A First in Man Evaluation of the Safety and Efficacy of an Allogeneic Targeted Microbiome Transplant in Adults With Moderate-to-Severe Atopic Dermatitis (ADRN-08)
Phase: PHASE1
Conditions: Atopic Dermatitis (AD)
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

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ATOPIC DERMATITIS RESEARCH NETWORK 
PROTOCOL ADRN-08 
A First in Man Evaluation of the Safety and Efficacy of an Allogeneic Targeted Microbiome Transplant in 
Adults with Moderate-to-Severe Atopic Dermatitis  
Short title: Targeted Microbiome Transplant in Atopic Dermatitis 
Version Number 2.0 / Version Date 14 February 2019 
Investigational New Drug (IND) # 17286 
Study Sponsor(s): 
 
The National Institute of Allergy and Infectious Diseases (NIAID) 
NIAID Funding Mechanism:  Grant 1U19AI117673-01 and Grant UM2AI117870 
 
 
IND Sponsor/Number: The National Institute of Allergy and Infectious Diseases # 17286 
Study Drug Manufacturer/Provider: University of California – San Diego 
PROTOCOL CHAIR- RICHARD GALLO, MD, 
PHD 
Professor and Interim Chair, 
Department of Dermatology 
University of California – San Diego 
9500 Gilman Drive 
Mail Code 0869 
La Jolla, CA 92093-0869 
Phone: 858-822-4608 
Fax: 858-822-6985 
E-mail: rgallo@ucsd.edu  
 MEDICAL MONITOR-AMANDA RUDMAN 
SPERGEL , MD 
Division of Allergy, Immunology, and 
Transplantation (DAIT) 
National Institute of Allergy and Infectious 
Diseases  
5601 Fishers Lane, Room 6B54 
Bethesda, MD 20892 
Phone: 240-627-3840 
Fax: 301-480-4258 
E-mail: rudmana@niaid.nih.gov 
 STATISTICAL AND CLINICAL COORDINATING 
CENTER (SACCC) PRINCIPAL 
INVESTIGATOR- GLORIA DAVID, PHD, 
MHSC 
Principal Research Scientist 
Rho Federal Systems Division, Inc. 
6330 Quadrangle Drive 
Chapel Hill, NC 27517 
Phone: 919-595-6321 
Fax: 919-287-3009 
E-mail: gloria_david@rhoworld.com 
 
PROTOCOL CO-CHAIR- TISSA HATA, MD  
HS Professor of Dermatology, 
Department of Dermatology 
University of California – San Diego 
9500 Gilman Drive 
Mail Code 0869 
La Jolla, CA 92093-0869 
Phone: 858-657-8390 
Fax:858-657-8391 
E-mail: thata@mail.ucsd.edu  
 
PROJECT MANAGER- JOY LAURIENZO-PANZA, 
RN, BSN 
Division of Allergy, Immunology, and 
Transplantation 
National Institute of Allergy and Infectious 
Diseases 
5601 Fishers Lane, Room 6B51 
Bethesda, MD 20892 
Phone: 240-627-3515 
Fax: 301-480-1566 
E-mail: JLaurienzo@niaid.nih.gov 
REGULATORY OFFICER- PAUL PRICE, PHD 
Office of Regulatory Affairs 
Division of Allergy, Immunology, and 
Transplantation 
National Institute of Allergy and 
Infectious Diseases 
5601 Fishers Lane, Room 7B46 
Bethesda, MD 20892 
Phone: 301-761-7835 
Fax: 301-480-1537 
E-mail: PAUL.PRICE@NIH.GOV  
Confidentiality Statement 
The information contained within this document is not to be disclosed in any way without the prior permission of the Protocol Chair, or  
the Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases of the National Institutes  
of Health. 
 
 

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INVESTIGATOR SIGNATURE PAGE 
Protocol: ADRN-08 
  
Version/Date: 2.0 / 14 Feb 2019 
  
Title: A First in Man Evaluation of the Safety and Efficacy of an Allogeneic Targeted 
Microbiome Transplant in Adults with Moderate-to-Severe Atopic Dermatitis 
  
Study Sponsor: The National Institute of Allergy and Infectious Diseases (NIAID) 
 
INSTRUCTIONS: The site Principal Investigator (PI) should print, sign, and date at the indicated location 
below. A copy should be kept for your records and the original signature page sent. After signature, 
please return the original of this form by surface mail to:  
DAIT Regulatory Management Center (RMC) 
Pharmaceutical Product Development (PPD) 
3900 Paramount Parkway 
Morrisville, NC 27560 
 
I confirm that I have read the above protocol in the latest version. I understand it, and I will work 
according to the principles of Good Clinical Practice (GCP) as described in the United States Code of 
Federal Regulations (CFR) – 45 CFR part 46 and 21 CFR parts 50, 56, and 312, and in the most current 
International Conference on Harmonization (ICH) document Guidance for Industry: E6 Good Clinical 
Practice: Consolidated Guidance. Further, I will conduct the study in keeping with local legal and 
regulatory requirements. 
As the site Principal Investigator, I agree to carry out the study by the criteria written in the protocol 
and understand that no changes can be made to this protocol without the written permission of the 
Institutional Review Board (IRB) and NIAID. 
 
____________________________________     
Site Principal Investigator (Print) 
 
____________________________________                                      _________________ 
Site Principal Investigator (Signature)                                                          Date 

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Protocol Synopsis 
Title 
A First in Man Evaluation of the Safety and Efficacy of an Allogeneic 
Targeted Microbiome Transplant in Adults with Moderate-to-Severe 
Atopic Dermatitis 
Short Title 
Targeted Microbiome Transplant in Atopic Dermatitis 
Clinical Phase 
Phase I 
Number of Sites 
2 Clinical Sites in the United States 
IND Sponsor/Number  
NIAID / IND # 17286 
Study Objectives 
Primary Objective 
To assess the safety profile of 1 week of Targeted Microbiome Transplant 
lotion (TMT) application or placebo application, as determined by the 
count of serious and non-serious treatment-emergent adverse events 
(AEs) during the time period of Day 0 to Day 8 per participant within each 
group 
Secondary Objectives 
1. To compare the count of serious and non-serious treatment-
emergent AEs during the time period of Day 0 to Day 8 per 
participant between the groups receiving TMT and placebo 
application 
2. To compare the proportion of participants experiencing at least 
one serious or non-serious treatment-emergent AE during the 
time period of Day 0 to Day 8 between the groups receiving TMT 
and placebo application 
3. To compare the count of serious and non-serious AEs during 
study participation per participant between the groups receiving 
TMT and placebo application 
4. To compare the proportion of participants experiencing at least 
one serious or non-serious AE during study participation 
between the groups receiving TMT and placebo application 
5. To compare the effect of 1 week of TMT application to placebo 
application on disease severity measures  
6. To compare the abundance of Coagulase-negative 
staphylococcus (CoNS) bacteria between lesional and non-
lesional skin for up to 4 days after completion of 1 week of 
treatment separately within the groups receiving TMT or 
placebo application 
7. To compare the change from baseline levels of CoNS bacteria 
abundance between lesional and non-lesional skin for up to 4 
days after completion of 1 week of treatment separately within 
the groups receiving TMT or placebo application  
8. To compare the change from baseline levels of S. hominis A9 
bacteria abundance between lesional and non-lesional skin for 
up to 4 days after completion of 1 week of treatment separately 

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within the groups receiving TMT or placebo application  
9. To compare the effect of 1 week of TMT application to placebo 
application separately on lesional and non-lesional skin S. aureus 
abundance for up to 4 days after completion of treatment 
10. To compare the effect of 1 week of treatment separately within 
the groups receiving TMT or placebo application on S. aureus 
abundance between lesional and non-lesional skin for up to 4 
days after completion of treatment 
11. To compare the change from baseline levels of S. aureus 
abundance between lesional and non-lesional skin for up to 4 
days after completion of 1 week of treatment separately within 
the groups receiving TMT or placebo application 
12. To compare the effect of 1 week of TMT application to placebo 
application for up to 4 days after completion of 1 week of 
treatment on abundance of bacterial deoxyribonucleic acid 
(DNA) separately on lesional and non-lesional skin by 
quantitative polymerase chain reaction (qPCR) of the following:  
a. Combined S. hominis 
b. Combined Staphylococci 
c. 
Combined bacteria 
 
Exploratory Objective 
1. To identify the diversity of the lesional and non-lesional skin 
microbiome by DNA sequencing after completion of 1 week of 
TMT or placebo application 
Study Design 
Phase I, first in man, randomized, double-blind placebo controlled multi-
site trial  
Primary Endpoint 
The count of serious and non-serious treatment-emergent AEs per 
participant during the time period of Day 0 to Day 8  
Secondary Endpoints  
1. The occurrence of at least one serious or non-serious treatment-
emergent AE during the time period of Day 0 to Day 8 
2. The count of serious and non-serious AEs per participant during 
study participation 
3. The occurrence of at least one serious or non-serious AE during 
study participation 
4. The Eczema Area and Severity Index (EASI) score of the ventral 
arms at Days 0, 4, 7, 8 and 11 
5. The Scoring Atopic Dermatitis (SCORAD) score at Days 0, 4, 7, 8 
and 11 
6. The Pruritus Visual Analog Scale (VAS) score of the ventral arms 
at Days 0, 4, 7, 8 and 11 
7. The Rajka-Langeland (RL) score at Days 0 and 7 
8. The abundance of CoNS, as measured by colony forming units 
per centimeter squared (CFU/cm2)  and qPCR (relative colony 
forming units per centimeter squared [rCFU/cm2]) on lesional 
and non-lesional skin at Days 0, 4, 7, 8 and 11 
9. The change from baseline levels of CoNS bacteria  abundance as 
measured by CFU/cm2 and qPCR (rCFU/cm2) on lesional and non-
lesional skin at Days 0 (1 hour post treatment), 4, 7, 8 and 11 

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10. The change from baseline levels of S. hominis A9 bacteria  
abundance as measured by qPCR (rCFU/cm2) on lesional and 
non-lesional skin at Days 0 (1 hour post treatment), 4, 7, 8 and 
11 
11. The abundance of S. aureus, as measured by CFU/cm2 and qPCR 
(rCFU/cm2) on lesional and non-lesional skin at Days 0, 4, 7, 8 
and 11 
12. The change from baseline levels of S. aureus abundance, as 
measured by CFU/cm2 and qPCR (rCFU/cm2) on lesional and non-
lesional skin at Days 0 (1 hour post treatment), 4, 7, 8 and 11 
13. The abundance of bacterial DNA (rCFU/cm2) on lesional and non-
lesional skin at Days 0, 4, 7, 8 and 11; specific bacteria of interest 
are the following:  
• 
Combined S. hominis 
• 
Combined Staphylococci 
• 
Combined bacteria 
 
Exploratory Endpoint 
1. The proportion (% relative abundance) by Phylum: Class and 
Shannon Diversity Index of the microbiome on lesional and non-
lesional skin at Day 7 after completion of 1 week of TMT or 
placebo application 
Accrual Objective 
This study will enroll approximately 54 adult participants, 18-80 years of 
age, with moderate-to-severe atopic dermatitis (AD) and a positive S. 
aureus colonized lesion (at least 15 cm2) on the upper extremities.  
Study Duration 
Approximately 3 years to complete; we anticipate that participant 
enrollment and follow up will take approximately 2 years and data 
analysis and manuscript preparation will take approximately 1 additional 
year.  
Treatment Description 
(Investigational Products) 
Active (TMT): 50% Cetaphil® lotion and 50% Vegetable glycerin containing 
healthy donor-derived (allogeneic) commensal Staph species, S. hominis 
A9 (Manufactured and packaged by University of California – San Diego 
[UCSD]) applied to the right and left ventral upper extremities (wrist to 
upper arm) twice a day for 1 week  
Placebo: 50% Cetaphil® lotion and 50% Vegetable glycerin (Manufactured 
and packaged by UCSD) applied to the right and left ventral upper 
extremities twice a day for 1 week 
Inclusion Criteria 
Individuals who meet all of the following criteria are eligible for 
enrollment as study participants: 
1. Participant must be able to understand and provide informed 
consent 
2. Male or female participants 18-80 years of age, inclusive at time 
of Screening Visit 
3. Meet Atopic Dermatitis Research Network (ADRN) Standard 
Diagnostic Criteria (Appendix A) for active AD 
4. Positive S. aureus colonized lesion, at least 15 cm2, on the 
ventral upper extremity 

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5. An Investigator Global Assessment (IGA) score, on the ventral 
arms, of at least moderate severity 
6. Body surface area (BSA), as measured by Mosteller BSA 
Calculator, between 1.26 m2 and 2.25 m2 
7. Females of childbearing potential who are willing to use 
adequate contraception 30 days prior to the Screening Visit and 
until participation in the study is complete. Females of 
childbearing potential must agree to use an acceptable method 
of birth control (e.g. total abstinence, oral contraceptives, 
intrauterine device (IUD), barrier method with spermicide, 
surgical sterilization or surgically sterilized partner, Depo-
Provera, Norplant, NuvaRing, or hormonal implants) for the 
duration of study participation. 
8. Male participants who are willing to use an acceptable method 
of contraception (e.g. barrier methods with spermicide, surgical 
sterilization, or surgically sterilized partner) or practice 
abstinence until participation in the study is complete. 
Exclusion Criteria 
Individuals who meet any of these criteria are not eligible for enrollment 
as study participants: 
1. Inability or unwillingness of participant to give written informed 
consent or comply with study protocol 
2. Pregnant or lactating females, or females who desire to become 
pregnant and/or breast feed within the duration of study 
participation 
3.  Active bacterial, viral, or fungal skin infections  
4. Any noticeable breaks or cracks in the skin on the upper 
extremities, including severely excoriated skin or skin with open 
or weeping wounds suggestive of an active infection or 
increased susceptibility to infection 
5. Sensitivity to or difficulty tolerating Dove fragrance-free bar 
soap, Cetaphil® Lotion, alcohol-based cleaners, macadamia nuts, 
soy, Vegetable glycerin, or palm kernels  
6. Participants with prosthetic heart valves, pacemakers, 
intravascular catheters, or other foreign or prosthetic devices 
7. Participants with Netherton’s syndrome or other 
genodermatoses that result in a defective epidermal barrier 
8. Any participant who is immunocompromised (e.g. history of 
lymphoma, Human Immunodeficiency Virus (HIV)/ Acquired 
Immune Deficiency Syndrome (AIDS), Wiskott-Aldrich Syndrome) 
or has a history of malignant disease (with the exception of non-
melanoma skin cancer)  
9. Participants with a history of psychiatric disease or history of 
alcohol or drug abuse that would interfere with the ability to 
comply with the study protocol 
10. Past or current medical problems or findings from physical 
examination or laboratory testing that are not listed above, 
which, in the opinion of the investigator, may pose additional 

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risks from participation in the study, may interfere with the 
participant’s ability to comply with study requirements or that 
may impact the quality or interpretation of the data obtained 
from the study 
11. Ongoing participation in another investigational trial or use of 
investigational drugs within 8 weeks, or 5 half-lives (if known), 
whichever is longer, of the Screening Visit 
12. Treatment with biologics within 16 weeks of Screening Visit 
13. Participants with close contacts (e.g. spouses, children, or 
members in the same household) that have severe barrier 
defects or are immunocompromised  
14. Use of topical (including steroids and calcineurin inhibitors) AD 
treatments within 7 days of the Treatment Initiation Visit; Use of 
topical steroids on areas outside of where investigational 
product is to be applied may be permitted, per investigator 
discretion 
15. Treatment of AD with prescription moisturizers classified as 
medical device (e.g., Atopiclair®, MimyX®, Epiceram®, Cerave®, 
etc.) within 7 days of the Treatment Initiation Visit 
16. Use of any oral or topical antibiotics within 7 days of the 
Treatment Initiation Visit 
17. Participants who have taken a bleach bath within 7 days of the 
Treatment Initiation Visit  
18. Use of any oral AD therapies (steroids, immunosuppressive 
therapies) within 28 days of the Treatment Initiation Visit  
19. Any phototherapy for skin disease (such as narrow band 
ultraviolet B [NBUVB], ultraviolet B [UVB], ultraviolet A1 [UVA1], 
psoralen + UVA [PUVA]) or regular use (more than 2 visits per 
week) of a tanning bed within 28 days of the Treatment 
Initiation Visit  
Study Stopping Rules 
This trial will be stopped pending immediate Data and Safety Monitoring 
Board (DSMB) review for the following reasons: 
1. A single participant experiences any serious adverse event (SAE) 
for which there is a reasonable possibility that the 
investigational product caused the SAE 
2. The development of any severe (Grade 3) AE for which attribution 
is defined as related or possibly related in: 
a. 1 out of the first 10 participants enrolled, 
b. 2 out of the first 20 participants enrolled,  
c. 
3 out of the first 30 participants enrolled, 
d. 4 out of the first 40 participants enrolled, 
e. 5 out of the first 50 participants enrolled. 
                     
 
 
 

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Table of Contents 
Glossary of Abbreviations ..................................................................................................................................................... 13 
1. 
Background and Rationale ............................................................................................................................................ 17 
1.1. 
Background and Scientific Rationale ..................................................................................................................... 17 
1.2. 
Rationale for Selection of Investigational Product or Intervention ...................................................................... 18 
1.3. 
Preclinical Experience ........................................................................................................................................... 18 
1.4. 
Clinical Studies ...................................................................................................................................................... 22 
2. 
Study Hypotheses/Objectives ....................................................................................................................................... 23 
2.1. 
Hypotheses............................................................................................................................................................ 23 
2.2. 
Primary Objective .................................................................................................................................................. 23 
2.3. 
Secondary Objectives ............................................................................................................................................ 23 
2.4. 
Exploratory Objective............................................................................................................................................ 24 
3. 
Study Design .................................................................................................................................................................. 24 
3.1. 
Description of Study Design .................................................................................................................................. 24 
3.2. 
Primary Endpoint .................................................................................................................................................. 27 
3.3. 
Secondary Endpoints ............................................................................................................................................ 27 
3.4. 
Exploratory Endpoint ............................................................................................................................................ 27 
3.5. 
Stratification, Randomization, and Blinding/Masking .......................................................................................... 27 
3.5.1. 
Procedure for Unblinding .................................................................................................................................. 28 
4. 
Selection of Participants and Clinical Sites/Laboratories.............................................................................................. 28 
4.1. 
Rationale for Study Population ............................................................................................................................. 28 
4.2. 
Inclusion Criteria ................................................................................................................................................... 28 
4.3. 
Exclusion Criteria ................................................................................................................................................... 29 
5. 
Known and Potential Risks and Benefits to Participants .............................................................................................. 30 
5.1. 
Risks of Investigational Product or Intervention as cited in Investigator Brochure ............................................. 30 
5.2. 
Risks of Investigational Product or Intervention cited in Medical Literature ....................................................... 30 
5.3. 
Risks of Other Protocol Specified Medications ..................................................................................................... 30 
5.4. 
Risks of Study Procedures ..................................................................................................................................... 30 
5.4.1. 
Risks Associated with Stopping the Use of Protocol Prohibited Medications/Therapies ................................. 30 
5.4.2. 
Risks Associated with Skin Swab Collection ...................................................................................................... 30 
5.4.3. 
Risks Associated with Physical Exam ................................................................................................................. 30 
5.4.4. 
Risks associated with Questionnaires ............................................................................................................... 30 

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5.4.5. 
Risks associated with Blood Collection ............................................................................................................. 31 
5.5. 
Potential Benefits .................................................................................................................................................. 31 
6. 
Investigational Agent .................................................................................................................................................... 31 
6.1. 
Investigational Agent ............................................................................................................................................ 31 
6.1.1. 
Targeted Microbiome Transplant Lotion (TMT) ............................................................................................... 31 
6.1.1.1. 
Formulation, Packaging, and Labeling ...................................................................................................... 31 
6.1.1.2. 
Dosage, Preparation, and Administration ................................................................................................. 32 
6.1.2. 
Placebo .............................................................................................................................................................. 33 
6.1.2.1. 
Formulation, Packaging, and Labeling ...................................................................................................... 33 
6.1.2.2. 
Dosage, Preparation, and Administration ................................................................................................. 33 
6.2. 
Investigational Products Accountability ............................................................................................................... 34 
6.3. 
Assessment of Participant Compliance with Investigational Agent ..................................................................... 34 
6.4. 
Toxicity Prevention and Management .................................................................................................................. 34 
6.5. 
Premature Discontinuation of Investigational Products ....................................................................................... 35 
7. 
Other Medications ........................................................................................................................................................ 35 
7.1. 
Concomitant Medications ..................................................................................................................................... 35 
7.2. 
Prophylactic Medications ...................................................................................................................................... 35 
7.3. 
Prohibited Medications/Therapies ....................................................................................................................... 36 
7.4. 
Rescue Medications .............................................................................................................................................. 36 
8. 
Study Procedures .......................................................................................................................................................... 36 
8.1. 
Recruitment Visit .................................................................................................................................................. 36 
8.2. 
Screening Visit (Day -38 ± to -2) ............................................................................................................................ 36 
8.3. 
Post-Screening Phone Visit (Day -37 to -1) ........................................................................................................... 37 
8.4. 
Repeat Culture Visit, as needed (Day -15 to -2) .................................................................................................... 38 
8.5. 
Post-Culture Phone Visit, as needed (Day -14 to-1) ............................................................................................. 38 
8.6. 
Treatment Initiation Visit (Day 0) .......................................................................................................................... 39 
8.7. 
Mid-Treatment Visit (Day 4 ± 1 Day) ..................................................................................................................... 40 
8.8. 
End of Treatment Visit (Day 7 ±1 Day) .................................................................................................................. 40 
8.9. 
24 Hour Follow-Up Visit (Day 8) ............................................................................................................................ 41 
8.10. 
96 Hour Follow-Up Visit (Day 11 ±1 Day) .......................................................................................................... 41 
8.11. 
End of Study Phone Visit (Day 38 ±7 Days) ....................................................................................................... 42 
8.12. 
Unscheduled Visits ............................................................................................................................................ 42 
8.13. 
Visit Windows.................................................................................................................................................... 43 

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9. 
Sample Collection and Assays ....................................................................................................................................... 43 
9.1. 
Skin Swab Samples ................................................................................................................................................ 43 
9.1.1. 
Skin Swab Collection Procedure .................................................................................................................... 43 
9.1.2. 
Staphylococcus aureus Screening Assay ....................................................................................................... 43 
9.1.3. 
CFU Quantification of Live Staphylococcus aureus and CoNS ...................................................................... 44 
9.1.4. 
Quantification of S. aureus, S. hominis, Combined Staphylococci, and Combined Bacteria DNA by qPCR .. 44 
9.1.5. 
Analysis of Microbial Populations by 16S rRNA Sequencing......................................................................... 44 
9.2. 
Blood Samples ....................................................................................................................................................... 45 
9.2.1. 
Blood Collection Procedure .......................................................................................................................... 45 
9.2.2. 
Blood Tests .................................................................................................................................................... 45 
10. 
Biospecimen Storage................................................................................................................................................. 45 
11. 
Criteria for Participant and Study Completion and Premature Study Termination.................................................. 45 
11.1. 
Participant Completion ..................................................................................................................................... 45 
11.2. 
Participant Stopping Rules and Withdrawal Criteria ........................................................................................ 45 
11.3. 
Participant Replacement ................................................................................................................................... 46 
11.4. 
Follow-up after Early Study Withdrawal ........................................................................................................... 46 
11.5. 
Study Stopping Rules ......................................................................................................................................... 46 
12. 
Safety Monitoring and Reporting ............................................................................................................................. 46 
12.1 Overview ................................................................................................................................................................... 46 
12.2 Definitions ................................................................................................................................................................. 47 
12.2.1 Adverse Event (AE) ............................................................................................................................................. 47 
12.2.2 Unexpected Adverse Event ................................................................................................................................ 47 
12.2.3 Serious Adverse Event (SAE) .............................................................................................................................. 47 
12.3 Grading and Attribution of Adverse Events .............................................................................................................. 48 
12.3.1 Grading Criteria .................................................................................................................................................. 48 
12.3.2 Attribution Definitions ....................................................................................................................................... 48 
12.4 Collection and Recording of Adverse Events ............................................................................................................ 49 
12.4.1 Collection Period ................................................................................................................................................ 49 
12.4.2 Collecting Adverse Events .................................................................................................................................. 49 
12.4.3 Recording Adverse Events .................................................................................................................................. 49 
12.5 Reporting of Serious Adverse Events and Adverse Events ....................................................................................... 49 
12.5.1 Reporting of Serious Adverse Events to DAIT/NIAID ......................................................................................... 49 
12.5.2 Reporting to Health Authority ........................................................................................................................... 50 

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12.5.3 Reporting of Adverse Events to the Central IRB ................................................................................................ 51 
12.6  
Pregnancy Reporting ......................................................................................................................................... 51 
12.7 Reporting of Other Safety Information ..................................................................................................................... 52 
12.8 Review of Safety Information ................................................................................................................................... 52 
12.8.1 Medical Monitor Review .................................................................................................................................... 52 
12.8.2 DSMB Review ..................................................................................................................................................... 52 
13. 
Statistical Considerations and Analytical Plan .......................................................................................................... 53 
13.1 
Overview ............................................................................................................................................................... 53 
13.2 
Endpoints .............................................................................................................................................................. 53 
13.2.1 
Primary Endpoint .......................................................................................................................................... 53 
13.2.2  
Secondary Endpoints..................................................................................................................................... 53 
13.2.3 Exploratory Endpoint ......................................................................................................................................... 54 
13.3 
Measures to Minimize Bias ................................................................................................................................... 54 
13.4 
Analysis Plan .......................................................................................................................................................... 54 
13.4.1 
Analysis Samples ........................................................................................................................................... 54 
13.4.2 
Primary Analyses of Primary Endpoint.......................................................................................................... 54 
13.4.3 
Supportive Analyses of the Primary Endpoint .............................................................................................. 55 
13.4.4 
Analyses of Secondary and Exploratory Endpoints ....................................................................................... 55 
13.4.5 
Descriptive Analyses ..................................................................................................................................... 55 
13.5 
Interim Analyses .................................................................................................................................................... 56 
13.5.1 
Interim Analysis of Efficacy Data ................................................................................................................... 56 
13.5.2 
Interim Analysis of Safety Data ..................................................................................................................... 56 
13.5.3 
Futility Analysis ............................................................................................................................................. 56 
13.6 
Statistical Hypotheses ........................................................................................................................................... 56 
13.7 
Sample Size Considerations .................................................................................................................................. 57 
14. 
Identification and Access to Source Data ................................................................................................................. 58 
14.1. 
Source Data ....................................................................................................................................................... 58 
14.2. 
Access to Source Data ....................................................................................................................................... 58 
15. 
Protocol Deviations ................................................................................................................................................... 58 
15.1. 
Protocol Deviation Definitions .......................................................................................................................... 58 
15.2. 
Reporting and Managing Protocol Deviations .................................................................................................. 59 
16. 
Ethical Considerations and Compliance with Good Clinical Practice ........................................................................ 59 
16.1. 
Quality Control and Quality Assurance ............................................................................................................. 59 

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16.2. 
Statement of Compliance ................................................................................................................................. 59 
16.3. 
Informed Consent Process ................................................................................................................................ 59 
16.4. 
Privacy and Confidentiality ............................................................................................................................... 60 
17. 
Publication Policy ...................................................................................................................................................... 60 
18. 
References ................................................................................................................................................................ 60 
Appendix A: ADRN Standard Diagnostic Criteria (Version 3.0 09May2014) ......................................................................... 62 
Appendix B: Schedule of Events ............................................................................................................................................ 63 
 
 

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Glossary of Abbreviations 
AD 
Atopic Dermatitis 
ADRN 
Atopic Dermatitis Research Network 
AE  
Adverse Event 
AIDS 
Acquired Immune Deficiency Syndrome 
AMP(s) 
Antimicrobial Peptides 
AMT 
Autologous Microbiome Transplant 
ANCOVA 
Analysis of Covariance  
APGAR 
Appearance, Pulse, Grimace, Activity, and Respiration 
BSA 
Body Surface Area 
CBC 
Complete Blood Count 
cDNA 
Complementary Deoxyribonucleic Acid 
CFR 
Code of Federal Regulations 
CFU 
Colony Forming Units 
CoNS 
Coagulase Negative Staphylococcal Species 
CRF 
Case Report Form 
CTCAE 
Common Terminology Criteria for Adverse Events 
DAIT 
Division of Allergy, Immunology, and Transplantation 
DNA 
Deoxyribonucleic Acid 
DSMB 
Data and Safety Monitoring Board 
EASI 
Eczema Area Severity Index 
eCRF 
Electronic Case Report Form 
EC 
Ethics Committee 
EDC 
Electronic Data Capture 
EH 
Eczema Herpeticum  
EV 
Eczema Vaccinatum  

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FDA 
Food and Drug Administration 
FLG 
Filaggrin 
GAS 
Group A Streptococcus 
GBS 
Group B Streptococcus 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
HIV 
Human Immunodeficiency Virus 
HMW 
High-Molecular-Weight 
HPLC 
High-Performance Liquid Chromatography  
HSV 
Herpes Simplex Virus 
ICH 
International Conference on Harmonization 
IGA 
Investigator Global Assessment  
IgE 
Immunoglobulin E 
IND 
Investigational New Drug 
IP 
Investigational Product 
IRB 
Institutional Review Board 
IUD 
Intrauterine Device  
MCB 
Master Cell Bank 
MCV 
Molluscum Contagiosum Virus 
MITT 
Modified-Intent-to-Treat 
MOP 
Manual of Procedures 
mRNA 
Messenger Ribonucleic Acid 
MRSA 
Methicillin-Resistant Staphylococcus aureus 
MSSA 
Methicillin-Sensitive Staphylococcus aureus 
NA 
Non-Atopic 
NBUVB 
Narrow Band Ultraviolet B 

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NCI 
National Cancer Institute  
NIAID 
National Institute of Allergy and Infectious Diseases 
NIH 
National Institutes of Health 
NS 
Normal Saline  
OHRP 
Office for Human Research Protections 
OTU 
Operational Taxonomic Unit 
PI 
[Site] Principal Investigator 
PCR 
Polymerase Chain Reaction 
PHI 
Personal Health Identifiers 
PP 
Per Protocol 
PSM 
Phenol-Soluble Modulin 
PUVA 
Psoralen Ultraviolet A 
QIIME 
Quantitative Insights Into Microbial Energy 
qPCR 
Quantitative Polymerase Chain Reaction 
rCFU 
Relative Colony Forming Units 
RL 
Rajka-Langeland 
RNA 
Ribonucleic Acid 
rRNA 
Ribosomal Ribonucleic Acid 
SACCC 
Statistical and Clinical Coordinating Center 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SAR 
Suspected Adverse Reaction 
SCORAD 
Scoring Atopic Dermatitis  
SOP 
Standard Operating Procedure 
SUSAR 
Serious Unexpected Suspected Adverse Reaction 
TSB 
Tryptic Soy Broth 

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TMT 
Targeted Microbiome Transplant Lotion 
UVA 
Ultraviolet A 
UVB 
Ultraviolet B 
UCSD 
University of California – San Diego 
USP 
U.S. Pharmacopeial Convention 
VAS 
Visual Analog Scale 
VV 
Vaccinia Virus 
WCB 
Working Cell Bank 
 
 
 

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1. Background and Rationale  
1.1. Background and Scientific Rationale 
Atopic Dermatitis (AD) is a common, chronic, inflammatory skin disease complicated by recurrent bacterial as well as 
viral skin infections (Higaki et al., 1999; Travers et al., 2001; Ricci et al., 2003; Sugimoto et al., 2006; De Bendetto et al., 
2009). The skin of AD patients is highly susceptible to infections by viruses, bacteria, and fungi. These microorganisms 
interact with the human immune system to trigger the onset of, or exacerbate the disease. Studies suggest that 7-10% 
of AD participants have difficulty containing infections caused by viruses including herpes simplex virus (HSV), vaccinia 
virus (VV); causing eczema herpeticum (EH), eczema vaccinatum (EV), and molluscum contagiosum virus (MCV) (60). 
Preliminary data in the Atopic Dermatitis Research Network (ADRN) Registry study indicate 40% of AD participants and 
only 2% of non-atopics (NA) are S. aureus colonized on lesional and/or non-lesional skin. These observations are 
consistent with the understanding that patients with AD have defects in innate and adaptive immune responses and 
thus have a general defect in the control of skin infections. 
Several lines of experimental evidence support the concept that the multiple defects in epithelial barrier function in AD 
promote dysbiosis, a state of microbial imbalance, and that this dysbiosis then promotes the immunological disorder 
characteristic of AD. Dysbiosis in AD has been shown to be closely associated with disease severity (Kong et al., 2012a). 
Antibiotic therapy is a mainstay of treatment for normalization of dysbiosis; however, antibiotic treatment 
nonspecifically kills bacteria and may induce additional dysbiosis. In addition, long-term treatments generate resistant 
bacteria. Antimicrobial peptides (AMPs) such as defensins and cathelicidins are important mediators to maintain the 
balance of epithelial microflora. Our studies indicate that the innate immune defense of the skin is mediated not only by 
AMPs produced by an individual’s own cells, but also by antimicrobial molecules contributed by commensal 
staphylococcus species, such as S. epidermidis and S. hominis (Lai et al., 2009; Lai et al., 2010; Cogen et al., 2010a; Cogen 
et al., 2010b). Previously published data (Nakatsuji et al., 2017) suggest that AD skin colonized by S. aureus has a lower 
frequency of these antimicrobial Staph species compared to normal skin. Studies have also shown that AD patients 
colonized by S. aureus have more severe disease states and are prone to more frequent flares of their AD (Kong et al., 
2012a; Schnopp et al., 2010; Ong et al., 2002; Kong & Segre, 2012b). More recently, to further examine if topical 
application of antimicrobial coagulase negative staphylococcal species (CoNS) can decrease S. aureus survival on the skin 
of AD participants, a pilot study of an autologous microbiome transplant (AMT) was conducted by the University of 
California – San Diego (UCSD) as the Investigational New Drug (IND) Sponsor under IND# 15786. Antimicrobial CoNS 
strain(s) were isolated from the non-lesional skin of each of the 5 AD participants who were S. aureus culture positive 
(see Table 1.1 for active strains used for each patient). To transiently increase their abundance, the active strain(s) of 
each participant were expanded, mixed with Cetaphil® lotion at 1x107 colony forming units per gram (CFU/g), and then 
reapplied to the lesional forearm skin of the same participant to get 1x105CFU/cm2, from which the active colonies were 
isolated. After 24 hours of a single application of AMT lotion, S. aureus CFU decreased; whereas, vehicle (Cetaphil® 
lotion) applied to the contralateral arm in a double-blind comparison did not (Figure 1.4, a-b). From these results, we 
hypothesize that an increase in the ratio of antimicrobial Staph to the level found on normal skin would normalize the 
balance of microflora in AD participants, thereby improving abnormal immune reactions in AD skin. The goal of this 
study is to develop a therapy of healthy donor-derived (allogeneic) targeted microbiome transplant lotion (TMT) of 
antimicrobial Staph strain, S. hominis A9, to help normalization of skin dysbiosis in moderate-to-severe AD. By 
decreasing S. aureus, and possibly inflammation, we propose TMT as a novel therapy for AD.  

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Table 1.1 AMT formula transplanted to each AD participant 
Participant 
CoNS species 
Active clones used 
for AMT 
AMT 1 
S. epidermidis 
AMT1-A9 
AMT 2 
S. hominis 
AMT2-A12 
AMT 3 
S. hominis 
AMT3-A12 
AMT 4 
S. hominis 
AMT4-C2, 
AMT4-D12, 
AMT4-G1 
AMT 5 
S. epidermidis 
AMT5-C5, 
AMT5-G6 
1. The total CFU in AMT formula for each participant was 1×107CFU/g. 
2. The total CFU applied on the skin of each participant was 1×105 CFU/cm2. 
1.2. Rationale for Selection of Investigational Product or Intervention 
We have made a highly innovative discovery of newly recognized species such as S. hominis, as well as newly identified 
strains of S. epidermidis from the human skin microbiome that produce previously unknown antimicrobials that will 
selectively kill pathogens such as S. aureus while not harming the resident commensals. Because of this, these 
commensal bacteria can provide selective antimicrobial protection against pathogens on the skin surface yet maintain 
diversity. One example of such protective bacteria is a strain of S. epidermidis that produces Phenol Soluble Modulins 
(PSMs) gamma and delta (Cogen et al., 2010a). We have shown that these helical peptides are potent against S. aureus 
in vitro and on human skin. More recently, with the prior support of National Institute of Allergy and Infectious Diseases 
(NIAID), we have discovered a novel S. epidermidis-derived antibiotic we have named Firmocidin that selectively kills S. 
aureus [including methicillin-resistant S. aureus (MRSA) strains], group A Streptococcus (GAS), group B Streptococcus 
(GBS) and Pseudomonas aeruginosa. Another commensal strain of S. epidermidis produces a specific protease (esp) that 
disrupts S. aureus biofilms and has been used successfully in a human clinical trial to decrease nasal colonization (Iwase 
et al., 2010). We have also discovered that S. hominis, which is also a major commensal on the human skin, produces 
two novel AMPs we have named Hogocidin alpha and Hogocidin beta that kills S. aureus by a different mechanism. 
These findings indicate that multiple bacteria inhabiting the surface of normal human skin contribute directly to the 
skin’s antimicrobial defenses. Importantly, we have now identified 4 specific strains in the microbiome with beneficial 
antimicrobial function that can be used in a new paradigm for host defense whereby the commensal bacteria defend 
their host by producing AMPs. Stability testing of these 4 specific strains in Cetaphil® lotion has revealed S. hominis and 
its antimicrobial, hogocidin alpha, to be the best formulation for our targeted microbiome transplant. This will be a 
Phase I, first in human, clinical trial evaluating the safety and efficacy of a novel therapy for AD, a targeted microbiome 
transplant lotion. The allogeneic targeted microbiome transplant lotion or TMT will be composed of 50% Cetaphil® 
lotion, 50% Vegetable glycerin, and commensal Staph species, S. hominis A9. 
1.3. Preclinical Experience 
It has been known for decades that patients with AD have increased colonization with bacteria and are susceptible to 
infections with S. aureus and viruses such as herpes and vaccinia. An alteration in the physical barrier by mutations in 
filaggrin (FLG) (Irvine 2007) and our findings of a decreased antimicrobial barrier from altered expression of 
antimicrobial proteins (Ong et al., 2002) have been hypothesized to contribute to the abnormal microbial colonization. 
Once the skin barrier is impaired and the expression of AMPs is reduced, it is likely that the homeostasis between host 
and microbe is shifted. This is consistent with more recent observations that show the whole skin microbial community 
is abnormal in AD. Several recent findings in patients with AD reveal a dramatic change in microbial community 

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structures compared to healthy volunteers (Kong & Serge, 2012b; Hata & Gallo, 2008). Worsening disease and lower skin 
bacterial diversity are associated with each other. Microbial shifts are localized to sites of disease predilection. This 
suggests that ecological niches such as the antecubital and popliteal creases are important for the initiation of disease 
and are influenced by the microbial communities that live in them.  
Figure 1.3a AD skin contains a microbiome that is deficient in the ability to inhibit S. aureus. 
 
 
Clinical improvement in AD is associated with higher bacterial diversity, indicating that current treatments that promote 
bacterial diversity promote improvement of the disease. Increases of specific bacterial genera, such as Corynebacterium, 
Streptococcus, and Propionibacterium, are observed during therapy indicating more complex species relationships 
during AD than known from culture-based methods (Kong et al., 2012a). Our prior work in the ADRN has further 
extended the understanding of the microbiome by demonstrating that the microbiome of AD participants is deficient in 
bacterial strains that provide anti-S. aureus activity. Figure 1.3a shows the percentage of coagulase negative Staph that 
secretes activity that will inhibit S. aureus growth. The data are conservatively biased since it eliminates coagulase 
positive bacteria from the calculation. 
Each data point represents the proportion of coagulase negative Staph isolates recovered from the surface of an 
individual participant’s forearm skin. One hundred isolates were measured from each individual. Bacterial colonies were 
cultured and sterile supernatant of that culture was added to S. aureus strain 113. Suppression of the growth of S. 
aureus was assessed in each assay by comparison with internal controls to evaluate growth in conditioned medium from 
a well-defined control strain of S. epidermidis that does not produce anti-Staph activity (negative control) and 
comparison with strains of S. epidermidis that do produce anti-Staph activity (positive control). 
These observations show that not only is the skin of AD patients defective in host-derived protective factors (FLG, β- 
defensins, cathelicidins, etc.) but it also has a defect in protection from the microbiome. This is important to AD because 
of the risk that increased abundance of S. aureus has to infection and because of recent observations suggesting that the 
presence of δ-toxin produced by S. aureus will directly enhance allergic responses in mice (Nakamura et al., 2013). 
Recognition that AD has a lack of specific strains of bacteria supports the rationale behind our current proposal. Our 
microbiome transplant will inform how to replace some of the bacteria that are necessary for normal host defense of 
the skin. 
To understand how the microbiome can directly inhibit S. aureus, we have sought to identify specific strains of the 
commensal microbiome that contribute to this activity. This work has been highly successful, and we have discovered 

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three novel antibiotics. All are common on normal skin but are relatively absent in AD. The activity of the products of 
two of these antimicrobial strains is illustrated in Figure 1.3b below. 
Figure 1.3b Identification of molecules from the skin microbiome that inhibit growth of S. aureus. 
 
Part A illustrates the capacity of S. hominis A9 (culture supernatant) to inhibit S. aureus. Zones of inhibition of S. aureus 
are shown to illustrate heat stability, protease sensitivity, and ammonium sulfate precipitation of the purified native 
peptide from S. hominis. Parts B and C indicate S. hominis A9 strain produces two antimicrobial components. Part B 
illustrates the high-performance liquid chromatography (HPLC) purification of two antimicrobial peptides from culture 
supernatant of S. hominis A9. Part C illustrates the structure of purified antimicrobial peptides, Hogocidin-α and 
Hogocidin-β. Parts D and E illustrate potency of each hogocidin to kill S. aureus. The minimal bactericidal concentration 
of Hogocidin-α and Hogocidin-β was 0.63 and 1.25 μm, respectively, much lower than host antimicrobial peptides. The 
hogocidins exerted synergistic antimicrobial activity when combined with skin antimicrobial peptide, LL-37. Part F 
illustrates the antimicrobial dose response of Firmocidin identified in S. epidermidis. Comparisons of potency between 
synthetic and naturally purified Firmocidin and activity of a highly potent topical antimicrobial (Benzyl peroxide) to 
inhibit GAS, GBS, Methicillin-Sensitive S. aureus (MSSA) and MRSA are also shown. Parts G and H show data from a 
single IV dose of Firmocidin (20 mg/kg) given to mice 24 hours after starting a deep skin infection by subcutaneous 
injection of 108 CFU of GAS. Three days later mice given only one dose of Firmocidin showed no open wounds and 3 logs 
fewer bacteria at the injection site (not shown). We confirmed that these compounds are active on the skin. To test this, 

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we developed a method for stable formulation of commensal bacteria in a lotion base. The lotion base Cetaphil® is well 
tolerated by participants with AD.  
Figure 1.3c below shows results of an experiment where survival of S. aureus was measured on the skin of mice after a 
single application of bacteria shown in Figure 1.3b. It shows that our transplant approach has a high likelihood to 
succeed in achieving the endpoint of decreasing S. aureus. 
Figure 1.3c A bacterial transplant inhibits the survival of S. aureus on ex vivo pig skin (a) and mouse skin (b). 
 
Having established an association between AMP-producing commensal CoNS and colonization with S. aureus (Figure 
1.3a), and having identified active peptides produced by these strains (Figure 1.3b), we next sought to directly test if the 
presence of S. hominis producing Hogocidins (A9 strain) will reduce colonization by S. aureus. First, we employed an ex 
vivo pig skin colonization model. In this model, peptides or bacteria were applied to the surface of sanitized pig skin on 
which defined amounts of S. aureus had first been applied (1x105 CFU/cm2). A significant decrease in survival of S. aureus 
was seen after a single application of S. hominis A9 at a final application density consistent with estimates of the density 
of bacteria on normal human skin (1×105 CFU/cm2) (Figure 1.3c, a). A similar density of S. hominis A9 that were killed and 
rinsed prior to application, or use of multiple S. hominis isolates that did not show antimicrobial activity in culture (C4, 
C5 and C6 strains) did not affect S. aureus survival. Similarly, a single application of active S. hominis A9 to mice dorsal 
skin on which defined amounts of S. aureus had been applied (1×105 CFU/cm2) reduced the survival of S. aureus on the 
skin (Figure 1.3c, b). In contrast, application of inactive strains (C4, C5, and C6 strains) at the similar density did not show 
this activity. 
We have also published additional evidence that this approach can be successful using another beneficial S. epidermidis 
strain on human skin (Cogen et al., 2010a; Cogen et al., 2010b). In these studies, we demonstrated that application of 
these bacteria to human fingertips will inhibit > 99.9% survival of GAS, and application of only nanomoles of the purified 
AMP will inhibit growth of GAS abundance on the forearm of volunteer participants with a p value of <0.001. Thus, we 
have strong preliminary evidence in animals and on normal human skin that only a single application of a single 
antimicrobial will be effective to inhibit S. aureus. 
Our approach will build on this preliminary data by using a strategy similar to what we have observed in normal skin. 
Multiple antimicrobial strains of commensal bacteria are present at the same time. We have chosen one strain based on 

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its stability, potency, complementary activity, and prior experience in vivo. This approach will permit us to collect vital 
new information on the interactions of the microbiome with AD patients, to better understand the mechanistic factors 
that influence the stability and effects of the microbiome, and evaluate a potential therapeutic intervention that may be 
a major modifier of clinical outcome. 
1.4. Clinical Studies 
In order to further examine if topical application of antimicrobial CoNS can decrease S. aureus survival on the skin of AD 
participants, a preliminary double-blind, placebo-controlled AMT study was conducted under IND# 15786 (IND Sponsor: 
UCSD). An antimicrobial CoNS strain was isolated from the non-lesional skin of each of 5 AD participants who were S. 
aureus culture positive. To transiently increase their abundance on each participant, the active strain(s) were expanded 
and then reapplied to the lesional forearm skin of the same participant, from which the active colonies were isolated 
(Table 1.1), to a final concentration of 1×105 CFU/cm2, a density similar to previous assessments of the abundance of 
bacteria on normal human skin. A single application of the functionally defined and autologously-derived CoNS strain(s) 
decreased S. aureus CFU within 24 hours; whereas, vehicle applied to the contralateral arm in a double-blind 
comparison did not (Figure 1.4, a-b). However, CoNS survival on the arm 24 hours after AMT application was similar to 
the baseline. These results suggest that a single application of CoNS at a dose of 1×105 CFU/cm2 was sufficient to 
transiently decrease survival of S. aureus, but the majority of transplanted CoNS died within 24 hours. Autologous 
derived S. hominis A9 (AMT) did not survive beyond 24 hours on AD lesional skin; it is unknown how long S. hominis A9 
as applied in the allogeneic TMT product will remain alive and active on lesional or non-lesional AD skin. Therefore, we 
propose to apply the allogeneic TMT at a final concentration of bacteria that ranges from 1 x 106 CFU of bacteria/ gram 
Vegetable glycerin-Cetaphil® to 2 x 109 CFU of bacteria/ gram Vegetable glycerin-Cetaphil®, and for multiple applications 
(twice a day for 1 week) for better survival of transplanted CoNS.  
Figure 1.4. Transplantation of antimicrobial CoNS reduces survival of S. aureus colonized on the skin surface (The 
manuscript including this data has not yet been published. 
 
Figure 1.4 panel (a) demonstrates the effect of transplantation of antimicrobial CoNS strain(s) on survival of S. aureus on 
the skin surface of participants with AD. S. aureus survival was measured on the lesional sites in both antecubital fossa 
of the AD participant before and 24 hours after either treatment with antimicrobial CoNS strain(s) autologously 
screened from the same participant or vehicle. Panel (b) illustrates S. aureus survival on the forearm 24 hours after 
treatment with autologous strain(s) of CoNS or treatment with vehicle. Relative CFU (rCFU) of S. aureus is shown as 

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percent of baseline and different color symbols indicate data from each individual participant. In panel (c) CFUs of CoNS 
on the skin surface of participants with AD were simultaneously counted as shown in panel (a). Panel (d) shows CoNS 
survival on the forearm 24 hours after treatment with autologous strain(s) of CoNS or treatment with vehicle. Relative 
CFU of CoNS is shown as percent of baseline. 
In the pilot study of 5 participants evaluating an AMT lotion (IND#15786), no serious adverse events (SAEs) were noted. 
Two participants noted mild worsening of AD, which was deemed unrelated to the AMT lotion, given AMT was not 
applied on the area with worsening AD. One participant noted mild worsening of AD with an increase in pruritus and 
erythema on both arms. Since AMT was applied to only one arm, it is less likely that the adverse event (AE) was related 
to the AMT given the bilateral worsening of AD on the upper extremities. Overall, the AMT was very well tolerated and 
had no significant AEs. 
2. Study Hypotheses/Objectives 
2.1. Hypotheses 
We propose an interventional clinical trial that will apply S. hominis A9 to S. aureus colonized skin of participants with 
moderate-to-severe atopic dermatitis. S. hominis A9 is a specific strain of bacteria commonly found on normal human 
skin but deficient in patients with AD. This strain has been selected based on its capacity to kill S. aureus in pre-clinical 
models.  
Our central hypothesis is that this intervention will be safe and well tolerated by participants with AD. Furthermore, we 
hypothesize that the reintroduction of this commensal microbe to the skin of AD participants will decrease colonization 
of S. aureus.  
Testing these hypotheses will allow us to proceed with development of an intervention that will successfully treat S. 
aureus colonization in clinical patients with AD and eliminate the negative consequences caused by S. aureus on the 
health of skin. 
2.2. Primary Objective 
The primary objective of this trial is to assess the safety profile of 1 week of TMT application or placebo application, as 
determined by the count of serious and non-serious treatment-emergent AEs during the time period of Day 0 to Day 8 
per participant within each group. 
2.3. Secondary Objectives 
1. To compare the count of serious and non-serious treatment-emergent AEs during the time period of Day 0 to 
Day 8 per participant between the groups receiving TMT and placebo application 
2. To compare the proportion of participants experiencing at least one serious or non-serious treatment-emergent 
AE during the time period of Day 0 to Day 8 between the groups receiving TMT and placebo application 
3. To compare the count of serious and non-serious AEs during study participation per participant between the 
groups receiving TMT and placebo application 
4. To compare the proportion of participants experiencing at least one serious or non-serious AE during study 
participation between the groups receiving TMT and placebo application 
5. To compare the effect of 1 week of TMT application to placebo application on disease severity measures  
6. To compare the abundance of CoNS bacteria between lesional and non-lesional skin for up to 4 days after 
completion of 1 week of treatment separately within the groups receiving TMT or placebo application 

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7. To compare the change from baseline levels of CoNS bacteria abundance between lesional and non-lesional skin 
for up to 4 days after completion of 1 week of treatment separately within the groups receiving TMT or placebo 
application 
8. To compare the change from baseline levels of S. hominis A9 bacteria abundance between lesional and non-
lesional skin for up to 4 days after completion of 1 week of treatment separately within the groups receiving 
TMT or placebo application 
9. To compare the effect of 1 week of TMT application to placebo application separately on lesional and non-
lesional skin S. aureus abundance for up to 4 days after completion of treatment 
10. To compare the effect of 1 week of treatment separately within the groups receiving TMT or placebo application 
on S. aureus abundance between lesional and non-lesional skin for up to 4 days after completion of treatment 
11. To compare the change from baseline levels of S. aureus abundance between lesional and non-lesional skin for 
up to 4 days after completion of 1 week of treatment separately within the groups receiving TMT or placebo 
application 
12. To compare the effect of 1 week of TMT application to placebo application for up to 4 days after completion of 1 
week of treatment on abundance of bacterial deoxyribonucleic acid (DNA) separately on lesional and non-
lesional skin by quantitative polymerase chain reaction (qPCR) of the following:  
a. Combined S. hominis 
b. Combined Staphylococci 
c. Combined bacteria  
 
2.4. Exploratory Objective 
1. To identify the diversity of the lesional and non-lesional skin microbiome by DNA sequencing after completion of 
1 week of TMT or placebo application 
 
3. Study Design 
3.1. Description of Study Design  
This is a phase I, first in man, randomized, double-blind placebo controlled multi-site trial designed to assess the safety, 
efficacy, and steady-state of allogeneic TMT in adults with moderate-to-severe AD. Approximately 54 adult AD 
participants, 18 to 80 years of age, will complete 1 week of TMT or placebo applications to non-lesional and S. aureus 
colonized lesional skin on the right and left ventral upper extremities (wrist to upper arm). Participants who withdraw or 
are discontinued from the study before completing the End of Treatment (Day 7) Visit will be replaced.  
During the Screening Visit, participants will provide informed consent for study participation. Consented participants will 
then be further assessed for study eligibility through the collection of medical history, including medication/therapy use, 
a physical exam, assessment of AD severity, and swab collection for S. aureus screening. Participants who require a 
washout period of more than 14 days will be required to return to clinic for a repeat Staph culture.  
Participants who are eligible based on their positive Staph culture results will be randomized 2:1 active to placebo. One 
lesional site measuring at least 15 cm2 and one non-lesional site of equal size will be identified on the participant’s 
ventral upper extremities as the target swabbing areas. These sites will be photographed and marked for swabbing for 
reference at the participant’s future visits. Participants will be instructed to apply investigational product with gloved 
hands to their ventral upper extremities bilaterally from the wrist to the upper arm, which will include the identified 
lesional and non-lesional swabbing sites twice a day for 1 week starting on Day 0. Participants will return to clinic on Day 
4 for the assessment of AEs, the collection of skin swabs from the identified target sites, and to obtain additional 

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investigational product and gloves. Participants will complete an additional clinic visit on Day 7 to correspond with the 
end of their 1 week treatment. During this visit, participants will be assessed for AEs and provide skin swab samples. All 
unused product and empty packets will be returned during the Day 4 and Day 7 visits. Two additional clinic visits on Days 
8 and 11 will be scheduled for additional skin swabs to assess safety and the abundance of CoNS bacteria and S. aureus  
colonization. Participants will be followed through Day 38 to assess for safety and disease status.  
Approximately 54 moderate-to-severe AD participants with a positive S. aureus colonized lesion on the upper 
extremities will be enrolled for this trial. Based on preliminary data from the ADRN Registry protocol, we estimate that 
approximately 40% of AD participants will be S. aureus positive on their lesional skin, and we may need to screen up to 
133 participants to meet enrollment goals. We anticipate it will take approximately 2 years to reach recruitment and 
enrollment goals and to complete participant follow up for this trial. The study flow diagram is provided in Figure 3.1. 
 
Figure 3.1 Study Visit Flow Diagram 
Recruitment 
 
 
 
 
 
Screening 
Day -38 to -2 
 
 
Post-Screening Phone 
Day -37 to -1 
 
 
 
 
Repeat Culture Visit,  
as needed 
Day -15 to -2 
 
Post-Culture Phone,  
as needed 
Day -14 to -1 
 
 
 
 
 
Treatment Initiation 
(Day 0) 
 
 
Obtain informed consent, screen participants by inclusion/exclusion criteria, collect demographics, 
medical history, physical exam, AD assessment, perform pregnancy test on female participants of child-
bearing potential who do not self-report as pregnant, assessment of concomitant medications, vital 
signs plus height and weight, obtain lesional skin swab, AE assessment 
Interim medical history, physical exam, AD assessment, perform pregnancy test on female participants of 
child-bearing potential who do not self-report as pregnant, assessment of concomitant medications, vital 
signs, Randomization (2:1), photos of lesional AD and non-lesional sites, collect lesional and non-lesional 
skin swabs, apply investigational product, additional lesional and non-lesional skin swabs at 1 hour post 
application of investigational product, additional application of investigational product following 1 hour 
swab, AE assessment, dispense investigational product and participant diary 
AE assessment, provide Staph result, and confirm eligibility. If lesional swab is S. aureus positive and a 
medication/ therapy washout of 14 days or less is required, schedule Treatment Initiation (Day 0) Visit. If 
lesional swab is S. aureus positive, and washout of more than 14 days is needed, schedule Repeat 
Culture Visit for time point after the applicable washout window 
Interim medical history, physical exam, AD assessment, perform pregnancy test on female participants 
of child-bearing potential who do not self-report as pregnant, assessment of concomitant medications, 
vital signs, obtain lesional skin swab, AE assessment 
AE assessment, provide Staph result, and confirm eligibility. If lesional swab is S. aureus positive, 
schedule Treatment Initiation (Day 0) Visit. If lesional swab is S. aureus negative, participant is a screen 
failure. Participant can rescreen in 7 days. 
Recruit potential participants, assess participant eligibility, and invite potential eligible participants to a 
Screening Visit 

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Mid-Treatment 
(Day 4 ± 1 Day) 
 
 
 
 
End of Treatment) 
(Day 7± 1 Day) 
 
 
 
 
 
24 Hour Follow-Up 
(Day 8) 
 
 
96 Hour Follow-Up 
(Day 11± 1 Day) 
 
 
 
 
 
 
End of Study Phone 
(Day 38 ± 7 Days) 
 
 
 
Unscheduled,  
as needed 
 
AE assessment, status of AD, assessment of 
concomitant medications, confirm pregnancy status 
of female participants of child-bearing potential 
who do not self-report as pregnant 
Collect unused investigational product and any dispensed empty packets, review participant diary, AE 
assessment, AD assessment, perform pregnancy test on female participants of child-bearing potential 
who do not self-report as pregnant, assessment of concomitant medications, vital signs, photos of 
lesional AD and non-lesional sites,  collect lesional and non-lesional skin swabs,  dispense new 
investigational product and participant diary 
Collect unused investigational product and any dispensed empty packets, review participant diary, AE 
assessment, AD assessment, perform pregnancy test on female participants of child-bearing potential 
who do not self-report as pregnant, assessment of concomitant medications, vital signs, photos of 
lesional AD and non-lesional sites, collect lesional and non-lesional skin swabs, dispense participant diary 
Review participant diary, AE assessment, AD assessment, assessment of concomitant medications, vital 
signs, photos of lesional AD and non-lesional sites, collect lesional and non-lesional skin swabs 
 AE assessment, AD Assessment, perform pregnancy test on female participants of child-bearing 
potential who do not self-report as pregnant, assessment of concomitant medications, vital signs, 
photos of lesional AD and non-lesional sites, collect lesional and non-lesional skin swabs 
AE assessment, physical exam, AD assessment, assessment of concomitant medications, vital signs, 
photos of lesional AD and non-lesional sites, collect lesional and non-lesional skin swabs, blood collection 
36 participants 
TMT  
18 participants 
placebo  

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3.2. Primary Endpoint 
The count of serious and non-serious treatment-emergent AEs per participant during the time period of Day 0 to Day 8 
3.3. Secondary Endpoints 
1. The occurrence of at least one serious or non-serious treatment-emergent AE during the time period of Day 0 to 
Day 8 
2. The count of serious and non-serious AEs per participant during study participation 
3. The occurrence of at least one serious or non-serious AE during study participation 
4. The Eczema Area and Severity Index (EASI) score of the ventral arms at Days 0, 4, 7, 8 and 11 
5. The Scoring Atopic Dermatitis (SCORAD) score at Days 0, 4, 7, 8 and 11 
6. The Pruritus Visual Analog Scale (VAS) score of the ventral arms at Days 0, 4, 7, 8 and 11 
7. The Rajka-Langeland (RL) score at Days 0 and 7 
8. The abundance of CoNS as measured by CFU/cm2 and qPCR (rCFU/cm2) on lesional and non-lesional skin at Days 
0, 4, 7, 8 and 11 
9. The change from baseline levels of CoNS bacteria abundance as measured by CFU/cm2 and qPCR (rCFU/cm2) on 
lesional and non-lesional skin at Days 0 (1 hour post treatment), 4, 7, 8 and 11 
10. The change from baseline levels of S. hominis A9 bacteria abundance as measured by qPCR (rCFU/cm2) on 
lesional and non-lesional skin at Days 0 (1 hour post treatment), 4, 7, 8 and 11 
11. The abundance of S. aureus, as measured by CFU/cm2 and qPCR (rCFU/cm2) on lesional and non-lesional skin at 
Days 0, 4, 7, 8 and 11 
12. The change from baseline levels of S. aureus abundance, as measured by CFU/cm2 and qPCR (rCFU/cm2) on 
lesional and non-lesional skin at Days 0 (1 hour post treatment), 4, 7, 8 and 11 
13. The abundance of bacterial DNA (rCFU/cm2) on lesional and non-lesional skin at Days 0, 4, 7, 8 and 11; specific 
bacteria of interest are the following: 
a. Combined S. hominis 
b. Combined Staphylococci 
c. Combined bacteria 
3.4. Exploratory Endpoint 
1. The proportion (% relative abundance) by Phylum: Class and Shannon Diversity Index of the microbiome on 
lesional and non-lesional skin at Day 7 after completion of 1 week of TMT or placebo application 
3.5. Stratification, Randomization, and Blinding/Masking 
Approximately 54 participants with a positive S. aureus colonized lesion on their ventral upper extremity will be 
randomized 2:1 to receive either TMT or placebo for 1 week. Randomization will be performed centrally at the Statistical 
and Clinical Coordinating Center (SACCC) using a stratified block randomization design. The design will stratify by S. 
aureus abundance (low or high abundance) between treatment arms by clinical site. S. aureus abundance will be 
assessed at Screening, or at the Repeat Culture Visit for those requiring a medication/ therapy washout of more than 14 
days, and will be based on quadrant growth on blood agar plates (score 1-4). A score of 1 will be classified as low 
abundance and scores 2-4 will be classified as high abundance.  
Clinical staff and laboratory staff processing and analyzing samples will be blinded to participant treatment assignments. 
Since analysis of samples can be unblinding, samples from a participant will only be analyzed after completion of Day 38 
or early termination from the study. Samples from a pre-selected minimum number of participants, across time points, 
will be batched for analysis. The CFU analyses will batch lesional and non-lesional skin swabs separately. The qPCR 
analyses will collectively batch lesional and non-lesional skin swabs. Within each batch, all applicable samples will be 
analyzed in a random order to ensure that laboratory staff cannot associate sample results to a single participant.  

