients (methylcellulose, Tween 80 (polysorbate 80)) 
14. Patients who are pregnant, lactating, or female patients who have a positive serum hCG 
as determined by laboratory testing 
15. Immunocompromised due to illness or organ transplant 
16. History of chronic or recurrent infections (≥ 3 infections at the same site within 
12 months) other than the index infected osteosynthesis site 
17. History of any type of cancer (excluding non-melanomatous localized skin cancer or 
completely excised and cured carcinoma-in-situ of uterine cervix) 
18. Poorly controlled diabetes mellitus (hemoglobin A1c > 9.0% for ≥ 6 months despite 
management by a physician) 
19. History of medical noncompliance 
20. Other medical conditions which, in the opinion of the Principal Investigator, would 
jeopardize the safety of the study subject or impact the validity of the study results. 
21. Current incarceration  
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SUBJECT ENROLLMENT 
Potential patients will undergo screening medical history and physical examination. If they are 
deemed appropriate candidates for study, they will be asked to provide appropriate informed 
consent. After informed consent is signed additional baseline evaluation will be performed, 
including but not limited to clinical laboratory assessment, radiographic evaluation, 
electrocardiogram (ECG) and pregnancy test if applicable. Only patients with an acceptable 
medical history and physical exam, ECG without clinically significant abnormalities, and 
laboratory results within acceptable limits will be randomized in the study. Randomization will 
occur using an IVRS system immediately after a patient has met all study entry criteria. 
5.1 
Medical History 
Medical history and demographic data, including gender, date of birth, ethnicity, and race will be 
recorded. 
5.2 
Physical Exam 
Each patient will receive a physical examination (head, ears, eyes, nose, throat, chest, heart, 
abdomen, and skin) including vital signs, weight (kg), and height (cm). Each patient will also 
receive a detailed evaluation of the index fracture site and involved extremity. 
5.3 
Studies 
Following signing of the informed consent form, each patient will undergo all screening 
evaluations as provided in the Table of Study Events. These evaluations should be completed no 
more than 2 weeks prior to surgery date; after a screened subject is confirmed to be eligible for 
the study, this qualified subject will be randomized prior to surgery to receive the investigational 
product. 
5.4 
Laboratory Tests at Screening Visit 
Hematology White blood cells (WBC), red blood cells (RBC), hemoglobin, hematocrit, platelet count, 
MCV, absolute neutrophils, absolute lymphocytes, absolute monocytes, absolute 
eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, blood urea nitrogen (BUN), glucose, 
creatinine, total protein, albumin, total bilirubin, direct bilirubin, alkaline phosphatase 
(ALP), AST (SGOT), ALT (SGPT), GGT, creatinine kinase (CK), calcium, magnesium, 
Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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STUDY PROCEDURES 
See the Table of Study Events outlining study procedures in Appendix 1. For the study site visit 
at Week 2, a visit window of + 4 days will be allowed; for study site visits Weeks 6 – 24, a visit 
window of ± 8 days will be allowed. 
6.1 
Description of Study Procedures 
6.1.1 
Medical History 
A comprehensive medical history will be taken on all patients at Screening, including but not 
limited to past medical history, past surgical history, current medications, allergic history and 
psychosocial history. 
6.1.2 
Physical Exams 
A comprehensive physical examination will be performed on all patients at Screening, including 
assessments of height, weight, head, ears, eyes, nose, throat, chest, heart, abdomen, and skin. 
Interval physical exams will be performed at all subsequent study visits according to the 
schedule in Appendix 1 and will focus on the surgical site, with assessments of local erythema, 
induration, drainage and degree of healing. 
6.1.3 
Vital Signs 
Vital signs include blood pressure, pulse, respiratory rate and body temperature; vital signs will 
be assessed according to the schedule in Appendix 1. 
6.1.4 
12-lead ECG 
Testing will be conducted at screening, baseline, and 48 hours. The ECG trace will be stored at 
the investigational sites as source document; clinical interpretation, including normal, abnormal 
but not clinically significant, and abnormal and clinically significant, will be determined by the 
investigator and reported on the CRFs.  
6.1.5 
Laboratory Tests 
All clinical laboratory tests will be performed by the local clinical site laboratory. 
Blood and urine will be collected for hematology, serology, serum chemistry, urinalysis, and 
pregnancy testing (as indicated) according to the schedule in Appendix 1. 
Hematology WBC, RBC, hemoglobin, hematocrit, platelet count, MCV, absolute neutrophils, absolute 
lymphocytes, absolute monocytes, absolute eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, BUN, glucose, creatinine, total protein, 
albumin, total bilirubin, direct bilirubin, alkaline phosphatase (ALP), AST (SGOT), ALT 
(SGPT), GGT, creatinine kinase (CK), calcium, magnesium, Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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6.1.6 
BisEDT (MBN-101) Blood Levels 
BisEDT levels in whole blood after MBN-101 administration will be assessed with a qualified 
Inductively Coupled Plasma Mass Spectrometry (ICP-MS) assay method using bismuth as a 
surrogate for BisEDT according to the schedule in Appendix 1. 
6.1.7 
Pain Assessments 
Pain related specifically to the surgical site (Surgical Site Pain Score) will be assessed via a 
Visual Analog Scale (VAS, 0-100 mm, where 0=no pain at all and 100 =the worst possible pain) 
utilizing a 24 hour recall at screening, baseline, Hour 48 and Weeks 2, 6, 12, and 24. 
6.1.8 
Patient Reported Outcomes 
Patient-reported outcomes will be collected using the Veterans Rand 12 Item Health Survey 
(VR-12) and Short Musculoskeletal Function Assessment (SMFA) according to the schedule in 
Appendix 1. 
6.1.9 
Microbiology 
The microbiology of the index site will be assessed at baseline and at the time of any subsequent 
surgical procedure at the index site. The presence of viable microorganisms will be determined 
by standard microbiological culture methods and include speciation and antimicrobial 
susceptibility testing of any bacterial isolates found (see flowchart, Appendix 2). 
6.1.9.1 
Specimen Collection 
Samples collected will include at least one tissue site (bone when possible; eraser head size, 
suitable for dividing into two samples) from the fracture site (if accessed) or involved tissue 
adjacent to the implant(s), two swabs of the peri-implant deep tissue, and two swabs of the 
superficial tissue/wound closure site. One set of specimens (i.e. 1 tissue specimen, 1 deep swab, 
1 superficial swab) will be placed into local site transport vessels. The duplicate set of samples 
will be placed into transport vessels provided by the central laboratory (International Health 
Management Associates, Inc.; IHMA). One set of specimens will be delivered to the local site 
microbiology laboratory using the standard storage and transport procedures employed at each 
site. The duplicate set of specimens will be transported to IHMA. The details regarding specimen 
packaging, transport, and processing will be described in the central laboratory study manual that 
will be provided to each study site. 
6.1.9.2 
Specimen Processing: Local Laboratory 
The tissue site sample and swabs will be analyzed immediately in the local laboratory for the 
presence of infectious pathogens by Gram stain and microbiological culture for both aerobic and 
anaerobic bacteria. The specimens will be processed (primary isolation, identification to species 
level and susceptibility testing) per the standard methods of each local site microbiology 
laboratory. Following isolation and identification of each microorganism, the susceptibility of 
each to one or more standard antibacterial agents (but not including MBN-101), as specified by 
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the surgeon or per local site standard procedures, will be determined. It is recognized that the 
local site laboratory may be using one of a variety of susceptibility test methods, and therefore, 
the susceptibility result may be reported as a specific Minimal Inhibitory Concentration (MIC) 
value or as a categorical result (i.e. Susceptible, Intermediate or Resistant). Susceptibility to 
MBN-101 will not be determined at the local site laboratory; the susceptibility results determined 
locally are for the use of the surgeon in the care of the patient. All Gram stain and microbiology 
results from the local site laboratory will be recorded on the CRF. 
6.1.9.3 
Specimen Processing: IHMA (Central Laboratory) 
The tissue site sample and swabs will be analyzed immediately in the central laboratory for the 
presence of infectious pathogens by Gram stain and microbiological culture for both aerobic and 
anaerobic bacteria. The specimens will be processed (primary isolation, identification to species 
level, and susceptibility testing) per the central laboratory methods, as described in the central 
laboratory study manual. 
Following identification, the susceptibility of the isolates to MBN-101 and comparator agents 
will be determined using either the reference broth microdilution method (for aerobic/facultative 
bacteria) or the reference agar dilution method (for anaerobic bacteria) as detailed by the Clinical 
and Laboratory Standards Institute (CLSI). Susceptibility tests will be quality-controlled as 
detailed by CLSI using reference quality control strains and previously-established ranges for 
MBN-101 and comparators. Susceptibility testing will be conducted with batches of study 
isolates as each study cohort is completed. Patient and specimen identifier and microbiology 
results will be recorded in the database. The bacterial isolates recovered from the specimens will 
be propagated and archived at the central laboratory. 
6.1.9.4 
Integration of Local Site Laboratory and Central Laboratory Primary Isolation and 
Identification Results 
There may be instances where the organism(s) isolated from a given specimen may be different 
at the local site laboratory and the central laboratory. In this instance, the central laboratory will 
first confirm the identification of the archived isolate. If the identification is confirmed, the 
pathogens present in the specimen will be defined as the total number of pathogens recovered by 
the local site laboratory and the central laboratory. For example, if the local site laboratory were 
to recover S. aureus and the central laboratory recovered S. aureus and P. acnes, the specimen 
would be defined as containing both S. aureus and P. acnes following merger of the data. 
It is possible that local site laboratory may perform susceptibility tests with agents that are also 
present in the central laboratory test panel. The MIC value (and interpretation) provided by the 
central laboratory supersedes the local site determination for the purposes of clinical trial data 
analysis and inclusion in the Clinical Study Report. The local site susceptibility test results are 
for use by the surgeon in the local care of the patient; however, these data will also be captured 
in the study database. 
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6.1.10 
Radiographic Evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6, 12, and 24. Radiographs 
(at least two orthogonal views) will be reviewed for union, interval callus formation, loss or 
change in reduction, and hardware failure. 
6.1.11 
Surgical Site Signs and Symptoms Evaluation 
The following signs and symptoms of the surgical site will be evaluated: 
• 
local erythema extending beyond suture material or staples 
• 
induration  
• 
drainage from surgical incision 
• 
degree of healing of the surgical incision 
Patients with non-healing or worsening status of their surgical site may be considered for 
additional standard of care treatment, but should be encouraged to remain in the study in order to 
complete study evaluations. In case additional treatment is given, the start/stop dates and dose 
regimen of the new treatment will be recorded on the CRFs. 
6.2 
Screening and Baseline Assessments 
Patients who meet initial screening criteria by medical history and physical exam will be offered 
participation on study. If the patient agrees to participate, they will be asked to provide written 
informed consent, after which additional evaluation may be performed, including but not limited 
to clinical laboratory assessments, electrocardiogram (ECG), radiographic evaluation and 
pregnancy test if applicable. Only patients with an acceptable medical history and physical exam, 
ECG without clinically significant abnormalities, and laboratory results within acceptable limits 
will be randomized in the study prior to surgery. 
6.3 
Randomization Procedure 
Subjects will be randomized in a 3:1 (active:placebo) ratio up to 24 hours prior to surgery via a 
central randomization scheme. The central randomization will be accomplished using an IVRS 
system linked to study drug treatment kits securely stored under appropriate conditions at the 
study site pharmacy. The randomization number assigned to a subject will be captured on the 
CRF. The specific study drug treatment kit will be utilized by the study pharmacist or other 
qualified individual to perform the appropriate dilution of drug product under sterile conditions 
into a vial to be transported to the operating room. Verification of study patient and study drug 
treatment kit will take place in the operating room prior to treatment with the investigational 
product. The appropriately diluted drug product must be administered within 8 hours of 
preparation. 
6.4 
Unblinding Procedure 
This study is a single blind study; however, knowledge of treatment assignment should remain 
limited to those directly involved with the patient’s surgical procedure and other individuals on a 
need to know basis. In order to provide unblinding data in an emergency in the absence of an 
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individual privy to treatment assignment, sites will be provided with a numbered unblinding 
envelope corresponding to each numbered test kit the site is delivered. These envelopes will be 
securely stored in the pharmacy. The unblinding envelope specifies the treatment group of the kit 
and should only be opened when absolutely necessary. For treatment of adverse events, it should 
be assumed that the patient has received study drug, thus avoiding the need to unblind the 
patient. However, in the event the Investigator determines the randomization assignment 
information is required to treat the patient for an adverse event, the Medical Monitor should be 
contacted. If the Medical Monitor cannot be reached, the blind may be broken by opening the 
envelope. The site should document the unblinding process in the patient’s source documents. 
6.5 
Investigational Product Administration 
6.5.1 
Surgical Site Identification 
Individuals undergoing surgical treatment for more than one infected fracture are excluded from 
participation in this study. 
6.5.2 
Study Drug Administration 
On the day of surgery, randomized subjects will receive the investigational product during their 
surgical procedure. Investigational product is only administered during the surgical procedure by 
the operating surgeon; therefore, 100% compliance with investigational product administration is 
assured. The operating surgeon will record the approximate surface area of the surgical site as 
well as the amount and location of investigational product administration in the operative note 
and on the CRF. All other details of the surgical procedure will be recorded in the operative note. 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 18 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
5. Alcohol wipes 
6. One pre-printed "Diluted MBN-101 Drug Product" label 
7. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
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The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose”) 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the MBN-101 Stock Formulation and 
Diluent provided in the Drug Product Kit according to the DFU provided. The Treatment Dose 
will be provided to the surgeon in a vial from which an 8 mL volume will be drawn up in the 
operating room into a sterile 10 mL syringe. Surgeons will be instructed to use sufficient volume 
(up to the full 8 mL provided) to sparingly coat the bone at the site of infection, the exposed 
surfaces of any retained hardware, and the surfaces of any new hardware to be implanted. 
Following application, OR personnel will record in the CRF the actual volume (in tenths of 
milliliters) of any unapplied Treatment Dose remaining in the syringe. 
Application to retained hardware:  Access to infected wound surfaces and implanted orthopedic 
hardware will be provided by surgical intervention. The surgeon will use a 10 mL syringe to 
apply, followed by a gloved finger to spread, a thin layer of the investigational product directly 
onto all accessible surfaces of the orthopedic hardware, as well as surrounding bone. Other 
wound surfaces will not be coated, resulting in administration of the investigational product to 
only a limited area of the wound. 
Application to new hardware:  In cases where hardware is replaced or in cases of two-stage 
procedures, MBN-101 will be applied to all accessible surfaces of hardware and adjacent bone 
(target structures) following implantation of hardware and immediately prior to definitive 
closure. Other wound surfaces will not be coated, resulting in administration of the 
investigational product to only a limited area of the wound. 
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In all cases, the minimum amount of MBN-101 required to coat the relevant structures within the 
infected osteosynthesis site should be used. The suspension should be applied in a thin layer to 
cover all affected areas of bone as well as any exposed hardware. Direct application to muscle 
and other soft tissues should be avoided. The approximate area of the osteosynthesis site should 
be calculated based on the length of exposed bone multiplied by the width of bone exposed; the 
surface area of the hardware should be added to this value to derive the approximate area of the 
osteosynthesis site. Recommended maximum volumes of MBN-101 for various areas of the 
osteosynthesis site are provided in the table below. 
Area of Osteosynthesis Site 
Recommended Volume of MBN-101 
25 cm2 
0.5 mL 
50 cm2 
1.0 mL 
75 cm2 
1.5 mL 
100 cm2 
2.0 mL 
125 cm2 
2.5 mL 
150 cm2 
3.0 mL 
175 cm2 
3.5 mL 
200 cm2 
4.0 mL 
225 cm2 
4.5 mL 
250 cm2 
5.0 mL 
275 cm2 
5.5 mL 
300 cm2 
6.0 mL 
325 cm2 
6.5 mL 
350 cm2 
7.0 mL 
375 cm2 
7.5 mL 
400 cm2 
8.0 mL 
 
