Clinical trial NCT04233424
Conditions: Surgical Site Infection Colon Surgery Abdominal Surgery Post-Op Infection
Keywords: Surgical site infection Abdominal surgery Colon and small bowl surgery
Sponsor: PolyPid Ltd.
Start date: 2020-06-24; Completion date: 2022-09-02
Enrollment: 977 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Phase III, Prospective, Multinational, Multicenter, Randomized, Controlled, Two-arm, Double Blind Study to assess Efficacy and Safety of D-PLEX Administered Concomitantly with the Standard of Care (SoC), compared to a SoC treated control arm, in prevention of post abdominal surgery incisional infection.

Detailed description:
D-PLEX is a new formulation of extended controlled release of Doxycycline in the applied area for about 30 days. This study is aimed to assess the safety and efficacy of D-PLEX in prevention of post abdominal surgery incisional infection.

The study population includes male and female, 18 years old and above at screening, undergoing an elective colorectal surgery involving resection, with or without a stoma, that includes at least 1 incision that is \> 10 cm (target incision). Eligible and willing subjects will be randomly allocated into 2 blinded study arms D-PLEX with SOC or SOC alone.

D-PLEX will be applied during the surgery at the final stage of incision closure. All patients will be followed up for additional 5 visits over 2 months, for safety and incisional wound assessment. This will include blood tests for hematology and chemistry well as physicians assessment of the incisional wound.

The final number of subjects will be determined following a comparative interim analysis for an early efficacy or futility stop or unblinded sample size re-estimation: when about 750 subjects will complete their 30 days (1 month) follow-up and evaluated for primary endpoint

Arms: arm 1: D-PLEX is provided to suitable and willing study subjects as an adjunct to the SoC treatment arm 2: The SoC for prophylactic antibiotic treatment is based on international guidelines
Interventions: intervention 1: D-PLEX intervention 2: Standard of Care (SoC)
Intervention descriptions: intervention 1: D-PLEX is a new formulation of extended release of Doxycycline. Each 5g D-PLEX vial contains 54.6mg Doxycycline free base (1.09%), which is equivalent to 63mg Doxycycline hyclate (1.26%). D-PLEX is supplied as a sterile powder to be reconstituted to paste in the operating room, using standard aseptic techniques and is intended for single administration. The non-active components of the extended release antibiotic formulation are β Tri-Calcium polymer and a lipid matrix. All formulation components are biodegradable. intervention 2: prophylactic, pre-operation per institution guidelines

Protocol documents:
Prot_000.pdf: 




D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
CONFIDENTIAL 
INVESTIGATOR SIGNATURE 
Protocol #: 
Study D‐PLEX 311 
Protocol Title: 
Phase III, Prospective, Multinational, 
Multicenter, Randomized, Controlled, Two‐arm, 
Double Blind Study to Assess Efficacy and Safety 
of D‐PLEX Administered Concomitantly with the 
Standard of Care (SoC), Compared to a SoC 
Treated Control Arm, in Prevention of Post 
Abdominal Surgery Incisional Infection 
Protocol Version: 
06 
EudraCT Number: 
2020‐002325‐28 
IND Number: 
131060 
I have read and understood this clinical trial protocol and appendices and I agree to adhere 
to the requirements. I will provide copies of this clinical trial protocol and all pertinent 
information to the trial personnel under my supervision. I will discuss this material with 
them and ensure they are fully informed regarding the Investigational Product and the 
conduct of the trial. 
I will conduct the trial in accordance with the clinical trial protocol, ICH GCP guidelines, as 
well as local regulations. I also accept respective revisions to the clinical trial protocol 
approved by authorized personnel of the Sponsor and by regulatory authorities. 
This document contains proprietary and confidential information of PolyPid. Do not copy, 
distribute, or share with others without prior written authorization from PolyPid 
Principal Investigator (print name) 
Principal Investigator (signature) 
Date 
D-PLEX 311 Clinical Trial Protocol
P-000066
Protocols
Version 6.0
22-2-2022
Page 3 of 99
Effective






 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
1 TABLE OF CONTENTS 
1 
TABLE OF CONTENTS ....................................................................................................... 6 
2 
LIST OF ABBREVIATIONS ................................................................................................ 11 
3 
TRIAL PERSONNEL ......................................................................................................... 13 
3.1 
Sponsors Representatives ...................................................................................... 13 
4 
SUMMARY ..................................................................................................................... 14 
5 
INTRODUCTION ............................................................................................................. 27 
5.1 
BACKGROUND ........................................................................................................ 27 
5.1.1 
Background Information on The Product ........................................................ 27 
5.1.2 
Unmet Medical Need for Prevention of Post Abdominal Surgery Incisional 
Infection ........................................................................................................................ 29 
5.1.3 
Justification for the Use of D‐PLEX for Prevention of Post Abdominal Surgery 
Incisional Infection ........................................................................................................ 29 
5.2 
NON‐CLINICAL DATA ............................................................................................... 30 
5.3 
CLINICAL DATA ........................................................................................................ 32 
5.4 
SAFETY PROFILE OF DOXYCYCLINE .......................................................................... 33 
5.5 
POTENTIAL BENEFITS OF D‐PLEX FOR PREVENTION OF POST ABDOMINAL SURGERY 
INCISIONAL INFECTION ..................................................................................................... 34 
5.6 
POTENTIAL RISKS OF D‐PLEX FOR PREVENTION OF POST ABDOMINAL SURGERY 
INCISIONAL INFECTIONS AND THEIR MITIGATIONS ........................................................... 34 
5.7 
SAFETY & EFFICACY SUMMARY .............................................................................. 37 
6 
OBJECTIVES ................................................................................................................... 37 
7 
STUDY ENDPOINTS ........................................................................................................ 37 
7.1 
PRIMARY EFFICACY ENDPOINT ............................................................................... 37 
7.2 
SECONDARY EFFICACY ENDPOINTS ......................................................................... 38 
7.2.1 
Key endpoints: ................................................................................................. 38 
7.2.2 
Additional endpoints: ...................................................................................... 38 
7.3 
SAFETY EVALUATION .............................................................................................. 39 
8 
TRIAL DESIGN ................................................................................................................ 39 
8.1 
OVERALL DESIGN .................................................................................................... 39 
8.2 
DESCRIPTION & JUSTIFICATION OF THE DURATION OF TREATMENT, SUBJECT 
PARTICIPATION AND TRIAL FOLLOW‐UP ........................................................................... 40 
 
 
 
22-2-2022
Page 6 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
8.3 
SELECTION OF SUBJECTS ......................................................................................... 41 
8.4 
INCLUSION CRITERIA ............................................................................................... 41 
8.5 
EXCLUSION CRITERIA .............................................................................................. 41 
8.6 
Contraceptive methods .......................................................................................... 43 
8.7 
RECRUITMENT ........................................................................................................ 44 
9 
STUDY PROCEDURES & SCHEDULE OF ASSESSMENTS ................................................... 44 
9.1 
STUDY PROCEDURES ............................................................................................... 44 
9.1.1 
Informed Consent Procedure .......................................................................... 44 
9.1.2 
Screen Failure .................................................................................................. 45 
9.1.3 
Randomization / Enrolment ............................................................................ 45 
9.1.4 
Blinding ............................................................................................................ 45 
9.1.5 
Emergency Unblinding .................................................................................... 46 
9.1.6 
Assessment of the Infection Rate .................................................................... 47 
9.1.7 
Management of Suspected SSI ........................................................................ 49 
9.1.8 
Safety Evaluation ............................................................................................. 49 
9.1.9 
Adverse Events ................................................................................................ 50 
9.1.10  Laboratory Examinations ................................................................................. 50 
9.1.11  Central Laboratory ........................................................................................... 50 
9.1.12  Local Laboratory .............................................................................................. 52 
9.1.13  Bacteriological Testing ‐ (Should be Taken in Any Case of Suspected Infection 
Before Starting Antibiotic Treatment) ........................................................................... 52 
9.1.14  Physical Examination ....................................................................................... 53 
9.1.15  Vital Signs ........................................................................................................ 53 
9.1.16  Medical History ............................................................................................... 53 
9.1.17  Allergy Questionnaire ...................................................................................... 53 
9.1.18  Assessment of Surgical Site ............................................................................. 53 
9.1.19  ASEPSIS: (Additional Treatment, Serous Discharge, Erythema, Purulent 
Exudate, Separation of Deep Tissue, Isolation of Bacteria, Stay Duration as Inpatient) 
Scoring Method ............................................................................................................. 54 
9.1.20  Pharmacokinetics ............................................................................................ 54 
9.2 
STUDY VISITS & ASSESSMENTS ............................................................................... 55 
9.2.1 
Visit 1: Screening Period (Day ‐21  Day 0) ...................................................... 55 
 
 
 
22-2-2022
Page 7 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
9.2.2 
Visit 2: Surgery  Index Procedure (Day 0) ...................................................... 56 
9.2.3 
Visits 3  6: Follow‐Up Visits (Days 1, 5 ,14 & 30 Post‐Surgery) ....................... 57 
9.2.4 
Unscheduled Visit(s) ........................................................................................ 58 
9.2.5 
Visit 7 ‐ End of Study (60 Days Post‐Surgery) ................................................... 58 
9.2.6 
Study Assessments Summary .......................................................................... 58 
TABLE 1: STUDY ASSESSMENTS ......................................................................................... 59 
9.3 
EFINITION OF END OF TRIAL ................................................................................... 60 
9.4 
DISCONTINUATION/WITHDRAWAL OF PARTICIPANTS & STOPPING RULES .......... 60 
10  NAME & DESCRIPTION OF ALL DRUGS USED IN THE TRIAL ........................................... 61 
10.1 
STUDY TREATMENT D‐PLEX ................................................................................. 61 
10.1.1  Product Description ......................................................................................... 61 
10.1.2  Product Composition ....................................................................................... 61 
10.1.3  Product Handling (storage & preparation) ...................................................... 61 
10.1.4  Product Usage and Dosage .............................................................................. 63 
10.1.5  Contra‐Indications ........................................................................................... 64 
10.1.6  Use in Specific Populations .............................................................................. 64 
10.1.7  Warnings and Precautions ............................................................................... 64 
10.1.8  Overdose: Guidance on the recognition and treatment of possible overdose 
and adverse drug reactions ........................................................................................... 64 
10.1.9  Packaging ......................................................................................................... 65 
10.2 
CONCOMITANT MEDICATION ............................................................................. 65 
10.2.1  Medication(s)/ Treatment(s) Permitted .......................................................... 65 
10.2.2  Medication(s) Prohibited During the Trial ....................................................... 65 
10.3 
PREPARATION & LABELLING OF INVESTIGATIONAL PRODUCT (IP) ..................... 65 
10.4 
DRUG ACCOUNTABILITY ...................................................................................... 66 
10.5 
RECORDING & REPORTING OF ADVERSE EVENTS & REACTIONS ......................... 66 
10.6 
DEFINITIONS ........................................................................................................ 66 
10.6.1  Adverse Event (AE) .......................................................................................... 66 
10.6.2  Adverse Drug Reaction (ADR) .......................................................................... 67 
10.6.3  Serious Adverse Event (SAE) ............................................................................ 67 
10.6.4  Unexpected Serious Adverse Reaction ............................................................ 68 
 
 
 
22-2-2022
Page 8 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
10.7 
A serious adverse reaction, the nature, severity or outcome of which is not 
consistent with the reference safety information (i.e. Investigator Brochure (IB)) in effect 
at the time of its occurrence.  ASSESSMENT OF ADVERSE EVENT ..................................... 68 
10.7.1  Severity ............................................................................................................ 68 
10.7.2  Causality .......................................................................................................... 69 
10.7.3  Outcome .......................................................................................................... 69 
10.7.4  Expectedness ................................................................................................... 69 
10.7.5  Seriousness ...................................................................................................... 70 
10.8 
DOCUMENTATION AND REPORTING OF SAE and SSI .......................................... 70 
10.9 
TIME PERIOD AND FREQUENCY FOR reporting AEs ............................................. 70 
10.9.1  Procedures for Recording & Reporting Serious Adverse Events ...................... 71 
10.9.2  Notification of Deaths ..................................................................................... 71 
10.10 
REPORTING OF SUSARs (Suspected Unexpected Serious Adverse Reaction) ...... 71 
10.11 
DEVELOPMENT OF SAFETY UPDATE REPORTS .................................................... 72 
10.12 
THE TYPE & DURATION OF THE FOLLOW‐UP OF SUBJECTS AFTER AEs ............... 72 
11  NOTIFICATION OF PROTOCOL DEVIATION .................................................................... 72 
12  DATA MANAGEMENT & QUALITY ASSURANCE ............................................................. 72 
12.1 
CONFIDENTIALITY................................................................................................ 72 
12.2 
DATA COLLECTION TOOLS & SOURCE DOCUMENT IDENTIFICATION .................. 72 
12.3 
DATA HANDLING & ANALYSIS ............................................................................. 73 
13  RECORD KEEPING & ARCHIVING.................................................................................... 73 
The investigator shall arrange for the retention of all study records for at least 15 years 
after completion of the study. .......................................................................................... 73 
14  STATISTICAL ANALYSIS CONSIDERATIONS ..................................................................... 74 
14.1 
SAMPLE SIZE AND POWER .................................................................................. 74 
14.1.1  Blinded sample size re‐estimation‐ .................................................................. 74 
14.2 
ANALYSIS POPULATIONS ..................................................................................... 75 
14.2.1  Intention to Treat (ITT) Set .............................................................................. 75 
14.2.2  Safety Analysis Set ........................................................................................... 75 
14.2.3  Modified Intention to Treat (mITT) Set ............................................................ 75 
14.2.4  Per Protocol (PP) Set ....................................................................................... 75 
14.3 
STATISTICAL AND ANALYTICAL PLANS ................................................................. 76 
 
 
 
22-2-2022
Page 9 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
14.3.1  Analysis of Demographics and Baseline Subject Characteristics ...................... 76 
14.3.2  Primary Endpoint Analysis ............................................................................... 76 
14.3.3  Secondary Efficacy Endpoint Analysis .............................................................. 77 
14.3.4  Type 1 error control ......................................................................................... 78 
14.3.5  Subgroup analysis ............................................................................................ 79 
14.3.6  Safety Evaluations ........................................................................................... 79 
14.3.7  Handling of Missing Data ................................................................................. 79 
14.3.8  Interim Analyses .............................................................................................. 80 
14.4 
NAME OF COMMITTEES INVOLVED IN TRIAL ...................................................... 80 
14.4.1  DATA MONITORING COMMITTE (DMC) .......................................................... 80 
14.4.2  ENDPOINTS ADJUDICATION COMMITTEE (EPAC) ............................................ 81 
15  DIRECT ACCESS TO SOURCE DATA DOCUMENTS ........................................................... 81 
16  ETHICS & REGULATORY REQUIREMENTS ...................................................................... 81 
17  QUALITY CONTROL (STUDY MONITORING) ................................................................... 82 
18  QUALITY ASSURANCE (QA) ............................................................................................ 82 
19  INSURANCE ................................................................................................................... 82 
20  PUBLICATION POLICY .................................................................................................... 82 
21  STATEMENT OF COMPLIANCE ....................................................................................... 83 
22  APPENDICES .................................................................................................................. 83 
23  REFERENCES .................................................................................................................. 84 
Appendix 1: ASEPSIS Score Assessment ............................................................................ 86 
Appendix 2: Modified Vancouver Scar Scale ..................................................................... 87 
Appendix 3: PK instructions for Collection and Processing ............................................... 88 
Appendix 4: SURGICAL SITE ASSESSMENT QUESTIONNAIRE ............................................. 89 
Appendix 5: Charlson co‐morbidity index (CCI) ................................................................. 91 
Appendix 6: DOCUMENT CHANGE HISTORY ...................................................................... 93 
 
 
 
 
 
 
22-2-2022
Page 10 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
2 LIST OF ABBREVIATIONS 
2.1 AE ‐ Adverse Event 
2.2 ASEPSIS ‐ Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation 
of deep tissue, Isolation of bacteria, Stay duration as inpatient 
2.3 ALT(SGPT) ‐ Alanine Aminotransferase 
2.4 AST(SGOT) ‐ Aspartate Transaminase 
2.5 AUC  Area Under Curve 
2.6 BMI ‐ Body Mass Index 
2.7 Β‐TCP ‐ β‐ Tri‐Calcium Phosphate 
2.8 BP  Blood Pressure 
2.9 CDC ‐ Center for Disease Control 
2.10 CDMS ‐ Clinical Data Management System 
2.11 CKD ‐ Chronic Kidney Disease 
2.12 CM ‐ Centimetres 
2.13 CRF ‐ Case Report Form 
2.14 ECRF ‐ Electronic Case Report Form 
2.15 CRP ‐ C‐Reactive Protein 
2.16 CVA ‐ Cerebro Vascular Accident 
2.17 DMC ‐ Data Monitoring Committee 
2.18 DSUR  Development Safety Update Report 
2.19 DSSI ‐ Deep Surgical Site Infection 
2.20 EA ‐ Enterobacter Aerogenes 
2.21 EC/IRB ‐ Ethics Committee/Independent Review Board 
2.22 ESRD ‐ End Stage Renal Disease 
2.23 EU ‐ European Union 
2.24 G ‐ Gram 
2.25 GCP ‐ Good Clinical Practice 
2.26 GMP ‐ Good Manufacturing Practice 
2.27 HR  Heart Rate 
2.28 IAP ‐ Interim Analysis Plan 
2.29 IB ‐ Investigators Brochure 
2.30 ICF ‐ Informed Consent Form 
2.31 ICH ‐ International Council for Harmonisation Of Technical Requirements For 
Pharmaceuticals For Human Use 
2.32 IP ‐ Investigational Product 
 
 
 
22-2-2022
Page 11 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
2.33 IPAL ‐ Investigational Product Accountability Log 
2.34 ISO ‐ International Organization for Standardization 
2.35 ITT ‐ Intention to Treat 
2.36 IV ‐ Intravenous 
2.37 IWRS ‐ Interactive Web Randomization System 
2.38 LDH ‐ Lactate Dehydrogenase 
2.39 MG ‐ Milligram 
2.40 MIC ‐ Minimal Inhibitory Concentration 
2.41 MITT ‐ Modified Intention To Treat 
2.42 MOH ‐ Ministry Of Health 
2.43 MRSA ‐ Methicillin‐Resistant Staphylococcus Aureus 
2.44 NHSN ‐ National Healthcare Safety Network 
2.45 NIS ‐ National Inpatient Sample 
2.46 OR ‐ Operation Room 
2.47 PI ‐ Principal Investigator 
2.48 PK ‐ Pharmacokinetics   
2.49 PLEX ‐ Polymer‐Lipid Encapsulation Matrix 
2.50 PP ‐ Per Protocol 
2.51 PT ‐ Preferred Term 
2.52 QA ‐ Quality Assurance 
2.53 QC ‐ Quality Control 
2.54 RBC ‐ Red Blood Cell 
2.55 SAP ‐ Statistical Analysis Plan 
2.56 SAR ‐ Serious Adverse Reaction 
2.57 SAE ‐ Serious Adverse Event 
2.58 SOC ‐ Standard of Care 
2.59 SOP ‐ Standard Operating Procedure 
2.60 SSI ‐ Surgical Site Infection 
2.61 SSSI ‐ Superficial Incisional Surgical Site Infection 
2.62 SUSAR ‐ Suspected Unexpected Serious Adverse Reaction 
2.63 TEAE ‐ Treatment Emergent Adverse Event 
2.64 TIA ‐ Transient Ischemic Attack 
2.65 WBC ‐ White Blood Cell 
2.66 WOCBP ‐ Women of Childbearing Potential 
 
 
 
 
22-2-2022
Page 12 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
3 TRIAL PERSONNEL 
3.1 
SPONSORS REPRESENTATIVES 
 
 
 
 
 
 PolyPid Ltd. 
 18 Hasivim Street,  
 Petach Tikva, 4959376 
 Israel    
 Tel: 
 
 
 
 
 
 
Clinical Development Manager 
PolyPid Ltd. 
18 Hasivim Street,  
Petach Tikva, 4959376 
Israel    
 
 
 
 
 
 
 
 
 
 
22-2-2022
Page 13 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
4 SUMMARY 
Study Number: 
Study D‐PLEX‐311 
Study Title: 
Phase III, Prospective, Multinational, Multicenter, Randomized, 
Controlled, Two‐arm, Double Blind Study to assess Efficacy and 
Safety of D‐PLEX Administered Concomitantly with the Standard 
of Care (SoC), compared to a SoC treated control arm, in 
prevention of post abdominal surgery incisional infection. 
Phase: 
Phase III 
Objectives: 
● To assess the anti‐infective efficacy of D‐PLEX administered 
concomitantly with the Standard of Care (SoC) over a period of 
30 days post operation, by preventing surgical site infection 
(SSI), defined as superficial and/or deep infection in the target 
incision, compared to the SoC treated control arm. 
● To assess the safety of D‐PLEX administered concomitantly with 
the Standard of Care (SoC). 
Number of Centers: 
About 
 sites in the US, EU and Israel 
Subject Population: 
Male and female, 18 years old and above at screening, 
undergoing an elective colorectal surgery, involving colon or 
rectal resection.  
The study will enrol participants who reflect the demographic 
for clinically relevant population with regards to: age, gender, 
race and ethnicity. This population reflects the US and Europe 
population undergoing abdominal colorectal surgeries. 
Number of Subjects: 
Minimum of 950 subjects will be enrolled and randomized into 
the study, with a maximum of 1400 subjects. 
The final number of subjects will be determined following a 
comparative interim analysis for an early efficacy or futility stop 
or unblinded sample size re‐estimation: when about 750 
subjects will complete their 30 days (1 month) follow‐up and 
evaluated for primary endpoint. 
 
 
 
22-2-2022
Page 14 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
Test Product: 
D‐PLEX is a new formulation of extended release of Doxycycline. 
Each 5g D‐PLEX vial contains 
 Doxycycline free base 
(
), which is equivalent to 
 Doxycycline hyclate 
). 
D‐PLEX is supplied as a sterile powder to be reconstituted to 
paste in the operating room using standard techniques. D‐PLEX 
is intended for single administration. 
The non‐active components of the extended release antibiotic 
formulation are 
 
 
All formulation components are biodegradable. 
Indication: 
D‐PLEX is indicated for prevention of post abdominal surgery 
incisional infection. 
Other Drugs Required for 
the Study: 
NA 
Standard of Care: 
The SoC for prophylactic antibiotic treatment is based on 
international guidelines3. It will be consistent and standardized 
for all sites in the clinical study and is composed of IV antibiotic 
prior to surgery, with or without mechanical bowel preparation 
in the preceding several days. Each site will use the same pre‐
defined SoC for all its subjects during the study.  
IV antibiotic treatment will be composed of the 1st or 2nd 
generation of Cephalosporin family plus Metronidazole given 
within 60 minutes prior to surgery and should be discontinued 
maximum 24‐hour post‐surgery. In case of allergy to the 
Cephalosporin/ Penicillin families or Metronidazole, other IV 
antibiotic may be used. Pre‐operation prophylactic oral 
antibiotic is not allowed.  Mechanical bowel preparation (use of 
a laxative (polyethylene glycol, sodium phosphate, or a 
magnesium citratebased regimen) or a high‐volume enema) 
will be at the discretion of the PI per each site's SOP.  Subjects 
will be stratified to 2 cohorts according to usage of mechanical 
bowel preparation prophylactic care (Yes or No) and by region 
(US or Europe + Israel).    
Dose Administration: 
D‐PLEX dose is individualized, pending length of the abdominal 
target incision, 2‐3 vials (5g each, a total max of 15g) in a single 
 
 
 
22-2-2022
Page 15 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
application. 
Application will be done at the time of initial closure of the 
abdominal wall target incision. Following closure of the fascia, 
D‐PLEX reconstituted paste will be applied on the fascia suture 
line, followed by soft tissues of the abdominal wall along the 
whole length of the surgical wound (including muscle, fat and 
dermis). D‐PLEX will not be applied on top of the skin (suture 
line). 
Duration of Dosing: 
D‐PLEX is administered as a single application. 
The active ingredient (Doxycycline) is continuously released for 
approximately 4 weeks. 
Study Design: 
 
This is a phase III, prospective, multinational, multicenter, 
randomized, controlled, two‐arm, double blind (participant and 
outcome assessor) study. The study population includes male 
and female, 18 years old and above at screening, undergoing an 
elective colorectal surgery involving resection, with or without a 
stoma formation, that includes at least 1 abdominal incision that 
is > 10 cm (target incision).  
Subjects who meet the inclusion criteria and none of the 
exclusion criteria and who provide a signed Informed Consent 
Form will be enrolled in the study. 
Subjects will be randomized into either the investigational arm 
(D‐PLEX + SoC) or to the control arm (SoC only) in a 1:1 ratio. 
Subjects will be stratified by type of SoC prophylactic antibiotic 
regimens (prophylactic IV antibiotic with mechanical bowel 
preparation or prophylactic IV antibiotic without mechanical 
bowel preparation) and by region (US or Europe + Israel). 
The sponsor, the outcome assessor, the subjects and all staff 
involved in the collection and recording of the clinical and 
laboratory data, based on which the independent adjudication 
committee will perform their assessment, will be blinded to the 
treatment assignment. The OR staff will be trained to maintain 
in confidence the treatment assignment and not to disclose it to 
other staff members. In addition, all aspects of data 
management and clean‐up will be done using blinded datasets. 
 
 
 
22-2-2022
Page 16 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
Subjects randomized to the investigational arm will be treated 
with D‐PLEX during the surgery (index procedure), as an adjunct 
to the SoC (see below). D‐PLEX will be applied during the closure 
of the abdominal target incision. D‐PLEX will not be re‐
administered if any reintervention occurs.  
Subjects randomized to the control arm will be treated only with 
prophylactic IV antibiotic according to SoC. Pre‐operation 
prophylactic oral antibiotic is not allowed.  Mechanical bowel 
preparation will be at the discretion of the PI per each site's SOP 
(see also section 8.1).   
For both arms the prophylactic SoC will be consistent and 
standardized for all sites in the clinical study. Each site will use 
the same pre‐defined SoC for all its subjects during the study.   
Post‐operative care (excluding prophylactic antibiotics) will be 
performed per site SoC. Post‐operative resumption of activity is 
at the discretion of the Investigator, based on the subjects 
medical condition. 
Doxycycline pharmacokinetic sampling will be collected in selected 
sites from all randomized subjects in these sites (sites from Czech 
Republic will not participate in the PK sub‐study). About 
 series of 
samples per set will be analyzed. About 
series will be 
analyzed from subjects receiving 2 vials, about 
 series will be 
analyzed from subjects receiving 3 vials.  
Spontaneous Adverse Events (AEs) including death will be 
recorded throughout the study. Pregnancy will be reported using 
a specific form and will be followed up until resolution.  
The planned clinical program will establish the efficacy and 
safety of D‐PLEX by the reduction in the number of abdominal 
wall incisional infections observed during 30 days after surgical 
index procedure. All subjects will be followed for an overall of 60 
days for safety. 
Primary Efficacy Endpoint: 
● Infection rate as measured by the proportion of subjects 
with at least one abdominal target incisional infection event, 
occurring within 30 days post abdominal surgery and 
 
 
 
22-2-2022
Page 17 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
determined by a blinded independent adjudication 
committee. 
[abdominal incisional infection is defined as Deep Incisional 
Surgical Site Infection (DSSI) and/or Superficial Incisional 
Surgical Site Infection (SSSI)]. 
All‐cause mortality and re‐intervention at the primary incision 
site (target) due to  suspected SSI or due to poor wound healing, 
including wound dehiscence (as verified by the blinded 
adjudication committee),  within 30 days post index surgery will 
be analysed as treatment failure. 
Reinterventions for other reasons likely unrelated to the initial 
treatment (e.g. anastomosis leaks, intraabdominal hemorrhage, 
bowel obstruction), will not be considered as treatment failure 
in  the primary analysis of the primary endpoint. These events 
will be considered as treatment failure in a sensitivity analysis. 
Reintervention is defined as re‐opening of the surgery incision, 
used for the original index surgery, in the operation room (OR). 
An independent and blinded adjudication committee will review 
each case suspected for SSI and will adjudicate if meets the SSI 
endpoint criteria.   
Secondary Efficacy Endpoints: 
Key endpoints: 
● Infection rate as measured by the proportion of subjects with 
at least one abdominal target incisional infection event only, 
occurring within 30 days post abdominal index surgery and de‐
termined by a blinded and independent adjudication commit‐
tee. 
● Number (percent) of subjects with at least 1 score of 
ASEPSIS > 20, within 30 days post abdominal index surgery. 
Additional endpoints: 
● Incidence of SSSI during 30 days post index surgery. 
● Incidence of DSSI during 30 days post index surgery. 
● All‐cause mortality rate within 30 days post randomization. 
 
 
 
22-2-2022
Page 18 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
● All‐cause mortality rate within 60 days post randomization. 
● Time to adjudicated SSI during 30 days post index surgery. 
● Number (percent) of subjects re‐admitted during 30 days 
post‐surgery (for any reason) that have experienced 
adjudicated SSI during this re‐admission. 
● Number (percent) of subjects who experienced at least 1 
surgical re‐intervention due to adjudicated SSI during 30 
days post‐surgery. Re‐intervention is defined as re‐opening 
of the surgery incision, used for the original index surgery, in 
the operation room (OR). 
 
SSI related Additional Endpoints: 
● Number (percent) of subjects with adjudicated SSI where at 
least one Doxycycline‐resistant bacteria has grown in bacte‐
riology tests  
● Number (percent) of Doxycycline‐resistant bacteria out of all 
bacteria that were cultured during bacteriology test from 
subjects with adjudicated SSI. 
● Number (percent) of subjects who experienced adjudicated 
SSI during 30 days post‐surgery that was treated by IV 
antibiotic. 
● Number of IV antibiotic treatment days, administered to 
subjects who experienced adjudicated SSI during 30 days 
post‐surgery.  
● Average of subjects cumulative ASEPSIS assessment score 
(AUC) for subjects with adjudicated SSI during 30 days post‐
surgery.  
● Number (percent) of subjects with at least 1 score of 
ASEPSIS > 20 in subject with adjudicated SSI within 30 days 
post abdominal index surgery. 
Identification of an SSI will be based on CDC/NHSN Patient Safety 
Component Manual criteria (January 2020, chapter 9) 
Safety Evaluation: 
The following safety parameters will be evaluated in this trial: 
● AEs, physical examinations & vital signs. 
 
 
 
22-2-2022
Page 19 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
● Incisional wound healing (including Hernia) will be assessed 
by a blinded Investigator, using a visual examination (part of 
a Surgical Site Assessment questionnaire) as well as 
Modified Vancouver Scar Scale wound assessment 
questionnaires. 
● Safety laboratory parameters: hematology, chemistry. 
It is expected that each subject will be in the study for 
approximately 60 days. 
 
Inclusion Criteria: 
Subjects who meet all of the following criteria will be eligible to 
participate in the study: 
1. Subjects undergoing an elective colorectal surgery involving 
resection, with or without a stoma formation, that includes 
at least 1 abdominal incision that is > 10cm (target incision).  
2. Subjects are preoperative hemodynamically stable 
(BPf180/110 and 90/60 mmHg, and HRf100 and 60 bpm, 
and temperature f38.50C and 35.50C). 
3. Male or non‐pregnant female. 
4. Female of child‐bearing potential should have a negative 
pregnancy test (serum or urine dipstick) prior to index 
procedure. 
 Note: All female subjects of child‐bearing potential must agree to 
use a highly effective method of contraception consistently and 
correctly for the duration of the study (see Section 8.6  
CONTRACEPTIVE METHODS). 
5. Subjects' age 18 years old and above at screening. 
6. Subjects who sign the written Informed Consent Form. 
7. Subjects who are willing and able to participate and meet all 
study requirements. 
8. Survival expectancy of at least 60 days post randomization 
Exclusion Criteria: 
Subjects who meet any of the following exclusion criteria are 
prohibited from participating in the study: 
1. Subjects with suspected/diagnosed intestinal perforation,  
intra‐abdominal abscess,  or any emergency/urgent 
colorectal surgery with acute intestinal obstruction (ex. toxic 
 
 
 
22-2-2022
Page 20 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
colitis, ileus/sub‐ileus, megacolon, diverticulitis, volvulus, 
ect.)  
2.   Subjects who underwent an intra‐abdominal surgery within the 
last 6 months prior to randomization. 
3. Subjects with any preoperative active infection or who are 
receiving any antibiotic therapy in the past 1 week prior to 
randomization, excluding pre‐operative prophylaxis. 
4. Subjects undergoing concomitant major procedures in 
addition to the abdominal surgery, including concomitant 
repair of ventral hernia.  
Salpingo‐oophorectomy and cholecystectomy are allowed.   
5. Subjects who received any anti‐cancer treatment within the 
last 4 weeks of surgery.  
6. Subjects who received radiation for colorectal cancer to the 
abdomen area, prior to the planned abdominal surgery. 
7. Subjects who received oral or IV Doxycycline or Tetracycline 
family antibiotics during the past 4 weeks prior to 
randomization. 
8. Subjects with known allergy to Doxycycline and/or to the 
tetracycline family of drugs or to the D‐PLEX's excipients. 
9. Subjects with known allergies to more than 3 substances (an 
allergy questionnaire will be completed during the screening 
process). 
10. Subjects with history of severe allergic reaction to any 
substance, having required treatment with intravenous 
steroids/intramuscular epinephrine, or who in the opinion of 
the PI is at high risk of developing severe allergic reactions. 
11. Subjects with End Stage Renal Disease (ESRD/ CKD stage 5). 
12. Subjects with severe hepatic impairment. 
13. Subjects with chronic urticaria. 
14. Subjects diagnosed with CVA within the past 6 months prior 
to randomization. 
 
 
 
22-2-2022
Page 21 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
15. Subjects who underwent any abdominal surgery and current 
planned index surgery involves re‐opening the scar of a prior 
abdominal surgery performed within the last 3 years. 
16. Any subject with an active malignancy, other than resectable 
non‐metastatic colorectal cancer, that is the reason for the in‐
dex surgery, or carcinoma in situ (or other cancer "in situ = 
Stage 0"), or squamous cell carcinoma of the skin, or basal cell 
carcinoma of the skin, or a malignancy that has not been in 
complete clinical remission and without maintenance chemo or 
immunotherapy for at least 3 years.  
17. Subjects with other concurrent severe and/or uncontrolled 
medical condition. 
18. Psychiatric or any other disorder that compromises ability to 
provide informed consent for participation in this study. 
19. Chronic alcoholic or drug abuse subjects. 
20. Pregnant or breast‐feeding women or women of child‐
bearing age who refuse or are prohibited of using an 
effective contraceptive method of birth control throughout 
study participation, including the safety follow‐up period. 
21. Subjects who received any investigational drug within 
30 days or 5 half‐lives prior to randomization to the study 
(whichever is longer) and through the study. 
22. Subjects participating in any other interventional study. 
23. Subjects, who in the opinion of Investigator, are not eligible 
to participate in the study and/or to comply with the 
protocol requirements (e.g. due to a cognitive or medical 
condition). 
Sample Size: 
The study will enrol a minimum of 950 subjects, with 475 subjects 
allocated to each treatment group.   
The sample size calculation was based on powering the study with 
respect to the primary efficacy endpoint. It was assumed that the 
SSI rate in the SOC arm would as high as 16% range. The study 
predefined assumption is that D‐PLEX +SOC will have effect of 50% 
on this rate (halving infection rate) relative to SOC alone, thus 8% 
infection rate in D‐PLEX+SOC arm. Assuming rate equal to 
 for 
 
 
 
22-2-2022
Page 22 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
both arms with regard to 30‐day treatment failure due to all‐cause 
mortality  or re‐intervention in the target incision due to suspected 
SSI or due to poor wound healing, including wound dehiscence, the 
assumed treatment failure rates were 
 and 
, for SOC and 
DPLEX+SOC, respectively. It was calculated that a sample of 882 
total subjects provides 90% power to detect the assumed 
difference in treatment failure rates. The calculation was based on 
a chi square test, and to account for the planned interim analysis 
for efficacy (to be performed with two‐sided α=0.01), a 
conservative two‐sided α=0.04 level of significance was employed.   
In order to account for an anticipated about 5% lost‐to‐follow‐up 
rate, a minimum of 950 subjects (475/treatment arm) will be 
enrolled.  
One comparative interim analysis for an early efficacy or futility 
stop or unblinded sample size re‐estimation will be conducted 
when about 750 subjects will complete the 1‐month follow‐up and 
evaluated for the primary endpoint. The interim analysis will 
include a group sequential design stopping rule for efficacy or 
futility, combined with unblinded sample size re‐assessment based 
on the Promising Zone approach. 
The outcome of this interim analysis will be either early stopping 
for efficacy or futility, or continuation to planned final (950 
subjects) or continue with sample size increased up to maximal size 
of 1400 only if the comparative result falls in a predefined 
Promising Zone. The interim decision will be made by the 
independent DMC according to a pre‐planned interim analysis plan, 
and comparative information will be maintained confidential within 
the independent statistician until the study finally unblinded.  
Randomization: 
Subjects will be randomized to either the investigational arm (SoC + 
D‐PLEX) or to the control arm (SoC only) in a 1:1 ratio. 
Randomization will be stratified by type of SoC prophylactic 
antibiotic regimens (prophylactic IV antibiotic with mechanical 
bowel preparation or prophylactic IV antibiotic without mechanical 
bowel preparation) and by region (US or Europe + Israel). 
Statistical Methods: 
The following analysis populations will be defined for the study:  
Intention to Treat (ITT): The ITT analysis set will consist of all 
subjects who have been randomized to receive either D‐PLEX + 
 
 
 
22-2-2022
Page 23 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
SoC or SoC alone. In this analysis set, treatment will be assigned 
based on the treatment to which subjects were randomized, 
regardless of which treatment they actually receive.  
Modified Intent to Treat (mITT): The mITT analysis set is a subset 
of the ITT set and will consist of all subjects randomized and 
treated with D‐PLEX + SoC or SoC alone who underwent the index 
surgery and have no eligibility criteria deviation. In this analysis 
set, treatment will be assigned based on the treatment to which 
subjects were randomized, regardless of which treatment they 
actually received. The exclusion from the mITT population will be 
determined in a blinded manner prior to database lock. Subjects 
who will die during the study will not be excluded from the mITT 
population. 
Per Protocol (PP): The PP analysis set is a subset of the mITT set 
and will consist of all subjects in the mITT set that have no major 
protocol deviations and were assessed for the primary endpoint 
(i.e. completed the Day 30 assessment, unless had prior to that 
adjudicated post‐surgical SSI, or death  or re‐intervention in the 
index surgery due to suspected SSI or due to poor wound healing, 
including wound dehiscence). 
Safety: The safety analysis set will consist of all subjects who have 
been randomized and treated. In this population, treatment will 
be assigned based upon the treatment the subjects actually 
received, regardless of the treatment to which they were 
randomized.  
The analysis of the primary and key secondary efficacy endpoints will 
be performed on the ITT, mITT and PP populations, with the ITT 
population serving as the primary analysis set. Analyses of additional 
efficacy endpoints will be performed on the populations as described 
in the Statistical Analysis Plan (SAP) for the study.  
Analyses of safety will be performed on the safety population.  
 
Analysis of Primary Efficacy Endpoint 
The primary analysis will be based on a composite treatment failure 
(Yes/No) variable indicating if a subject had at least one of the 
following treatment‐failure events: SSI, as determined by a blinded and 
independent adjudication committee, within 30 days post abdominal 
surgery, or all‐cause mortality by 30 days. Also re‐interventions at the 
 
 
 
22-2-2022
Page 24 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
primary incision site due to suspected SSI or due to poor wound 
healing, including wound dehiscence, as determined by a blinded and 
independent adjudication committee, within 30 days post index 
surgery and indeterminate outcome (due to missing data) will be 
considered a treatment failure for the primary ITT analysis. The 
number and proportion of subjects with treatment‐failure will be 
tabulated per treatment group. A 95% confidence interval will be 
constructed for each proportion. A Cochran Mantel‐Haenszel (CMH) 
test will compare the proportion between the two groups, using the 
study stratification factors used for randomization, and corresponding 
risk difference estimate will be presented with 95% confidence interval 
(using the method of MantelHaenszel stratum weights, as applied in 
the COMMONRISKDIFF option in the SAS FREQ procedure). The 
following hypotheses will be tested for a significant difference in the 
primary endpoint proportions between D‐PLEX+SoC (PDPLEX) and SoC 
(PSoC) treatment: 
H0: PDPLEX = PSoC 
vs. 
H1: PDPLEX ≠ PSoC 
The significance level for this test will be two‐sided 5%. In the case of 
small number of events (less than 5 events in any study arm), the 
Fisher exact test will be used. 
The number and percent of each of the failure types will be described 
by group. 
Analysis of Safety 
All AEs will be coded using the MedDRA coding dictionary. The number 
and proportion of subjects reporting at least one treatment emergent 
adverse event (TEAE) and the number and proportion of subjects 
reporting at least one TEAE by MedDRA system organ class and 
preferred term will be reported. This analysis will be repeated for 
serious AEs (SAEs) and for treatment‐related AEs. Additional 
summaries of TEAEs will be performed by severity and by relationship 
to treatment.    
Vital sign measurements and clinical laboratory parameters will be 
summarized via descriptive statistics (mean, standard deviation, 
median, minimum, maximum, and number of non‐missing 
observations) for each post‐treatment time point. Shift tables will be 
 
 
 
22-2-2022
Page 25 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
 
 
 
constructed for physical exams to display any changes in body system 
findings over time. Responses to the Modified Vancouver Scar Scale 
will be summarized with counts and proportions by time point. 
All other analyses of efficacy and safety will be conducted as described 
in the main body of this clinical study protocol. 
Interim analysis: 
One un‐blinded comparative interim analysis will be conducted after a 
total of about N=750 subjects have been assessed for the primary 
efficacy endpoint.  The interim analysis will include a group sequential 
design stopping rule for efficacy and futility, combined with unblinded 
sample size re‐assessment based on the Promising Zone approach. 
The outcome of this interim analysis will be either early stopping for 
efficacy or futility, or continuation to planned final (950 subjects) or 
continue with sample size increased up to maximal size of 1400 only if 
the comparative result falls in a predefined Promising Zone. 
 
 
 
22-2-2022
Page 26 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
5 INTRODUCTION 
5.1 BACKGROUND 
5.1.1 Background Information on The Product 
5.1.1.1 Product Name 
D‐PLEX (Doxycycline/Polymer‐Lipid Encapsulation MatriX) 
5g D‐PLEX per vial contains 
 w/w Doxycycline hyclate equivalent to
 (
) 
Doxycycline free base. 
5.1.1.2 Drug Substance Chemical Name and Structure 
Doxycycline Hyclate 
The chemical name of Doxycycline hyclate is 2‐Naphthacenecarboxamide, 4‐
(dimethylamino)‐1,4,4a,5,5a, 6,11,12a‐octahydro‐3,5,10,12,12a‐pentahydroxy‐6‐methyl‐
1,11‐dioxo‐, monohydrochloride, compound with ethanol (2:1), monohydrate, [4S‐
(4α,4aα,5α,5aα,6α, 12aα)]‐ Doxycycline Hyclate chemical structure is shown in Figure 1 
below. 
 
Figure 1: 
Chemical Structure of Doxycycline Hyclate 
 
Molecular Formula: C22H24N2O8  HCl  0.5H2O  0.5C2H5OH 
Molecular Weight: 512.9 
5.1.1.3 Proposed Indication 
D‐PLEX is indicated for prevention of post abdominal surgery incisional infection. 
5.1.1.4 Dosage Form, Route of Administration, and Dosing Regimen (Frequency and Duration) 
Dosage form: D‐PLEX is a biodegradable, extended‐release formulation of Doxycycline (as 
doxycycline hyclate) supplied as a sterile powder for reconstitution and application as 
paste, and intended for a single use. D‐PLEX is reconstituted with 2‐5ml of sterile saline 
solution to form a paste. 
Each vial contains 5g of D‐PLEX. The total percentage of Doxycycline in D‐PLEX in the initial 
clinical formulation is 
 Doxycycline which is equivalent to 
 Doxycycline hyclate. 
 
 
 
22-2-2022
Page 27 of 99
Effective




 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
5.1.2 Unmet Medical Need for Prevention of Post Abdominal Surgery Incisional 
Infection   
Surgical site infections are one of the most frequent complications in open abdominal 
surgeries, and they represent a significant cause of mortality and morbidity. Approximately ten 
million (10,000,000) abdominal surgeries are performed annually in the US; of these, 7.1 
million (7,100,000) are general (gastroenterological) surgeries which include 575,000 
colorectal resection surgeries1,2, 2.9 million (2,900,000) gynecological surgeries, and 608,000 
urological surgeries. 
The SSI rate ranges from approximately 5.0%‐30.0% of abdominal soft tissue surgeries. SSIs 
occur in up to 4.0% of hysterectomies3,  30.0%4 of colorectal surgeries and approximately 6.8% 
in urological procedures5. Chemotherapy and other immuno‐suppressive medications affect 
the function of the immune system and have the potential to increase the SSI rate6. 
SSIs are classified as superficial incisional if limited to the skin and subcutaneous tissue, or 
deep incisional when involving the fascia and muscle. These infections are classified as organ 
space when involving an organ within the body cavity (i.e., below the fascia). Such organ space 
infections are usually manifested as abscess7,8. Deep tissue and organ space surgical site 
infections are less frequently encountered than superficial infections, but are associated with 
greater morbidity/mortality, more readmission rates, longer hospital stay, long term antibiotic 
treatment and increased overall hospital‐associated costs when compared to superficial 
surgical site infections. Although superficial wound infections are more reliably treated with 
systemic and/or topical antibiotics than deep wound infections, they can lead to clinically 
important complications such as non‐healing wounds, systemic infections, surgical site revision 
surgeries, and, if hospitalization is pro‐longed, an increased risk of developing co‐infection 
with antimicrobial‐resistant pathogens.  
While many SSIs are uncomplicated, others may be severe and more challenging to manage, 
such as necrotizing deep soft tissue infections. The latter often requires extensive surgical 
debridement, multiple reoperations, and can be life‐threatening7. 
5.1.3 Justification for the Use of D‐PLEX for Prevention of Post Abdominal Surgery 
Incisional Infection 
D‐PLEX represents a novel formulation of Doxycycline that improves the potential for the 
prevention of post abdominal surgery incisional infections over currently utilized preventive 
measures.  Such measures include: (a) additionally applied mechanical measures; (b) 
administering prophylactic antibiotics prior to incision; (c) clipping rather than shaving the 
operative site; (d) maintaining normal body temperature and oxygen supplementation 
perioperatively, and achieving adequate glycemic control7,911; (e) introduction of a sterile area 
in the operating room in order to restrict movement, and increased sterile airflow and air ex‐
change in the proximity of the patient; and (f) wearing specialized gowning by surgeons 
 
 
 
22-2-2022
Page 29 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
(space suits) to prevent airflow from the surgeon onto the patient.  While these measures 
have reduced the rate of infection, they have not completely eliminated it8,12. Therefore, the 
prevention of post abdominal surgery infection represents an unmet medical need. 
Part of the reason for the persistence of these types of infections despite the above 
procedures is because a local hematoma forms at the surgical site following surgery. This is a 
wet environment that encourages bacterial growth. In an attempt to reduce the hematoma, 
strict homeostasis and drainage are used. However, drains also constitute a risk for bacterial 
introduction. In addition, the blood supply and lymph fluid at the hematoma site are 
disrupted. Therefore, systemic antibiotics and immune defences have impaired ability to reach 
the affected areas, causing these areas to be more susceptible to proliferation of bacteria and 
subsequent development of infection. With low local prophylactic antibiotic concentrations, 
there is a risk of developing antibiotic resistant bacteria.  Raising the systemic antibiotic dose 
to improve local exposures may cause systemic toxicity. In an attempt to over‐come this 
problem, some surgeons apply antibiotics locally before closing of the incision. This antibiotic 
treatment is effective for very short durations of 1‐2 hours and does not prevent development 
of bacterial infection1316. In addition, the American Society of Health‐System Pharmacists, 
Surgical Infection Society, Infectious Diseases Society of America, and Society for Healthcare 
Epidemiologists of America have all stated that lacking sufficient evidence, the use of currently 
available topical antibiotics cannot be recommended17. A product such as D‐PLEX that provides 
sustained local high levels of Doxycycline has the potential of achieving a reduction in infection 
not achievable with present available products or procedures.   
As indicated above, D‐PLEX is a new extended‐release formulation of Doxycycline for 
administration in the abdominal sites following surgery. D‐PLEX releases Doxycycline 
immediately upon product administration and during approximately four weeks following 
administration. This is the period in which most of the laparotomy colon surgical site infection 
occur8. During this period, the expected local Doxycycline concentration from D‐PLEX is well 
above the minimal inhibitory concentration (MIC) of sensitive organisms. By preventing 
growth of bacteria via high local concentration of Doxycycline at the surgical site during the 
four weeks post‐administration, D‐PLEX is intended to be effective for prevention of 
abdominal surgery site infections. 
5.2 NON‐CLINICAL DATA 
Non‐clinical pharmacology studies, performed to demonstrate D‐PLEX antimicrobial activity, 
include the following: 
● Three studies in rabbit abdominal incision site infection model (each with a different 
clinically relevant bacteria: Methicillin‐Resistant Staphylococcus Aureus (MRSA), 
Enterobacter aerogenes (EA), Enterococcus feacium (VRE)) showed that D‐PLEX at an applied 
dose comparable to 5g administered to a 70kg adult on a mg/kg basis, demonstrates 
reduction of infection (as reflected in lesser clinical signs, no incidence of systemic 
 
 
 
22-2-2022
Page 30 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
temperature rise together with approximately 3‐4 log bacterial load lower than groups that 
received only bacteria with or without placebo). 
● In vitro antimicrobial studies demonstrated D‐PLEX ability to reduce the load of six clinically 
relevant bacteria. 
● These findings support the claim of antibacterial activity of D‐PLEX in prevention of 
infections in soft tissue environment in human. 
Non‐clinical pharmacokinetic studies were performed to demonstrate Doxycycline local and 
systemic concentration after its administration. 
● According to a local PK study in a rabbit abdominal surgical incision model, the Doxycycline 
concentrations in the abdominal incision area are maintained for considerable time above 
the MIC value of sensitive, clinically relevant bacterial species. A high concentration of 
Doxycycline is achieved up to ~5 hours after D‐PLEX administration (>30µg/mL). This is 
followed by constant Doxycycline concentrations in the range of approximately ~ 3‐5µg/mL 
that is maintained for approximately 30 days. These levels are well above the MIC of the 
sensitive strain, Staphylococcus aureus (MIC of 1µg/mL). 
● D‐PLEX's ability to release Doxycycline for a period of at least 29 days in vivo was shown in 
rats after subcutaneous administration of D‐PLEX.   
Non‐clinical safety and toxicity studies, include the following: 
5.2.1 A safety and toxicity pivotal study in which D‐PLEX was administered into an abdominal 
incision in miniature swine, shows that administration of D‐PLEX comparable on a 
mg/kg basis to 20g D‐PLEX dose administered to a 70‐kg adult, demonstrates no 
macroscopic or microscopic adverse effect systemic effects and completed bio‐
degradation of D‐PLEX by 6‐months.  
5.2.2 The safety of D‐PLEX administration in the abdominal wall incision (muscle, fat and 
subcutaneous) was investigated in rabbits and swine. D‐PLEX had no local or systemic 
adverse effects and did not impair the healing of the incision nor increase the 
adhesions to the incision for about 30 days post‐administration.   
5.2.3 Two safety studies performed to evaluate the peritoneum reaction to D‐PLEX after 24 
hours and 28 days from D‐PLEX administration in case of intra‐abdominal leakage in rat 
abdominal model showed that D‐PLEX exposure (comparable on mg/kg basis to 15gr D‐
PLEX in a 70‐kg adult) to abdominal cavity is safe. 
Hence, D‐PLEX can be considered safe and suitable for its intended use.  
For detailed non‐clinical studies summary of the D‐PLEX, see D‐PLEX Investigators Brochure, 
#DV‐0079. 
 
 
 
22-2-2022
Page 31 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
5.3 CLINICAL DATA 
A Phase II, Prospective, Multicenter, Randomized, Controlled, Two‐arm, Single Blind  (Participant, 
Outcome assessor) Study to assess Safety and Efficacy of D‐PLEX Administered Concomitantly 
with SoC, compared to a SoC treated control arm, in prevention of post abdominal surgery 
incisional infection was performed in 8 sites in Israel. The study enrolled a total of 201 subjects, 
that were scheduled for elective abdominal colon surgery involving resection and including at 
least 1 incision that is g 5cm. 
The following were shown:  
 
Proportion of subjects, who experienced SSI or mortality within 30 days: 10 subjects on D‐
PLEX + SoC as compared to 24 subjects on SoC treatment arm (ITT population, N=201) met 
the Primary Endpoint (p‐value = 0.0086) with SSI prevention rate of 59%. 
 
In the mITT population (N=185) analysis, 9 subjects on D‐PLEX + SoC as compared to 23 
subjects on SoC treatment arm met the Primary Endpoint (p‐value = 0.0066) with SSI 
prevention rate of 61%. 
 
In the PP population analysis (N=179) 7 subjects on D‐PLEX + SoC as compared to 23 subjects 
on SoC treatment arm met the Primary Endpoint (p‐value = 0.0024) with SSI prevention rate 
of 69%. 
 
PK data (in 20 subjects) demonstrated that the D‐PLEX extended‐release formulation re‐
leases Doxycycline constantly over a period of 30 days as well as that the systemic exposure 
of D‐PLEX is lower than any dose of Doxycycline‐based product administered orally; related 
to Cmax compared to similar PK variables of the following Reference Listed Products, i.e., rela‐
tive, non‐head to head Cmax comparisons to ACTICLATE, VIBRAMYCIN and DORYX (labelling 
information data) and a medical literature citation18.  
 
Three (3) subjects on SoC treatment arm died during the first 30 days post‐surgery, while 
none on D‐PLEX + SoC treatment arm. According to PIs, these cases were not related to 
study drug. 
 
During the Follow‐up period (60 days) 5 subjects on SoC treatment arm died (3 of them died 
during the first 30 days post‐surgery). According to PIs, these cases were not related to study 
drug. 
 
Total Number of Study Drug‐Related Adverse Events (AEs) as assessed by the Investigators is 
8 TEAEs reported from 8 subjects (N=99) on D‐PLEX + SoC versus 18 TEAEs reported from 13 
subjects (N=100) on SoC treatment arm. 
 
One (1) subject (N=101) on D‐PLEX + SoC and 8 subjects (N=100) on SoC treatment arm 
discontinued the study. None of them discontinued the study due to AEs. 
 
 
 
 
22-2-2022
Page 32 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
An additional Phase Ib/II clinical trial in the Sternal Surgical Site indication was conducted in 
Israel and included two parts: part 1, open label single arm, and part 2, randomized, controlled, 
single‐blinded to assess the safety and efficacy of D‐PLEX concomitantly with SoC vs. SoC alone, 
in the prevention of sternal wound infection post cardiac surgery for up to 24 weeks (6 months) 
following surgery. The study included a total of 81 subjects that were scheduled for open heart 
surgery, including but not limited to subjects with high risk factors for infection: 20 subjects in 
part 1 (all in the treatment arm) and 61 subjects in part 2 of the study (21 subjects in the SoC 
arm and 40 subjects in the treatment arm). 
A total of 60 subjects were randomized to D‐PLEX with SoC group. One subject withdrew 
consent before treatment. 
 
In a final Clinical Study report for the study the following were shown: 
 
A single subject in the SoC group (4.8%) experienced a superficial surgical wound infection 
on Day 6 post‐surgery. 
 
No subjects in the treatment group experienced any surgical wound infection (0%). 
 
No hospitalizations, re‐admissions or surgical re‐interventions due to SSI were reported in 
the study. 
 
No safety issues were indicated, and no AE/SAE related to D‐PLEX has been reported. 
18/21 subjects in the SoC group (85.7%) and 48/60 subjects (80%) in the D‐PLEX with SoC 
group experienced AEs. One subject in the D‐PLEX plus SoC group died due to cardiogenic 
shock on Day 6 post‐surgery, not related to D‐PLEX or the study procedure. 
 
PK data demonstrated that D‐PLEX releases Doxycycline continuously over a period of 30 
days as well as that the systemic exposure of D‐PLEX is lower than any dose of Doxycycline‐
based product administered orally; related to Cmax compared to ACTICLATE, VIBRAMYCIN 
and DORYX (labelling information data) and a medical literature citation18. 
These results are highly clinically meaningful and statistically significant, and therefore support 
the robustness of D‐PLEX in abdominal SSI prevention. In addition, in this study high safety 
profile of the D‐PLEX was shown. 
 
5.4 SAFETY PROFILE OF DOXYCYCLINE 
Doxycycline has been on the market for over 5 decades and its side effects are well established. 
Information on adverse reactions of Doxycycline capsules/ tablets are provided in the IB. 
Furthermore, given the total dose of Doxycycline present in D‐PLEX (i.e., maximum 163.8mg), 
which is lower than the overall daily dose of systemically administered Doxycycline (200mg), and 
given it is being gradually released over a period of approximately 4 weeks, it is unlikely that 
 
 
 
22-2-2022
Page 33 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
clinically significant systemic levels will be present to give significant side effects. This is further 
supported by pharmacokinetic data derived from a phase II clinical study which was recently 
completed. It shows detectable plasma levels of Doxycycline for well into four weeks following 
administration of the D‐PLEX formulation. 
5.5  POTENTIAL BENEFITS OF D‐PLEX FOR PREVENTION OF POST ABDOMINAL 
SURGERY INCISIONAL INFECTION 
● Prevention of SSI, which may occur within 30 days post‐surgery. 
● Significant improvement in prevention of SSI when used in surgical procedures that hold 
high risk of infection. 
● Induces faster recovery and early return to normal activity as compared to SoC due to lower 
SSI rate. 
● Reduction in the number of surgical re‐interventions due to surgical site infections. 
● Reduction in the number of hospitalizations and/or shortening hospitalization, thus 
providing financial savings and reducing hospital load. 
● Used concomitantly with SoC. 
● Ease of administration, no special training is required. 
● Local administration of effective dose of Doxycycline during surgery (which results in local 
concentration above the MIC for Doxycycline sensitive bacteria), which cannot be achieved 
by systemic or current local solutions. 
● Administration of low total dose of Doxycycline compared to the dose in oral administered 
Doxycycline capsules. 
● Broad spectrum activity of Doxycycline (gram‐negative and gram‐positive). 
● Low potential risk for development of bacterial resistance. 
● D‐PLEX excipients are biodegradable, widely used in the medicinal or medical device 
industry, and have an established history of safety and clinical use. 
● Reduced risks of overall toxicity and adverse side effects due to minimization of systemic ex‐
posure. 
5.6 POTENTIAL RISKS OF D‐PLEX FOR PREVENTION OF POST ABDOMINAL SURGERY 
INCISIONAL INFECTIONS AND THEIR MITIGATIONS 
Potential contamination of microorganisms and pyrogens by the aseptic product. 
Mitigation: 
 
Clear and detailed instructions on how to store, administer and use. 
 
 
 
22-2-2022
Page 34 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
Potential for local toxicity by drug product, including irritation of the tissues. 
Mitigations at the subject level: 
 
In case of serious local toxicity induced by D‐PLEX, removal and washing out the product 
will be done by the surgeon. 
Mitigations at the population level: 
 
Close follow up of subjects 
 
Safety Monitoring 
Hypersensitivity to Doxycycline and to the Tetracycline family of antibiotics 
Mitigation: 
 
Exclude susceptible subjects with known allergy to Doxycycline / Tetracycline family and/or 
three different allergens. 
 
In case of allergic reaction to Doxycycline, the administered D‐PLEX can be removed by re‐
exploring the surgical target incision and washing out the D‐PLEX. 
Potential of bacteria resistant to Doxycycline‐treatment failure/ increased severity of infection. 
Mitigation: 
 
SoC concomitantly administered with D‐PLEX provides systemic antibacterial coverage. 
Administration outside of the target surgery site. 
Mitigations: 
 
Training of the surgeons participating in the clinical trials, as part of the study initiation and 
the protocol training. 
 
Clear instructions how to apply, detailed in section 0.    
Inadequate antibacterial activity of the product 
Mitigations: 
 
SoC concomitantly administered with D‐PLEX provides systemic antibacterial coverage. 
Re‐use of D‐PLEX between different subjects, can lead to cross contamination. 
Mitigations: 
 
D‐PLEX vial will be re‐allocated to a different subject only if (i) package carton was never 
opened (ii) storage conditions were kept and (iii) with the permission of the site's head of 
pharmacy. If, for some reason, it was not used also after the 2nd allocation ‐ any remaining 
drug not applied should be discarded. 
 
Training of site clinical staff. 
Photosensitivity reaction: exaggerated sun burn reaction. 
Mitigations: 
 
Close follow up of subjects 
Transient hypercalcemia 
 
 
 
 
22-2-2022
Page 35 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
Mitigation: 
 
Close follow up of subjects. 
Blood levels of calcium are tested at screening and every visit after the procedure during the 
clinical study. 
5.6.1 
Potential Risks and Mitigations due to COVID‐19 pandemic  
Potential risks due to COVID‐19 pandemic were evaluated according to Guidance on the 
management of clinical trials during the Covid‐19 (coronavirus pandemic)risks and 
mitigations are presented below in the table below. 
Risk 
Mitigation 
1. Subject may be infected 
with SARS‐2‐COV prior to 
enrollment to the study 
Charlson Patient characterization: the updated Charlson co‐morbidity index 
(CCI) that include question Is this a COVID‐19 patient? is used (see Appen‐
dix 5). 
2. Subject was diagnosed to 
be infected with SARS‐2‐
COV and must undergo ab‐
dominal surgery  
 
Hospital has all facilities necessitate to operate COVID‐19 patients as 
needed.  
 
D‐PLEX is a new formulation of extended release of Doxycycline to be 
administered locally as a single application during abdominal surgeries. 
Systemic exposure of Doxycycline from D‐PLEX is lower than any dose 
of Doxycycline‐based product administered orally. Therefore, no poten‐
tial interaction is expected with any additional medications as needed 
in this situation. 
3. Subject treatment can be 
interrupted due to arriv‐
ing/visits issues 
As D‐PLEX is administered locally as a single application, there is no risk to 
interrupt the continuing treatment due to COVID‐19 pandemic situation. 
4. Study Follow‐up visits cant 
be performed on site due 
to COVID‐19 pandemic sit‐
uation and safety of the 
subject can be compro‐
mised 
 
During the study, 4 of 7 visits are conducted during the primary hospi‐
talization for the abdominal surgery. The additional 3 visits can be done 
by phone.  
 
According to Table 1, in case the subject is unable to attend a visit, in‐
formation related to his wound assessment (as per Sponsors desig‐
nated form) should be obtained in a phone conversation with him/his 
community physician/ a first degree relative.  
 
During remote visit, the patient will be asked to photocopy the incision 
area only, using their cellular phone per instructions provided as a sep‐
arate manual to help the investigator and independent and blinded ad‐
judication committee to perform wound assessment (see Section 
9.1.18). 
 
In case Central laboratory cant be used due to COVID‐19 pandemic 
(home visits and/or connection disturbances), Local laboratories can be 
used to assess the safety and efficacy (bacteriology test) of the subject. 
 
 
 
22-2-2022
Page 36 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
5.7 SAFETY & EFFICACY SUMMARY 
Based on the current data available from 2 clinical studies with D‐PLEX, in which 99 subjects, 
who underwent abdominal surgery, and 58 cardiac subjects were treated with D‐PLEX, no safety 
concern was observed. Overall, based on risk/benefit assessment, the expected benefits 
outweigh the expected risks associated with the use of D‐PLEX. 
Therefore, a clinical trial with D‐PLEX in subjects undergoing abdominal surgery procedures, may 
be beneficial. 
6 OBJECTIVES 
● 
To assess the anti‐infective efficacy of D‐PLEX (administered concomitantly with SoC) over a 
period of 30 days post operation, by preventing SSI defined as superficial and/or deep 
abdominal wall surgical incision infection, compared to the SoC treatment control arm. 
● 
To assess the safety of D‐PLEX. 
 
7 STUDY ENDPOINTS 
7.1 PRIMARY EFFICACY ENDPOINT 
The following will be evaluated in this trial: 
Infection rate as measured by the proportion of subjects with an SSI event, occurring within 
30 days post abdominal surgery and determined by a blinded and independent adjudication 
committee. 
The blinded and independent adjudication committee review will include all index surgery 
incisions, regardless of any re‐intervention at the target site (i.e. re‐opening of the surgery 
incision, used for the original index surgery), for the determination of infection status. The 
committee will also assess re‐interventions at the primary incision site through the abdominal 
incision (target) for the determination of re‐intervention due to suspected SSI or due to poor 
wound healing, including wound dehiscence. Such event as well as  all‐cause mortality within 30 
days post index surgery will be analysed as treatment failure.  
 
Reinterventions for other reasons likely unrelated to the initial treatment (as determined by 
the blinded independent adjudication committee; e.g. anastomosis leaks, intraabdominal 
hemorrhage, bowel obstruction), will be not  be considered as failures in the primary analysis 
of the primary endpoint. 
Reintervention is defined as re‐opening of the surgery incision, used for the original index 
surgery, in the operation room (OR). 
 
SSI is defined as Deep Incisional Surgical Site Infection (DSSI) and/or Superficial Incisional Surgical 
Site Infection (SSSI). 
 
 
 
22-2-2022
Page 37 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
 
Superficial incisional SSI ‐ 
Infection involves only skin and subcutaneous tissue of the incision 
and does not include diagnosis/treatment of cellulitis, a stitch 
abscess alone or a localized stab wound or pin site infection. 
Deep incisional SSI ‐ 
Infection involves deep tissues, such as fascia and muscle layers; this 
also includes infection involving both superficial and deep incision 
sites.   
An organ/space SSI (e.g., infection/abscess in the operated organ or peritoneal cavity) will not be 
accounted as an endpoint event. 
Identification of an SSI will be based on CDC/NHSN Patient Safety Component Manual criteria 
(January 2020, chapter 9). 
 
7.2 SECONDARY EFFICACY ENDPOINTS 
7.2.1 
Key endpoints: 
● Infection rate as measured by the proportion of subjects with at least one abdominal target 
incisional infection event only, occurring within 30 days post abdominal surgery and 
determined by a blinded and independent adjudication committee. 
[abdominal incisional infection is defined as Deep Incisional Surgical Site Infection (DSSI) 
and/or Superficial Incisional Surgical Site Infection (SSSI)]. 
● Number (percent) of subjects with at least 1 score of ASEPSIS > 20 within 30 days post 
abdominal surgery. 
7.2.2 
Additional endpoints: 
● Incidence of SSSI during 30 days post index surgery. 
● Incidence of DSSI during 30 days post index surgery. 
● All‐cause mortality rate within 30 days post randomization. 
● All‐cause mortality rate within 60 days post randomization. 
● Time to adjudicated target incisional SSI post‐surgery during 30 days post index surgery.   
● Number (percent) of subjects, re‐admitted during 30 days post‐surgery (for any reason) and 
experienced adjudicated SSI during this re‐admission. 
● Number (percent) of subjects who experienced at least 1 surgical re‐intervention due to 
adjudicated SSI during 30 days post‐surgery. Re‐intervention is defined as re‐opening of the 
surgery incision, used for the original index surgery, in the operation room (OR) 
7.2.2.1 SSI related Additional Endpoints: 
● Number (percent) of subjects with adjudicated SSI where at least one Doxycycline‐re‐
sistant bacteria has grown during the bacteriology tests.  
 
 
 
22-2-2022
Page 38 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
● Number (percent) of Doxycycline‐resistant bacteria out of all bacteria that were grown 
during the bacteriological tests from subjects with adjudicated SSI.  
● Number (percent) of subjects who experienced adjudicated SSI during 30 days post‐
surgery that was treated by IV antibiotic. 
● Number of IV antibiotic treatment days administered to subjects experienced adjudicated 
abdominal incisional SSI during 30 days post‐surgery. 
● Average of subjects cumulative ASEPSIS assessment score (AUC) for subjects with 
adjudicated SSI during 30 days post‐surgery. 
● Number (percent) of subjects with at least 1 score of ASEPSIS > 20 in subjects with 
adjudicated SSI within 30 days post abdominal index surgery. 
 
7.3 SAFETY EVALUATION 
The following safety parameters will be evaluated in this trial: 
 
AEs, physical examinations & vital signs. 
 
Incisional wound healing (including Hernia) will be assessed by a blinded Investigator, 
using a visual examination (part of a Surgical Site Assessment questionnaire) as well as 
Modified Vancouver Scar Scale wound assessment questionnaires. 
 
Safety laboratory parameters: hematology, chemistry. 
8 TRIAL DESIGN 
8.1  OVERALL DESIGN 
This  is  a  phase  III,  prospective,  multinational,  multicenter,  randomized,  controlled,  two‐arm, 
double blind study. The study population includes male and female subjects, 18 years old and 
above at screening, undergoing an elective colorectal surgery involving resection, with or without 
a stoma formation that includes at least 1 abdominal target incision that is > 10 cm.  The study will 
enrol participants who reflect the demographic for clinically relevant population with regards to: 
age, gender, race and ethnicity. This population reflect the US and Europe population undergoing 
abdominal colorectal surgeries. Subjects who meet the inclusion criteria and none of the exclusion 
criteria and who provide a signed Informed Consent Form will be enrolled in the study. 
Subjects will be randomized to either the investigational arm (SoC + D‐PLEX) or to the control arm 
(SoC only) in a 1:1 ratio. Subjects will be stratified by type of SoC prophylactic antibiotic regimens 
(prophylactic  IV  antibiotics  with  mechanical  bowel  preparation  or  prophylactic  IV  antibiotics 
without mechanical bowel preparation) and by region (US or Europe + Israel). 
The sponsor, the outcome assessor, the subjects and all staff involved in the collection and 
recording of the clinical and laboratory data, based on which the independent adjudication 
 
 
 
22-2-2022
Page 39 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
committee will perform their assessment, will be blinded to the treatment assignment. The 
OR staff will be trained to maintain in confident the treatment assignment and not to disclose 
it to other staff members. In addition, all aspects of data management and clean‐up should be 
done using blinded datasets. For subjects randomized to the investigational arm, D‐PLEX 
treatment will be applied during the abdominal surgery at the stage of closure of the 
abdominal wall surgical target incision (index procedure), as an adjunct to the SoC treatment 
per protocol.  
D‐PLEX will not be re‐administered if any reintervention occurs. Reintervention is defined as 
re‐opening of the surgery incision, used for the original index surgery, in the operation room 
(OR).  
For subjects randomized to the control arm, the surgical treatment will be as per SoC treatment. 
SoC will be consistent and standardized for all sites in the study and is composed of IV antibiotic 
immediately prior to surgery. Each site will use the same pre‐defined SoC for all its subjects during 
the study. 
For subjects from both arms, preoperative IV antibiotics will be composed of 1st or 2nd generation 
of Cephalosporin family plus Metronidazole given within 60 minutes prior to surgery and should 
be discontinued maximum 24‐hour post‐surgery. In case of allergy to the Cephalosporin, Penicillin 
families  or  Metronidazole,  other  IV  antibiotic  may  be  used.    Pre‐operation  prophylactic  oral 
antibiotic is not allowed.  Mechanical bowel preparation will be at the discretion of the PI per each 
site's SOP. Post‐operative resumption of activity is at the discretion of the Investigator based on 
the subject's medical condition. 
Doxycycline  pharmacokinetic  sampling  will  be  collected  in  selected  sites  from  all  randomized 
subjects in these sites (sites from Czech Republic will not participate in the PK sub‐study). About 
 series of 
samples per set will be analyzed. About
 series will be analyzed from subjects 
receiving 2 vials, about 
series will be analyzed from subjects receiving 3 vials.  
The occurrence of any Adverse Events (AE/SAE) including death will be recorded throughout the 
study. 
The planned clinical study will evaluate the efficacy of D‐PLEX in the prevention of SSIs over a 
period of 30 days for the primary outcome. All subjects will be followed for an overall of 60 days 
for safety. 
8.2 DESCRIPTION & JUSTIFICATION OF THE DURATION OF TREATMENT, SUBJECT 
PARTICIPATION AND TRIAL FOLLOW‐UP 
The infection rate is measured within 30 days of index surgery, based on the literature that this 
is the time period in which most of the abdominal surgery surgical wound infections occur 3,14,15. 
 
 
 
22-2-2022
Page 40 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
The 60 days follow‐up period was determined to allow a sufficient follow‐up period to 
demonstrate the initial and sustainability safety endpoints of D‐PLEX. 
8.3 SELECTION OF SUBJECTS 
The study will enrol a minimum of 950 subjects, with 475 subjects allocated to each treatment group.  
The final number of subjects will be determined following an unblinded sample size re‐estimation: 
when about 750 subjects will complete their 30 days (1 month) follow‐up and evaluated for primary 
endpoint. See details in the section 14.3.8.   
8.4 INCLUSION CRITERIA 
Deviations from any inclusion criteria are not allowed because such deviations can potentially 
jeopardize the scientific integrity of the study, regulatory acceptability or subject safety. 
Therefore, adherence to the criteria as specified in the protocol is essential. 
Subjects eligible for enrolment in the study must meet all of the following criteria: 
1. Subjects undergoing an elective colorectal surgery involving resection, with or without a 
stoma formation, that includes at least 1 abdominal incision that is > 10cm (target incision).  
2. Subjects are preoperative hemodynamically stable (BPf180/110 and 90/60 mmHg, and 
HRf100 and 60 bpm, and temperature f38.50C and 35.50C). 
3. Male or non‐pregnant female. 
4. Female of child‐bearing potential should have a negative pregnancy test (serum or urine 
dipstick) prior to index procedure. Note: All female subjects of child‐bearing potential must 
agree to use a highly effective method of contraception consistently and correctly for the 
duration of the study (see Section 8.6  CONTRACEPTIVE METHODS). 
5. Subjects age 18 years old and above at screening. 
6. Subjects who sign the written Informed Consent Form. 
7. Subjects who are willing and able to participate and meet all study requirements. 
8. Survival expectancy of at least 60 days post randomization. 
 
8.5 EXCLUSION CRITERIA 
Deviations from any exclusion criteria are not allowed because such deviations can potentially 
jeopardize the scientific integrity of the study, regulatory acceptability or subject safety. 
Therefore, adherence to the criteria as specified in the protocol is essential. 
Subjects who meet any of the exclusion criteria are prohibited from participating in the study: 
1. Subjects with suspected/diagnosed intestinal perforation, intra‐abdominal abscess, or any 
 
 
 
22-2-2022
Page 41 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
emergency/urgent colorectal surgery with acute intestinal obstruction (ex. toxic colitis, 
ileus/sub‐ileus, megacolon, diverticulitis, volvulus, ect.)  
2. Subjects who underwent an intra‐abdominal surgery within the last 6 months prior to 
randomization. 
3. Subjects with any preoperative infection or who are receiving any antibiotic therapy in the 
past one week prior to randomization, excluding pre‐operative prophylaxis or antibiotics for 
the treatment of the disease that is the indication for surgery. 
4. Subjects undergoing concomitant major procedures in addition to the abdominal surgery, 
including concomitant repair of ventral hernia. Salpingo‐oophorectomy and cholecystectomy 
are allowed.  
5. Subjects who received any anti‐cancer treatment within the last 4 weeks of surgery. 
6. Subjects who received radiation for colorectal cancer to the abdomen area, prior to the 
planned abdominal surgery. 
7. Subjects who received oral or IV Doxycycline/Tetracycline family antibiotic during the past 4 
weeks prior to randomization. 
8. Subjects with known allergy to Doxycycline and/or to the tetracycline family of drugs or to 
the D‐PLEX's excipients. 
9. Subjects with known allergies to more than 3 substances (an allergy questionnaire will be 
completed during the screening process). 
10. Subjects with history of severe allergic reaction to any substance, having required treatment 
with intravenous steroids/intramuscular epinephrine, or who in the opinion of the PI is at 
high risk of developing severe allergic reactions. 
11. Subjects with End Stage Renal Disease (ESRD/CKD stage 5). 
12. Subjects with severe hepatic impairment. 
13. Subjects with chronic urticaria. 
14. Subjects diagnosed with CVA within the past 6 months prior to randomization. 
15. Subjects that undergone any abdominal surgery and current planned index surgery involves 
re‐opening the scar of a prior abdominal surgery performed within the last 3 years. 
16. Any subject with an active malignancy, other than resectable non‐metastatic colorectal 
cancer, that is the reason for the index surgery, or carcinoma in situ (or other cancer "in situ 
= Stage 0"), or squamous cell carcinoma of the skin or basal cell carcinoma of the skin; or a 
malignancy that has not been in complete clinical remission and without maintenance chemo 
or immunotherapy for at least 3 years.  
17. Subjects with other concurrent severe and/or uncontrolled medical condition. 
 
 
 
22-2-2022
Page 42 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
18. Psychiatric or any other disorder that compromises the ability to provide Informed Consent 
Form for participation in this study. 
19. Chronic alcoholic or drug abuse subjects. 
20. Pregnant or breast‐feeding women or women of child‐bearing age who refuse or are 
prohibited of using an effective contraceptive method of birth control throughout study 
participation, including the safety follow‐up period. 
21. Subjects who received any investigational drug within 30 days or 5 half‐lives prior to 
randomization to the study (whichever is longer) and through the study. 
22. Subjects participating in any other interventional studies. 
23. Subjects, who in the opinion of Investigator, are not eligible to participate in the study 
and/or to comply with protocol requirements (e.g., due to a cognitive or medical condition). 
8.6 CONTRACEPTIVE METHODS 
Women of child bearing potential (WOCBP), will only be included in the study after confirmed 
menstrual period and a negative serum/dipstick pregnancy test. Women of childbearing 
potential (WOCBP) is defined as any woman or adolescent who has begun menstruation. A post‐
menopausal woman is defined as a woman who is over the age of 45 and has not had a 
menstrual period for at least 12 months. 
All WOCBP must agree to use a highly effective contraception method from the following list for 
the duration of the study (until visit 7  Day 60): 
 
Combined (estrogen‐ and progestogen‐ containing) hormonal contraception asso‐
ciated with inhibition of ovulation1 (oral, intravaginal, transdermal) 
 
Progestogen‐only hormonal contraception associated with inhibition of ovulation1 
(oral, injectable, implantable2) 
 
Intrauterine device (IUD)2 
 
Intrauterine hormone‐releasing system (IUS)2  
 
Bilateral tubal occlusion2 
 
Vasectomised partner 2,3 
 
Sexual abstinence4 
1 Hormonal contraception may be susceptible to interaction with IMP, which may reduce the 
efficacy of the contraception method. 
2 Contraception methods that in the context of guidance are considered to have low user 
dependency. 
3 Vasectomised partner is a highly effective contraception method provided that the partner is 
the sole sexual partner of the WOCBP trial participant and that the vasectomised partner has 
received medical assessment of the surgical success. 
 
 
 
22-2-2022
Page 43 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
4 Sexual abstinence is considered a highly effective method only if defined as refraining from 
heterosexual intercourse during the entire period of risk associated with the study intervention. 
The reliability of sexual abstinence needs to be evaluated in relation to the duration of the study 
and the preferred and usual lifestyle of the subject. 
    
Note: The following are not acceptable methods of contraception: 
 
Periodic abstinence (calendar, symptothermal, post‐ovulation methods), withdrawal (coi‐
tus interruptus), spermicides only, and lactational amenorrhea method (LAM). 
 
Male condom with cap, diaphragm, or sponge with spermicide. 
 
Male and female condom should not be used together (due to risk of failure with friction).    
8.7 RECRUITMENT 
Subject recruitment will be conducted in general surgery departments at sites in US, Europe & Israel. 
Recruitment period is expected to take approximately 12 months. 
9 STUDY PROCEDURES & SCHEDULE OF ASSESSMENTS 
9.1 STUDY PROCEDURES  
9.1.1 
Informed Consent Procedure 
An Informed Consent Form (ICF) will be prepared in accordance with the study protocol, ICH 
GCP and any applicable global and national regulations/requirements. The consent will include 
the information that data will be recorded, collected, processed, and may be transferred to 
Competent Authorities. In accordance with the applicable global and national regulations, the 
data will not identify any subjects taking part in the study. 
The final EC/IRB approved ICF and a copy of the approval must be submitted to the Sponsor 
prior to the initiation of subject enrolment at each investigational site. 
Prior to any study‐specific procedure or assessment, all subjects must document their consent, 
in writing, for study participation and authorization for use and disclosure of health 
information by signing the ICF. As part of the consent process, the subject will have the 
opportunity to ask questions and receive answers from the personnel conducting the study 
and will have ample time to consider and consult prior to providing consent to participate in 
the study.   
An original signed copy of the ICF will be retained at the investigational site and a copy of the 
signed consent form will be provided to the subject. 
Procedures conducted as part of the subjects routine clinical management (e.g., imaging) and 
obtained prior to signing of the ICF may be used for screening or baseline purposes provided 
the procedure meets the protocol‐defined criteria and has been performed within the 
timeframe specified in the protocol. 
 
 
 
22-2-2022
Page 44 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
If during the study new information becomes available that can significantly affect the 
subjects future health and medical care, such information shall be provided to the respective 
affected subject in writing.  If relevant, all affected subjects shall be asked to confirm their 
continuing informed consent in writing.   
 
9.1.2 
Screen Failure 
Subjects who sign the ICF, but do not meet the eligibility criteria and were not randomized will 
be considered as screen failures. 
For such subjects, the reason for screen failure will be recorded in the screening log, the Case 
Report Form (CRF) and in the source documents. 
 
9.1.3 
Randomization / Enrolment 
Upon confirmation that the subject fulfils all inclusion criteria and none of the exclusion 
criteria are met, he/she will be randomized through an interactive web randomization system 
(IWRS) integrated with the eCRF, based on subjects information collected during the 
screening period and details of the planned index surgery. 
Randomization will be done centrally using a randomization specification prepared by the 
study statistician and generated by an independent statistician (not involved to the study), 
which will assign subjects in a 1:1 ratio to: 
● Investigational Arm  Standard of Care (SoC) concurrently with D‐PLEX application. 
● Control Arm  SoC treatment alone. 
Randomization will be stratified by type of SoC prophylactic antibiotic regimens 
(prophylactic IV antibiotic with mechanical bowel preparation or prophylactic IV antibiotic 
without mechanical bowel preparation) and by region (US or Europe + Israel).  
Instructions and training for randomization and stratification process will be provided 
during the site initiation visit. 
9.1.4 
Blinding 
This is a double blind clinical trial. The sponsor, the subjects, outcomes assessor and all staff 
involved in the collection and recording of the clinical and laboratory data, based on which the 
independent adjudication committee will perform their assessment, will be blinded to 
treatment assignment. In addition, all aspects of data management and clean‐up will be done 
in blinded datasets. 
 
 
 
22-2-2022
Page 45 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
The study site personnel, who perform the index surgery or re‐intervention procedure (OR 
staff), will be trained not to disclose the treatment arm to the blinded Investigator, or other 
staff members, the subject(s), his/her family, to other health care providers not present during 
the surgery or to the study Sponsor representatives. 
When relevant, unblinded information (e.g., surgery report) will be reviewed by the unblinded 
site team and all reference to the allocated treatment arm will be removed, prior to filing of 
the relevant document to the patient study file. 
Wound assessment, AE assessment and other study outcomes throughout the study follow‐up 
visits will be done by a blinded Investigator, who will not be involved in the surgery. 
All blinded /unblinded activities are described in each sites blinding plan. 
An emergency card containing the Study Name, NIH number, Center Name/number, PIs name 
and contact details will be provided to the subjects. Subjects will be instructed to keep this 
card with them at all times and present it to medical staff in case of a medical urgency. 
 
9.1.5 
Emergency Unblinding 
As a general rule, code breaks should occur only in exceptional circumstances when revealing 
of the actual treatment is absolutely essential for further management of the subject. For each 
study subject there is at least one Investigator (treating surgeon) that is unblinded to the study 
treatment. In occasion this person is unavailable and unblinding is deemed necessary and 
emergent, unblinding could be done by the unblinded Sponsor representative (24/7 support 
via phone call).  
In general, the actual allocation will be not disclosure to the subject. In case it will be 
necessary for the subjects safety, the Investigator will disclose the actual treatment 
information to the said subject. 
The Investigator is requested to maintain the blinding as much as possible. Investigators are 
encouraged to discuss unblinding in advance with a Sponsor's representative if he/she believes 
that unblinding is necessary. The actual treatment allocation must NOT be disclosed to the 
subject and/or other blinded study personnel including blinded site personnel, monitors, 
corporate Sponsors or project office staff. 
The Investigator must report all code breaks (with reason) as they occur to the study monitor. 
 
 
 
 
 
 
 
22-2-2022
Page 46 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
9.1.6 
Assessment of the Infection Rate 
Infection rate is measured by the proportion of subjects with an SSI event, determined by the 
blinded and independent adjudication committee, within 30 days post abdominal surgery. All‐
cause mortality within 30 days post index surgery, will be analysed as treatment failure. The 
blinded and independent adjudication committee review will include all index surgery 
incisions, regardless of any re‐intervention at the target site (i.e. re‐opening of the surgery 
incision, used for the original index surgery), for the determination of infection status. 
SSI is composed of Deep SSI and/or Superficial SSI. 
Superficial incisional SSI ‐  
Infection involves only skin and subcutaneous tissue of the 
incision and does not include diagnosis/treatment of cellulitis, a 
stitch abscess alone or a localized stab wound or pin site infection. 
Deep incisional SSI ‐  
Infection involves deep tissues, such as fascia and muscle layers; 
this also includes infection involving both superficial and deep 
incision sites. 
An organ/space SSI (e.g. infection/abscess in the operated organ or peritoneal cavity) is 
excluded and will not be accounted as an endpoint event. 
SSI will be identified by the predefined criteria based on CDC/NHSN Patient Safety Component 
Manual (January 2020, chapter 9). 
Superficial Incisional SSI must meet the following criteria: 
Date of event for infection occurs within 30 days after any NHSN operative procedure (where 
Day 1 = the procedure date) 
       AND 
  Involves only skin and subcutaneous tissue of the incision 
 AND 
  Patient has at least one of the following: 
a) 
Purulent drainage from the superficial incision 
b)  
Organisms identified from an aseptically‐obtained specimen from the superficial 
incision or subcutaneous tissue by a culture or non‐culture based microbiologic testing 
method which is performed for purposes of clinical diagnosis or treatment (for example, 
not Active Surveillance Culture/Testing (ASC/AST)). 
c) 
Superficial incision that is deliberately opened by a surgeon, physician or physician 
designee and culture or non‐culture based testing of the superficial incision or 
subcutaneous tissue is not performed 
       AND 
 
 
 
22-2-2022
Page 47 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
Patient has at least one of the following signs or symptoms: (1) localized pain or 
tenderness, (2) localized swelling, (3) erythema or (4) heat.   
d) 
Diagnosis of a Superficial Incisional SSI by the blinded investigator. 
*The following do not qualify as criteria for meeting the NHSN definition of superficial incisional 
SSI: 
 
Diagnosis/treatment of cellulitis (redness/warmth/swelling), by itself, does not meet criterion 
for superficial incisional SSI. Conversely, an incision that is draining or that has organisms 
identified by culture or non‐culture based testing is not considered a cellulitis. 
 
A stitch abscess alone (minimal inflammation and discharge confined to the points of suture 
penetration). 
 
A localized stab wound or pin site infection is not considered an SSI; depending on the depth, 
these infections might be considered either a skin (SKIN) or soft tissue (ST) infection. 
Deep Incisional SSI must meet the following criteria: 
The date of event for infection occurs within 30 days after the operative procedure (where 
Day 1 = the procedure date) 
       AND 
Involves deep soft tissues of the incision (e.g., fascia and muscle layers) 
        AND 
Patient has at least one of the followings: 
a)     Purulent drainage from the deep incision.   
b)     A deep incision that spontaneously dehisces, or is deliberately opened or aspirated by 
a physician and organism is identified from the deep soft tissues of the incision by a culture 
or non‐culture based microbiologic testing method which is performed for purposes of 
clinical diagnosis or treatment (for example, not Active Surveillance Culture/Testing 
(ASC/AST)) or culture or non‐culture based microbiologic testing method is not performed. 
A culture or non‐culture based test from the deep soft tissues of the incision that has a 
negative finding does not meet this criterion. 
               AND 
              Patient has at least one of the following signs or symptoms: (1) fever (>38°C); (2) 
localized pain or (3) tenderness. 
  c)     An abscess or other evidence of infection involving the deep incision that is detected        
on gross anatomical or histopathologic exam, or imaging test. 
 
 
 
 
22-2-2022
Page 48 of 99
Effective




 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
9.1.9 
Adverse Events 
The Investigator and site staff are responsible for detecting, documenting, and reporting 
events that meet the definition of an AE.  
AEs will be collected from randomization, throughout the study, and until study termination at 
visit 7 (60 days after surgery).  AEs suspected to be related to the IP should be followed up 
until resolution or permanent outcome. 
Details on AE detecting, documenting, and reporting can be found in section 10. 
 
The study sponsors medical representative will review and assess SAEs and  AEs suspected to 
be related to investigational medicinal product. 
The sponsor will adjudicate if a safety report meet the definition of SUSAR, based on the 
applicable regulations. Details on SUSAR reporting can be found in section 10.10 REPORTINGS 
OF SUSARs.    
In case of dispute between the Investigator and the sponsor, the more severe assessment will 
prevail. 
SSI will be handled as AEs and will be followed by the protocols applicable sections for AE 
collection and reporting. Symptoms of SSI that do not meet an SSI diagnosis will be reported as 
AEs. 
Pregnancy will be reported using a specific form and will be followed up until resolution. 
The Data Monitoring Committee (DMC) will review all study safety data periodically until last 
subject last visit and provide its recommendation to the Sponsor if study may continue based 
on subjects' safety and any other ethical consideration as applicable.  
Details on AE definition, assessment and reporting can be found in section 10.5 RECORDING 
& REPORTING OF ADVERSE EVENTS & REACTIONS.   
 
9.1.10 Laboratory Examinations 
All protocol‐required laboratory assessments must be conducted in accordance with the 
Central Laboratory Manual and Protocol Time and Events Schedule. 
If any local laboratory assessments are performed during the course of the trial and they result 
in a change in subject management (for example due to a S/AE) the assessment data must be 
recorded in the subjects eCRF. 
9.1.11 Central Laboratory 
Complete clinical chemistry and hematology samples will be collected and shipped to the ICON 
Central Laboratory.  
 
 
 
 
 
22-2-2022
Page 50 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
Laboratory requisition forms must be completed, and samples must be clearly labelled with 
the subject number, protocol number, site/ center number, and visit date. Details regarding 
the preparation and shipment of samples, and a list of reference ranges for all safety 
parameters will be provided by the central laboratory in the Central Laboratory manual.   
Clinical Chemistry Parameters 
Albumin 
Alkaline Phosphatase 
Alanine Transaminase (ALT) 
Aspartate Aminotransferase (AST) 
Blood Urea Nitrogen (BUN) 
Calcium 
Chloride 
Creatinine 
C‐Reactive Protein (CRP) 
Glucose 
Lactate Dehydrogenase (LDH) 
Phosphate 
Potassium 
Sodium 
Total Bilirubin 
Total Protein 
Creatinine Phosphokinase (CPK) 
Hematology Parameters 
Red Blood Cell (RBC) Count 
Hemoglobin (HGB) 
Hematocrit (HCT) 
Platelet Count 
White Blood Cell (WBC) Count 
WBC Differential (expressed as % and as absolute): 
Basophils 
Eosinophils 
Lymphocytes 
Monocytes 
Neutrophils 
 
 
 
22-2-2022
Page 51 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
9.1.12 Local Laboratory 
Accreditations and reference range will be collected for all local laboratories and thereafter 
defined in the eCRF. 
The following laboratory tests will be performed and analysed at the Screening visit and for 
baseline status only.  
 
Coagulation Parameters  to be done at Screening visit 
Prothrombin Time (PT) 
Activated Partial Thromboplastin Time (aPTT) 
International Normalized Ratio (INR) 
Urinalysis  to be done at Screening visit and as per Investigator discretion 
pH 
Specific Gravity 
Protein 
Glucose 
Bilirubin 
Ketones 
Nitrites 
Leukocytes 
Erythrocytes 
Pregnancy test (β‐HCG) by serum or urine dipstick at screening only, will be performed in 
female subjects of child‐bearing potential only.  
Any abnormal laboratory finding compared to baseline, assessed by the Investigator as 
clinically significant, should be recorded as an AEs in the relevant eCRF form. 
 
9.1.13 Bacteriological Testing ‐ (Should be Taken in Any Case of Suspected Infection Before 
Starting Antibiotic Treatment)   
Bacteriological tests (from the surgical site drainage) will be performed in order to assess 
infection at the abdomen surgical target incision site. 
Bacteriological tests from the wound will be taken if there is a wound discharge. 
The test kit will be forwarded to ICON Central Laboratory where bacterial growth, 
identification and sensitivity to Doxycycline and other common practice antibiotics, will be 
assessed. 
Results will be reported back to the referring Investigator. 
 
 
 
22-2-2022
Page 52 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
Any abnormal finding, assessed by the Investigator as clinically significant, should be recorded 
as an AE in the eCRF. 
9.1.14 Physical Examination 
The Investigator will perform a complete physical examination of the major body systems and 
will assess whether the subject experiences Doxycycline reactions or other allergies. 
Any abnormal finding, compared to baseline, should be recorded as an AE in the eCRF. 
9.1.15 Vital Signs 
Systolic/diastolic blood pressure, heart rate, & temperature measurements will be performed 
at each visit after 5 minutes of rest. 
Weight and height will be measured, or the subject will be asked for this information at 
screening/admission. 
All measurements and the time of measurements will be recorded in the eCRF. 
Any abnormal finding in the vital signs measurements stated above, assessed by the 
Investigator as clinically significant, should be recorded as an AE in the eCRF. 
9.1.16 Medical History  
Demographic data and a complete medical history of relevant past and present illnesses and 
surgeries as well as medications currently being taken to treat current illnesses will be 
recorded by the Investigator. 
The medical history will include alcohol consumption, tobacco use, concurrent diseases, 
detailed allergy status (an allergy questionnaire will be completed) and assessment of possible 
infection. Based on the medical history, a Charlson co‐morbidity index questionnaire will be 
completed for each potential subject. 
Subjects with known allergy to Doxycycline and/or tetracycline family of drugs, or to D‐PLEX's 
excipients should be excluded. 
9.1.17 Allergy Questionnaire 
An allergy questionnaire will be completed at screening as part of the subjects medical 
history. 
9.1.18 Assessment of Surgical Site 
A blinded Investigator/assessor will inspect the surgical site and assess the healing of the 
surgical wound. Special attention should be paid for signs of infection. The Investigator should 
follow the protocol guidelines for assessment of SSI (see section 9.1.6 above). 
Surgical site assessment questionnaire, that includes potential symptoms of incision infection 
 
 
 
22-2-2022
Page 53 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
according to CDC criteria and ASEPSIS scoring, as well as modified Vancouver questionnaire1 
will be completed by the assessor. 
To help the independent and blinded adjudication committee, in cases of a suspected infected 
wound, the assessor is asked to take a photographic picture of the incision area only, using 
their cellular phone per instructions provided as a separate manual. The photo(s) should 
include the incision area with a sticker of the subject study number and date only and 
uploaded to a save location according to the instructions in the manual.  
Every caution is to be made not to disclose any of the subjects' personal data or features such 
as tattoos.  
Every effort must be made to assess the incisional surgical site at every visit. In case a subject 
is un‐ willing or unable to attend a scheduled visit, a phone conversation should be conducted 
with the subject, his first degree family relative or community physician and assessment of the 
wound per CDC should be done.   
 
9.1.19 ASEPSIS: (Additional Treatment, Serous Discharge, Erythema, Purulent Exudate, 
Separation of Deep Tissue, Isolation of Bacteria, Stay Duration as Inpatient) Scoring 
Method 
ASEPSIS is an acronym of wound assessment and treatment parameters, which provides 
numerically score during an inspection of the surgical site. The final score is being interpreted 
to severity of wound appearance and the clinical consequences of the infection. 
Parameters are: serous exudate, erythema, purulent exudate, separation of deep tissue and 
also antibiotic therapy, drainage of pus under local/ general anaesthesia, isolation of 
pathogenic bacteria and stay as inpatient. 
 
 
9.1.20 Pharmacokinetics 
Doxycycline pharmacokinetic sampling will be collected in selected sites from all randomized 
subjects in these sites. About
 series of 
 samples per set will be analyzed (sites from Czech 
Republic will not participate in the PK sub‐study). About 
series will be analyzed from 
subjects receiving 2 vials, about 
series will be analyzed from subjects receiving 3 vials.   
Pharmacokinetic samples of 
 blood will be collected at each PK time point, prepared and 
shipped to the central laboratory. 
 
 
 
1 Modified Vancouver questionnaires will be completed following wound closure 
 
 
 
22-2-2022
Page 54 of 99
Effective




 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
 
Assign (from the eCRF) a sequential subject number. If a subject is withdrawn from the 
study or fails to undergo the treatment procedure, the subject number cannot be 
reassigned. 
 
Record demographics (including age, gender, etc.) 
 
Record medical history, and complete a Charlson co‐morbidity index.  
 
Complete allergy questionnaire. 
 
Record concomitant medications. 
 
Measure height, weight and vital signs (body temperature, heart rate & blood pressure). 
 
Perform physical examination. 
 
Hematology and Chemistry for Central Laboratory *. 
 
Coagulation and Urinalysis in local lab (tests done at the local lab performed as a routine 
procedure within 21 days prior to surgery and before ICF signature may be used for 
eligibility determination). 
 
Pre‐application Doxycycline PK sampling at selected sites. 
 
Pregnancy test (if applicable) ‐ local serum test or urine dipstick should be performed not 
more than 1 day before surgery.  
 
Record baseline conditions and planned procedures (any future planned elective 
procedure should be recorded so it will not be considered an S/AE). 
 
Eligibility determination according to inclusion and exclusion criteria 
 *Pregnancy test should be performed not more than 1 day before surgery. 
9.2.2 
Visit 2: Surgery  Index Procedure (Day 0) 
Subjects will be enrolled into the study and will be treated with D‐PLEX concomitantly with 
SoC or SoC alone. 
The SoC for prophylactic antibiotic treatment, used in this study, is based on international 
guidelines3,19. It will be consistently standardized for all sites in the clinical study and is 
composed of IV antibiotic immediately prior to surgery, with or without mechanical bowel 
preparation in the preceding several days. Each site will use the same pre‐defined SoC for all 
its subjects during the study. The IV antibiotic treatment will be composed of the 1st or 2nd 
generation of Cephalosporin family and Metronidazole given within 60 minutes before surgery 
and should be discontinued maximum 24‐hour post‐surgery. In case of allergy to the 
Cephalosporin/Penicillin families or Metronidazole, other IV antibiotic may be used. Pre‐
operation prophylactic oral antibiotic is not allowed.  Mechanical bowel preparation will be at 
the discretion of the PI per each site's SOP.  
  
 
 
 
22-2-2022
Page 56 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
The following will be performed during visit 2: 
 Confirmation of eligibility 
 
Randomization via the eCRF system (For surgery planned for early morning time, 
randomization via the eCRF could be done a day in advance). 
 
Vital signs before surgery unless taken for screening occurring on the day of surgery. 
 
Pre‐application Doxycycline PK sampling (selected sites, if not done during screening) 
 
Abdominal Surgery 
 
D‐PLEX administration (only for subjects randomized to D‐PLEX treatment arm) at the 
stage of closure of the abdominal wall surgical incision  
 
Post‐application Doxycycline PK sampling (at 2h & 6h)  selected sites 
 
AEs assessment and recording 
 
Concomitant Medication Review 
 
9.2.3 
Visits 3  6: Follow‐Up Visits (Days 1, 5 ,14 & 30 Post‐Surgery) 
Post‐operative care will be performed per SoC. Post‐operative resumption of activity is at the 
discretion of the Investigator based on the subject medical condition. 
The subsequent follow‐up visits (visits 3‐5) will take place at Day 1, Day 5 and Day 14 post‐
surgery. These visits are usually performed after this type of surgery. 
The additional follow‐up visit (visit 6) will take place 30 days post‐surgery and is required by 
the study, i.e., in addition to the routine visits usually performed after this kind of surgery. 
During all the above‐mentioned visits, the following procedures will be performed: 
 
Vital signs 
 
Assessment of surgical site, including visual examination: 
o Surgical Site Assessment questionnaires (only if wound is not dressed).  
o Modified Vancouver questionnaires will be completed following wound closure 
from day 14 onwards. 
 
Hematology and Chemistry for Central Laboratory 
 
Post‐application Doxycycline PK sampling  selected sites 
 
AEs assessment and recording 
 
Concomitant Medication Review 
 
Physical examination at visit 6 (Day 30) only  
 
Urinalysis will be performed only at the discretion of the Investigator. 
 
Bacteriology cultures will be taken if there is wound discharge.   
 
 
 
 
 
22-2-2022
Page 57 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
9.2.4 
Unscheduled Visit(s) 
An unscheduled visit may be performed at any time during the study at the subject's request 
or as deemed necessary by the Investigator.  
 
The date and reason for the unscheduled visit will be recorded.  
 
Assessment of surgical site,  
 
Vital signs,  
 
AEs  
 
Concomitant medications.  
 
In addition, any procedures and evaluations may be performed as deemed necessary by 
the Investigator for the subject's safety. 
This visit should be recorded in the eCRF, including all related procedure. 
 
9.2.5 
Visit 7 ‐ End of Study (60 Days Post‐Surgery) 
 
Vital signs 
 
Assessment of surgical site 
 
Hematology and Chemistry for Central Laboratory  
 
Post‐application Doxycycline PK sampling  selected sites 
 
AEs assessment and recording 
 
Concomitant Medication Review 
 
Physical examination 
 
Bacteriology cultures (if required) 
 
9.2.6 
Study Assessments Summary 
Table 1 details all planned study visits and assessments.
 
 
 
22-2-2022
Page 58 of 99
Effective




 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
9.3 DEFINITION OF END OF TRIAL 
Total duration of the study is expected to be approximately 12 months from first subject 
enrolled until last subject completed. The end of the trial will be the 60‐days final follow‐up visit 
for the last enrolled subject. 
9.4 DISCONTINUATION/WITHDRAWAL OF PARTICIPANTS & STOPPING RULES 
Every effort will be made to follow all subjects and collect their data until the end of the study. 
Subjects participation in a clinical trial is voluntary, and the subject has the right to withdraw 
consent at any time without penalty, loss of benefit or prejudice to further treatment. 
Although a subject is not obliged to give his/her reason(s) for withdrawing prematurely 
from a trial, the investigator should make a reasonable effort to ascertain the reason(s), while 
fully respecting the subject's rights. 
In the event a subject withdraws consent, every effort should be made to have the subject 
return for a final study follow‐up assessment and the information identified for collection at the 
60 days follow‐up visit will be obtained to the extent possible. Withdrawn subjects will not be 
replaced (the justified sample size considers an estimated allowance for attrition). 
The reason for early termination should be recorded in the subjects medical records and in the 
eCRF.  If more than one reason is cited for withdrawal, study personnel should identify the 
most significant reason.   
The Investigator may discontinue a subject from participation in the study if the Investigator 
feels that the subject can no longer fully comply with the requirements of the study or if any of 
the study procedures are deemed potentially harmful to the subject. 
The Sponsor may suspend or prematurely terminate this study either in an individual 
investigational site, or the entire study. Reasons for suspending or early terminating the study 
by Sponsor should be justified, documented and reported as applicable. 
EC/IRB or regulatory authority may suspend or prematurely terminate participation in the study 
at the investigational sites for which they are responsible. 
If suspicion of an unacceptable risk to subjects arises during the study, or when so instructed by 
the EC/IRB or regulatory authorities, the Sponsor shall suspend the clinical trial while the risk is 
assessed. The Sponsor shall terminate the study if an unacceptable risk is confirmed. 
Data that has already been collected on withdrawn subjects will be retained and used for 
analysis, but no new data will be collected after withdrawal. 
 
 
 
22-2-2022
Page 60 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
10  NAME & DESCRIPTION OF ALL DRUGS USED IN THE TRIAL 
D‐PLEX is the IP to be administered in this study. A comprehensive description is provided below. No 
additional drugs will be administered as part of the requirements of this clinical study. 
10.1 STUDY TREATMENT D‐PLEX 
10.1.1 Product Description 
D‐PLEX is a new formulation of extended release of Doxycycline. The total percentage of 
Doxycycline hyclate in D‐PLEX is 
 which is equivalent to 
Doxycycline free base. 
Doxycycline is being constantly released for approximately 4 weeks following 
administration. D‐PLEX is biodegradable. 
D‐PLEX is indicated for prevention of post abdominal surgery incisional infection. 
This product is a sterile powder and is intended for a single use. Each 10ml vial contains 5g 
of D‐PLEX. 
10.1.2 Product Composition 
D‐PLEX contains the following substances: 
Substance 
Description 
Doxycycline hyclate 
Antibiotic 
 
Release system 
 
 
10.1.3 Product Handling (storage & preparation) 
D‐PLEX is supplied as sterile powder to be reconstituted to paste in the OR and is intended for 
a single administration. 
D‐PLEX cannot be injected! 
Each 10‐ml vial contains 5g of D‐PLEX. 
D‐PLEX should be stored at 2‐8°C. 
The product can be kept at room temperature for up to 12h until use (before vial opening). 
Avoid exposure to extreme heat. 
D‐PLEX powder will be hydrated in a bowl, using standard aseptic techniques, with sterile 
saline, immediately before administration, following the instruction described here: 
 
 
 
 
22-2-2022
Page 61 of 99
Effective




 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
be administered should be poured into the same bowl. 
 
10.1.3.1 Product Preparation ‐ Step 2: 
To be conducted by a sterile nurse / surgeon: 
12. Slowly hydrate the D‐PLEX powder in the bowl with the following volume of sterile 
saline:    
D‐PLEX powder from 2 vials should be hydrated with 3.5ml of sterile saline. 
D‐PLEX powder from 3 vials should be hydrated with 5ml of sterile saline. 
13. Do not over hydrate. 
14. Mix the D‐PLEX powder, with sterile saline using a sterile spatula, for approximately 
1 minute, reaching a uniform paste appearance. 
15. In case over hydration occurred and the paste is too diluted to be applied, discard it 
and return to Step 1 for new preparation of the D‐PLEX paste. 
 
10.1.3.2 Product Administration ‐ Step 3:   
This step should be done by the operating surgeon. 
 
16. 
The paste is to be applied by the surgeon, after wearing a new set of sterile gloves. 
17. 
Administer the whole quantity of the D‐PLEX reconstituted paste immediately 
after hydration and mixing. The paste should be spread on the entire surface of 
each side of the abdominal incisional wall, along the whole length of the surgical 
wound (including muscle, fat, and dermis).  
Do not apply on top of the skin and above the suture line. 
18. 
In case application was not done immediately and the paste is over diluted, 
discard the paste and return to Step 1 with new vial(s) (package).   
19. 
Packages (all 3 vials and box) should be kept for inventory documentation 
purposes and returned to the unblinded study coordinator after each surgery. 
 
10.1.4 Product Usage and Dosage 
The product is to be administered on a single occasion prior to surgical wound closure 
following abdominal surgical procedures, as an adjunct to the SoC treatment. The total dose 
applied at the surgical site will be determined based on the surgical incision length. A 
maximum of three vials (15g) may be administered. Therefore, the total amount of 
Doxycycline free base for a single surgical procedure with D‐PLEX can reach up to 163.8mg. 
 
 
 
22-2-2022
Page 63 of 99
Effective




 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
15 gr per subject) in a single application. It is not expected to occur during the study as no 
more than maximum of 3 vials will be dispensed per subject. 
Overdose of D‐PLEX will be recognized by the report of number of vials used as documented 
by the operation room (OR) team. 
In case of an overdose or adverse drug reaction, treat symptomatically and institute 
supportive measures. Dialysis does not alter serum half‐life and thus would not be of benefit 
in treating cases of overdose. Per surgeon decision, the administered D‐PLEX can be removed 
by re‐exploring the surgical incision and washing out the D‐PLEX. 
All overdoses should be recorded and notified to the Sponsor.  
If an SAE is associated with the overdose, the PI should ensure the overdose if fully described 
in the SAE report form. 
Information on adverse drug reactions of D‐PLEX are provided in the IB. 
10.1.9 Packaging 
D‐PLEX is aseptically packed in sterile, de‐pyrogenated amber (brown) glass vial and closed 
with a sterile and de‐pyrogenated rubber stopper and aluminium flip‐off cap. 
Please note that the outer surface of the vial is not sterile. Only the vial content is sterile. 
 
10.2 CONCOMITANT MEDICATION 
10.2.1 Medication(s)/ Treatment(s) Permitted 
Antibiotics Treatment per SoC allowed in this Protocol: 
 
Prophylactic IV antibiotics as per protocol.  
 
Additional antibiotics (excluding Doxycycline) for the treatment of medical history 
condition or AE. 
10.2.2 Medication(s) Prohibited During the Trial 
 
Additional prophylactic antibiotics (including antimicrobial sutures).  
 
High steroids dose (more than 80mg per day).  
 
Doxycycline administration during the entire trial period. 
 
Any additional investigational drug 
 
10.3 PREPARATION & LABELLING OF INVESTIGATIONAL PRODUCT (IP) 
The Investigational Product (IP) is manufactured aseptically at
, at a 
Grade A (ISO 5) clean room. The IP will be provided to the investigational site by 
 via 
. upon EC/IRB approval of the protocol and the ICF, Investigator Agreement is 
signed, and all key documents required by GCP and local regulation have been collected. 
D‐PLEX is provided as a sterile and primarily packaged in a de‐pyrogenated inert glass amber vial 
 
 
 
22-2-2022
Page 65 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
(10 ml), and each product vial contains 5g of D‐PLEX.  The sterile vial is packaged in a carton box. 
Preparation and labelling of the IP will be completed in accordance with the relevant GMP 
guidelines. 
Information on the Product Handling (storage & preparation) can be found in section 0 of this 
protocol. 
 
10.4 DRUG ACCOUNTABILITY 
The Investigator or designee (i.e., SC, pharmacist) is responsible for ensuring adequate 
accountability of all used and unused study drug. This includes acknowledgment of receipt of 
each shipment of study product (quantity and condition) and recoding of subject dispensing, 
returned or destroyed study product. Dispensing records will document quantities received from 
the Sponsor and quantities dispensed to subjects, including lot number, date dispensed, subject 
identifier number, and the name of the person dispensing the medication. 
All drug supplies and associated documentation will be periodically reviewed and verified by the 
study monitor over the course of the study. 
Investigators will be notified in writing of enrolment completion. All unused D‐PLEX vials must be 
returned to the Sponsor when enrolment is complete according to Sponsors instructions. 
10.5 RECORDING & REPORTING OF ADVERSE EVENTS & REACTIONS 
The Investigator or designated site staff will be responsible for detecting, documenting and 
reporting events that meet the definition of an AE or SAE. 
10.6 DEFINITIONS 
10.6.1 Adverse Event (AE) 
Any untoward medical occurrence in a patient or clinical investigation subject administered a 
pharmaceutical product and which does not necessarily have a causal relationship with this 
treatment.  
NOTE: An AE can therefore be any unfavourable and unintended sign (including an abnormal 
clinically significant laboratory finding), symptom, or disease (new or exacerbated) temporally 
associated with the use of a medicinal product. 
 
Examples of events meeting the definition of an AE include: 
● Exacerbation of a chronic or intermittent pre‐existing condition including either 
an increase in frequency and/or grade of the condition. 
● 
New conditions detected or diagnosed after study treatment administration even 
though it may have been present prior to the start of the study. 
● 
Signs, symptoms, or the clinical sequelae of a suspected interaction of study 
medication with any other treatment provided to the subject. 
 
 
 
22-2-2022
Page 66 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
● 
Signs, symptoms, or the clinical sequela of suspected overdose of either study 
treatment or a concomitant medication (overdose per se will not be reported as 
an AE). 
Lack of efficacy or failure of expected pharmacology action per se will not be reported as 
an AE or SAE. However, the signs and symptoms and/or clinical sequelae resulting from lack of 
efficacy will be reported if they fulfil the definition of an AE or SAE. 
Events that do not meet the definition of an AE include: 
● 
Medical or surgery procedure (e.g. endoscopy, appendectomy); the condition 
that leads to the procedure should be recorded as an AE. 
● 
Situations where an untoward medical occurrence did not occur (social and/or 
convenience admission to a hospital). 
● 
Anticipated day‐to‐day fluctuations of pre‐existing disease(s) or condition(s) 
present or detected at the start of the study that do not worsen. 
● 
The disease/ disorder being studied, or expected progression, signs, or symptoms 
of the disease/ disorder being studied, unless more severe than expected for the 
subjects condition. 
10.6.2 Adverse Drug Reaction (ADR) 
Any untoward and unintended response in a subject to an investigational medicinal product 
which is related to any dose administered to that subject. The definition implies a reasonable 
possibility of a causal relationship between the event and the IP. 
This  includes  medication  errors,  uses  outside  of  protocol  (including  misuse  and  abuse  of  
product).  
10.6.3 Serious Adverse Event (SAE) 
SAE is any untoward medical occurrence that, at any dose: 
● 
Death or Results in death 
● 
Is life‐threatening 
NOTE: The term life‐threatening in the definition of serious refers to an event in 
which the subject was at risk of death at the time of the event. It does not refer to 
an event, which hypothetically might have caused death, if it was more severe. 
● 
Requires hospitalization or prolongation of existing hospitalization. 
NOTE: In general, hospitalization signifies that the subject has been detained 
(usually involving at least an overnight stay) at the hospital or emergency ward for 
observation and/or treatment that would not have been appropriate in the 
physicians office or outpatient setting. Complications that occur during 
hospitalization are AEs. If a complication prolongs hospitalization or fulfils any 
other serious criteria, the event is serious. When in doubt as whether 
hospitalization occurred or was necessary, the AE should be considered serious. 
Hospitalization for elective treatment of a pre‐existing condition that did not 
worsen from baseline is not considered an SAE. 
 
 
 
22-2-2022
Page 67 of 99
Effective






 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
10.7.5 Seriousness 
Seriousness as defined for an SAE in section 10.6.3. 
 
10.8 DOCUMENTATION AND REPORTING OF SAE AND SSI 
All SAEs and SSIs should be reported to the Sponsor within 24 hours of knowledge by a blinded 
investigator. 
SAEs will be reported through the study eCRF. In case the eCRF is not available, the  blinded 
investigator will complete the Sponsors SAE form and the form will be emailed to the Sponsor 
to the following email: 
 within 24 hours of knowledge. 
It is the PIs responsibility to ensure SAE queries raised by the Sponsor are responded as soon as 
possible. 
The information should be completed as fully as possible and contain: 
1. SAE Term  if diagnosis was provided, the SAE term should be the diagnosis, 
otherwise, symptoms should be reported as separated AE/SAEs.  
2. SAE onset date ‐ report the start date the event became SAE.  
3. SAE end date ‐ Report the date the subjects medical condition resolved or 
stabilised, or the date of discharge from hospital.  
Should signs and symptoms continued following discharge, report them as an AE  
4. Seriousness criteria 
5. Severity (mild, moderate, severe) 
6. Relatedness to the surgical procedure 
7. Relatedness to the IP (Related/Not Related) 
8. Action taken to resolve the SAE (e.g. Treatment, Other Action) 
9. Outcome (Ongoing, Resolved with Sequelae, Resolved, Death) 
10. SAE Narrative ‐ brief and comprehensive, including clinical symptoms and 
accompanied with a simple, brief description of the event, Lab data results, 
timelines and other important information.  
10.9 TIME PERIOD AND FREQUENCY FOR REPORTING AES  
The Investigator and site staff are responsible for detecting, documenting, and reporting events 
that meet the definition of an S/AE. or  
AEs will be collected from the time of randomization throughout the study, and until study 
termination at visit 7 (60 days after surgery). 
In addition, any SAE assessed as related to study participation (e.g., protocol‐mandated 
procedures, invasive tests etc.), will be recorded from the time subject consents to participate in 
the study. 
After the termination of the clinical trial, newly reported SAEs which are suspected to be related 
to the IP by the study PI, and therefore reported to the Sponsor will be collected, documented, 
and reported as required by local and global regulations. 
 
 
 
22-2-2022
Page 70 of 99
Effective




 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
10.11 DEVELOPMENT OF SAFETY UPDATE REPORTS 
The Sponsor will prepare a Development Safety Update Report (DSUR) on an annual basis and 
submit it to ECs/IRBs and the Ministry of Health/Regulatory Authority per local and global 
regulations. The DSUR will contain an annual review and evaluation of pertinent safety 
information collected during the reporting period related to the IP. 
10.12 THE TYPE & DURATION OF THE FOLLOW‐UP OF SUBJECTS AFTER AES 
AEs not related to the study product should be followed up until resolution, permanent outcome 
or subjects study termination, whichever is earliest. 
AEs suspected to be related to the IP should be followed up until resolution or permanent 
outcome. 
For SAE ‐ in case relevant information is not available at the time when the first report becomes 
available, the Investigator should report the known information within 24 hours of first 
awareness. Once additional information is received, the Investigator should fill in the missing 
follow‐up information in the eCRF within 24 hour of the awareness of the new available 
information. 
It is the responsibility of Investigators to inform the local Ethics Committee of SAEs (whether IP 
related or not) as required by the local Ethics Committee procedure and regulation. 
11  NOTIFICATION OF PROTOCOL DEVIATION 
The Investigator is responsible for ensuring the study is conducted in accordance with the 
procedures and evaluations described in this protocol. 
It is within the site's Sponsor to notify the regulatory authority in writing of any serious breach 
of (i) The conditions and principles of GCP in connection with that trial; or (ii) The protocol 
relating to that trial, as amended from time to time, within 7 days of becoming aware of that 
breach. 
The Sponsor will be notified immediately of any case where the above definition applies during 
the trial.   
12 DATA MANAGEMENT & QUALITY ASSURANCE 
12.1 
CONFIDENTIALITY 
The eCRF will not bear the subjects name or other personal identifiable data. The subjects date 
of birth and trial unique identification number will be used for identification. 
12.2 
DATA COLLECTION TOOLS & SOURCE DOCUMENT IDENTIFICATION 
Primary data collection based on source‐documented hospital and/or clinic chart reviews will be 
performed clearly and accurately by site personnel trained on the clinical trial protocol and eCRF 
completion. The Sponsor or designee will perform clinical monitoring throughout the study. 
It is the responsibility of the Investigator to ensure the accuracy, completeness, legibility, and 
timeliness of all data reported to the Sponsor in the eCRFs and in all required reports. 
 
 
 
22-2-2022
Page 72 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
12.3 
DATA HANDLING & ANALYSIS 
The procedures for data review and query management are described in the Data Management 
Plan and the Edit Checks Specification Table. Data will be reviewed throughout the study, in a 
blinded manner, according to these documents. 
Data will be collected using eCRFs that are specifically designed for this study. The data collected 
on the eCRFs will be captured in a clinical data management system (CDMS) that meets the 
technical requirements described in 21 CFR Part 11 and EU regulations. The CDMS will be fully 
validated to ensure that it meets the scientific, regulatory, and logistical requirements of the 
study before it is used to capture data from this study. Before using the CDMS, all users will 
receive training on the system and study‐specific training. After they are trained, users will be 
provided with individual system access rights. 
Data will be collected at the investigational center by appropriately designated and trained 
personnel, and eCRFs must be completed for each screened subject according to their source 
documents.  
Subject identity should not be discernible from the data provided on the eCRF. 
A comprehensive validation check program will verify the data and automatically generate 
discrepancies for resolution by the Investigator. 
Data will be verified using the source data by the study monitor and reviewed for consistency by 
data management using both automated logical checks and manual review.   
All data collected will be approved by the Investigator at the investigational center. This approval 
acknowledges the Investigators review and acceptance of the data as being complete and 
accurate. 
13 RECORD KEEPING & ARCHIVING 
The investigator shall arrange for the retention of all study records for at least 15 years after 
completion of the study. 
The Investigator should ensure that the following records are maintained: 
1. Subject files containing copies of completed Case Report Forms and supporting 
documentation and the signed ICFs. 
2. Investigator files containing copies of the documents required for the initiation of the study 
(e.g. signed Investigators Agreement, Curricula Vitae for the principal and all sub‐
Investigators, copy of the EC/IRB approval of the protocol and Informed Consent Form, 
copies of correspondence with the CRO/Sponsor etc.). In addition to these records required 
by regulations, the Sponsor requests that the Investigator keep a copy of the Financial 
Agreement between CRO/Sponsor and the Investigator. 
3. Files containing copies of the Investigational Medicinal Product Accountability Log (IPAL) or 
an equivalent form approved by CRO/Sponsor, and the Investigators Brochure. 
No records will be destroyed without the written consent of the Sponsor. It is the responsibility 
of the Sponsor to inform the Investigator when these documents no longer need to be retained. 
 
 
 
22-2-2022
Page 73 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
14 STATISTICAL ANALYSIS CONSIDERATIONS  
This protocol describes the statistical analysis as it is foreseen at the time of planning the study. A 
fully detailed Statistical Analysis Plan (SAP) will be produced and finalized after finalizing the protocol 
and before breaking the blind of the study. The SAP serves as a compliment to the protocol and 
supersedes it in case of differences. In case of major differences between the protocol and SAP, a 
protocol amendment will be considered. Any deviations from the statistical analyses planned in the 
protocol will be documented in the SAP and any deviations from the statistical analyses planned in 
the SAP will be documented in the final clinical study report. 
 
14.1 
SAMPLE SIZE AND POWER 
The study will enrol a minimum of 950 subjects, with 475 subjects allocated to each treatment 
group. The sample size calculation was based on powering the study with respect to the primary 
efficacy endpoint. It was assumed that the SSI rate in the SOC arm would be 16% and that D‐
PLEX +SOC will have effect of 50% on this rate (halving infection rate) relative to SOC alone, thus 
8% infection rate in D‐PLEX+SOC arm. Assuming rate equal to 
 for both arms with regard 30‐
day treatment failure due to all‐cause mortality or re‐intervention in the target incision, due to 
suspected SSI or due to poor wound healing, including wound dehiscence, the assumed 
treatment failure rates were 
 and 
, for SOC and DPLEX+SOC, respectively. A sample of 
882 total subjects provides 90% power to detect the assumed difference in treatment failure 
rate using chi square test, and to account for the planned interim analysis for efficacy (to be 
performed with a two‐sided α=0.01), a conservative two‐sided α=0.04 level of significance was 
employed. In order to account for an anticipated about 5% lost‐to‐follow‐up rate, a minimum of 
950 subjects (475/treatment arm) will be enrolled.   
 
14.1.1 Interim analysis for stopping early for efficacy or futility, or un‐blinded sample size re‐
estimation‐ 
One comparative interim analysis for an early efficacy or futility stop, or sample size re‐
estimation will be conducted when about 750 subjects will complete 1‐month Follow‐up and 
evaluated for the primary endpoint.  The interim analysis will include a group‐sequential 
design stopping rule for efficacy and futility, combined with unblinded sample size re‐
assessment based on the Promising Zone approach. The outcome of this interim analysis will 
be either early stopping for efficacy or continuation to planned final (950 subjects) or continue 
with sample size increased up to a total of 1400 subjects, only if the comparative result falls in 
a predefined Promising Zone. The interim decision will be made by the independent DMC 
according to a pre‐planned interim analysis plan, and comparative information will be 
maintained confidential within the independent statistician until the study finally unblinded. 
The pre‐defined stopping rule and the sample size re‐calculation will be detailed in an Interim 
analysis Plan to be finalized before the unblinding takes place. 
 
 
 
22-2-2022
Page 74 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
 
 
14.2 
ANALYSIS POPULATIONS 
The following analysis populations will be defined for the study: 
 
14.2.1 Intention to Treat (ITT) Set 
 The ITT analysis set will consist of all subjects who have been randomized to receive either D‐
PLEX plus SoC or SoC alone. In this analysis set, treatment will be assigned based on the 
treatment to which subjects were randomized, regardless of which treatment they actually 
received. 
 
14.2.2 Safety Analysis Set  
The safety analysis set will consist of all subjects who have been randomized and treated with 
D‐PLEX+SoC or SoC alone. In this population, treatment will be assigned based upon the 
treatment the subjects actually received, regardless of the treatment to which they were 
randomized. 
14.2.3 Modified Intention to Treat (mITT) Set  
The mITT analysis set is a subset of the ITT set and will consist of all subjects randomized and 
treated with D‐PLEX+SoC or SoC alone who underwent the index surgery, and have no 
eligibility criteria deviation. In this population, treatment will be assigned based upon the 
treatment to which subjects were randomized, regardless of the treatment they actually 
received. Exclusion from the mITT population will be determined in a blinded manner prior to 
database lock. Subjects who will die during the study will not be excluded from the mITT 
population. 
14.2.4 Per Protocol (PP) Set  
The PP analysis set is a subset of the mITT set and will consist of all subjects in the mITT who 
have no major protocol deviations and were assessed for the primary endpoint (i.e. completed 
the Day 30 assessment, or otherwise had prior to that adjudicated post‐surgical SSI or death or 
re‐intervention in the index surgery, due to suspected SSI or due to poor wound healing, 
including wound dehiscence). 
The analysis of the primary and key secondary efficacy endpoints will be performed on the ITT, 
mITT and PP populations, with the ITT population serving as the primary analysis set. Analyses 
of additional secondary efficacy endpoints will be performed on the populations as described 
in the Statistical Analysis Plan (SAP) for the study. Analyses of safety will be performed on the 
safety analysis set. Baseline subject characteristics and demographics will be summarized for 
the ITT population. 
 
 
 
 
22-2-2022
Page 75 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
14.3 
STATISTICAL AND ANALYTICAL PLANS 
14.3.1 Analysis of Demographics and Baseline Subject Characteristics 
Baseline and demographic characteristics will be summarized for all subjects in the ITT 
population by treatment group and overall. Continuous variables will be displayed via 
summary statistics (number of non‐missing observations, mean, median, standard deviation, 
minimum, and maximum). Categorical variables will be summarized via counts and 
percentages. 
 
14.3.2 Primary Endpoint Analysis 
The primary objective of the study is to assess the anti‐infective efficacy of DPLEX+SOC over a 
period of 30 days post operation, by preventing surgical site infection (SSI), defined as 
superficial and/or deep infection, in the index (target) incision, compared to the SoC alone 
control arm. 
The primary analysis will be based on a composite treatment‐failure (Yes/No) variable, 
indicating if a subject had at least one treatment‐failure event, defined as follows: SSI event, 
occurring within 30 days post abdominal surgery (up to and including the 30‐days follow‐up 
visit) and determined by a blinded and independent adjudication committee; or death (from 
any reason) within 30‐days from surgery. In addition, re‐intervention at the target incision site 
within 30 days of the index operation (due to suspected SSI or due to poor wound healing, 
including wound dehiscence, as determined by the adjudication committee) will be 
considered a treatment failure for the primary ITT analysis. To note, re‐intervention at a 
different access point than the index wound outcome or re‐intervention due to any other 
reason than suspected SSI or due to poor wound healing, including wound dehiscence, will not 
be considered as a treatment failure in the primary analysis.. In the rare case of indeterminate 
SSI outcome (i.e. missing outcome due to other reasons than death), it will also be counted as 
treatment failures for the primary analysis. 
The number and proportion of subjects with treatment‐failure as defined above will be 
tabulated per treatment group. A 95% confidence interval will be constructed for each 
proportion. A Cochran Mantel‐Haenszel (CMH) test will compare the proportion of treatment‐
failure between the two groups, using the study stratification factors used for randomization, 
and corresponding risk difference estimate will be presented with 95% confidence interval 
(using the method of MantelHaenszel stratum weights, as applied in the COMMONRISKDIFF 
option in the SAS FREQ procedure). The following hypotheses will be tested for a significant 
difference in the composite treatment‐failure proportions between D‐PLEX+SoC (PDPLEX) and 
SoC (PSoC) treatment: 
 
 
 
22-2-2022
Page 76 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
H0: PDPLEX = PSoC 
vs. 
H1: PDPLEX ≠ PSoC 
The interim analysis adjusted significance level will be used for this test, refer to 14.3.4 for 
details. In the case of small number of events (less than 5 events in any study arm), the Fisher 
exact test will be used. 
The number and percent of each of the failure types comprising the primary endpoint will be 
described by group. 
Sensitivity and supportive analyses for the primary endpoint analysis will be defined and 
detailed in the statistical analysis plan. These will address the following aspects:  
 
Using the mITT and PP populations 
 
To account for the possibility of errors in values of stratification factors used for randomi‐
zation, the primary analysis will supportively be repeated using the correct values. 
 
Difference between the treatment and control groups when controlling for possible 
imbalance in important baseline factors will be analysed by evaluating the odds ratio 
obtained from estimating a multiple logistic regression model. The list of baseline 
variables will be finalized in the SAP. 
 
Sensitivity analysis for the imputation of missing data due to other reason than death 
(please refer to Section 14.3.7). 
 
Descriptive statistics of the incidence of re‐interventions at the target incision site due to 
other reasons than suspected SSI or due to poor wound healing, including wound 
dehiscence within 30 days of the index operation. Analysis where these events will also 
be considered as treatment failure (in addition to the primary endpoint defined above) 
will also be performed. 
 
14.3.3 Secondary Efficacy Endpoint Analysis 
14.3.3.1 Key secondary efficacy endpoint 
The key secondary endpoints defined for the study are: 
● Infection rate as measured by the proportion of subjects with at least one SSI 
event only, occurring within 30 days post abdominal surgery and determined by a 
blinded and independent adjudication committee. 
● Number (percent) of subjects with at least 1 score of ASEPSIS > 20 within 30 days 
post abdominal index surgery. 
The number and proportion of subjects with SSI event as defined in the 1st key secondary 
endpoint above, will be tabulated per treatment group. A 95% confidence interval will be 
 
 
 
22-2-2022
Page 77 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
constructed for each proportion. A Cochran Mantel‐Haenszel (CMH) test will compare the 
proportion of SSI between the two groups, using the study stratification factors used for 
randomization, and corresponding risk difference estimate will be presented with 95% 
confidence interval (using the method of MantelHaenszel stratum weights, as applied in 
the COMMONRISKDIFF option in the SAS FREQ procedure). In the case of small number of 
events (less than 5 events in any study arm), the Fisher exact test will be used. This 
endpoint will be formally tested only if the primary endpoint is significant, using two‐
sided 5% significance level.  
The number and proportion of subjects who reached a score of ASEPSIS>20 within 30 
days post abdominal index surgery will be presented by group. Method of analysis of this 
endpoint will be as described for the 1st key secondary endpoint above. This endpoint 
will be formally tested only if the 1st key secondary endpoint is significant, using two‐
sided 5% significance level. 
Missing data strategy for these endpoints is described in section 14.3.7. The primary 
analysis for these endpoints will be ITT and sensitivity analyses will be defined and 
detailed in the SAP. 
 
14.3.3.2 Additional secondary efficacy endpoint 
Details regarding the analyses of the additional efficacy endpoints are described in the 
SAP for the study. 
 
14.3.4 Type 1 error control 
The overall study‐wise type I error will be 5%.  
To protect the study from type I error inflation, the key secondary endpoints will be 
interpreted inferentially only if a statistically significant treatment effect (p‐value f0.05) is 
detected in the primary endpoint. Type I error will be further controlled for the key 
secondary endpoints by employing the Hierarchical Approach, i.e., the 2nd key secondary 
endpoint will be formally analysed only in case the 1st key endpoint will be statistically 
significant (p‐value f0.05). 
The additional secondary endpoints will be used to enhance understanding the beneficial 
effect of D‐PLEX and there is no plan for formal inference for these. Thus, no multiplicity 
control is further planned beyond the key secondary endpoints. 
To account for the option of early stopping for efficacy, the type‐1 error spending approach 
will be utilized. The interim analysis is planned when about 750 subjects in total will be en‐
rolled and have the chance to complete 1‐month visit, and an alpha level of 1% regardless of 
the exact number of subjects included in the analysis will be used. For strict control of the 
overall type‐1 error, the alpha for the final analysis (in case the study does not stop at interim) 
will be calculated based on the actual information time of the interim analysis.   
 
 
 
22-2-2022
Page 78 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
The Promising Zone approach (Mehta and Pocock 2011) was chosen to rigidly control 
study overall type‐1 error due to the unblinded comparative size re‐estimation at the time 
of interim analysis, and its planned implementation strictly follows the rules that increase 
sample size only if comparative results fall in a pre‐defined Promising Zone, thus allowing 
final analysis to be preserved without further need for statistical adjustment (beyond 
adjustment due to the interim efficacy analysis as described above). 
14.3.5 Subgroup analysis  
The primary and key secondary endpoints will be analysed by incision length with the 
following categories: f20 cm, >20 cm. 
14.3.6 Safety Evaluations 
Prior to analysis, all AEs will be coded using the MedDRA coding dictionary.  
The number and proportion of subjects reporting at least one treatment‐emergent adverse 
event (TEAE) and the number and proportion of subjects reporting at least one TEAE by 
MedDRA system organ class (SoC) and preferred term will be reported. This analysis will be 
repeated for serious AEs (SAEs) and for treatment‐related AEs. Additional summaries of TEAEs 
will be performed by severity and by relationship to treatment.    
Vital sign measurements and clinical laboratory parameters will be summarized via descriptive 
statistics (mean, standard deviation, median, minimum, maximum, and number of non‐
missing observations) for each post‐treatment time point. Shift tables will be constructed for 
physical exams to display any changes in body system findings over time. Responses to the 
Modified Vancouver Scar Scale will be summarized with counts and proportions by time point. 
Additional analyses of safety will be described in the SAP for the study. 
 
14.3.7 Handling of Missing Data 
To be recalled, in the calculation of the primary endpoint (section 14.3.2), deaths occurring 
within the first 30 days post abdominal index surgery are addressed as treatment failure 
events and thus are not considered missing data problem, in either of the primary or 
sensitivity and supportive primary endpoint analysis. 
To note, re‐intervention in the target incision occurring within the first 30 days post abdominal 
index surgery, due to suspected SSI or due to poor wound healing, including wound 
dehiscence, will be addressed as treatment failure events in all sensitivity and supportive 
analyses of the primary efficacy endpoint. 
As specified in section 14.3.2, for the purpose of the primary efficacy analysis, based on ITT 
population, subjects, who have missing primary efficacy endpoint data due to other reasons 
than death (i.e. missing Day 30 SSI assessment (regardless of reason) or performed out of pre‐
specified visit window) and have not already been identified as treatment failures due to 
having experienced any adjudicated SSI event or re‐intervention in the target incision, due to 
suspected SSI or due to poor wound healing, including wound dehiscence, will be imputed as 
treatment failure. 
 
 
 
22-2-2022
Page 79 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
 
For the purpose of the sensitivity analyses to the primary efficacy endpoint analysis, missing 
data (arising from other reasons than death) will be imputed as follows: 
When using ITT population: 
1.Using Multiple Imputation (MI) technique 
2.Imputing as not treatment failure 
When using mITT and PP populations: no imputation will be performed (i.e., a complete case 
analysis will be used). 
Time to adjudicated SSI during 30 days post index surgery endpoint will handle the missing 
values as censored. 
There will be no imputation of missing data for all other study endpoints (i.e., a complete case 
analysis will be used), unless otherwise noted for a specific analysis. 
Full details on sensitivity analyses for handling missing data for the primary endpoints and for 
the key secondary endpoints will be provided in the SAP. 
 
14.3.8 Interim Analyses 
One formal analysis to stop the study early for efficacy or safety is planned for this study. The 
interim analysis will include a group‐sequential design stopping rule for efficacy or futility, 
combined with comparative sample size re‐estimation (please refer to section 14.1.1).  
 
14.4 
NAME OF COMMITTEES INVOLVED IN TRIAL  
14.4.1 DATA MONITORING COMMITTE (DMC) 
An independent of the Sponsor/Investigator involved in the study DMC will be utilized in this 
study to ensure external objective medical and/or statistical review of safety issues in order to 
protect the ethical and safety interests of subjects and to maintain the scientific validity of the 
study.  
In order to maintain blinding in communication with the DMC, an Independent Biostatistician 
separate from the study team will be appointed to provide required information to the DMC.  
Blinded tables and listings will contain pooled blinded data and will be distributed to PolyPid 
personnel by the unblinded statistician. Unblinded tables and listings will contain unblinded 
data and will be distributed only to DMC voting members directly by the unblinded statistician 
(at the beginning of such e‐mails, the unblinded statistician will detail who are the unblinded 
team members specifically for each case and with whom information can be forwarded to or 
discussed with). 
Data management and clean‐up will be done on blinded data sets. 
The schedule of any planned interim analysis and the analysis plan for DMC review is 
described in the charter. 
 
 
 
22-2-2022
Page 80 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
With regard to the interim analysis, the interim decision will be made by the independent 
DMC according to a pre‐planned interim analysis plan, and comparative information will be 
maintained confidential within the independent statistician until the study finally unblinded. 
 
14.4.2 ENDPOINTS ADJUDICATION COMMITTEE (EPAC) 
An independent of the Sponsor/Investigator involved in the study and blinded to treatment 
arm Endpoint Adjudication Committee will be established.  
This committee is an independent clinical events classification committee, composed of a 
minimum of 3 experts in the fields of surgeries and infectious disease, who will remain blinded 
to the treatment assignments. 
All information collected regarding efficacy (abdominal wall infection) will be reviewed by the 
Endpoint Adjudication Committee. In addition, the committee will review all death cases to 
verify if they may be related to abdominal wall infection, IP or other cause. It is within their 
scope to make an independent decision whether a subject has met the primary endpoint or to 
assess, in case of a death, for its relationship to infection or to the study drug. 
Vote followed by decision will be made based on an agreement of at least 2 out of 3. 
Committees adjudication blinded review will be forwarded to the Sponsor.  
In case of dispute between Investigator assessment of infection and the committees 
assessment, Endpoint Adjudication Committees assessment on primary endpoint evaluation 
will overrule the Investigator assessment.  
15 DIRECT ACCESS TO SOURCE DATA DOCUMENTS 
As required, the PI shall obtain permission for direct access to source documents from the subject, 
hospital administration and national regulatory authorities before starting the clinical trial. 
The Investigator will permit trial‐related monitoring, audits, EC/IRB review, and regulatory 
inspection(s), providing direct access to source data/documents. Trial participants are informed of 
this during the informed consent discussion.  Participants will consent to provide access to their 
medical notes. 
16 ETHICS & REGULATORY REQUIREMENTS 
The protocol, ICF and Authorization for the Use and Disclosure of Health Information or country 
specific confidentiality requirements must be reviewed and approved by the respective EC/IRB and 
the Sponsor before subject enrolment. Changes to the protocol must be approved in writing by the 
Sponsor and the EC/IRB (as applicable) before the change is implemented. 
Prior to subject enrolment, a signed copy of the EC/IRB approval letter addressed to the Investigator 
must be submitted to the Sponsor, certifying study approval.  Investigators are responsible for 
submitting and obtaining initial approval and continuing approval from the EC/IRB and forwarding 
copies of the approval letters to the Sponsor. The original letters are to be kept in the investigational 
centers' Regulatory Binder designated for this study.   
The Investigator will notify the Sponsor immediately of withdrawal of EC/IRB approval.   
 
 
 
22-2-2022
Page 81 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
17 QUALITY CONTROL (STUDY MONITORING) 
In accordance with applicable regulations, GCP, and Sponsors procedures, the site will be contacted 
prior to the start of the study to review with the site staff the protocol, study requirements, and 
their responsibilities to comply with regulatory, ethical, and Sponsors requirements.  When 
reviewing data collection procedures, the discussion will include identification, agreement and 
documentation of data items for which the CRF will serve as the source document. 
The Investigator and the head of the medical institution (where applicable) agree to allow the 
monitor direct access to all relevant documents and to allocate their time and the time of their staff 
to monitor to discuss findings and any issues. 
Monitoring visits will be conducted in a manner to ensure that the: 
● Data are authentic, accurate, and complete. 
● Safety and rights of subjects are being protected. 
● Study is conducted in accordance with the currently approved protocol and any other study 
agreements, ICH GCP, and all applicable regulatory requirements. 
A trial specific monitoring plan will be established for the study. The trial will be monitored according 
to the agreed plan. 
18 QUALITY ASSURANCE (QA) 
To ensure compliance with GCP and all applicable regulatory requirements, Sponsor may conduct a 
QA assessment and/or audit of the site. Regulatory authorities may conduct a regulatory inspection 
at any time during or after completion of the study. 
The Investigator (and institution) agree to grant the advisor(s), auditor(s) and inspector(s) direct 
access to all relevant documents and to allocate their time and the time of their staff to discuss the 
conduct of the study, any findings/relevant issues and to implement any corrective and/or 
preventive actions to address any findings/issues identified. 
19 INSURANCE 
The Sponsor will provide insurance or indemnify (legal and financial coverage), the Investigatory/ 
Institution against claims arising from the study, insurance covering the cost of treatment of the 
subjects in the event of clinical‐trial‐related injuries, in accordance with national regulations, except 
for claims that arise from malpractice, negligence, or non‐compliance with the protocol. The 
certificate of insurance and coverage will be provided upon request. 
20 PUBLICATION POLICY 
All data generated from this study are the property of Sponsor and shall be held in strict confidence 
along with all information furnished by Sponsor, subject to the right of the Investigator or any 
member of his/her staff to publish the results in accordance with the publication procedure to be 
defined in the clinical trial agreement. 
Independent analysis and/or publication of this data by the Investigator or any member of his/her 
staff are permitted subject to obtaining the prior written consent of Sponsor. 
Written permission to the Investigator will be contingent on the review by Sponsor of the statistical 
 
 
 
22-2-2022
Page 82 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
analysis and manuscript and will provide for nondisclosure of Sponsor confidential or proprietary 
information. In all cases, the parties agree to submit all manuscripts or abstracts to all other parties 
30 days prior to submission. This will enable all parties to protect proprietary information and to 
provide comments based on information that may not yet be available to other parties. 
21 STATEMENT OF COMPLIANCE 
The trial will be conducted in compliance with the approved protocol, Declaration of Helsinki, ICH 
GCP and local applicable regulatory requirement(s). 
The clinical trial shall not begin until the required approval or favourable opinion from the EC/IRB 
has been obtained and, if applicable, any local or national regulatory authority approvals or 
notifications have been obtained. 
The Sponsor has obtained clinical trial insurance that will cover expenses in the event of any physical 
injury resulting from research procedures. 
22  APPENDICES 
Appendix 1: ASEPSIS Score Assessment 
Appendix 2: Modified Vancouver Scar Scale 
Appendix 3: PK instructions for Collection and Processing 
Appendix 4: Surgical Site Assessment Questionnaire 
Appendix 5: Charlson Co‐Morbidity Index 
Appendix 6: Document Change History  
 
 
 
 
22-2-2022
Page 83 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
23  REFERENCES 
1.  
Carney MJ, Weissler JM, Fox JP, Tecce MG, Hsu JY, Fischer JP. Trends in open abdominal 
surgery in the United StatesObservations from 9,950,759 discharges using the 20092013 
National Inpatient Sample (NIS) datasets. The American Journal of Surgery. 2017;214(2):287‐
292. doi:10.1016/j.amjsurg.2017.01.001 
2.  
Fingar KR, Stocks C, Weiss AJ, Steiner CA. Most Frequent Operating Room Procedures 
Performed in U.S. Hospitals, 20032012: Statistical Brief #186. 2006. 
http://europepmc.org/abstract/med/25695123. Accessed November 5, 2019. 
3.  
Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical Practice Guidelines for Antimicrobial 
Prophylaxis in Surgery. Surgical Infections. 2013;14(1):73‐156. doi:10.1089/sur.2013.9999 
4.  
Mihaljevic AL, Müller TC, Kehl V, Friess H, Kleeff J. Wound Edge Protectors in Open Abdominal 
Surgery to Reduce Surgical Site Infections: A Systematic Review and Meta‐Analysis. PLOS ONE. 
2015;10(3):e0121187. doi:10.1371/journal.pone.0121187 
5.  
Alonso‐Isa M, Medina‐Polo J, Lara‐Isla A, et al. Surgical wound infection in urology. Analysis of 
risk factors and associated microorganisms. Actas Urológicas Españolas (English Edition). 
2017;41(2):109‐116. doi:10.1016/j.acuroe.2016.12.005 
6.  
Aga E, Keinan‐Boker L, Eithan A, Mais T, Rabinovich A, Nassar F. Surgical site infections after 
abdominal surgery: incidence and risk factors. A prospective cohort study. Infectious Diseases. 
2015;47(11):761‐767. doi:10.3109/23744235.2015.1055587 
7.  
Azoury SC, Farrow NE, Hu Q, et al. Postoperative abdominal wound infection  epidemiology, 
risk factors, identification, and management. In: ; 2015. doi:10.2147/cwcmr.s62514 
8.  
Fry DE. The Prevention of Surgical Site Infection in Elective Colon Surgery. Scientifica. 
doi:10.1155/2013/896297 
9.  
Avkan‐Oğuz V, Baykam N, Sökmen S, et al. Recommendations for intra‐abdominal infections 
consensus report. Ulus Cerrahi Derg. 2016;32(4):306‐321. doi:10.5152/UCD.2016.3688 
10.   Pellegrini JE, Toledo P, Soper DE, et al. Consensus Bundle on Prevention of Surgical Site 
Infections After Major Gynecologic Surgery. Journal of Obstetric, Gynecologic & Neonatal 
Nursing. 2017;46(1):100‐113. doi:10.1016/j.jogn.2016.10.003 
11.   Steiner HL, Strand EA. Surgical‐site infection in gynecologic surgery: pathophysiology 
and prevention. American Journal of Obstetrics and Gynecology. 2017;217(2):121‐128. 
doi:10.1016/j.ajog.2017.02.014 
12.   Mulder T, Kluytmans J. All care bundles are equal, but some are more equal than others. 
Annals of Laparoscopic and Endoscopic Surgery. 2017;2(9). doi:10.21037/4150 
 
 
 
22-2-2022
Page 84 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
13.   Huiras P, Logan JK, Papadopoulos S, Whitney D. Local Antimicrobial Administration for 
Prophylaxis of Surgical Site Infections. Pharmacotherapy: The Journal of Human Pharmacology 
and Drug Therapy. 2012;32(11):1006‐1019. doi:10.1002/phar.1135 
14.   Bennett‐Guerrero E, Pappas TN, Koltun WA, et al. GentamicinCollagen Sponge for Infection 
Prophylaxis in Colorectal Surgery. New England Journal of Medicine. 2010;363(11):1038‐1049. 
doi:10.1056/NEJMoa1000837 
15.   Bennett‐Guerrero E, Berry SM, Bergese SD, et al. A randomized, blinded, multicenter trial of a 
gentamicin vancomycin gel (DFA‐02) in patients undergoing abdominal surgery. The American 
Journal of Surgery. 2017;213(6):1003‐1009. doi:10.1016/j.amjsurg.2016.10.007 
16.   McHugh SM, Collins CJ, Corrigan MA, Hill ADK, Humphreys H. The role of topical antibiotics 
used as prophylaxis in surgical site infection prevention. J Antimicrob Chemother. 
2011;66(4):693‐701. doi:10.1093/jac/dkr009 
17.   Edmiston CE, Leaper D, Spencer M, et al. Considering a new domain for antimicrobial 
stewardship: Topical antibiotics in the open surgical wound. American Journal of Infection 
Control. 2017;45(11):1259‐1266. doi:10.1016/j.ajic.2017.04.012 
18.   Gschwend MH, Martin W, Erenmemişoğlu A, et al. Pharmacokinetics and Bioequivalence Study 
of Doxycycline Capsules in Healthy Male Subjects. Arzneimittelforschung. 2007;57(6):347‐351. 
doi:10.1055/s‐0031‐1296629 
19.    Ongom PA, Kijjambu SC. Antibiotic Prophylaxis in Colorectal Surgery: Evolving Trends. Journal 
of Molecular Pharmaceutics & Organic Process Research. 2013;1. doi:10.4172/2329‐
9053.1000109 
20.   Mehta CR, Pocock SJ. Adaptive Increase in Sample Size when Interim Results are Promising: A 
Practical Guide with Examples. Statist. Med. 2000; 00:162011 
 
 
 
 
 
 
 
 
22-2-2022
Page 85 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
APPENDIX 1: ASEPSIS SCORE ASSESSMENT 
ASEPSIS provides numerically score during an inspection of the surgical site. The final score is being 
interpreted to severity of wound appearance and the clinical consequences of the infection. 
 
 
 
 
 
 
 
 
22-2-2022
Page 86 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
APPENDIX 2: MODIFIED VANCOUVER SCAR SCALE 
The Modified Vancouver Scar Scale documents the change in scar appearance, through a numeric 
assessment of four characteristics of the wound. 
Lower scores indicate better wound healing. 
 
Modified Vancouver Scar Scale 
Vascularity 
Normal 
Pink 
Red 
Purple 
0 
1 
2 
3 
Pigmentation 
Normal 
Hypopigmentation 
Mixed 
Hyperpigmentation 
0 
1 
2 
3 
Pliability 
Normal 
Supple 
Yielding 
Firm 
Adherent 
0 
1 
2 
3 
4 
Height 
Flat 
1‐2 mm 
3‐4 mm 
5‐6 mm 
> 6 mm 
0 
1 
2 
3 
4 
 
 
 
 
 
 
 
22-2-2022
Page 87 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
APPENDIX 3: PK INSTRUCTIONS FOR COLLECTION AND PROCESSING 
 
The following instructions must be followed for the collection of plasma PK samples. 
1. At the allotted time points, draw at least 4 mL of venous blood into a polypropylene K2 EDTA 
lavender top tube.  Record time and date of collection for each sample. 
2. Gently invert tube at least 8 times to allow the specimen to mix with the anticoagulant in the 
tube to avoid clotting. 
3. Store vacutainer at ambient temperature prior to centrifugation.  Proceed to centrifugation 
within 18 hours of blood draw. 
4. Centrifuge the tube(s) at 2000 rpm (equivalent to 3000 g) for 15 minutes. 
5. Using a disposable pipette, transfer the supernatant (plasma) layer into 2 pre‐labelled poly‐
propylene 2ml Eppendorf tubes. Try to keep equal amounts of plasma with the 2 tubes.   
 
Mark these 2 tubes as:  A (primary) and B (back‐up), complete the appropriate label 
and place them onto the 2ml tubes.  
6. Plasma samples must be stored at or below ‐20C or below 
 
PK Sample Specimen Handling 
1. Two cryotubes (A and B) are obtained for each sample time point.  Shipments must be split 
(e.g. Set A is sent first, followed by Set B, dispatched 24h to 72h later). 
2. It is important that SHIPMENTS MUST NOT CONTAIN BOTH CRYOTUBES A and B for the same 
time point, in the same shipment.  
3. Specimen collection times must be documented in the source records.  These must be kept 
up to date. 
4. Cryotubes should be packed in groups with samples A and B packed separately, according to 
subject number and stored at ‐20C prior to shipment to: ICON Laboratories, Inc. 
Back‐up Sample Shipment  
Back‐up samples are to be shipped once ICON Laboratory confirms the primary samples have been 
received. ICON Laboratory will send an e‐mail alert to the site confirming receipt of the primary 
samples. Back‐up samples should be handled and shipped in the same manner as the primary 
samples.  
 
 
 
 
 
 
 
22-2-2022
Page 88 of 99
Effective




 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
Organisms identified by microbiologic testing method 
 
 
Superficial incision that is deliberately opened (i.e. removal of pins to better examine 
the incision) 
 
 
A deep incision that spontaneously dehisces, or is deliberately opened or aspirated 
by a physician  
 
 
Drainage of pus from the wound under local anesthetic  
 
 
 
 
Drainage of pus from the wound under general anesthetic 
 
 
An abscess or other evidence of infection involving the deep incision that is detected 
on gross anatomical or histopathologic exam, or imaging test 
 
 
Antibiotic treatment required (due to incision infection) 
 
 
Stays as inpatient > 14 days (due to incision infection)   
 
 
 
 
Diagnosis of a Superficial incisional SSI by the assessor 
 
 
 
Final Assessor Decision 
 
 
Yes 
No 
Superficial Surgical Site Infection 
Deep Surgical Site Infection 
 
 
 
 
 
 
22-2-2022
Page 90 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
APPENDIX 5: CHARLSON CO‐MORBIDITY INDEX (CCI) 
Predicts 10‐year survival in patients with multiple comorbidities. 
Medical Condition 
Score 
Age 
<50 years 
5059 years 
6069 years 
7079 years 
g80 years 
 
0 
+1 
+2 
+3 
+4 
Myocardial infarction 
History of definite or probable MI (EKG changes and/or enzyme changes) 
No 
Yes 
 
 
0 
+1 
Chronic Heart Failure 
Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or after‐
load reducing agents 
No 
Yes 
 
 
 
0 
+1 
Peripheral vascular disease 
Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or 
acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (g6 cm) 
No 
Yes 
 
 
 
0 
+1 
CVA or TIA 
History of a cerebrovascular accident with minor or no residua and transient ischemic attacks 
No 
Yes 
 
 
0 
+1 
Dementia 
Chronic cognitive deficit 
No 
Yes 
 
 
0 
+1 
COPD 
No 
Yes 
 
0 
+1 
Connective tissue disease 
No 
Yes 
 
0 
+1 
Peptic ulcer disease 
Any history of treatment for ulcer disease or history of ulcer bleeding 
No 
Yes 
 
 
0 
+1 
Liver disease 
Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis 
and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis 
without portal hypertension) 
 
 
 
 
 
 
 
22-2-2022
Page 91 of 99
Effective


 
D‐PLEX 311 Clinical Trial Protocol 
Legacy Document Number: CL‐0027 
 
CONFIDENTIAL 
Medical Condition 
Score 
None 
Mild 
Moderate to severe 
0 
+1 
+3 
Diabetes mellitus 
None or diet‐controlled 
Uncomplicated 
End‐organ damage 
 
0 
+1 
+2 
Hemiplegia 
No 
Yes 
 
0 
+2 
Moderate to severe Chronic Kidney Disease 
Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL 
(0.27 mmol/L) 
No 
Yes 
 
 
 
0 
+2 
Solid tumor 
None 
Localized 
Metastatic 
 
0 
+2 
+6 
Leukemia 
No 
Yes 
 
0 
+2 
Lymphoma 
No 
Yes 
 
0 
+2 
AIDS 
No 
Yes 
 
0 
+6 
Is this a COVID‐19 patient? 
For research purposes only;  
answer does NOT impact results. 
Confirmed positive 
Suspected 
Unlikely 
Confirmed negative 
 
 
Summary score 
 
 
 
 
 
 
22-2-2022
Page 92 of 99
Effective














D-PLEX 311 Clinical Trial Protocol
P-000066
Protocols
Version 6.0
22-2-2022
Page 99 of 99
Effective
Document Signatures
Participant Name
Participant Type
Action
Task Performed On
Olga Belotserkovsky
(Clinical 
Development 
Manager)
Approver
Send to QA 
Approval
2022-02-21 17:23
Lital Weinfeld 
Bergman (Clinical 
Operations 
Manager)
Approver
Send to QA 
Approval
2022-02-21 18:11
Dalit Hazan (VP 
R&D and RA)
Approver
Send to QA 
Approval
2022-02-21 18:30
Noam Emanuel 
(CSO)
Approver
Send to QA 
Approval
2022-02-22 09:45
Maria Rubin (VP 
Quality)
QA Approver
Approve Document
2022-02-22 10:02

SAP_001.pdf: 
Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 1 of 49 
 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
 
 
POLYPID LTD 
 
 
STATISTICAL ANALYSIS PLAN (SAP) 
 
 
Phase III, Prospective, Multinational, Multicenter, Randomized, 
Controlled, Two-arm, Double Blind Study to Assess Efficacy and Safety 
of D-PLEX Administered Concomitantly with the Standard of Care 
(SoC), Compared to a SoC Treated Control Arm, in Prevention of Post 
Abdominal Surgery Incisional Infection 
 
 
 
Study: D-PLEX 311 
Phase: III 
 
SAP Date:  16-JUN-2022 
SAP Version: 4 
 
Prepared by: 
 
 
 
 
 
 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 2 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
Version Control Page 
Version: 
Version Date: 
Comments 
1 
07-MAY-2020 
Initial version 
2 
19-AUG-2020 
Second version: to update following FDA recommendations 
and to align with changes in protocol version 04 
3 
28-APR-2022 
To update following protocol amendment #6 and provide 
further clarifications and details as required. 
4 
16-JUN-2022 
To document the adjusted significance level for the final 
analysis of the primary endpoint;  to include additional 
subgroup analysis and additional exploratory analysis. 
 
 
 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 4 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
TABLE OF CONTENTS 
GLOSSARY OF ABBREVIATIONS ........................................................................ 7 
1. 
PREFACE .......................................................................................................... 9 
2. 
STUDY OBJECTIVES .................................................................................... 11 
3. 
STUDY DESIGN .............................................................................................. 12 
3.1. 
GENERAL DESIGN AND STUDY SCHEMA ............................................................ 12 
3.2. 
STUDY ENDPOINTS ............................................................................................. 14 
3.2.1. Primary Efficacy Endpoint ........................................................................... 14 
3.2.2. Secondary Efficacy Endpoints ...................................................................... 15 
3.2.3. Safety Endpoints............................................................................................ 18 
3.3. 
SAMPLE SIZE AND POWER CONSIDERATIONS ..................................................... 19 
3.3.1. The Minimal Sample Size Calculation .......................................................... 19 
3.3.2. Interim Analysis for Stopping Early for Efficacy or Futility, or Unblinded 
Sample Size Re-estimation ........................................................................................ 19 
3.4. 
RANDOMIZATION AND BLINDING ....................................................................... 20 
3.4.1. Randomization .............................................................................................. 20 
3.4.2. Blinding ......................................................................................................... 20 
3.5. 
SEQUENCE OF PLANNED ANALYSES ................................................................... 21 
3.5.1. Interim Analyses............................................................................................ 21 
3.5.2. Final Analyses and Reporting ....................................................................... 21 
4. 
ANALYSIS POPULATIONS ........................................................................... 22 
4.1. 
SCREENED .......................................................................................................... 22 
4.2. 
INTENT TO TREAT (ITT) ..................................................................................... 22 
4.3. 
SAFETY .............................................................................................................. 22 
4.4. 
MODIFIED INTENT TO TREAT (MITT) ................................................................. 22 
4.5. 
PER PROTOCOL (PP) .......................................................................................... 22 
5. 
GENERAL ASPECTS FOR DATA ANALYSIS .............................................. 23 
5.1. 
GENERAL ........................................................................................................... 23 
5.2. 
SPECIFICATION OF BASELINE VALUES ............................................................... 23 
5.3. 
MULTIPLE COMPARISONS AND MULTIPLICITY ................................................... 23 
5.4. 
HANDLING WITHDRAWALS AND MISSING DATA ............................................... 24 
5.4.1. Primary Endpoint.......................................................................................... 24 
5.4.2. Secondary Endpoints .................................................................................... 25 
5.5. 
STUDY DAYS AND VISIT WINDOWS ..................................................................... 26 
6. 
STUDY POPULATION ................................................................................... 27 
6.1. 
GENERAL ........................................................................................................... 27 
6.2. 
SUBJECT DISPOSITION ........................................................................................ 27 
6.3. 
DEMOGRAPHICS AND BASELINE CHARACTERISTICS .......................................... 27 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 5 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
6.4. 
STRATIFICATION FACTORS FOR RANDOMIZATION ............................................. 29 
6.5. 
MEDICAL HISTORY ............................................................................................ 29 
6.6. 
PHYSICAL EXAMINATION ................................................................................... 30 
6.7. 
PROTOCOL DEVIATIONS ..................................................................................... 30 
7. 
EFFICACY ANALYSES ................................................................................. 31 
7.1. 
GENERAL ........................................................................................................... 31 
7.2. 
PRIMARY EFFICACY ANALYSIS .......................................................................... 31 
7.2.1. Primary Analysis ........................................................................................... 31 
7.2.2. Sensitivity and Supportive Analyses.............................................................. 32 
7.3. 
SECONDARY EFFICACY ANALYSES .................................................................... 33 
7.3.1. Key Secondary Efficacy Analyses ................................................................. 33 
7.3.2. Additional Secondary Efficacy Analyses ...................................................... 34 
7.4. 
SUB-GROUP ANALYSIS ....................................................................................... 36 
8. 
SAFETY ANALYSES ...................................................................................... 37 
8.1. 
GENERAL ........................................................................................................... 37 
8.2. 
ADVERSE EVENTS .............................................................................................. 37 
8.3. 
PHYSICAL EXAMINATION ................................................................................... 38 
8.4. 
VITAL SIGNS ...................................................................................................... 39 
8.5. 
INCISIONAL WOUND HEALING ........................................................................... 39 
8.6. 
LABORATORY TESTS .......................................................................................... 40 
8.7. 
OTHER SAFETY MEASURES ................................................................................ 41 
8.7.1. Concomitant Medications ............................................................................. 41 
8.7.2. Surgery Characteristics ................................................................................ 42 
8.7.3. Measures of Treatment Compliance ............................................................. 42 
8.7.4. Hospitalizations (During Study) ................................................................... 43 
9. 
PHARMACOKINETIC (PK) ANALYSES ...................................................... 44 
10. STATISTICAL SOFTWARE .......................................................................... 44 
11. SUMMARY OF CHANGES FROM LAST SAP VERSION ............................ 44 
12. LIST OF TABLES, FIGURES AND LISTINGS .............................................. 48 
13. REFERENCES ................................................................................................ 49 
 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 6 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
LIST OF TABLES 
TABLE 1: STUDY PROCEDURES AND ASSESSMENTS ........................................................... 13 
 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 7 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
GLOSSARY OF ABBREVIATIONS 
AE 
Adverse Event 
ASEPSIS 
Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of 
deep tissue, Isolation of bacteria, Stay duration as inpatient 
ATC 
Anatomical Therapeutic Chemical 
AUC 
Area Under the Curve 
BMI 
Body Mass Index 
COPD 
Chronic Obstructive Pulmonary Disease 
CRF 
Case Report Form 
CS 
Clinically Significant 
CSR 
Clinical Study Report 
DMC 
Data Monitoring Committee 
DSSI 
Deep Incisional Surgical Site Infection 
FAS 
Full Analysis Set 
FDA 
Food and Drug Administration 
ICF 
Informed Consent Form 
ICH 
International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use 
IP 
Investigational Product 
ITT 
Intention to Treat 
IWRS 
Interactive Web Randomization System 
mITT 
Modified Intention to Treat 
MedDRA 
Medical Dictionary for Regulatory Activities 
OR 
Operation Room 
PE 
Physical Examination 
PI 
Principal Investigator 
PK 
Pharmacokinetics 
PLEX 
Polymer-Lipid Encapsulation matrix 
PP 
Per Protocol 
PT 
Preferred Term 
PVD 
Peripheral Vascular Disease 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SD 
Standard Deviation  
SE 
Standard Error 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 8 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
SoC 
Standard of Care 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
SSI 
Surgical Site Infection 
SSR 
Sample Size Re-assessment 
SSSI 
Superficial Incisional Surgical Site Infection 
TEAE 
Treatment Emergent Adverse Event 
WHO-DD 
World Health Organization Drug Dictionary 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 9 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
1. 
PREFACE 
This Statistical Analysis Plan (SAP) describes the planned analysis and reporting for 
PolyPid study D-PLEX 311, (phase III, prospective, multinational, multicenter, 
randomized, controlled, two-arm, double blind study to assess efficacy and safety of D-
PLEX administered concomitantly with the Standard of Care (SoC), compared to a SoC 
treated control arm, in prevention of post abdominal surgery incisional infection), and was 
written in accordance with SOP 100-60-02 (Statistical Analysis Plan Preparation, Review 
and Approval, Bioforum’s Procedure). 
The structure and content of this SAP provides sufficient detail to meet the requirements 
identified by the FDA and International Council for Harmonization of Technical 
Requirements for Pharmaceuticals for Human Use (ICH): E9 Guidance on Statistical 
Principles in Clinical Trials. All work planned and reported for this SAP will follow 
internationally accepted guidelines, published by the American Statistical Association, and 
the Royal Statistical Society, for statistical practice. 
The following documents were reviewed in preparation of this SAP: 
 Clinical Study Protocol D-PLEX 311 Version 06, issued on 22-FEB-2022 
 Case Report Forms (CRFs) for Study D-PLEX 311 
 ICH E9 Guidance on Statistical Principles for Clinical Trials 
 ICH E3 Structure and Content of Clinical Study Reports 
 Conduct of Clinical Trials of Medical Products During the COVID-19 Public 
Health Emergency, Guidance for Industry, Investigators, and Institutional 
Review Boards 
The reader of this SAP is encouraged to also read the clinical protocol for details on the 
conduct of this study, and the operational aspects of clinical assessments and timing for 
completing a subject in this study.  
A separate Interim Statistical Analysis Plan (ISAP) accompanies and completes this 
document with the full details about the stopping rules and the sample size decision rules 
for the planned interim analysis. 
This SAP describes the statistical analyses as it is foreseen at the time of planning the study. 
The SAP serves as a compliment to the protocol and supersedes it in case of differences. 
In case of major differences between the protocol and SAP, a protocol amendment will be 
considered. Any deviations from the statistical analyses planned in the protocol will be 
documented in the SAP and any deviations from the statistical analyses planned in the SAP 
will be documented in the final clinical study report (CSR). 
The SAP may be updated during the study conduct and will be finalized before breaking 
the blind of the study and before the database lock for interim analysis. 
Version 2 is performed early during initiation of the study, responding to FDA 
recommendations and include additional clarifications and edits and alignment to protocol 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 10 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
version 04. Version 3 is performed in accordance with the issued protocol amendment 
version 06, while the study is ongoing, and the Sponsor is fully blinded. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 11 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
2. 
STUDY OBJECTIVES 
The primary objectives of this study are as follows: 
 To assess the anti-infective efficacy of D-PLEX, administered concomitantly with 
Standard of Care (SoC), over a period of 30 days post operation, by preventing 
surgical site infection (SSI), defined as superficial and/or deep abdominal wall 
surgical incision infection, compared to the SoC treated control arm. 
 To assess the safety of D-PLEX. 
 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 12 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
3. 
STUDY DESIGN   
3.1. 
General Design and Study Schema 
This is a phase III, prospective, multinational, multicenter, randomized, controlled, two-
arm, double blind study. The study population includes male and female subjects, 18 years 
old and above at screening, undergoing an elective colorectal surgery involving resection, 
with or without a stoma formation, that includes at least 1 abdominal incision that is > 
10cm (target incision). 
Subjects who meet the inclusion criteria and none of the exclusion criteria and who provide 
a signed Informed Consent Form will be enrolled in the study. 
Subjects will be randomized into either the investigational arm (D-PLEX + SoC) or to the 
control arm (SoC only) in a 1:1 ratio. Subjects will be stratified by prophylactic Standard 
of Care (prophylactic IV antibiotic with mechanical bowel preparation or prophylactic IV 
antibiotic without mechanical bowel preparation) and by region (USA or Europe+Israel). 
The sponsor, the outcome assessor, the subjects and all staff involved in the collection and 
recording of the clinical and laboratory data, based on which the independent adjudication 
committee will perform their assessment, will be blinded to the treatment assignment. The 
operation room (OR) staff will be trained to maintain in confident the treatment assignment 
and not to disclose it to other staff. In addition, all aspects of data management and clean-
up will be done using blinded datasets. 
For subjects randomized to the investigational arm, D-PLEX treatment will be applied 
during the abdominal surgery at the stage of closure of the abdominal wall surgical target 
incision (index procedure), as an adjunct to the SoC treatment. D-PLEX will not be re-
administered if any re-intervention occurs. 
For subjects randomized to the control arm, the surgical treatment will be as per SoC 
treatment. SoC will be consistent and standardized for all sites in the clinical study and is 
composed of IV antibiotic immediately prior to surgery. Each site will use the pre-defined 
SoC during the study. 
For subjects from both arms, preoperative IV antibiotics will be composed from the 1st or 
2nd generation of Cephalosporin family plus Metronidazole given within 60 minutes prior 
to surgery. In cases of allergy to the Cephalosporin or Penicillin families, other IV 
antibiotic may be used. Pre-operation prophylactic oral antibiotic is not allowed. 
Mechanical bowel preparation will be at the discretion of the principal investigator (PI) per 
each site's SOP. Post-operative resumption of activity will be at the discretion of the PI 
based on the subject's medical condition. 
Doxycycline pharmacokinetic sampling will be collected in selected sites from all 
randomized subjects in these sites (sites from Czech Republic will not participate in the 
PK sub‐ study). About 
 series of
 samples per set will be analyzed. About 
 series 
will be analyzed from subjects receiving 2 vials, about 
series will be analyzed from 
subjects receiving 3 vials.  




Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 14 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
3.2. 
Study Endpoints 
3.2.1. 
Primary Efficacy Endpoint 
The primary efficacy endpoint in this study is defined per subject as a binary treatment 
failure event ("Yes" / "No"), with "Yes" indicating if a subject had experienced within 30 
days post abdominal index surgery (up to and including 30 days post index surgery date) 
any Surgical Site Infection (SSI) event in the target incision, as determined by a blinded 
and independent adjudication committee. In addition, the following events occurring 
within 30 days post abdominal index surgery, will be considered as treatment failure 
events:  
 Death (from any reason) 
 Re‐ intervention at the primary incision site (target) due to suspected SSI or due to 
poor wound healing (including wound dehiscence), as verified by the blinded 
adjudication committee. 
To note, re-intervention at a different access point than the target incision or re-intervention 
at the target incision site due to any other reason than suspected SSI or poor wound healing 
(including wound dehiscence), will not be considered as treatment failure event in the 
primary analysis. 
SSI is composed of Deep Incisional Surgical Site Infection (DSSI) and/or Superficial 
Incisional Surgical Site Infection (SSSI). A SSSI is an infection that involves only skin and 
subcutaneous tissue of the incision and does not include diagnosis/treatment of cellulitis, a 
stitch abscess alone or a localized stab wound or pin site infection. A DSSI is an infection 
that involves deep tissues, such as fascia and muscle layers; this also includes infection 
involving both superficial and deep incision sites. 
Subjects who have a valid non-missing observation of “Day 30 SSI assessment”, performed 
within the pre-specified visit window (applicable visit window is defined below), and have 
not experienced any adjudicated SSI event or death or any adjudicated re-intervention in 
the target incision due to suspected SSI or due to poor wound healing, including wound 
dehiscence, within 30 days post abdominal index surgery, will be defined as "No". 
Those subjects who do not have a valid non-missing “Day-30 SSI assessment” as required 
for the assignment of a Failure=’No’ response will be considered as having missing data 
and will be imputed as Failure=Yes for the primary analysis of this endpoint. 
For the determination of a ‘Failure=No’ response, a valid non-missing observation for Day 
30 SSI assessment is any confirmation provided in the window of study day 
to study 
day
 Due to the COVID-19 pandemic, this confirmation can be collected retrospectively 
through visits performed after study day 
. For an event to be counted as ‘Failure=Yes’ 
response, date should be up to and including 30 days post index surgery date. 
Details on handling of missing primary endpoint data are described further in section 5.4. 
 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 15 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
3.2.2. 
Secondary Efficacy Endpoints 
3.2.2.1. 
Key Secondary Efficacy Endpoints 
The key secondary endpoints are defined as follows: 
1. Infection rate as measured by the proportion of subjects with at least one SSI event 
in the target incision, occurred within 30 days post abdominal index surgery, and 
determined by a blinded independent adjudication committee.  
This endpoint will be defined per subject as a binary ("Yes" / "No") variable, with 
"Yes" indicating that a subject have had at least one confirmed (by a blinded 
independent adjudication committee) SSI event within 30 days post index surgery 
(up to and including 30 days post index surgery date). Subjects who have a valid 
non-missing observation of “Day 30 SSI assessment”, performed within the pre-
specified visit window (the same as defined for the primary endpoint), and have not 
experienced any adjudicated SSI event within 30 days post index surgery, will be 
defined as "No". 
2. Number (percentage) of subjects with at least one score of ASEPSIS > 20 (further 
to an adjudicated SSI).  
This endpoint will be defined per subject as a binary ("Yes" / "No") variable, with 
"Yes" indicating that a subject have had at least one score of ASEPSIS > 20. 
Subjects that have not had a score of ASEPSIS > 20, will be defined as "No". 
To note, these endpoints refer to target incision at index surgery. Section 5.4 provides the 
details on handling missing data here. 
 
3.2.2.2. 
Additional Secondary Efficacy Endpoints 
The current section provides the definitions of the additional secondary efficacy endpoints 
of the study, general and SSI related. General endpoints will be defined for all subjects in 
the relevant analysis populations, while SSI related endpoints will be defined only for the 
sub-population of subjects who experienced at least one adjudicated SSI within 30 days 
post index surgery. 
Unless otherwise noted, and as relevant, endpoints will refer to target incision from index 
surgery. Section 5.4 provides the details on handling missing data. 
The general additional secondary efficacy endpoints are defined as follows: 
 Incidence of SSSI within 30 days post index surgery. 
This endpoint will be defined per subject as a binary ("Yes" / "No") variable, with 
"Yes" indicating that a subject has had at least one confirmed (by a blinded 
independent adjudication committee) SSSI event within 30 days post index surgery 
(up to and including 30 days post index surgery date). Subjects who have a valid 
non-missing observation on Day 30 SSI assessment, performed within the pre-
specified visit window (the same as defined for the primary endpoint), and have not 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 16 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
experienced any adjudicated SSSI event within 30 days post index surgery, will be 
defined as "No". 
 Incidence of DSSI within 30 days post index surgery. 
This endpoint will be defined per subject as a binary ("Yes" / "No") variable, with 
"Yes" indicating that a subject has had at least one confirmed (by a blinded 
independent adjudication committee) DSSI event within 30 days post index surgery 
(up to and including 30 days post index surgery date). Subjects who have a valid 
non-missing observation on Day 30 SSI assessment, performed within the pre-
specified visit window (the same as defined for the primary endpoint), and have not 
experienced any adjudicated DSSI event within 30 days post index surgery, will be 
defined as "No". 
 All-cause mortality rate within 30 days post randomization. 
In case there are no subjects with unknown survival status at 30 days post 
randomization, this endpoint will be defined per subject as a binary ("Yes" / "No") 
variable, with "Yes" indicating that a subject had died (from any reason) within 30 
days post randomization. Otherwise, the 30-days mortality rate will be estimated 
using a time-to-event analysis, by the Kaplan-Meier method. In this case, for each 
subject survival time will be calculated as days between randomization and death  
(in the event of death within 30-days) or the time from randomization to the earliest 
between last date of known to be alive or 30-days, yielding a censored survival 
time. 
 All-cause mortality rate within 60 days post randomization. 
This endpoint will be defined similarly to the 30 days mortality endpoint above, 
now with the time frame of 60 days post randomization.  
 Time to adjudicated SSI within 30 days post index surgery. 
This endpoint will be defined per subject as the difference between the date of 
adjudicated SSI and the date of index surgery. Subjects, who have not experienced 
an adjudicated SSI within 30 days post index surgery, will be handled as follows: 
o Subjects having a valid non-missing Day 30 SSI assessment (within the 
pre-specified visit window) will be censored at Day 30. 
o Subjects who died within 30 days post index surgery will be censored at 
the date of death. 
o Subjects having a missing Day 30 SSI assessment (or performed out of the 
pre-specified visit window) will be censored at the date of the last valid SSI 
assessment, performed within 30 days post index surgery. 
o Subjects having no valid SSI assessment within 30 days post index surgery 
will be censored at the date of index surgery (i.e. at Day 0). 
 Number (percentage) of subjects, re-admitted within 30 days post index surgery 
(for any reason) and experienced adjudicated SSI during this re-admission. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 17 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
This endpoint will be defined per subject as a binary ("Yes" / "No") variable, with 
"Yes" indicating that a subject had been re-admitted within 30 days post index 
surgery (for any reason) and experienced an adjudicated SSI during this re-
admission. Subjects who have a valid non-missing observation on Day 30 SSI 
assessment, performed within the pre-specified visit window (the same as defined 
for the primary endpoint), and have not been re-admitted within 30 days post index 
surgery (for any reason) with an adjudicated SSI during this re-admission, will be 
defined as "No". 
 Number (percentage) of subjects who experienced at least one adjudicated surgical 
re-intervention within 30 days post index surgery. 
This endpoint will be defined per subject as a binary ("Yes" / "No") variable, with 
"Yes" indicating that a subject had experienced at least one adjudicated surgical re-
intervention within 30 days post index surgery. Re-intervention is defined as re-
opening of the surgery incision, used for the original index surgery, in the operation 
room (OR). Adjudicated re-intervention is re-intervention due to suspected SSI or 
due to poor wound healing (including wound dehiscence), as verified by the blinded 
adjudication committee. Subjects who have a valid non-missing observation on 
Day 30 SSI assessment, performed within the pre-specified visit window (the same 
as defined for the primary endpoint), and have not experienced any adjudicated re-
intervention within 30 days post index surgery, will be defined as "No". 
 Number (percent) of subjects who experienced at least 1 surgical re-intervention 
during 30 days post index surgery. 
This endpoint will be defined as the previous endpoint, where now any re-
intervention (regardless of reason) will be considered for Yes outcome.  
The SSI related additional secondary efficacy endpoints will be applied only for subjects 
with adjudicated SSI within 30 days post index surgery and are defined as follows: 
 Number (percentage) of subjects that at least one bacteria resistant to Doxycycline 
was isolated during the bacteriological tests. 
This endpoint will be defined per subject as a binary ("Yes" / "No") variable, with 
"Yes" indicating that a subject had at least one bacteria (grown during the 
bacteriological tests) which is resistant to Doxycycline. 
 Number (percentage) of bacteria resistant to Doxycycline out of all bacteria grown 
during the bacteriological tests. 
This endpoint will be defined per unique bacteria (grown during the bacteriological 
tests) per subject as a binary ("Yes" / "No") variable, with "Yes" indicating that a 
unique bacteria is resistant to Doxycycline. 
 Number (percentage) of subjects who received antibiotic (any route) as a treatment 
for their adjudicated SSI. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 18 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
This endpoint will be defined per subject as a binary ("Yes" / "No") variable, with 
"Yes" indicating that a subject received antibiotic as a treatment for their 
adjudicated SSI. 
 Number of IV antibiotic treatment days. 
This endpoint will be defined per subject as the total number of days on which a 
subject was treated with IV antibiotic. Subjects who were not treated with IV 
antibiotic will be assigned a value of 0 days. 
 Average of subjects' cumulative ASEPSIS assessment score (AUC). 
This endpoint will be defined per subject as Area Under the Curve (AUC) of 
ASEPSIS assessment scores, calculated using the trapezoidal rule, in the time frame 
of 60 days from index surgery. This endpoint will be calculated to provide a 
measure of total burden (for example, for two patients reaching the same maximal 
score, a patient whose score applied for a larger duration will be scored higher than 
one with shorter duration). 
 Number (percentage) of subjects with at least one score of ASEPSIS > 20. 
This endpoint will be defined per subject in the same way as the second key 
secondary efficacy endpoint (refer to section 3.2.2.1, item 2), and will apply here 
only for sub-population of subjects with adjudicated SSI within 30 days post index 
surgery. 
 
3.2.3. 
Safety Endpoints 
The following safety endpoints will be evaluated: 
 Adverse events 
 Physical examination 
 Vital signs 
 Incisional wound healing 
 Laboratory tests 
In addition, concomitant medications, surgery and hospitalization characteristics are 
collected.  
The definitions and analyses of these safety measures are provided in section 8 of this SAP. 
 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 19 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
3.3. 
Sample Size and Power Considerations 
3.3.1. 
The Minimal Sample Size Calculation 
The sample size calculation for this study is based on powering the study with respect to 
the primary efficacy analysis. The treatment failure rates were compared between the two 
treatment groups: D-PLEX + Standard of Care (SoC) versus SoC alone.  
Assumptions for the sample size calculations were as follows: 
 Test: two-sample proportion difference using chi-square test 
 Significance level: two-sided α = 0.04, taken conservatively to account for the 
planned interim analysis for efficacy (to be performed with a two-sided α=0.01, 
refer to section 5.3 for full details). 
 Power = 90% 
 Null hypothesis: PSoC=PD-PLEX+SoC 
 Allocation ratio: 1:1 
 SoC SSI rate: 16% 
 Effect size of D-PLEX+SoC on SSI rate, compared to SoC alone: 50% (halving the 
SSI rate), therefore, the assumed D-PLEX+SoC SSI rate was 8%  
 All-cause Death or Adjudicated Re-intervention in the target incision due to 
suspected SSI or due to poor wound healing, including wound dehiscence, rate: 
 
for both treatment groups, therefore, the assumed treatment failure rates were 
 
and 
, for SoC and D-PLEX+SoC, respectively 
Based on the above assumptions, a sample of 882 subjects provide 90% power to detect 
the assumed difference in treatment failure proportions between the treatment groups. In 
order to account for an anticipated of about 5% lost-to-follow-up rate, a minimum of 950 
subjects (475 per treatment group) will be enrolled. 
 
3.3.2. 
Interim Analysis for Stopping Early for Efficacy or Futility, or Unblinded 
Sample Size Re-estimation 
One comparative interim analysis for an early efficacy or futility stop or unblinded sample 
size re-estimation will be conducted when about 750 subjects complete one month follow-
up and are evaluated for the primary endpoint. The interim analysis will include a group-
sequential design stopping rule for efficacy or futility, combined with unblinded sample 
size re-assessment based on the ‘Promising Zone’ approach. The outcome of this interim 
analysis will be either early stopping for efficacy or futility, or continuation to planned 
final (950 subjects) or continue with sample size increased up to total of 1400 subjects only 
if the comparative result falls in a predefined ‘Promising Zone’. The interim decision will 
be made by the independent DMC according to a pre-planned interim analysis plan, and 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 20 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
comparative information will be maintained confidential within the independent 
statistician until the study finally unblinded.  
The full details about the stopping rules and the sample size decision rules will be detailed 
in an Interim Statistical Analysis Plan (ISAP) accompanying this document.  
 
3.4. 
Randomization and Blinding 
3.4.1. 
Randomization 
Upon confirmation that the subject fulfils all inclusion criteria and none of the exclusion 
criteria are met, he/she will be randomized through an Interactive Web Randomization 
System (IWRS) integrated with the electronic Case Report Form (eCRF). Randomization 
will be stratified by type of prophylactic Standard of Care (prophylactic IV antibiotic with 
mechanical bowel preparation or prophylactic IV antibiotic without mechanical bowel 
preparation) and by region (USA or Europe+Israel). 
Randomization will be done centrally, using a randomization specification prepared by the 
study statistician and generated by an independent statistician (not involved in the study), 
and will assign subjects in a 1:1 ratio to: 
● Treatment Arm – Standard of Care (SoC) concurrently with D-PLEX application 
● Control Arm – SoC treatment alone 
Instructions and training for randomization and stratification process will be provided 
during site initiation visit. 
The randomization code will be stored within the IWRS database until unblinding of this 
study is requested. 
 
3.4.2. 
Blinding 
This is a double blind clinical trial. The sponsor, subjects, outcome assessor and all staff 
involved in the collection and recording of the clinical and laboratory data, based on which 
the independent adjudication committee will perform their assessment, will be blind to 
treatment assignment. In addition, all aspects of data management and clean-up as well as 
programming for final analysis will be done in blinded datasets. An unblinded statistician, 
external to the Sponsor, will be tasked with providing unblinded data to the Data 
Monitoring Committee (DMC) and will have access to the treatment codes via the 
Interactive Web Response System (IWRS). 
The study site personnel, who perform the index surgery (operation room staff), will be 
trained not to disclose the treatment arm to the blinded investigator, to the subject, his/her 
family, to other health care providers not present during the surgery or to the study Sponsor 
representatives. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 21 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
Wound assessment and other study outcomes throughout the study follow-up visits will be 
done by a blinded investigator that will not be involved in the surgery. 
 
3.5. 
Sequence of Planned Analyses 
3.5.1. 
Interim Analyses 
One formal interim analysis to stop the study early for efficacy or futility, or sample size 
re-estimation is planned, scheduled to be conducted when about 750 subjects will complete 
the 1-month follow-up and evaluated for the primary endpoint. The interim analysis will 
include a group-sequential design stopping rule for efficacy or futility, combined with 
unblinded comparative sample size re-estimation based on the ‘Promising Zone’ approach 
(Mehta and Pocock 2011). Only the primary efficacy endpoint will be analysed. 
The outcome of this interim analysis will be either early stopping for efficacy or futility, 
or continuation to planned final (950 subjects) or continue with sample size increased up 
to maximal size of 1400 only if the comparative result falls in a predefined ‘Promising 
Zone’. As specified in section 3.3.2, the full details about the stopping rules and the sample 
size decision rules will be detailed in an Interim Statistical Analysis Plan (ISAP) 
accompanying this document.  
 
3.5.2. 
Final Analyses and Reporting 
All final, planned analyses identified in this SAP will be performed only after the last 
randomized subject has completed the study. For the purpose of the interim analysis, the 
randomization codes will not be unblinded until the ISAP has been signed and approved 
and accordingly prior to final analysis, the randomization codes will not be unblinded until 
this document has been signed and approved. 
Any exploratory analyses completed to support study analyses, which were not identified 
in this SAP, will be documented and reported in appendices to the CSR.  
 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 22 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
4. 
ANALYSIS POPULATIONS 
The current section describes the analysis populations defined for the study. 
 
4.1. 
Screened 
This population will include all subjects who underwent screening and will be used for 
summary of disposition and data listings. 
 
4.2. 
Intent to Treat (ITT) 
The ITT population will include all abdominally-incision randomized subjects. In this 
population, treatment will be assigned based upon the treatment to which subjects were 
randomized regardless of which treatment they actually received. 
 
4.3. 
Safety 
The safety population will include all subjects randomized and treated with D-PLEX or 
SoC. In this population, treatment will be assigned based upon the treatment subjects 
actually received regardless of the treatment to which they were randomized.  
 
4.4. 
Modified Intent to Treat (mITT) 
The mITT analysis population is a sub-population of the ITT and will include all subjects 
randomized and treated with D-PLEX or SoC, who underwent the index surgery and have 
no eligibility criteria deviation. Exclusion from the mITT population will be determined in 
a blinded manner prior to database lock. In this population, treatment will be assigned 
based upon the treatment to which subjects were randomized regardless of which treatment 
they actually received. Subjects who will die during the study will not be excluded from 
the mITT population. 
 
4.5. 
Per Protocol (PP) 
The PP analysis population will include all mITT subjects who had no major protocol 
deviations and assessed for primary endpoint (i.e. had Day 30 SSI assessment within the 
pre-specified visit window, or had been defined as treatment failure before this assessment 
due to experiencing an adjudicated SSI event, or death, or adjudicated re-intervention on 
the target incision due to suspected SSI or due to poor wound healing, including wound 
dehiscence). In this population, treatment will be assigned based upon the treatment to 
which subjects were randomized regardless of which treatment they actually received. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 23 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
5. 
GENERAL ASPECTS FOR DATA ANALYSIS 
5.1. 
General 
The following is a list of general reporting conventions:  
1. Descriptive statistics for continuous variables include n (number of non-missing 
observations), mean, standard deviation (SD), standard error of the mean (SE), 25th 
and 75th percentiles, median, minimum, and maximum.  
2. Means, medians and percentiles will be reported with 1 more digit than the 
precision of the captured data. Standard deviations and confidence intervals will be 
reported at 2 more digits than the precision of the data. Minimum and maximum 
will be reported to the same level of precision as the original observations.  
3. Descriptive statistics for categorical variables will include counts (n) and 
percentages (%) and will be presented in the form of n (%).  
4. Percentages will be reported with 1 decimal place.  
5. No preliminary rounding should be performed; rounding should only occur after 
analysis.  To round, consider digit to right of last significant digit:  if < 5, then round 
down; if ≥ 5, then round up. 
6. Unless otherwise noted, all statistical analyses will be conducted with a significance 
level (α) of 0.05 and utilize two-sided testing. 
7. All data collected will be presented in the by-subject data listings, sorted by subject 
and by time point, where appropriate. 
If departures from these general conventions are present in the specific evaluation sections 
of this SAP, then those will take precedence over the above general conventions. 
 
5.2. 
Specification of Baseline Values 
In general, Baseline will be defined for each subject as the last available, valid, non-missing 
assessment before the initiation of first study treatment, i.e. before the administration of 
pre-operative IV antibiotic, given as part of Standard of Care procedures.   
 
5.3. 
Multiple Comparisons and Multiplicity 
The overall study-wise type I error will be 5%. To protect the study from type I error 
inflation, the key secondary endpoints will be interpreted inferentially only if a statistically 
significant treatment effect is detected in the primary endpoint. To note, as the secondary 
endpoints are to be tested once (not part of interim analysis), the first secondary endpoint 
will be tested in full 5% significance level in case the primary endpoint is successful. Type 
I error will be further controlled for the key secondary endpoints by employing the 
Hierarchical Approach, i.e., the second key secondary endpoint will be formally analysed 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 24 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
only in case the preceding first key secondary endpoint is statistically significant (p-value 
≤ 0.05).  
The additional secondary endpoints will be used to enhance understanding the beneficial 
effect of D-PLEX and there is no plan for formal inference for these. Thus, no multiplicity 
control is further planned beyond the key secondary endpoints. 
To account for the option of early stopping for efficacy, the type-1 error spending approach 
will be utilized. The interim analysis is planned when about 750 subjects in total will be 
enrolled and have the chance to complete 1-month visit, and an alpha level of 1% (two-
sided) regardless of the exact number of subjects included in the analysis will be used. For 
strict control of the overall type-1 error, the alpha for the final analysis (in case the study 
does not stop at interim) will be calculated based on the actual information time of the 
interim analysis (actual total # at interim/target maximal study size). 
As the interim analysis was performed with a total of 
patients and the final study size 
remained un-changed at 950 subjects, the calculated one-sided alpha level for the primary 
endpoint to maintain overall of 5% significance level is: 
 (
 one sided, 
 two sided). 
The ‘Promising Zone’ approach (Mehta and Pocock 2011) was chosen to rigidly control 
study overall type-1 error due to the unblinded comparative size re-estimation at the time 
of interim analysis, and its planned implementation strictly follows the rules that increase 
sample size only if comparative results fall in a pre-defined ‘Promising Zone’, thus 
allowing final analysis to be preserved without further need for statistical adjustment 
(beyond adjustment due to the interim efficacy analysis as described above). 
 
5.4. 
Handling Withdrawals and Missing Data 
5.4.1. 
Primary Endpoint 
To be recalled, in the calculation of the primary endpoint (section 3.2.1), deaths occurring 
within the first 30 days post abdominal index surgery are addressed as treatment failure 
events and thus are not considered missing data problem, in either of the primary or 
sensitivity and supportive primary endpoint analysis. 
To note, re-intervention in the target incision occurring within the first 30 days post 
abdominal index surgery due to suspected SSI or due to poor wound healing (including 
wound dehiscence), as verified by the blinded adjudication committee, will be addressed 
as treatment failure events ("Yes") in all sensitivity and supportive analyses of the primary 
efficacy endpoint. 
As specified in section 3.2.1, for the purpose of the primary efficacy analysis, based on ITT 
population, missing data will be imputed as follows: Subjects, who have missing primary 
efficacy endpoint data due to other reasons than death (i.e. missing Day 30 SSI assessment 
(regardless of reason) or performed out of pre-specified visit window) and have not already 
been identified as treatment failures due to having experienced any adjudicated SSI event 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 25 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
or any adjudicated re-intervention in the target incision, due to suspected SSI or due to poor 
wound healing, including wound dehiscence, will be imputed as treatment failures ("Yes").  
As defined in section 3.2.13.2.1, for the determination of a 'Failure=No' response, a valid 
non-missing observation for Day 30 SSI assessment is any confirmation of such response 
provided in the window of study day
 to study day 
 Due to the COVID-19 pandemic, 
this confirmation can be collected retrospectively through visits performed after study day 
.  
For the purpose of the sensitivity analyses to the primary efficacy endpoint analysis, 
missing data (arising from other reasons than death) will be imputed as follows: 
When using ITT population: 
1. Using Multiple Imputation (MI) technique 
2. Imputing as not treatment failure ("No") 
The MI technique will be performed in 3 steps:  
1. Step 1- Imputation: missing data will be filled in using 50 different sets of values, to 
produce 50 imputed datasets.  The imputed datasets will consist of 50 copies of the original 
ITT set, with the observed values being the same across all copies, and with imputed values 
varying from one copy to another. The logistic regression method as implemented in the 
MI procedure in SAS (the MONOTONE LOGISTIC statement) will be used for this step. 
The variables that will be included in the imputation model will be as follows: treatment 
group, stratification factors, age, gender and incisional length of > 20 cm (Yes/No). In case 
of complete separation issues, the baseline factors list (except treatment) may be reduced. 
2. Step 2- Analysis: each datasets will be analyzed separately using the same analytical 
approach defined for the primary analysis (namely, the CMH test). 
3. Step 3- Pooling: The results from the 50 imputed datasets will be combined into one 
result using Rubin’s rules which account for the uncertainty associated with imputed 
values. This pooling will be performed using the MIANALYZE procedure in SAS. A 
normalizing Wilson-Hilferty transformation will be applied to the CMH statistic and the 
resulted normal variable will be further standardized prior to pooling, following the method 
proposed in Ratitch et al. 
When using mITT and PP populations: no imputation will be performed (i.e., a complete 
case analysis will be used).  
 
5.4.2. 
Secondary Endpoints 
There will be no imputation of missing data for all other study endpoints (i.e., a complete 
case analysis will be used), unless otherwise noted for a specific analysis.  
Specifically for the key secondary efficacy endpoints, sensitivity analysis for missing data 
due to reasons other than deaths may be performed, depending on the number of these 
cases, using the same methods specified above for the primary endpoint. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 26 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
There is no planned sensitivity analysis for missing data in other secondary endpoints. 
Time to adjudicated SSI within 30 days post index surgery endpoint will handle the missing 
values as censored, as detailed in the definition of this endpoint in section 3.2.2.2. 
Details on imputation of partial dates for concomitant medications and for adverse events 
are provided further in sections 8.7.1 and 8.2, respectively. 
 
5.5. 
Study days and visit windows 
The day of initiation of study treatment in this study is defined as the day of index surgery 
(Day 0). Study days will be numbered relative to the day of index surgery (i.e. …, –2, –1, 
0, 1, 2, …), with day –1 being the day before index surgery, day 0 being the day of index 
surgery, day 1 being 1 day post index surgery. 
In general, the study data will be summarized as collected at the scheduled study visits 
regardless of visit window violations. For by-visit summaries, if there are multiple 
assessments at a post-baseline visit, then the last non-missing assessment at that visit will 
be used for the summary. 
For the primary efficacy endpoint definition, the pre-specified analysis-visit window for 
Day 30 follow-up visit will be used, as described in section 3.2.1 above. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 27 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
6. 
STUDY POPULATION 
6.1. 
General 
Study population summaries will be presented by treatment group and overall unless 
otherwise noted. Subject disposition will include all screened subjects. All other study 
population summaries will be based on ITT population unless otherwise noted.  
 
6.2. 
Subject Disposition 
The subject disposition will be summarized as follows and presented for each treatment 
group and overall, unless otherwise specified. The percentages will be calculated from the 
number of randomized subjects, unless otherwise specified. 
 The number of all screened subjects (i.e. the number of subjects in the Screened 
population), presented only for overall group 
 The number (%) of subjects who failed screening (% calculated from the Screened 
population), including the distribution of reasons for failing the screening, 
presented only for overall group 
 The number (%) of subjects screened but not randomized, if applicable (% 
calculated from the Screened population), presented only for overall group 
 The number of randomized subjects 
 The number (%) of randomized but not treated subjects, if applicable 
 The number (%) of subjects in the Safety population (i.e. treated subjects) 
 The number (%) of subjects in the ITT population 
 The number (%) of subjects in the mITT population (% calculated from ITT 
population) 
 The number (%) of subjects in the PP population (% calculated from ITT 
population) 
 The number (%) of subjects who completed the study 
 The number (%) of subjects who discontinued the study prematurely, including the 
distribution of reasons for premature discontinuation 
 
6.3. 
Demographics and Baseline Characteristics 
Demographics and baseline characteristics will be summarized by treatment group and 
overall using ITT and Safety populations. Summaries will be presented with the 
appropriate descriptive statistics as specified in section 5.1 above. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 28 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
The following will be provided: 
 Demographics: 
o Age (years) (continuous) 
o Gender: Male, Female (categorical) 
o Childbearing Potential: Yes, No (categorical, females only)  
o Ethnicity: Hispanic or Latino, Not Hispanic or Latino, Unknown, Not 
Stated (categorical) 
o Race: White, American Indian or Alaska native, Asian, Black or African 
American, Native Hawaiian or Other Pacific Islander, Other (categorical). 
As a subject may chose more than one categories, combinations will also be 
presented, such as a patient will contribute to only single category.  
 Baseline vital signs: 
o Height (cm) (continuous) 
o Weight (kg) (continuous) 
o BMI (kg/m2) (continuous) 
 Allergy History: 
o Any known allergy: Yes, No (categorical) 
o Any known allergy to Doxycycline and/or to the tetracycline family of 
drugs: Yes, No (categorical) 
o Any hospitalization due to allergy reaction: Yes, No (categorical) 
o Taking antihistamine drugs in the last year for any reason: Yes, No 
(categorical) 
o Suffering from allergic type symptoms: Yes, No (categorical) 
 Substance Use (only subjects for whom Substance Use data had been collected): 
o Cigarettes (Tobacco): 
 Usage: Current, Former, Never (categorical) 
 Number of Pack-Years (for current or former usage) (continuous) 
o Alcohol: 
 Usage: Current, Former, Never (categorical) 
 Frequency: Daily, Occasionally, Almost Never (for current or 
former usage) (categorical) 
o Recreational Drugs Abuse: 
 Usage: Current, Former, Never (categorical) 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 29 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
 Frequency: Daily, Occasionally, Almost Never (for current or 
former usage) (categorical) 
 Drug Type: Amphetamines, Barbiturates, Benzodiazepines, 
Cocaine, Methadone, Methamphetamines, Opiate, Phencyclidine, 
Tricyclic Antidepressants, Cannabinoids, Other, Unknown/Not 
reported (categorical) 
 Charlson Co-Morbidity Index (CCI), total score 
 Is this a COVID-19 patient: Confirmed Positive, Suspected, Unlikely, