A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects
Phase: PHASE1
Conditions: Bacterial Infection, Multiple-drug Resistance, Pathogen Resistance
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

DMID Protocol 16-0058 
Version 9.0 
IV Fosfomycin PK Study 
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DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of 
ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult 
Subjects 
DMID Protocol Number: 16-0058 
DMID Funding Mechanism: Vaccine and Treatment Evaluation Unit 
Pharmaceutical Support Provided by: Nabriva Therapeutics, Inc. 
IND Sponsor: NIH/NIAID/DMID 
Principal Investigators: Emmanuel B. Walter, MD, MPH and Loretta G. Que, MD 
DMID Clinical Project Manager: Maureen Mehigan, RN 
DMID Medical Officers: Varduhi Ghazaryan, MD, MPH  
DMID Medical Monitor: Tatiana Beresnev, MD 
Version Number: 9.0 
27 August 2020 
 
 
 

DMID Protocol 16-0058 
Version 9.0 
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27 August 2020 
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DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
STATEMENT OF COMPLIANCE 
The trial will be carried out in accordance with Good Clinical Practice (GCP) and as required by: 
• 
United States (US) 45 Code of Federal Regulations (CFR) Part 46: Protection of Human Subjects 
• 
Food and Drug Administration (FDA) Regulations, as applicable: 21 CFR Part 50 (Protection of 
Human Subjects), 21 CFR Part 54 (Financial Disclosure by Clinical Investigators), 21 CFR Part 56 
(Institutional Review Boards), and 21 CFR Part 11, 21 CFR Part 312 (Investigational New Drug 
Application). 
• 
International Conference on Harmonization (ICH) E6:GCP; 62 Federal Register 25691 (1997); and 
future revisions 
• 
Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research, 
Report of the National Commission for the Protection of Human Subjects of Biomedical and 
Behavioral Research 
• 
National Institutes of Health (NIH) Office of Extramural Research, Research Involving Human 
Subjects, as applicable 
• 
National Institute of Allergy and Infectious Diseases (NIAID) Clinical Terms of Award, as applicable 
• 
Applicable Federal, State, and Local Regulations and Guidance 
 
 

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DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
SIGNATURE PAGE 
The signature below provides the necessary assurance that the trial will be conducted according to all 
stipulations of the protocol, including all statements regarding confidentiality, and according to local legal 
and regulatory requirements and applicable US federal regulations and ICH E6: GCP guidelines. 
I agree to conduct the study in compliance with GCP and applicable regulatory requirements. 
I agree to conduct the study in accordance with the current protocol and will not make changes to the 
protocol without obtaining the Sponsor’s approval and Institutional Review Board (IRB)/Independent 
Ethics Committee (IEC) approval, except when necessary to protect the safety, rights, or welfare of 
subjects. 
 
Site Investigator Signature: 
 
Signed: 
 
Date: 
 
 
Emmanuel B. Walter, MD, MPH 
Professor of Pediatrics, Duke University 
 
 
 
Site Investigator Signature: 
 
Signed: 
 
Date: 
 
 
 Loretta G. Que, MD 
Professor of Medicine, Duke University 
 
 
 
 

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DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
TABLE OF CONTENTS 
Statement of Compliance .............................................................................................................................. 2 
Signature Page .............................................................................................................................................. 3 
Table of Contents .......................................................................................................................................... 4 
List of Tables ................................................................................................................................................ 8 
List of Figures ............................................................................................................................................... 9 
List of Abbreviations .................................................................................................................................. 10 
Protocol Summary ...................................................................................................................................... 14 
1. 
Key Roles ....................................................................................................................................... 19 
2. 
Background Information and Scientific Rationale ......................................................................... 22 
2.1. 
Background Information ................................................................................................................ 22 
2.2. 
Rationale ........................................................................................................................................ 26 
2.3. 
Potential Risks and Benefits .......................................................................................................... 27 
2.3.1. Potential Risks ............................................................................................................................... 27 
2.3.2. Known Potential Benefits .............................................................................................................. 29 
3. 
Objectives and Outcome Measures ................................................................................................ 30 
3.1. 
Study Objectives ............................................................................................................................ 30 
3.2. 
Study Outcome Measures .............................................................................................................. 30 
4. 
Study Design .................................................................................................................................. 32 
5. 
Study Enrollment and Withdrawal ................................................................................................. 33 
5.1. 
Subject Inclusion Criteria .............................................................................................................. 33 
5.2. 
Subject Exclusion Criteria ............................................................................................................. 34 
5.3. 
Treatment Assignment Procedures ................................................................................................ 37 
5.3.1. Randomization Procedures ............................................................................................................ 37 

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5.3.2. Reasons for Withdrawal and Discontinuation of Study Product Administration .......................... 37 
5.3.3. Handling of Withdrawals and Discontinuation of Administration ................................................ 38 
5.3.4. Subject Replacement ...................................................................................................................... 38 
5.3.5. Termination of Study ..................................................................................................................... 38 
6. 
Study Intervention/Investigational Product ................................................................................... 39 
6.1. 
Study Product Description ............................................................................................................. 39 
6.1.1. Acquisition ..................................................................................................................................... 39 
6.1.2. Formulation, Packaging, and Labeling .......................................................................................... 39 
6.1.3. Product Storage and Stability ......................................................................................................... 40 
6.2. 
Dosage, Preparation, and Administration of Study Drug .............................................................. 40 
6.3. 
Modification of Study Drug for a Subject ..................................................................................... 41 
6.4. 
Accountability Procedures for the Study Drug .............................................................................. 42 
6.5. 
Assessment of Subject Compliance with Study Drug ................................................................... 42 
6.6. 
Concomitant Medications/Treatments ........................................................................................... 42 
7. 
Study Schedule .............................................................................................................................. 43 
7.1. 
Screening (Day -30 to Day -1) ....................................................................................................... 43 
7.2. 
Enrollment/Baseline (Day -1 to Day 1) ......................................................................................... 43 
7.3. 
Day 1 to Day 2 ............................................................................................................................... 44 
7.4. 
Day 2 (Day of Discharge from DEPRU) ....................................................................................... 45 
7.5. 
Day 3 (Telephone Follow-up Call) ................................................................................................ 45 
7.6. 
Early Termination Visit ................................................................................................................. 45 
7.7. 
Unscheduled Visit (if needed) ....................................................................................................... 46 
8. 
Study Procedures/Evaluations ....................................................................................................... 47 
8.1. 
Clinical Evaluations ....................................................................................................................... 47 
8.2. 
Laboratory Evaluations .................................................................................................................. 47 

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8.2.1. Clinical Laboratory Evaluations .................................................................................................... 47 
8.2.2. Bronchoscopy and Bronchoalveolar Lavage (BAL) ...................................................................... 48 
8.2.3. Pharmacokinetic Blood and BAL Samples .................................................................................... 49 
8.2.4. Specimen Preparation, Handling, and Shipping ............................................................................ 51 
9. 
Assessment of Safety ..................................................................................................................... 52 
9.1. 
Specification of Safety Parameters ................................................................................................ 52 
9.2. 
Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters...................... 52 
9.2.1. Adverse Events .............................................................................................................................. 52 
9.2.2. Serious Adverse Events ................................................................................................................. 53 
9.2.3. Procedures to be Followed in the Event of Abnormal Laboratory Test Values or Abnormal 
Clinical Findings ......................................................................................................................................... 54 
9.3. 
Reporting Procedures ..................................................................................................................... 54 
9.3.1. Serious Adverse Events ................................................................................................................. 55 
9.3.2. Regulatory Reporting for Studies Conducted Under DMID-Sponsored IND ............................... 55 
9.3.3. Reporting of Pregnancy ................................................................................................................. 56 
9.4. 
Type and Duration of Follow-up of Subjects after Adverse Events .............................................. 56 
9.5. 
Halting Rules ................................................................................................................................. 56 
9.6. 
Safety Oversight ............................................................................................................................ 56 
9.6.1. Independent Safety Monitor (ISM) ................................................................................................ 57 
9.6.2. Safety Monitoring Committee (SMC) ........................................................................................... 57 
10. 
Clinical Monitoring ........................................................................................................................ 58 
10.1. 
Site Monitoring Plan ...................................................................................................................... 58 
11. 
Statistical Considerations ............................................................................................................... 59 
11.1. 
Study Hypotheses .......................................................................................................................... 59 
11.2. 
Sample Size Considerations ........................................................................................................... 59 

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11.3. 
Final Analysis Plan ........................................................................................................................ 60 
12. 
Source Documents and Access to Source Data/Documents .......................................................... 63 
13. 
Quality Control and Quality Assurance ......................................................................................... 64 
14. 
Ethics/Protection of Human Subjects ............................................................................................ 65 
14.1. 
Ethical Standard ............................................................................................................................. 65 
14.2. 
Institutional Review Board ............................................................................................................ 65 
14.3. 
Informed Consent Process ............................................................................................................. 65 
14.4. 
Exclusion of Women, Minorities, and Children (Special Populations) ......................................... 66 
14.5. 
Subject Confidentiality .................................................................................................................. 66 
14.6. 
Study Discontinuation .................................................................................................................... 67 
14.7. 
Costs, Subject Compensation, and Research Related Injuries ....................................................... 67 
14.8. 
Future Use of Stored Specimens and Data..................................................................................... 68 
15. 
Data Handling and Record Keeping .............................................................................................. 69 
15.1. 
Data Management Responsibilities ................................................................................................ 69 
15.2. 
Data Capture Methods ................................................................................................................... 69 
15.3. 
Types of Data ................................................................................................................................. 69 
15.4. 
Timing/Reports .............................................................................................................................. 70 
15.5. 
Study Records Retention................................................................................................................ 70 
15.6. 
Protocol Deviations ........................................................................................................................ 70 
16. 
Publication Policy .......................................................................................................................... 71 
17. 
Literature References ..................................................................................................................... 72 
18. 
Supplements/Appendices ............................................................................................................... 76 
Appendix A: Schedule of Study Procedures And Evaluations ................................................................... 76 
Appendix B: Adverse event toxicity grading scale ..................................................................................... 79 
Appendix C: Venipuncture schedule and volumes ..................................................................................... 87 

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DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
 
LIST OF TABLES 
Table 1: Study drug administration................................................................................................17 
Table 2: Bronchoscopy with BAL sampling times ........................................................................17 
Table 3: Blood PK sampling times ................................................................................................17 
Table 4: AEs occurring in ≥2% of patients receiving ZTI-01 in a phase 2/3 clinical trial ............26 
Table 5: ZTI-01 dose preparation guidelines .................................................................................40 
Table 6: ZTI-01 (disodium fosfomycin) reconstitution with WFI.................................................41 
Table 7: Pharmacokinetics sampling times....................................................................................49 
Table 8: Probability of observing at least one event for a range of true event rates based 
on a sample size of n=30 subjects...............................................................................60 
Table 9: Schedule of study procedures and evaluations ................................................................76 
Table 10: Clinical adverse event definition and grading scale ......................................................80 
Table 11: Laboratory adverse event definition and grading scale .................................................85 
Table 12: Venipuncture schedule and volumes .............................................................................87 
 
 
 
 
 

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LIST OF FIGURES 
Figure 1: Schematic of Study Design ............................................................................................18 
 
 

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DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
LIST OF ABBREVIATIONS 
AE 
Adverse Event/Adverse Experience 
ALT 
 Alanine Aminotransferase 
AM 
Alveolar Macrophage 
ALP 
 Alkaline Phosphatase 
AST 
Aspartate Aminotransferase 
AUC 
Area under the concentration-time curve 
AUC0-t 
AUC calculated to the last measured concentration 
AUC0-inf 
AUC extrapolated to infinity 
BAL 
Bronchoalveolar lavage 
BMI 
Body Mass Index 
Cmax 
Maximum Measured Concentration 
CRF 
Case Report Form 
CDC 
Centers for Disease Control and Prevention 
CFR 
Code of Federal Regulations 
CFU 
Colony Forming Unit 
CL 
Clearance 
CrCl 
Creatinine Clearance 
CRE 
Carbapenem-Resistant Enterobacteriaceae 
CROMS 
Clinical Research Operations and Management Support 
DCC 
Data Coordinating Center 
DEPRU 
Duke Early Phase Research Unit 
DHHS 
Department of Health and Human Services 
DMID 
Division of Microbiology and Infectious Diseases 

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DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
DMID-CMS 
DMID Clinical Materials Services (CMS, Fisher BioServices) 
ECG 
Electrocardiograph 
ELF 
Epithelial Lining Fluid 
ESBL 
Extended-Spectrum Beta-Lactamase 
FDA 
Food and Drug Administration 
FSH 
Follicle-Stimulating Hormone 
FWA 
Federal Wide Assurance 
GCP 
Good Clinical Practice 
GI 
Gastrointestinal 
HBsAg 
Hepatitis B Surface Antigen 
HCV 
Hepatitis C Virus 
IB 
Investigator’s Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonization 
ICMJE 
International Committee of Medical Journal Editors 
IM 
Intramuscular 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ISM 
Independent Safety Monitor 
IV 
Intravenous 
LC-MS/MS 
Liquid chromatography-mass spectrometry/mass spectrometry 
MIC 
Minimum Inhibitory Concentration 
MOP 
Manual of Procedures 
MDR 
Multi-Drug Resistant 
MRSA 
Methicillin Resistant S. aureus 

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N 
Number (typically refers to subjects) 
NCI 
National Cancer Institute 
NDA 
New Drug Application 
NEJM 
New England Journal of Medicine 
NIAID 
National Institute of Allergy and Infectious Diseases 
NIH 
National Institutes of Health 
OCRA 
Office of Clinical Research Affairs 
OHRP 
Office for Human Research Protections 
OHSR 
Office for Human Subjects Research 
ORA 
Office of Regulatory Affairs 
PD 
Pharmacodynamics 
PHI 
Protected Health Information 
PI 
Principal Investigator 
PIP-TAZ 
Piperacillin-Tazobactam 
PK 
Pharmacokinetics 
PRSP 
Penicillin Resistant S. pneumonia 
PST 
Product Support Team 
QA 
Quality Assurance 
QC 
Quality Control 
RIC 
Resistance Inhibitory Concentration 
RLD 
Reference Listed Drug 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SMC 
Safety Monitoring Committee 
SOP 
Standard Operating Procedure 
T½ 
Terminal Elimination Half-Life 

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Tmax 
Time to Maximum Concentration 
TEAE 
Treatment-Emergent Adverse Event 
TOC 
Test-of-Cure Visit 
US 
United States 
USP 
United States Pharmacopeia 
UTI 
Urinary Tract Infections 
Vd 
Volume of Distribution 
VRE 
Vancomycin Resistant Enterococci 
WFI 
Sterile Water for Injection 
 
 

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PROTOCOL SUMMARY 
Title: 
A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of ZTI-
01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects 
Phase: 
1 
Population: 
40 healthy male and female adults will be enrolled and randomized (to 
obtain 30 evaluable subjects) aged 18-45 years, inclusive, with BMI 
18-30 kg/m2, inclusive, and body weight >50 kg (110 lbs) 
Number of Sites: 
1 (Duke Early Phase Research Unit [DEPRU], Durham, NC) 
Study Duration: 
Approximately 6 months 
Subject Participation Duration: 
Individual subject participation will be approximately 33 days to 
include up to 30 days between screening and baseline/enrollment, 2 
days treatment (dosing) and 1 day of post-dosing follow-up 
Description of Agent or 
Intervention: 
 
ZTI-01 [intravenous (IV) fosfomycin disodium] packed in a single 
Type 1 glass vial equivalent to 4 g of fosfomycin and 1.28 g of sodium 
with inactive ingredient of recrystallized succinic acid.  
Objectives: 
Safety: 
• 
Determine the safety of multiple doses of ZTI-01 (6 g dose 
administered as a 1-hour IV infusion (+10 minute window), every 
8 hours, for a total of 18 g in three doses) 
Pharmacokinetic: 
• 
Determine the plasma and intrapulmonary pharmacokinetics (PK) 
(epithelial lining fluid, and alveolar macrophage concentrations of 
fosfomycin) after multiple doses of ZTI-01 (6 g dose administered 

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as a 1-hour IV infusion (+10 minute window), every 8 hours, for a 
total of 18 g in three doses) 
Outcome Measures: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Description of Study Design: 
Safety: 
• 
The occurrence of adverse events (AEs), summary of physical 
exam findings, vital signs, clinical laboratory tests, and ECGs (B) 
at any time from the start of study drug administration through the 
end of subject follow-up 
Pharmacokinetic: 
• 
Plasma ZTI-01 concentrations will be measured by a validated LC-
MS/MS assay for the blood samples collected during the study 
(Table 3). PK parameters of ZTI-01 will be estimated from the 
plasma concentration including maximum measured plasma 
concentration (Cmax), area under the concentration vs. time curve 
(AUC0-8), time to peak concentration (tmax), terminal elimination 
half-life (t1/2), terminal-phase elimination rate constant (λz), 
volume of distribution (Vd), and clearance (CL). 
• 
Intrapulmonary PK of ZTI-01 defined as percent penetration of 
lung epithelial lining fluid (ELF) and alveolar macrophages 
(AMs). The ratios of ELF and AM concentrations of fosfomycin to 
simultaneous plasma concentrations will be calculated for each 
subject and summarized for each sampling time. The median 
concentrations of fosfomycin from the BAL sampling times will 
be used to estimate the AUC0-8 of plasma, ELF, and AM. The ratio 
of AUC0-8 of ELF-to-plasma and AM-to-plasma will be calculated 
to determine the percent penetration.  
 
This is a Phase 1, open-label, multiple-dose study conducted at a single 
center. The treatment period will consist of 18 g of ZTI-01 in three 
divided doses (Table 1). A total of 30 enrolled subjects will be 
randomized to undergo a single standardized bronchoscopy with 
bronchoalveolar lavage (BAL) at one of five sampling times as defined 
below (Table 2). A total of 6 subjects will be assigned to each BAL-

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sampling time. Ten additional enrolled subjects will act as alternates to 
obtain 30 evaluable subjects.  
Each subject will complete Screening, Baseline, Treatment and 
Follow-up Phases. The Screening Phase will be conducted on an 
outpatient basis within 30 days of the Baseline Phase, which will 
consist of admission to DEPRU on the day before the first dose (Day -
1) for pre-dosing assessments. The Treatment Phase will start on the 
day of first dose (Day 1) and end at the time of discharge from 
DEPRU. Three IV doses of ZTI-01 will be administered every 8 hours 
(hours 0, 8, and 16 during the Treatment Phase). Blood samples for PK 
measurements will be collected before each dose, up to 8 hours after 
the start of the first IV infusion of ZTI-01, and up to 12 hours after the 
start of the third IV infusion (Tables 2 and 3). One bronchoscopy with 
BAL will be completed on each subject at the timepoint to which that 
subject was randomized. Key electrolytes will be remeasured prior to 
each subject’s bronchoscopy in order to minimize risk of arrhythmia. 
Subjects will be discharged following the final 12-hour blood sampling 
time point (if safety parameters are acceptable to the Investigator). 
Safety assessments will be conducted during the entire 24-hour 
Treatment Phase. The Follow-Up Phase consists of a telephone 
interview on Day 3 for symptom-driven safety assessments. 
 
Estimated Time to Complete 
Enrollment: 
 
Approximately 12 weeks 
 
 
 

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Table 1: Study drug administration 
Study drug 
Formulation/Strength 
Each dose/Route 
Dosing interval 
Total no. of doses 
ZTI-01 
Fosfomycin, disodium 
salt, 4 g fosfomycin per 
vial 
6 g fosfomycin per 
200 mL dose, 
1-hour IV infusion 
(+10 minute 
window) 
Every 8 hours 
3 
 
Table 2: Bronchoscopy with BAL sampling times 
 
BAL sampling times after start of third IV infusion of ZTI-01* 
30 minutes 
1 hour 15 minutes 
2 hours 
5 hours 
8 hours 
No. subjects (n=30 
completed) 
6 
6 
6 
6 
6 
*Each subject will complete a single standardized bronchoscopy with BAL randomized to one of the five 
sampling times shown.   
 
 Table 3: Blood PK sampling times 
 
 
 
Dosing 
Dose 1 
Dose 2 
Dose 3 
Pre-Dose 
During/After Dose 
Pre-Dose 
Pre-Dose 
During/After Dose 
Timing of PK 
blood sample 
Within 10 
minutes 
before 
starting the 
1-hour 
infusion 
30 minutes, 1 
hour, 1 hour 15 
minutes, 2, and 5 
hours after starting 
the first dose 
Within 10 
minutes before 
starting the 1-
hour infusion 
Within 10 
minutes 
before 
starting the 
1-hour 
infusion 
30 minutes, 1 hour, 
1 hour 15 minutes, 
2, 5, 8, and 12 
hours after starting 
the third (last) dose 

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Figure 1: Schematic of Study Design 
 

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1. 
KEY ROLES 
Individuals: 
Site Principal Investigator: 
DMID Clinical Project 
Manager: 
 
Emmanuel B. Walter, MD, MPH and Loretta G. Que, MD 
 
Maureen Mehigan, RN  
Bacteriology and Mycology Branch  
DMID/NIAID/NIH/HHS  
5601 Fishers Lane/Rm7E19 
Bethesda, MD 20892  
Phone:240-627-3317 
mmehigan@niaid.nih.gov 
DMID Medical Officer  
Varduhi Ghazaryan, MD, MPH 
DMID Medical Monitor 
Tatiana Beresnev, MD, MSHS  
Institutions: 
Duke Vaccine and Trials Unit (DVTU) 
2608 Erwin Road, Ste 210 
Durham, NC 27705 
Emmanuel Walter, MD, MPH 
919-620-5346 
chip.walter@duke.edu 
 
Duke Early Phase Research Unit 
40 Duke Medicine Circle 
Durham, NC 27710 
Jeff Guptill, MD, MA, MHS 
919-668-0504 

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jeffrey.guptill@duke.edu 
 
Duke Investigational Drug Service 
200 Trent Drive, Duke Clinic 
Durham, NC 27710 
Safety and Pharmacovigilance 
Contractor: 
 
DMID Pharmacovigilance Group 
Clinical Research Operations and Management Support (CROMS) 
6500 Rock Spring Dr., Suite 650 
Bethesda, MD 20817 
SAE Hot Line: 1-800-537-9979 (US) 
SAE Fax: 800-275-7619 (US) 
SAE Email: PVG@dmidcroms.com 
 
Data Coordinating Center: 
 
The Emmes Corporation 
 
401 N. Washington St., Suite 700 
 
Rockville, MD  20850 
 
Phone: 301-251-1161 
BMB_Studies@emmes.com 
 
 
Clinical Materials Services: 
 
 
DMID-CMS 
20439 Seneca Meadows Parkway 
Germantown, MD 20876 
Tel: (240) 477-1350 
Fax: (240) 477-1360 
E-mail: DMID.CMS@ThermoFisher.com 

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Laboratory(ies), if applicable: 
 
 
DUHS Clinical Laboratories 
4425 Ben Franklin Blvd 
Durham NC, 27704 
Phone: 919-681-6335 
Fax: 919-620-1648 
 
Duke Early Phase Research Unit Core Laboratory 
40 Medicine Circle 
Durham, NC 27710 
Phone: 919-613-5015  
 
Frontage Laboratories 
700 Pennsylvania Drive 
Exton, PA 19341 
Phone: 610-232-0100 
Fax: 610-232-0101 

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2. 
BACKGROUND INFORMATION AND SCIENTIFIC 
RATIONALE 
2.1. 
Background Information 
Bacterial resistance against antimicrobials has reached alarming levels in recent decades resulting in crisis 
and necessitating the need for more antibiotic treatment options, particularly among Gram-negative 
bacteria, including those that express extended-spectrum beta-lactamases (ESBLs) and the carbapenem-
resistant Enterobacteriaceae (CRE). The lack of available and effective antibiotics for these organisms has 
created an unmet medical need that is widely acknowledged (Alemayehu et al, 2012). Infections with 
CRE are difficult to treat and there are limited treatment choices available or options suitable for certain 
patients. Mortality rates as high as 40%-50% have been associated with CRE infection, and thus the 
Centers for Disease Control and Prevention (CDC) considers this an urgent threat to public health (CDC 
Report 2013). 
Since the first report in a US hospital in 2001, CRE prevalence in the US has increased rapidly with an 
estimated 6% of all hospitals having reported at least one such infection. Data from the European 
Antimicrobial Resistance Surveillance Network (EARS-Net) showed statistically significant increases in 
the prevalence of carbapenem resistance among K. pneumoniae isolates from 2005 to 2010 in 
progressively more countries across Europe (Magiorakos et al, 2013). Given the rapid rise of carbapenem 
resistance outside the US, it is very probable that we will see increasing rates in the US as well. In 
particular, rising rates among long-term-care facilities, where an estimated 25% of elderly persons in the 
US will reside at some point in their lives, is alarming. In a cross-sectional study of facility residents seen 
in the emergency department for urinary tract infections (UTIs), multidrug-resistant (MDR) bacteria were 
identified in up to 80% of isolates (Genao and Buhr, 2012).  
There has been a renewed interest and effort to expedite the availability of antibiotics effective against 
these resistant pathogens. To fill the void of desperately needed therapeutic options, a re-evaluation of 
“forgotten,” older antibiotics and their different formulations has been proposed (Kanj and Khanafani, 
2011; Pulcini et al, 2012). Despite years of safe and effective use, many of these drugs require a 
“modernization” of PK-pharmacodynamics (PD) to adequately bridge clinical data and thereby ensure 
successful therapeutic results in the era of increased resistance. Evidence suggests that the development of 
resistance is associated with the use of suboptimal dosing regimens, while optimal dosing regimens are 
associated with a higher likelihood of suppressing the development of resistance (Drusano, 2003). For 
this to be feasible, alternative approaches to the development of these forgotten antibiotics must be 
employed and used in support of marketing approval. 
ZTI-01 is fosfomycin for injection, a phosphonic acid derivative formulated as a disodium salt. 
Fosfomycin acts by inhibiting peptidoglycan assembly, thereby disrupting cell wall synthesis (Kahan et 
al., 1974). Uptake into the bacterial cell occurs via active transport, by the L-α-glycerophosphate transport 

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and hexose phosphate uptake systems. Once inside the bacterium, fosfomycin competes with 
phosphoenolpyruvate to irreversibly inhibit the enzyme enolpyruvyl transferase, which catalyzes the first 
step of peptidoglycan synthesis, and thereby interrupt cell wall synthesis.  
The antimicrobial spectrum of fosfomycin is very broad. It exhibits bactericidal activity against anaerobic 
pathogens and many Gram-positive and -negative bacteria, including the increasingly problematic CRE 
and ESBL-producing organisms. Staphylococcus aureus (including MRSA), Streptococcus pneumoniae 
(including PRSP), Escherichia coli, Neisseria meningitidis, Haemophilus influenzae, Klebsiella 
pneumoniae, Enterococcus faecalis (including VRE), Serratia marcescens, Pseudomonas aeruginosa, 
and Proteus mirabilis are among the many organisms in which fosfomycin is active (Michalopoulos et al, 
2011).  
In Europe and Japan, IV fosfomycin has provided a safe and effective option for treating patients with 
UTIs and a variety of other, often very severe, infections, including MDR infections in patients with 
cystic fibrosis (Mirakhur et al, 2003) and sepsis (Matzi, 2010) for more than 45 years. ZTI-01 penetrates 
rapidly into tissues and achieves clinically relevant concentrations in serum, urine, soft tissues, lung, 
bone, cerebrospinal fluid, and heart valves, making it a desirable antibiotic treatment option (Roussous et 
al, 2009). Falagas et al (2008) compiled literature evidence regarding the effectiveness and safety of oral, 
IV, and intramuscular (IM) fosfomycin for the treatment of patients with Gram-positive and/or Gram-
negative bacterial infections, excluding UTI and gastrointestinal (GI) infection. Of the 1311 potentially 
relevant studies, 62 studies involving 1604 patients with a variety of infections (pneumonia and other 
respiratory infections; osteomyelitis; meningitis; ear, nose, and throat infections; surgical infections; 
obstetric and gynecological infections; arthritis; septicemia; peritonitis; cervical lymphadenitis; eye 
infections; diabetic foot infections; and typhoid fever) were included. The most frequently involved 
pathogens were S. aureus and P. aeruginosa, and fosfomycin was administered via oral, IV, or IM routes 
at dosages of 2-24 g daily, administered in divided doses every 6-8 hours. The mean duration of 
fosfomycin treatment ranged from 5 to 21 days, including fosfomycin administered alone or in 
combination with other antibiotics. Cures were achieved in 81.2% (1242/1529) of patients, and clinical 
improvement was noted in 3.0% (46/1529) of patients.  
Among 664 patients in these studies, fosfomycin treatment was also well tolerated: 5.4% reported mild GI 
symptoms (e.g., nausea, diarrhea, epigastralgia, vomiting); 4.0% developed skin manifestations (e.g., 
rash, dermatitis, exanthema); 3.0% experienced pain at the injection site or phlebitis; and 2.1%, 1.2%, and 
0.1% showed moderate increases in platelet count, eosinophil count, and transaminase level, respectively. 
In general, fosfomycin shows little toxicity, and adverse effects are generally mild following parenteral 
doses up to 24 g/day. Renal impairment significantly decreases the excretion of fosfomycin and doses 
should be reduced if the creatinine clearance is less than 50 ml/min. Since fosfomycin shows synergistic 
action with other antimicrobials, it is often used in combination (Kastoris et al, 2010). In fact, treatment 
with fosfomycin is considered free from the nephrotoxicity that characterizes treatment with 
aminoglycosides. Animal studies have demonstrated that fosfomycin protects against nephrotoxicity by 
inhibiting aminoglycoside-induced histamine release from mast-cell destruction. Fosfomycin also 

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increases oxygen levels in mitochondria and cyclic-AMP levels in mast cells (Walwarawooth, 2004; 
Popovic et al, 2010). 
Despite decades of use, fosfomycin has retained excellent antimicrobial activity. The emergence of MDR 
organisms such as fluoroquinolone-resistant E. coli, ESBL-producing bacteria, and carbapenem-resistant 
K. pneumoniae has prompted the re-evaluation of fosfomycin, due to the dwindling number of effective 
antimicrobial options (Pulcini et al, 2012).  
ZTI-01 has been granted Qualified Infectious Disease Product (QIDP) and Fast Track designations by the 
FDA as an antibiotic drug intended to treat serious or life-threatening infections, including those caused 
by MDR or emerging pathogens, for which limited or no antibacterial therapy has been developed. Two 
clinical studies (DMID-13-0064 and ZEUS) support US registration of ZTI-01. 
A Phase 1, single-dose, randomized, three-period, crossover study (Wenzler, 2017) was conducted at a 
single center to assess the safety, tolerability, and PK of ZTI-01 (fosfomycin for injection) in healthy 
adults. Subjects were randomized to receive one of three treatment sequences (1 or 8 g ZTI-01 
administered as a 1-hour IV infusion (+10 minute window) or 3 g fosfomycin tromethamine [sachet, 
Monurol®] administered orally per label instructions). Each treatment sequence was enrolled in parallel, 
and each subject received all three treatments in crossover fashion. Each crossover period included a 
single dose of study drug under fasted conditions, followed by safety assessments and blood/urine 
collections for PK measures up to 48 hours. Each treatment period was separated by a 3- to 7-day 
washout period.  
A total of 30 healthy subjects were enrolled and randomized, and 28 of them completed all study 
procedures. The mean age was 27 years (range, 18-44). There were no serious adverse events (SAEs), and 
no subjects discontinued treatment due to treatment-emergent adverse events (TEAEs).  
The incidence of TEAEs was 39.3% in the ZTI-01 IV (1-g) group, 67.9% in the ZTI-01 IV (8-g) group, 
and 43.3% in the oral Monurol group. The most common TEAEs (>2 subjects in any group) in the ZTI-01 
IV (1-g), ZTI-01 IV (8-g), and Monurol groups were decreased heart rate (10.7, 28.3, and 16,7%), 
decreased blood calcium (17.9, 10.7, and 13.3%), and headache (10.7, 7.1, and 3.3%), respectively. None 
of the reported TEAEs was considered clinically significant based on clinical evaluation and course. 
Abnormal laboratory findings were mild, asymptomatic, and not considered clinically significant. The 
most common (affecting >2 subjects) laboratory abnormality was hypocalcemia. There were no clinically 
significant changes in vital signs in any subject during the study. The most common (affecting >2 
subjects) abnormality in vital sign measurements was a decreased heart rate. A decrease in systolic blood 
pressure was reported by 1 subject in the ZTI-01 IV (1-g) group, considered mild in severity and related 
to study treatment by the Investigator. There were no subjects with abnormal ECG intervals. 
A Phase 2/3, multicenter, randomized, double-blind, comparative study (ZEUS, NCT02753946, 
unpublished) to evaluate the safety and efficacy of ZTI-01 (fosfomycin disodium) vs. piperacillin/ 
tazobactam (PIP-TAZ) in the treatment of complicated UTIs, including acute pyelonephritis (AP), in 

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hospitalized adults was recently completed. A total of 465 subjects were randomized at 72 sites in Central 
and Eastern Europe and the US. The mean age of treated patients was 50 years (range, 18-89) across 
treatment arms, and most (63%) were female. About 30% of patients had sepsis at baseline, based on 
systemic inflammatory response syndrome (SIRS) criteria, and 9% of patients had bacteremia at baseline. 
Subjects were randomized (1:1) to receive a fixed duration of 7 to 14 days of either ZTI-01 (6 g) IV 
infused over 1 hour every 8 hours (18 g/day), or PIP-TAZ (4 g piperacillin/0.5 g tazobactam) IV infused 
over 1 hour every 8 hours. All but 1 subject (in the PIP-TAZ group) received at least 1 dose of study drug. 
Most subjects completed study drug treatment: 219 (94.0%) subjects in the ZTI-01 group and 222 
(95.7%) subjects in the PIP-TAZ group. 
The primary efficacy endpoint was the proportion of subjects with an overall success (clinical cure and 
microbiologic eradication) in the m-MITT Population at the test-of-cure (TOC) Visit. Overall responses 
were programmatically determined, and microbiological response presumed that the same bacterial 
species were identical at the Screening and TOC Visits. Overall success was higher in the ZTI-01 group 
(64.7%) compared to the PIP-TAZ group (54.5%). The treatment difference was 10.2% (95% CI, -0.4 to 
20.8) and the lower bound of the 95% CI met the prespecified non-inferiority margin of -15%, 
demonstrating that ZTI-01 was non-inferior to PIP-TAZ.  
The microbiologic eradication analysis (part of Overall Success determination) presumed that any 
pathogen strains recovered at baseline and again at TOC were identical. Patient isolates from both 
treatment arms underwent blinded pulse-field gel electrophoresis analysis. These molecular data 
confirmed 20 strains with unique identity and a reanalysis of the primary objective was performed. Using 
this classification, higher overall success rates for both treatment arms was observed; ZTI-01 (69.0%) 
compared to PIP-TAZ (57.3%); the treatment difference was 11.7% (95% CI, 1.3 to 22.1), indicating that 
ZTI-01 was superior to PIP-TAZ. 
Both study drugs were well-tolerated, and study drug discontinuations or interruptions due to AEs were 
uncommon. The incidence of TEAEs was higher in the ZTI-01 group (42.1%) compared to the PIP-TAZ 
group (32.0%); however, most TEAEs in the ZTI-01 group were well-described class effects, including 
asymptomatic laboratory abnormalities (e.g., elevated liver transaminases, hypokalemia) or GI disorders. 
The incidence of SAEs was low and similar in the ZTI-01 (5 [2.1%]) and PIP-TAZ (6 [2.6%]) groups. No 
unique SAE occurred in >1 subject in either treatment group. There were no deaths and only one SAE 
deemed related to ZTI-01 (hypokalemia) in the study. 
 