The table shows the specified volume of MBN-101 to be applied based on the area (in cm2) of 
the target infected osteosynthesis site. By following these application requirements, the 
administered doses will be: 
• Cohort 1: 0.025 mg/mL MBN-101 = 0.5 µg/cm2 
• Cohort 2: 0.075 mg/mL MBN-101 = 1.5 µg/cm2 
• Cohort 3: 0.250 mg/mL MBN-101 = 5.0 µg/cm2 
The use of drains and vacuum assisted closure devices at the site of hardware will be allowed per 
surgeon preference. The drainage volume over the first 24 hours or prior to discontinuation of the 
drain will be recorded in the eCRF. 
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6.6 
Study Assessments 
Each patient enrolled in the study will have an assessment at 48 hours following surgery and at 
Weeks 2, 6, 12, and 24. Study assessments will be performed according to Section 6.1 and 
Appendix 1. The Week 24 assessment will be the final assessment for adverse events. Any 
adverse events ongoing at the Week 24 assessment will be followed until resolution of the event 
or stabilization of the condition. 
6.7 
Safety Monitoring 
Patients will be instructed to inform the Investigator and/or a member of the study staff of any 
adverse events that occur at any time during the study. Patients will be asked a general health 
question at each clinic visit to identify changes in the state of their health since their last study 
visit. 
6.8 
Study Monitoring 
The Sponsor or the Sponsor’s designee will provide training on the protocol for the study site 
personnel prior to giving the site permission to begin enrollment. Once the enrollment and 
dosing phases of the study have begun, the Sponsor or the Sponsor’s designee will visit the site 
to monitor the clinical conduct of the trial, the adequacy of study documentation and compliance 
with safety reporting. Clinical site monitoring will continue on a periodic basis until the site has 
been closed or all patients at the site have completed the study. The frequency of monitoring 
visits may vary depending on enrollment at the study site. 
6.9 
Patient Withdrawals 
Patients will be free to withdraw at any time for any reason, or they may be withdrawn if 
necessary to protect their health and safety or the integrity of the study. Any patient that is 
randomized but not treated will be replaced. The final report will include reasons for 
withdrawals. As this study involves a single administration of study drug, significant patient 
withdrawals are not anticipated. 
All efforts should be made to have subjects complete the Week 24 (end of study) procedures 
prior to withdrawal from the study. 
6.10 Individual Patient Stopping Rules 
Patients who develop adverse events at any time during the study will be treated appropriately 
according to standard of care. Adverse events will be assessed and followed as described in 
Section 9. As this is a single dose study with the investigational product applied directly into a 
surgical site, specific stopping rules for individual patients have not been established. 
6.11 Study Stopping Rules 
Patient enrollment on study will be stopped if the number of individual patients experiencing 
possibly-related or probably-related adverse events > Grade 2 exceeds 2 in any dose cohort or if 
there is any death on study. Should the study stopping rules be invoked, all safety data on all 
patients will be assembled for review by the Data Review Committee (DRC). The study will not 
resume until this information has been reviewed by the DRC and the Sponsor, discussed with the 
FDA, and concurrence reached with the FDA as to the resumption of the study. 
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CONCOMITANT MEDICATIONS 
All patients will received their usual concomitant medications for any underlying medical 
conditions without interruption. Efforts should be made to maintain all concomitant medications 
at a stable dose for the duration of the 24 week study. Patients will also receive standard of care 
treatment for their postoperative fracture site infection that includes systemic antibacterial 
treatment per prevailing standard of care guidelines (i.e., national, institutional, or physician 
preference) and other indicated postoperative medications, including pain medications. All 
concomitant medications will be recorded in the CRF. Pain medication usage, including 
medication, dose, route, day and time of administration, will be recorded on a separate CRF. Use 
of any other bismuth-containing compounds is prohibited from Screening through Week 4. 
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STUDY ENDPOINTS 
8.1 
Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
• Treatment-emergent adverse events. 
• Treatment-emergent serious adverse events. 
• Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
• Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
• Changes in physical exams. 
• Clinical findings of 12-lead electrocardiograms. 
• Change in microbiology status. 
8.2 
Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
• Proportion of treatment failures. A treatment failure defined as a subject with non-healing 
or worsening status of their surgical site requiring serious intervention by Week 24. 
• Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 24. 
• Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed fracture 
site. 
• Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed fracture site by Week 24. 
• Time to removal of orthopedic hardware due to a healed fracture site. 
• Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
• Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
• Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale 
(VAS, 0-100 mm). 
• Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
• Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination.  
• Change in serologic markers CRP and ESR at each post baseline time point. 
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8.3 
Pharmacokinetic Endpoint 
8.3.1 
Sample Collection and Handling 
Blood samples will be obtained to measure blood concentrations of Bismuth (Bi) as a surrogate 
for BisEDT. A pre-dose sample will be collected prior to administration of the investigational 
product. Blood will be drawn for PK samples at nominal 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 (Day 
3), 96 (Day 4), and 336 (Day 14) hr after application of MBN-101 to the surgical site. 
Documentation stating the exact time of blood sampling (5 mL per timepoint) in relation to the 
time of study drug administration will be collected and provided. 
Primary and back-up blood samples will be stored at -70°C.  
8.3.2 
Assay Methodology 
Bismuth (Bi) levels, a surrogate for BisEDT, will be assayed in whole blood using a validated 
inductively coupled plasma mass spectrometry (ICP-MS) assay performed by Medpace 
Bioanalytical Laboratories (Cincinnati, Ohio). The samples are prepared for analysis by 
digestion with 2% nitric acid followed by dilution into 2% Tetramethyl Ammonium Hydroxide 
(TMAH) with 0.02% Triton X-100, and subsequent quantitation of Bi by ICP-MS analysis. 
A detailed method description, including validation, calibration and quality assurance 
procedures, will be included in the analytical report which will be part of the Final Study Report. 
8.3.3 
PK Analysis 
Bismuth (Bi) concentration data will be analyzed by noncompartmental analysis (NCA) with 
Phoenix™ WinNonlin® Version 6.3 or higher, using an extravascular administration model and 
actual sampling times. The following PK parameters will be derived from blood concentrations 
of Bi using extravascular noncompartmental PK analysis: 
Tmax 
Time to maximum observed concentrations of Bi 
Cmax 
Maximum observed concentrations of Bi 
AUC0-t Area under the Bi concentration vs time curve from time zero to the time of the last 
measurable concentration. 
AUC0-∞ Area under the Bi concentration vs time curve from time zero and extrapolated to 
infinity. 
T1/2 
The apparent half-life of Bi after extravascular administration of BisEDT 
CL/F 
Apparent clearance after extravascular administration of BisEDT 
Vz/F 
Apparent volume of distribution after extravascular administration of BisEDT 
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ADVERSE EVENTS 
An adverse event is an undesirable medical occurrence (sign, symptom, or diagnosis) or 
worsening of a pre-existing medical condition (e.g., diabetes) that occurs after initiation of the 
investigational study whether or not it is considered to be related to the investigational product. 
A worsening of an existing medical condition is one that was present at Day 1 (e.g., diabetes) 
and became more severe, more frequent, or increased in duration during investigational product 
treatment. Clinically relevant abnormal results of diagnostic procedures including abnormal 
laboratory findings (e.g., requiring unscheduled diagnostic procedures or treatment measures, or 
resulting in withdrawal from the study) are considered to be AEs. 
All adverse events (AEs) will be recorded throughout the study, beginning when the subject 
signs the Informed Consent Form. 
A treatment-emergent adverse event (TEAE) is defined as any AE starting after the first dose of 
the investigational agent or placebo is administered. If the AE is present prior to the 
administration of the first dose of the investigational agent or placebo but increases in severity, it 
will also be considered a TEAE. 
Treatment-emergent adverse events will be recorded beginning with the first exposure to 
investigational product and continuing until the subject is discharged from the study due to 
completion or early termination. 
Adverse events will be categorized as local adverse events and as systemic adverse events. 
The Principal Investigator, or medically qualified designee, must completely and promptly 
record each AE on the appropriate CRF. The Principal Investigator should attempt, if possible, to 
establish a diagnosis based on the presenting signs and symptoms. In such cases, the diagnosis 
should be documented as the AE and not the individual sign/symptom. If a clear diagnosis 
cannot be established, each sign and symptom must be recorded individually. Once a diagnosis is 
established, the CRFs should be updated with the final diagnosis. 
Any adverse event ongoing at the time of study completion will be recorded and followed-up 
according to the safety procedures described in the following sections. 
9.1 
Reporting and Following Adverse Events 
All AEs encountered during the study will be reported on the AE page of the CRF in a timely 
manner. All AEs should be followed in accordance with good medical practice until resolved or 
fully characterized. 
Serious adverse events: Section 9.4 presents the definition and reporting obligations for Serious 
Adverse Events (SAEs). After the initial report, a follow-up SAE Report Form should be filled 
out and sent to Medpace Clinical Safety within 24 hours. Updates are to be provided by the site 
as soon as relevant information (especially regarding outcome) is available. 
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9.2 
Severity 
The Investigator must indicate the severity of the adverse event in the description of the adverse 
event. A severity category of mild, moderate, or severe, as defined below, should be determined 
and entered on the Adverse Events page of the Case Report Form (CRF). 
• 
Mild (Grade 1): Transient or mild symptoms; no limitation in activity; no intervention 
required. The AE does not interfere with the participant’s baseline functioning level. It 
may be an annoyance. 
• 
Moderate (Grade 2): Symptom results in mild to moderate limitation in activity; no or 
minimal intervention required. The AE produces some impairment of baseline 
functioning, but it is not hazardous to health. It is uncomfortable or an embarrassment. 
• Severe (Grade 3): Symptom results in significant limitation in activity; medical 
intervention may be required. The AE produces significant impairment of functioning or 
incapacitation. 
• Potentially Life-Threatening (Grade 4): Symptoms cause inability to perform basic self-
care functions immediately necessary to sustain life or require medical or operative 
intervention to prevent permanent impairment, persistent disability or death. 
9.3 
Relationship to Clinical Trial Material 
The Investigator must document their opinion of the relationship of the event to the 
investigational product as follows: 
• 
NONE: The event can be readily explained by the subject’s underlying medical condition, 
a concomitant therapy or other cause and the Investigator believes no relationship exists 
between the event and the investigational product. In this case, the Investigator should 
document the condition, concurrent/underlying illness, medication, study procedure or 
other cause they believe to be the cause of the adverse event. 
• 
UNLIKELY: The event does not follow a reasonable temporal sequence from 
administration of the investigational product nor does the event follow a known or expected 
response pattern to the investigational product and may have another cause. In this case, 
the Investigator should document the condition, concurrent/underlying illness, medication, 
study procedure or cause they believe may have contributed to the adverse event. 
• 
POSSIBLE: The subject’s condition, concurrent/underlying illness, medication, or study 
procedures cannot explain the event, and there is a plausible temporal relationship 
between the event and the investigational product administration. 
• PROBABLE: The temporal relationship between the administration of the investigational 
product and the adverse event strongly suggests a relationship, and/or the adverse event 
cannot be reasonably explained by another condition, concurrent/underlying illness, 
medication, study procedure or other cause, or the adverse event abates with 
discontinuation of the investigational product, and recurs with re-administration. 
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9.4 
Serious Adverse Events 
To report SAEs in a timely manner, monitor subject care, and to fulfill regulatory requirements, 
SAEs (regardless of their relationship to the investigational product) must be reported to 
Medpace Clinical Safety within 24 hours of knowledge of the event by the Investigator or 
members of the study staff.  
9.4.1 
Definition 
SAEs are defined as those adverse events that meet any of the following criteria: 
• 
Life threatening, that is, any event that, in the opinion of the Investigator, poses an 
immediate risk of death from that event 
• 
Results in death 
• 
Results in or prolongs hospitalization 
• 
Results in persistent or significant disability/incapacity 
• 
Results in congenital anomaly/birth defect 
In addition, events which may not meet these criteria, but, in the opinion of the Investigator, are 
very unusual, potentially serious, or require medical or surgical intervention to prevent one of the 
outcomes listed above, should also be reported in the same manner as events which meet the 
serious adverse event criteria.  
9.4.2 
Reporting 
Serious AEs require immediate reporting (within 24 hours of the site’s knowledge of the event) 
to Medpace Clinical Safety whether or not the Investigator believes that the experience is related 
to the investigational product. A completed SAE CRF signed by the Investigator must be faxed 
to Medpace Clinical Safety. Criteria for documenting the relationship to study product and 
severity will be the same as those previously described in Sections 9.2 and 9.3. 
SAEs must also be reported by the study site to the responsible IRB immediately. The 
Investigator is responsible for complying with the local IRB regulations regarding the reporting 
of AEs. 
Reporting of a suspected SAE should not be delayed in order to obtain additional information. 
Any additional information, if collected, can be reported as a follow-up to the initial report. Any 
SAE that occurs at any time during the study, whether or not related to the investigational 
product, must be reported to Medpace Clinical Safety.  
All possibly- and probably-related serious adverse events must be followed until the outcome is 
known or the event is otherwise explained. All serious adverse events that are not resolved at the 
end of the study are to be followed until resolution, the condition stabilizes, the event is 
otherwise explained, or the subject is lost to follow-up.  
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9.5 
Pregnancies 
Pregnancies occurring after the first dose of investigational product are considered immediately 
reportable events. While not considered a serious adverse event unless a serious criterion is met, 
pregnancies occurring in subjects enrolled on the study must be reported and followed to 
outcome. The investigator should complete the pregnancy report form and fax it to Medpace 
Clinical Safety within one working day of knowledge of the pregnancy. Following delivery or 
termination of pregnancy, the follow-up pregnancy report form should be completed and 
submitted via fax to Medpace Clinical Safety. Spontaneous abortions should always be reported 
as SAEs. Follow-up information regarding the outcome of the pregnancy and any postnatal 
sequelae in the infant will be required. 
9.6 
Data Review Committee (DRC) 
An independent Data Review Committee will be established to review unblinded clinical trial 
data prior to dose escalation and on an as-needed basis. A statistician, serving as a non-voting 
member to the DRC, will provide data preparation support to the DRC. A sponsor representative 
will also serve as a non-voting member of the DRC to facilitate sponsor internal planning. 
The primary role of the DRC will be to assess unblinded safety data on all patients in a dose 
cohort completing the Week 6 visit, and to determine whether dose escalation should occur. The 
DRC may recommend dose escalation, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
The DRC will also be asked to assess unblinded safety data on an as-needed basis. The Chair of 
the DRC will be informed by Microbion Corporation of the potential need for ad hoc meetings 
and will coordinate any ad hoc meeting with the remainder of the DRC members. The DRC may 
recommend no modifications to the study, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
A formal DRC Charter will be prepared and finalized prior to study enrollment. The DRC will 
meet prior to initiation of the clinical trial in order to review, revise and reach concurrence on the 
content of a DRC charter. The draft charter will be provided by Microbion Corporation to the 
DRC prior to the initial meeting. 
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 INVESTIGATIONAL PRODUCT MANAGEMENT 
10.1 Study Drug 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied.  
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 18 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
5. Alcohol wipes 
6. One pre-printed "Diluted MBN-101 Drug Product" label 
7. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose” 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
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10.2 Study Drug Packaging and Labeling 
All shipments of the investigational product will be accompanied by an inventory form. The 
contents of the shipments should be inventoried immediately upon receipt and confirmation of 
inventory shall be performed according to instructions provided by the clinical supplies 
distributor. 
The following information will be provided with each shipment of study drug: Sponsor name and 
contact information (telephone number), study protocol number, description of the contents of 
the container, conditions for storage, and a statement regarding the investigational (clinical trial) 
use of the study drug.  
Each package unit of the investigational product will be labeled with the following information: 
Sponsor name, study protocol number, description of the contents, a statement regarding the 
investigational (clinical trial) use of the study drug, and a packaging lot number.  
10.3 Study Drug Storage 
The investigational product should be kept in a limited-access area at 15-30 degrees C at the 
study site.  
10.4 Study Drug Accountability 
It is the responsibility of the Principal Investigator or his/her designee at each site to ensure that 
all investigational product quantities received at the site will be inventoried and reconciled 
throughout the study and the result recorded on the drug accountability form maintained in the 
study file. 
10.5 Study Drug Handling and Disposal 
Only qualified study personnel familiar with procedures that minimize undue exposure to 
themselves and to the environment should undertake the handling of pharmaceutical agents. 
The study monitor will verify that the disposition of all investigational materials at the trial site is 
in accordance with Sponsor specifications and applicable regulatory requirements. Requirements 
for disposition of used, unused, damaged/quarantined, and expired investigational materials will 
be provided to applicable site personnel. The study monitor will confirm associated 
documentation is filed in the Investigator site file and copies retrieved for the Sponsor or 
Sponsor-designee Investigator File. 
Used, damaged, and expired investigational materials will be destroyed as directed by the Study 
Monitoring Plan. Specific instructions of on-site destruction, return of materials to a 3rd party 
vendor, or any other mechanism of removal of the investigational materials from the site will be 
detailed in the Study Monitoring Plan. 
The study monitor will not take possession of investigational materials. Any deviations from this 
process must be approved in advance by the Sponsor or Sponsor-designee.  
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 GENERAL CONSIDERATIONS 
11.1 Basic Principles 
This research will be carried out in accordance with the clinical research guidelines established 
by the Basic Principles defined in the U.S. 21 CFR Parts 50, 56, and 312, the principles 
enunciated in the Declaration of Helsinki concerning medical research in humans (“Ethical 
Principles for Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 
1975, Venice 1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, 
Washington 2002 and Tokyo 2004), and the Good Clinical Practice (GCP) guidelines of the 
International Conference on Harmonization (ICH) of the Technical Requirements for 
Registration of Pharmaceuticals for Human Use, ICH E6 (May 1996). 
11.2 Institutional Review Board 
Prior to initiation of any study procedures, the Clinical Study Protocol, Informed Consent Form, 
and Product Information will be submitted to the IRB for review and approval. In addition, any 
amendments to the protocol or informed consent document will be reviewed and approved (if 
necessary) by the IRB. The Principal Investigator (PI) at each clinical site assumes responsibility 
for ensuring that the protocol is submitted to the IRB for any required periodic review. The PI 
must receive a letter documenting the IRB approval at the clinical site prior to the initiation of 
the study. Any subsequent IRB correspondence must also be submitted to the investigator. The 
Investigator is responsible for providing the appropriate reports to the reviewing IRB during the 
course of the clinical study. This will include the following: 
• Informing the IRB of the study progress periodically as required, but at least annually 
• Reporting any unanticipated adverse product per IRB Policies & Procedures 
• Reporting any deviations from the clinical protocol to protect the life or well-being of a 
subject in the case of an emergency within 5 working days after the emergency occurred 
• Providing any other reports requested by the IRB 
After the final visit of the last subject, a final report will be sent to the IRB per their Policies & 
Procedures that includes a summary of the results of the study by the PI. 
The IRB must be constituted and operate in accordance with the principles and requirements 
described in the U.S. Code of Federal Regulations (21 CFR Part 56). 
11.3 Informed Consent 
The purpose of the study, the procedures to be carried out and the potential hazards will be 
described to the subjects in non-technical terms. Subjects will be required to read and sign a 
consent form summarizing the discussion prior to enrollment, and will be assured that they may 
withdraw from the study at any time without jeopardizing their medical care. 
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11.4 Study Termination 
The Investigator reserves the right to terminate the study in the interest of subject safety and 
welfare. The Sponsor reserves the right to terminate the study at any time for administrative 
reasons. 
11.5 Regulatory Documentation 
Documents that must be provided to the Sponsor prior to study drug shipment are as follows: 
• Up-to-date curriculum vitae for each investigator and sub-investigator 
• Signed and dated Investigator Agreement 
• Applicable local regulatory documentation (e.g., FDA 1572 Form) 
• A copy of the formal written notification to the investigator regarding approval of the 
protocol by an IRB that is in compliance with regulatory guidelines. The written 
notification is to be signed by the chairman or authorized designee and must identify the 
specific protocol. In cases where an IRB member has a known conflict of interest, 
abstention of that individual from voting should be documented; an investigator 
(or sub-investigator) may be a member of the IRB, but may not vote on any research in 
which he or she is involved. 
• Name and address of the IRB with a statement that it is organized and operates according 
to GCP and the applicable laws and regulations, and a current list of the IRB members. 
If accompanied by a letter of explanation from the IRB, a general statement may be 
substituted for this list. 
• A copy of the IRB approved informed consent form and other adjunctive materials 
(e.g., advertising) to be used in the study, including written documentation of IRB 
approval of these items. 
• Name and address of any local laboratory conducting tests for the study, a dated copy of 
the laboratory reference values for tests to be performed during the study and a copy of 
the certification or other documentation establishing adequacy of the facility. 
• Required financial agreement. 
In addition to the documents required prior to the study, other documentation may be required 
during the course of the study. 
11.6 Study Documentation 
All documents pertaining to the study, including a copy of the approved protocol, copy of the 
Informed Consent Form, and case report forms, will be retained in the permanent archives of the 
study site. These will be available for inspection at any time by the Sponsor or the U.S. Food and 
Drug Administration (FDA). 
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11.7 Data Handling and Record Keeping 
As electronic trial data handling and/or remote electronic trial data systems will be used, 
Microbion and/or its designee will: 
• Ensure and document that the electronic data processing system(s) conforms to the 
Sponsor’s established requirements for completeness, accuracy, reliability, and consistent 
intended performance 
• Maintain SOPs for using these systems 
• Ensure that the systems are designed to permit data changes in such a way that the data 
changes are documented and that there is no deletion of entered data (i.e., maintain an 
audit trail, data trail, edit trail) 
• Maintain a security system that prevents unauthorized access to the data 
• Maintain a list of the individuals who are authorized to make data changes 
• Maintain adequate backup of the data 
• Safeguard the blinding, if any (e.g., maintain the blinding during data entry and 
processing) 
Moreover: 
• An unambiguous subject identification code will be used that will allow identification of 
all the data reported for each subject 
• Microbion and/or its designee will retain all of the Sponsor-specific essential documents 
pertaining to the trial in conformance with the applicable regulatory requirement(s) of the 
country(ies) where the product is approved and/or where it intends to apply for approval  
• Specific essential documents will be retained until at least 2 years after the last approval 
of a marketing application in an ICH region and until there are no pending or 
contemplated marketing applications in an ICH region or at least 2 years have elapsed 
since the formal discontinuation of clinical development of the investigational product. 
These documents should be retained for a longer period, however, if required by the 
applicable regulatory requirement(s) or if needed by the Sponsor. 
• Microbion and/or its designee will inform the investigator(s)/institution(s) in writing of 
the need for record retention and should notify the investigator(s)/institution(s) in writing 
when the trial related records are no longer needed 
11.8 Use of Information and Publication 
All information concerning BisEDT, MBN-101, MBN-101 diluent, Microbion operations, patent 
applications, formulas, manufacturing processes, basic scientific data, and formulation 
information, supplied by the Sponsor to the investigator and not previously published, is 
considered confidential and remains the sole property of Microbion Corporation. The 
investigator agrees to use this information only to accomplish this study and will not use it for 
other purposes without the Sponsor’s written consent. 
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The investigator understands that the information developed in the clinical study will be used by 
Microbion in connection with the continued development of MBN-101 and BisEDT, and thus 
may be disclosed as required to other clinical investigators or government regulatory agencies. 
To permit the information derived from the clinical studies to be used, the investigator is 
obligated to provide the Sponsor with all data obtained in the study. 
Any publication or other public presentation of results from this study requires prior review and 
written approval of Microbion Corporation. Draft abstracts, manuscripts, and materials for 
presentation at scientific meetings should be provided to the Sponsor at least 30 working days 
prior to abstract or other relevant submission deadlines. Authorship of publications resulting 
from this study will be based on generally accepted criteria for major medical journals. 
11.9 Independent Medical Monitor 
In accordance with US Army Medical Research and Materiel Command (USAMRMC) and 
Department of Defense (DOD) requirements, an independent medical monitor will be identified. 
The independent medical monitor should be physicians, dentists, psychologists, nurses, or other 
healthcare providers capable of overseeing the progress of research protocols, especially issues 
of individual volunteer management and safety. The medical monitor must be independent of the 
investigative team and possess sufficient educational and professional experience to serve as the 
volunteer advocate. Depending on the nature of the study, the medical monitor may be assigned 
to assess one or more of the following phases of research project: volunteer recruitment, 
volunteer enrollment, data collection, or data storage and analysis. The medical monitor provides 
an independent evaluation of serious adverse events and unanticipated problems involving risk to 
subjects or others to the IRB and the Office of Research Protections (ORP). The medical monitor 
may be assigned to discuss research progress with the PI, interview volunteers, consult on 
individual cases, or evaluate adverse event reports. The medical monitor must promptly report 
discrepancies or problems to the IRB and the ORP. They shall have the authority to stop a 
research study in progress, remove individual volunteers from a study, and take whatever steps 
are necessary to protect the safety and well-being of research volunteers until the IRB can assess 
the medical monitor report. 
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 STATISTICAL ANALYSIS METHODOLOGY 
A formal statistical analysis plan (SAP) will be prepared and finalized before database lock for 
the final analysis for the study report. The SAP will provide details regarding the definition of 
analysis subjects (populations), analysis variables and analysis methodology to meet all study 
objectives. 
The principle and key elements of the SAP are provided as follows: 
In general, safety and efficacy data will be summarized with descriptive statistics, including 
means, standard deviations, medians, minimums and maximums for continuous variables, the 
number of subjects and percent in each category for categorical variables.  
Data from all subjects randomized and treated with placebo in each cohort will be pooled for the 
analysis; data from the subjects randomized and treated with MBN-101 will be presented by dose 
as well as combined.  
Data from each individual will be tabulated as appropriate. Efficacy and safety endpoints will be 
tabulated by treatment group and time point.  
12.1 Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
• Proportion of treatment failures. A treatment failure is defined as a subject with 
non-healing or worsening status of their surgical site requiring serious intervention by 
Week 24. 
Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 24. 
• Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed fracture 
site.  
• Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed fracture site by Week 24. 
• Time to removal of orthopedic hardware due to a healed fracture site. 
• Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
• Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
• Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale (VAS, 
0-100 mm).  
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• Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
• Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination.  
12.2 Changes in serologic markers CRP and ESR at each post baseline time 
point.Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
• Treatment-emergent adverse events. 
• Treatment-emergent serious adverse events. 
• Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
• Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
• Changes in physical exams. 
• Clinical findings of 12-lead electrocardiograms. 
• Change in microbiology status. 
12.3 Sample Size Considerations 
Sample size for this study was chosen empirically for the purpose of the study without any 
formal statistical hypothesis to be tested. 
Nine subjects will receive active drug in each dose cohort. With 9 subjects receiving active drug, 
the probability of observing at least one of 9 subjects in a dose cohort exhibiting an AE of a 
specific type is 95% if the true background incidence rate for that event-type were approximately 
0.283 or greater. Hence, if an AE of a specific type is not observed in the study in a sample size 
of 9 subjects receiving active study drug at a given dose, one would “rule-out” this AE as having 
an incidence rate of more than 0.283 with 95% confidence. 
Similarly, if a rare event of interest is not reported in the 27 subjects treated with the active study 
drug, one could conclude that the rate of the event would be 0.105 or less with 95% confidence. 
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12.4 Analysis Datasets 
The following analysis datasets will be identified for the purpose of analysis:  
Screened Subjects: All subjects who signed informed consent for the study will be included in 
the Screened Subjects analysis set. 
Randomized Subjects: All subjects who were randomized in the study will be included in the 
Randomized Subjects analysis set. A randomized subject may or may not be treated with the 
assigned study drug. This is the classic Intent-to-Treat (ITT) analysis set. 
Treated Subjects: All subjects who received any amount of study drug (active or placebo) will be 
included in the Treated Subjects analysis set. All treated subject will be included in the safety 
analysis. This analysis set is also referenced as the Safety Analysis Set. 
Modified Intent-to-Treat (mITT) Subjects: the ITT subjects who received any amount of study 
(active or placebo) and have at least one post-treatment assessment will be included in the mITT 
analysis set. The mITT analysis set is the primary dataset for efficacy analysis. 
PK Concentration Subjects (i.e., PK Concentration Population): The PK Concentration 
Population will include all subjects with any measurable bismuth blood concentrations. 
PK Evaluable Subjects (i.e., PK Evaluable Population): The PK Evaluable Population will 
include all subjects providing sufficient measurable bismuth blood concentrations to facilitate 
determination of PK parameters. 
In the event that a subject received study drug treatment that is not the assigned/randomized 
treatment group, the subject has a major protocol deviation. The subject, however, will be 
included in the analysis for safety and efficacy in the actual treatment group received.  
Subjects randomized but not treated for any reason will be included in the disposition tabulation 
and will be excluded from the safety and efficacy analysis.  
12.5 Disposition and Study Population Characteristics 
Disposition summaries will be prepared to include number and percent of subjects screened, 
randomized, treated, subjects that completed the study and reason for discontinuation. Reason for 
screening failure will also be tabulated.  
Subject characteristics summaries will include demographics (age, gender, race, and ethnicity), 
baseline characteristics (weight, height, BMI), surgery site characteristics (type of injuries, type 
of fraction fixation, surgical site location), microbiology analysis results, time from previous 
surgery to study enrollment, and type of previous treatment), current surgery characteristics 
(area of the osteosynthesis site, with or without hardware replacement, etc.), and medical history.  
Disposition summary will be based on randomized treatment group (i.e., planned treatment) 
whereas the baseline characteristics summaries will be based on the actual treatment group.  
Subjects with protocol deviations will be identified. The nature of the deviation and potential 
impact on the deviation on study outcome will also be assessed.  
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12.6 Efficacy Analysis 
12.6.1 
Treatment Failure 
A treatment failure is defined as a subject with non-healing or worsening status of their surgical 
site requiring serious intervention by Week 24. 
The number of subjects meeting treatment failure criteria during the study will be tabulated by 
treatment group. If data permit, the difference in proportion of treatment failures between the 
groups and the corresponding 95% confidence intervals for the difference will be presented. 
Fisher’s exact test may be used to test the difference between the groups; difference in rates and 
95% confidence intervals for the relative risk will be derived. Dose-response assessment may be 
performed. 
12.6.2 
Incidence of Serious Interventions  
All interventions meeting the following criteria are serious interventions: 
• Initiation of antibiotic treatment in patient not previously on antibiotics 
• Change in the route of antibiotic administration from oral to intravenous for escalation of 
treatment 
• Change in the type or dosage of antibiotic drug for escalation of treatment 
• Readmission (exclusive of readmissions associated with a healed fracture site) 
• Reoperation (exclusive of reoperations associated with a healed fracture site) 
The number of subjects with at least one serious intervention (exclusive of serious interventions, 
readmissions, and reoperations associated with a healed fracture site) and total number of serious 
interventions will be tabulated for the following periods:  
• duration of the study;  
• within the first 4 weeks after the surgery; 
• from week 4 to week 8 
• from week 8 to week 12  
• from week 12 to week 24 
The difference between the placebo arm and the active arms will be evaluated as follows if data 
permits: Fisher’s exact test may be used to test the difference between the groups; difference in 
rates and 95% confidence intervals for the relative risk will be derived.  
Similar summaries will be prepared for incidence of re-admission and incidence of re-operation. 
Time elapsed between the initial hospital discharge to hospital readmission and between the 
operations will be derived and tabulated.  
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12.6.3 
Time to First Serious Interventions  
Time to the first serious intervention exclusive of serious interventions, readmissions, and 
reoperations associated with a healed fracture site will be derived. Time to first serious 
intervention will be calculated as the number of study days from the study surgery date to the 
event onset date plus 1. Subjects who do not have any serious intervention will be censored to 
the last observation date. 
No formal inferential statistics will be carried out for this endpoint. 
12.6.4 
Subjects Undergoing Removal of Stabilizing Orthopedic Hardware 
The number of subjects undergoing removal of hardware due to a healed fracture site and the 
time to removal of hardware due to a healed fracture site will be derived. Time to removal of 
hardware will be calculated as the number of study days from the study surgery date to the event 
date plus 1.  
12.6.5 
Surgical Site Signs and Symptoms 
The surgical site will be examined for local erythema, induration, drainage and degree of 
healing. 
Subjects with non-healing or worsening status of their surgical sites will be tabulated. 
12.6.6 
Patient-Report Outcomes 
12.6.6.1 
The Veterans RAND 12 Item Health Survey (VR-12) Questionnaire  
The Veterans RAND 12 Item Health Survey (VR-12) is a brief, generic, multi-use, self-
administered health survey comprised of 12 items. The instrument is primarily used to measure 
health related quality of life, to estimate disease burden and to evaluate disease-specific 
benchmarks with other populations. The 12 items in the questionnaire correspond to eight 
principal physical and mental health domains including general health perceptions; physical 
functioning; role limitations due to physical and emotional problems; bodily pain; energy-
fatigue, social functioning and mental health (Selim, 2009; Veterans Affairs website, 2014). 
VR-12 total score, physical health domain score (PCS), and mental health domain score (MCS) 
will be tabulated by visit; change from baseline in total score, physical health domain score and 
mental health domain score will also be derived and tabulated.  
12.6.6.2 
The Short Musculoskeletal Function Assessment Questionnaire (SMFA) 
The 46-item SMFA questionnaire comprises two parts: the dysfunction index with 34 items and 
the bother index with 12 items. The dysfunction index assesses the patients perceptions of the 
amount of difficulty they have in the performance of certain functions (25 items) and how often 
the patients have difficulty when performing certain functions (9 items). The dysfunction items 
are grouped into four categories: daily activities, emotional status, function of the arm and hand, 
and mobility. Each item has a 5-point response format (1 point for good function and 5 points for 
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poor function). The bother index asks the patients to assess how much they are bothered by 
problems in various areas of life (e.g., recreation, work, sleep and rest). These items also have a 
5-point response format (1 point for not at all bothered and 5 points for extremely bothered). 
The scores of the dysfunction and the bother indices are calculated by summing up the responses 
to the items and then transforming the scores according to the formula: (actual raw score - lowest 
possible raw score)/(possible range of raw score) ×100. 
This transformation formula gives the final scores, which ranged from 0 to 100. The higher 
scores indicate poorer function. In the case of the dysfunction index, unanswered items in a 
category are replaced by the individual’s mean score for that category, as long as more than 
50 per cent of the items in that category have been answered. Substitution with the mean is not 
appropriate for the bother index as each item addresses a unique area of function (Swiontkowski, 
1999; Short Musculoskeletal Function Assessment Injury and Arthritis Survey, 
www.grossortho.com/forms/injury.pdf). 
SMFA results and change from baseline will be summarized by visit and treatment group with 
descriptive statistics. 
12.6.7 
Pain Assessments 
Surgical site pain score utilizing a 24 hour recall will be assessed via Visual Analog Scale (VAS) 
(Burckhardt, 2003; Brokelman, 2012; Briggs, 1999) at baseline, and Weeks 2, 6, 12, and 24. 
Change in pain from baseline will be derived; observed pain score and change from baseline will 
be tabulated by visit and treatment group. 
12.6.8 
Microbiology 
Microbiology will be assessed at baseline and at the time of any subsequent surgical procedure at 
the index site. The presence of viable microorganisms will be determined by standard 
microbiological culture methods and include speciation and antimicrobial susceptibility testing 
of any bacterial isolates found (see flowchart, Appendix 2). Samples collected will include at 
least one tissue site (eraser head size; suitable for dividing into two samples) from the fracture 
site (if accessed) or involved tissue adjacent to the implant(s), two swabs of the infected 
hardware (in situ or ex vivo), two swabs of the deep infection site, and two swabs of the 
superficial tissue/wound closure site when possible. Duplicate specimens will be transported 
aerobically and anaerobically, respectively. Specimens will be processed by the local laboratory 
and the central laboratory as presented in Sections 6.1.9.3 and 6.1.9.2. 
Microorganisms isolated from each assessment will be listed. This information may also be used 
to identify potential subgroups. 
Microbiological success is assessed by clearance of infection. The proportion of subjects that 
meet the treatment success criteria per microbiologic evaluations will be identified and tabulated 
by each treatment group. 
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12.6.9 
Radiographic evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6, 12, and 24. 
Radiographic success is assessed by healing on radiographic examination. The proportion of 
subjects that met the treatment success criteria per radiographic examination will be identified 
and tabulated by each treatment group. 
12.6.10 Serologic Markers 
Serology markers CRP and ESR will be assessed at baseline and Weeks 2, 6, 12, and 24. 
Serology markers CRP and ESR have been used together with clinical signs and symptoms for 
periprosthetic infection diagnosis. The values for each serologic marker and the number of 
subjects with normal or abnormal serologic marker values at each visit will be tabulated by 
treatment group.  
12.6.11 Subgroup Analyses for Efficacy Endpoints 
If data permit, the following potential covariates will be identified and subgroup analysis may be 
performed for those subgroups. 
1. 
Area of the osteosynthesis site 
2. 
Method of fracture fixation 
3. 
Type of infection (per identified microorganism) 
4. 
Anatomic location of the surgery site 
5. 
Hardware retention status (retained vs. exchanged) 
6. 
Influence of host factors 
7. 
Method of wound closure / wound management 
12.6.12 Sensitivity Analyses for Efficacy Endpoints 
The primary efficacy analysis set (mITT) will included all randomized subjects who received 
any amount of study drug and have at least one post-treatment assessment. In addition, in the 
event that a subject received treatment that is different from the assigned treatment, the subject 
will be included in the actual treatment received in the mITT analysis. 
An ‘as assigned’ analysis will be performed on the mITT subjects as a sensitivity analysis for the 
primary efficacy endpoint. In this analysis, subjects who received a treatment that is not the 
assigned treatment will be included in the ‘assigned’ treatment group for this analysis. 
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12.7 Safety Analysis 
12.7.1 
Study Drug Exposure and Concentrations 
Study drug exposure will be presented by treatment group. Descriptive statistics will be provided 
without any formal inferential statistics.  
12.7.2 
Adverse Events 
The Medical Dictionary for Regulatory Activities (MedDRA Version 16 or higher) will be used 
to classify all AEs with respect to system organ class (SOC) and preferred term. Summary of 
adverse events will include: 
1. Treatment emergent adverse events by SOC, preferred term, and intensity 
2. Treatment emergent adverse events by SOC, preferred term, and relationship to study 
drug  
3. All AEs leading to study discontinuation by SOC and preferred term 
4. All serious adverse events by SOC and preferred term 
Summary tables will provide total number of events and number of subjects with the event. 
The incidence and intensity of each pre-specified local AEs will be tabulated by visit and 
treatment groups. 
12.7.3 
Clinical Laboratory Tests 
Laboratory includes hematology, serology, serum chemistry, and urinalysis; laboratory collected 
prior to surgery will be the baseline laboratory. The study will utilize local lab for all clinical 
laboratory testing. Laboratory data will be tabulated based on the following result class. 
• Normal: result is within the local lab normal range 
• Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each lab test without formal inferential statistics. If data permits shift 
in result class from baseline to post baseline may also be tabulated. 
12.7.4 
12-lead ECG 
ECG findings at each time point will be tabulated by treatment group without inferential 
statistics. 
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12.7.5 
Vital Sign Measurements 
Vital signs collected immediately prior to receiving study drug will be the baseline vital signs. 
Observed vital sign values and change from baseline in vital signs at each visit will be 
summarized without formal statistical testing. 
Vital sign result may also be tabulated based on the following result class. 
• Normal: result is within the normal range 
• Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each vital sign. 
12.7.6 
Physical Examinations  
Findings of physical examinations will be tabulated by treatment groups without inferential 
statistics. 
12.7.7 
Subgroup Analyses for Safety Endpoints 
No subgroup analysis is planned for safety endpoints. 
12.8 PK Analysis 
Blood bismuth concentration vs. time profiles after administration of MBN-101 will be 
summarized for each nominal sampling time point and by dose group using descriptive statistics 
generated by WinNonlin. The NCA PK parameters (AUC0-t, AUC0-inf, Tmax, Cmax, T1/2, CL/F, 
Vz/F) will also be summarized with descriptive statistics (generated by WinNonlin) for each dose 
group as well as for all treated subjects in the PK Evaluable Population. 
If data permit, the correlation between Bismuth concentration and efficacy and/or safety 
endpoints may be explored. 
12.9 Interim Evaluation 
Interim analyses are planned for this study for the purpose of DRC. The purpose of the interim 
analysis is to allow the DRC to review the data and to make recommendation to the Sponsor on 
whether or not the next cohort of the subjects should be studied as planned.  
An analysis plan for the DRC will be prepared as an appendix of the DRC charter. The scope of 
the interim analyses for the DRC will be defined in this analysis plan. 
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13. Heller A, McIff TE, Lai SM, Burton DC. Intrawound vancomycin powder decreases 
Staphylococcal surgical site infections following posterior instrumented spinal arthrodesis. 
J Spinal Disord Tech. Epub ahead of print 2013. PubMed PMID: 24189484. 
14. Hetrick EM, Schoenfisch MH. Reducing implant-related infections: active release strategies. 
Chem Soc Rev. 2006;35(9):780-9. 
15. Kwon A, Park G, Ryu S, Lim D, Lim D, Choi C, Park Y, Lim Y. Higher biofilm formation in 
multidrug-resistant clinical isolates of Staphylococcus aureus. Int J Antimicrob Ag. 
2008;32:68-72. 
16. Martin JR, Adogwa O, Brown CR, Bagley CA, Richardson WJ, Lad SP, Kuchibhatla M, 
Gottfried ON. Experience with intrawound vancomycin powder for spinal deformity surgery. 
Spine (Phila Pa 1976). Epub ahead of print 2013. PubMed PMID: 24158179. 
17. Morris BJ, Unger RZ, Archer KR, Mathis SL, Perdue AM, Obremskey WT. Risk factors of 
infection after ORIF of bichondylar tibial plateau fractures. J Orthop Trauma. 
2013;27(9):e196-e200. 
18. Nowinski RJ, Gillespie, RJ, Shishani Y, Cohen B, Walch G, Gobezie R. Antibiotic-loaded 
bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a 
retrospective, cohort study of 501 shoulders. J Shoulder and Elbow Surgery. 
2012;21(3):324-8. doi: 10.1016/j/jse.2011.08.072. 
19. Parra-Ruiz J, Vidaillac C, Rybak MJ.Macrolides and staphylococcal biofilms. Rev Esp 
Quimioter. 2012;25(1):10-16. 
20. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the 
tibia: current management concepts. Journal of the American Academy of Orthopaedic 
Surgeons. 2005;13(6):417-27. 
21. Reiter K, Da Silva Paim TG, De Oliveira CF, D’Azevedo PA. High biofilm production by 
invasive multiresistant staphylococci. Acta Pathologica Microbiologica et Immunologica 
Scandinavia. 2011;119:776-81. 
22. Robson MC. Wound infection. A failure of wound healing caused by an imbalance of 
bacteria. Surg Clin North Am. 1997;77(3):637-50. 
23. Robson MC. Award recipient address: Lessons gleaned from the sport of wound watching. 
Wound Repair Regen. 1999;7(1):2-6. 
24. Salgado CD, Dash S, Cantey JR, Marculescu CE. Higher risk of failure of methicillin-
resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res. 
2007;461:48-53. 
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25. Schmidt AH, Swiontkowski MF. Pathophysiology of infections after internal fixation of 
fractures. Journal of the American Academy of Orthopaedic Surgeons. 2000;8(5):285-91. 
26. Selhi HS, Mahindra R, Yamin M, Jain D, De Long WG, Singh J. Outcomes in patients with 
an infected nonunion of the long bones treated with a reinforced antibiotic cement rod. 
J Orthop Trauma. 2012;26(3):184-8. 
27. Selim AJ, Rogers W, Fleishman JA, Qian SX, Fincke BG, Rothendler JA, Kazis LE. 
Updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12). 
Qual Life Res. 2009;18(1):43-52. doi: 10.1007/s11136-008-9418-2. Epub 2008 Dec 3. 
28. Short Musculokeletal Function Assessment Injury and Arthritis Survey; 
http://www.grossortho.com/forms/injury.pdf, accessed 05-16-2014. 
29. Swiontkowski MF, Engelberg R, Martin DP, Angel J. Short musculoskeletal function 
assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am. 
1999;81(9):1245-60. 
30. Tosh PK, McDonald LC. Infection control in the multidrug-resistant era: tending the human 
microbiome. Clin Infect Dis. 2012;54(5);707-13. 
31. Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic only versus 
local intrawound vancomycin antibiotic powder application in addition to intravenous 
antibiotics on postoperative infection in spine surgery in 907 patients. Spine (Phila Pa 1976), 
2013;38(25):2149-55. doi:10.1097/BRS.0000000000000015. PubMed PMID: 24048091. 
32. U.S. Department of Veterans Affairs [internet]. Washington: U.S. Department of Veterans 
Affairs; last updated 21 January 2014. Health Economics Resource Center: Cost-Effective 
Analysis. Available from: http://www.herc.research.va.gov/include/page.asp?id=cost-
effectiveness-analysis#vr36. 
33. Zalavras CG Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop 
Surg. 2003;11(3):212-9. 
 
 
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 APPENDICES 
Appendix 1: 
Table of Study Events ............................................................................................62 
Appendix 2: 
 Flowchart for Microbiological Specimen Processing ...........................................63 
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Appendix 1: Table of Study Events 
 
 
Procedure 
Screening 
Baseline/ 
Day of Surgery 
Hour 48- 60 
Hour 72 
Hour 96 
Week 2 
Week 6 
Week 12 
Week 24, EOT 
Early Term / 
Tx Failure 
Day 1 
Day 2 
Day 3 
Day 4 
Day 14 
±4 days 
Day 42 
±8 days 
Day 84 
±8 days 
Day 168 
±8 days 
Review of eligibility criteria 
X 
X 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
Surgery/Administration of the 
Investigational Product 
 
X 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
 
 
 
 
Interval physical exam 
 
X 
X 
 
 
X 
X 
X 
X 
X 
Hematology 
X 
 
X 
 
 
 
X 
X 
X 
X 
Serology 
 
X 
 
 
 
X 
X 
X 
X 
X 
Serum chemistry 
X 
 
X 
 
 
 
X 
X 
X 
X 
Urinalysis 
X 
 
X 
 
 
 
X 
X 
X 
X 
Pregnancy test 
X 
X 
 
 
 
 
 
 
X 
X 
BisEDT Blood levels1 
 
X 
X 
X 
X 
X 
 
 
 
 
12-lead ECG 
X 
X 
X 
 
 
 
 
 
X 
X 
Vital signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Patient-reported outcomes2 
X 
 
 
 
 
X 
X 
X 
X 
X 
Surgical site signs and symptoms 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Surgical site pain score 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Microbiology 
 
X 
(X)3 
 
 
(X) 
(X) 
(X) 
(X) 
(X) 
Radiographic evaluation 
 
X 
 
 
 
X 
X 
X 
X 
X 
Concomitant medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
1 PK blood samples will be collected pre-dose and at nominal 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 (Day 3), 96 (Day 4) and 336 (Day 14; Week 2) hours after administration of the 
investigational product 
2 Patient-reported outcomes include the Veterans Rand 12 Item Health Survey (VR-12) and Short Musculoskeletal Function Assessment (SMFA) 
3 Microbiology will be performed at any time that a new surgical intervention is required. 
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Appendix 2:  Flowchart for Microbiological Specimen Processing 
 
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PROTOCOL CHANGE FORM 
 
DATE:  05/06/15                                                             
 
Changes in Version 1 April 14, 2015 to Version 1 May 6, 2015 
 
PROTOCOL NUMBER:  MBN-101-201 (Version 1.0) 
 
 
 
 
 
 
SPONSOR: Microbion Corporation 
 
PROTOCOL TITLE: A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week Escalating Dose 
Study to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally Applied MBN-101 
to Infected Osteosynthesis Sites 
 
 
REASON(S) FOR CHANGE(S): Changes were implemented immediately prior to the IND filing to update the study 
drug application procedure, correct drug product description, change spelling within protocol for consistency with the 
rest of the IND filing. 
 
CHANGE(S):  
Note – All changes refer to page numbers in the Track Changes Version 1.0  
Location 
From 
To 
Comment 
Page 1 
Issue Date: 14 April 2015 
Version 1.0 Issue Date: 06 May 
2015 
Replaces Version 1.0 Dated 14 
April 2015 
Update date of Version 1 
Multiple 
pages 
orthopaedic 
orthopedic 
Consistency of spelling 
throughout the protocol and 
rest of IND filing 
Page 18 
Unique mechanism of action 
Apparently unique mechanism of 
action 
Correct to improve accuracy 
of statement 
Page 31 
Adminstration 
Administration 
Spelling correction 
Page 32 
Application to retained 
hardware:  Access to infected 
wound surfaces and implanted 
orthopaedic hardware will be 
provided by surgical 
intervention. The surgeon will 
use a 10 mL syringe to apply, 
followed by a gloved finger to 
spread, a thin layer of the 
investigational product directly 
onto all accessible surfaces of 
the orthopaedic hardware, as 
well as surrounding bone and 
other connective tissue surfaces 
that are likely to come into 
contact with the orthopaedic 
hardware. Wound surfaces that 
are not in the immediate vicinity 
of the orthopaedic hardware will 
not be coated, resulting in 
administration of the 
investigational product to only a 
limited area of the wound. 
Application to retained hardware:  
Access to infected wound surfaces 
and implanted orthopedic hardware 
will be provided by surgical 
intervention. The surgeon will use 
a 10 mL syringe to apply, followed 
by a gloved finger to spread, a thin 
layer of the investigational product 
directly onto all accessible surfaces 
of the orthopedic hardware, as well 
as surrounding bone. Other wound 
surfaces will not be coated, 
resulting in administration of the 
investigational product to only a 
limited area of the wound. 
 
Update study drug 
application procedure 
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PROTOCOL CHANGE FORM 
 
DATE:  05/06/15                                                             
 
Changes in Version 1 April 14, 2015 to Version 1 May 6, 2015 
 
PROTOCOL NUMBER:  MBN-101-201 (Version 1.0) 
 
 
 
 
 
 
 
Page 32 
Application to new hardware:  
Prior to implantation, the 
surgeon will use a gloved finger 
to sparingly coat all hardware 
with a thin layer of the 
investigational product. 
Following surgical implantation 
of the coated hardware, a thin 
layer of the investigational 
product will be applied to 
surrounding bone and other 
connective tissue surfaces that 
are likely to come into contact 
with the orthopaedic hardware 
using a gloved finger. Wound 
surfaces that are not in the 
immediate vicinity of the 
orthopaedic hardware will not be 
coated, resulting in 
Administration of the 
investigational product being 
limited to target areas, 
specifically orthopaedic 
hardware and the immediately 
adjacent, accessible bone 
(osseous) surfaces. 
 
Application to new hardware:  
Prior to implantation, the surgeon 
will use a gloved finger to 
sparingly coat all hardware with a 
thin layer of the investigational 
product. Following surgical 
implantation of the coated 
hardware, a thin layer of the 
investigational product will be 
applied to surrounding bone using 
a gloved finger. Administration of 
the investigational product will 
therefore be limited to target areas, 
specifically orthopedic hardware 
and the immediately adjacent, 
accessible bone (osseous) surfaces. 
 
Update study drug 
application procedure 
Page 33 
The gel should be applied in a 
thin layer to cover all affected 
areas of bone as well as any 
exposed hardware (target 
structures). Direct application to 
muscle and other soft tissues 
(non-target structures) should be 
avoided. 
The suspension should be applied 
in a thin layer to cover all affected 
areas of bone as well as any 
exposed hardware. Direct 
application to muscle and other 
soft tissues should be avoided. 
Correct drug product 
description from gel to 
suspension.  Delete redundant 
description, i.e., target, non-
target structures  
Page 33 
volumes of gel  
volumes of MBN-101. 
 
Correct drug product 
designation 
Page 52 
(Selim, 2009) 
(Selim, 2009; Veterans Affairs 
website, 2014). 
Add reference 
 
 
 
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1 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 
24-week Escalating Dose Study to Assess the Safety, Tolerability 
and Clinical Activity of 3 Concentrations of Locally Applied MBN-101 
to Infected Osteosynthesis Sites 
PROTOCOL NUMBER: MBN-101-201 
Issue Date: 06 May 2015 
Regulatory Sponsor: 
Microbion Corporation 
1102 West Babcock, Suite B 
Bozeman MT 59715 
Version: 1.0 
Microbion Corporation 
 
Reviewed and Approved by: 
 
 
 
12 May2015 
Dr. Brett Baker 
Microbion Corporation 
President and Chief Scientific Officer 
 
Date 
Confidentiality 
This document is the confidential property of Microbion Corporation. 
No part of it may be reproduced, published, or transmitted by other persons 
without written permission of Microbion Corporation. 
 
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INVESTIGATOR AGREEMENT 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week Escalating Dose Study 
to Assess the Safety, Tolerability and Clinical Activity of 3 Concentrations of Locally Applied 
MBN-101 to Infected Osteosynthesis Sites 
I have read the protocol and agree that it contains all necessary details for carrying out the study 
as described. I will conduct this protocol as outlined therein and will make all reasonable efforts 
to complete the study within the designated time. 
I will provide copies of the protocol and access to all information furnished by Microbion 
Corporation to study personnel under my supervision. I will discuss this material with them to 
ensure that they are fully informed about the drug and the study. 
I understand that the study may be terminated or enrollment suspended at any time by Microbion 
Corporation with or without cause, or by me, if it becomes necessary to protect the best interests 
of the study subjects. 
I agree to conduct this study in accordance with the requirements of this protocol and in 
accordance with the following: 
 Good Clinical Practice: Consolidated Guideline International Conference on Harmonisation 
of Technical Requirements for the Registration of Pharmaceuticals for Human Use, ICH E6 
(May 1996) 
 United States (U.S.) Code of Federal Regulations (CFR) associated with clinical studies 
(21 CFR parts 50, 56, 312) 
 Declaration of Helsinki, concerning medical research in humans (“Ethical Principles for 
Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 1975, Venice 
1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, Washington 
2002 and Tokyo 2004). 
 
  
Investigator’s Printed Name 
  
Investigator’s Signature 
 Date 
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PROTOCOL SYNOPSIS 
Protocol Number 
MBN-101-201 
Title 
A Phase 2a Randomized, Single-Blind, Placebo-Controlled, 24-week 
Escalating Dose Study to Assess the Safety, Tolerability and Clinical 
Activity of 3 Concentrations of Locally Applied MBN-101 to Infected 
Osteosynthesis Sites 
Regulatory Sponsor 
Microbion Corporation, 1102 West Babcock, Suite B, Bozeman MT 59715 
Name of 
Investigational 
Product 
MBN-101 
Phase 
2a 
Investigators/Study 
Centers 
3-4 Study Centers in the United States  
Objectives: 
Primary Objective 
To evaluate the safety and tolerability of single escalating doses of locally 
administered MBN-101 or placebo as adjunct to standard of care 
antimicrobial and surgical therapy 
Secondary Objectives  
To evaluate the clinical activity of single escalating doses of locally 
administered MBN-101 
 
To evaluate the pharmacokinetics of single escalating doses of locally 
administered MBN-101 
Number of Subjects 
36 
Study Design and 
Methodology 
This is a randomized, single-blind, placebo-controlled, multi-center study to 
assess the safety and tolerability of single escalating doses of MBN-101 
applied directly to target structures within infected osteosynthesis sites during 
revision surgery with or without hardware removal and replacement for 
patients diagnosed with an apparent fracture site infection within one year of 
the last surgical intervention. Three successive cohorts of 12 patients will be 
enrolled in this trial. Consecutive patients from each of the study sites will be 
screened for potential participation as they present to the orthopedic service 
for clinical care for their postoperative infections. Patients meeting eligibility 
criteria on screening will be offered participation in the study. 
Following baseline evaluation, patients will receive standard of care 
treatment for their postoperative fracture site infection that includes systemic 
antibacterial treatment per institutional standard of care guidelines and 
revision surgery with or without hardware removal and replacement as 
indicated. A single application of MBN-101 or placebo, applied 
intraoperatively directly to target structures within infected osteosynthesis 
sites, will be performed following the final irrigation and debridement 
procedure and immediately prior to definitive closure. In cases where original 
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hardware is retained, MBN-101 will be applied to all accessible surfaces of 
hardware and adjacent bone (target structures). In cases where hardware is 
replaced or in cases of two-stage procedures, MBN-101 will be applied to all 
surfaces of new hardware immediately prior to implantation, and following 
implantation to adjacent bone and accessible hardware surfaces. If wounds 
are left open, the investigational product will be applied immediately prior to 
definitive closure. The minimum amount of MBN-101 required to achieve a 
thin coat of the relevant target structures within the infected osteosynthesis 
site will be used. 
Patients will be randomized 3:1 (active:control) to three successive doses 
(0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up 
to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent). Enrollment to the 
next dose cohort will not commence until an evaluation by the Data Review 
Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort. 
PK assessments will be performed predose and at 1, 6, 12, 24, 36, 48 (Day 2), 
60, 72 (Day 3), 96 (Day 4), and 336 (Day 14; Week 2) hours after 
administration of study drug. 
Patients will undergo study visits at Hour 48 and Weeks 2, 6, 12, and 24. All 
patients will be followed for a total of 24 weeks after surgery. 
Study Population: 
Inclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “YES” answer (unless not applicable): 
1. Patients who: 
 
have had operative fracture fixation of the upper extremity 
(AO/OTA class 15, 11-13, 21-23), lower extremity (AO/OTA class 
31-34, 41-44, 81, 82) or pelvis (61, 62), or have undergone 
arthrodesis 
 
are diagnosed with an apparent fracture site infection within one year 
of their last surgical intervention and have at least one of the 
following: 
 
Elevated ESR above the upper limit of normal 
 
Elevated CRP above the upper limit of normal 
 
Draining wound / sinus tract 
 
Positive culture from site of prior surgery by aspirate or other 
modality 
 
Local erythema or induration at the site of prior surgery 
 
Exposed hardware 
 
Periosteal reaction on x-ray 
 
Loose or broken hardware  
 
require revision surgery with or without removal and replacement of 
existing hardware 
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2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed 
and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as 
per institution’s standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after 
revision surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile 
or at least 2 years postmenopausal, must agree to use one of the 
following forms of contraception from screening through the Week 24 
visit: hormonal (oral, implant, or injection) begun >30 days prior to 
screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications 
and they must ensure their female sexual partner complies with the 
contraception requirements:  
 
Be sexually abstinent from Baseline through Week 24  
 
Be > 6 months post-vasectomy  
 
Agree to use a condom with spermicide from Baseline through 
Week 24 
7. Have read and signed the Informed Consent Form (ICF) after the nature 
of the study has been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of 
personal health information in accordance with Health Insurance 
Portability and Accountability Act (HIPAA) 
Exclusion Criteria: 
To be eligible for this study, each of the following criteria must be satisfied 
with a “NO” answer (unless not applicable): 
1. Patients who are no longer hardware dependent or are definitively treated 
for their infection by hardware removal without replacement 
2. Greater than one year time lapse from last operative procedure 
3. Patients with a previous revision surgery at the site 
4. Patients with multiple, non-contiguous fracture site infections 
5. Pathologic fracture (not including osteoporosis)  
6. Patient requires immunosuppressive therapy (Topical or inhaled 
corticosteroids are permitted) 
7. Serum creatinine, ALT, AST or Alkaline Phosphatase >1.5 times the 
upper limit of the normal range of the local testing laboratory 
8. Absolute neutrophil count <1000 
9. Patients without definitive soft-tissue coverage over the surgical site at 
time of study product administration 
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10. Any condition that has required treatment with any other bismuth 
containing compound within the last 2 weeks (i.e., Kaopectate or 
Pepto-Bismol) 
11. Participation in an investigational trial to evaluate pharmaceuticals or 
biologics within the past 3 months 
12. Individuals undergoing surgical treatment for more than one infected 
fracture 
13. Known allergy to metals or materials comprising the orthopedic 
hardware, bismuth and/or MBN-101 excipients (methylcellulose, 
Tween 80 (polysorbate 80)) 
14. Patients who are pregnant, lactating, or female patients who have a 
positive serum hCG as determined by laboratory testing 
15. Immunocompromised due to illness or organ transplant 
16. History of chronic or recurrent infections (≥ 3 infections at the same site 
within 12 months) 
17. History of any type of cancer (excluding non-melanomatous localized 
skin cancer or completely excised and cured carcinoma-in-situ of uterine 
cervix) 
18. Poorly controlled diabetes mellitus 
19. History of medical noncompliance 
20. Other medical conditions which, in the opinion of the Principal 
Investigator, would jeopardize the safety of the study subject or impact 
the validity of the study results. 
21. Current incarceration 
Investigational 
Product, Dose and 
Mode of 
Administration: 
MBN-101: A suspension of 0.025, 0.075, or 0.25 mg/mL (w:v) BisEDT 
powder in 3% methylcellulose / 0.5% Tween 80 / 10 mM sodium chloride / 
10 mM sodium phosphate, pH 7.4 (up to 8 mL dose volume) applied directly 
to structures within infected osteosynthesis sites during revision surgery with 
or without hardware removal and replacement as an adjunct to standard care 
systemic antimicrobial therapy. 
Reference Therapy, 
Dose and Mode of 
Administration: 
MBN-101 diluent (placebo): 3% methylcellulose / 0.5% Tween 80 / 
10 mM sodium chloride / 10 mM sodium phosphate, pH 7.4 (up to 8 mL dose 
volume) applied directly to structures within infected osteosynthesis sites 
during revision surgery with or without hardware removal and replacement 
as an adjunct to standard care systemic antimicrobial therapy. 
Study Duration 
24 weeks 
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Criteria for Evaluation: 
Efficacy Endpoints 
 
Proportion of treatment failures. A treatment failure is defined as a 
subject with non-healing or worsening status of their surgical site 
requiring serious intervention by Week 24. 
 
Cumulative number of serious interventions (as defined in Section 
12.6.2) at Week 24. 
 
Time to first serious intervention, time to readmission and time to 
reoperation, exclusive of serious interventions, readmissions, and 
reoperations associated with a healed fracture site. 
 
Number of subjects undergoing removal of stabilizing orthopedic 
hardware due to a healed fracture site by Week 24. 
 
Time to removal of orthopedic hardware due to a healed fracture site. 
 
Incidence and intensity of surgical site signs and symptoms, including 
local erythema, induration, drainage and degree of healing. 
 
Change from baseline in patient-reported outcomes at each post baseline 
time point. Patient-reported outcomes will include Veterans Rand 12 
Item Health Survey (VR-12) and Short Musculoskeletal Function 
Assessment (SMFA). 
 
Surgical site pain score and change from baseline in pain score at each 
post baseline time point. Pain intensity at the surgical site will be 
assessed by Visual Analog Scale (VAS, 0-100 mm). 
 
Findings of microbiology evaluations at the surgical site. Microbiologic 
success is assessed by clearance of infection. 
 
Findings of radiographic evaluations at the surgical site. Radiographic 
success is assessed by healing on radiologic examination. 
 
Changes in serologic markers CRP and ESR at each post baseline time 
point. 
Safety Endpoints 
 
Treatment-emergent adverse events. 
 
Treatment-emergent serious adverse events. 
 
Changes in clinical laboratory tests (clinical chemistry, hematology, and 
urinalysis). 
 
Changes in vital signs (blood pressure, pulse, respiratory rate and body 
temperature). 
 
Changes in physical exams. 
 
Clinical findings of 12-lead electrocardiograms. 
 
Change in microbiology status 
Pharmacokinetic 
Endpoints 
 
Whole blood concentrations of Bismuth (Bi) will be measured after 
administration of single escalating doses of MBN-101 (bismuth as a 
surrogate for BisEDT) and will be used to calculate pharmacokinetic 
parameters (i.e., Tmax, Cmax, AUC0-t, AUC0- ∞, T1/2, CL/F, Vz/F). 
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Statistical Methods: 
Statistical Analysis 
Consideration: 
The study sample of size of 36 subjects was chosen empirically for the 
purpose of the study without considering any formal statistical hypothesis 
testing. 
The safety analysis set will include all subjects who are randomized and 
receive any study drug; the efficacy analysis set will include all randomized 
subject with at least one post treatment assessment. Pharmacokinetic analysis 
set will include all subjects who have sufficient plasma samples to allow for 
calculation of pharmacokinetic parameters.  
All safety and efficacy endpoints will be tabulated with descriptive statistics; 
data from all placebo subjects (3 per cohort; 9 subjects in total) will be 
pooled. Data from BisEDT treated subjects will be presented by dose 
(9 subjects per dose) and combined (a total of 27 subjects). If data permits, 
differences between the treatment groups and 95% confidence intervals for 
the difference will be presented. 
If data permit, exploratory dose-response analyses will be performed for 
selected efficacy and safety endpoints.  
The primary analyses of efficacy and safety endpoints will be based on the 
actual treatment received in the event that the received treatment is not the 
assigned treatment; however, ‘as assigned’ sensitivity analyses are planned to 
evaluate the robustness of the efficacy data. 
 
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SPONSOR CONTACT INFORMATION 
Medical Monitor 
Name: 
Brian Murphy, MD 
Sr. Medical Director, Medpace Infectious Diseases 
Office Phone Number: 
513-579-9911, ext. 2416 
Mobile Phone Number: 
859-619-0037 
E-mail: 
b.murphy1@medpace.com 
Other Appropriate Trial Contact Personnel 
Name 
Ronnie McAdams 
Clinical Trial Manager, Associate Director, Medpace 
Office Phone Number 
513-579-9911, ext. 2845 
Mobile Phone Number 
513-394-0516 
Fax 
513-579-0444 
E-mail: 
r.mcadams@medpace.com 
Name 
Markus Heep, MD 
Medical Director Infectious Diseases 
Medpace Germany GmbH 
Office Phone Number 
+49 174 190 6865 
E-mail: 
M.Heep@Medpace.com 
24 Hour Emergency Contact Information 
Medpace Clinical Safety: 
 
SAE hotline: 
800-730-5779, ext. 2999 
Facsimile: 
866-336-5320 
E-mail: 
medpace-safetynotification@medpace.com 
 
If any Sponsor contact information needs to be changed during the course of the study, this will 
be done by the Sponsor, with written notification to the Investigator, and will not require a 
protocol amendment. 
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LIST OF ABBREVIATIONS 
AE 
Adverse event 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase (Serum glutamic pyruvic transaminase [SGPT]) 
AO/OTA 
Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association 
AST 
Aspartate aminotransferase (Serum glutamic oxaloacetic transaminase [SGOT]) 
AUC0-∞ 
Area under the curve from time 0 to infinity 
AUC0-t 
Area under the curve from time 0 to the time of the last measurable concentration 
Bi 
Bismuth, used as a surrogate in concentration and PK analyses after MBN-101 
administration 
BisEDT 
Bismuth-1,2-ethanedithiol 
BMI 
Body mass index 
BUN 
Blood urea nitrogen 
CFR 
Code of Federal Regulations 
CK 
Creatinine kinase 
CL/F 
Apparent clearance after extravascular administration  
CLSI 
Clinical and Laboratory Standards Institute 
Cm 
Centimeter 
Cmax 
Maximum observed concentration 
CRF 
Case report form 
CRP 
C-reactive protein 
DFU 
Directions for Use 
DOD 
Department of Defense 
DRC 
Data Review Committee 
ECG 
Electrocardiogram 
ESBL 
Extended spectrum beta lactamase 
ESR 
Erythrocyte sedimentation rate 
FDA 
U.S. Food and Drug Administration 
GCP 
Good Clinical Practice 
GGT 
Gamma glutamyl transferase 
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hCG 
Human chorionic gonadotropin 
HIPAA 
Health Insurance Portability and Accountability Act 
ICF 
Informed Consent Form  
ICH 
International Conference on Harmonization  
ICP-MS 
Inductively coupled plasma mass spectrometry 
IHMA 
International Health Management Associates, Inc. 
IRB 
Institutional Review Board  
ITT 
Intent to treat 
IUD 
Intrauterine device 
IV 
Intravenous 
IVRS 
Interactive Voice Response System 
Kg 
Kilogram 
MBN-101 
Bismuth-1,2-ethanedithiol (BisEDT) suspension 
MC 
Methylcellulose 
MCS 
Mental health domain score 
MCV 
Mean corpuscular volume 
MDR 
Multidrug Resistant 
MedDRA 
Medical Dictionary for Regulatory Activities 
mg 
milligram 
mg/mL 
Milligrams per milliliter 
MIC 
Minimal inhibitory concentration 
mITT 
Modified intent to treat 
mL 
Milliliter 
mm 
Millimeter 
mM 
Millimolar 
MRSA 
Methicillin resistant Staphylococcus aureus 
MRSE 
Methicillin resistant Staphylococcus epidermidis 
MSSA 
Methicillin-sensitive Staphylococcus aureus 
NCA 
Non-compartmental (PK) analysis 
ng/mL 
Nanograms per milliliter 
OR 
Operating room 
ORP 
Office of Research Protections 
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PCS 
Physical health domain score 
PI 
Principal investigator 
PK 
Pharmacokinetics 
PT 
Prothrombin time 
PTT 
Partial thromboplastin time 
QIDP 
Qualified Infectious Disease Product 
RBC 
Red blood cells 
SAE 
Serious Adverse Event 
SAE CRF 
Serious Adverse Event Case Report Form 
SAP 
Statistical Analysis Plan 
SGOT 
Serum glutamic oxaloacetic transaminase 
SGPT 
Serum glutamic pyruvic transaminase 
SMFA 
Short Musculoskeletal Function Assessment 
SOC 
System organ class 
SOP 
Standard Operating Procedure 
T1/2 
Apparent half-life after extravascular administration 
TEAE 
Treatment-emergent adverse event 
Tmax 
Time of the maximal observed concentration 
USAMRMC US Army Medical Research and Materiel Command 
VAS 
Visual Analog Scale 
VR-12 
Veterans Rand 12 Item Health Survey 
Vz/F 
Apparent volume of distribution after extravascular administration 
w/v 
Weight:volume 
w:w 
Weight:weight 
WBC 
White blood cells 
 
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TABLE OF CONTENTS 
Investigator Agreement ................................................................................................................... 2 
Protocol Synopsis............................................................................................................................ 3 
Sponsor Contact Information .......................................................................................................... 9 
List of Abbreviations .................................................................................................................... 10 
 
INTRODUCTION ................................................................................................................17 
1.1 
Clinical Problem .......................................................................................................17 
1.2 
Investigational Therapy ............................................................................................18 
1.3 
Value of MBN-101 for the Treatment of the Clinical Problem ................................19 
 
OBJECTIVES .......................................................................................................................20 
2.1 
Primary ......................................................................................................................20 
2.2 
Secondary ..................................................................................................................20 
 
INVESTIGATIONAL PLAN ...............................................................................................21 
3.1 
Study Description......................................................................................................21 
3.2 
Number of Subjects...................................................................................................22 
3.3 
Number of Sites ........................................................................................................22 
3.4 
Clinical Trial Material...............................................................................................22 
3.4.1 
MBN-101 .....................................................................................................22 
3.4.2 
Placebo (MBN-101 diluent) ........................................................................22 
3.5 
Dose ..........................................................................................................................23 
 
STUDY POPULATION .......................................................................................................24 
4.1 
Inclusion Criteria ......................................................................................................24 
4.2 
Exclusion Criteria .....................................................................................................25 
 
SUBJECT ENROLLMENT .................................................................................................26 
5.1 
Medical History ........................................................................................................26 
5.2 
Physical Exam ...........................................................................................................26 
5.3 
Studies .......................................................................................................................26 
5.4 
Laboratory Tests at Screening Visit ..........................................................................26 
 
STUDY PROCEDURES ......................................................................................................27 
6.1 
Description of Study Procedures ..............................................................................27 
6.1.1 
Medical History ...........................................................................................27 
6.1.2 
Physical Exams ............................................................................................27 
6.1.3 
Vital Signs ...................................................................................................27 
6.1.4 
12-lead ECG ................................................................................................27 
6.1.5 
Laboratory Tests ..........................................................................................27 
6.1.6 
BisEDT (MBN-101) Blood Levels .............................................................28 
6.1.7 
Pain Assessments ........................................................................................28 
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6.1.8 
Patient Reported Outcomes .........................................................................28 
6.1.9 
Microbiology ...............................................................................................28 
6.1.9.1 
Specimen Collection ...................................................................28 
6.1.9.2 
Specimen Processing: Local Laboratory ....................................28 
6.1.9.3 
Specimen Processing: IHMA (Central Laboratory) ...................29 
6.1.9.4 
Integration of Local Site Laboratory and Central Laboratory 
Primary Isolation and Identification Results ..............................29 
6.1.10 Radiographic Evaluation .............................................................................30 
6.1.11 Surgical Site Signs and Symptoms Evaluation ...........................................30 
6.2 
Screening and Baseline Assessments........................................................................30 
6.3 
Randomization Procedure .........................................................................................30 
6.4 
Unblinding Procedure ...............................................................................................30 
6.5 
Investigational Product Administration ....................................................................31 
6.5.1 
Surgical Site Identification ..........................................................................31 
6.5.2 
Study Drug Administration .........................................................................31 
6.6 
Study Assessments ....................................................................................................34 
6.7 
Safety Monitoring .....................................................................................................34 
6.8 
Study Monitoring ......................................................................................................34 
6.9 
Patient Withdrawals ..................................................................................................34 
6.10 
Individual Patient Stopping Rules ............................................................................34 
6.11 
Study Stopping Rules ................................................................................................34 
 
CONCOMITANT MEDICATIONS ....................................................................................35 
 
STUDY ENDPOINTS ..........................................................................................................36 
8.1 
Safety Endpoints .......................................................................................................36 
8.2 
Efficacy Endpoints ....................................................................................................36 
8.3 
Pharmacokinetic Endpoint ........................................................................................37 
8.3.1 
Sample Collection and Handling .................................................................37 
8.3.2 
Assay Methodology .....................................................................................37 
8.3.3 
PK Analysis .................................................................................................37 
 
ADVERSE EVENTS ............................................................................................................38 
9.1 
Reporting and Following Adverse Events ................................................................38 
9.2 
Severity .....................................................................................................................39 
9.3 
Relationship to Clinical Trial Material .....................................................................39 
9.4 
Serious Adverse Events ............................................................................................40 
9.4.1 
Definition .....................................................................................................40 
9.4.2 
Reporting .....................................................................................................40 
9.5 
Pregnancies ...............................................................................................................41 
9.6 
Data Review Committee (DRC) ...............................................................................41 
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INVESTIGATIONAL PRODUCT MANAGEMENT .........................................................42 
10.1 
Study Drug ................................................................................................................42 
10.2 
Study Drug Packaging and Labeling ........................................................................43 
10.3 
Study Drug Storage ...................................................................................................43 
10.4 
Study Drug Accountability .......................................................................................43 
10.5 
Study Drug Handling and Disposal ..........................................................................43 
 
GENERAL CONSIDERATIONS ........................................................................................44 
11.1 
Basic Principles .........................................................................................................44 
11.2 
Institutional Review Board .......................................................................................44 
11.3 
Informed Consent......................................................................................................44 
11.4 
Study Termination ....................................................................................................45 
11.5 
Regulatory Documentation .......................................................................................45 
11.6 
Study Documentation................................................................................................45 
11.7 
Data Handling and Record Keeping .........................................................................46 
11.8 
Use of Information and Publication ..........................................................................46 
11.9 
Independent Medical Monitor...................................................................................47 
 
STATISTICAL ANALYSIS METHODOLOGY ................................................................48 
12.1 
Efficacy Endpoints ....................................................................................................48 
12.2 
Changes in serologic markers CRP and ESR at each post baseline time 
point.Safety Endpoints ..............................................................................................49 
12.3 
Sample Size Considerations ......................................................................................49 
12.4 
Analysis Datasets ......................................................................................................50 
12.5 
Disposition and Study Population Characteristics ....................................................50 
12.6 
Efficacy Analysis ......................................................................................................51 
12.6.1 Treatment Failure ........................................................................................51 
12.6.2 Incidence of Serious Interventions ..............................................................51 
12.6.3 Time to First Serious Interventions .............................................................52 
12.6.4 Subjects Undergoing Removal of Stabilizing Orthopedic Hardware .........52 
12.6.5 Surgical Site Signs and Symptoms ..............................................................52 
12.6.6 Patient-Report Outcomes ............................................................................52 
12.6.6.1 The Veterans RAND 12 Item Health Survey (VR-12) 
Questionnaire ..............................................................................52 
12.6.6.2 The Short Musculoskeletal Function Assessment 
Questionnaire (SMFA) ...............................................................52 
12.6.7 Pain Assessments ........................................................................................53 
12.6.8 Microbiology ...............................................................................................53 
12.6.9 Radiographic evaluation ..............................................................................54 
12.6.10 Serologic Markers .......................................................................................54 
12.6.11 Subgroup Analyses for Efficacy Endpoints ................................................54 
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12.6.12 Sensitivity Analyses for Efficacy Endpoints ...............................................54 
12.7 
Safety Analysis .........................................................................................................55 
12.7.1 Study Drug Exposure and Concentrations ..................................................55 
12.7.2 Adverse Events ............................................................................................55 
12.7.3 Clinical Laboratory Tests ............................................................................55 
12.7.4 12-lead ECG ................................................................................................55 
12.7.5 Vital Sign Measurements ............................................................................56 
12.7.6 Physical Examinations ................................................................................56 
12.7.7 Subgroup Analyses for Safety Endpoints ....................................................56 
12.8 
PK Analysis ..............................................................................................................56 
12.9 
Interim Evaluation ....................................................................................................56 
 
REFERENCES .....................................................................................................................57 
 
APPENDICES ......................................................................................................................60 
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INTRODUCTION 
1.1 
Clinical Problem 
Postoperative orthopedic infections, particularly antibiotic-resistant infections, present a serious 
clinical challenge to surgeons and other treating physicians, since these infections involve 
foreign materials (stabilizing orthopedic hardware) which are frequently associated with 
persistent microbial biofilms (Hetrick, 2006). Surgical intervention, including irrigation, 
debridement and potential replacement of orthopedic hardware, combined with a prolonged 
course of systemic antibiotics, is the standard of care for postoperative infections (Schmidt, 
2000; Patzakis, 2005). However, outcomes associated with these infections are often poor, 
including chronic/recurrent infections, repeated hospitalizations, repeated surgeries, multiple 
courses of systemic antibiotic treatment, loss of function, disability, amputation and death 
(Berkes, 2010). 
Systemic antibiotics are poorly efficacious in the treatment of heavily contaminated or infected 
wounds (Zalavras, 2003; Robson, 1997) and often antibiotics “…have practical and potential 
value only if a therapeutic blood level or, more importantly, tissue level is achieved within the 
first 4 hours after wounding” (Robson, 1999), i.e., before biofilm formation. The ‘contest’ 
between bacteria and host tissues with respect to speed of colonization of foreign objects such as 
orthopedic medical devices has been described as the “race for the surface’ (Gristina, 1988). 
Bacteria are able to adhere to foreign, implanted objects almost immediately, facilitating rapid 
formation of microbial biofilms which drastically increase the resistance of wound-associated 
bacteria and contribute significantly to persistence and virulence of the infection (Parra-Ruiz, 
2012; Gristina, 1994). Such biofilms can serve as quiescent reservoirs of adherent, antibiotic-
tolerant or antibiotic-resistant bacteria within the wound, or as foci of active infections, which 
helps to explain the chronic and/or recurrent nature of many device-related infections. In 
addition, biofilms are hypermutable (Ciofu, 2011), increasing the likelihood of developing 
genetically-based antibiotic resistance. Finally, biofilms serve as environments in which bacteria 
can exchange genetic material encoding antibiotic resistance genes (Ghigo, 2001). Recent studies 
have shown that the most highly multidrug resistant (MDR) bacteria are also the strongest 
biofilm-forming bacteria (Kwon, 2008), and similarly, that invasive MDR bacteria are usually 
biofilm-forming bacteria (Reiter, 2011). 
The high incidence of postoperative orthopedic device-related infections, as well as the 
shortcomings of the standard of care treatment in resolving those infections, particularly 
considering the increasing prevalence of antibiotic-resistant pathogens, has resulted in an 
expanding unmet need for safe, innovative, new and effective therapies to reduce the infectious 
risks and consequences of these infections, which increasingly involve antibiotic- resistant 
strains (Gessman, 2012; Morris, 2013; Tosh, 2012). Antibiotic resistance adds significantly to 
the challenge of successfully resolving these orthopedic infections (Ferry, 2010; Salgado, 2007). 
For example, infection treatment failures are nine times more frequent in orthopedic patients 
with MRSA infections than methicillin-sensitive S. aureus (MSSA) infections (Salgado, 2007).  
Development of local therapies that eradicate established biofilms or prevent the formation of 
biofilms (as a new target) is an innovative new clinical strategy, particularly considering the 
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shortcomings of systemically administered antibiotics for treatment of wound infections. For 
example, several groups have investigated the direct, local application of vancomycin powder on 
the surgical wound in combination with systemic prophylaxis to prevent or treat infection. The 
outcomes of these studies have been mixed, with some groups reporting a reduced infection rate 
and/or a reduction in patient treatment costs (Heller, 2013; Godil, 2013) and others reporting no 
benefit (Tubaki, 2013; Martin, 2013). Antibiotic-loaded bone cement containing tobramycin, 
gentamicin, or vancomycin/tobramycin or other antibiotic combinations have been investigated 
for their ability to reduce infection rates and /or reduce costs when applied locally in a variety of 
orthopedic surgical procedures (Cummins, 2009; Nowinski, 2012; Selhi, 2012). Evidence 
suggests that local therapies may reduce implant related surgical site infections. 
1.2 
Investigational Therapy 
MBN-101 [Bismuth-1,2-ethanedithiol (BisEDT) suspension] represents the first drug product 
from a new class of antimicrobial agents with apparently unique mechanisms of action. In 
nonclinical models, BisEDT has been shown to be effective against a broad-spectrum of 
orthopedic device-associated bacteria including antibiotic-resistant strains. 
BisEDT has several characteristics especially suited to the treatment of postoperative orthopedic 
infections: 
a) Broad spectrum antimicrobial activity against the most critically important antibiotic-
resistant bacteria, including MRSA, MRSE, antibiotic-resistant Pseudomonas 
aeruginosa, ESBL-positive Klebsiella pneumoniae, and antibiotic-resistant Enterobacter 
species. 
b) Apparently unique mechanisms of action. 
c) Anti-biofilm capabilities. 
d) Extremely low spontaneous mutation frequency, superior to many conventional 
antibiotics. 
e) Efficacy against both aerobic and anaerobic bacteria. 
f) Demonstrated lack of interference with the activity of a wide range of antibiotics. 
g) Enhanced activity in combination with specific antibiotics; in some cases synergy, has 
been demonstrated in vitro and in vivo. 
h) Maintenance of antimicrobial activity in the presence of excessive protein. 
i) A favorable safety and tolerability profile in nonclinical toxicology studies in a variety of 
species, including absence of effect on wound healing or bone repair 
j) A favorable safety and tolerability profile in a clinical Phase 1 study evaluating topical 
administration. 
Based in part on these characteristics, BisEDT has been granted Qualified Infectious Disease 
Product (QIDP) designation by the FDA for the local, intra-operative treatment of resistant post-
surgical orthopedic implant infections. 
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1.3 
Value of MBN-101 for the Treatment of the Clinical Problem  
The broad-spectrum antimicrobial, anti-biofilm activity of BisEDT, its activity against relevant 
antibiotic-resistant pathogens, and its ability to enhance the activity of certain other antibiotics 
are properties that will promote more rapid and/or more complete eradication of infection, and 
reduce infectious risks to patients. With comparatively elevated rates of postoperative infection 
associated with repair of traumatic orthopedic wounds, the development of a new and innovative 
treatment strategy to complement the current standard of care would therefore be expected to 
result in a substantial reduction in mortality, amputation, morbidity, and disability, along with a 
reduction in patient treatment costs. 
MBN-101 provides important potential advantages over current standard of care treatment for 
orthopedic infections. Direct, local contact of MBN-101 with infected target tissue and 
contaminated device surfaces immediately delivers a therapeutically active dose of BisEDT to 
the site of infection. Combined antimicrobial and anti-biofilm effects are achieved with minimal 
systemic exposure. Systemic antibiotics administered alone are frequently ineffective, in part 
because altered perfusion at the surgical wound site hinders effective and timely delivery of 
systemic antibiotics, making it difficult to reach therapeutic antibiotic levels at wound 
tissues/surfaces. The combined effect of IV administered antibiotics, which already serve as a 
pillar of the current standard of care for orthopedic device-related infections, along with the local 
administration of MBN-101, is expected to eradicate bacteria from postoperative orthopedic 
wounds, and will ultimately also serve to reduce the likelihood of development of antibiotic-
resistant bacteria. By reducing the time to resolution of infection and improving the ability of 
current antibiotic therapies to effectively control and eliminate post-surgical orthopedic device-
related infections, MBN-101 will contribute to reductions in the number of additional serious 
interventions needed to resolve infections including reduction in repeat surgeries, additional 
rounds of systemic antibiotics, patient hospitalization time, morbidity and mortality in both 
civilian and military populations. 
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OBJECTIVES 
2.1 
Primary 
To evaluate the safety and tolerability of single escalating doses of locally administered 
MBN-101 or placebo as adjunct to standard of care antimicrobial and surgical therapy. 
2.2 
Secondary 
 To evaluate the clinical activity of single escalating doses of locally administered MBN-101. 
 To evaluate the pharmacokinetics of single escalating doses of locally administered 
MBN-101. 
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INVESTIGATIONAL PLAN 
3.1 
Study Description 
This is a randomized, single-blind, placebo-controlled multi-center study to assess the safety and 
tolerability of escalating doses of MBN-101 applied directly to target structures within infected 
osteosynthesis sites during revision surgery with or without hardware removal and replacement 
for patients diagnosed with an apparent fracture site infection within one year of the last surgical 
intervention. Three successive cohorts of 12 patients will be enrolled in this trial. Consecutive 
patients from each of the study sites will be screened for potential participation as they present to 
the orthopedic service for clinical care for their postoperative infections. After signing an 
Informed Consent Form (ICF), subjects will complete screening procedures. Patients meeting all 
eligibility criteria on screening will be offered participation in the study. Patients accepting 
participation in the study will be randomized 3:1 (active:control) to three successive doses 
(0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 
2.0 mg, respectively) or placebo (diluent). Enrollment to the next dose cohort will not commence 
until an evaluation by the Data Review Committee (DRC) of all available safety data on all 
patients through Week 6 of study supports escalation to the next cohort. The DRC will monitor 
all safety data in an ongoing manner from all patients enrolled onto this study. 
Following baseline evaluation, patients will receive standard of care treatment for their post-
operative fracture site infection that includes systemic antibacterial treatment per institutional 
standard of care guidelines and revision surgery with or without hardware removal and 
replacement as indicated. Multiple debridements, soft tissue transfer, and revision fixation 
procedures may be performed prior to definitive closure. A single application of the 
investigational product, MBN-101 or placebo, applied intraoperatively directly to target 
structures within infected osteosynthesis sites, will be performed following the final irrigation 
and debridement procedure and immediately prior to definitive closure. In cases where original 
hardware is retained, the investigational product will be sparingly applied to all accessible 
surfaces of hardware and adjacent bone. In cases where hardware is replaced or in cases of two-
stage procedures, the investigational product will be applied to all surfaces of new hardware 
immediately prior to implantation, and following implantation to adjacent bone and accessible 
hardware surfaces. The volume applied will be determined by the surgeon’s assessment of the 
size (in cm2) of the target area, and guided by the Table in Section 6.5.2. If wounds are left open, 
the investigational product will be applied immediately prior to definitive closure. The minimum 
amount of MBN-101 required to achieve a thin coat of the relevant target structures within the 
infected osteosynthesis site will be used (see Section 6.5.2). 
All patients will receive standard postoperative care per institutional guidelines, and will be 
discharged from the hospital in accordance with local standards. Patients will undergo study 
visits at Hour 48 and Weeks 2, 6, 12, and 24. All patients will be followed for a minimum of 
24 weeks after surgery. 
See Appendix 1 for a Schedule of Activities. 
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3.2 
Number of Subjects 
Thirty-six adult male or female patients meeting protocol-specified eligibility criteria may 
participate in the study, with the objective of having a total of 9 patients per dose level in the 
MBN-101-treated group and 9 patients in a pooled placebo-treated group. Patients who are 
randomized but do not receive study drug may be replaced. 
3.3 
Number of Sites 
Three or four U.S. study sites are anticipated to enroll an adequate number of eligible patients. 
 
3.4 
Clinical Trial Material 
Patients will be randomized 3:1 (active:control) to three successive doses (0.025, 0.075, or 
0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose of up to 0.2, 0.6, or 2.0 mg, respectively) 
or placebo (diluent). Enrollment to the next dose cohort will not commence until an evaluation 
by the Data Review Committee (DRC) of all available safety data on all patients through Week 6 
of study supports escalation to the next cohort.  
3.4.1 
MBN-101 
MBN-101 is Bismuth-1,2-ethanedithiol (BisEDT) suspension (0.025, 0.075, or 0.25 mg/mL, 
w:v) in diluent (3% methylcellulose / 0.5% Tween 80 / 10mM sodium chloride / 10 mM sodium 
phosphate, pH 7.4). 
 
 
Structural Formula 
Molecular Formula 
C6H12S6Bi2 
Molecular Weight 
694.51 g/mol 
Stereochemistry/Chirality 
BisEDT has no chiral centers. 
 
3.4.2 
Placebo (MBN-101 diluent) 
Placebo is MBN-101 diluent comprised of 3% methylcellulose / 0.5% Tween 80 / 10mM sodium 
chloride / 10 mM sodium phosphate, pH 7.4. 
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3.5 
Dose 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
Investigational product kits (MBN-101 and placebo) configured for each dose cohort will be 
provided and will contain the supplies necessary for preparation of the specified concentrations 
of MBN-101 or placebo for administration to each patient. 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the Stock Formulation and Diluent 
provided in the Drug Product Kit according to the Directions for Use (DFU) provided. The 
Treatment Dose will be provided to the surgeon in an 8 mL volume in a sterile 10 mL syringe. 
Surgeons will be instructed to use sufficient volume (up to the full 8 mL provided for the largest 
exposed target areas) to lightly coat the bone at the site of infection, the exposed surfaces of any 
retained hardware, and the surfaces of any new hardware to be implanted. With dose volume 
determined according to Section 6.5.2, the volume of MBN-101 required to achieve a thin coat 
of the relevant structures within the infected osteosynthesis site will be applied. Following 
application, OR personnel will record in the CRF the volume (in tenths of milliliters) of any 
unapplied Treatment Dose remaining in the syringe. 
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STUDY POPULATION 
The study population will include 36 male or female adults who meet all of the study entry 
requirements. 
4.1 
Inclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “YES” answer 
(unless not applicable): 
1. Patients who: 
 have had operative fracture fixation of the upper extremity (AO/OTA class 15, 11-13, 
21-23), lower extremity (AO/OTA class 31-34, 41-44, 81, 82) or pelvis (61, 62), or 
have undergone arthrodesis 
 are diagnosed with an apparent fracture site infection within one year of their last 
surgical intervention and have at least one of the following: 
 Elevated ESR above the upper limit of normal 
 Elevated CRP above the upper limit of normal 
 Draining wound / sinus tract 
 Positive culture from site of prior surgery by aspirate or other modality 
 Local erythema or induration at the site of prior surgery 
 Exposed hardware 
 Periosteal reaction on x-ray 
 Loose or broken hardware  
 require revision surgery with or without removal and replacement of existing hardware 
2. Male or female ≥18 and <75 years of age at the time the ICF is reviewed and signed 
3. Patients receiving or anticipated to receive systemic antibiotic therapy as per institution’s 
standard of care 
4. Patients requiring postoperative hospitalization for at least 48 hours after revision surgery 
5. Female subjects of childbearing potential, defined as not surgically sterile or at least 
2 years postmenopausal, must agree to use one of the following forms of contraception 
from screening through the Week 24 visit: hormonal (oral, implant, or injection) begun 
>30 days prior to screening, barrier (condom, diaphragm with spermicide), intrauterine 
device (IUD), or vasectomized partner (6 months minimum) 
6. Male participants must meet at least one of the following specifications and they must 
ensure their female sexual partner complies with the contraception requirements:  
 Be sexually abstinent from Baseline through Week 24  
 Be > 6 months post-vasectomy  
 Agree to use a condom with spermicide from Baseline through Week 24 
7. Have read and signed the Informed Consent Form (ICF) after the nature of the study has 
been fully explained 
8. Be willing and able to provide authorization for the use and disclosure of personal health 
information in accordance with Health Insurance Portability and Accountability Act 
(HIPAA) 
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4.2 
Exclusion Criteria 
To be eligible for this study, each of the following criteria must be satisfied with a “NO” answer 
(unless not applicable): 
1. Patients who are no longer hardware dependent or are definitively treated for their 
infection by hardware removal 
2. Greater than one year time lapse from last operative procedure 
3. Patients with a previous revision surgery at the site 
4. Patients with multiple, non-contiguous fracture site infections 
5. Pathologic fracture (not including osteoporosis)  
6. Patient requires immunosuppressive therapy (Topical or inhaled corticosteroids are 
permitted) 
7. Serum creatinine, ALT, AST or Alkaline Phosphatase >1.5 times the upper limit of the 
normal range of the local testing laboratory 
8. Absolute neutrophil count <1000 
9. Patients without definitive soft-tissue coverage over the surgical site at time of study 
product administration 
10. Any condition that has required treatment with any other bismuth containing compound 
within the last 2 weeks (i.e., Kaopectate or Pepto-Bismol) 
11. Participation in an investigational trial to evaluate pharmaceuticals or biologics within the 
past 3 months 
12. Individuals undergoing surgical treatment for more than one infected fracture 
13. Known allergy to metals or materials comprising the orthopedic hardware, bismuth 
and/or MBN-101 excipients (methylcellulose, Tween 80 (polysorbate 80)) 
14. Patients who are pregnant, lactating, or female patients who have a positive serum hCG 
as determined by laboratory testing 
15. Immunocompromised due to illness or organ transplant 
16. History of chronic or recurrent infections (≥ 3 infections at the same site within 
12 months) 
17. History of any type of cancer (excluding non-melanomatous localized skin cancer or 
completely excised and cured carcinoma-in-situ of uterine cervix) 
18. Poorly controlled diabetes mellitus 
19. History of medical noncompliance 
20. Other medical conditions which, in the opinion of the Principal Investigator, would 
jeopardize the safety of the study subject or impact the validity of the study results. 
21. Current incarceration  
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SUBJECT ENROLLMENT 
Potential patients will undergo screening medical history and physical examination. If they are 
deemed appropriate candidates for study, they will be asked to provide appropriate informed 
consent. After informed consent is signed additional baseline evaluation will be performed, 
including but not limited to clinical laboratory assessment, radiographic evaluation, 
electrocardiogram (ECG) and pregnancy test if applicable. Only patients with an acceptable 
medical history and physical exam, ECG without clinically significant abnormalities, and 
laboratory results within acceptable limits will be randomized in the study. Randomization will 
occur using an IVRS system immediately after a patient has met all study entry criteria. 
5.1 
Medical History 
Medical history and demographic data, including gender, date of birth, ethnicity, and race will be 
recorded. 
5.2 
Physical Exam 
Each patient will receive a physical examination (head, ears, eyes, nose, throat, chest, heart, 
abdomen, and skin) including vital signs, weight (kg), and height (cm). Each patient will also 
receive a detailed evaluation of the index fracture site and involved extremity. 
5.3 
Studies 
Following signing of the informed consent form, each patient will undergo all screening 
evaluations as provided in the Table of Study Events. These evaluations should be completed no 
more than 2 weeks prior to surgery date; after a screened subject is confirmed to be eligible for 
the study, this qualified subject will be randomized prior to surgery to receive the investigational 
product. 
5.4 
Laboratory Tests at Screening Visit 
Hematology White blood cells (WBC), red blood cells (RBC), hemoglobin, hematocrit, platelet count, 
MCV, absolute neutrophils, absolute lymphocytes, absolute monocytes, absolute 
eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, blood urea nitrogen (BUN), glucose, 
creatinine, total protein, albumin, total bilirubin, direct bilirubin, alkaline phosphatase 
(ALP), AST (SGOT), ALT (SGPT), GGT, creatinine kinase (CK), calcium, magnesium, 
Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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STUDY PROCEDURES 
See the Table of Study Events outlining study procedures in Appendix 1. For the study site visit 
at Week 2, a visit window of + 4 days will be allowed; for study site visits Weeks 6 – 24, a visit 
window of ± 8 days will be allowed. 
6.1 
Description of Study Procedures 
6.1.1 
Medical History 
A comprehensive medical history will be taken on all patients at Screening, including but not 
limited to past medical history, past surgical history, current medications, allergic history and 
psychosocial history. 
6.1.2 
Physical Exams 
A comprehensive physical examination will be performed on all patients at Screening, including 
assessments of height, weight, head, ears, eyes, nose, throat, chest, heart, abdomen, and skin. 
Interval physical exams will be performed at all subsequent study visits according to the 
schedule in Appendix 1 and will focus on the surgical site, with assessments of local erythema, 
induration, drainage and degree of healing. 
6.1.3 
Vital Signs 
Vital signs include blood pressure, pulse, respiratory rate and body temperature; vital signs will 
be assessed according to the schedule in Appendix 1. 
6.1.4 
12-lead ECG 
Testing will be conducted at screening, baseline, and 48 hours. The ECG trace will be stored at 
the investigational sites as source document; clinical interpretation, including normal, abnormal 
but not clinically significant, and abnormal and clinically significant, will be determined by the 
investigator and reported on the CRFs.  
6.1.5 
Laboratory Tests 
All clinical laboratory tests will be performed by the local clinical site laboratory. 
Blood and urine will be collected for hematology, serology, serum chemistry, urinalysis, and 
pregnancy testing (as indicated) according to the schedule in Appendix 1. 
Hematology WBC, RBC, hemoglobin, hematocrit, platelet count, MCV, absolute neutrophils, absolute 
lymphocytes, absolute monocytes, absolute eosinophils, absolute basophils, PT, PTT. 
Serologies 
ESR, CRP. 
Serum 
Chemistry 
Sodium, potassium, chloride, carbon dioxide, BUN, glucose, creatinine, total protein, 
albumin, total bilirubin, direct bilirubin, alkaline phosphatase (ALP), AST (SGOT), ALT 
(SGPT), GGT, creatinine kinase (CK), calcium, magnesium, Vitamin D. 
Other 
Urine analysis 
Serum pregnancy test for women of childbearing potential 
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6.1.6 
BisEDT (MBN-101) Blood Levels 
BisEDT levels in whole blood after MBN-101 administration will be assessed with a qualified 
Inductively Coupled Plasma Mass Spectrometry (ICP-MS) assay method using bismuth as a 
surrogate for BisEDT according to the schedule in Appendix 1. 
6.1.7 
Pain Assessments 
Pain related specifically to the surgical site (Surgical Site Pain Score) will be assessed via a 
Visual Analog Scale (VAS, 0-100 mm, where 0=no pain at all and 100 =the worst possible pain) 
utilizing a 24 hour recall at screening, baseline, Hour 48 and Weeks 2, 6, 12, and 24. 
6.1.8 
Patient Reported Outcomes 
Patient-reported outcomes will be collected using the Veterans Rand 12 Item Health Survey 
(VR-12) and Short Musculoskeletal Function Assessment (SMFA) according to the schedule in 
Appendix 1. 
6.1.9 
Microbiology 
The microbiology of the index site will be assessed at baseline and at the time of any subsequent 
surgical procedure at the index site. The presence of viable microorganisms will be determined 
by standard microbiological culture methods and include speciation and antimicrobial 
susceptibility testing of any bacterial isolates found (see flowchart, Appendix 2). 
6.1.9.1 
Specimen Collection 
Samples collected will include at least one tissue site (bone when possible; eraser head size, 
suitable for dividing into two samples) from the fracture site (if accessed) or involved tissue 
adjacent to the implant(s), two swabs of the peri-implant deep tissue, and two swabs of the 
superficial tissue/wound closure site. One set of specimens (i.e. 1 tissue specimen, 1 deep swab, 
1 superficial swab) will be placed into local site transport vessels. The duplicate set of samples 
will be placed into transport vessels provided by the central laboratory (International Health 
Management Associates, Inc; IHMA). One set of specimens will be delivered to the local site 
microbiology laboratory using the standard storage and transport procedures employed at each 
site. The duplicate set of specimens will be transported to IHMA. The details regarding specimen 
packaging, transport, and processing will be described in the central laboratory study manual that 
will be provided to each study site. 
6.1.9.2 
Specimen Processing: Local Laboratory 
The tissue site sample and swabs will be analyzed immediately in the local laboratory for the 
presence of infectious pathogens by Gram stain and microbiological culture for both aerobic and 
anaerobic bacteria. The specimens will be processed (primary isolation, identification to species 
level and susceptibility testing) per the standard methods of each local site microbiology 
laboratory. Following isolation and identification of each microorganism, the susceptibility of 
each to one or more standard antibacterial agents (but not including MBN-101), as specified by 
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the surgeon or per local site standard procedures, will be determined. It is recognized that the 
local site laboratory may be using one of a variety of susceptibility test methods, and therefore, 
the susceptibility result may be reported as a specific Minimal Inhibitory Concentration (MIC) 
value or as a categorical result (i.e. Susceptible, Intermediate or Resistant). Susceptibility to 
MBN-101 will not be determined at the local site laboratory; the susceptibility results determined 
locally are for the use of the surgeon in the care of the patient. All Gram stain and microbiology 
results from the local site laboratory will be recorded on the CRF. 
6.1.9.3 
Specimen Processing: IHMA (Central Laboratory) 
The tissue site sample and swabs will be analyzed immediately in the central laboratory for the 
presence of infectious pathogens by Gram stain and microbiological culture for both aerobic and 
anaerobic bacteria. The specimens will be processed (primary isolation, identification to species 
level, and susceptibility testing) per the central laboratory methods, as described in the central 
laboratory study manual. 
Following identification, the susceptibility of the isolates to MBN-101 and comparator agents 
will be determined using either the reference broth microdilution method (for aerobic/facultative 
bacteria) or the reference agar dilution method (for anaerobic bacteria) as detailed by the Clinical 
and Laboratory Standards Institute (CLSI). Susceptibility tests will be quality-controlled as 
detailed by CLSI using reference quality control strains and previously-established ranges for 
MBN-101 and comparators. Susceptibility testing will be conducted with batches of study 
isolates as each study cohort is completed. Patient and specimen identifier and microbiology 
results will be recorded in the database. The bacterial isolates recovered from the specimens will 
be propagated and archived at the central laboratory. 
6.1.9.4 
Integration of Local Site Laboratory and Central Laboratory Primary Isolation and 
Identification Results 
There may be instances where the organism(s) isolated from a given specimen may be different 
at the local site laboratory and the central laboratory. In this instance, the central laboratory will 
first confirm the identification of the archived isolate. If the identification is confirmed, the 
pathogens present in the specimen will be defined as the total number of pathogens recovered by 
the local site laboratory and the central laboratory. For example, if the local site laboratory were 
to recover S. aureus and the central laboratory recovered S. aureus and P. acnes, the specimen 
would be defined as containing both S. aureus and P. acnes following merger of the data. 
It is possible that local site laboratory may perform susceptibility tests with agents that are also 
present in the central laboratory test panel. The MIC value (and interpretation) provided by the 
central laboratory supersedes the local site determination for the purposes of clinical trial data 
analysis and inclusion in the Clinical Study Report. The local site susceptibility test results are 
for use by the surgeon in the local care of the patient; however, these data will also be captured 
in the study database. 
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6.1.10 
Radiographic Evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6, 12, and 24. Radiographs 
(at least two orthogonal views) will be reviewed for union, interval callus formation, loss or 
change in reduction, and hardware failure. 
6.1.11 
Surgical Site Signs and Symptoms Evaluation 
The following signs and symptoms of the surgical site will be evaluated: 
 
local erythema extending beyond suture material or staples 
 
induration  
 
drainage from surgical incision 
 
degree of healing of the surgical incision 
Patients with non-healing or worsening status of their surgical site may be considered for 
additional standard of care treatment, but should be encouraged to remain in the study in order to 
complete study evaluations. In case additional treatment is given, the start/stop dates and dose 
regimen of the new treatment will be recorded on the CRFs. 
6.2 
Screening and Baseline Assessments 
Patients who meet initial screening criteria by medical history and physical exam will be offered 
participation on study. If the patient agrees to participate, they will be asked to provide written 
informed consent, after which additional evaluation may be performed, including but not limited 
to clinical laboratory assessments, electrocardiogram (ECG), radiographic evaluation and 
pregnancy test if applicable. Only patients with an acceptable medical history and physical exam, 
ECG without clinically significant abnormalities, and laboratory results within acceptable limits 
will be randomized in the study prior to surgery. 
6.3 
Randomization Procedure 
Subjects will be randomized in a 3:1 (active:placebo) ratio up to 24 hours prior to surgery via a 
central randomization scheme. The central randomization will be accomplished using an IVRS 
system linked to study drug treatment kits securely stored under appropriate conditions at the 
study site pharmacy. The randomization number assigned to a subject will be captured on the 
CRF. The specific study drug treatment kit will be utilized by the study pharmacist or other 
qualified individual to perform the appropriate dilution of drug product under sterile conditions 
into a vial to be transported to the operating room. Verification of study patient and study drug 
treatment kit will take place in the operating room prior to treatment with the investigational 
product. The appropriately diluted drug product must be administered within 8 hours of 
preparation. 
6.4 
Unblinding Procedure 
This study is a single blind study; however, knowledge of treatment assignment should remain 
limited to those directly involved with the patient’s surgical procedure and other individuals on a 
need to know basis. In order to provide unblinding data in an emergency in the absence of 
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individual privy to treatment assignment, sites will be provided with a numbered unblinding 
envelope corresponding to each numbered test kit the site is delivered. These envelopes will be 
securely stored in the pharmacy. The unblinding envelope specifies the treatment group of the kit 
and should only be opened when absolutely necessary. For treatment of adverse events, it should 
be assumed that the patient has received study drug, thus avoiding the need to unblind the 
patient. However, in the event the Investigator determines the randomization assignment 
information is required to treat the patient for an adverse event, the Medical Monitor should be 
contacted. If the Medical Monitor cannot be reached, the blind may be broken by opening the 
envelope. The site should document the unblinding process in the patient’s source documents. 
6.5 
Investigational Product Administration 
6.5.1 
Surgical Site Identification 
Individuals undergoing surgical treatment for more than one infected fracture are excluded from 
participation in this study. 
6.5.2 
Study Drug Administration 
On the day of surgery, randomized subjects will receive the investigational product during their 
surgical procedure. Investigational product is only administered during the surgical procedure by 
the operating surgeon; therefore, 100% compliance with investigational product administration is 
assured. The operating surgeon will record the location of investigational product administration 
in the operative note and on the CRF. All other details of the surgical procedure, including the 
dimensions and approximate surface area of the surgical incision, will be recorded in the 
operative note. 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied. 
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 15 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
5. Alcohol wipes 
6. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
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The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose”) 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
The Treatment Dose for each patient will be prepared at the clinical site under sterile conditions 
no more than 8 hours prior to dose administration using the MBN-101 Stock Formulation and 
Diluent provided in the Drug Product Kit according to the DFU provided. The Treatment Dose 
will be provided to the surgeon in a vial from which an 8 mL volume will be drawn up in the 
operating room into a sterile 10 mL syringe. Surgeons will be instructed to use sufficient volume 
(up to the full 8 mL provided) to sparingly coat the bone at the site of infection, the exposed 
surfaces of any retained hardware, and the surfaces of any new hardware to be implanted. 
Following application, OR personnel will record in the CRF the actual volume (in tenths of 
milliliters) of any unapplied Treatment Dose remaining in the syringe. 
Application to retained hardware:  Access to infected wound surfaces and implanted orthopedic 
hardware will be provided by surgical intervention. The surgeon will use a 10 mL syringe to 
apply, followed by a gloved finger to spread, a thin layer of the investigational product directly 
onto all accessible surfaces of the orthopedic hardware, as well as surrounding bone. Other 
wound surfaces will not be coated, resulting in administration of the investigational product to 
only a limited area of the wound. 
Application to new hardware:  Prior to implantation, the surgeon will use a gloved finger to 
sparingly coat all hardware with a thin layer of the investigational product. Following surgical 
implantation of the coated hardware, a thin layer of the investigational product will be applied to 
surrounding bone using a gloved finger. Administration of the investigational product will 
therefore be limited to target areas, specifically orthopedic hardware and the immediately 
adjacent, accessible bone (osseous) surfaces. 
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In all cases, the minimum amount of MBN-101 required to coat the relevant structures within the 
infected osteosynthesis site should be used. The suspension should be applied in a thin layer to 
cover all affected areas of bone as well as any exposed hardware. Direct application to muscle 
and other soft tissues should be avoided. The approximate area of the osteosynthesis site should 
be calculated based on the length of exposed bone multiplied by the width of bone exposed; the 
surface area of the hardware should be added to this value to derive the approximate area of the 
osteosynthesis site. Recommended maximum volumes of MBN-101 for various areas of the 
osteosynthesis site are provided in the table below. 
Area of Osteosynthesis Site 
Recommended Volume of MBN-101 
25 cm2 
0.5 mL 
50 cm2 
1.0 mL 
75 cm2 
1.5 mL 
100 cm2 
2.0 mL 
125 cm2 
2.5 mL 
150 cm2 
3.0 mL 
175 cm2 
3.5 mL 
200 cm2 
4.0 mL 
225 cm2 
4.5 mL 
250 cm2 
5.0 mL 
275 cm2 
5.5 mL 
300 cm2 
6.0 mL 
325 cm2 
6.5 mL 
350 cm2 
7.0 mL 
375 cm2 
7.5 mL 
400 cm2 
8.0 mL 
 
The table shows the specified volume of MBN-101 to be applied based on the area (in cm2) of 
the target infected osteosynthesis site. By following these application requirements, the 
administered doses will be: 
 Cohort 1: 25 µg/mL MBN-101 = 0.5 µg/cm2 
 Cohort 2: 75 µg/mL MBN-101 = 1.5 µg/cm2 
 Cohort 3: 250 µg/mL MBN-101 = 5.0 µg/cm2 
The use of drains and vacuum assisted closure devices at the site of hardware will be allowed per 
surgeon preference. The drainage volume over the first 24 hours or prior to discontinuation of the 
drain will be assayed for BisEDT. 
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6.6 
Study Assessments 
Each patient enrolled in the study will have an assessment at 48 hours following surgery and at 
Weeks 2, 6, 12, and 24. Study assessments will be performed according to Section 6.1 and 
Appendix 1. The Week 24 assessment will be the final assessment for adverse events. Any 
adverse events ongoing at the Week 24 assessment will be followed until resolution of the event 
or stabilization of the condition. 
6.7 
Safety Monitoring 
Patients will be instructed to inform the Investigator and/or a member of the study staff of any 
adverse events that occur at any time during the study. Patients will be asked a general health 
question at each clinic visit to identify changes in the state of their health since their last study 
visit. 
6.8 
Study Monitoring 
The Sponsor or the Sponsor’s designee will provide training on the protocol for the study site 
personnel prior to giving the site permission to begin enrollment. Once the enrollment and 
dosing phases of the study have begun, the Sponsor or the Sponsor’s designee will visit the site 
to monitor the clinical conduct of the trial, the adequacy of study documentation and compliance 
with safety reporting. Clinical site monitoring will continue on a periodic basis until the site has 
been closed or all patients at the site have completed the study. The frequency of monitoring 
visits may vary depending on enrollment at the study site. 
6.9 
Patient Withdrawals 
Patients will be free to withdraw at any time for any reason, or they may be withdrawn if 
necessary to protect their health and safety or the integrity of the study. Any patient that is 
randomized but not treated will be replaced. The final report will include reasons for 
withdrawals. As this study involves a single administration of study drug, significant patient 
withdrawals are not anticipated. 
All efforts should be made to have subjects complete the Week 24 (end of study) procedures 
prior to withdrawal from the study. 
6.10 Individual Patient Stopping Rules 
Patients who develop adverse events at any time during the study will be treated appropriately 
according to standard of care. Adverse events will be assessed and followed as described in 
Section 9. As this is a single dose study with the investigational product applied directly into a 
surgical site, specific stopping rules for individual patients have not been established. 
6.11 Study Stopping Rules 
Patient enrollment on study will be stopped if the number of individual patients experiencing 
possibly-related or probably-related adverse events > Grade 2 exceeds 2 in any dose cohort or if 
there is any death on study. Should the study stopping rules be invoked, all safety data on all 
patients will be assembled for review by the Data Review Committee (DRC). The study will not 
resume until this information has been reviewed by the DRC and the Sponsor, discussed with the 
FDA, and concurrence reached with the FDA as to the resumption of the study. 
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CONCOMITANT MEDICATIONS 
All patients will received their usual concomitant medications for any underlying medical 
conditions without interruption. Efforts should be made to maintain all concomitant medications 
at a stable dose for the duration of the 24 week study. Patients will also receive standard of care 
treatment for their postoperative fracture site infection that includes systemic antibacterial 
treatment per prevailing standard of care guidelines (i.e., national, institutional, or physician 
preference) and other indicated postoperative medications, including pain medications. All 
concomitant medications will be recorded in the CRF. Pain medication usage, including 
medication, dose, route, day and time of administration, will be recorded on a separate CRF. Use 
of any other bismuth-containing compounds is prohibited from Screening through Week 4. 
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STUDY ENDPOINTS 
8.1 
Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
 Treatment-emergent adverse events. 
 Treatment-emergent serious adverse events. 
 Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
 Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
 Changes in physical exams. 
 Clinical findings of 12-lead electrocardiograms. 
 Change in microbiology status. 
8.2 
Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
 Proportion of treatment failures. A treatment failure defined as a subject with non-healing 
or worsening status of their surgical site requiring serious intervention by Week 24. 
 Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 24. 
 Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed fracture 
site. 
 Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed fracture site by Week 24. 
 Time to removal of orthopedic hardware due to a healed fracture site. 
 Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
 Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
 Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale 
(VAS, 0-100 mm). 
 Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
 Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination.  
 Change in serologic markers CRP and ESR at each post baseline time point. 
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8.3 
Pharmacokinetic Endpoint 
8.3.1 
Sample Collection and Handling 
Blood samples will be obtained to measure blood concentrations of Bismuth (Bi) as a surrogate 
for BisEDT. A pre-dose sample will be collected prior to administration of the investigational 
product. Blood will be drawn for PK samples at 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 (Day 3), 
96 (Day 4), and 336 (Day 14) hr after application of MBN-101 to the surgical site. 
Documentation stating the exact time of blood sampling (5 mL per timepoint) in relation to the 
time of study drug administration will be collected and provided. 
Primary and back-up blood samples will be stored at -70°C.  
8.3.2 
Assay Methodology 
Bismuth (Bi) levels, a surrogate for BisEDT, will be assayed in whole blood using a validated 
inductively coupled plasma mass spectrometry (ICP-MS) assay performed by Medpace 
Bioanalytical Laboratories (Cincinnati, Ohio). The samples are prepared for analysis by 
digestion with 2% nitric acid followed by dilution into 2% Tetramethyl Ammonium Hydroxide 
(TMAH) with 0.02% Triton X-100, and subsequent quantitation of Bi by ICP-MS analysis. 
A detailed method description, including validation, calibration and quality assurance 
procedures, will be included in the analytical report which will be part of the Final Study Report. 
8.3.3 
PK Analysis 
Bismuth (Bi) concentration data will be analyzed by noncompartmental analysis (NCA) with 
Phoenix™ WinNonlin® Version 6.3 or higher, using an extravascular administration model and 
actual sampling times. The following PK parameters will be derived from blood concentrations 
of Bi using extravascular noncompartmental PK analysis: 
Tmax 
Time to maximum observed concentrations of Bi 
Cmax 
Maximum observed concentrations of Bi 
AUC0-t Area under the Bi concentration vs time curve from time zero to the time of the last 
measurable concentration. 
AUC0-∞ Area under the Bi concentration vs time curve from time zero and extrapolated to 
infinity. 
T1/2 
The apparent half-life of Bi after extravascular administration of BisEDT 
CL/F 
Apparent clearance after extravascular administration of BisEDT 
Vz/F 
Apparent volume of distribution after extravascular administration of BisEDT 
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ADVERSE EVENTS 
An adverse event is an undesirable medical occurrence (sign, symptom, or diagnosis) or 
worsening of a pre-existing medical condition (e.g., diabetes) that occurs after initiation of the 
investigational study whether or not it is considered to be related to the investigational product. 
A worsening of an existing medical condition is one that was present at Day 1 (e.g., diabetes) 
and became more severe, more frequent, or increased in duration during investigational product 
treatment. Clinically relevant abnormal results of diagnostic procedures including abnormal 
laboratory findings (e.g., requiring unscheduled diagnostic procedures or treatment measures, or 
resulting in withdrawal from the study) are considered to be AEs. 
All adverse events (AEs) will be recorded throughout the study, beginning when the subject 
signs the Informed Consent Form. 
A treatment-emergent adverse event (TEAE) is defined as any AE starting after the first dose of 
the investigational agent or placebo is administered. If the AE is present prior to the 
administration of the first dose of the investigational agent or placebo but increases in severity, it 
will also be considered a TEAE. 
Treatment-emergent adverse events will be recorded beginning with the first exposure to 
investigational product and continuing until the subject is discharged from the study due to 
completion or early termination. 
Adverse events will be categorized as local adverse events and as systemic adverse events. 
The Principal Investigator, or medically qualified designee, must completely and promptly 
record each AE on the appropriate CRF. The Principal Investigator should attempt, if possible, to 
establish a diagnosis based on the presenting signs and symptoms. In such cases, the diagnosis 
should be documented as the AE and not the individual sign/symptom. If a clear diagnosis 
cannot be established, each sign and symptom must be recorded individually. Once a diagnosis is 
established, the CRFs should be updated with the final diagnosis. 
Any adverse event ongoing at the time of study completion will be recorded and followed-up 
according to the safety procedures described in the following sections. 
9.1 
Reporting and Following Adverse Events 
All AEs encountered during the study will be reported on the AE page of the CRF in a timely 
manner. All AEs should be followed in accordance with good medical practice until resolved or 
fully characterized. 
Serious adverse events: Section 9.4 presents the definition and reporting obligations for Serious 
Adverse Events (SAEs). After the initial report, a follow-up SAE Report Form should be filled 
out and sent to Medpace Clinical Safety within 24 hours. Updates are to be provided by the site 
as soon as relevant information (especially regarding outcome) is available. 
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9.2 
Severity 
The Investigator must indicate the severity of the adverse event in the description of the adverse 
event. A severity category of mild, moderate, or severe, as defined below, should be determined 
and entered on the Adverse Events page of the Case Report Form (CRF). 
 
Mild (Grade 1): Transient or mild symptoms; no limitation in activity; no intervention 
required. The AE does not interfere with the participant’s baseline functioning level. It 
may be an annoyance. 
 
Moderate (Grade 2): Symptom results in mild to moderate limitation in activity; no or 
minimal intervention required. The AE produces some impairment of baseline 
functioning, but it is not hazardous to health. It is uncomfortable or an embarrassment. 
 Severe (Grade 3): Symptom results in significant limitation in activity; medical 
intervention may be required. The AE produces significant impairment of functioning or 
incapacitation. 
 Potentially Life-Threatening (Grade 4): Symptoms cause inability to perform basic self-
care functions immediately necessary to sustain life or require medical or operative 
intervention to prevent permanent impairment, persistent disability or death. 
9.3 
Relationship to Clinical Trial Material 
The Investigator must document their opinion of the relationship of the event to the 
investigational product as follows: 
 
NONE: The event can be readily explained by the subject’s underlying medical condition, 
a concomitant therapy or other cause and the Investigator believes no relationship exists 
between the event and the investigational product. In this case, the Investigator should 
document the condition, concurrent/underlying illness, medication, study procedure or 
other cause they believe to be the cause of the adverse event. 
 
UNLIKELY: The event does not follow a reasonable temporal sequence from 
administration of the investigational product nor does the event follow a known or expected 
response pattern to the investigational product and may have another cause. In this case, 
the Investigator should document the condition, concurrent/underlying illness, medication, 
study procedure or cause they believe may have contributed to the adverse event. 
 
POSSIBLE: The subject’s condition, concurrent/underlying illness, medication, or study 
procedures cannot explain the event, and there is a plausible temporal relationship 
between the event and the investigational product administration. 
 PROBABLE: The temporal relationship between the administration of the investigational 
product and the adverse event strongly suggests a relationship, and/or the adverse event 
cannot be reasonably explained by another condition, concurrent/underlying illness, 
medication, study procedure or other cause, or the adverse event abates with 
discontinuation of the investigational product, and recurs with re-administration. 
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9.4 
Serious Adverse Events 
To report SAEs in a timely manner, monitor subject care, and to fulfill regulatory requirements, 
SAEs (regardless of their relationship to the investigational product) must be reported to 
Medpace Clinical Safety within 24 hours of knowledge of the event by the Investigator or 
members of the study staff.  
9.4.1 
Definition 
SAEs are defined as those adverse events that meet any of the following criteria: 
 
Life threatening, that is, any event that, in the opinion of the Investigator, poses an 
immediate risk of death from that event 
 
Results in death 
 
Results in or prolongs hospitalization 
 
Results in persistent or significant disability/incapacity 
 
Results in congenital anomaly/birth defect 
In addition, events which may not meet these criteria, but, in the opinion of the Investigator, are 
very unusual, potentially serious, or require medical or surgical intervention to prevent one of the 
outcomes listed above, should also be reported in the same manner as events which meet the 
serious adverse event criteria.  
9.4.2 
Reporting 
Serious AEs require immediate reporting (within 24 hours of the site’s knowledge of the event) 
to Medpace Clinical Safety whether or not the Investigator believes that the experience is related 
to the investigational product. A completed SAE CRF signed by the Investigator must be faxed 
to Medpace Clinical Safety. Criteria for documenting the relationship to study product and 
severity will be the same as those previously described in Sections 9.2 and 9.3. 
SAEs must also be reported by the study site to the responsible IRB immediately. The 
Investigator is responsible for complying with the local IRB regulations regarding the reporting 
of AEs. 
Reporting of a suspected SAE should not be delayed in order to obtain additional information. 
Any additional information, if collected, can be reported as a follow-up to the initial report. Any 
SAE that occurs at any time during the study, whether or not related to the investigational 
product, must be reported to Medpace Clinical Safety.  
All possibly- and probably-related serious adverse events must be followed until the outcome is 
known or the event is otherwise explained. All serious adverse events that are not resolved at the 
end of the study are to be followed until resolution, the condition stabilizes, the event is 
otherwise explained, or the subject is lost to follow-up.  
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9.5 
Pregnancies 
Pregnancies occurring after the first dose of investigational product are considered immediately 
reportable events. While not considered a serious adverse event unless a serious criterion is met, 
pregnancies occurring in subjects enrolled on the study must be reported and followed to 
outcome. The investigator should complete the pregnancy report form and fax it to Medpace 
Clinical Safety within one working day of knowledge of the pregnancy. Following delivery or 
termination of pregnancy, the follow-up pregnancy report form should be completed and 
submitted via fax to Medpace Clinical Safety. Spontaneous abortions should always be reported 
as SAEs. Follow-up information regarding the outcome of the pregnancy and any postnatal 
sequelae in the infant will be required. 
9.6 
Data Review Committee (DRC) 
An independent Data Review Committee will be established to review unblinded clinical trial 
data prior to dose escalation and on an as-needed basis. This DRC will include a Statistician, an 
orthopedic surgeon and a Medical Safety Officer. An independent statistician, serving as a non-
voting member to the DRC, will provide data preparation support to the DRC.  
The primary role of the DRC will be to assess unblinded safety data on all patients in a dose 
cohort completing the Week 6 visit, and to determine whether dose escalation should occur. The 
DRC may recommend dose escalation, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
The DRC will also be asked to assess unblinded safety data on an as-needed basis. The Chair of 
the DRC will be informed by Microbion Corporation of the potential need for ad hoc meetings 
and will coordinate any ad hoc meeting with the remainder of the DRC members. The DRC may 
recommend no modifications to the study, specific modification to the study protocol, or study 
termination. In each case, the recommendation will be provided to Microbion Corporation for 
final disposition. 
A formal DRC Charter will be prepared and finalized prior to study enrollment. The DRC will 
meet prior to initiation of the clinical trial in order to review, revise and reach concurrence on the 
content of a DRC charter. The draft charter will be provided by Microbion Corporation to the 
DRC prior to the initial meeting. 
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 INVESTIGATIONAL PRODUCT MANAGEMENT 
10.1 Study Drug 
Three successive doses (0.025, 0.075, or 0.25 mg/mL w:v) of MBN-101 (up to 8 mL, for a dose 
of up to 0.2, 0.6, or 2.0 mg, respectively) or placebo (diluent) will be studied.  
The MBN-101 Kit for administration to patients randomized to treatment with MBN-101 will 
contain the following: 
1. One 5 mL clear glass vial of MBN-101 containing 2.5 mL of sterile 2.5 mg/mL 
MBN-101 (“Stock Formulation”) rubber stoppered and sealed. 
2. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed (“Diluent”). 
3. Sterile polypropylene syringe (1 mL) and 15 gauge needle(s) for preparation of 
Treatment Dose by dilution of Stock Formulation with Diluent in the clinical site 
pharmacy. 
4. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product (Treatment Dose) in the operating room. 
5. Alcohol wipes 
6. Detailed directions-for-use (DFU) for preparation of the specified concentration of drug 
product for each cohort (“Treatment Dose”). 
The Placebo Kit for administration to patients randomized to treatment with Placebo will contain 
the following: 
1. One 20 mL clear glass vial of MBN-101 diluent containing 9 mL sterile diluent solution 
rubber-stoppered and sealed. 
2. Sterile 10 mL polypropylene syringe and 14 gauge needle for administration of diluted 
drug product in the operating room. 
3. Alcohol wipes 
4. Detailed directions-for-use (DFU) for preparation of the target dose (“Treatment Dose” 
Additionally each clinical site will be provided with a vortex mixer designated to be used for 
dilution and resuspension of Stock Formulation and of the final Treatment Dose preparation. 
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10.2 Study Drug Packaging and Labeling 
All shipments of the investigational product will be accompanied by an inventory form. The 
contents of the shipments should be inventoried immediately upon receipt and confirmation of 
inventory shall be performed according to instructions provided by the clinical supplies 
distributor. 
The following information will be provided with each shipment of study drug: Sponsor name and 
contact information (telephone number), study protocol number, description of the contents of 
the container, conditions for storage, and a statement regarding the investigational (clinical trial) 
use of the study drug.  
Each package unit of the investigational product will be labeled with the following information: 
Sponsor name, study protocol number, description of the contents, a statement regarding the 
investigational (clinical trial) use of the study drug, and a packaging lot number.  
10.3 Study Drug Storage 
The investigational product should be kept in a limited-access area at 15-30 degrees C at the 
study site.  
10.4 Study Drug Accountability 
It is the responsibility of the Principal Investigator or his/her designee at each site to ensure that 
all investigational product quantities received at the site will be inventoried and reconciled 
throughout the study and the result recorded on the drug accountability form maintained in the 
study file. 
10.5 Study Drug Handling and Disposal 
Only qualified study personnel familiar with procedures that minimize undue exposure to 
themselves and to the environment should undertake the handling of pharmaceutical agents. 
The study monitor will verify that the disposition of all investigational materials at the trial site is 
in accordance with Sponsor specifications and applicable regulatory requirements. Requirements 
for disposition of used, unused, damaged/quarantined, and expired investigational materials will 
be provided to applicable site personnel. The study monitor will confirm associated 
documentation is filed in the Investigator site file and copies retrieved for the Sponsor or 
Sponsor-designee Investigator File. 
Used, damaged, and expired investigational materials will be destroyed as directed by the Study 
Monitoring Plan. Specific instructions of on-site destruction, return of materials to a 3rd party 
vendor, or any other mechanism of removal of the investigational materials from the site will be 
detailed in the Study Monitoring Plan. 
The study monitor will not take possession of investigational materials. Any deviations from this 
process must be approved in advance by the Sponsor or Sponsor-designee.  
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 GENERAL CONSIDERATIONS 
11.1 Basic Principles 
This research will be carried out in accordance with the clinical research guidelines established 
by the Basic Principles defined in the U.S. 21 CFR Parts 50, 56, and 312, the principles 
enunciated in the Declaration of Helsinki concerning medical research in humans (“Ethical 
Principles for Medical Research Involving Human Subjects,” Helsinki 1964, amended Tokyo 
1975, Venice 1983, Hong Kong 1989, Somerset West 1996, Edinburgh 2000 and clarifications, 
Washington 2002 and Tokyo 2004), and the Good Clinical Practice (GCP) guidelines of the 
International Conference on Harmonization (ICH) of the Technical Requirements for 
Registration of Pharmaceuticals for Human Use, ICH E6 (May 1996). 
11.2 Institutional Review Board 
Prior to initiation of any study procedures, the Clinical Study Protocol, Informed Consent Form, 
and Product Information will be submitted to the IRB for review and approval. In addition, any 
amendments to the protocol or informed consent document will be reviewed and approved (if 
necessary) by the IRB. The Principal Investigator (PI) at each clinical site assumes responsibility 
for ensuring that the protocol is submitted to the IRB for any required periodic review. The PI 
must receive a letter documenting the IRB approval at the clinical site prior to the initiation of 
the study. Any subsequent IRB correspondence must also be submitted to the investigator. The 
Investigator is responsible for providing the appropriate reports to the reviewing IRB during the 
course of the clinical study. This will include the following: 
 Informing the IRB of the study progress periodically as required, but at least annually 
 Reporting any unanticipated adverse product per IRB Policies & Procedures 
 Reporting any deviations from the clinical protocol to protect the life or well-being of a 
subject in the case of an emergency within 5 working days after the emergency occurred 
 Providing any other reports requested by the IRB 
After the final visit of the last subject, a final report will be sent to the IRB per their Policies & 
Procedures that includes a summary of the results of the study by the PI. 
The IRB must be constituted and operate in accordance with the principles and requirements 
described in the U.S. Code of Federal Regulations (21 CFR Part 56). 
11.3 Informed Consent 
The purpose of the study, the procedures to be carried out and the potential hazards will be 
described to the subjects in non-technical terms. Subjects will be required to read and sign a 
consent form summarizing the discussion prior to enrollment, and will be assured that they may 
withdraw from the study at any time without jeopardizing their medical care. 
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11.4 Study Termination 
The Investigator reserves the right to terminate the study in the interest of subject safety and 
welfare. The Sponsor reserves the right to terminate the study at any time for administrative 
reasons. 
11.5 Regulatory Documentation 
Documents that must be provided to the Sponsor prior to study drug shipment are as follows: 
 Up-to-date curriculum vitae for each investigator and sub-investigator 
 Signed and dated Investigator Agreement 
 Applicable local regulatory documentation (e.g., FDA 1572 Form) 
 A copy of the formal written notification to the investigator regarding approval of the 
protocol by an IRB that is in compliance with regulatory guidelines. The written 
notification is to be signed by the chairman or authorized designee and must identify the 
specific protocol. In cases where an IRB member has a known conflict of interest, 
abstention of that individual from voting should be documented; an investigator 
(or sub-investigator) may be a member of the IRB, but may not vote on any research in 
which he or she is involved. 
 Name and address of the IRB with a statement that it is organized and operates according 
to GCP and the applicable laws and regulations, and a current list of the IRB members. 
If accompanied by a letter of explanation from the IRB, a general statement may be 
substituted for this list. 
 A copy of the IRB approved informed consent form and other adjunctive materials 
(e.g., advertising) to be used in the study, including written documentation of IRB 
approval of these items. 
 Name and address of any local laboratory conducting tests for the study, a dated copy of 
the laboratory reference values for tests to be performed during the study and a copy of 
the certification or other documentation establishing adequacy of the facility. 
 Required financial agreement. 
In addition to the documents required prior to the study, other documentation may be required 
during the course of the study. 
11.6 Study Documentation 
All documents pertaining to the study, including a copy of the approved protocol, copy of the 
Informed Consent Form, and case report forms, will be retained in the permanent archives of the 
study site. These will be available for inspection at any time by the Sponsor or the U.S. Food and 
Drug Administration (FDA). 
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11.7 Data Handling and Record Keeping 
As electronic trial data handling and/or remote electronic trial data systems will be used, 
Microbion will: 
 Ensure and document that the electronic data processing system(s) conforms to the 
Sponsor’s established requirements for completeness, accuracy, reliability, and consistent 
intended performance 
 Maintain SOPs for using these systems 
 Ensure that the systems are designed to permit data changes in such a way that the data 
changes are documented and that there is no deletion of entered data (i.e., maintain an 
audit trail, data trail, edit trail) 
 Maintain a security system that prevents unauthorized access to the data 
 Maintain a list of the individuals who are authorized to make data changes 
 Maintain adequate backup of the data 
 Safeguard the blinding, if any (e.g., maintain the blinding during data entry and 
processing) 
 An unambiguous subject identification code will be used that will allow identification of 
all the data reported for each subject 
 Microbion will retain all of the Sponsor-specific essential documents pertaining to the 
trial in conformance with the applicable regulatory requirement(s) of the country(ies) 
where the product is approved and/or where it intends to apply for approval  
 Specific essential documents will be retained until at least 2 years after the last approval 
of a marketing application in an ICH region and until there are no pending or 
contemplated marketing applications in an ICH region or at least 2 years have elapsed 
since the formal discontinuation of clinical development of the investigational product. 
These documents should be retained for a longer period, however, if required by the 
applicable regulatory requirement(s) or if needed by the Sponsor. 
 Microbion will inform the investigator(s)/institution(s) in writing of the need for record 
retention and should notify the investigator(s)/institution(s) in writing when the trial 
related records are no longer needed 
11.8 Use of Information and Publication 
All information concerning BisEDT, MBN-101, MBN-101 diluent, Microbion operations, patent 
applications, formulas, manufacturing processes, basic scientific data, and formulation 
information, supplied by the Sponsor to the investigator and not previously published, is 
considered confidential and remains the sole property of Microbion Corporation. The 
investigator agrees to use this information only to accomplish this study and will not use it for 
other purposes without the Sponsor’s written consent. 
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The investigator understands that the information developed in the clinical study will be used by 
Microbion in connection with the continued development of MBN-101 and BisEDT, and thus 
may be disclosed as required to other clinical investigators or government regulatory agencies. 
To permit the information derived from the clinical studies to be used, the investigator is 
obligated to provide the Sponsor with all data obtained in the study. 
Any publication or other public presentation of results from this study requires prior review and 
written approval of Microbion Corporation. Draft abstracts, manuscripts, and materials for 
presentation at scientific meetings should be provided to the Sponsor at least 30 working days 
prior to abstract or other relevant submission deadlines. Authorship of publications resulting 
from this study will be based on generally accepted criteria for major medical journals. 
11.9 Independent Medical Monitor 
In accordance with US Army Medical Research and Materiel Command (USAMRMC) and 
Department of Defense (DOD) requirements, an independent medical monitor will be identified. 
The independent medical monitors should be physicians, dentists, psychologists, nurses, or other 
healthcare providers capable of overseeing the progress of research protocols, especially issues 
of individual volunteer management and safety. Medical monitors must be independent of the 
investigative team and possess sufficient educational and professional experience to serve as the 
volunteer advocate. Depending on the nature of the study, the medical monitor may be assigned 
to assess one or more of the following phases of research project: volunteer recruitment, 
volunteer enrollment, data collection, or data storage and analysis. The medical monitor provides 
an independent evaluation of serious adverse events and unanticipated problems involving risk to 
subjects or others to the IRB and the Office of Research Protections (ORP). The medical monitor 
may be assigned to discuss research progress with the PI, interview volunteers, consult on 
individual cases, or evaluate adverse event reports. The medical monitor must promptly report 
discrepancies or problems to the IRB and the ORP. They shall have the authority to stop a 
research study in progress, remove individual volunteers from a study, and take whatever steps 
are necessary to protect the safety and well-being of research volunteers until the IRB can assess 
the medical monitor report. 
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 STATISTICAL ANALYSIS METHODOLOGY 
A formal statistical analysis plan (SAP) will be prepared and finalized before database lock for 
the final analysis for the study report. The SAP will provide details regarding the definition of 
analysis subjects (populations), analysis variables and analysis methodology to meet all study 
objectives. 
The principle and key elements of the SAP are provided as follows: 
In general, safety and efficacy data will be summarized with descriptive statistics, including 
means, standard deviations, medians, minimums and maximums for continuous variables, the 
number of subjects and percent in each category for categorical variables.  
Data from all subjects randomized and treated with placebo in each cohort will be pooled for the 
analysis; data from the subjects randomized and treated with MBN-101 will be presented by dose 
as well as combined.  
Data from each individual will be tabulated as appropriate. Efficacy and safety endpoints will be 
tabulated by treatment group and time point.  
12.1 Efficacy Endpoints 
Clinical activity of locally administered MBN-101 will be assessed by: 
 Proportion of treatment failures. A treatment failure is defined as a subject with 
non-healing or worsening status of their surgical site requiring serious intervention by 
Week 24. 
Cumulative number of serious interventions (as defined in Section 12.6.2) at Week 24. 
 Time to first serious intervention, time to readmission and time to reoperation, exclusive 
of serious interventions, readmissions, and reoperations associated with a healed fracture 
site.  
 Number of subjects undergoing removal of stabilizing orthopedic hardware due to a 
healed fracture site by Week 24. 
 Time to removal of orthopedic hardware due to a healed fracture site. 
 Incidence and intensity of surgical site signs and symptoms, including local erythema, 
induration, drainage and degree of healing. 
 Change from baseline in patient-reported outcomes at each post baseline time point. 
Patient-reported outcomes will include Veterans Rand 12 Item Health Survey (VR-12) 
and Short Musculoskeletal Function Assessment (SMFA). 
 Surgical site pain score and change from baseline in pain score at each post baseline time 
point. Pain intensity at the surgical site will be assessed by Visual Analog Scale (VAS, 
0-100 mm).  
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 Findings of microbiology evaluations at the surgical site. Microbiologic success is 
assessed by clearance of infection. 
 Findings of radiographic evaluations at the surgical site. Radiographic success is assessed 
by healing on radiologic examination.  
12.2 Changes in serologic markers CRP and ESR at each post baseline time 
point.Safety Endpoints 
The safety and tolerability of locally administered MBN-101 will be assessed by: 
 Treatment-emergent adverse events. 
 Treatment-emergent serious adverse events. 
 Changes in clinical laboratory tests (clinical chemistry, hematology, and urinalysis). 
 Changes in vital signs (blood pressure, pulse, respiratory rate and body temperature). 
 Changes in physical exams. 
 Clinical findings of 12-lead electrocardiograms. 
 Change in microbiology status. 
12.3 Sample Size Considerations 
Sample size for this study was chosen empirically for the purpose of the study without any 
formal statistical hypothesis to be tested. 
Nine subjects will receive active drug in each dose cohort. With 9 subjects receiving active drug, 
the probability of observing at least one of 9 subjects in a dose cohort exhibiting an AE of a 
specific type is 95% if the true background incidence rate for that event-type were approximately 
0.283 or greater. Hence, if an AE of a specific type is not observed in the study in a sample size 
of 9 subjects receiving active study drug at a given dose, one would “rule-out” this AE as having 
an incidence rate of more than 0.283 with 95% confidence. 
Similarly, if a rare event of interest is not reported in the 27 subjects treated with the active study 
drug, one could conclude that the rate of the event would be 0.105 or less with 95% confidence. 
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12.4 Analysis Datasets 
The following analysis datasets will be identified for the purpose of analysis:  
Screened Subjects: All subjects who signed informed consent for the study will be included in 
the Screened Subjects analysis set. 
Randomized Subjects: All subjects who were randomized in the study will be included in the 
Randomized Subjects analysis set. A randomized subject may or may not be treated with the 
assigned study drug. This is the classic Intent-to-Treat (ITT) analysis set. 
Treated Subjects: All subjects who received any amount of study drug (active or placebo) will be 
included in the Treated Subjects analysis set. All treated subject will be included in the safety 
analysis. This analysis set is also referenced as the Safety Analysis Set. 
Modified Intent-to-Treat (mITT) Subjects: the ITT subjects who received any amount of study 
(active or placebo) and have at least one post-treatment assessment will be included in the mITT 
analysis set. The mITT analysis set is the primary dataset for efficacy analysis. 
PK Concentration Subjects (i.e., PK Concentration Population): The PK Concentration 
Population will include all subjects with any measurable bismuth blood concentrations. 
PK Evaluable Subjects (i.e., PK Evaluable Population): The PK Evaluable Population will 
include all subjects providing sufficient measurable bismuth blood concentrations to facilitate 
determination of PK parameters. 
In the event that a subject received study drug treatment that is not the assigned/randomized 
treatment group, the subject has a major protocol deviation. The subject, however, will be 
included in the analysis for safety and efficacy in the actual treatment group received.  
Subjects randomized but not treated for any reason will be included in the disposition tabulation 
and will be excluded from the safety and efficacy analysis.  
12.5 Disposition and Study Population Characteristics 
Disposition summaries will be prepared to include number and percent of subjects screened, 
randomized, treated, subjects that completed the study and reason for discontinuation. Reason for 
screening failure will also be tabulated.  
Subject characteristics summaries will include demographics (age, gender, race, and ethnicity), 
baseline characteristics (weight, height, BMI), surgery site characteristics (type of injuries, type 
of fraction fixation, surgical site location), microbiology analysis results, time from previous 
surgery to study enrollment, and type of previous treatment), current surgery characteristics 
(area of the osteosynthesis site, with or without hardware replacement, etc.), and medical history.  
Disposition summary will be based on randomized treatment group (i.e., planned treatment) 
whereas the baseline characteristics summaries will be based on the actual treatment group.  
Subjects with protocol deviations will be identified. The nature of the deviation and potential 
impact on the deviation on study outcome will also be assessed.  
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12.6 Efficacy Analysis 
12.6.1 
Treatment Failure 
A treatment failure is defined as a subject with non-healing or worsening status of their surgical 
site requiring serious intervention by Week 24. 
The number of subjects meeting treatment failure criteria during the study will be tabulated by 
treatment group. If data permit, the difference in proportion of treatment failures between the 
groups and the corresponding 95% confidence intervals for the difference will be presented. 
Fisher’s exact test may be used to test the difference between the groups; difference in rates and 
95% confidence intervals for the relative risk will be derived. Dose-response assessment may be 
performed. 
12.6.2 
Incidence of Serious Interventions  
All interventions meeting the following criteria are serious interventions: 
 Initiation of antibiotic treatment in patient not previously on antibiotics 
 Change in the route of antibiotic administration from oral to intravenous for escalation of 
treatment 
 Change in the type or dosage of antibiotic drug for escalation of treatment 
 Readmission (exclusive of readmissions associated with a healed fracture site) 
 Reoperation (exclusive of reoperations associated with a healed fracture site) 
The number of subjects with at least one serious intervention (exclusive of serious interventions, 
readmissions, and reoperations associated with a healed fracture site) and total number of serious 
interventions will be tabulated for the following periods:  
 duration of the study;  
 within the first 4 weeks after the surgery; 
 from week 4 to week 8 
 from week 8 to week 12  
 from week 12 to week 24 
The difference between the placebo arm and the active arms will be evaluated as follows if data 
permits: Fisher’s exact test may be used to test the difference between the groups; difference in 
rates and 95% confidence intervals for the relative risk will be derived.  
Similar summaries will be prepared for incidence of re-admission and incidence of re-operation. 
Time elapsed between the initial hospital discharge to hospital readmission and between the 
operations will be derived and tabulated.  
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12.6.3 
Time to First Serious Interventions  
Time to the first serious intervention exclusive of serious interventions, readmissions, and 
reoperations associated with a healed fracture site will be derived. Time to first serious 
intervention will be calculated as the number of study days from the study surgery date to the 
event onset date plus 1. Subjects who do not have any serious intervention will be censored to 
the last observation date. 
No formal inferential statistics will be carried out for this endpoint. 
12.6.4 
Subjects Undergoing Removal of Stabilizing Orthopedic Hardware 
The number of subjects undergoing removal of hardware due to a healed fracture site and the 
time to removal of hardware due to a healed fracture site will be derived. Time to removal of 
hardware will be calculated as the number of study days from the study surgery date to the event 
date plus 1.  
12.6.5 
Surgical Site Signs and Symptoms 
The surgical site will be examined for local erythema, induration, drainage and degree of 
healing. 
Subjects with non-healing or worsening status of their surgical sites will be tabulated. 
12.6.6 
Patient-Report Outcomes 
12.6.6.1 
The Veterans RAND 12 Item Health Survey (VR-12) Questionnaire  
The Veterans RAND 12 Item Health Survey (VR-12) is a brief, generic, multi-use, self-
administered health survey comprised of 12 items. The instrument is primarily used to measure 
health related quality of life, to estimate disease burden and to evaluate disease-specific 
benchmarks with other populations. The 12 items in the questionnaire correspond to eight 
principal physical and mental health domains including general health perceptions; physical 
functioning; role limitations due to physical and emotional problems; bodily pain; energy-
fatigue, social functioning and mental health (Selim, 2009; Veterans Affairs website, 2014). 
VR-12 total score, physical health domain score (PCS), and mental health domain score (MCS) 
will be tabulated by visit; change from baseline in total score, physical health domain score and 
mental health domain score will also be derived and tabulated.  
12.6.6.2 
The Short Musculoskeletal Function Assessment Questionnaire (SMFA) 
The 46-item SMFA questionnaire comprises two parts: the dysfunction index with 34 items and 
the bother index with 12 items. The dysfunction index assesses the patients perceptions of the 
amount of difficulty they have in the performance of certain functions (25 items) and how often 
the patients have difficulty when performing certain functions (9 items). The dysfunction items 
are grouped into four categories: daily activities, emotional status, function of the arm and hand, 
and mobility. Each item has a 5-point response format (1 point for good function and 5 points for 
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poor function). The bother index asks the patients to assess how much they are bothered by 
problems in various areas of life (e.g., recreation, work, sleep and rest). These items also have a 
5-point response format (1 point for not at all bothered and 5 points for extremely bothered). 
The scores of the dysfunction and the bother indices are calculated by summing up the responses 
to the items and then transforming the scores according to the formula: (actual raw score - lowest 
possible raw score)/(possible range of raw score) ×100. 
This transformation formula gives the final scores, which ranged from 0 to 100. The higher 
scores indicate poorer function. In the case of the dysfunction index, unanswered items in a 
category are replaced by the individual’s mean score for that category, as long as more than 
50 per cent of the items in that category have been answered. Substitution with the mean is not 
appropriate for the bother index as each item addresses a unique area of function (Swiontkowski, 
1999; Short Musculoskeletal Function Assessment Injury and Arthritis Survey, 
www.grossortho.com/forms/injury.pdf). 
SMFA results and change from baseline will be summarized by visit and treatment group with 
descriptive statistics. 
12.6.7 
Pain Assessments 
Surgical site pain score utilizing a 24 hour recall will be assessed via Visual Analog Scale (VAS) 
(Burckhardt, 2003; Brokelman, 2012; Briggs, 1999) at baseline, and Weeks 2, 6, 12, and 24. 
Change in pain from baseline will be derived; observed pain score and change from baseline will 
be tabulated by visit and treatment group. 
12.6.8 
Microbiology 
Microbiology will be assessed at baseline and at the time of any subsequent surgical procedure at 
the index site. The presence of viable microorganisms will be determined by standard 
microbiological culture methods and include speciation and antimicrobial susceptibility testing 
of any bacterial isolates found (see flowchart, Appendix 2). Samples collected will include at 
least one tissue site (eraser head size; suitable for dividing into two samples) from the fracture 
site (if accessed) or involved tissue adjacent to the implant(s), two swabs of the infected 
hardware (in situ or ex vivo), two swabs of the deep infection site, and two swabs of the 
superficial tissue/wound closure site when possible. Duplicate specimens will be transported 
aerobically and anaerobically, respectively. Specimens will be processed by the local laboratory 
and the central laboratory as presented in Sections 6.1.9.3 and 6.1.9.2. 
Microorganisms isolated from each assessment will be listed. This information may also be used 
to identify potential subgroups. 
Microbiological success is assessed by clearance of infection. The proportion of subjects that 
meet the treatment success criteria per microbiologic evaluations will be identified and tabulated 
by each treatment group. 
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12.6.9 
Radiographic evaluation 
Radiographic evaluation will be performed at baseline and Weeks 2, 6, 12, and 24. 
Radiographic success is assessed by healing on radiographic examination. The proportion of 
subjects that met the treatment success criteria per radiographic examination will be identified 
and tabulated by each treatment group. 
12.6.10 Serologic Markers 
Serology markers CRP and ESR will be assessed at baseline and Weeks 2, 6, 12, and 24. 
Serology markers CRP and ESR have been used together with clinical signs and symptoms for 
periprosthetic infection diagnosis. The values for each serologic marker and the number of 
subjects with normal or abnormal serologic marker values at each visit will be tabulated by 
treatment group.  
12.6.11 Subgroup Analyses for Efficacy Endpoints 
If data permit, the following potential covariates will be identified and subgroup analysis may be 
performed for those subgroups. 
1. 
Area of the osteosynthesis site 
2. 
Method of fracture fixation 
3. 
Type of infection (per identified microorganism) 
4. 
Anatomic location of the surgery site 
5. 
Hardware retention status (retained vs. exchanged) 
6. 
Influence of host factors 
7. 
Method of wound closure / wound management 
12.6.12 Sensitivity Analyses for Efficacy Endpoints 
The primary efficacy analysis set (mITT) will included all randomized subjects who received 
any amount of study drug and have at least one post-treatment assessment. In addition, in the 
event that a subject received treatment that is different from the assigned treatment, the subject 
will be included in the actual treatment received in the mITT analysis. 
An ‘as assigned’ analysis will be performed on the mITT subjects as a sensitivity analysis for the 
primary efficacy endpoint. In this analysis, subjects who received a treatment that is not the 
assigned treatment will be included in the ‘assigned’ treatment group for this analysis. 
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12.7 Safety Analysis 
12.7.1 
Study Drug Exposure and Concentrations 
Study drug exposure will be presented by treatment group. Descriptive statistics will be provided 
without any formal inferential statistics.  
12.7.2 
Adverse Events 
The Medical Dictionary for Regulatory Activities (MedDRA Version 16 or higher) will be used 
to classify all AEs with respect to system organ class (SOC) and preferred term. Summary of 
adverse events will include: 
1. Treatment emergent adverse events by SOC, preferred term, and intensity 
2. Treatment emergent adverse events by SOC, preferred term, and relationship to study 
drug  
3. All AEs leading to study discontinuation by SOC and preferred term 
4. All serious adverse events by SOC and preferred term 
Summary tables will provide total number of events and number of subjects with the event. 
The incidence and intensity of each pre-specified local AEs will be tabulated by visit and 
treatment groups. 
12.7.3 
Clinical Laboratory Tests 
Laboratory includes hematology, serology, serum chemistry, and urinalysis; laboratory collected 
prior to surgery will be the baseline laboratory. The study will utilize local lab for all clinical 
laboratory testing. Laboratory data will be tabulated based on the following result class. 
 Normal: result is within the local lab normal range 
 Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each lab test without formal inferential statistics. If data permits shift 
in result class from baseline to post baseline may also be tabulated. 
12.7.4 
12-lead ECG 
ECG findings at each time point will be tabulated by treatment group without inferential 
statistics. 
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12.7.5 
Vital Sign Measurements 
Vital signs collected immediately prior to receiving study drug will be the baseline vital signs. 
Observed vital sign values and change from baseline in vital signs at each visit will be 
summarized without formal statistical testing. 
Vital sign result may also be tabulated based on the following result class. 
 Normal: result is within the normal range 
 Abnormal: result is either higher or lower than the normal range 
All abnormal values will be assessed for clinical significance; clinical significance will be 
captured in the case report form. Number and percent of subjects within each result class will be 
tabulated by time point for each vital sign. 
12.7.6 
Physical Examinations  
Findings of physical examinations will be tabulated by treatment groups without inferential 
statistics. 
12.7.7 
Subgroup Analyses for Safety Endpoints 
No subgroup analysis is planned for safety endpoints. 
12.8 PK Analysis 
Blood bismuth concentration vs. time profiles after administration of MBN-101 will be 
summarized for each nominal sampling time point and by dose group using descriptive statistics 
generated by WinNonlin. The NCA PK parameters (AUC0-t, AUC0-inf, Tmax, Cmax, T1/2, CL/F, 
Vz/F) will also be summarized with descriptive statistics (generated by WinNonlin) for each dose 
group as well as for all treated subjects in the PK Evaluable Population. 
If data permit, the correlation between Bismuth concentration and efficacy and/or safety 
endpoints may be explored. 
12.9 Interim Evaluation 
Interim analyses are planned for this study for the purpose of DRC. The purpose of the interim 
analysis is to allow the DRC to review the data and to make recommendation to the Sponsor on 
whether or not the next cohort of the subjects should be studied as planned.  
An analysis plan for the DRC will be prepared as an appendix of the DRC charter. The scope of 
the interim analyses for the DRC will be defined in this analysis plan. 
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22. Robson MC. Wound infection. A failure of wound healing caused by an imbalance of 
bacteria. Surg Clin North Am. 1997;77(3):637-50. 
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25. Schmidt AH, Swiontkowski MF. Pathophysiology of infections after internal fixation of 
fractures. Journal of the American Academy of Orthopaedic Surgeons. 2000;8(5):285-91. 
26. Selhi HS, Mahindra R, Yamin M, Jain D, De Long WG, Singh J. Outcomes in patients with 
an infected nonunion of the long bones treated with a reinforced antibiotic cement rod. 
J Orthop Trauma. 2012;26(3):184-8. 
27. Selim AJ, Rogers W, Fleishman JA, Qian SX, Fincke BG, Rothendler JA, Kazis LE. 
Updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12). 
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28. Short Musculokeletal Function Assessment Injury and Arthritis Survey; 
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29. Swiontkowski MF, Engelberg R, Martin DP, Angel J. Short musculoskeletal function 
assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am. 
1999;81(9):1245-60. 
30. Tosh PK, McDonald LC. Infection control in the multidrug-resistant era: tending the human 
microbiome. Clin Infect Dis. 2012;54(5);707-13. 
31. Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic only versus 
local intrawound vancomycin antibiotic powder application in addition to intravenous 
antibiotics on postoperative infection in spine surgery in 907 patients. Spine (Phila Pa 1976), 
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32. U.S. Department of Veterans Affairs [internet]. Washington: U.S. Department of Veterans 
Affairs; last updated 21 January 2014. Health Economics Resource Center: Cost-Effective 
Analysis. Available from: http://www.herc.research.va.gov/include/page.asp?id=cost-
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33. Zalavras CG Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop 
Surg. 2003;11(3):212-9. 
 
 
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 APPENDICES 
Appendix 1: 
Table of Study Events ............................................................................................61 
Appendix 2: 
 Flowchart for Microbiological Specimen Processing ...........................................62 
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Appendix 1: Table of Study Events 
 
 
Procedure 
Screening 
Baseline/ 
Day of Surgery 
Hour 48- 60 
Hour 72 
Hour 96 
Week 2 
Week 6 
Week 12 
Week 24, EOT 
Early Term / 
Tx Failure 
Day 1 
Day 2 
Day 3 
Day 4 
Day 14 
±2 days 
Day 28 
±8 days 
Day 84 
±8 days 
Day 168 
±8 days 
Review of eligibility criteria 
X 
X 
 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
Surgery/Administration of the 
Investigational Product 
 
X 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
 
 
 
 
Interval physical exam 
 
X 
X 
 
 
X 
X 
X 
X 
X 
Hematology 
X 
 
X 
 
 
 
X 
X 
X 
X 
Serology 
 
X 
 
 
 
X 
X 
X 
X 
X 
Serum chemistry 
X 
 
X 
 
 
 
X 
X 
X 
X 
Urinalysis 
X 
 
X 
 
 
 
X 
X 
X 
X 
Pregnancy test 
X 
X 
 
 
 
 
 
 
X 
X 
BisEDT Blood levels1 
 
X 
X 
X 
X 
X 
 
 
 
 
12-lead ECG 
X 
X 
X 
 
 
 
 
 
X 
X 
Vital signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Patient-reported outcomes2 
X 
 
 
 
 
X 
X 
X 
X 
X 
Surgical site signs and symptoms 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Surgical site pain score 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Microbiology 
 
X 
(X)3 
 
 
(X) 
(X) 
(X) 
(X) 
(X) 
Radiographic evaluation 
 
X 
 
 
 
X 
X 
X 
X 
X 
Concomitant medications 
X 
X 
X 
 
 
X 
X 
X 
X 
X 
Adverse events 
 
X 
X 
 
 
X 
X 
X 
X 
X 
1 PK blood samples will be collected pre-dose and at 1, 6, 12, 24, 36, 48 (Day 2), 60, 72 (Day 3), 96 (Day 4) and 336 (Day 14; Week 2) hours after administration of the 
investigational product 
2 Patient-reported outcomes include the Veterans Rand 12 Item Health Survey (VR-12) and Short Musculoskeletal Function Assessment (SMFA) 
3 Microbiology will be performed at any time that a new surgical intervention is required. 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
407

Protocol MBN-101-201 
CONFIDENTIAL 
Version 1.0, Issue Date 06 May 2015 
Microbion Corporation 
Page 62 of 62 
Appendix 2:  Flowchart for Microbiological Specimen Processing 
 
Microbion Corporation 
Clinical Study Report MBN-101-201
Confidential & Proprietary 
Version 1.0, 08 May 2019
408