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An unblinded pharmacist will dispense the assigned treatment. To maintain study blind the packaging and appearance of 
the TMT and placebo will be identical. 
3.5.1. Procedure for Unblinding 
If a clinically significant event occurs and knowledge of the treatment assignment is required, the study 
treatment may be unblinded. Unblinding must be approved by the Division of Allergy, Immunology, and 
Transplantation (DAIT) /NIAID Medical Monitor unless an immediate life threatening condition has developed 
and the DAIT/NIAID Medical Monitor is not accessible. The site investigator will notify DAIT/NIAID Medical 
Monitor of the unblinding event on the next business day, following the emergency unblinding. The emergency 
unblinding will also be reported to the Data and Safety Monitoring Board (DSMB).  
A full account of the event will be recorded, including the date and time of the unblinding, the reason for the 
decision to unblind, and the name of the individual who made the decision, and the names of the DAIT/NIAID 
Medical Monitor, and others who were notified. The reasons for unblinding of a participant’s treatment will be 
documented. 
Unblinding will also occur for IND Safety Reports that will be reported to the Food and Drug Administration 
(FDA), DSMB, and Institutional Review Board (IRB) as specified in the current FDA IND Safety Reporting 
guidance.  
 
Unblinding the study due to an approved interim analysis, final analysis, or study termination will require written 
approval from NIAID. 
4. Selection of Participants and Clinical Sites/Laboratories 
4.1. Rationale for Study Population 
In AD, a state of microbial imbalance known as dysbiosis occurs and is closely associated with disease severity. An 
important characteristic of the dysbiosis in AD is an increased abundance of S. aureus and a decrease in overall bacterial 
diversity. Several lines of experimental evidence support the concept that the multiple defects in epithelial barrier 
function in AD promote dysbiosis and that this dysbiosis then promotes the immunological disorder characteristic of AD. 
These characteristics, dysbiosis and immunological disorder, make AD patients most suitable for the transplant of 
beneficial skin microbiome species to help regulate the imbalance. AD patients will also be used as the control 
population. This study will be limited to adult moderate-to-severe AD participants, ages 18-80 years. 
4.2. Inclusion Criteria 
Individuals who meet all of the following criteria are eligible for enrollment as study participants:  
1. Participant must be able to understand and provide informed consent 
2. Male or female participants 18-80 years of age, inclusive at time of Screening Visit 
3. Meet ADRN Standard Diagnostic Criteria (Appendix A) for active AD  
4. Positive S. aureus colonized lesion, at least 15 cm2, on the ventral upper extremity 
5. An Investigator Global Assessment (IGA) score, on the ventral arms, of at least moderate severity 
6. Body surface area (BSA), as measured by Mosteller BSA Calculator, between 1.26 m2 and 2.25 m2 
7. Females of childbearing potential who are willing to use adequate contraception 30 days prior to the Screening 
Visit and until participation in the study is complete. Females of childbearing potential must agree to use an 
acceptable method of birth control (e.g. total abstinence, oral contraceptives, intrauterine device (IUD), barrier 
method with spermicide, surgical sterilization or surgically sterilized partner, Depo-Provera, Norplant, NuvaRing, 
or hormonal implants) for the duration of study participation. 

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8. Male participants who are willing to use an acceptable method of contraception (e.g. barrier methods with 
spermicide, surgical sterilization, or surgically sterilized partner) or practice abstinence until participation in the 
study is complete. 
4.3. Exclusion Criteria 
Individuals who meet any of these criteria are not eligible for enrollment as study participants:  
1. Inability or unwillingness of participant to give written informed consent or comply with study protocol 
2. Pregnant or lactating females, or females who desire to become pregnant and/or breast feed within the 
duration of study participation 
3. Active bacterial, viral, or fungal skin infections  
4. Any noticeable breaks or cracks in the skin on the upper extremities, including severely excoriated skin or skin 
with open or weeping wounds suggestive of an active infection or increased susceptibility to infection 
5. Sensitivity to or difficulty tolerating Dove fragrance-free bar soap, Cetaphil® Lotion, alcohol-based cleaners, 
macadamia nuts, soy, Vegetable glycerin, or palm kernels  
6. Participants with prosthetic heart valves, pacemakers, intravascular catheters, or other foreign or prosthetic 
devices 
7. Participants with Netherton’s syndrome or other genodermatoses that result in a defective epidermal barrier 
8. Any participant who is immunocompromised (e.g. history of lymphoma, Human Immunodeficiency Virus (HIV)/ 
Acquired Immune Deficiency Syndrome (AIDS), Wiskott-Aldrich Syndrome) or has a history of malignant disease 
(with the exception of non-melanoma skin cancer) 
9. Participants with a history of psychiatric disease or history of alcohol or drug abuse that would interfere with the 
ability to comply with the study protocol 
10. Past or current medical problems or findings from physical examination or laboratory testing that are not listed 
above, which, in the opinion of the investigator, may pose additional risks from participation in the study, may 
interfere with the participant’s ability to comply with study requirements or that may impact the quality or 
interpretation of the data obtained from the study 
11. Ongoing participation in another investigational trial or use of investigational drugs within 8 weeks, or 5 half-
lives (if known), whichever is longer, of the Screening Visit 
12. Treatment with biologics within 16 weeks of Screening Visit  
13. Participants with close contacts (e.g. spouses, children, or members in the same household) that have severe 
barrier defects or are immunocompromised  
14. Use of topical (including steroids and calcineurin inhibitors) AD treatments within 7 days of the Treatment 
Initiation Visit; Use of topical steroids on areas outside of where investigational product is to be applied may be 
permitted, per investigator discretion 
15. Treatment of AD with prescription moisturizers classified as medical device (e.g., Atopiclair®, MimyX®, 
Epiceram®, Cerave®, etc.) within 7 days of the Treatment Initiation Visit 
16. Use of any oral or topical antibiotics within 7 days of the Treatment Initiation Visit 
17. Participants who have taken a bleach bath within 7 days of the Treatment Initiation Visit 
18. Use of any oral AD therapies (steroids, immunosuppressive therapies) within 28 days of the Treatment Initiation 
Visit  
19. Any phototherapy for skin disease (such as narrow band ultraviolet B [NBUVB], ultraviolet B [UVB], ultraviolet A1 
[UVA1], psoralen + UVA [PUVA]) or regular use (more than 2 visits per week) of a tanning bed within 28 days of 
the Treatment Initiation Visit 
 

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5. Known and Potential Risks and Benefits to Participants 
5.1. Risks of Investigational Product or Intervention as cited in Investigator Brochure  
There is a theoretical risk of skin infection associated with the application of allogeneic TMT, although the likelihood of 
participants developing a skin infection is low given that we will only be transplanting non-pathogenic bacteria that have 
AMP-producing abilities onto the skin of participants. Furthermore, we will be applying these bacteria topically and will 
examine all participants prior to application to ensure that they do not have any cracks or excoriated skin on their arms. 
Theoretical risks of contact dermatitis to Vegetable glycerin or Cetaphil® lotion are also possible both with the TMT 
product and the placebo. Participants will be instructed to avoid applying lotion to mucosal surfaces such as the 
conjunctiva. If applied to mucosal surfaces, there may be a higher risk of irritation or infection. We will also avoid 
applying the investigational product (IP) to the hand since the hand would be a likely source of spreading these bacteria 
onto other surfaces that other people may contact. Disposable nitrile gloves will be provided to participants to use 
during application of the allogeneic TMT or placebo. Participants with close contacts (e.g. spouses, children, or members 
in the same household) that have severe barrier defects or are immunocompromised will be excluded from 
participating, per study exclusion criteria.  
Should an infection occur, the participant would be treated according to standard treatment including antibiotics (for 
infection) and ointment (for irritation and dryness). Refer to Section 7.4 for more information on rescue medications. 
Contact allergic reactions to Cetaphil® lotion or Vegetable glycerin will be treated with mid-potency topical steroids such 
as fluocinonide ointment 0.05%.  
5.2. Risks of Investigational Product or Intervention cited in Medical Literature 
Not Applicable 
5.3. Risks of Other Protocol Specified Medications 
In the event of infection, the elected rescue treatment will follow guidelines specified in Section 7.4. There is theoretical 
risk associated with the use of topical or oral antibiotics as a rescue medication. Specific risks will vary between 
treatments. In general risks of antibiotics are hypersensitivity, urticaria, nausea, vomiting, diarrhea, sun sensitivity, 
anaphylaxis, and death.  
5.4. Risks of Study Procedures  
5.4.1. Risks Associated with Stopping the Use of Protocol Prohibited Medications/Therapies 
AEs associated with stopping the use of protocol-prohibited medications/therapies may include 
worsening of the condition being treated and will be reported as such. In an effort to minimize these 
risks, participants with severe AD who may have difficulty tolerating periods without 
medication/therapy use will be excluded from participating, per study exclusion criteria. 
5.4.2. Risks Associated with Skin Swab Collection 
There are no significant risks associated with skin swab collection. 
5.4.3. Risks Associated with Physical Exam 
There are no known risks associated with the physical exam.  
5.4.4. Risks associated with Questionnaires 
There is a possibility that participants may find questions too personal. Participants may refuse to 
answer any questions that make them feel uncomfortable. There is also a possibility that a participant’s 

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answers may be read by others; however, participants’ records are carefully protected so this is very 
unlikely. See section 16.4 for more information on confidentiality.  
5.4.5. Risks associated with Blood Collection 
Risks associated with drawing blood include possible pain when the needle is inserted, as well as 
bleeding, bruising and/or infection at the puncture site. Some people may experience lightheadedness, 
nausea, or fainting. A numbing agent may be placed on the skin before the blood draw to reduce the 
pain of the stick. Side effects from this cream (mainly skin rash) may occur. There is a potential for slight 
psychological stress from the procedure. If psychological stress is too much in the opinion of the 
participant or the physician/nurse the procedures will be halted. National Institutes of Health (NIH) 
guidelines for blood collection (amount and frequency based on age) will be followed. 
5.5. Potential Benefits 
There may or may not be any direct benefits for the participants who elect to enroll in this study. One potential benefit 
is that the investigational product may improve the participant’s AD; however, there is no guarantee that the product 
will help the participant’s condition. The participant’s skin condition may even get worse by withholding his/her 
previous/regular AD treatment, or the participant could be in the placebo group and not receive active treatment, in 
which case his/her AD may also flare. 
The results of this study may also provide identification and/or validation of new targets for the future development of 
therapeutics for participants with AD, as well as increase current knowledge on the ability to transform the cutaneous 
microbiome, which could lead to potential therapeutic strategies for treating a variety of inflammatory skin conditions. 
6. Investigational Agent  
6.1. Investigational Agent 
6.1.1. Targeted Microbiome Transplant Lotion (TMT) 
6.1.1.1. 
Formulation, Packaging, and Labeling 
The allogeneic TMT product will be manufactured and packaged at UCSD. The UCSD Manufacturing Lab has 
isolated Staphylococcus hominis strain A9 from the skin surface of a healthy donor. This S. hominis A9 strain 
produces potent antimicrobial activity against S. aureus. UCSD has characterized antimicrobial peptides 
produced by this strain with protein purification, protein sequencing, and genomic sequencing approaches. 
The UCSD Manufacturing Lab will establish the Master Cell Bank (MCB) of the S. hominis A9 strain, and it will 
be stored in a locked -80oC freezer at UCSD. The Working Cell Bank (WCB) will be prepared from a single 
colony of the MCB and stored in a locked -80oC freezer at UCSD. 
 
Each batch of the allogeneic TMT product will be prepared from a single-use vial from the WCB. A vial of the 
S. hominis A9 from the WCB will be thawed and cultured in animal-free tryptic soy broth (TSB) media at 37°C 
to expand the number of S. hominis A9. Bacterial concentration will be assessed, after culturing, by OD600. 
The cultured bacteria will then be washed twice with an equal volume of normal saline (NS) to remove the 
animal-free TSB. Based on pre-clinical data, proteins are undetectable in the supernatant after the second 
wash. Bacterial density of the resuspension will be measured by OD600. 
 
Washed bacteria will be sterilely mixed in 50% Cetaphil® lotion and 50% Vegetable glycerin using a sterile 
bowl and sterile spatula. Each batch will be assigned a unique lot number and will undergo a visual test for 

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appearance, Microbial Limits Testing in accordance with U. S. Pharmacopeial Convention (USP) <61> and 
<62> testing, potency testing by bacterial concentration testing and radial diffusion testing, and identity 
testing by polymerase chain reaction (PCR) for the hogocidin gene. Two gram aliquots of final allogeneic 
TMT product will be transferred into sterile heat-sealing pouches with a sterile dispenser under the sterile 
hood. The packet will be sealed with a heat-sealer. Twenty-two single-use packets will be grouped in boxes 
and labeled with the lot number and box ID. Pre-labeled boxes will be provided to the UCSD Manufacturing 
Lab by Eminent. Packaged boxes will be stored in a -80°C freezer at UCSD until shipment to clinical sites. 
After packaging, one percent of single-use packets will be selected and potential pathogens will be screened 
for Microbial Limits Testing in accordance with USP <61> and <62> testing, visual appearance testing, and 
also undergo potency testing by bacterial concentration testing and radial diffusion testing, and identity 
testing by PCR for the hogocidin gene. The final TMT product will be formulated at a S. hominis A9 
concentration range from 1 x 106 CFU of bacteria/gram Vegetable glycerin-Cetaphil® to 2 x 109 CFU of 
bacteria/gram Vegetable glycerin-Cetaphil® 
Potency testing will be performed by both the radial diffusion assay and bacterial concentration testing. 
Potency of TMT is acceptable if 4 out of 5 S. hominis A9 colonies grown from the TMT product show S. 
aureus inhibition zones greater than 1 mm in diameter. Bacterial concentration of the TMT will be checked 
by plating a known quantity of the TMT on an agar plate and incubating the plate overnight at 37 ̊ C. The 
number of viable colonies will be counted the following day. All colonies will be checked to ensure they 
show the same morphology. Only TMT that has a final concentration of bacteria that ranges from 1 x 
106 CFU of bacteria/gram Vegetable glycerin-Cetaphil® to 2 x 109 CFU of bacteria/gram Vegetable glycerin-
Cetaphil® will be used in the clinical trial.  
Identity testing will be confirmed by the presence of the Hogocidin- α gene by PCR.  
Any TMT that does not meet these requirements will be discarded as per UCSD’s hazardous waste protocol.  
6.1.1.2. 
 Dosage, Preparation, and Administration 
6.1.1.2.1. 
Dosage 
6.1.1.2.1.1. Targeted Density of Transplanted CoNS 
There is considerable variability in the abundance of CoNS bacteria on human skin. A recent 
unpublished study by the UCSD laboratory has found CoNS bacteria with antimicrobial activity can 
be detected at a range of abundance between 1 x102 CFU/cm2 and 1 x107CFU/cm2. No deleterious 
effects were observed in participants colonized at this density, but participants with this range of 
antimicrobial CoNS abundance were not colonized by S. aureus. Therefore, the application of CoNS 
in a lotion formulation to a final density of as low as 102 CFU/cm2 can be predicted to be effective at 
inhibiting S. aureus, and a density as high as 1 x 10 7CFU/cm2 is within the density typically observed 
on human skin and can be considered safe. 
Using the body surface area calculations of Mosteller (Mosteller 1987), we estimate that the 
smallest potential participant of 4’10” and 85 pounds has a BSA of 1.26 m2. The largest participant of 
6’3” and 210 pounds has a BSA of 2.25 m2. Using the Rule of Nines, each arm is estimated as 9% of 
the total BSA. Therefore, the ventral surface would be 4.5% of the total BSA. Since one hand is 1% of 

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BSA, the ventral surface of one arm not including the hand would be 3.5% of BSA. Thus the smallest 
participant has an area on their ventral arm of 441 cm2, and the largest participant 787 cm2.  
We seek to achieve a final concentration of 1x 105 CFU/cm2 of transplanted bacteria on the skin 
which mimics the concentration on normal skin. To achieve this, the investigational product will be 
formulated at a final concentration of bacteria that ranges from 1 x 106 CFU of bacteria/gram 
Vegetable glycerin-Cetaphil® to 2 x 109 CFU of bacteria/gram Vegetable glycerin-Cetaphil®, and a 
total mass of 2 g of product will be applied to each participant’s arm twice a day. The acceptable 
dosage range will be between 2 x 103 CFU/cm2 and 1 x 107 CFU/cm2 to account for variability in 
participant surface area, bacteria survival, and loss of product during application. This range is 
within the predicted effective and safe concentration of 102 CFU/cm2 to 107 CFU/cm2. 
6.1.1.2.2. 
Preparation 
Boxed TMT packets, 22 packets per box, will be shipped to clinical sites on dry ice and stored at -80°C 
until dispensation to study participants. TMT will be thawed to 4˚C prior to the first IP administration in 
clinic at the Treatment Initiation (Day 0) Visit. Four packets of TMT will be applied in clinic. The 
remaining TMT, 18 packets, will be dispensed to participants with instructions that the packets should 
be stored at 4˚C. An additional supply of TMT product, 22 packets, will be dispensed to participants at 
their Mid-Treatment (Day 4) Visit.  
6.1.1.2.3. 
Administration  
The TMT will be provided in single-dose sealed packets. The lotion should be stored at 4°C. Participants 
randomized to active TMT will apply 2 g of TMT to each ventral upper extremity (wrist to upper arm) 
twice a day for one week.  
6.1.2. Placebo 
6.1.2.1. 
Formulation, Packaging, and Labeling 
Formulation of matching placebo will be identical to TMT, but without the bacteria and will be supplied in 
identical boxes of sterile single-use packets. Each single-use packet will contain 2 g of placebo containing 
50% Vegetable glycerin and 50% Cetaphil® moisturizing lotion. Prior to shipping, each batch of placebo will 
undergo quality control testing, and additionally one percent of the aliquots will be randomly selected for 
release testing after packaging into single-use packets. Each aliquot will undergo Microbial Limits Testing in 
accordance with USP <61> and <62> testing. If the product is not free from contaminants in accordance with 
USP <61> and <62> testing, the entire lot will be discarded appropriately, and will not be provided to clinical 
sites.  
6.1.2.2. 
Dosage, Preparation, and Administration 
6.1.2.2.1. 
Dosage 
Each single-use packet will contain 2 g of placebo containing 50% Vegetable glycerin and 50% Cetaphil® 
moisturizing lotion. 
6.1.2.2.2. 
Preparation 
Boxed placebo packets, 22 packets per box, will be shipped to clinical sites on dry ice, and stored at -
80°C until dispensation to study participants. Placebo will be thawed to 4˚C prior to the first IP 
administration in clinic at the Treatment Initiation (Day 0) Visit. Four packets of placebo will be applied 

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in clinic. The remaining placebo, 18 packets, will be dispensed to participants with instructions that the 
packets should be stored at 4°C. An additional supply of placebo, 22 packets, will be dispensed to 
participants at their Mid-Treatment (Day 4) visit.  
6.1.2.2.3. 
Administration 
Placebo will be provided in single-dose sealed packets. The lotion should be stored at 4˚C. Participants 
randomized to placebo will apply 2 g of placebo to each ventral upper extremity (wrist to upper arm) 
twice a day for one week.  
6.2. Investigational Products Accountability 
Under Title 21 of the Code of Federal Regulations (21CFR §312.62), the investigator will maintain adequate records of 
the disposition of the investigational products, including the date and quantity of the product received, to whom the 
product was dispensed (participant-by-participant accounting), and a detailed accounting of any product accidentally or 
deliberately destroyed. Details of investigational product dispensation to each participating site will be maintained by 
the manufacturing lab.  
Records for receipt, storage, use, and disposition will be maintained by the study site. A product-dispensing log will be 
kept current for each participant. This log will contain the study identification number of each participant and the date 
and quantity of product dispensed. 
All records regarding the disposition of the investigational product will be available for inspection. At the termination of 
the study, all unused product will be destroyed. For more information on handling of the investigational product please 
refer to the manual of procedures (MOP).  
6.3. Assessment of Participant Compliance with Investigational Agent 
Each clinical site will keep an inventory of TMT and placebo packets with information on date of original preparation, 
and date received on site. Participants will be required to return all packets of product dispensed, used or unused. Study 
staff will record the count of opened, unopened, and missing packets. A reconciliation of recorded data per box, prior to 
dispensation and after, will be used to assess compliance. In addition, participants will record completed and missed 
applications in their participant diary.  
6.4. Toxicity Prevention and Management 
All steps will be taken to minimize potential risks of the study. Participants with known sensitivities/allergies to any of 
the products used during this study will be excluded from enrollment and study participation. Participants with any 
cracks or breaks in their skin, including severely excoriated or bleeding skin suggesting that the participant may be 
susceptible to an infection will be excluded. Similarly, participants with prosthetic or implanted devices will also be 
excluded. Any AE, defined as any undesirable sign, symptom, or medical condition occurring after the participant’s 
written consent to participate is completed, will be recorded and reported to the Principal Investigator (PI), DAIT/NIAID, 
FDA, and the IRB as required. If the PI believes an AE is possibly related to the study, the PI will determine whether or 
not it is in the best interest of the participant to continue in the study. If the participant is injured as a result of 
participation in this research, treatment will be available at the clinical center where they are completing the study. 
Further details of the services, including costs and coverage will be explained in the informed consent, signed by the 
participant. In the case of a skin infection, the participant would be treated according to standard treatment practices. 
The treatment will include antibiotics (for infection) and Cetaphil® moisturizing lotion (for irritation and dryness). Refer 
to Section 7.4 for more information on rescue medications.  

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6.5. Premature Discontinuation of Investigational Products 
Investigational products may be prematurely discontinued for any participant for any of the following reasons: 
1. Evidence of infection either cutaneously or systemically. 
2. Severe worsening of AD which in the opinion of the investigator requires stopping of the investigational product. 
3. Evidence of contact allergy to investigational product. 
4. Evidence of non-compliance to study protocol or eligibility criteria that in the opinion of the investigator 
requires discontinuation of investigational product. 
5. Any serious or unexpected AE that is possibly or definitely related to the investigational product.  
6. Pregnancy in a female participant or in a partner of a male participant.  
Investigational product may also be prematurely discontinued for any participant if the investigator believes that 
continuing use of the investigational product is no longer in the best interest of the participant. 
If a participant is prematurely discontinued from investigational product, the participant will be asked to complete any 
remaining study visits, per protocol, through Day 38.  
7. Other Medications 
7.1. Concomitant Medications 
7.1.1. Protocol-mandated 
Not Applicable 
7.1.2. Other permitted concomitant medications 
During study participation, participants are permitted to use topical steroids per discretion of the 
investigator on areas of their body outside of the investigational product treatment areas.  
 
Use of antihistamines will not be exclusionary for protocol enrollment. However, participants using 
antihistamines at the time of the Treatment Initiation Visit will be asked to maintain a stable dose until 
their completion of the 96 Hour (Day 11) Follow-Up Visit.  
 
7.2. Prophylactic Medications 
Female participants of child-bearing potential must use an effective method of contraception (e.g. total abstinence, oral 
contraceptives, IUDs, barrier method with spermicide, surgical sterilization or surgically sterilized partner, Depo-Provera, 
Norplant, NuvaRing, or hormonal implants) for the duration of study participation. Male participants must also use an 
acceptable method of contraception (e.g. barrier methods with spermicide, surgical sterilization, or surgically sterilized 
partner) or abstain until participation in the study is complete.  
Pregnancy tests will be performed on female participants of child-bearing potential who do not self-report as pregnant 
at the Screening, Repeat Culture, Treatment Initiation (Day 0), Mid-Treatment (Day 4), and End of Treatment (Day 7) 
Visits, and a final pregnancy test will be conducted at the 96 Hour Follow-Up Visit (Day 11). These participants will also 
be asked during their End of Study (Day 38) Phone Visit whether they have tested positive to a pregnancy test since their 
last study visit.  
Male participants will be asked if a partner has tested positive to a pregnancy test at the Screening, Repeat Culture, 
Treatment Initiation (Day 0), Mid-Treatment (Day 4), End of Treatment (Day 7), 96 Hour Follow-Up Visit (Day 11), and 
End of Study (Day 38) Visits.  

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All reported pregnancies, in female participants and the partners of male participants will be followed as described in 
Section 12.6. 
7.3. Prohibited Medications/Therapies 
Until participant completion of the 96 Hour (Day 11) Follow-Up Visit, participants are prohibited to use the following 
medications/therapies: 
• 
Topical AD treatments (including steroids and topical calcineurin inhibitors); Use of topical steroids on 
areas outside of where investigational product is applied is permitted per investigator discretion, as 
described in Section 7.1.2. 
• 
Any lotions or creams other than Cetaphil ® moisturizing lotion (provided by the research clinic) 
including, prescription moisturizers classified as a medical device (e.g., Atopiclair®, MimyX®, Epiceram®, 
Cerave®, etc.) 
• 
Oral or topical antibiotics 
• 
Bleach baths 
• 
Oral AD therapies (steroids, immunosuppressive therapies) 
• 
Phototherapy (such as NBUVB, UVB, UVA1, PUVA) or tanning beds 
7.4. Rescue Medications  
If infection occurs, treatment will include topical and/or oral antibiotics depending on the severity of the infection 
clinically, and Cetaphil® moisturizing lotion (for irritation and dryness). The antibiotic sensitivity profile of Staphylococcus 
hominis A9, includes sensitivity to Mupirocin, Clindamycin, Linezolid, Rifampin, Trimethoprim, Sulfamethoxazole, 
Vancomycin, Cefazolin, Daptomycin, and Oxacillin; intermediate sensitivity to Erythromycin, and Ciprofloxacin; and 
resistant to Penicillin G and Tetracycline. Thus the topical antibiotic of choice will be Mupirocin. The oral antibiotic of 
choice will depend on the individual participant’s medical history, including any possible contraindications to certain 
medications due to allergies or other concomitant medication use, but Dicloxacillin will be the first line oral antibiotic, 
followed by Trimethoprim/Sulfamethoxazole or Clindamycin. Contact allergic reactions to Cetaphil® lotion or Vegetable 
glycerin or palm kernels will be treated with mid-potency topical steroids such as fluocinonide ointment 0.05%.  
8. Study Procedures 
A summary of complete study procedures is included in Appendix B Schedule of Events.  
8.1. Recruitment Visit 
Potential participants will be recruited using standardized questionnaires that collect contact information and disease 
status related to inclusion and exclusion criteria. Participants may be recruited by phone or in person. Those who have 
no obvious characteristics making them ineligible for the study and who are interested in participating will be invited to 
clinic to complete the Screening Visit.  
8.2. Screening Visit (Day -38 ± to -2) 
The purpose of the Screening Visit is to confirm eligibility to continue in the study. During the visit, written informed 
consent will be obtained from the participant prior to performing any other study procedures.  
The following procedures, assessments, and laboratory measures will be conducted to determine participant eligibility:  
• 
Collection of demographics 

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• 
Medical History and physical examination, including assessment of AD severity (IGA of ventral arms, EASI 
of ventral arms, SCORAD and Pruritus VAS of ventral arms) by a study physician or other qualified 
medical professional 
• 
Urine pregnancy test for female participants of child-bearing potential who do not self-report as 
pregnant 
• 
Assessment of concomitant medications 
• 
Vital signs, plus height and weight  
• 
Skin Swab Collection to assess for S. aureus colonization 
• 
Assessment of AEs 
Participants who meet inclusion and exclusion criteria including the required washout periods for medications/therapies 
will have a skin swab collected. Participants who do not meet inclusion and exclusion criteria due to assessment of their 
concomitant medications/therapies will be asked whether they would be willing to washout of their 
medications/therapies if they are eligible based on their preliminary swab. Participants who agree to the washout will 
have a skin swab collected for a preliminary assessment of S. aureus colonization. Participants who do not wish to 
washout out of the prohibited medications/therapies will be identified as screen failures and will not continue in the 
study.  
Participants who are eligible at this point will be given Dove moisturizing soap and will be instructed to use it whenever 
they shower, but to avoid the upper extremities. Participants will be given an instructional hand card with restrictions on 
bathing/showering, exercise, and use of emollient. Participants will be instructed to refrain from swimming in 
chlorinated pools and hot tubs for the duration of the study. Participants will be provided emollient for use outside of 
the treatment area. At the conclusion of this visit, participants will be instructed to refrain from the use of prohibited 
medications/therapies as described in Section 7.3. Female participants of child-bearing potential and male participants 
will be instructed to use an acceptable method of contraception as defined in Section 7.2.  
8.3. Post-Screening Phone Visit (Day -37 to -1) 
The purpose of the Post-Screening Phone Visit is to inform the participant of his/her eligibility based on whether the 
lesional swab culture was positive for S. aureus and to assess for AEs.   
Participants who tested positive for S. aureus and require a medication/ therapy washout of 14 days or less will be 
eligible and will be asked to schedule their Day 0 Treatment Initiation Visit. These participants must be randomized 
within 14 days of their Screening Visit.  
Participants who tested positive for S. aureus and require a medication / therapy washout of more than 14 days to meet 
the full inclusion and exclusion criteria prior to receiving study treatment will be required to complete a Repeat Culture 
Visit following their washout. The washout periods will be defined such that the participant’s Day 0 Treatment Initiation 
Visit can occur within the visit Window of the Day -14 Post-Culture Phone Visit.  
Participants who tested negative for S. aureus and those who tested positive but do not wish to complete the 
medication/therapy washout will be identified as screen failures. These participants may resume the use of prohibited 
medications/therapies, bathing/showering, exercising, and swimming without restrictions, and the use of the soap and 
emollient of their choice.  
Participants who are continuing in the study at this point will be reminded to use Dove moisturizing soap, whenever 
they shower, but to avoid the upper extremities. Participants will be given instructions regarding restrictions on 

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bathing/showering, exercise, and use of emollient. Participants will be reminded to refrain from swimming in 
chlorinated pools and hot tubs and to refrain from the use of prohibited medications/therapies as described in Section 
7.3. Female participants of child-bearing potential and male participants will be instructed to use an acceptable method 
of contraception as defined in Section 7.2. 
8.4. Repeat Culture Visit, as needed (Day -15 to -2) 
The purpose of the Repeat Culture Visit is to confirm if the participant is still S. aureus culture positive, following the 
protocol mandated medication/therapy washout. This visit will only be required for participants who were S. aureus 
positive at their Screening Visit and required a medication/therapy washout of more than 14 days to meet full inclusion 
and exclusion criteria.  
The following procedures, assessments, and laboratory measures will be conducted to determine participant eligibility:  
• 
Interim medical history and physical examination, including assessment of AD severity (IGA of ventral 
arms, EASI of ventral arms, SCORAD, and Pruritus VAS of ventral arms) by a study physician or other 
qualified medical professional 
• 
Urine pregnancy test for female participants of child-bearing potential who do not self-report as 
pregnant 
• 
Assessment of concomitant medications 
• 
Vital signs 
• 
Skin Swab Collection for assessment of S. aureus colonization 
• 
Assessment of AEs 
Participants who are still eligible at this point will have a skin swab collected and will be instructed to use Dove 
moisturizing soap whenever they shower, but to avoid the upper extremities. Participants will be given instructions 
regarding restrictions on bathing/showering, exercise, and use of emollient. Participants will be reminded to refrain 
from swimming in chlorinated pools and hot tubs and to refrain from the use of prohibited medications/therapies as 
described in Section 7.3. Female participants of child-bearing potential and male participants will be instructed to use an 
acceptable method of contraception as described in Section 7.2. 
8.5. Post-Culture Phone Visit, as needed (Day -14 to-1) 
The purpose of the Post-Culture Phone Visit is to inform the participant of his/her eligibility based on whether his/her 
repeat lesional swab culture was positive for S. aureus and to assess for AEs.  Participants who tested positive for S. 
aureus will be eligible and will be asked to schedule their Day 0 Treatment Initiation Visit. These participants will be 
reminded to use Dove moisturizing soap whenever they shower, but to avoid the upper extremities. Participants will be 
given instructions regarding restrictions on bathing/showering, exercise, and use of emollient. Participants will be 
reminded to refrain from swimming in chlorinated pools and hot tubs and to refrain from the use of prohibited 
medications/therapies as described in Section 7.3. Female participants of child-bearing potential and male participants 
will be instructed to use an acceptable method of contraception as described in Section 7.2. 
Participants who tested negative for S. aureus and those who tested positive but do not wish to continue the 
medication/therapy washout will be identified as screen failures. These participants may resume the use of prohibited 
medications/therapies, bathing/showering, exercising, and swimming without restrictions, and the use of the soap and 
emollient of their choice. Screen failures may rescreen in 7 days. 

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8.6. Treatment Initiation Visit (Day 0) 
The purpose of the Day 0 Treatment Initiation Visit is to initiate study treatment. The following procedures, 
assessments, and laboratory measures will be conducted at this initial treatment visit: 
• 
Interim medical history and physical examination, including assessment of AD severity (EASI of ventral 
arms, RL, SCORAD, and Pruritus VAS of ventral arms) by study physician or other qualified medical 
professional 
• 
Urine pregnancy test for female participants of child-bearing potential who do not self-report as 
pregnant 
• 
Assessment of concomitant medications 
• 
Vital Signs 
• 
Randomization 
• 
AD Lesion Assessment, including photographs of the measured lesional and non-lesional sites 
• 
Lesional and non-lesional skin swab collection for assessment of live S. aureus and CoNS colonization by 
CFU quantification and the assessment of bacterial genomic DNA by qPCR and 16S ribosomal ribonucleic 
acid (rRNA) sequencing 
• 
TMT or placebo application 
• 
Participants will remain in clinic for up to 1 hour following the application of investigational product. 
Additional lesional and non-lesional skin swabs for S. aureus and CoNS colonization and  the assessment 
of bacterial genomic DNA by qPCR and 16S rRNA sequencing will be collected at 1 hour post-application. 
• 
TMT or placebo reapplication after 1 hour swab 
• 
Assessment of AEs 
• 
TMT or placebo dispensation with participant instructions to apply twice daily as detailed in the MOP 
• 
Completion of baseline diary entry and review of participant diary. Participants will be instructed to 
complete one diary entry per day until their final clinic visit on Day 8. Participants will be asked to record 
any symptoms and track their compliance for each lotion application in an electronic diary. Paper diaries 
will be provided to track symptoms and compliance in the event participants do not have access to a 
device with internet access.  
At the conclusion of this visit, participants will be reminded to complete their daily diary entry, use Dove moisturizing 
soap, whenever they shower, but to avoid the upper extremities, until after their last in-clinic visit on Day 11 is 
complete. Participants will be given instructions regarding restrictions on bathing/showering, exercise, and use of 
emollient. Participants will be reminded to refrain from swimming in chlorinated pools and hot tubs and to refrain from 
the use of prohibited medications/therapies as described in Section 7.3. Female participants of child-bearing potential 
and male participants will be instructed to use an acceptable method of contraception as described in Section 7.2.  
Participants will be given an instructional hand card describing the symptoms of skin and systemic infections, such as 
pain or swelling at the site of treatment; fever; chills; or night sweats. Participants will be provided instructions on when 
to contact the research clinic if they experience any of the listed symptoms. Contact information for the study physician 
and the 24 hour on call physician will also be listed on the hand card. The physician receiving the call will assess if the 
participant will need to be seen in clinic or if any further treatment is necessary. Alternatively, the participants will be 
instructed to take an emergency contact hand card with them should they seek medical care at another facility. The 
emergency contact hand card will state that the participant is currently in a clinical trial involving the application of non-
pathogenic bacteria to the skin, and will also include a list of the antibiotic sensitivities of S. hominis, and instructions to 
call the research clinic if an infection of the skin or blood is suspected. The hand card will recommend that the acute 

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care physician collect at minimum two skin swabs using a standard sterile swab for culture and speciation, a blood 
culture, and a CBC for local processing, in addition to any other tests they deem medically necessary.  
8.7. Mid-Treatment Visit (Day 4 ± 1 Day) 
The purpose of the Mid-Treatment Day 4 Visit is to return for clinical and AE assessments and dispense a new supply of 
investigational product. Participants will be asked to return to the clinic on Day 4 approximately 4 hours after their last 
investigational product application.  
The following procedures, assessments, and laboratory measures will be conducted at this visit: 
• 
Collection of dispensed product, including empty packets 
• 
Review of participant diary  
• 
Assessment of AEs 
• 
Assessment of AD severity (EASI of ventral arms, SCORAD, and Pruritus VAS of ventral arms) by study 
physician or other qualified medical professional 
• 
Urine pregnancy test for female participants of child-bearing potential who do not self-report as 
pregnant 
• 
Assessment of concomitant medications 
• 
Vital Signs 
• 
AD Lesion Assessment, including photographs of the measured lesional and non-lesional sites 
• 
Lesional and non-lesional skin swab collection for assessment of S. aureus and CoNS colonization by CFU 
quantification and the assessment of bacterial DNA by qPCR and 16S rRNA sequencing 
• 
TMT or placebo dispensation with participant instructions as detailed in the MOP 
• 
Dispensation of paper participant diary  
At the conclusion of this visit, participants will be reminded to complete their daily diary entry, use Dove moisturizing 
soap, whenever they shower, but to avoid the upper extremities, until after their last in-clinic visit on Day 11 is 
complete. Participants will be given instructions regarding restrictions on bathing/showering, exercise, and use of 
emollient. Participants will be reminded to refrain from swimming in chlorinated pools and hot tubs and to refrain from 
the use of prohibited medications/therapies as described in Section 7.3. Female participants of child-bearing potential 
and male participants will be instructed to use an acceptable method of contraception as described in Section 7.2. 
Replacement instructional and emergency contact hand cards, as described in Section 8.6, describing the symptoms of 
skin and systemic infections, sensitivities of S. hominis, and whom to contact at the research clinic if they experience any 
of the listed symptoms will be redistributed to participants, as needed.  
8.8. End of Treatment Visit (Day 7 ±1 Day) 
The purpose of the End of Treatment Visit is to conduct clinical and AE assessments following a one week application of 
TMT or placebo. Participants will be asked to return to the clinic on Day 7 approximately 4 hours after their last lotion 
application.  
The following procedures, assessments, and laboratory measures will be conducted at this visit: 
• 
Collection of dispensed product, including empty packets 
• 
Review of participant diary 
• 
Assessment of AEs 

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• 
Assessment of AD severity (EASI of ventral arms, RL, SCORAD, and Pruritus VAS of ventral arms) by study 
physician or other qualified medical professional.  
• 
Urine pregnancy test for female participants of child-bearing potential who do not self-report as 
pregnant 
• 
Assessment of concomitant medications 
• 
Vital Signs 
• 
AD Lesion Assessment, including photographs of the measured lesional and non-lesional sites 
• 
Lesional and non-lesional skin swab collection for assessment of S. aureus and CoNS colonization by CFU 
quantification and the assessment of bacterial genomic DNA by qPCR and 16S rRNA sequencing  
• 
Dispensation of paper participant diary 
At the conclusion of this visit, participants will be reminded to complete their daily diary entry, use Dove moisturizing 
soap, whenever they shower, but to avoid the upper extremities, until after their last in-clinic visit on Day 11 is 
complete. Participants will be given instructions regarding restrictions on bathing/showering, exercise, and use of 
emollient. Participants will be reminded to refrain from swimming in chlorinated pools and hot tubs and to refrain from 
the use of prohibited medications/therapies as described in Section 7.3. Female participants of child-bearing potential 
and male participants will be instructed to use an acceptable method of contraception as described in Section 7.2. 
8.9. 24 Hour Follow-Up Visit (Day 8) 
The purpose of the 24 Hour Follow-Up Visit is to assess S. aureus and CoNS, including S. hominis A9,  bacteria 
abundance, and AEs after the completion of TMT or placebo application. 
The following procedures, assessments, and laboratory measures will be conducted at this visit: 
• 
Review of participant diary 
• 
Assessment of AEs 
• 
Assessment of AD severity (EASI of ventral arms, SCORAD, and Pruritus VAS of ventral arms) by study 
physician or other qualified medical professional.  
• 
Assessment of concomitant medications 
• 
Vital Signs 
• 
AD Lesion Assessment, including photographs of the measured lesional and non-lesional sites 
• 
Lesional and non-lesional skin swab collection for assessment of S. aureus and CoNS colonization by CFU 
quantification and the assessment of bacterial genomic DNA  by qPCR and 16S rRNA sequencing  
At the conclusion of this visit, participants will be reminded to use Dove moisturizing soap, whenever they shower, but 
to avoid the upper extremities, until after their last in-clinic visit on Day 11 is complete. Participants will be given 
instructions regarding restrictions on bathing/showering, exercise, and use of emollient.  Participants will be reminded 
to refrain from swimming in chlorinated pools and hot tubs and to refrain from the use of prohibited medications/ 
therapies as described in Section 7.3.  Female participants of child-bearing potential and male participants will be 
instructed to use an acceptable method of contraception as described in Section 7.2. 
8.10. 
96 Hour Follow-Up Visit (Day 11 ±1 Day) 
The purpose of the 96 Hour Follow-Up Visit is to assess S. aureus and CoNS, including S. hominis A9,   bacteria 
abundance after the completion of TMT or placebo application. 
The following procedures, assessments, and laboratory measures will be conducted at this visit: 

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• 
Assessment of AEs 
• 
Assessment of AD severity (EASI of ventral arms, SCORAD, and Pruritus VAS of ventral arms) by study 
physician or other qualified medical professional 
• 
Urine pregnancy test for female participants of child-bearing potential who do not self-report as 
pregnant 
• 
Assessment of concomitant medications 
• 
Vital Signs 
• 
AD Lesion Assessment, including photographs of the measured lesional and non-lesional sites 
• 
Lesional and non-lesional skin swab collection for assessment of S. aureus and CoNS colonization by CFU 
quantification and the assessment of bacterial genomic DNA by qPCR and 16S rRNA sequencing  
At the conclusion of this visit, participants may resume prohibited medications/therapies as described in Section 7.3, as 
needed, bathing/showering, exercising, and swimming without restrictions, and may use their choice of soap and 
emollient. Female participants of child-bearing potential and male participants will be instructed to use an acceptable 
method of contraception as described in Section 7.2. 
8.11. 
End of Study Phone Visit (Day 38 ±7 Days) 
The purpose of the Day 38 End of Study Phone Visit is to complete participant follow-up. The visit will occur 
approximately one month following the participant’s scheduled 24 Hour Follow-Up Visit. This visit will be brief, and 
participants will be asked to report any new AEs and to answer questions regarding the status of their AD and 
concomitant medication use. Female participants of child-bearing potential will be asked whether they have tested 
positive to a pregnancy test since their last visit. Male participants will be asked whether their partner has tested 
positive to a pregnancy test since their last visit. Any participant with an ongoing AE/SAE at the time of this phone 
contact will continue to be followed until the event is resolved with or without sequelae or the AE/SAE stabilizes.  
8.12. 
Unscheduled Visits  
If disease activity increases, participants experience signs and symptoms as described on the study hand card, or other 
concerns arise between regularly scheduled visits, participants will be instructed to contact study personnel and may be 
asked to return to the study site for an “unscheduled” visit.  
The following procedures, assessments, and laboratory measures will be conducted at the unscheduled visit: 
• 
Assessment of AEs 
• 
Physical examination, including assessment of AD severity (EASI of the ventral arms, SCORAD, and 
Pruritus VAS of ventral arms) by study physician or other qualified medical professional 
• 
Assessment of concomitant medications 
• 
Vital Signs 
• 
AD Lesion Assessment, including photographs of the measured lesional and non-lesional sites 
• 
Skin Swab collection, per investigator discretion 
• 
Blood collection, per investigator discretion 
If a participant presents to the research clinic with a suspected skin or systemic infection, skin swabs and/or blood 
samples may be collected. If collected, skin swab samples will be cultured and speciated to determine whether the 
transplant Staph strain caused the infection. A complete blood count (CBC) with differential and blood culture will be 
performed on the blood sample, if collected, to assess for infection.  

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Participants will be given a hand card to present to clinical staff should they seek care for an infection at another facility. 
The hand card, as described in Section 8.6, will state that the participant is currently in a clinical trial involving the 
application of non-pathogenic bacteria to the skin, list the sensitivities of S. hominis, and include instructions to call the 
research site if an infection of the skin or blood is suspected.  
8.13. 
Visit Windows 
Study visits should take place within the time limits specified above: the designated visit windows (i.e. +/- n days) for 
each scheduled visit are also indicated in Appendix B Schedule of Events.  
9. Sample Collection and Assays 
This section describes the proposed methodologies for this study. The techniques are state-of-the-art at the time of the 
writing of this protocol. Even so, the techniques will be updated and/or changed should there be additional technical 
breakthroughs in this area of research. Details of the laboratory processes are described in Standard Operating 
Procedures (SOPs) maintained by each laboratory. 
9.1. Skin Swab Samples 
9.1.1. Skin Swab Collection Procedure 
The most severe lesion measuring at least 15 cm2 on the ventral upper extremities will be defined as the lesional 
swab location. Lesions closer to the antecubital region will take precedence in defining this area. One lesional 
swab location will be defined at Screening and the Repeat Culture Visits. A lesional and non-lesional site will be 
defined at Day 0, for assessment through Day 11. The non-lesional swab location will be defined as an area of 
normal skin on the ventral upper extremities measuring at least 15 cm2. The designated lesional and non-
lesional sites for swabbing will be marked with a pen and non-identifying digital photographs will be taken for 
reference during future visits. The designated sites for swabbing will be measured for each participant and the 
total lesional and non-lesional area (cm x cm) recorded. A minimum of 6 swabs, 3 lesional swabs and 3 non-
lesional swabs will be obtained from each participant. Each swab will cover a 5 cm2 area. Using a swab, the 
lateral edge of the swab will be rubbed across the measured area in a cross-wise manner while rotating the 
swab handle between the thumb and forefinger. Swabbing will be performed for at least 30 seconds. If sampling 
area allows, up to 6 additional swabs may be obtained from each participant, 3 additional swabs from the 
lesional and non-lesional each. A maximum of 12 swabs may be obtained from each participant.  
9.1.2. Staphylococcus aureus Screening Assay 
Skin swabs will be collected from pre-measured areas of lesional and non-lesional skin per Section 9.1.1. Swabs 
will then be used to inoculate blood agar plates (5% sheep blood; No. R01202; Remel Inc.; Lenexa, Kansas). A 
Spectra MRSA agar plate (Remel Spectra MRSA Screen plate; No. R01821; Remel Inc.) will also be swabbed for 
qualitative evaluation only. Blood agar plates will be incubated up to 48 hours in a 5% CO2 incubator at 37◦ C. 
Colonies appearing to be Staphylococcus aureus on the blood agar will be tested for coagulase and catalase. If 
the tests are positive, the colonies will be identified as Staphylococcus aureus species. Positive plates will be 
scored from 1-4 based on the number of quadrants with S. aureus growth. The MRSA plates will be incubated up 
to 24 hours in a non-CO2 incubator at 35°C. Any colonies growing on the Spectra MRSA plate after 24 hours will 
be identified as MRSA.  

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9.1.3. CFU Quantification of Live Staphylococcus aureus and CoNS 
Skin swabs will be collected from pre-measured areas of lesional and non-lesional skin per Section 9.1.1. Swabs 
will be suspended in 1.5 mL TSB containing 15% (v/v) USP-grade glycerin and stored frozen at -80°C. Live CFUs of 
coagulase positive S. aureus will be determined by rapid thawing of frozen swab samples and then immediate 
inoculation on a bacterial culture plate containing mannitol salt agar with egg yolk for selective growth of 
Staphylococcus spp. S. aureus will be conventionally distinguished from CoNS according to mannitol metabolism 
and the egg yolk reaction, and coagulase positive and negative Staphylococcus will be quantified by manual 
counting of limiting dilutions of the stock solution.  
Lesional and non-lesional skin swabs will be separately analyzed in batches consisting of all applicable swabs 
available for a pre-selected minimum number of participants after all selected participants have either 
completed the Day 38 Visit or terminated early from the study. In order to help maintain the blind throughout 
the process of sample analysis, swabs in each batch will be relabeled and processed in random order so that 
swabs from a single participant are not analyzed in sequence. To help ensure the random order and to maintain 
the blind within the lab, a separate technician will arrange the samples for processing and assay the samples.  
9.1.4. Quantification of S. aureus, S. hominis, Combined Staphylococci, and Combined Bacteria DNA by qPCR 
To collect bacterial DNA, pre-measured areas adjacent to those used for bacterial culture will be rubbed with a 
swab pre-moistened with Tris-EDTA buffer containing 0.1% TritonX-100 and 0.05% Tween-20 (w/v). Bacterial-
genomic DNA will be extracted for qPCR with the QIAamp DNA Micro kit (QIAGEN: 56304). DNA will be eluted 
with 25 µL elution buffer. One µL of the elution will be used for qPCR using universal 16S rRNA primers and 
species- or genus-specific primers. For quantification of S. aureus and S. hominis DNA, DNA extracted from an 
authentic number of each bacterium (S. aureus ATCC35556 and S. hominis ATCC27845, respectively) will be used 
for standard curves. For quantification of combined staphylococci DNA, a standard curve from an authentic 
number of S. epidermidis ATCC12228 will be used. The standard curve will be used for determination of absolute 
number of bacteria (as rCFU/µL). This known amount of bacteria for S. aureus and S. hominis will range from 1x 
101 to 1x106 CFU/µL. For total 16S rRNA quantification, relative abundance will be calculated with the Delta-
Delta-Ct method.  
 
Lesional and non-lesional skin swabs will be analyzed in batches consisting of all applicable swabs available for a 
pre-selected minimum number of participants after all selected participants have either completed the Day 38 
Visit or terminated early from the study. In order to help maintain the blind throughout the process of sample 
analysis, swabs in each batch will be relabeled and processed in random order so that swabs from a single 
participant are not analyzed in sequence. To help ensure the random order and to maintain the blind within the 
lab, a separate technician will arrange the samples for processing and assay the samples.  
9.1.5. Analysis of Microbial Populations by 16S rRNA Sequencing 
V1-V3 16S rRNA gene will be amplified with Phusion High-Fidelity polymerase (Thermo Scientific, Waltham, MA) 
using dual-indexed coded primers, normalized, pooled and paired-end sequenced (2 × 300bp) on an Illumina 
MiSeq (Illumina, San Diego, CA). The 16S rRNA bacterial sequence reads will be assessed for quality and analyzed 
using phylogenetic and Operational Taxonomic Unit (OTU) methods in the Quantitative Insights into Microbial 
Ecology (QIIME) software, version 1.9.1. Read pairs will be assembled using fastq-join from the ea-utils package 
(http://code.google.com/p/ea-utils), requiring at least 20 bases of overlap and allowing a maximum of 10% 
mismatched bases. OTUs will be picked using the reference-based USEARCH (version 5.2) pipeline in QIIME, 
using the May 2013 release of the GreenGenes 99% OTU database. OTU clusters with less than four sequences 

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will be removed, and representative sequences used to make taxonomic assignments for each cluster will be 
selected on the basis of abundance. The RDP Naïve Bayesian Classifier will be used for taxonomic classification 
with the GreenGenes reference database. 
9.2. Blood Samples 
9.2.1. Blood Collection Procedure 
If disease activity increases, participants experience signs and symptoms as described on the study hand card, or 
other concerns arise between regularly scheduled visits, participants may return to clinic for an Unscheduled 
Visit. If a participant presents to the research clinic with a suspected skin or systemic infection, whole blood 
samples may be collected by venipuncture.  
9.2.2. Blood Tests 
In order to assess for infection, venous blood will be collected for culture and a CBC with differential.  
10. Biospecimen Storage 
Lesional and non-lesional skin swabs will be obtained from all study participants. These skin swabs and any derivative 
samples will be obtained for potential future analysis of additional parameters that describe the composition and 
function of the skin microbiome. Such analysis may include deep sequencing of bacterial DNA for more precise 
identification of the metagenome or analysis of the metabalome by advanced mass spectrometry techniques. 
Participants will be asked to give permission for long-term storage and future use during the consent process. All 
samples stored for future use will be kept in a central repository at UCSD.  
Instructions for sample preparation, handling, storage, and shipping are included in the MOP. The PIs will be responsible 
for acknowledging and implementing all the regulations for classification, sample handling, packaging and labeling, 
permits or authorizations, and personnel training for shipment of biological and hazardous materials required for the 
conduct of this study.  
11. Criteria for Participant and Study Completion and Premature Study Termination 
11.1. 
Participant Completion 
Participant participation will be defined as complete at the conclusion of the Day 38 End of Study Phone Visit.  
11.2. 
Participant Stopping Rules and Withdrawal Criteria 
Participants may be prematurely terminated from the study for the following reasons: 
1. The participant elects to withdraw consent from all future study activities, including follow-up. 
2. The participant is “lost to follow-up” (i.e., no further follow-up is possible because attempts to reestablish 
contact with the participant have failed). The ADRN standard definition of lost to follow-up, as defined in the 
MOP will be used.  
3. The participant dies.  
4. The investigator no longer believes participation is in the best interest of the participant. 
5. Individual safety stopping rules  
a. Evidence of infection either cutaneously or systemically. 

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b. Severe worsening of AD which in the opinion of the investigator requires stopping of the investigational 
product. 
c. Evidence of contact allergy to investigational product. 
d. Evidence of non-compliance to study protocol or eligibility criteria that in the opinion of the investigator 
requires discontinuation of investigational product. 
e. Any serious or unexpected AE that is possibly or definitely related to the investigational product.  
f. Pregnancy in a female participant or in a partner of a male participant.  
 
 
11.3. 
Participant Replacement 
Participants who were randomized and who withdraw or are withdrawn prior to the completion of the End of Treatment 
Visit on Day 7 or who fail to meet the criteria of the Modified-Intent-to-Treat (MITT) sample may be replaced as 
necessary to obtain an MITT sample as defined in Section 13.4.1. 
11.4. 
Follow-up after Early Study Withdrawal 
If a participant is withdrawn from the study for any reason, the participant will be asked to complete a final visit by 
phone to assess any AEs since his/her last visit and to answer questions about the status of his/her AD. Any participant 
with an ongoing AE/SAE at the time of this phone contact will continue to be followed until the event is resolved with or 
without sequelae or until the AE stabilizes or until 30 days after the participant prematurely withdraws (without 
withdrawing consent)/or is withdrawn from the study, whichever occurs first. 
11.5. 
Study Stopping Rules 
The trial will be stopped pending immediate DSMB review for the following reasons: 
• 
A single participant experiences any SAE for which there is a reasonable possibility that the 
investigational product caused the SAE. 
• 
The development of any severe (Grade 3) AE for which attribution is defined as related or possibly related 
in: 
o 1 out of the first 10 participants enrolled, 
o 2 out of the first 20 participants enrolled,  
o 3 out of the first 30 participants enrolled, 
o 4 out of the first 40 participants enrolled, 
o 5 out of the first 50 participants enrolled. 
If any of these criteria are met, enrollment will be suspended and participants currently receiving study treatment will be 
instructed to stop applying investigational product. The study will not be resumed until the relevant information has been 
discussed with the DSMB and the DSMB concurs with resumption of the study. 
12. Safety Monitoring and Reporting 
12.1 Overview 
This section defines the types of safety data that will be collected under this protocol and outlines the procedures for 
appropriately collecting, grading, recording, and reporting those data. AEs that are classified as serious according to the 
definition of health authorities must be reported promptly (per Section 12.5) to the sponsor DAIT/NIAID. Appropriate 
notifications will also be made to site PIs, IRBs, and health authorities.  

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Information in this section complies with International Conference on Harmonization (ICH) Guideline E2A: Clinical Safety 
Data Management: Definitions and Standards for Expedited Reporting, ICH Guideline E-6: Guideline for Good Clinical 
Practice (GCP), 21CFR Parts 312 and 320, and applies the standards set forth in the National Cancer Institute (NCI), 
Common Terminology Criteria for Adverse Events (CTCAE), Version 4.03: http://ctep.cancer.gov/reporting/ctc.html. 
12.2 Definitions 
12.2.1 Adverse Event (AE) 
Any untoward or unfavorable medical occurrence associated with the participant’s participation in the research, 
whether or not considered related to the participant’s participation in the research (modified from the 
definition of AEs in the 2018 ICH E-6 Guidelines for Good Clinical Practice) (from Office of Human Research 
Protections (OHRP) "Guidance on Reviewing and Reporting Unanticipated Problems Involving Risks to Subjects 
or Others and Adverse Events (1/15/07)" http://www.hhs.gov/ohrp/policy/advevntguid.html#Q2 )  
For this study, an AE will include any untoward or unfavorable medical occurrence associated with:  
• 
TMT or Placebo regimen: An AE occurring from the time of consent and within one month after 
the last study-mandated TMT or placebo application  
• 
Study mandated procedures:  
o Blood Draw 
The following events related to the blood draw procedure will be considered an AE if they 
occur within 48 hours of the blood draw: 
o Fainting / Vasovagal Events 
o Bruising at the puncture site larger than 2 cm in diameter 
o Bleeding from the puncture site lasting more than 30 minutes 
o Swelling at puncture site larger than 2 cm 
12.2.1.1 Suspected Adverse Reaction (SAR)  
Any AE for which there is a reasonable possibility that the investigational study product regimen caused 
the AE. For the purposes of safety reporting, ‘reasonable possibility’ means there is evidence to suggest 
a causal relationship between the product and the AE. A SAR implies a lesser degree of certainty about 
causality than adverse reaction, which means any AE caused by a drug (21 CFR 312.32(a)). 
12.2.2 Unexpected Adverse Event  
An AE or SAR is considered “unexpected” if it is not listed in the Investigator Brochure or is not listed at the 
specificity, severity, or rate of occurrence that has been observed. 
12.2.3 Serious Adverse Event (SAE) 
An AE or SAR is considered “serious” if, in the view of either the investigator or the DAIT/NIAID Medical Monitor, 
it results in any of the following outcomes (21 CFR 312.32(a)): 
1. Death. 
2. A life-threatening event: An AE or SAR is considered “life-threatening” if, in the view of either the 
investigator or the DAIT/NIAID Medical Monitor, its occurrence places the participant at immediate risk of 
death. It does not include an AE or SAR that, had it occurred in a more severe form, might have caused 
death.  
3. Inpatient hospitalization or prolongation of existing hospitalization. 

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4. Persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions. 
5. Congenital anomaly or birth defect.  
6. Important medical events that may not result in death, be life threatening, or require hospitalization may be 
considered serious when, based upon appropriate medical judgment, they may jeopardize the participant 
and may require medical or surgical intervention to prevent one of the outcomes listed above. 
Elective hospitalizations are not to be reported as an SAE unless hospitalization is prolonged due to 
complications. 
12.3 Grading and Attribution of Adverse Events 
12.3.1 Grading Criteria 
The study site will grade the severity of AEs experienced by the study participants according to the criteria set 
forth in the NCI-CTCAE Version 4.03. This document (referred to herein as the NCI-CTCAE manual) provides a 
common language to describe levels of severity, to analyze and interpret data, and to articulate the clinical 
significance of all AEs. The NCI-CTCAE has been reviewed by the study investigators and sponsor and has been 
deemed appropriate for the participant population to be studied in this protocol.  
AEs will be graded on a scale from 1 to 5 according to the following standards in the NCI-CTCAE manual: 
Grade 1 = mild AE 
Grade 2 = moderate AE 
Grade 3 = severe and undesirable AE 
Grade 4 = life-threatening or disabling AE 
Grade 5 = death 
Events grade 1 or higher will be recorded on the appropriate AE electronic case report form (eCRF) for this 
study. 
For grading an abnormal value or result of a clinical or laboratory evaluation (including, but not limited to, a 
radiograph, an ultrasound, an electrocardiogram etc.), a treatment-emergent AE is defined as an increase in 
grade from baseline or from the last post-baseline value that doesn’t meet grading criteria. Changes in grade 
from screening to pre-treatment and enrollment at Day 0 will also be recorded as AEs, but are not treatment-
emergent. If a specific event or result from a given clinical or laboratory evaluation is not included in the NCI-
CTCAE manual, then an abnormal result would be considered an AE if changes in therapy or monitoring are 
implemented as a result of the event/result. 
For additional information and a printable version of the NCI-CTCAE manual, consult the NCI-CTCAE web 
site: http://ctep.cancer.gov/reporting/ctc.html. 
12.3.2 Attribution Definitions 
The relationship, or attribution, of an AE to the investigational product regimen or study procedure(s) will 
initially be determined by the site investigator and recorded on the appropriate AE eCRF. Final determination of 
attribution for safety reporting will be determined by the DAIT/NIAID Medical Monitor. The relationship of an AE 
to study therapy regimen or procedures will be determined using the descriptors and definitions provided in 
Table 12.3.2.  
 
 
 
 

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Table 12.3.2 Attribution of Adverse Events 
 
 
 
 
 
 
 
 
 
12.4 Collection and Recording of Adverse Events 
12.4.1 Collection Period 
AEs will be collected from the time of consent until a participant completes study participation or until 30 days 
after he/she prematurely withdraws (without withdrawing consent) or is withdrawn from the study. 
12.4.2 Collecting Adverse Events 
AEs (including SAEs) may be discovered through any of these methods: 
• 
Observing the participant. 
• 
Interviewing the participant in an objective manner [e.g., using structured questioning]. 
• 
Reviewing the participant diary. 
• 
Receiving an unsolicited complaint from the participant. 
• 
Receiving a call from the participant outside of their regular study visits; instructions for contacting the clinic 
will be provided on an instructional hand card at the Treatment Initiation Visit, as well as in the participant 
diary. 
• 
In addition, an abnormal value or result from a clinical or laboratory evaluation can also indicate an AE, as 
defined in Section 12.3. 
12.4.3 Recording Adverse Events 
Throughout the study, the investigator will record AEs and SAEs as described previously (Section 12.2) on the 
appropriate AE/SAE eCRF regardless of the relationship to study therapy regimen or study procedure. 
Once recorded, an AE/SAE will be followed until it resolves with or without sequelae, or the AE/SAE stabilizes, or 
until the end of study participation, or until 30 days after the participant prematurely withdraws (without 
withdrawing consent)/or is withdrawn from the study, whichever occurs first. 
12.5 Reporting of Serious Adverse Events and Adverse Events 
12.5.1 Reporting of Serious Adverse Events to DAIT/NIAID  
This section describes the responsibilities of the site investigator to report SAEs to the sponsor and the SACCC 
via the SAE eCRF. Timely reporting of AEs is required by 21 CFR and ICH E6 guidelines.  
Code 
Descriptor 
Relationship (to investigational products or study 
procedure: blood draw) 
NOT RELATED CATEGORY 
1 
Not 
Related 
The AE is clearly not related: there is insufficient 
evidence to suggest a causal relationship. 
 RELATED CATEGORIES 
2 
Possible 
The AE has a reasonable possibility to be related; 
there is evidence to suggest a causal relationship. 
3 
Related 
The AE is clearly related. 

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Site investigators will report all SAEs (see Section 12.2.3), regardless of relationship or expectedness within 24 
hours of discovering the event. 
For SAEs, all requested information on the SAE eCRF will be provided. However, unavailable details of the event 
will not delay submission of the known information. Initial SAE eCRF should include as much information as 
possible, but at a minimum must include the following:  
• 
AE term.  
• 
Relationship to investigational product.  
• 
Relationship to stopping protocol prohibited medications/therapy.  
• 
Relationship to study procedure.  
• 
Reason why the event is serious.  
• 
Supplementary case report form (CRF) pages that are current at the time of SAE reporting: medical 
history, concomitant medications, demographics, investigational product administration.  
As additional details become available, the SAE eCRF should be updated and submitted. Every time the SAE eCRF 
is submitted, it should be electronically signed by the investigator or sub-investigator.  
 
For additional information regarding SAE reporting, contact Rho Product Safety:  
Rho Product Safety  
6330 Quadrangle Drive, Suite 500  
Chapel Hill, NC 27517  
Toll-free: 1-888-746-7231  
SAE Fax Line: 1-888-746-3293  
Email: rho_productsafety@rhoworld.com 
12.5.2 Reporting to Health Authority 
After an AE, requiring 24 hour reporting (per Section 12.5.1), is submitted by the site investigator and assessed 
by DAIT/NIAID, there are two options for DAIT/NIAID to report the AE to the appropriate health authorities: 
12.5.2.1 Annual Reporting 
DAIT/NIAID will include in the IND Annual Report to the FDA all reported AEs classified as:  
o Serious, expected, suspected adverse reactions (see Section 12.2.1.1 and Section 12.2.2). 
o Serious and not a suspected adverse reaction (see Section 12.2.2). 
o Pregnancies.  
Note that all AEs (not just those requiring 24-hour reporting) will be reported in the IND Annual Report 
12.5.2.2 Expedited Safety Reporting  
This option, with 2 possible categories, applies if the AE is classified as one of the following: 
Category 1: Serious and unexpected suspected adverse reaction [SUSAR] (see Section 12.2.1.1, Section 
12.2, and 21 CFR 312.32(c) (1) i).  
The sponsor shall report any SAR that is both serious and unexpected. The sponsor shall report 
an AE as a SAR only if there is evidence to suggest a causal relationship between the 
investigational product and the AE, such as: 

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1. A single occurrence of an event that is uncommon and known to be strongly associated 
with investigational product exposure (e.g. sepsis, cellulitis or deep tissue infections); 
2. One or more occurrences of an event that is not commonly associated with 
investigational product exposure, but is otherwise uncommon in the population 
exposed to the drug (e.g., tendon rupture); 
3. An aggregate analysis of specific events observed in a clinical trial (such as known 
consequences of the underlying disease or condition under investigation or other events 
that commonly occur in the study population independent of investigational product 
regimen) that indicates those events occur more frequently in the investigational 
product treatment group than in a concurrent or historical control group. 
 
 
Category 2: Any findings from studies that suggest a significant human risk  
 
The sponsor shall report any findings from other epidemiological studies, analyses of AEs within 
the current study or pooled analysis across clinical studies or animal or in vitro testing (e.g. 
mutagenicity, teratogenicity, carcinogenicity) that suggest a significant risk in humans exposed 
to the investigational product that would result in a safety-related change in the protocol, 
informed consent, investigator brochure or package insert or other aspects of the overall 
conduct of the study.  
DAIT/NIAID shall notify the FDA and all participating investigators of expedited Safety Reports within 15 
calendar days; unexpected fatal or immediately life-threatening suspected adverse reaction(s) shall be 
reported as soon as possible or within 7 calendar days. 
12.5.3 Reporting of Adverse Events to the Central IRB 
All investigators shall report AEs, including expedited reports, in a timely fashion to their local and central 
IRB in accordance with applicable regulations and guidelines. All Safety Reports to the FDA shall be 
distributed by DAIT/NIAID or designee to all participating institutions for site IRB/ Ethics Committee (EC) 
submission. 
  12.6  Pregnancy Reporting 
The investigator shall be informed of any pregnancy in a female study participant or the partner of a male study 
participant immediately upon becoming aware of the event. A pregnant participant, or a male participant with a 
pregnant partner, shall be instructed immediately to stop application of investigational product and will be 
withdrawn from the study, as described in Section 11.2. The investigator shall counsel the participant and 
discuss the risks of continuing with the pregnancy and the possible effects on the fetus. Monitoring of the 
pregnant participant or partner of the male participant shall continue until the conclusion of the pregnancy.   
The investigator shall report to the SACCC all pregnancies within 1 business day of becoming aware of the event 
using the Pregnancy eCRF. The SACCC will report all pregnancies to DAIT/NIAID. All pregnancies identified during 
the study shall be followed to conclusion and the outcome of each must be reported. The Pregnancy eCRF shall 
be updated and submitted to the SACCC when details about the outcome are available.  
Information requested about the delivery shall include: 
o 
Gestational age at delivery 
o 
Birth weight, length, and head circumference 
o 
Gender 

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o 
Appearance, pulse, grimace, activity, and respiration (APGAR) score at 1 minute, 5 minutes, and 24 hours 
after birth, if available 
o 
Any abnormalities. 
Should pregnancy complications result in a congenital abnormality, birth defect, miscarriage, or medically 
indicated abortion - an SAE must be submitted to the SACCC using the SAE reporting procedures described 
above.  
12.7 Reporting of Other Safety Information 
An investigator shall promptly notify their local and central IRB, in accordance with applicable regulations and 
guidelines, as well as the SACCC and DAIT/NIAID via email when an “unanticipated problem involving risks to 
participants or others” is identified, which is not otherwise reportable as an AE. 
12.8 Review of Safety Information 
12.8.1 Medical Monitor Review 
The DAIT/NIAID Medical Monitor shall receive monthly reports from the SACCC compiling new and accumulating 
information on AEs, SAEs, and pregnancies recorded by the study sites on appropriate eCRFs. 
In addition, the DAIT/NIAID Medical Monitor shall review and make decisions on the disposition of the SAE and 
pregnancy reports received by the SACCC (See Sections 12.5.1and 12.6).  
12.8.2 DSMB Review  
The SACCC will provide the NIAID Allergy-Asthma [Alpha] DSMB with a listing of all AEs and SAEs on an ongoing 
basis, including quarterly reports of all SAEs. Furthermore, the DSMB will be informed of expedited reports of 
SAEs. 
12.8.2.1 Planned DSMB Reviews  
The DSMB shall review safety data at least yearly during planned DSMB Data Review Meetings. Data for 
the planned safety reviews will include, at a minimum, a listing of all reported AEs and SAEs.  
12.8.2.2 Ad hoc DSMB Reviews  
In addition to the pre-scheduled data reviews and planned safety monitoring, the DSMB may be called 
upon for ad hoc reviews when an event occurs that is of sufficient concern to the DAIT/NIAID Medical 
Monitor and/or the protocol chair(s) to warrant DSMB review, this includes all Expedited Safety Reports. 
The DSMB will be notified within 24 to 48 hours by the NIAID Medical Monitor and will promptly review 
any event that potentially impacts safety at the request of the protocol chair or DAIT/NIAID or any 
occurrence that meets the definition of the Participant Stopping Rules or Study Stopping Rules defined in 
Sections 11.2 and 11.5.  
After review of the data, the DSMB will make recommendations regarding study conduct and/or 
continuation. 
12.8.2.2.1 Temporary Suspension of Enrollment and Study Treatment for ad hoc DSMB Safety 
Review  
A temporary halt in enrollment and investigational product application will be implemented if 
an ad hoc DSMB safety review is required. New participants will not be consented for study 

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participation during the enrollment and treatment halt. Participants already on therapy will not 
continue TMT or placebo application. Participants screened but not yet randomized will not be 
allowed to continue with the Day 0 Treatment Initiation Visit. All participants not randomized 
within 14 days of the Screening Visit must rescreen.  
13. Statistical Considerations and Analytical Plan 
13.1 
Overview  
This is a phase I, first in man, randomized, double-blind placebo controlled multi-site trial designed to assess the safety, 
efficacy, and steady-state of allogeneic TMT in adults with moderate-to-severe AD. Approximately 54 adult AD 
participants, 18 to 80 years of age, will complete TMT or placebo applications to non-lesional and S. aureus colonized 
lesional skin over the course of 1 week.  
13.2 
Endpoints 
13.2.1  Primary Endpoint 
The count of serious and non-serious treatment-emergent AEs per participant during the time period of Day 0 to 
Day 8 
13.2.2  Secondary Endpoints 
1. The occurrence of at least one serious or non-serious treatment-emergent AE during the time period of Day 
0 to Day 8 
2. The count of serious and non-serious AEs per participant during study participation 
3. The occurrence of at least one serious or non-serious AE during study participation 
4. The EASI score of the ventral arms at Days 0, 4, 7, 8 and 11 
5. The SCORAD score at Days 0, 4, 7, 8 and 11 
6. The Pruritus VAS score of the ventral arms at Days 0, 4, 7, 8 and 11 
7. The RL score at Days 0 and 7 
8. The abundance of CoNS as measured by CFU/cm2 and qPCR (rCFU/cm2) on lesional and non-lesional skin at 
Days 0, 4, 7, 8 and 11 
9. The change from baseline levels of CoNS bacteria  abundance as measured by CFU/cm2 and qPCR (rCFU/cm2) 
on lesional and non-lesional skin at Days 0 (1 hour post treatment), 4, 7, 8 and 11 
10. The change from baseline levels of S. hominis A9 bacteria abundance, as measured by qPCR (rCFU/cm2) on 
lesional and non-lesional skin at Days 0 (1 hour post treatment), 4, 7, 8 and 11 
11. The abundance of S. aureus, as measured by CFU/cm2 and qPCR (rCFU/cm2) on lesional and non-lesional skin 
at Days 0, 4, 7, 8 and 11 
12. The change from baseline levels of S. aureus abundance, as measured by CFU/cm2 and qPCR (rCFU/cm2) on 
lesional and non-lesional skin at Days 0 (1 hour post treatment), 4, 7, 8 and 11  
13. The abundance of bacterial DNA (rCFU/cm2) on lesional and non-lesional skin at Days 0, 4, 7, 8 and 11; 
specific bacteria of interest are the following:  
a. Combined S. hominis 
b. Combined Staphylococci 
c. Combined bacteria  

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13.2.3 Exploratory Endpoint 
1. The proportion (% relative abundance) by Phylum: Class and Shannon Diversity Index of the microbiome on 
lesional and non-lesional skin at Day 7 after completion of 1 week of TMT or placebo application 
13.3 
Measures to Minimize Bias  
Stratified block randomization will be performed centrally at the SACCC, and will balance baseline S. aureus abundance 
(low vs high) between treatment arms by clinical site. Clinical staff, laboratory personnel analyzing samples, and study 
participants will be blinded to treatment arm. Laboratory personnel analyzing samples will remain blinded as described 
in Section 3.5. 
13.4 
Analysis Plan 
13.4.1 Analysis Samples 
• 
Safety Sample 
o The safety sample will include all participants who are randomized and receive any amount of 
TMT/placebo. 
• 
Modified Intent-to-Treat (MITT) Sample 
o The Modified Intent-to-Treat sample will include all participants who are randomized, provide skin 
swabs on Days 0 and 7 and administer 75% of doses of TMT/placebo. The MITT sample will not 
exclude participants with lesional CFU=0 at the Treatment Initiation Visit.  
• 
Per-Protocol (PP) Sample 
o The per-protocol sample will include all MITT participants who commit no major protocol deviations. 
The PP sample will not exclude participants with lesional CFU=0 at the Treatment Initiation Visit.  
o Additional PP samples will be defined in the statistical analysis plan (SAP). 
• 
Interim Analysis Sample 
o The Interim Analysis sample will include all participants who meet the following criteria:  
 
Are randomized 
 
Administer at least 75% of doses of TMT/placebo 
 
Provide skin swabs with analyzable results at each of the Days 0, 7 and 11 visits 
 
Complete the Day 38 visit on or prior to the time of the interim analysis, which will be on or 
after the date when both of the following criteria are satisfied: 1) 10 participants given 
active TMT application complete the Day 38 visit and meet the 3 criteria above and 2) 5 
participants given placebo complete the Day 38 visit and meet the 3 criteria above. All 
participants eligible at the time of the interim analysis and with analyzed samples will be 
included in the Interim Analysis sample. 
13.4.2 Primary Analyses of Primary Endpoint 
The primary analysis will be conducted using a negative binomial or Poisson model with robust standard error, 
as appropriate, adjusting for site and S. aureus growth stratum at Screening. Zero-inflated negative binomial or 
Poisson models will be considered if a large number of participants experience no AEs throughout the study. 
Analyses will be performed on the Safety Sample within the TMT treatment arm and the placebo arm 
separately. 
As this is a Phase 1 study, the primary endpoint is descriptive, and comparisons between TMT and placebo arms 
will be done as secondary analyses. All analyses will be used to inform future studies. 

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13.4.3 Supportive Analyses of the Primary Endpoint  
Similar analyses as those described above will be performed as sensitivity analyses, adjusting for covariates 
found to be relevant and unbalanced between treatment arms (e.g. severity measures, age, gender, etc.). 
Further sensitivity analyses will be performed similarly on the MITT and PP samples and on additional PP 
samples defined in the SAP. 
13.4.4 Analyses of Secondary and Exploratory Endpoints 
Comparisons between treatment arms of the counts of serious or non-serious adverse events per participant 
will be conducted using a similar model as described in the primary analysis and corresponding supportive 
analyses, adjusting for time in days of follow-up. Comparisons between treatment arms of the proportions of 
participants experiencing at least one serious or non-serious adverse event will be performed using a Pearson 
Chi-square test or Fisher’s exact test, as appropriate. 
Analyses of disease severity (e.g. SCORAD, RL, EASI of ventral arms, and Pruritus VAS of ventral arms) will be 
conducted using analysis of covariance (ANCOVA) comparing treatment arms at each applicable visit, adjusting 
for Day 0 severity measure and site. Random effects of participant and time will be included in the model. 
Covariates similar to those used in support of the primary endpoint will be considered for inclusion in severity 
analyses. 
Secondary analyses comparing bacterial abundance (e.g. CoNS, S.  hominis A9 and S. aureus) on lesional and 
non-lesional skin between treatment arms will be performed using ANCOVA on the log10 transformed 
abundance of bacteria over all applicable timepoints, adjusting for the log10 (pre-dosing Day 0 bacteria 
abundance) and site. Random effects of participant and time will be included in the model. Comparisons will be 
made on the MITT sample between the TMT treatment arm and the placebo arm. 
Change from baseline in S. aureus, CoNS or S. hominis A9 bacteria abundance comparisons between lesional and 
non-lesional skin in the applicable treatment arm will be analyzed using ANCOVA on the difference in log10 
transformed abundance over baseline, adjusting for the log10 (pre-dosing Day 0 bacteria abundance) and site. 
Random effects of participant and time will be included in the model.  Additional analyses adjusting for the 
abundance at other visits in lieu of pre-dosing Day 0 abundance will be considered and defined in the SAP. 
Analyses of microbiome diversity (e.g. % relative abundance by Phylum: Class and Shannon Diversity Index) will 
be conducted using ANCOVA comparing treatment arms at Day 7, adjusting for Day 0 measure. Analyses at 
additional time points may be considered. Covariates similar to those used in support of the primary endpoint 
will be considered for inclusion in microbiome diversity analyses. 
13.4.5 Descriptive Analyses  
Descriptive analyses will be reported separately for each treatment arm. Continuous baseline measures will be 
reported as 1) means (or geometric means) with 95% confidence intervals, or 2) median with 1st and 3rd quartile, 
as appropriate. Categorical baseline and demographic characteristics and study disposition will be reported as 
proportions with 95% exact confidence intervals.  

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13.5 
Interim Analyses  
13.5.1 Interim Analysis of Efficacy Data 
An interim analysis will be performed based on cumulative efficacy data of all participants in the Interim Analysis 
sample (see Section 13.4.1). 
The purpose of the interim analysis is to provide critical information for future studies regarding the potency of 
the intervention to decrease S. aureus CFU as well as detect any tendency of the S. hominis A9 to accumulate on 
the skin after repeated applications. Skin total staphylococcal CFU, S. aureus CFU, qPCR of total DNA abundance 
of staphylococci, S. aureus specific DNA, hogocidin lantibiotic and total S. hominis DNA will be analyzed as part 
of the interim analysis. Clinical endpoints of disease severity (EASI, SCORAD, pruritus VAS and RL score) will also 
be analyzed. 
The interim analysis will support our primary endpoint of safety to determine if there is an accumulation of 
bacteria during the course of treatment or if there is an increase in clinical disease severity. The interim analysis 
will also inform secondary endpoints regarding the ability of the microbiome transplant to decrease S. aureus 
survival and total abundance. This information is necessary for design of future studies. There will be no 
decisions made regarding the conduct of this clinical trial (e.g. stopping for efficacy or futility) based on the 
results of the interim analysis. Enrollment will not be impacted or paused while the interim analysis is being 
performed. 
Secondary objectives 5 through 12 will be analyzed for the interim analysis based on secondary endpoints 4 
through 13. Analyses will be performed as specified in Section 13.4.4. 
Since all participants involved in the interim analysis will have completed the study, there will be no risk in 
biasing site staff concerning AE reporting for these participants. Furthermore, AE data will not be analyzed in any 
fashion for the interim analysis. Blinding will be maintained for all fully blinded individuals, according to the 
guidelines defined in the Randomization Plan. By-participant data listings will not be included. Results will be 
reported to the protocol chair Dr. Richard Gallo, the ADRN PI Dr. Donald Leung, and staff at the NIAID and Rho. 
Since the interim analysis involves only secondary objectives related to efficacy data, there will be no penalty in 
type I error adjustment of the primary analysis for an early look at the data. 
Further details for the interim analysis will be specified in the SAP. 
13.5.2 Interim Analysis of Safety Data 
The DSMB will receive periodic safety reports on enrolled participants along with all investigational product 
discontinuation cases. The DSMB may request modifications to the protocol based on its review of the findings. 
13.5.3 Futility Analysis 
 
No formal interim analyses are planned for futility.  
13.6 
Statistical Hypotheses  
For the analysis of the primary endpoint, we hypothesize that the TMT application taken over the course of 1 week is 
safe for AD participants with S. aureus skin colonization. Safety will be assessed by the count of serious and non-serious 
treatment-emergent AEs per participant during the time period of Day 0 to Day 8. As this is a Phase 1 study, the primary 
endpoint is descriptive, and comparisons between TMT and placebo arms will be done as secondary analyses. All 
analyses will be used to inform future studies. 

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Null hypotheses of secondary analyses are described below. All corresponding alternative hypotheses are that there are 
differences between both groups being compared (i.e. 2-sided comparisons). 
1. 
There is no difference in the proportion of participants experiencing at least one serious or non-serious 
treatment-emergent AE during the time period of Day 0 to Day 8 between the TMT and placebo arm. 
2. 
There is no difference in the count of serious and non-serious AEs per participant between the TMT and 
placebo arm during study participation. 
3. 
There is no difference in the proportion of participants experiencing at least one serious or non-serious 
AE between the TMT and placebo arm during study participation. 
4. 
There is no difference in the EASI score of the ventral arms between the TMT and placebo arm at each 
applicable time point (individually). 
5. 
There is no difference in the SCORAD score between the TMT and placebo arm at each applicable time 
point (individually). 
6. 
There is no difference in the Pruritus VAS of the ventral arms between the TMT and placebo arm at each 
applicable time point (individually). 
7. 
There is no difference in the RL score between the TMT and placebo arm at each applicable time point 
(individually). 
8. 
There is no difference in CoNS bacteria abundance on lesional and non-lesional skin between the TMT 
and placebo arm at each applicable time point (individually). 
9. 
There is no difference in the change from baseline of CoNS bacteria abundance between lesional and 
non-lesional skin at each applicable timepoint (individually). 
10. 
There is no difference in the change from baseline of S. hominis A9 bacteria abundance between lesional 
and non-lesional skin at each applicable timepoint (individually). 
11. 
There is no difference in S. aureus abundance on lesional and non-lesional skin between the TMT arm 
and the placebo arm at each applicable time point (individually). 
12. 
There is no difference in the change from baseline of S. aureus abundance between lesional and non-
lesional skin at each applicable time point (individually).  
13. 
There is no difference in the bacterial DNA abundance on lesional and non-lesional skin between the 
TMT arm and the placebo arm at each applicable time point (individually). 
13.7 
Sample Size Considerations  
The proposed sample size for this study is 36 participants in the TMT arm and 18 in the placebo arm (2:1 
randomization). The primary objective of the analysis is to estimate the count of serious and non-serious treatment-
emergent AEs during the time period of Day 0 to Day 8 per participant for participants completing 1 week of TMT 
application and for participants completing 1 week of placebo application. The proposed sample size allows us to 
determine a safety profile of TMT application taken for 1 week, as well as to estimate parameters of secondary 
analyses to power for future efficacy studies. 
 
Table 13.7 below shows 95% confidence intervals per treatment arm associated with a hypothetical observed mean 
number of serious or non-serious adverse events per participant, assuming a Poisson distribution. 

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Table 13.7 Hypothetical Observed Means of the Per Participant Adverse Event Counts and Associated 95% 
Confidence Intervals 
Hypothetical Observed Mean of 
the Per Participant Adverse 
Event Count 
95% Confidence Interval- TMT 
Arm (N=36) 
95% Confidence Interval- 
Placebo Arm (N=18) 
0.33 
0.14, 0.52 
0.07, 0.60 
0.67 
0.40, 0.93 
0.29, 1.04 
1.0 
0.67, 1.33 
0.54, 1.46 
1.33 
0.96, 1.71 
0.80, 1.87 
1.67 
1.24, 2.09 
1.07, 2.26 
2.0 
1.54, 2.46 
1.35, 2.65 
3.0 
2.43, 3.57 
2.20, 3.80 
5.0 
4.27, 5.73 
3.97, 6.03 
10.0 
8.97, 11.03 
8.54, 11.46 
 
14. Identification and Access to Source Data 
14.1. 
Source Data 
Source documents and source data are considered to be the original documentation where participant information, visit 
consultations, examinations and other information are recorded. Documentation of source data is necessary for the 
reconstruction, evaluation, and validation of clinical findings, observations and other activities during a clinical trial.  
14.2. 
Access to Source Data 
The site investigators and site staff will make all source data available to the DAIT/NIAID, authorized representatives of 
DAIT/NIAID, as well as to relevant health authorities. Authorized representatives as noted above are bound to maintain 
the strict confidentiality of medical and research information that may be linked to identified individuals. 
15. Protocol Deviations 
15.1. 
Protocol Deviation Definitions 
Protocol Deviation – The investigators and site staff will conduct the study in accordance to the protocol; no deviations 
from the protocol are permitted. Any change, divergence, or departure from the study design or procedures constitutes 
a protocol deviation. As a result of any deviation, corrective actions will be developed by the site and implemented 
promptly. 
 
Major Protocol Deviation (Protocol Violation) - A Protocol Violation is a deviation from the IRB approved protocol that 
may affect the participant's rights, safety, or well-being and/or the completeness, accuracy and reliability of the study 
data. In addition, protocol violations include willful or knowing breaches of human subject protection regulations, or 
policies, any action that is inconsistent with the NIH Human Research Protection Program’s research, medical, and 
ethical principles, and a serious or continuing noncompliance with federal, state, local or institutional human subject 
protection regulations, policies, or procedures. Examples of Major Protocol Deviations are described in the MOP.  
 

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Non-Major Protocol Deviation - A non-major protocol deviation is any change, divergence, or departure from the study 
design or procedures of a research protocol that does not have a major impact on the participant's rights, safety, or 
well-being, or the completeness, accuracy and reliability of the study data. 
15.2. 
Reporting and Managing Protocol Deviations 
The study site PI has the responsibility to identify, document and report protocol deviations as directed by DAIT/NIAID. 
However, protocol deviations may also be identified during site monitoring visits or during other forms of study conduct 
review.  
Upon determination that a protocol deviation has occurred, the study staff will a) notify the site PI, b) notify the SACCC 
and c) will complete a Protocol Deviation form. The protocol deviation form will document at minimum the date the 
deviation occurred, the date it was identified, a description of the event, whether the deviation resulted in an SAE/AE, PI 
signature, IRB report requirement, and documentation of a corrective action plan. DAIT/NIAID may request discussion 
with the site PI to determine the effect of the protocol deviation on the study participant and his/her further study 
participation, the effect of the protocol deviation on the overall study, and corrective actions. The PI will sign the paper 
source Protocol Deviation CRF, electronically sign Major Deviations in the electronic data capture (EDC) system, and 
submit the deviation to the central IRB, and local IRB/EC per IRB regulations. Major protocol deviations will be reported 
to the DSMB by the DAIT/NIAID Medical Monitor at the medical monitor’s discretion.  
16. Ethical Considerations and Compliance with Good Clinical Practice 
16.1. 
Quality Control and Quality Assurance 
The investigator is required to keep accurate records to ensure that the conduct of the study is fully documented. The 
investigator is required to ensure that all CRFs are completed for every participant entered in the trial.  
The sponsor is responsible for regular inspection of the conduct of the trial, for verifying adherence to the protocol, and 
for confirming the completeness, consistency, and accuracy of all documented data.  
The CRFs will be completed online via a web-based EDC system that has been validated and is compliant with Part 11 
Title 21 of the Code of Federal Regulations. Study staff at the site will enter information into the eCRFs, and the data will 
be stored remotely at a central database. Data quality will be ensured through the EDC system’s continuous monitoring 
of data and real-time detection and correction of errors. All elements of data entry (i.e., time, date, verbatim text, and 
the name of the person performing the data entry) will be recorded in an electronic audit trail to allow all changes in the 
database to be monitored and maintained in accordance with federal regulations. 
16.2. 
Statement of Compliance 
This clinical study will be conducted using GCP, as delineated in Guidance for Industry: E6 Good Clinical Practice 
Consolidated Guidance, and according to the criteria specified in this study protocol. Before study initiation, the protocol 
and the informed consent documents will be reviewed and approved by the central IRB. Any amendments to the 
protocol or to the consent materials will also be approved by the central IRB before they are implemented. 
16.3. 
Informed Consent Process 
The consent process will provide information about the study to a prospective participant and will allow adequate time 
for review and discussion prior to his/her decision. The PI listed on the FDA 1572 or a designee will review the consent 
and answer questions. Consent designees must be listed on the site delegation of responsibilities log, complete 
consenting certification, and have demonstrated knowledge of the protocol and study procedures. The prospective 

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participant will be told that being in the trial is voluntary and that he or she may withdraw from the study at any time, 
for any reason. The participant will read, sign, and date a consent form before undergoing any study procedures. 
Consent materials will be presented in the participant’s primary language. A copy of the signed informed consent form 
will be given to the participant. 
The consent process will be ongoing. The informed consent form will be revised when important new safety information 
is available, the protocol is amended, and/or new information becomes available that may affect participation in the 
study.  
16.4. 
Privacy and Confidentiality 
Following the Health Insurance Portability and Accountability Act (HIPAA) guidelines a participant’s privacy and 
confidentiality will be maintained throughout the study. Each participant will be assigned a unique identification number 
and these numbers rather than names will be used to collect, store, and report participant information. All biological 
samples will be labeled with the identification number. Data reported in medical journals or scientific meetings will be 
presented in aggregate for participants as a whole. No individual participant will be identified in any way. Site personnel 
will not transmit documents containing personal health identifiers (PHI) to the study sponsor or their representatives.  
17. Publication Policy 
The ADRN Publications Policy will apply to presentations and publications of the results of this trial. 
18. References 
Cogen AL, Yamasaki K, Muto J, Sanchez KM, Crotty Alexander L, Tanios J, Lai Y, Kim JE, Nizet V, and Gallo RL. 
Staphylococcus epidermidis antimicrobial delta-toxin (phenol-soluble modulin-gamma) cooperates with host 
antimicrobial peptides to kill group A Streptococcus. PLoS One. 2010;5(1):e8557. 
Cogen AL, Yamasaki K, Sanchez KM, Dorschner RA, Lai Y, MacLeod DT, Torpey JW, Otto M, Nizet V, Kim JE, et al. Selective 
antimicrobial action is provided by phenol-soluble modulins derived from Staphylococcus epidermidis, a normal resident 
of the skin. J Invest Dermatol. 2010;130(1):192-200. 
De Benedetto A, Agnihothri R, McGirt LY, Bankova LG, Beck LA. Atopic dermatitis: a disease caused by innate immune 
defects? J Invest Dermatology. 129(1):14-30, 2009. 
Hata T and Gallo R. Antimicrobial peptides, skin infections, and atopic dermatitis. Seminars In Cutaneous Medicine and 
Surgery. 2008;27(2):144-50. 
Higaki S ,Morohashi M, Yamagishi T, Hasegawa Y. Comparative study of staphylococci from the skin of atopic dermatitis 
patients and from healthy participants. Int J Dermatol. 38:265-9, 1999. 
Irvine AD. Fleshing out filaggrin phenotypes. J Invest Dermatol. 2007;127(3):504-7. 
Iwase T, Uehara Y, Shinji H, Tajima A, Seo H, Takada K, Agata T, and Mizunoe Y. Staphylococcus epidermidis Esp inhibits 
Staphylococcus aureus biofilm formation and nasal colonization. Nature. 2010;465(7296):346-9. 
Kong HH, Oh J, Deming C, Conlan S, Grice EA, Beatson MA, Nomicos E, Polley EC, Komarow HD, Murray PR, et al. 
Temporal shifts in the skin microbiome associated with disease flares and treatment in children with atopic dermatitis. 
Genome Res. 2012;22(5):850-9. 
Kong HH and Segre JA. Skin microbiome: looking back to move forward. J Invest Dermatol. 2012;132(3 Pt 2):933-9. 

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Kuo IH, Carpenter-Mendini A, Yoshida T, McGirt LY, Ivanov AI, Barnes KC, Gallo RL, Borkowski AW, Yamasaki K, Leung DY, 
et al. Activation of epidermal toll-like receptor 2 enhances tight junction function: implications for atopic dermatitis and 
skin barrier repair. J Invest Dermatol. 2013;133(4):988-98. 
Lai Y, Cogen AL, Radek KA, Park HJ, Macleod DT, Leichtle A, Ryan AF, Di Nardo A, and Gallo RL. Activation of TLR2 by a 
small molecule produced by Staphylococcus epidermidis increases antimicrobial defense against bacterial skin 
infections. J Invest Dermatol. 2010;130(9):2211-21. 
Lai Y, Di Nardo A, Nakatsuji T, Leichtle A, Yang Y, Cogen AL, Wu ZR, Hooper LV, Schmidt RR, von Aulock S, et al. 
Commensal bacteria regulate Toll-like receptor 3-dependent inflammation after skin injury. Nat Med. 2009;15(12):1377-
82. 
Mosteller RD. Simplified Calculation of Body-Surface Area. The New England Journal of Medicine. 317(17): 1098, 1987 
Nakamura Y, Oscherwitz J, Cease KB, Chan SM, Munoz-Planillo R, Hasegawa M, Villaruz AE, Cheung GY, McGavin MJ, 
Travers JB, et al. Staphylococcus delta-toxin induces allergic skin disease by activating mast cells. Nature. 
2013;503(7476):397-401. 
Nakatsuji T, Chen TH, Narala S, Chun KA, Two AM, Yun T, Shafiq F, Kotol PF, Bouslimani A, Melnik AV, Latif H, Kim JN, 
Lockhart A, Artis K, David G, Taylor P, Streib J, Dorrestein PC, Grier A, Gill SR, Zengler K, Hata TR, Leung DY, Gallo RL. 
Antimicrobials from human skin commensal bacteria protect against Staphylococcus aureus and are deficient in atopic 
dermatitis. Sci Transl Med. 2017 Feb 22;9(378). 
Ong PY, Ohtake T, Brandt C, Strickland I, Boguniewicz M, Ganz T, Gallo RL, and Leung DY. Endogenous antimicrobial 
peptides and skin infections in atopic dermatitis. N Engl J Med.2002;347(15):1151-60. 
Ricci G, Patrizi A, Neri I, Bendandi B, Masi M. Frequency and clinical role of Staphylococcus aureus over infection in 
atopic dermatitis in children. Pediatr Dermatol, 20:389-92, 2003. 
Schnopp C, Ring J, and Mempel M. The role of antibacterial therapy in atopic eczema. Expert Opin Pharmacother. 
2010;11(6):929-36. 
Sugimoto K, Ishikawa N, Terano T, Kitukawa Y, Kubosawa H, Ito S, Hattori T. The importance of bacterial superantigens 
produced by Staphylococcus aureus in the treatment of atopic dermatitis using povidone-iodine. Dermatology. 212 
Suppl 1:26-34, 2006. 
Travers JB, Norris DA, Leung DY. The keratinocyte as a target for staphylococcal bacterial toxins. J Investig Dermatol 
Symp Proc. 6:225-30, 2001. 
 
 

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Appendix A: ADRN Standard Diagnostic Criteria (Version 3.0 09May2014) 
The following definitions will be used consistently throughout ADRN protocols. In children less than 4 years of age, the 
disease must be present for at least six months to minimize the likelihood of recruiting children with other eczematous 
disorders that mimic atopic dermatitis. 
I. 
Atopic Dermatitis (AD)1  
A. Active Atopic Dermatitis (AD)1  
Participants must have Atopic Dermatitis (as defined below) within the last 3 months. 
 
 
B. Inactive Atopic Dermatitis (AD)1  
Participants must have an absence of Atopic Dermatitis (as defined below) within the last 12 months.  
 
C. Definition 
Participants must have, according to medical records, or based on a careful and credible history (provided by the 
participant, caregiver, parent, or guardian) or by physical exam by an ADRN investigator: 
1. Pruritus 
2. Eczema (acute, subacute, chronic) 
a. Typical morphology and age-specific patterns which include: 
• 
Facial, neck, and extensor involvement in infants and children 
• 
Current or prior flexural lesions in any age group 
• 
Sparing groin and axillary regions  
b. Chronic or relapsing history 
c. Most participants will have the following clinical associations that add support to the diagnosis: 
• 
Early age at onset 
• 
Atopy 
a. Personal and/or family history 
b. Immunoglobulin (IgE) reactivity 
• 
Xerosis 
 
Participants may have the following clinical associations which help to suggest the diagnosis of AD but are too non-
specific for defining or detecting AD for research or epidemiological studies: 
1. Atypical vascular responses (e.g., facial pallor, white dermographism, delayed blanch response) 
2. Keratosis pilaris/hyperlinear palms/ichthyosis 
3. Ocular/peri-orbital changes 
4. Other regional findings (e.g., peri-oral changes/peri-auricular lesions) 
5. Peri-follicular accentuation/lichenification/prurigo lesions 
 
II. References 
1. Eichenfield F, Hanifin J, Luger T, Stevens S, Pride H. Consensus Conference on Pediatric Atopic Dermatitis. J Am 
Acad Dermatology 2003;49:1088-95. 

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Appendix B: Schedule of Events 
Study Visit 
Recruitment 
Screening1 
Post-
Screening 
Phone2 
Repeat 
Culture3 
Post-Culture 
Phone4 
Treatment 
Initiation 
Mid-
Treatment5  
End of 
Treatment5 
24 Hour 
Follow-Up 
96 Hour 
Follow-Up 
End of 
Study Phone  
Unscheduled 
Visit6 
Day (D), Visit Window 
 
Day -38 to 
-2 
Day -37 to 
-1 
Day -15 
to  
-2 
Day -14 
to  
-1 
Day 0 
 
Day 4 ± 
1 Day 
Day 7 ± 
1 Day 
Day 87 
Day 11 
± 
1 Day 
Day 38 ± 
7 Days 
 
Study Assessments 
Recruitment Script 
X 
 
 
 
 
 
 
 
 
 
 
 
Informed Consent 
 
X 
 
 
 
 
 
 
 
 
 
 
Demographics 
 
X 
 
 
 
 
 
 
 
 
 
 
Medical History 
 
X 
 
X8 
 
X8 
 
 
 
 
 
 
Physical Exam 
 
X 
 
X 
 
X 
 
 
 
 
 
X 
AD Severity Assessment 
 
X9 
 
X9 
 
X10 
X11 
X10 
X11 
X11 
 
X11 
Pregnancy Test12 
 
X 
 
X 
 
X 
X 
X 
 
X 
X13 
 
Concomitant 
Medications 
 
X 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
Vital Signs14 
 
X15 
 
X 
 
X 
X 
X 
X 
X 
 
X 
Participant 
Randomization 
 
 
 
 
 
X16 
 
 
 
 
 
 
AD Lesion Assessment17 
 
 
 
 
 
X 
X 
X 
X 
X 
 
X 
Skin Swab Collection 
 
X 
 
X 
 
X18 
X 
X 
X 
X 
 
X19 
AE Assessment 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
IP Application 
 
 
 
 
 
X 
 
 
 
 
 
 
IP Dispensation 
 
 
 
 
 
X 
X 
 
 
 
 
 
Review of Participant 
Diary 
 
 
 
 
 
X20 
X21 
X21 
 
 
 
 
Paper Participant Diary 
Dispensation22 
 
 
 
 
 
X 
X 
X 
 
 
 
 
IP Collection 
 
 
 
 
 
 
X23 
X23 
 
 
 
 
Blood Collection 
 
 
 
 
 
 
 
 
 
 
 
X1 

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1. 
Assessment of full inclusion and exclusion criteria will occur during the Screening Visit, after participants have consented to study participation. 
2. 
Screened participants who test positive for S. aureus on their lesional skin swab and require a medication/therapy washout of 14 days or less will be contacted via 
telephone to schedule their Treatment Initiation (Day 0) Visit. Participants who test positive for S. aureus on their lesional swab and require a medication/therapy washout 
of more than 14 days will be scheduled for a Repeat Culture Visit, following their washout. 
3. 
Only participants who test positive for S. aureus on their Screening lesional swab and require a medication/therapy washout of more than 14 days will be scheduled for a 
Repeat Culture Visit to confirm they are still S. aureus positive prior to treatment initiation.  
4. 
Only participants who complete the Repeat Culture Visit will have a Post-Culture Phone Visit.  
5. 
Participants will be requested to return for their Mid-Treatment and End of Treatment Visits on Day 4 and Day 7 approximately four hours after their last TMT or placebo 
application. 
6. 
If disease activity increases, participants experience signs and symptoms as described on the instructional hand card, or other concerns arise between regularly scheduled 
visits, participants may be asked to return to the study site for an Unscheduled Visit. 
7. 
If participants cannot return on Day 8  for the 24 Hour Follow -Up visit, this data will be treated as missing, and the participant will be asked to continue with any remaining 
visits, as required. 
8. 
An abbreviated Medical History will be collected at the Repeat Culture and Treatment Initiation visits to confirm participant still meets eligibility.  
9. 
AD disease severity will be assessed using the Investigator Global Assessment of the ventral arms, Eczema Area and Severity Index of the ventral arms, SCORing Atopic 
Dermatitis, and Pruritus VAS of the ventral arms standardized scales. 
10. AD disease severity will be assessed using the Eczema Area and Severity Index of the ventral arms, Rajka-Langeland, SCORing Atopic Dermatitis, and Pruritus VAS of the 
ventral arms standardized scales. 
11. AD disease severity will be assessed using the Eczema Area and Severity Index of the ventral arms, SCORing Atopic Dermatitis, and Pruritus VAS of the ventral arms 
standardized scales. 
12. A urine pregnancy test will be completed for all female participants of child bearing potential who do not self-report as pregnant. 
13. During the End of Study Phone Visit, female participants of child-bearing potential will be asked whether they have tested positive to a pregnancy test, since their last study 
visit. Male participants will be asked whether their partner has tested positive to a pregnancy test, since their last study visit. 
14. Vital signs will include temperature, heart rate, respiration, systolic blood pressure, and diastolic blood pressure.  
15. Vital signs, including temperature, heart rate, respiration, systolic blood pressure, diastolic blood pressure, plus height and weight, will be collected at the Screening Visit.  
16. Participants who meet all inclusion and exclusion criteria and require a medication/therapy washout of 14 days or less must be randomized within 14 days of their 
Screening Visit.  
17. Digital photographs of the lesional and non-lesional swab sites will be taken prior to swab collection. Each photograph will include a ruler so the scale of the site can be 
determined. 
18. Participants will remain in clinic for up to 1 hour following the application of investigational product during the Treatment Initiation Visit. Additional skin swabs will be 
collected at 1 hour post application.  
19. Skin swabs and/or blood may be collected during an Unscheduled Visit per investigator discretion.  
20. Participants will complete a baseline diary entry during their Treatment Initiation (Day 0) Visit.  
21. Paper diaries will be collected, during the in clinic review of the participant diary, if the participant completed a paper diary in lieu of the electronic diary.  
22. Paper diaries will be provided to track symptoms and compliance in the event participants do not have access to a device with internet access. 
23. The study team will collect all dispensed packets of investigational product from participants, including empty and unused investigational product.