 
 
 

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Table 4: AEs occurring in ≥2% of patients receiving ZTI-01 in a phase 2/3 clinical trial 
Adverse event (%) 
Complicated UTIs, including pyelonephritis 
ZTI-01 (N=233) 
Piperacillin-Tazobactam (N=231) 
Nausea 
4.3 
1.3 
Diarrhea 
3.9 
4.8 
Vomiting 
3.9 
0.4 
Phlebitis 
0.9 
2.6 
Increased ALT 
8.6 
2.6 
Increased AST 
7.3 
2.6 
Hypokalemia 
6.4 
1.3 
Headache 
2.6 
2.2 
2.2. 
Rationale 
Given the urgent medical need and the spread of bacterial resistance, ZTI-01 may provide a useful option 
for health care providers. ZTI-01 is a proven and useful therapeutic agent with more than 45 years of 
clinical experience documenting that both oral and IV formulations are effective and well-tolerated in a 
variety of patient populations. In addition to the FDA-approved oral formulation, an IV formulation of 
fosfomycin (ZTI-01, fosfomycin for injection) would represent a useful therapy option for difficult-to-
treat infections and thus an important addition to the US therapeutic armamentarium. 
Intrapulmonary penetration of antibiotics is considered a crucial factor in their ability to treat lower 
respiratory tract infections (Rodvold et al, 2011; Ambrose et al, 2010). Pulmonary epithelial lining fluid 
(ELF) and alveolar macrophages (AMs) have been described as important sites of infection with common 
extracellular and intracellular respiratory pathogens, respectively. Measurement of drug concentrations in 
ELF and AMs by bronchoscopy with BAL has become a practical and reliable method to assess 
intrapulmonary penetration. Knowledge of a drug’s penetration (i.e., time course of drug entry and 
magnitude of drug concentration) in different lung compartments, and the most-likely pathogen’s location 
within the lung, can assist in the design of antibiotic dosing regimens to effectively treat lower respiratory 
tract infections. 
The development pathway for ZTI-01 includes evaluating treatment of patients with serious lower 
respiratory tract infections. It is anticipated that this trial will provide sufficient evidence on two 
development fronts. The first of these is to determine the concentrations of fosfomycin in the ELF and 
AMs relative to fosfomycin concentrations in plasma. The second is to provide adequate information to 
establish safety of the selected dosing regimen to enable further evaluation of ZTI-01 in the intended 
patient population. 
This trial will evaluate a single dose sequence of ZTI-01: three 6-g doses of fosfomycin, administered as a 
1-hour IV infusion (+10 minute window), every 8 hours. The dosage selection was directly influenced by 
applying PK-PD principles of anti-infective agents. Recent studies have provided useful information for 

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modernizing and optimizing fosfomycin dosing regimens. VanScoy et al found that the PK-PD parameter 
that most strongly associated with efficacy was the percentage of fosfomycin concentrations above the 
resistance inhibitory concentration (RIC) [% T>RIC] during the dosing interval (VanScoy et al, 2015). 
The proposed magnitude % T>RIC associated with net bacterial stasis and a 1-log10 and 2-log10 colony 
forming unit (CFU) reduction in bacterial density over 24 hours was 11.8, 20.9, and 32.7%, respectively. 
Total daily fosfomycin doses of 8 g and 32 g resulted in a rapid reduction in bacterial density without 
amplification of a drug-resistant subpopulation. A subsequent study suggested that the lowest fosfomycin 
dosing regimen that did not amplify a drug-resistant bacterial subpopulation was 4 g administered every 8 
hours (VanScoy, et al 2016). An in-vivo study performed in a neutropenic murine thigh model (Lepak et 
al, 2015) used dose fractionation to assess PK-PD targets and survival. This study demonstrated ZTI-01 
potency against E. coli, K. pneumoniae, and P. aeruginosa, including ESBL-producing and carbapenem-
resistant phenotypes in vivo. In this 24-hour model, the index AUC/MIC was most closely linked with 
efficacy. Notably, targets for AUC/MIC and T>Threshold were similar between organism groups. 
Enterobacteriaceae stasis was noted at AUC/MIC exposures of ~20 and maximal survival was observed at 
exposures similar to stasis endpoints. 
2.3. 
Potential Risks and Benefits 
2.3.1. 
Potential Risks 
The oral and IV formulations of fosfomycin have been used for >45 years within and outside the US. As 
such, the potential risks for subject participation include procedures associated with the trial (e.g., blood 
sampling, ECG, and bronchoscopy) and/or those risks associated with well-characterized, low-incidence 
AEs that have followed IV fosfomycin administration. 
IV fosfomycin has a high sodium load, which may result in hypokalemia and may require oral or IV 
potassium supplementation in some subjects. Serum electrolyte levels and water balance must be 
monitored during IV fosfomycin therapy. Caution is advised when IV fosfomycin is used in patients with 
cardiac insufficiency, hypertension, hyperaldosteronism, hypernatremia, or pulmonary edema. 
Acute, potentially life-threatening hypersensitivity reactions (e.g., anaphylactic shock) may occur rarely. 
At the first signs of potential anaphylaxis (i.e., sweating, nausea, cyanosis), the infusion will be 
discontinued. Depending upon the clinical situation, appropriate emergency measures may need to be 
initiated. 
Antibacterial agent-associated colitis and pseudo-membranous colitis have been reported with nearly all 
antibacterial agents including fosfomycin, and may range in severity from mild to life-threatening. 
Therefore, it is important to consider this diagnosis in patients who present with diarrhea during or after 
IV fosfomycin therapy. 
The following AEs have been observed commonly or uncommonly following IV fosfomycin therapy in 
published literature or clinical trials, or are recognized in labeling outside the US: 

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• 
Common (≥1/100 to <1/10): nausea, vomiting, diarrhea, abdominal discomfort, injection-site 
phlebitis, liver enzyme abnormalities, QT interval prolongation, hypocalcemia, hypokalemia, 
hypophosphatemia, headache 
• 
Uncommon (≥1/1,000 to <1/100): decreased appetite, hypernatremia,  dysgeusia,  vertigo, 
confusion, visual changes, dyspnea, rash, fatigue, edema,  
• 
Rare (≥1/10,000 to <1/1000): aplastic anemia, eosinophilia 
• 
Very rare (<1/10,000): fatty liver (completely reversible after drug discontinuation), 
anaphylaxis, visual impairment 
• 
Unknown frequency: pseudomembranous colitis, hepatitis, cholestasis, tachycardia, asthma 
attack, allergic reaction (angioedema, pruritis, urticaria), agranulocytosis, granulocytopenia, 
leukopenia, pancytopenia, thrombocytopenia, neutropenia, confusion 
 
The following potential risks are associated with other study procedures done as part of the trial: 
• 
Associated with insertion of peripheral IV catheter and venous phlebotomy: momentary 
discomfort and bruising; infection, excess bleeding, clotting, or fainting are unlikely. 
• 
Associated with ECG: skin irritation, itching, and redness from placement of ECG electrode 
pads.  
• 
Associated with bronchoscopy: hemoptysis, epistaxis, local discomfort, fever, sore throat, 
respiratory distress, and respiratory failure. Sedative medications may be given as part of the 
bronchoscopy and may cause hypotension, lightheadedness, or dizziness; these side effects 
are somewhat common but very transient. Appropriate monitoring equipment and 
medications will be used to promptly identify and manage complications if they 
occur. Bronchoscopy may cause coughing and occasionally gagging. Fever or chills may 
occur, especially following BAL. Chest pain from atelectasis may occur. Some people 
experience temporary vomiting, and sore nose/throat. Mild-to-moderate cough may occur for 
up to 24 hours after the procedure. 
 
Protection against risk: During the bronchoscopy, subjects will be placed on supplemental oxygen and 
monitored continuously for oxygen saturation and electrocardiogram changes. The topical anesthesia and 
sedation dosages will be monitored, and limits will be set and adhered to closely. Pre- and post-
bronchoscopy care will be provided and will include adequate nursing staff and standard post-sedation 
recovery care with direct investigator oversight. To protect against the risk of QT prolongation, which 
could be caused by abnormalities in potassium, magnesium, calcium, and phosphorus, these electrolytes 

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will be measured prior to subjects undergoing the stress of bronchoscopy. Subjects with grade II or higher 
abnormalities in these electrolytes will not undergo bronchoscopy.  
2.3.2. 
Known Potential Benefits 
Given the nature of this single-dose trial in healthy subjects, there are no direct benefits to subjects 
outside of the laboratory screening and physical exam that each subject will receive. However, there is 
potential societal benefit. Participation in this study provides an assessment of the safety and PK of ZTI-
01, enabling PK estimations and dosing identification to proceed into patients, including those requiring a 
new therapeutic option for difficult-to-treat infections caused by ESBL-producing and MDR bacteria. 
 

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3. 
OBJECTIVES AND OUTCOME MEASURES 
3.1. 
Study Objectives 
Safety: 
• 
Determine the safety of multiple doses of ZTI-01 (6 g dose every 8 hours, administered as a 1-hour 
IV infusion, for a total of 18 g in three doses) 
Pharmacokinetic: 
• 
Determine the plasma and intrapulmonary PK (ELF and AM concentrations of ZTI-01) after multiple 
doses of ZTI-01 (6 g dose every 8 hours, administered as a 1-hour IV infusion, for a total of 18 g in 
three doses) 
3.2. 
Study Outcome Measures 
Safety: 
The safety outcome measure will be the occurrence of adverse events (AEs), summary of physical exam 
findings, vital signs, clinical laboratory tests, and ECGs (Appendix B) at any time from the start of study 
drug administration through the end of subject follow-up. 
All subjects who receive at least one dose of study drug will be included in the safety outcome measure. 
AEs will be collected from the time of dosing on Day 1 through the telephone follow-up interview on Day 
3. TEAEs will be assessed by severity and relationship to the study drug as determined by the 
investigator. 
 
Pharmacokinetics: 
The pharmacokinetic outcome measures will be plasma and intrapulmonary concentrations of ZTI-01 by 
validated bioassays.  
Plasma PK parameters will be derived from the plasma concentration vs. time curves after the third dose 
of study drug. The parameters include, but are not limited to:   
• 
Maximum measured plasma concentration (Cmax) 
• 
Area under the concentration vs. time curve (AUC0-8 and AUC0-inf) 
• 
Time to peak concentration (tmax) 
• 
Terminal elimination half-life (t1/2) 

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Terminal-phase elimination rate constant (λz) 
• 
Volume of distribution (Vd)  
• 
Clearance (CL) 
Intrapulmonary PK parameters will be derived from the ratios of drug concentrations in ELF and AMs to 
simultaneous drug concentrations in plasma for each subject and summarized for each sampling time. The 
median concentrations of fosfomycin from the BAL sampling times will be used to estimate the AUC0-8 
of plasma, ELF, and AM. The ratio of AUC0-8 of ELF-to-plasma and AM-to-plasma will be calculated to 
determine the percent lung penetration.   

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4. 
STUDY DESIGN 
This is a Phase 1, open-label, multiple-dose trial conducted at a single center. The treatment period will 
consist of three 6 g doses of ZTI-01 as a 1 h IV infusion (Table 1). A total of 30 enrolled subjects will be 
randomized. Ten additional enrolled subjects will act as alternates. An evaluable subject is defined as a 
subject who receives all doses of ZTI-01, undergoes BAL at the randomized sampling timepoint with 
BAL return volume adequate for testing, and undergoes at least the one blood sampling timepoint that is 
concurrent with the assigned BAL sampling timepoint, with blood sampling volume that is adequate for 
testing. 
Each subject will complete Screening, Baseline, Treatment, and Follow-up Phases. The Screening Phase 
will be conducted on an outpatient basis within 30 days of the Baseline Phase. Baseline Phase will consist 
of admission to DEPRU on the day before the first dose (Day -1) for pre-dosing assessments. The 
Treatment Phase (Day 1 to Day 2) will include dosing 6 g of ZTI-01, administered as a 1-hour IV infusion 
(+10 minute window), every 8 hours for a total 18 g in 3 doses, followed by post-treatment safety 
assessments, and BAL and blood sample collections for PK measurements. Each subject will undergo a 
single standardized bronchoscopy with BAL after the start of the last IV infusion of ZTI-01 (Table 2).  
Blood samples for PK measurements will be collected before each dose, up to 8 hours after the start of the 
first IV infusion of ZTI-01, and up to 12 hours after the start of the third IV infusion (Table 3).  
 Subjects will remain in DEPRU during the Treatment Phase and will be discharged at least 12 hours after 
the start of the third IV infusion (if safety parameters are acceptable to the investigator). Safety 
assessments will be conducted during the entire Treatment Phase. The Follow-Up Phase will consist of a 
telephone interview on Day 3 for symptom-driven safety assessments. 

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5. 
STUDY ENROLLMENT AND WITHDRAWAL 
Subjects will not be enrolled unless they meet the following inclusion and exclusion criteria. The 
investigator or other study personnel will document in the source documents (e.g., the clinical chart) that 
the informed consent form (ICF) was signed and dated before study screening. The time and date that 
informed consent was obtained will be recorded in the source documents and electronic case report form 
(eCRF). The presence of inclusion criteria and the absence of exclusion criteria will be recorded in the 
eCRF. 
5.1. 
Subject Inclusion Criteria 
To be considered for study enrollment, subjects must meet all of the following inclusion criteria: 
1. Healthy1 men and women aged 18-45 years with no clinically significant findings2 at Screening 
and Baseline (Day -1 to Day 1)2 
1Healthy is defined by the absence of any medical condition described in the exclusion 
criteria in a subject with a normal physical exam including vital signs. If the subject has 
another current, ongoing medical condition, the condition cannot meet any of the following 
criteria: 1) first diagnosed within 3 months of enrollment; 2) is worsening in terms of clinical 
outcome in the last 6 months; or 3) involves need for medication.  
2Including findings on medical history, physical exam, vital signs, 12-lead ECG, or clinical 
laboratory tests.  
 
2. Body Mass Index (BMI) = 18-30 kg/m2, inclusive, and body weight >50 kg (110 lbs) 
 
3. Females who have been surgically sterilized via bilateral oophorectomy and/or hysterectomy at 
least 90 days prior to Screening are considered lacking childbearing potential and will be eligible3 
3Postmenopausal females are not eligible, as the definition of menopause would require age 
>45, and all subjects in this study are age ≤45. 
 
4. Females of childbearing potential must have a negative serum pregnancy test at Screening, a 
negative urine pregnancy test at Baseline (Day -1 to Day 1), and must use acceptable 
contraception4 
4Acceptable contraception methods are restricted to surgical sterilization (bilateral tubal 
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sterilization with documented radiological confirmation at least 90 days after the procedure), 
use of long-acting reversible contraceptive devices (progestin-releasing subdermal implants 
[Nexplanon and Implanon, Merck], copper intrauterine devices [Paragard, Teva], and 
levonorgestrel-releasing intrauterine devices [Mirena, Bayer; Skyla, Bayer; Liletta, 
Allergan/Medicines360]), licensed hormonal products such as injectables or oral 
contraceptives, barrier methods such as condoms or diaphragms with spermicidal agents, 
and abstinence from sexual intercourse with a male partner. 
Subjects must have used the above-listed method for a minimum of 30 days prior to the first 
dose of study drug and be willing to use the method for at least 30 days after the final dose of 
study drug. 
 
5. Male subjects5 whose partners are of childbearing age or pregnant must be willing to use 
condoms during the study and through the Day 3 follow-up call. 
5including men who have had vasectomies 
6. Able to abstain from alcoholic beverages within 48 hours before Baseline (Day -1 to Day 1) and 
throughout the Treatment Phase 
7. Able to abstain from caffeine use within 7 days before Baseline (Day -1 to Day 1) and throughout 
the inpatient period 
8. Willing to remain in DEPRU during the Baseline and Treatment Phases  
9. Have a high probability for compliance and completion of the trial  
10. Sign a dated, witnessed, written ICF 
11. Have adequate venous access for infusions and blood draws 
5.2. 
Subject Exclusion Criteria 
Subjects must meet none of the following exclusion criteria: 
1. Any surgical or medical condition that in the opinion of the investigator could interfere with drug 
absorption, distribution, metabolism, or excretion. 
 
2. Any surgical or medical condition that in the opinion of the investigator may place the subject at 
increased risk while participating in the trial.  
 

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3. History or presence of cardiovascular disease including coronary artery disease and chronic 
hypertension (systolic pressure >140 mmHg or diastolic pressure >90 mmHg) 
 
4. Abnormal ECG at screening, as determined by the investigator to be clinically significant 
 
5. History or presence of renal impairment or chronic renal disease 
 
6. History or presence of liver disease (ALT, AST, or total bilirubin above the upper limit of 
normal)  
 
7. History or presence of chronic pulmonary disease, including asthma, requiring use of medication 
in the year before screening 
8. History of intolerance or hypersensitivity to phosphonic acid derivative antibiotics or any of its 
constituents (i.e., oral or IV fosfomycin) 
9. Have cancer or have a history of cancer within the past 5 years, with the exception of non-
melanomatous skin cancer, treated, without evidence of recurrence 
10. Any medical condition that prevents a subject from undergoing bronchoscopy with BAL 
11. Serum creatinine above the upper limit of normal, or estimated creatinine clearance (CrCl) <60 
mL/min as determined by Cockcroft-Gault equation6 
6Cockcroft-Gault equation where age is in years, weight is in kilograms, and serum Cr is in 
mg/dL units: 
Males: CrCl (mL/min) = (140 – age) x Weight / (72 x Cr) 
Females: CrCl (mL/min) = [(140 – age) x Weight / (72 x Cr)] x 0.85 
12. History of regular alcohol consumption within 6 months of Baseline (Day -1 to Day 1)7  
7History of regular alcohol consumption is defined as an average weekly intake of >14 drinks 
for males or >7 drinks for females. One drink is equivalent to 12 g of alcohol: 12 ounces 
(360 mL) of beer, 5 ounces (150 mL) of wine, or 1.5 ounces (45 mL) of 80 proof distilled 
spirits.   
13. History of ≥10 pack-years smoking, or history of any nicotine use8 in the 6 months before 
Baseline (Day -1 to Day 1) or positive urine cotinine screen at Baseline (Day -1 to Day 1)9.   
8Including cigarettes, pipe, cigar, chewing tobacco, nicotine patch 
9A positive urine cotinine at screening is allowed if negative at baseline 
14. History of illicit drug use within 6 months of Baseline (Day -1 to Day 1)10 

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10Use of cannabinoids with 1 month of Baseline (Day -1 to Day 1) is excluded, but other use 
of cannabinoids within 6 months is permitted. 
15. Use of any prescription drugs, except acceptable contraception methods listed above, within 30 
days of Baseline (Day -1 to Day 1) 
16. Involvement in other investigational studies of any type (drugs, devices, procedures) within 30 
days of Baseline (Day -1 to Day 1) 
17. Blood or blood products donation within 30 days of Baseline (Day -1 to Day 1) 
18. Planning egg or sperm donation any time before Day 3 follow-up call 
19. Use of any non-prescription medications, vitamins, consumption >2 times/week of products 
containing genuine licorice, caffeine, or dietary or herbal supplements within 7 days of Baseline 
(Day -1 to Day 1)11 
11Excluded from this list is intermittent use of acetaminophen at doses ≤2 g/day. Herbal 
supplements must be discontinued 7 days before the initial dose of study drug on Day 1.  
20. Presence of any acute illness, including febrile illness with temperature >37.8°C (>100.0°F), 
within 7 days of Baseline (Day -1 to Day 1)  
21. Currently pregnant or breastfeeding as determined by subject report 
22. Positive tests for human immunodeficiency virus (HIV) 1 and 2 antibodies, hepatitis B surface 
antigen (HBsAg), or hepatitis C virus (HCV) antibody 
23. Positive urine drug or positive breathalyzer test for alcohol at Screening or Baseline (Day -1 to 
Day 1) or positive cotinine at Baseline (Day -1 to Day 1) 
24. Weight loss or gain of >10% within 30 days of Baseline (Day -1 to Day 1)  
25. Any laboratory value at screening or enrollment that is Grade 2 or more (Appendix B). A 
laboratory value that is Grade 1 will be allowed if not considered to be clinically significant by 
the investigator.12 
12Excluded from this list of permissible Grade 1 laboratory values are ALT, AST, or Total 
bilirubin per Exclusion Criteria 6; serum creatinine per Exclusion Criteria 11; and serum 
electrolytes including sodium, potassium, calcium, phosphorus and magnesium.  
26. History of infection with SARS-CoV-2 (COVID-19) within 3 months of Baseline (Day -1 to Day 
1) or unresolved symptoms of COVID-19.  
27. Positive test for SARS-CoV-2 (COVID-19) at Screening or Baseline (Day -1 to Day 1) within 72 
hours of admission 
 

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5.3. 
Treatment Assignment Procedures 
5.3.1. 
Randomization Procedures 
Subjects will be randomized to a single standardized bronchoscopy with BAL sampling timepoint upon 
study enrollment using an assignment schedule as follows: 30 subjects will be randomized 1:1:1:1:1 to 
each of the five BAL sampling timepoints (30 minutes, 75 minutes, 2 hours, 5 hours, or 8 hours after the 
start of the third IV infusion of ZTI-01). Up to ten (10) subjects will be enrolled as alternates.  Alternates 
will arrive at DEPRU on Day -1 to Day 1 and will adopt the planned BAL sampling timepoint of any 
other enrolled subject who fails to present for check-in or who fails to meet inclusion/exclusion criteria on 
Day -1 to Day 1. If all scheduled subjects present for check-in and meet Day -1 to Day 1 
inclusion/exclusion criteria, then alternates will not undergo any further study procedures at that time. In 
that case, alternates may be assigned to a new bronchoscopy time on a future date, alternate status for a 
future date, or as replacement subjects (see Section 5.3.4). 
Subjects will be enrolled online using the enrollment module of AdvantageEDCSM software. The 
randomization code will be prepared by DCC statisticians and included in the enrollment module for this 
study. AdvantageEDCSM will assign each subject to a sampling timepoint after the demographic and 
eligibility data have been entered. 
Instructions for use of the enrollment module are included in the AdvantageEDCSM User’s Guide. Manual 
back-up procedures and instructions are provided for use in case the site temporarily loses Internet access 
or the online enrollment system is unavailable. 
5.3.2. 
Reasons for Withdrawal and Discontinuation of Study Product Administration 
Subjects may voluntarily withdraw their consent for study participation at any time without penalty or 
loss of benefits to which they are otherwise entitled.   
An investigator may also withdraw a subject from receiving the study drug for any reason. Follow-up 
safety evaluations will be conducted, if the subject agrees. If a subject withdraws or is withdrawn before 
completion of the study, the reason for this decision will be recorded in the eCRF. The reasons might 
include, but are not limited to the following: 
• 
Subject no longer meets eligibility criteria 
• 
Subject becomes noncompliant 

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• 
Subjects develops a medical disease or condition, or new clinical finding(s), for which continued 
participation, in the opinion of the investigator, might compromise the safety of the subject, interfere 
with the subject's successful completion of this study, or interfere with the evaluation of responses 
• 
Subject is lost to follow-up 
• 
Subject becomes pregnant 
The investigator will be explicit regarding study follow-up (e.g., safety follow-up) that might be carried 
out despite the fact the subject will not receive further study drug. If the subject consents, every attempt 
will be made to follow all AEs through resolution. The procedures that collect safety data for the purposes 
of research will be included in the original ICF or the investigator may seek subsequent informed consent 
using an IRB/IEC-approved ICF with the revised procedures. 
The investigator will inform the subject that data already collected will be retained and analyzed even if 
the subject withdraws from the trial.  
5.3.3. 
Handling of Withdrawals and Discontinuation of Administration 
Subjects who discontinue will be asked about the reason(s) for their discontinuation and about the 
presence of any AEs. If possible, they will be seen and assessed by an investigator(s). AEs will be 
followed to resolution and/or until deemed stabilized by the investigator. Subjects who discontinue may 
be subject to replacement as described in Section 5.3.4. If subjects are not evaluable and thus are 
replaced, their samples will be discarded. If the subject received any amount of study drug, they will be 
encouraged to follow up for safety. 
5.3.4. 
Subject Replacement 
Subjects who initiate the Treatment Phase but are not evaluable will be replaced.  
An evaluable subject is defined as a subject who receives all doses of ZTI-01, undergoes BAL at the 
randomized sampling timepoint with BAL return volume adequate for testing, and undergoes at least the 
one blood sampling timepoint that is concurrent with the assigned BAL sampling timepoint, with blood 
sampling volume that is adequate for testing. Replacement subjects will undergo study procedures on a 
separate date. 
5.3.5. 
Termination of Study  
The trial may be terminated at any time at the discretion of the Sponsor, DMID. Other possible reasons 
for study termination include development of significant laboratory toxicities outside of those AEs 
characterized in the label and/or literature for the study drug. If the trial is prematurely terminated by the 
Sponsor, any regulatory authority, or the investigator for any reason, the investigator will promptly 
inform the study subjects and assure appropriate therapy or follow-up for the subjects, as necessary. The 
investigator will provide a detailed written explanation of the termination to the IRB/IEC. 

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6. 
STUDY INTERVENTION/INVESTIGATIONAL 
PRODUCT 
6.1. 
Study Product Description 
6.1.1. 
Acquisition 
The non-US commercial drug product that will be used in the trial is a single vial of ZTI-01 disodium 
powder (4 g presentations with recrystallized succinic acid, in a Type 1 glass vials). Nabriva Therapeutics 
Inc. will provide DMID an adequate amount of ZTI-01 to support the trial, and will ship it to the 
following address at Fisher BioServices for storage and site distribution: 
DMID-CMS 
20439 Seneca Meadows Parkway 
Germantown, MD 20876 
Tel: (240) 477-1350 
Fax: (240) 477-1360 
E-mail: DMID.CMS@ThermoFisher.com 
Sterile water for injection (WFI) will be the diluent and will be supplied by DMID through Fisher 
BioServices.  
Study product will be shipped to DEPRU upon request and approval by NIAID. 
6.1.2. 
Formulation, Packaging, and Labeling 
ZTI-01 
Each Type 1, glass vial of ZTI-01 contains sterile white powder consisting of 5.28 g of fosfomycin 
disodium (equivalent to 4 g of fosfomycin and 1.28 g of sodium) and the inactive ingredient: 
recrystallized succinic acid. Each gram of ZTI-01 contains 330 mg of sodium.   
Vials will be labeled with protocol number, product identity – 4 g of ZTI-01 (fosfomycin for injection), 
lot number, expiry date, and the IND caution statement “New Drug – Limited by Federal Law to 
Investigational Use Only,” a statement to store at controlled room temperature, and a statement that each 
vial is for intravenous, single use only. 
WFI 

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The WFI, United States Pharmacopeia (USP) is nonpyrogenic and contains no bacteriostatic, 
antimicrobial agent, or added buffer. This product will be used to dilute the ZTI-01 and will be supplied 
as a single-dose vial. 
6.1.3. 
Product Storage and Stability 
Glass vials of ZTI-01 will be stored in a secure and locked research pharmacy, with limited access and 
available to appropriate study personnel only, at controlled room temperature of 20°C to 25°C (68°F to 
77°F).  If a temperature excursion outside of 15°C to 30°C (59°F to 86°F) occurs, the site will discontinue 
use of the vial(s) and notify the DMID Product Support Team (PST) and Nabriva within 24 hours of 
awareness of the excursion, according to the MOP. 
The Investigator, or a designee (e.g., research pharmacist) will ensure that all study drugs are 
appropriately stored and in accordance with applicable regulatory requirements. 
Sterile water for injection (WFI) will be stored at USP controlled room temperature 20°C to 25°C (68°F 
to 77°F).  
6.2. 
Dosage, Preparation, and Administration of Study Drug 
Preparation of ZTI-01 for IV infusion will be performed by DEPRU’s Research Pharmacist according to 
the protocol-specific MOP. The procedure for reconstituting the vials with sterile water for injection 
(WFI) is presented in Table 5. 
 
Table 5: ZTI-01 dose preparation guidelines 
ZTI-01 
(fosfomycin) 
dosage 
Number of vials 
reconstituted with 
20 mL of sterile WFI 
added to each vial 
Volume of 
Sterile WFI to 
dissolve ZTI-01 
powder 
Volume of 
dissolved ZTI-
01 to be added 
for infusion 
Volume of 
WFI to be 
added for 
infusion 
Total 
volume for 
infusion 
6 g 
2 
40 mL (20 mL 
for each of two 
vials) 
30 mL  
(15 mL from 
each of two 
vials) 
170 mL 
200 mL 
Each 1 g dose of ZTI-01 contains 330 mg of sodium. Due to the salt load of the formulation, sterile WFI 
will be used to reconstitute each ZTI-01 vial and to prepare the 200 ml ZTI-01 infusion (Table 6).   
A total of two 4 g vials are required to prepare the 6 g dose. Deliver 20 mL of sterile WFI from the 
syringe into each vial containing 4 g of ZTI-01 powder to dissolve the powder. Always use sterile WFI 
and aseptic technique to reconstitute the powder. A slight degree of warming occurs when the powder is 
dissolved upon reconstitution of the vial, due to an exothermic reaction. After reconstitution, the product 

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will be used to prepare the infusion solution as follows, and as further detailed in the MOP: Using aseptic 
technique, withdraw an equal amount (15 mL) from each reconstituted vial (a total volume of 30 mL from 
both vials). The solution that is left in each vial will remain “unused.” Add the 30 mL of diluted ZTI-01 
to 170 mL of sterile WFI to yield the 200 mL total volume for infusion. The storage for the infusion bag, 
before administration, is limited to 4 hours at room temperature (20-25°C) or 24 hours at refrigerated 
conditions (2 - 8°C).  
  
Table 6: ZTI-01 (disodium fosfomycin) reconstitution with WFI 
Dose 
Preparation Steps 
6 g 
Step 1:  Add 20 mL of sterile WFI to each of two vials of ZTI-01 powder 
 
Step 2:  Draw 30 mL total from both vials of diluted ZTI-01. Note: Draw an equal 
amount (15 mL) from each dissolved vial; the 5 mL left in the vials remain “unused.” 
 
Step 3:  Add the 30 mL of dissolved ZTI-01 to 170 mL of sterile WFI to yield the 200 
mL total volume for infusion. 
Note: The pharmacy will need to use/reconstitute 2 vials for each 6 g dose.   
ZTI-01 should always be administered as a 200 mL infusion over 1 hour (+10 minute window).  
Note: Each 1 g dose of ZTI-01 contains 330 mg of sodium; a 6 g dose of ZTI-01 contains 1980 mg of 
sodium. Each subject receiving 3 doses per protocol will be administered 5940 mg of sodium. 
The ZTI-01 6 g infusion solution will be infused intravenously over 1 hour (+10 minute window) using an 
IV infusion pump at a rate set to 200 mL/hr. A dose will be administered every 8 hours for 3 doses. 
Administering sterile WFI alone (i.e., with no additives) may increase risk of hemolysis in some subjects 
due to hypotonicity. Although the IV infusion of sterile WFI alone is contraindicated, the addition of ZTI-
01 to sterile WFI is appropriate and recommended for IV administration. The use of 0.9% NaCl (isotonic 
saline) for infusion with ZTI-01 will be avoided, as the resultant hyperosmolar solution may irritate the 
vein.  
6.3. 
Modification of Study Drug for a Subject 
None 

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6.4. 
Accountability Procedures for the Study Drug 
Chain of custody will be documented between the on-site pharmacy and the clinical staff responsible for 
administering the study drug. 
The Site Principal Investigator (PI) is responsible for the distribution and disposition of the study drug, 
and has ultimate responsibility for accountability. The PI may delegate to the Site Research Pharmacist 
responsibility for study drug accountability. The Research Pharmacist will be responsible for and will 
maintain and document logs of receipt, accountability, dispensation, storage conditions, and final 
disposition of study drug. Upon completion or termination of the trial, all unused and used vials of ZTI-01 
will be disposed according to DEPRU’s standard operating procedures (SOPs) after accountability. The 
investigator is responsible for ensuring that no study drug is disposed until it is fully accounted for by the 
monitor. 
6.5. 
Assessment of Subject Compliance with Study Drug  
Study staff will be present for and during all study drug administrations. Visual inspection by study staff 
of the complete infusion is expected and will be appropriately recorded in the eCRF. It is important to 
document that the entire 200 mL infusion is administered with each dose. All interruptions or premature 
terminations of infusion will be documented. 
6.6. 
Concomitant Medications/Treatments 
Medications to treat any AEs the subject experiences during the trial are permitted. All information on 
concomitant medications will be recorded on the subject’s eCRF and will include the name of the 
procedure or drug and duration of the treatment (start/stop times), dosages, and route. The intermittent 
intake of acetaminophen (maximum 2 g/day) is permitted throughout the trial if approved by the Site PI. 
Subjects are required to refrain from the use of all prescription medications for at least 30 days before 
administration of the first dose of study drug on Day 1 until the last PK sample is taken. The consumption 
of beverages containing alcohol is prohibited for 48 hours before Baseline (Day -1 to Day 1) until 
completion of the Treatment Phase. The consumption of caffeine is prohibited for 7 days prior to Baseline 
(Day -1 to Day 1) and during the Treatment Phase. Herbal supplements and over-the-counter meds 
(except acetaminophen at doses ≤2 g/day) must be discontinued 7 days before the first dose of study drug 
until completion of the Treatment Phase. The use of illegal drugs is prohibited within the 6 months prior 
to Baseline (Day -1 to Day 1) and is not permitted while subjects are enrolled in this study. A urine drug 
screen will be performed at Screening. If a subject is unable to comply with the restrictions described 
above, the subject’s continued participation in the trial will be re-evaluated by the investigator. 

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7. 
STUDY SCHEDULE 
7.1. 
Screening (Day -30 to Day -1)  
Subjects will be screened within 30 days before Enrollment/Baseline (Day -1 to Day 1). A sufficient 
number of individuals will be screened to identify 40 subjects for enrollment that fulfill all entry criteria 
in order to obtain 30 evaluable subjects at the end of the trial. After the subject has signed the IRB-
approved ICF, the following evaluations will be performed and/or recorded in the eCRF: 
• 
Demographics (date of birth, gender, and race/ethnicity) 
• 
Complete medical history and prior medication history to include all drugs taken (including non-
prescription and herbal products) within 30 days before screening procedures  
• 
Physical exam to include the following organs and organ systems: vital signs (temperature, blood 
pressure, respiratory rate, heart rate, peripheral oxygen saturation), skin, head and neck, lungs, heart, 
liver, spleen, extremities, lymph nodes, and nervous system.  
• 
Record history of alcohol (within prior 6 months) and tobacco use (lifetime) 
• 
Height and weight to determine BMI  
• 
Standard 12-lead ECG  
• 
Laboratory tests (urine and blood specimens) as outlined in Appendix A 
• 
Urine drug screen, urine cotinine, and alcohol test (breathalyzer) 
• 
Serum pregnancy test for females of childbearing potential 
• 
Collect birth control method and counsel subjects on acceptable contraceptive measures 
• 
Counsel participants to avoid consumption of non-prescription medications, vitamins, licorice (in 
large amounts), caffeine or dietary or herbal supplements in the 7 days prior to confinement and to 
avoid consumption of beverages and foods containing alcohol for 48 hours prior to confinement 
• 
Confirm all inclusion and exclusion criteria are fulfilled 
• 
SARS-CoV-2 (COVID-19) test will occur within 72 hours prior to admission at the Screening Visit 
(Day -30 to Day -1) if Screening Visit occurs between (Day -3 to Day -2)  
7.2. 
Enrollment/Baseline (Day -1 to Day 1) 
Subjects will be admitted to DEPRU on Day -1 or Day 1 before the first dose of study drug on Day 1. 
After admission to DEPRU, the following Enrollment/Baseline tests and evaluations will be performed. 

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All Enrollment/Baseline tests and evaluations will be performed within 36 hours of randomization to a 
bronchoscopy time. 
• 
Physical exam to include the following organs and organ systems: vital signs (temperature, blood 
pressure, respiratory rate, heart rate, peripheral oxygen saturation), skin, head and neck, lungs, heart, 
liver, spleen, extremities, lymph nodes, and nervous system 
• 
Weight 
• 
Review changes in the subject’s medical history since screening  
• 
Laboratory tests as outlined in Appendix A 
• 
Urine pregnancy test for females of childbearing potential 
• 
Counsel subjects on acceptable contraceptive measures 
• 
Urine drug screen, urine cotinine, and alcohol breath test (breathalyzer) 
• 
Review prior concomitant medication history since screening 
• 
Record non-pharmacologic treatments/procedures within 72 hours before enrollment in the eCRF 
• 
Confirm all inclusion and exclusion criteria are fulfilled 
• 
Standard 12-lead ECG  
• 
Randomize to a bronchoscopy time 
• 
Place two peripheral IVs 
• 
 SARS-CoV-2 (COVID-19) test will occur within 72 hours prior to admission at the Baseline Visit 
(Day -1 to Day 1) if test was not administered during Screening Visit   
7.3. 
Day 1 to Day 2 
• 
Administer study drug to subjects every 8 hours for a total of 3 doses. 
• 
Obtain vital signs, including heart rate, blood pressure, temperature, respiratory rate and peripheral 
oxygen saturation before each dose of study drug, and at approximately 0.5, 1, 2, and 5 hours after the 
start of each dose of study drug (T0 = time of each infusion start)  
• 
Review and record any AEs and SAEs 
• 
Review and record any concomitant medications, vitamins and herbal supplements 
• 
Perform a standard 12-lead ECG within 2 hours after the third (last) dose of study drug 

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• 
Obtain PK blood samples at 15 timepoints: before (within 10 minutes) the first, second, and third 
doses of study drug, at 30 minutes (during infusion), 1 hour (within 5 minutes after the end of 
infusion), 1 hour 15 minutes, 2, and 5 hours from the start time of the first infusion of ZTI-01, and at 
30 minutes (during infusion), 1 hour (within 5 minutes after the end of infusion), 1 hour 15 minutes, 
2, 5, 8, and 12 hours from the start time of the third (last) infusion of ZTI-01 
• 
Measurement of sodium, potassium, magnesium, calcium, and phosphorus approximately 2 hours 
prior to the assigned bronchoscopy timepoint 
• 
A standardized bronchoscopy with BAL sampling will be performed at single timepoint based on 
each subject’s schedule assignment at either 30 minutes, 1 hour 15 minutes, 2, 5, or 8 hours after the 
start time of the third (last) infusion of ZTI-01 
• 
Collect a blood sample to measure serum urea concentration just before or during bronchoscopy 
7.4. 
Day 2 (Day of Discharge from DEPRU) 
• 
Laboratory tests and urinalysis as outlined in Appendix A  
• 
Review and record any AEs and SAEs 
• 
Review and record any concomitant medications, non-pharmacologic treatments or procedures 
• 
Perform a physical exam to include the following organs and organ systems: vital signs (temperature, 
blood pressure, respiratory rate, heart rate, peripheral oxygen saturation), skin, head and neck, lungs, 
heart, liver, spleen, extremities, lymph nodes, and nervous system; measure weight before discharge 
7.5. 
Day 3 (Telephone Follow-up Call) 
A telephone call follow-up will be conducted the day following each subject’s discharge from DEPRU to 
ask about subject’s clinical status, concomitant medications, and AEs/SAEs. In the event of ongoing or 
new AEs/SAEs, subjects may be asked to return to DEPRU for evaluation at the investigator’s discretion. 
Ongoing AEs/SAEs will be followed until resolved or stable/improving over two assessments and no 
further intervention is required. 
7.6. 
Early Termination Visit 
If the subject is prematurely discontinued from the trial, the same exit procedures as those performed on 
Day 1 or 2 will be performed before discharging the subject from DEPRU. If no clinical or laboratory 
abnormalities are observed, subjects are considered to have completed the protocol and will exit the trial. 
Additional follow-up visits will be scheduled if a subject has an ongoing clinically significant 
abnormality at this visit and/or the clinical laboratory evaluations reveal a clinically significant laboratory 
abnormality, as deemed appropriate by the investigator or designee. Clinically significant laboratory 

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abnormalities will be monitored periodically until resolution or until they are considered irreversible, or 
until there is a satisfactory explanation for the changes observed. 
7.7. 
Unscheduled Visit (if needed) 
• 
Review and record any AEs and/or SAEs 
• 
Review and record any concomitant medications, non-pharmacologic treatments or procedures 
• 
Perform a physical exam to include the following organs and organ systems: vital signs (temperature, 
blood pressure, respiratory rate, heart rate, peripheral oxygen saturation), skin, head and neck, lungs, 
heart, liver, spleen, extremities, lymph nodes, and nervous system 
• 
Obtain a standard 12-lead ECG at the investigator’s discretion  
• 
Other studies as clinically indicated at the investigator’s discretion 

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8. 
STUDY PROCEDURES/EVALUATIONS 
8.1. 
Clinical Evaluations 
Medical history: history or presence of prior and current medical conditions or significant surgical 
procedures  
Physical exam: overall physical assessment (to include vital signs [temperature, blood pressure, 
respiratory rate, heart rate, peripheral oxygen saturation], skin, head and neck, lungs, heart, liver, spleen, 
extremities, lymph nodes, and nervous system) and weight will be collected at Screening, Baseline (Day -
1 to Day 1) and Day 2 (day of discharge). Height will be measured and BMI calculated at screening only.  
ECG: performed in the supine or semi-recumbent position after resting for at least 10 minutes at 3 
timepoints: Screening, Baseline (Day -1 to Day 1), and Day 2 within 2 hours of the third (last) dose of 
study drug. Each ECG will be interpreted and abnormal results acted upon by the investigator as outlined 
for each timepoint (Screening and Baseline ECG abnormalities per Exclusion Criteria, Day 2 ECG 
abnormalities per Appendix B). In case of premature discontinuation, ECG will be performed before 
discharge. 
Vital signs: heart rate, blood pressure, temperature, respiratory rate, and peripheral oxygen saturation will 
be measured with the subject in the supine or semi-recumbent position, will be obtained at the following 
timepoints: Screening, Baseline (Day -1 to Day 1), before each of 3 doses of study medication, 
approximately at 0.5, 1, 2, and 5 hours after the start of each infusion of study drug, and before discharge 
from DEPRU on Day 2. Since changes in vital signs are expected during bronchoscopy, when a vital sign 
timepoint is scheduled during a subject’s bronchoscopy, that timepoint will be measured immediately 
before the start of bronchoscopy. If vital signs are abnormal, repeat readings will be obtained up to twice 
more (total of 3 measurements including the first one), 5-10 minutes apart. If they remain abnormal, 
unscheduled vital signs will be repeatedly obtained until they normalize (at investigator’s discretion).  
Prior/Concomitant Medications/Treatments: information regarding allergies and use of prescription 
medications, non-prescription medications, herbal supplements, nicotine, caffeine, alcohol, and illicit 
drugs will be obtained at Screening, Baseline (Day -1 to Day 1), Treatment (Days 1-2), Day 2 before 
discharge, and throughout each subject’s enrollment as required. 
8.2. 
Laboratory Evaluations 
8.2.1. 
Clinical Laboratory Evaluations 
Serum chemistry: albumin, glucose, blood urea nitrogen (BUN), potassium, magnesium, calcium, 
sodium, total protein, creatinine, triglycerides, total cholesterol, creatine phosphokinase (CPK), 
phosphorus, alkaline phosphatase (ALP), AST, ALT, total bilirubin, direct bilirubin, and lactate 
dehydrogenase (LDH) will be collected at Screening and Day 2 before discharge. Albumin, glucose, 

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BUN, potassium, magnesium, calcium, sodium, phosphorus, total protein, creatinine, CPK, ALP, AST, 
ALT, and total bilirubin will be collected at Baseline (Day -1 to Day 1). Sodium, potassium, magnesium, 
calcium, and phosphorus will be collected approximately 2 hours prior to the assigned bronchoscopy 
timepoint. 
Hematology: CBC with differential (hemoglobin, hematocrit, platelet count, white blood cell (WBC) 
count, neutrophils, lymphocytes, monocytes, eosinophils, basophils) will be collected at Screening and 
Day 2 before of discharge.  
Coagulation: PT and aPTT will be collected at Screening and Day 2 before discharge. 
Urinalysis: leukocyte esterase, blood, pH, specific gravity, glucose, protein. A microscopic test will be 
performed if urinalysis is abnormal. The microscopic urinalysis result for the presence of blood will 
supersede the dipstick urinalysis result. Urinalyses will be performed at Screening and Day 2 before 
discharge.  
Serum and urine pregnancy test: a serum pregnancy test will be performed on all females of childbearing 
potential at Screening, a urine pregnancy test will be performed on all females of childbearing potential at 
Baseline (Day -1 to Day 1). 
Test for SARS-CoV-2 (COVID-19) at Screening or Baseline (Day -1 to Day 1) within 72 hours of 
admission 
Screening for Chronic Infections: HIV antibody, HBsAg, and HCV antibody will be measured at 
screening 
Alcohol (breathalyzer) test, urine cotinine, and urine drug testing: performed at Screening and Baseline 
(Day -1 to Day 1). Urine will be collected and tested separately for cotinine and illicit drugs: barbiturates, 
benzodiazepines, THC, cocaine, opiates, and amphetamine/methamphetamine. 
Urea: a blood sample for plasma urea concentration will be obtained just before or during each subject’s 
scheduled bronchoscopy. 
8.2.2. 
Bronchoscopy and Bronchoalveolar Lavage (BAL) 
Each subject will be assigned to one bronchoscopy sampling timepoint. The bronchoscopy sampling 
times will be at 30 minutes, 1 hour 15 minutes, 2, 5, and 8 hours from the start time of the third (last) 
infusion of ZTI-01. A total of 6 subjects will be assigned to each of the five BAL sampling times. 
Sodium, potassium, magnesium, calcium, and phosphorus will be measured approximately 2 hours prior 
to each subject’s bronchoscopy timepoint. Subjects with grade 2 or higher abnormalities (Appendix B) in 
these electrolytes will not receive any further study product and will not undergo bronchoscopy. 
Bronchoscopy will be performed in a standardized fashion according to the MOP. Topical lidocaine will 
be applied to the upper airways to prepare subjects for bronchoscopy. If needed, 1.0% percent lidocaine 

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will be used in the lower airway. A fiberoptic bronchoscope will be inserted into the right middle lobe. 
Four 50-mL aliquots of sterile normal saline will be instilled into the right middle lobe and each specimen 
will be immediately aspirated and placed on ice. BAL samples for PK measures will be obtained ±15 
minutes from the subject’s assigned sampling time. The start and stop times of BAL will be recorded on 
the eCRF. 
Subjects will be continuously monitored during bronchoscopy. Blood pressure, heart rate, respiratory rate, 
and peripheral oxygen saturation will be recorded before and at the end of bronchoscopy. Subjects will 
undergo cardiac monitoring during bronchoscopy. 
8.2.3. 
Pharmacokinetic Blood and BAL Samples 
An assay to measure ZTI-01 concentrations in plasma, BAL, and cell pellet samples and urea in plasma 
and BAL samples will be conducted at a central analytical lab using a validated LC-MS/MS bioanalytical 
assay. Timing of samples will be with respect to the start of each dose of study drug (pre-dose and post-
infusion start, when applicable). The date and time of each PK sample and BAL collection will be 
recorded in the eCRF. Blood PK samples will be drawn for all subjects within the following windows: -
10 to -1 minute for scheduled samples at pre-dose; ±5 minutes for scheduled samples at 30 minutes, 1 
hour 15 minutes, and 2 hours; +0-5 minutes from end of infusion for the scheduled sample at 1 hour; and 
±15 minutes for scheduled samples at 5, 8, and 12 hours. BAL samples for PK (fosfomycin and urea 
assays) will be obtained within +/- 15 minutes of the assigned sampling time.  
Instructions for collecting, processing, storage, and shipping of plasma, BAL, and urine samples will be 
provided in the MOP. 
Blood and BAL samples are summarized in Table 7. 
 
 
 
 
 
 
 
 

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Table 7: Pharmacokinetics sampling times 
Study day  
Dosing 
Blood sampling times* 
BAL sampling times§ 
Day 1-2 
Dosing 
First dose: 
ZTI-01 6 g IV infusion 
over 1 hour (+10 minute 
window)  
All subjects:  
Pre-dose (-10 to -1 minutes), 
30 minutes (during the 1-hour 
infusion), and 1 hour, 1 hour 
15 minutes, 2, and 5 hours 
after the start of the first dose 
No sampling 
Second dose: 
ZTI-01 6 g IV infusion 
over 1 hour (+10 minute 
window)  
All subjects:  
Pre-dose (-10 to -1 minutes) 
No sampling 
Third dose: 
ZTI-01 6 g IV infusion 
over 1 hour (+10 minute 
window) 
All subjects: 
Pre-dose (-10 to -1 minutes), 
30 minutes (during the 1-hour 
infusion), and 1 hour, 1 hour 
15 minutes, and 2, 5, 8, and 
12 hours after the start of the 
third (last) infusion of ZTI-01 
Each subject: 
Complete a single 
bronchoscopy with BAL at 
one of the five sampling 
times: 30 minutes (during 
the 1-hour infusion), 1 hour 
15 minutes, 2, 5, or 8 hours  
from the start of the third 
(last) infusion of ZTI-01 
Day 2  
At Discharge 
No further dosing 
All subjects:  
12 hours after the start of the 
third (last) infusion of ZTI-01 
No sampling 
* Blood PK samples will be drawn for all subjects within the following windows: -10 to -1 minutes for scheduled 
samples at pre-dose; ±5 minutes for scheduled samples between 30 minutes, 1 hour 15 minutes, and 2 hours; +0-5 
minutes from end of infusion for the scheduled sample at 1 hour; ±15 minutes for scheduled samples at 5, 8, and 12 
hours. Actual times for dosing and sample will be recorded. 

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§ BAL samples for PK (fosfomycin and urea) will be drawn ±15 minutes for scheduled samples. Actual times for dosing 
and sampling will be recorded. A blood sample will be collected to measure serum urea concentration just before or 
during the bronchoscopy. 
8.2.4. 
Specimen Preparation, Handling, and Shipping 
Please reference the protocol-specific MOP for detailed instruction for collection, processing, labeling, 
storing, handling and shipping. 
8.2.4.1. 
Instructions for Specimen Preparation, Handling, and Storage 
All samples collected and processed for PK analysis will be shipped in accordance with the MOP to 
DMID-CMS at the address below, and will be tracked using DMID’s Global Trace Sample Tracking 
system. 
 
DMID-Clinical Materials Services (Fisher BioServices) 
20439 Seneca Meadows Parkway 
Germantown, MD 20876 
Tel: 240-477-1350, 
Fax: 240-477-1360 
Email: dmid.cms@thermofisher.com 
Blood samples: For each blood sample timepoint (according to Sections 8.2.1 and 8.2.3), approximately 4 
mL of blood will be drawn into a vacutainer tube and will be processed according to the MOP.  
BAL samples: BAL samples will be collected according to Section 8.2.2 and processed for PK and urea 
measurements according to the MOP. 
Specimen shipment: Plasma and BAL cell pellet samples will be shipped overnight on dry ice to DMID-
CMS, which will then send one set of samples to the bioanalytical lab performing the PK analysis. See 
the MOP for details for shipping. 
 

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9. 
ASSESSMENT OF SAFETY 
9.1. 
Specification of Safety Parameters 
All DMID studies are conducted in accordance with 45 CFR 46, which provides for the protection of 
study subjects. The Site PI or designee is responsible for the safe conduct of the trial and for reporting 
AEs and SAEs according to the protocol and applicable federal regulations. An Independent Safety 
Monitor (ISM) is a physician experienced in the conduct of clinical studies, located close to DEPRU, and 
appointed to independently review all SAEs and related Grade 3 AEs and thoroughly investigate those 
considered both serious and unexpected. The DMID Medical Monitor reviews progress and safety 
reports, reviews safety reports prepared in advance for SMC meetings and comments on their accuracy, 
reviews SMC recommendations, and has the authority to halt, suspend, or stop the study. 
9.2. 
Methods and Timing for Assessing, Recording, and Analyzing Safety 
Parameters 
9.2.1. 
Adverse Events 
ICH E6 defines an AE as any untoward medical occurrence in a patient or clinical investigation subject 
administered a pharmaceutical product, and that does not necessarily have a causal relationship with this 
treatment. An AE can therefore be any unfavorable and unintended sign (including a clinically significant 
laboratory abnormality), symptom, or disease temporally associated with use of the study drug, whether 
or not it is deemed related to the study drug. The occurrence of an AE may come to the attention of study 
personnel during study visits and interviews of a study subject presenting for medical care, or upon 
review by a study monitor. The period of observation for AE reporting will begin on Day 1 at the time of 
first dosing and continue through the final visit, a follow-up call on Day 3.  
All AEs including local and systemic reactions not meeting the criteria for SAEs will be captured on the 
appropriate eCRF. Information to be collected includes event description, time of onset, clinician’s 
assessment of severity, relationship to study drug (assessed only by those with the training and authority 
to make a diagnosis), outcome, action taken, and time of resolution/stabilization of the AE. All AEs 
occurring while on study will be documented appropriately regardless of relationship. All AEs will be 
followed until they adequately resolve or are determined by the PI to be medically stable (stable or 
improving over two assessments and no further intervention required). Any medical condition that is 
present at the time that the subject is screened will be considered as a baseline finding and not reported as 
an AE. However, if its Grade increases at any time during the trial such that it meets the AE definition 
specified above, it will be recorded as an AE. 
All systemic and laboratory AEs will be graded using the Adverse Event Toxicity Grading Scale 
(Appendix B). Laboratory toxicity grading will be determined by using these tables as modified for the 
study to accommodate the reference range of the Central Laboratory and the acceptable ranges used in 

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determining eligibility. If a subject was enrolled in the trial with a laboratory value that is outside the 
reference range, but within the acceptable ranges, , an AE will be recorded if it otherwise meets the 
definition of AE in Section 9.3 and the on-study value is higher (if initially high) or lower (if initially 
low) than the screening value. 
Severity of Event:   
All AEs will be assessed by the clinician using the protocol-defined grading system in Appendix B. 
Changes in the severity of an AE will be documented to allow an assessment of the duration of the AE at 
each level of intensity to be performed. AEs characterized as intermittent require documentation of onset 
and duration of each episode. 
Relationship to Study Products:  
The clinician’s assessment of an AE's relationship to the study drug is part of the documentation process, 
but it is not a factor in determining what is or is not reported in the trial. If there is any doubt as to 
whether a clinical observation is an AE, it will be reported. All AEs will have their relationship to the 
study drug assessed using the terms “related” or “not related.” In a clinical trial, the study drug must 
always be suspect. To help assess relatedness, the following guidelines are used. 
• 
Related: There is a reasonable possibility that the study drug caused the AE. Reasonable possibility 
means that there is evidence to suggest that the study drug caused the AE. 
• 
Not Related: There is not a reasonable possibility that the study drug caused the AE.  
9.2.2. 
Serious Adverse Events 
An AE or suspected AE is considered “serious” if, in the view of either the investigator or Sponsor, it 
results in any of the following outcomes:  
• 
Death, 
• 
a life-threatening AE,  
• 
An adverse event is considered life-threatening if, in the view of either the site principal investigator 
or sponsor, its occurrence places the patient or subject at immediate risk of death. It does not include 
an adverse event that, had it occurred in a more severe form, might have caused death. 
• 
inpatient hospitalization or prolongation of existing hospitalization,  
• 
a persistent or significant incapacity or substantial disruption of the ability to conduct normal life 
functions, or  
• 
a congenital anomaly/birth defect.   

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• 
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 
subject and may require medical or surgical intervention to prevent one of the outcomes listed in this 
definition.  Examples of such medical events include allergic bronchospasm requiring intensive 
treatment in an emergency room or at home, blood dyscrasias or convulsions that do not result in 
inpatient hospitalization, or the development of drug dependency or drug abuse. 
All SAEs will be: 
• 
Assessed for severity and relationship to the study drug and alternate etiology, 
• 
Recorded on the appropriate SAE data collection form and eCRF, 
• 
Followed through resolution, 
• 
Reviewed and evaluated by the ISM (as deemed necessary), SMC (periodic review unless related), 
DMID, and IRB. 
9.2.3. 
Procedures to be Followed in the Event of Abnormal Laboratory Test Values or 
Abnormal Clinical Findings 
A licensed study physician will make the determination of seriousness, severity, and causality, provide a 
medical evaluation of adverse events, and classify adverse events based upon medical judgment. 
Abnormal laboratory test values or abnormal clinical findings for all enrolled subjects, including values 
and findings noted at screening and baseline, will be assessed using the toxicity scales in Appendix B. 
Abnormal values and findings noted at Screening or Baseline will only be considered AEs if they increase 
in grade after study product administration. For abnormalities noted from the time of study drug 
administration, any Grade 1 or higher laboratory abnormality listed on the toxicity table in Appendix B 
will be entered in the database as an AE. Abnormal clinical/laboratory findings will be collected, 
assessed, documented, reported, and followed appropriately.  
9.3. 
Reporting Procedures 
AEs will be reported from the time of dosing on Day 1 through the Telephone Follow-up Interview on 
Day 3. 
All AEs will be followed until resolution. Resolution of an AE is defined as the return to pretreatment 
status or stabilization of the condition with the expectation that it will remain chronic. 
All AEs and SAEs will be reported, whether or not that are deemed causally related to the study drug. All 
AEs and SAEs will be recorded in the eCRF.  
SAEs will be followed until resolution even if this extends beyond the study-reporting period.   

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The Site PI is responsible for informing the IRB of the SAE as per local requirements. DMID will be 
responsible of informing the US Regulatory Authority of the SAE as per federal requirements. 
9.3.1. 
Serious Adverse Events 
Any AE that meets a protocol-defined serious criterion will be submitted immediately (within 24 hours of 
site awareness) on an SAE form to the DMID Pharmacovigilance Group, at the following address:  
DMID Pharmacovigilance Group 
Clinical Research Operations and Management Support (CROMS) 
6500 Rock Spring Drive, Suite 650 
Bethesda, MD 20817, USA 
SAE Hot Line: 1-800-537-9979 (US) or 1-301-897-1709 (outside US) 
SAE FAX Number: 1-800-275-7619 (US) or 1-301-897-1710 (outside US) 
SAE Email Address: PVG@dmidcroms.com 
In addition to the SAE form, select SAE data fields will also be entered into the DCC system (e.g., 
Advantage EDC). Please see the protocol-specific MOP for details regarding this procedure.  
Other supporting documentation of the SAE may be requested by the DMID Pharmacovigilance Group 
and will be provided as soon as possible.  
DEPRU will send a copy of the SAE report(s) to the ISM when they are provided to the DMID 
Pharmacovigilance Group. The DMID Medical Monitor and DMID Clinical Project Manager will be 
notified of the SAE by the DMID Pharmacovigilance Group. The DMID Medical Monitor will review 
and assess the SAE for regulatory reporting and potential impact on subject safety and protocol conduct. 
At any time after completion of the study, if the Site PI or appropriate sub-investigator becomes aware of 
an SAE that is suspected to be related to the study drug, the Site PI or appropriate sub-investigator will 
report the SAE to the DMID Pharmacovigilance Group. 
9.3.2. 
Regulatory Reporting for Studies Conducted Under DMID-Sponsored IND 
Following notification from the investigator, the IND sponsor DMID will report any suspected AE that is 
both serious and unexpected. DMID will report an AE as a suspected adverse reaction only if there is 
evidence to suggest a causal relationship between the study drug and the AE. DMID will notify FDA and 
all participating investigators (i.e., all investigators to whom the Sponsor is providing drug under its INDs 
or under any investigator’s IND) in an IND safety report of potential serious risks from clinical trials or 
any other source, as soon as possible, but in no case later than 15 calendar days after the Sponsor 
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also notify FDA of any unexpected fatal or life-threatening suspected AE as soon as possible but in no 
case later than 7 calendar days after the Sponsor’s initial receipt of the information. Relevant follow-up 
information to an IND safety report will be submitted as soon as the information is available. Upon 
request from FDA, DMID will submit to FDA any additional data or information that the agency deems 
necessary, as soon as possible, but in no case later than 15 calendar days after receiving the request. 
All SAEs designated as “not related” to the study drug will be reported to the FDA at least annually in a 
summary format. 
9.3.3. 
Reporting of Pregnancy 
Pregnancies occurring in study subjects will be reported via AdvantageEDCSM on the Pregnancy Report 
form. All pregnancies occurring during the trial will be followed for information regarding the course of 
pregnancy and any outcome, delivery and condition of the newborn. Follow-up will be provided by the 
investigator to the Medical Monitor (or designee) in a timely manner.  
9.4. 
Type and Duration of Follow-up of Subjects after Adverse Events 
All AEs will be followed until resolution or until determined by the PI to be medically stable 
(stable/improving and no further intervention required). 
9.5. 
Halting Rules 
If any of the halting rules, as outlined below, is met, further enrollment and dosing will be withheld until 
the SMC reviews the safety data and provides its recommendations.  
• 
Two subjects experience any related Grade 3 systemic AE   
• 
Two subjects experience the same related Grade 3 laboratory AE (per Medical Dictionary for 
Regulatory Activities High Level Group Term) 
• 
One subject experiences a related SAE 
A decision to reinitiate the trial and proceed with study drug administration will be made by DMID based 
on the recommendation of the SMC. 
If the following individual halting rule is met, the individual will not undergo further dosing or study 
procedures. 
• 
Subject experiences a grade 2 or higher abnormality in sodium, potassium, magnesium, calcium, or 
phosphorus, when checked approximately 2 hours prior to the bronchoscopy timepoint 
9.6. 
Safety Oversight 
The safety oversight for the trial will be conducted under the direction of DMID.  

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9.6.1. 
Independent Safety Monitor (ISM) 
An ISM will oversee the safety of subjects and provide independent evaluation of all SAEs and related 
Grade 3 AEs. The ISM will communicate with the Site Investigators to discuss subject-related issues and 
resolve queries generated by the ISM, DMID Medical Monitor, and SMC, as applicable. 
9.6.2. 
Safety Monitoring Committee (SMC) 
An SMC will be appointed to monitor subject safety.  The SMC will consist of independent evaluators 
who will have no relationship with the conduct of the trial. The SMC will operate under the rules of a 
DMID-approved charter that will be written at the organizational meeting of the SMC. In the charter, 
meeting frequency and each data element that the SMC will assess will be clearly defined. 
The SMC will review safety data for increased rate of occurrence of serious suspected AEs. If halting 
rules are met, more frequent meetings may be held. Ad hoc meetings may also be held to address any 
safety issues that may arise. 
If the trial is halted, the SMC will be consulted to review the data and provide a recommendation related 
to the continued dosing of the subjects. 
The SMC will advise DMID of its recommendations. At the end of study enrollment, the SMC will 
review clinical safety and PK data, and provide recommendations regarding further safety assessments in 
studies with ZTI-01. Since the study is an open-label trial, a statistician may provide independent analyses 
to the SMC as needed. 

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10. 
CLINICAL MONITORING 
Site monitoring of the trial will be conducted to ensure the safety and conduct of the trial complies with 
21 CFR 11, 21 CFR 50, 21 CFR 54, 21 CFR 56, 45 CFR 46, 21 CFR 312 GCP and ICH Guidelines, and 
DMID guidelines, as appropriate. 
10.1. 
Site Monitoring Plan 
Site monitoring is conducted to ensure that the human subjects’ protections, study and laboratory 
procedures, study intervention administration, and data collection processes are of high quality and meet 
Sponsor, ICH/GCP guidelines, and applicable regulations, and that the trial is conducted in accordance 
with the protocol, protocol-specific MOP, and applicable Sponsor SOPs. DMID, the Sponsor, or its 
designee will conduct site-monitoring visits as detailed in the clinical monitoring plan. 
Site visits will be made at standard intervals as defined by DMID and may be made more frequently as 
directed by DMID. Monitoring visits will include, but are not limited to, review of regulatory files, 
accountability records, eCRFs, ICFs, medical and laboratory reports, and protocol and GCP compliance. 
Site monitors will have access to DEPRU, study personnel, and all study documentation according to the 
DMID-approved site monitoring plan. Study monitors will meet with the Site PI to discuss any problems 
and actions to be taken, and will document site visit findings and discussions. 

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11. 
STATISTICAL CONSIDERATIONS 
11.1. 
Study Hypotheses 
The objectives of the study are to assess safety and pharmacokinetics for a multiple dose regimen of IV-
infused ZTI-01.  The study is not designed to test any formal hypotheses, but will provide exposure 
information on the IV formulation of ZTI-01. These exposure data should act as a bridge between the new 
IV formulation and the approved oral reference drug.  
These data could permit the application of previously submitted information (e.g. safety, pharmacology, 
toxicology, genotoxicity, carcinogenicity) in support of the new IV formulation.   
This study will also provide adequate information to confirm the safety and PK of ZTI-01 and further 
evaluate its use in the intended patient population. 
11.2. 
Sample Size Considerations 
Since statistical analyses are not intended to serve as a basis of definitive conclusions, statistical power 
considerations for determination of sample size were not performed. The sample size for this study was 
selected as adequate for determining the safety and PK of ZTI-01. The sample size is based on clinical 
experience and judgment relative to study design and objectives. The study is designed to enroll 40 
healthy male and female adult subjects, aged 18 to 45 years, to have 30 evaluable subjects complete the 
trial. This will result in 30 plasma and BAL concentration-time profiles available for PK profiling.  Table 
8 displays probabilities of detecting at least one safety event for a range of true event rates using the 
specified sample size of 30 subjects.  Administration of ZTI-01 to any alternate subjects may result in a 
sample size higher than 30 for safety analyses.  In this case, the probability of observing safety events will 
be higher than displayed in Table 8. 
 
 
 
 
 
 
 

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Table 8: Probability of observing at least one event for a range of true event rates based on 
a sample size of n=30 subjects 
True Event 
Rate 
Probability of 
observing 1 or 
more events 
0.1% 
3% 
0.5% 
14% 
1% 
26% 
2% 
45% 
5% 
79% 
7% 
89% 
10% 
96% 
15% 
99% 
11.3. 
Final Analysis Plan 
Analysis Populations: 
All subjects who receive any amount of ZTI-01 will be included in the safety population.  The 
pharmacokinetic analyses will be performed using the population of evaluable subjects. An evaluable 
subject is defined as a subject who receives all doses of ZTI-01, undergoes BAL at the randomized 
sampling timepoint with BAL return volume adequate for testing, and undergoes at least the one blood 
sampling timepoint that is concurrent with the BAL sampling timepoint, with blood sampling volume that 
is adequate for testing. 
Safety:   
The safety outcome measure will be the occurrence of AEs (Appendix B) at any time from the start of 
study drug administration through the end of subject follow-up. 
All subjects in the safety population will be included in the safety analyses. AEs will be collected from 
the time of dosing on Day 1 through the Telephone Follow-Up Interview on Day 3. TEAEs will be 
tabulated by severity (mild, moderate, or severe), type (MedDRA system organ class and preferred term), 
and by the relationship to the study drug as assessed by the investigator. TEAEs will be summarized both 
by incidence and frequency. For summaries by incidence, subjects will be tabulated according to the most 
severe grade of AE experienced (each subject counted only once per type of AE).  For summaries of 

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frequency, each AE (by type) will be tabulated by severity, with each occurrence of the AE being counted 
(same subject can contribute multiple events to frequency).  Tabulations of incidence and frequency will 
be performed separately for AEs overall and for related AEs only.  
Observed and change-from-baseline vital signs, laboratory, and ECG data will be summarized using the 
mean, median, standard deviation, minimum, and maximum. The most recent measurement prior to start 
of infusion of the first ZTI-01 dose will be regarded as baseline. The number and percentage of subjects 
with laboratory, vital sign, and ECG abnormalities at baseline, subsequent visits, or early termination 
from the trial will be tabulated. The results of all laboratory tests, physical exam findings, ECGs, and vital 
signs will be presented in data listings. 
Pharmacokinetics: 
The pharmacokinetic outcome measures will be plasma and intrapulmonary PK of ZTI-01.  
The following plasma PK parameters will be derived from the plasma concentration vs. time curves for 
fosfomycin after ZTI-01 administration. Noncompartmental analysis will be used to determine PK 
parameters, but other modeling techniques can be employed as needed. The below PK parameters will be 
estimated using Phoenix® WinNonlin® version 8.0 or later, and using plasma concentrations collected 
after start of the first and/or third doses. 
• 
Maximum measured plasma concentration (Cmax) 
• 
Observed and extrapolated area under the concentration versus time curve (AUC0-8; AUC0-12; AUC0-
inf) 
• 
Time to peak concentration (tmax) 
• 
Terminal elimination half-life (t1/2) 
• 
Terminal-phase elimination rate constant (λz) 
 
• 
Volume of distribution (Vd)  
• 
Clearance (CL)  
PK parameters (Cmax, tmax,  and AUC0-8) will be compared by dose and the accumulation ratio will be 
estimated using both Cmax and AUC0-8. 
Intrapulmonary PK of ZTI-01 will be derived as follows. Serum and BAL urea measurements will be 
used to estimate the volume of ELF recovered in the BAL samples. The ratios of ELF and AM 
concentrations of fosfomycin to simultaneous plasma concentrations will be calculated for each subject 
and summarized for each sampling time. The median concentrations of fosfomycin from the BAL 
sampling times will be used to estimate the population average AUC0-8 of plasma, ELF, and AM. The 

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ratio of population average AUC0-8 of ELF-to-plasma and AM-to-plasma will be calculated to determine 
the percent penetration.  
 
Specific details of pharmacokinetic analysis will be included in the study-specific pharmacokinetic 
analysis plan. 
 

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12. 
SOURCE DOCUMENTS AND ACCESS TO SOURCE 
DATA/DOCUMENTS 
DEPRU will maintain appropriate medical and research records for this study, in compliance with Section 
4.9 of ICH E6 GCP, and regulatory and institutional requirements for the protection of confidentiality of 
subjects. As part of participating in a DMID-sponsored study, DEPRU will permit authorized 
representatives of DMID and regulatory agencies to examine (and when required by applicable law, to 
copy) clinical records for the purposes of quality assurance reviews, audits and evaluation of the study 
safety and progress.  
Source data are all information, original records of clinical findings, observations, or other activities in a 
trial necessary for the reconstruction and evaluation of the trial. Examples of these original documents 
and data records include, but are not limited to, hospital records, clinical and office charts, laboratory 
notes, memoranda, evaluation checklists, pharmacy dispensing records, recorded data from automated 
instruments, copies or transcriptions certified after verification as being accurate and complete, 
microfiches, photographic negatives, microfilm or magnetic media, x-rays, and subject files and records 
kept at the pharmacies, laboratories, and medico-technical departments involved in the trial. 

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13. 
QUALITY CONTROL AND QUALITY ASSURANCE 
Following a written DMID-accepted site quality management plan, DEPRU and its subcontractors are 
responsible for conducting routine quality assurance (QA) and quality control (QC) activities to internally 
monitor study progress and protocol compliance. The Site PI will provide direct access to all study-related 
sites, source data/data collection forms, and reports for monitoring and auditing by the Sponsor, and 
inspection by local and regulatory authorities. The Site PI will ensure all study personnel are 
appropriately trained and applicable documentations are maintained at DEPRU. 
The DCC will implement quality control procedures beginning with the data entry system and generate 
data quality control checks that will be run on the database. Any missing data or data anomalies will be 
communicated to DEPRU for clarification and resolution. 

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14. 
ETHICS/PROTECTION OF HUMAN SUBJECTS 
14.1. 
Ethical Standard 
The Site PI will ensure that the trial is conducted in full conformity with principles of the Belmont 
Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research of the 
National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research 
(April 18, 1979) and codified in 45 CFR 46, 21 CFR 50 and 56, and ICH E6; 62 Federal Regulations 
25691 (1997), if applicable. The Site PI’s institution will hold a current Federalwide Assurance (FWA) 
issued by the Office of Human Research Protection (OHRP) for federally-funded research. 
14.2. 
Institutional Review Board 
Before enrollment of subjects into the trial, the protocol and ICF will be reviewed and approved by the 
appropriate IRB listed on its FWA. 
The responsible official for the IRB will sign the IRB letter of protocol approval before the start of the 
trial and provide a copy and the IRB FWA number to DMID. 
If amendments to the protocol are required, they will be written by the Sponsor and provided to the Site 
PI for submission to the IRB. 
14.3. 
Informed Consent Process 
The Site PI will choose subjects in accordance with the eligibility criteria detailed in Section 5.1. Before 
any study procedures are performed, subjects must sign an ICF that complies with the requirements of 21 
CFR 50, 45 CFR 46, and the local IRB. Study personnel may employ recruitment efforts before obtaining 
consent if a subject-specific screening consent is on record or if the IRB has agreed that chart review is 
allowed without a fully executed screening consent. If there is no subject-specific screening consent on 
record, DEPRU clinical staff may pre-screen via chart review and refer potential subjects to the research 
staff. Research staff would obtain written consent per the standard informed consent process before 
conducting protocol-specific screening activities. 
Informed consent is a process that is initiated before an individual agrees participate in a trial and 
continues throughout the subject’s trial participation. Before any study procedures are performed, 
including pre-screening of subjects for eligibility, subjects will receive a comprehensive explanation of 
the proposed study procedures and study drug. This will include the nature, risks, and possible benefits of 
the trial, alternate therapies, any known AEs, the investigational status of the study drug, and other 
elements that are part of obtaining proper informed consent. Subjects will also receive a detailed 
explanation of the proposed use and disclosure of their protected health information, including 
specifically their blood, urine, and BAL samples. Subjects will be allowed sufficient time to consider 
participation in the trial, after having the nature, risks, and possible benefits of the trial explained to them, 

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and have the opportunity to discuss the trial with their family, friends, or legally authorized 
representative, or think about it before agreeing to participate. 
ICFs describing in detail the study drug, procedures, risks, and possible benefits will be given to subjects. 
The ICF will not include any exculpatory statements. ICFs will be IRB-approved and subjects will be 
asked to read and review the appropriate document. Upon reviewing the appropriate document, the Site PI 
or designee will explain the trial to subjects and answer any questions that they have. Subjects must sign 
the ICF, and written documentation of the informed consent process is required before starting any study 
procedures being done specifically for the trial, including determining eligibility and administering study 
drug. 
By signing the ICF, subjects agree to complete all study procedures required by the trial, unless the 
subject withdraws voluntarily, or is withdrawn or terminated from the trial for any reason. The rights and 
welfare of subjects will be protected by emphasizing to subjects that the quality of their medical care will 
not be adversely affected if they decline to participate in or withdraw from the trial. 
DMID will provide the Site PI, in writing, any new information that significantly impacts the subject’s 
risk of receiving the study drug. This new information will be communicated by the Site PI to subjects 
who consent to participate in the trial in accordance with IRB requirements. The ICF will be updated and 
subjects will be re-consented per IRB requirements, if necessary. Subjects will be given a copy of all ICFs 
that they sign. 
14.4. 
Exclusion of Women, Minorities, and Children (Special Populations) 
The trial will enroll all subjects aged 18 to 45 years who meet all the Subject Inclusion Criteria (see 
Section 5.1.1) and do not meet any of the Subject Exclusion Criteria (see Section 5.1.2), regardless of 
religion, sex, race, or ethnicity.  Persons younger than 18 years of age will not be included in this study.  
This trial is being performed to learn about the pulmonary pharmacokinetics of fosfomycin in healthy 
adults.   The additional risks of performing bronchoscopy in pediatric populations warrants the exclusion 
of children in this trial. 
14.5. 
Subject Confidentiality 
Subject confidentiality is strictly held in trust by the Site PI, other study personnel, the Sponsor, and their 
agents. This confidentiality is extended to cover testing of biological samples, in addition to the clinical 
information relating to subjects. Subjects will be identified by code numbers and not by name. 
The study protocol, documentation, data, and all other information generated will be held in strict 
confidence. No information concerning the trial or the data will be released to any unauthorized third 
party without prior written approval of the Sponsor. 
All information provided by the Sponsor and all data and information generated by DEPRU as part of the 
trial (other than a subject’s medical records) will be kept confidential by the Site PI and other study 

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personnel to the extent permitted by law. This information and data will not be used by the Site PI or 
other study personnel for any purpose other than conducting the trial. These restrictions do not apply to: 
(1) information which becomes publicly available through no fault of the Site PI or other study personnel; 
(2) information which is necessary to disclose in confidence to an IRB solely for evaluation of the trial; 
(3) information which is necessary to disclose in order to provide appropriate medical care to a subject; or 
(4) study results which may be published as described in Section 16.  
The study monitor, applicable regulatory authorities (e.g., FDA), or other authorized representatives of 
the Sponsor may inspect all documents and records required to be maintained by the Site PI. This 
includes, but is not limited to, medical records (office, clinic, or hospital) and pharmacy records for the 
subjects in the trial. DEPRU will permit access to such records. 
To protect privacy, we have received a Certificate of Confidentiality. With this Certificate, the researchers 
cannot be forced to release information that may identify the research subject, even by a court subpoena, 
in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings. The 
researchers will use the Certificate to resist any demands for information that would identify the subject, 
except as explained below. 
The Certificate cannot be used to resist a demand for information from personnel of the United States 
Government that is used for auditing or evaluation of federally funded projects, like this study, or for 
information that must be released in order to meet the requirements of the Federal Food and Drug 
Administration (FDA). 
A Certificate of Confidentiality does not prevent the subject from voluntarily releasing information about 
themselves or their involvement in this research. If any person or agency obtains a written consent to 
receive research information, then the researchers may not use the Certificate to withhold that 
information.  
The Certificate of Confidentiality does not prevent the researchers from reporting without the subject’s 
consent, information that would identify the subject as a participant in the research project regarding 
matters that must be legally reported including: child and elder abuse, sexual abuse, or wanting to harm 
themselves or others. 
14.6. 
Study Discontinuation 
If the trial is discontinued, subjects who have signed the ICF and are administered study drug, will 
continue to be followed for safety for the duration of the scheduled follow-up period. No further study 
drug will be administered. 
14.7. 
Costs, Subject Compensation, and Research Related Injuries 
There is no cost to subjects for the research tests, procedures, and study drug while taking part in the trial. 
Procedures and treatment for clinical care may be billed to the subject, subject’s insurance, or third party. 

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Subjects may be compensated for their participation in the trial. Compensation will be in accordance with 
the local IRB’s policies and procedures, and subject to IRB approval. 
14.8. 
Future Use of Stored Specimens and Data 
Aside from plasma or BAL sample reanalysis, no future use of specimens is intended with this protocol. 
Plasma and BAL samples will be stored at –20 to –70°C for up to 189 days from collection to be used in 
case of need for reanalysis. All samples will remain coded to provide subject confidentiality. Samples will 
be discarded when analysis is complete or after 189 days, whichever is first. 

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15. 
DATA HANDLING AND RECORD KEEPING 
The Site PI is responsible for ensuring the accuracy, completeness, legibility, and timeliness of reported 
data. 
Data collection forms will be derived from the eCRF and provided by the DCC to record and maintain 
data for each subject enrolled in the trial. All data collection forms will be completed in a neat, legible 
manner to ensure accurate interpretation of data. Black or blue ink is required to ensure clarity of 
reproduced copies. When making a change or correction, cross out the original entry with a single line 
and initial and date the change. Do not erase, overwrite, or use correction fluid or tape on the original. 
Data reported in the eCRF derived from the data collection forms should be consistent with the data 
collection forms or the discrepancies should be explained. 
The Sponsor or designee will provide guidance to the Site PI and other study personnel on making 
corrections to the data collection forms and eCRF. 
15.1. 
Data Management Responsibilities 
All data collection forms and laboratory reports will be reviewed by the clinical team and data entry 
personnel, who will ensure that they are accurate and complete. AEs will be recorded on the appropriate 
data collection form, assessed for severity and relationship, and reviewed by the Site PI or appropriate 
sub-investigator. 
Data collection is the responsibility of the study personnel at DEPRU under the supervision of the Site PI. 
During the trial, the Site PI will maintain complete and accurate documentation for the trial. 
The DCC for the trial will be responsible for data management, quality review, analysis, and reporting. 
15.2. 
Data Capture Methods 
Clinical (including, but not limited to, AE/SAEs, concomitant medications, medical history, physical 
assessments, and clinical laboratory values), will be entered into a 21 CFR 11-compliant Internet Data 
Entry System provided by the DCC. The data system includes password protection and internal quality 
checks, such as automatic range checks, to identify data that appear inconsistent, incomplete, or 
inaccurate. Clinical data will be entered directly from the data collection forms completed by the study 
personnel. 
15.3. 
Types of Data 
A variety of data will be collected and used in the aforementioned analysis. These data include, but are 
not limited to demographics, medical history and prior medications, hematology, coagulation, urinalysis 
and blood chemistry, vital signs, ECGs, and PK blood and BAL samples (Appendix A). 

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15.4. 
Timing/Reports 
As the duration of the trial is short, an initial review of data is anticipated for QC purposes. All data will 
be thoroughly reviewed upon completion before analysis and writing of the study report. 
15.5. 
Study Records Retention 
DEPRU will maintain appropriate medical and research records for the trial, in compliance with ICH E6 
R1, Section 4.9, regulatory and institutional requirements for the protection of confidentiality of subjects. 
DEPRU will permit authorized representatives of the Sponsor, DMID, and regulatory agencies to 
examine (and when required by applicable law, copy) clinical records for the purposes of clinical site 
monitoring, quality assurance reviews, audits, and evaluation of the study safety and progress. A Site 
Master File will be maintained to include essential documents.     
Study documents will be retained for at least 2 years after the last marketing application approval or 2 
years from the formal discontinuation of clinical development of an investigational drug. These 
documents will be retained for a longer period, if required by local regulations. No record will be 
destroyed without the written consent of the Sponsor. 
15.6. 
Protocol Deviations 
A protocol deviation is any noncompliance with the clinical trial protocol, GCP, or protocol-specific 
MOP requirements. The noncompliance may be either on the part of the subject, the Site PI, or DEPRU 
personnel. If deviations occur, corrective actions will be promptly developed and implemented by 
DEPRU. 
These practices are consistent with ICH E6: 
4.5 
Compliance with Protocol, Sections 4.5.1, 4.5.2, and 4.5.3 
5.1 
Quality Assurance and Quality Control, Section 5.1.1 
5.20 
Noncompliance, Sections 5.20.1, and 5.20.2. 
It is the responsibility of the Site PI and personnel to use continuous vigilance to identify and report 
deviations within 5 working days of identification of the protocol deviation, or within 5 working days of 
the scheduled protocol-required activity. All deviations will be promptly reported to DMID per the DCC 
protocol deviation reporting procedures. 
All protocol deviations, as defined above, will be addressed in study subject data collection forms. A 
completed copy of the DMID Protocol Deviation Form will be maintained in the Regulatory File, as well 
as in the subject's chart. Protocol deviations will be sent to the local IRB/IEC per their guidelines. The 
Site PI and personnel are responsible for knowing and adhering to their IRB requirements. 

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16. 
PUBLICATION POLICY 
Following completion of the trial, the investigator will publish the results of this research in a scientific 
journal. All manuscripts resulting from the trial will be reviewed by representatives from DEPRU, DMID, 
and Nabriva Therapeutics, Inc. Each institution will have at least 30 days to review the publication before 
submission.  
All investigators funded by the NIH must submit or have submitted for them to the National Library of 
Medicine’s PubMed Central (http://www.ncbi.nlm.nih.gov/pmc/) an electronic version of their final, peer-
reviewed manuscripts upon acceptance for publication, to be made publicly available no later than 12 
months after the official date of publication. The NIH Public Access Policy ensures the public has access 
to the published results of NIH funded research.  It requires investigators to submit final peer-reviewed 
journal manuscripts that arise from NIH funds to the digital archive PubMed Central upon acceptance for 
publication. Further, the policy stipulates that these papers must be accessible to the public on PubMed 
Central no later than 12 months after publication. 
Refer to: 
• 
NIH Public Access Policy, http://publicaccess.nih.gov/ 
• 
NIH Office of Extramural Research (OER) Grants and Funding, http://grants.nih.gov/grants/oer.htm 
As of January 2018, all clinical trials supported by the NIH must be registered on ClinicalTrials.gov, no 
later than 21 days after the enrollment of the first subject. Results of all clinical trials supported by the 
NIH, generally, need to be submitted no later than 12 months following the primary completion date. A 
delay of up to 2 years is available for trials that meet certain criteria and have applied for certification of 
delayed posting. 
As part of the result posting a copy of this protocol (and its amendments) and a copy of the Statistical 
Analysis Plan will be posted on ClincialTrials.gov. 
For this trial the Investigators will register the trial and post results.   
The responsible party does not plan to request certification of delayed posting. 
Refer to: 
• 
Public Law 110-85, Section 801, Clinical Trial Databases 
• 
42CFR11 
• 
NIH NOT-OD-16-149 

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17. 
LITERATURE REFERENCES 
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Alemayehu D, Quinn J, Cook J, Kunkel M and Knirsch CA. A Paradigm Shift in Drug Development for 
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Al-Hasan MN, Eckel-Passow JE, Baddour LM. Bacteremia Complicating Gram-Negative Urinary Tract 
Infections: A Population-Based Study. J Infect. 2010 April ; 60(4): 278–285. 
Ambrose PG, Bhavnani SM, Rubino CM, Louie A, Gumbo T, Forrest A, Drusano GL.     
Pharmacokinetics-pharmacodynamics of antimicrobial therapy: It’s not just for mice anymore. Clin Infect 
Dis 2007; 44:79-86. 
Ambrose PG, Bhavnani SM, Ellis-Grosse EJ, Drusano GL.     Pharmacokinetics- pharmacodynamics 
considerations in the design of hospital-acquired or ventilator-associated bacterial pneumonia studies: 
look before you leap! Clin Infect Dis 2010; 51(Suppl 1):S103-S110. 
Asuphon O, Montakantikul P, Houngsaitong J, Kiratisin P, Sonthisombat P.  Optimizing intravenous 
fosfomycin dosing in combination with carbapenems for treatment of Pseudomonas aeruginosa infections 
in critically ill patients based on pharmacokinetic/pharmacodynamics (PK/PD) simulations.  Int J Infect 
Dis 2016;50:23-9. 
Craig WA, Ebert SC. Killing and regrowth of bacteria in vitro: a review. Scand J Infect Dis Suppl 1990; 
74:63–70. 
Dinh A, Salomon J, Bru JP Bernard L. Fosfomycin: efficacy against infections caused by multidrug-
resistant bacteria. Scand J Infect Dis. 2012;44(3):182-189. 
Drusano G. Prevention of Resistance: A Goal for Dose Selection for Antimicrobial Agents. Clin Infect 
Dis 2003; 36(Suppl 1):S42–50. 
Endimiani A, Patel G, Hujer KM, Swaminathan M, Perez F, and Rice LB. In vitro activity of fosfomycin 
against blaKPC-containing Klebsiella pneumoniae isolates, including those non-susceptible to tigecycline 
and/or colistin. Antimicrob Agents Chemother 2010;54:526–529. 
Edwards JR, Peterson KD, Banerjee S, Allen-Bridson K, Morrell G, Dudeck MA, Pollock DA, and Horan 
TC. National Healthcare Safety Network (NHSN) report: Data summary for 2006 through 2008, issued 
December 2009.  Am J Infect Control 2009;37:783-805. 
Falagas ME, Konstatina PG, Kokolakis GN and Rafilidis PI. Fosfomycin: Use Beyond Urinary Tract and 
Gastrointestinal Infections. Clin Infect Dis 2008;46(7):1069-1077. 

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Falagas ME, Vouloumanou EK, Toglas AG, Karadima M, Kapaskelis AM, Rafailidis P, and Athanasiou 
S. Fosfomycin versus other antibiotics for the treatment of cystitis: a meta-analysis of randomized 
controlled trials. J Antimicrob Chemother 2010;65:1862–1877 
Falagas ME, Kastoris AC, Kapaskelis AM, Karageorgopoulos DE. Fosfomycin for the treatment of 
multidrug-resistant, including extended-spectrum Beta- lactamase producing, Enterobacteriaceae 
infections: a systematic review. Lancet Infect Dis 2010b;10:43–50.  
Florent A, Chinchmanian RM, Cua E and Pulcini C. Adverse events associated with intravenous 
fosfomycin. Intl J Antimicrobial Agents 2011; 37:82–92 
Genao L, Buhr GT. Urinary tract infections in older adults residing in long-term care facilities. Annals of 
Long-Term Care: Clinical Care and Aging. 2012;20(4):33-38.  
Granowitz E, Brown R. Antibiotic Adverse Reactions and Drug Interactions. Critical Care Clinics. 
2008;24(2). 
Kanj SS and Kanafani ZA. Current Concepts in Antimicrobial Therapy Against Resistant Gram-Negative 
Organisms: Extended-Spectrum β-Lactamase–Producing Enterobacteriaceae, Carbapenem-Resistant 
Enterobacteriaceae, and Multidrug-Resistant Pseudomonas aeruginosa. Mayo Clin Proc. 2011;86(3):250-
259. 
Kahan FM, Kahan JS, Cassidy PJ, Kropp H. The mechanism of action of fosfomycin (phosphonomycin). 
Ann N Y Acad Sci 1974;235:364–386.  
Karageorgopoulos DE, Wang R, Xu-hong Y, and Falagas ME. Fosfomycin: evaluation of the published 
evidence on the emergence of antimicrobial resistance in Gram-negative pathogens. J Antimicrob 
Chemother 2012;67:255–268. 
Kasotris AC, Rafailidis PI, Vouloumanou EK, Gkegkes ID, and Falagas ME.  Synergy of fosfomycin 
with other antibiotics for Gram-positive and Gram Negative Bacteria. Eur J Clin Pharmacol. 
2010;66:359-368. 
Kawabata T, Yokota M, Mayama T and Shimizu K. A post-marketing surveillance study of fosfomycin 
sodium for injection: A nationwide prospective study of safety in 100,000 cases. Translated from Jap J 
Chemo. 2000;48(11):851-874. 
Koeijers JJ, Verbon A, Kessels AGH, Bartelds A, Donker G, Nys S, Stobberingh EE. Urinary tract 
infection in male general practice patients: uropathogens and antibiotic susceptibility. Urology: 2010, 
76(2), 336-340. 
Koeda T, Odaki M, Sasaki H, Yokota M, Watanabe H, Kawaoto H, Ito T, Ishiwatari N. Toxicological 
studies on fosfomycin-Na salt. I. Acute toxicity in mice and rats (author’s transl). Jpn J Antibiot 1979 
Jan;32(1):61-66. 

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Koeda T, Odaki M, Sasaki H, Yokota M, Niizato T, Watanabe H, Kawaoto H, Ito T, Kumagai K, 
Ishiwatari N. and Suzuki H. Toxicological studies on fosfomycin-Na salt. II. Subscute toxicity in rats and 
rabbits (author’s transl). Jpn J Antibiot 1979b Jan;32(1):67-81. 
Klevens RM, Edwards JR, Richards CL, Horan TC, Gaynes RP, Pollock DA and Cardo DM. Estimating 
Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports. March–
April 2007;122:160-166. 
Lepak AJ, Zhao M, Vanscoy B, Taylor DS, Ellis-Grosse E, Ambrose PG, and Andes DR. In vivo 
Pharmacokinetics and Pharmacodynamics of ZTI-01 (Fosfomycin for Injection) in the Neutropenic 
Murine Thigh Infection Model against E. coli, K. pneumoniae, and P. aeruginosa.  Antimicrob. Agents 
Chemother. AAC.00476-17; Accepted manuscript posted online 10 April 2017 
Magiorakos AP, Suetens C, Monnet DL, Gagliotti C, Heuer OE, and EARS-Net Coordination Group and 
EARS-Net Participants. The rise of carbapenem resistance in Europe: just the tip of the iceberg? 
Antimicrobial Resistance and Infection Control 2013, 2:6. 
Matzi V, Lindenmann J, Porubsky C, Kugler SA, Maier A, Dittrich P, et al. Extracellular concentrations 
of fosfomycin in lung tissue of septic patients. J Antimicrob Chemother 2010; 65:995–8. 
Mazzuli T. Diagnosis and management of simple and complicated urinary tract infections (UTIs). Can J 
Urol 2012;19(Suppl 1):42-48. 
Michalopoulos A, Virtzili S, Rafailidis P, Chalevelakis G, Damala M, and Falagas ME. Intravenous 
fosfomycin for the treatment of nosocomial infections due to carbapenem-resistant Klebsiella pneumoniae 
in critically ill patients: a prospective evaluation. Clin Microbiol Infect 2010;16:184–186.  
Michalopoulos A, Lividitis IG, and Gougoutas V. Review: The revival of fosfomycin. International 
Journal of Infectious Diseases. 2011;15: e732–e739 
Mirakhur A, Gallagher MJ, Ledson MJ, Hart CA, Walshaw MJ. Fosfomycin for multiresistant 
pseudomonas aeruginosa in cystic fibrosis. Journal of Cystic Fibrosis 2 (2003) 19–24.  
Nilsson AI, Berg OG, Aspevall O, Kahlmeter G, and Andersson DI. Biological costs and mechanisms of 
fosfomycin resistance in Escherichia coli. Antimicrob Agents Chemother 2003;47;2850-2858. 
Popovic M, Steinort D, Pillai S, Joukhadar C. Fosfomycin: an old, new friend? Eur J Clin Microbiol 
Infect Dis 2010;29:127–142.  
Pulcini C, Bush K, Craig WA, Frimody-Meller N, Grayson ML, Mouton JW, Turnidge J, Harbarth S, 
Gyssens IC and ESCMID Study Group for Antibiotic Policies. Forgotten Antibiotics: An Inventory in 
Europe, the United States, Canada, and Australia.  Clin infect Dis 2012;54(2):268–274 
Rodvold KA, George JM, and Yoo L. Penetration of anti-infective agents into epithelial lining fluid: 
focus on antibacterial agents. Clin Pharmacokinet 2011;50:637–664.  

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Roussos N, Karageorgopoulos DE, Samonis G, and Falagas ME. Clinical significance of the 
pharmacokinetic and pharmacodynamic characteristics of fosfomycin for the treatment of patients with 
systemic infections. J Antimicrob Agents 2009;34:506–515.  
Waiwarawooth J. Combination Treatment of Piperacillin/Tazobactam, Amikacin and Fosfomycin for 
Probable Multidrug- Resistant Pseudomonas aeruginosa Infection: A Case Report. J Infect Dis 
Antimicrob Agents 2004;21:89-91. 
VanScoy BD, McCauley J, Ellis-Grosse EJ, Okusanya OO, Bhavnani SM, Forrest A, Amborse PG.  
Exploration of the pharmacokinetic-pharmacodynamic relationships for fosfomycin efficacy using an in 
vitro infection model.  Antimicrob Agents Chemother 2015;59:7170–7. 
VanScoy BD, McCauley J, Bhavnani SM, Ellis-Grosse EJ, Amborse PG.  Relationship between 
fosfomycin exposure and amplification of Escherichia coli subpopulations with reduced susceptibility in 
a hollow-fiber infection model.  Antimicrob Agents Chemother 2016;60:5141–5. 
Wenzler E, Ellis-Grosse EJ, Rodvold KA. Pharmacokinetics, safety, and tolerability of single-dose 
intravenous (ZTI-01) and oral fosfomycin in healthy volunteers. Antimicrob Agents Chemother 
2017;61:e00775-17. 
 

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18. 
SUPPLEMENTS/APPENDICES 
APPENDIX A: SCHEDULE OF STUDY PROCEDURES AND 
EVALUATIONS 
Table 9: Schedule of study procedures and evaluations 
 
 
Activities 
Screening 
Visit 
Baseline  
Visit 
Treatment 
Phase 
Discharge 
Visit 
Telephone 
Follow-Up 
Early Termination 
Unscheduled Visit 
Day  
-30 to -1 
Day  
-1 to 1 
Days  
1 to 2 
Day 2 
Day 3 
Informed Consent 
X 
 
 
 
 
 
 
Review Eligibility Criteria 
X 
X 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
Admission to DEPRU 
 
X 
 
 
 
 
 
Medical History 
X 
Xa 
 
 
 
 
 
Counsel on Birth Control 
X 
 
 
X 
 
X 
 
Counsel on non-prescription 
medications 
X 
 
 
 
 
 
 
Prior/Concomitant Medication 
Review 
X 
X 
X 
X 
X 
X 
X 
Collect and Record AEs/SAEsb 
 
 
X 
X 
X 
X 
X 
Height / BMI 
X 
 
 
 
 
X 
 
Vital Signsc 
X 
X 
X 
X 
 
X 
X 
Physical Exam (including weight) 
X 
X 
 
X 
 
X 
Xd 

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Alcohol and Tobacco Historye 
X 
 
 
 
 
 
 
ECG (12-lead)f 
X 
X 
X 
 
 
 
X 
HIV Antibody, Hepatitis B Ag, 
Hepatitis C Antibody  
X 
 
 
 
 
 
 
Hem-Coag-UAg 
X 
 
X 
X 
 
X 
 
Chemistryg 
X 
X 
X 
X 
 
X 
 
Lipids, LDHg 
X 
 
X 
X 
 
X 
 
Pregnancy Testsh 
X 
X 
 
 
 
 
 
Urine & Breath Tox Screensi  
X 
X 
 
 
 
 
 
SARS-CoV- 2 (COVID-19) Testj  
X 
X 
 
 
 
 
 
Place Two Peripheral IVs 
 
X 
 
 
 
 
 
Study Drug Administrationk 
 
 
X 
 
 
 
 
Blood for Urea Assayl 
 
 
X 
 
 
 
 
Blood PK Samplesm 
 
 
X 
 
 
 
 
Bronchoscopy and BALn 
 
 
X 
 
 
 
 
Discharge from DEPRU 
 
 
 
X 
 
 
 
a Update medical history as appropriate since screening including non-pharmacologic 
treatments/procedures within 72 hours before enrollment in the eCRF 
b Collect and record AEs and SAEs from the time the start of treatment (Day 1) through Day 3. 
c Vital signs (heart rate, blood pressure, temperature, respiratory rate, and peripheral oxygen saturation), 
measured with subject in the supine or semi-recumbent position, will be obtained at the following 
timepoints: Screening, Baseline (Day -1), immediately prior (within 10 minutes) to each of three doses of 
Study Drug, at approximately 0.5, 1, 2, and 5 hours (each ± 10 minutes) as after the start of infusion for 
each dose, and before discharge from DEPRU. If vital signs are abnormal, repeated readings will be 
obtained up to twice more, 5 to 10 minutes apart. If they remain abnormal, unscheduled vital signs will be 
repeatedly obtained until they normalize (at investigator’s discretion). Since changes in vital signs are 
expected during bronchoscopy, when a vital sign timepoint is scheduled during a subject’s bronchoscopy, 
that time point will be measured immediately before the start of bronchoscopy. 
d At unscheduled visits, weight may be performed as part of the physical exam but is not required  

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e Alcohol history within past 6 months, lifetime tobacco history 
f ECGs will be performed in the supine or semi-recumbent position (after rest for at least 10 min) at 3 
timepoints: at Screening, Day 1 (before first dose of Study Drug), and within 1-2 hours of the last dose 
(3rd dose) of study drug. In case of premature discontinuation of study drug, ECG is to be performed 
before discharge. 
g  At Screening, and before discharge (Day 2), obtain hematology labs (white blood cell count, 
hemoglobin, hematocrit, and platelet count, neutrophils, lymphocytes, monocytes, eosinophils, 
basophils); coagulation tests (aPTT and PT), chemistry labs (albumin, glucose, blood urea nitrogen 
(BUN), potassium, magnesium, calcium, sodium, phosphorus, total protein, creatinine, triglycerides, 
total cholesterol, CPK, phosphorus, AST, ALT, total bilirubin, direct bilirubin, ALP, LDH), and 
urinalysis (leukocyte esterase, blood, glucose, protein, pH, and specific gravity via dipstick with 
addition of urine microscopy if dipstick abnormal). At Baseline (Day -1 to Day 1) obtain albumin, 
glucose, BUN, potassium, magnesium, calcium, sodium, phosphorus, total protein, creatinine, CPK, 
AST, ALT, total bilirubin, and ALP. Approximately two hours prior to bronchoscopy (Day 2) obtain 
sodium, potassium, magnesium, calcium, and phosphorus. 
h  Serum pregnancy test for women of childbearing potential at screening, and urine pregnancy test for 
women of childbearing potential at Baseline (Day -1 to Day 1) 
i  Alcohol Breathalyzer test, Urine cotinine, and Urine drug screen at Screening and Baseline (Day -1 to 
Day 1/admission to DEPRU). Cotinine will be reported qualitatively as positive/negative. Urine drug 
screen will consist of: barbiturates, benzodiazepines, THC, cocaine, opiates, and 
amphetamine/methamphetamine.  
j.   Test for SARS-CoV-2 (COVID-19) at Screening or Baseline (Day -1 to Day 1) within 72 hours of 
admission 
k Subjects will receive a total of three doses of ZTI-01 (fosfomycin disodium) 6g, administered every 8 
hours, as 1-hour intravenous infusion (+10 minute window) 
l Blood sample to determine plasma urea concentration will be obtained just before or during the 
scheduled bronchoscopy 
m  PK blood samples will be collected at 15 timepoints: before (within 10 minutes) the first, second, and 
third doses of study drug, at 30 minutes (during infusion), 1 hour (within 5 minutes after the end of 
infusion), 1 hour 15 minutes, 2, and 5 hours from the start time of the first dose of ZTI-01, and at 30 
minutes (during infusion), 1 hour (within 5 minutes after the end of infusion), 1 hour 15 minutes, 2, 5, 
8, and 12 hours from the start time of the third (last) infusion of ZTI-01. Blood PK samples will be 
drawn for all subjects within the following windows: -1 to -10 minutes for scheduled samples at pre-
dose; +/- 5 minutes for scheduled samples at 30 minutes, 1 hour 15 minutes, and 2 hours; +0-5 minutes 

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after end of infusion for the scheduled sample at 1 hour; +/- 15 minutes for scheduled samples at 5, 8, 
and 12 hours. Actual times for dosing and sample will be recorded. 
n Bronchoscopy with BAL at 30 minutes (during the 1-hr infusion), 1 hr 15 minutes, 2, 5, or 8 hours from 
T0 (defined as the start time of the last [third] infusion of ZTI-01). BAL PK samples will be obtained 
within +/- 15 minutes of scheduled timepoint. Actual times for dosing and sample will be recorded.  
APPENDIX B: ADVERSE EVENT TOXICITY GRADING SCALE 
ABBREVIATIONS:  Abbreviations utilized in the Table: 
 
ULN = Upper Limit of Normal              
LLN = Lower Limit of Normal 
Rx = Therapy                                       
Req = Required 
Mod = Moderate                                  
IV = Intravenous 
ADL = Activities of Daily Living            
Dec = Decreased 
 
ESTIMATING SEVERITY GRADE 
 
For abnormalities NOT found elsewhere in the Toxicity Tables use the scale below to estimate grade of 
severity: 
 
GRADE 1 
Mild 
Events require minimal or no treatment and do not interfere with the 
subject’s daily activities.  
GRADE 2 
Moderate 
Events result in a low level of inconvenience or concern with the 
therapeutic measures.  Moderate events may cause some interference 
with functioning.  
GRADE 3 
Severe 
Events interrupt a subject’s usual daily activity and may require 
systemic drug therapy or other treatment.  Severe events are usually 
incapacitating.  
 
SERIOUS OR LIFE-THREATENING AEs 

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ANY clinical event that meets the SAE criteria, is considered a grade 3 event. (examples of clinical 
events considered to be life-threatening include, but are not limited to:  seizures, coma, tetany, diabetic 
ketoacidosis, disseminated intravascular coagulation, diffuse petechiae, paralysis, acute psychosis, severe 
depression). 
COMMENTS REGARDING THE USE OF THESE TABLES 
• 
Standardized and commonly used toxicity tables (Division of AIDS, National Cancer Institute 
[NCI] Common Toxicity Criteria [CTC], and World Health Organization [WHO]) have been 
adapted for use by the Division of Microbiology and Infectious Diseases (DMID) and modified to 
better meet the needs of participants in DMID trials. 
• 
For parameters not included in the following Toxicity Tables, DEPRU should refer to the “Guide 
for Estimating Severity Grade” located above. 
• 
Criteria are generally grouped by body system. 
• 
Some protocols may have additional protocol specific grading criteria, which will supersede the 
use of these tables for specified criteria. 
 
Table 10: Clinical adverse event definition and grading scale 
Clinical Adverse Events 
 
 
 
 
VITAL SIGNS  
Mild 
(Grade 1) 
Moderate  
(Grade 2) 
Severe 
(Grade 3) 
Fever (°C) * 
38.0 – 38.4 
38.5 – 38.9 
≥39.0 
* Oral 
temperature; no 
recent hot or 
cold beverages 
or smoking.   
             (°F) * 
100.4 – 101.1 
101.2 – 102.0 
≥102.1  
Tachycardia - beats per 
minute 
101 – 115 and 
>25% change 
from baseline 
116 – 130 and 
>25% change 
from baseline 
> 130 or 
ventricular 
dysrhythmias and 
>25% change 
from baseline 

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Bradycardia - beats per 
minute  
50 – 54  or 45 - 
49 bpm if 
baseline <60 bpm 
- Subject is 
asymptomatic; no 
treatment 
required 
45 – 49 or 40 -
44 if baseline 
<60 bpm -  
 Subject is 
asymptomatic; 
no treatment 
required; Site 
PI/sub-
investigator may 
confirm with 
ECG or 12-lead 
Holter monitors 
to rule out 
arrhythmia or 
advanced heart 
block. 
< 45 or  <40 bpm 
if baseline <60  
bpm - Subject is 
symptomatic 
and/or requires 
treatment; Site 
PI/sub-
investigator 
should confirm 
with ECG or 12-
lead Holter 
monitors to rule 
out arrhythmia or 
advanced heart 
block 
 
 Hypertension (systolic)- mm 
Hg 
141-150 
151-160 
> 160 
Assuming 
supine position, 
10 min at rest 
conditions, not 
sleeping 
subjects 
measurements 
on the same arm 
and several 
concordant 
results.  
Hypertension (diastolic) - mm 
Hg 
91-95 
96-100 
> 100 
Hypotension (systolic) - mm 
Hg 
85-89 
80-84 
< 80 
 
Tachypnea – breaths per 
minute 
 
 
 
23-25 
26-30 
>30 
CARDIOVASCULAR 
 Grade 1  
 Grade 2  
 Grade 3  

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Hemorrhage, Blood Loss  
Estimated blood 
loss < 100 mL  
Estimated blood 
loss > 100 mL, 
no transfusion  
required 
Transfusion 
required  
QTc interval (prolonged) 
QTc 450-480 
msec 
 
QTc 481-500 
msec 
 
QTc >500 msec 
 
 
PR Interval (prolonged) 
PR 200-250 msec 
and >25% change 
from baseline 
PR >250 msec 
and >25% 
change from 
baseline 
AV block 2nd 
degree Type II or 
higher OR 
ventricular pause 
>3 sec 
 
QRS Interval (prolonged) 
QRS 120-150 
msec and >25% 
change from 
baseline 
QRS 150-180 
msec and >25% 
change from 
baseline 
New bundle 
branch block 
 
RESPIRATORY    
 Grade 1  
 Grade 2  
 Grade 3  
Cough  
Transient- no 
treatment  
Persistent cough;  Interferes with 
daily activities 
Bronchospasm, Acute 
Transient; no 
treatment; 71% - 
80% FEV1 of 
peak flow  
Requires 
treatment; 
normalizes with 
bronchodilator; 
FEV1 60% - 
70% (of peak 
flow)  
No normalization 
with 
bronchodilator; 
FEV1 <60% of 
peak flow 
Dyspnea   
Does not 
interfere with 
usual and social 
activities 
Interferes with 
usual and social 
activities, no 
treatment 
Prevents daily 
and usual social 
activity or 
requires 
treatment 
GASTROINTESTINAL   
 Grade 1  
 Grade 2  
 Grade 3  
Nausea  
No interference 
with activity 
Some 
interference with 
activity 
Prevents daily 
activities 

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Vomiting  
No interference 
with activity or 1 
- 2 episodes/24 
hours 
Some 
interference with 
activity or > 2 
episodes/24 
hours 
Prevents daily 
activity or 
requires IV 
hydration 
Diarrhea  
2 - 3 loose or 
watery stools or 
< 400 gm/24 
hours 
4 - 5 loose or 
watery stools or 
400 - 800 gm/24 
hours 
6 or more loose 
or watery stools 
or > 800gms/24 
hours or requires 
IV hydration 
REACTOGENICITY 
  
  
LOCAL REACTIONS 
 Grade 1  
 Grade 2  
 Grade 3  
Pain 
Does not 
interfere with 
activity 
Repeated use of 
non-narcotic 
pain reliever > 
24 hours or 
interferes with 
activity 
Any use of 
narcotic pain 
reliever or 
prevents daily 
activity 
Tenderness 
 Discomfort only 
to touch 
Discomfort with 
movement 
Significant 
discomfort at rest 
 
Erythema/Redness ** 
2.5 - 5 cm 
5.1 - 10 cm 
> 10 cm 
** In addition to 
grading the 
measured local 
reaction at the 
greatest single 
diameter, the 
measurement 
should be 
recorded as a 
continuous 
variable. 
Induration/Swelling *** 
2.5 - 5 cm and 
does not interfere 
with activity 
5.1 - 10 cm or 
interferes with 
activity 
> 10 cm or 
prevents daily 
activity 
***Induration/S
welling should 
be evaluated and 
graded using the 
functional scale 
as well as the 

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actual 
measurement 
SYSTEMIC  
Grade 1  
 Grade 2  
Grade 3  
 
Allergic Reaction  
 pruritus without 
rash  
 localized 
urticaria  
 generalized 
urticaria; 
angioedema or 
anaphylaxis  
 
Headache  
No interference 
with activity 
Repeated use of 
non-narcotic 
pain reliever > 
24 hours or 
some 
interference with 
activity 
Significant; any 
use of narcotic 
pain reliever or 
prevents daily 
activity 
Fatigue  
No interference 
with activity 
Some 
interference with 
activity 
Significant; 
prevents daily 
activity 
Myalgia 
No interference 
with activity 
Some 
interference with 
activity 
Significant; 
prevents daily 
activity 
ALL OTHER CONDITIONS 
Grade 1 
Grade 2 
Grade 3 
Illness or clinical adverse 
event (as defined according to 
applicable regulations) 
No interference 
with activity 
Some 
interference with 
activity not 
requiring 
medical 
intervention 
Prevents daily 
activity and 
requires medical 
intervention 
 
 
 

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Table 11: Laboratory adverse event definition and grading scale 
LABORATORY ADVERSE EVENTS 
  
  
  
BLOOD, SERUM, PLASMA  
Mild  
(Grade 1) 
Moderate 
(Grade 2) 
Severe  
(Grade 3) 
Sodium – Hyponatremia mEq/L 
132 – <LLN 
130 – <132 
<130 
Sodium – Hypernatremia mEq/L 
>ULN – 148 
>148 – 150  
>150 
Potassium – Hyperkalemia mEq/L 
>ULN – 5.2 
>5.2 - 5.4 
>5.4 
Potassium – Hypokalemia mEq/L 
3.1-<LLN 
3.0-<3.1 
<3.0 
Glucose – Hypoglycemia mg/dL 
65 - 69 
55 - <65 
<55 
Glucose – Hyperglycemia  
Fasting – mg/dL 
>ULN - 120 
>120 - 130 
>130 
Glucose – Hyperglycemia  
Random – mg/dL 
141 - 159 
>159 – 200 
>200 
Blood Urea Nitrogen mg/dL 
21-26 
>26 – 31 
> 31 
Creatinine – mg/dL 
>ULN – 1.7 
>1.7 – 2.0 
>2.0 
Calcium – hypocalcemia mg/dL 
8.0 – <LLN 
7.5 – <8.0 
<7.5 
Calcium – hypercalcemia mg/dL 
>ULN – 11.0 
>11.0 – 11.5 
>11.5 
Magnesium – hypomagnesemia mg/dL 
1.3 – 1.7 
1.1 – <1.3 
<1.1 
Phosphorous – hypophosphatemia 
mg/dL 
2.1 – 2.2 
1.9 – <2.1 
<1.9 
CPK – mg/dL 
221-1000 
>1000-1500 
>1500 
Albumin – Hypoalbuminemia g/dL 
2.8 – 3.4 
2.5 – <2.8 
< 2.5 
Total Protein – Hypoproteinemia g/dL 
5.2 – <LLN 
5.0 – <5.2 
< 5.0 
Alkaline phosphatase (ALP) – U/L 
111 - 240 
>240– 360 
>360 
AST U/L 
42 – 105 
>105-175 
>175 
ALT U/L (Female) 
>ULN - 105 
>105-175 
>175 
ALT U/L (Male) 
>ULN – 105 
>105-175 
>175 
Bilirubin (serum total) - mg/dL 
1.6 - 2.5 
>2.5 - 3.0 
> 3.0  
Direct bilirubin – mg/dL 
0.7-2.0 
>2.0-3.5 
>3.5 
Total cholesterol – mg/dL 
301 – 400 
>400-500 
>500 
Triglycerides – mg/dL 
>500 – 750 
>750 – 1000 
>1000 
Lactate dehydrogenase – U/L  
>200-500 
>500-800 
>800 
Hemoglobin (Female) - g/dL 
11.0 – 11.9 
9.5 – <11.0 
< 9.5  

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Hemoglobin (Male) - g/dL 
12.0 – 13.6 
10.0 – <12.0 
<10.0 
WBC Increase - cell/mm3 
9900 – 15,000 
>15,000 – 20,000 
> 20,000 
WBC Decrease - cell/mm3 
2,500 – 3100 
1,500 – <2,500 
< 1500 
Lymphocytes Decrease - cell/mm3 
500 – <600 
400 – <500 
< 400 
Neutrophils Decrease - cell/mm3 
1,500 - < 2000 
1000 - <1500 
< 1000 
Eosinophils - cell/mm3 
> 700 - 750 
>750 - 1500 
> 1500 
Platelets Decreased - cell/mm3 
120,000 – < 149,000 
100,000 – <120,000 
<100,000 
PT – seconds (prothrombin time) 
> ULN – 14.4 
>14.4 – 15.7 
> 15.7 
aPTT – seconds (activated partial 
thromboplastin time) 
> ULN – 42.1 
>42.1 – 50.0 
> 50.0 
URINE  
Mild 
(Grade 1) 
Moderate  
(Grade 2) 
Severe 
(Grade 3) 
Protein 
1+ 
2+ 
>2+ 
Glucose 
1+ 
2+ 
>2+ 
Blood (microscopic) - red blood cells per 
high power field (rbc/hpf) 
5-10* 
>10-50*  
> 50 and/or 
gross 
blood* 
* Isolated presence of blood in urinalysis is acceptable for menstruating females. 
 
 

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APPENDIX C: VENIPUNCTURE SCHEDULE AND VOLUMES 
Table 12: Venipuncture schedule and volumes 
 
Scheduled Laboratory 
Assessments 
Study Days 
Blood 
Volume 
per 
Sample 
(mL) 
Total 
Number of 
Samples 
Total 
Blood 
Volume 
(mL) 
Screening 
(Day -30 to 
Day -1) 
 
Baseline 
(Day -1 to 
Day 1) 
Treatment 
and 
Discharge 
(Days 1-2) 
 
 
 
Chemistry 
X 
X 
X 
9 
3 
27 
Electrolytes (only) 
 
 
X 
4.5 
1 
4.5 
Hematology 
X 
 
X 
4 
2 
8 
Coagulation 
X 
 
X 
2.7 
2 
5.4 
Serum Pregnancy   
X 
 
 
5 
1 
5 
Serologya 
X 
 
 
8.5 
1 
8.5 
Urea Blood Sample 
 
 
X 
4 
1 
4 
PK Blood Samples 
 
 
X 
4 
15 
60 
Total blood volume 
(mL)b 
29.2 
9 
84.2 
 
 
122.4 
 
a Serology is for testing of HIV antibody, Hepatitis B antigen, Hepatitis C antibody. 
b  The total blood volume of 122.4 ml will be collected from each subject; blood volume per study phase is 
reflected at the bottom of each column.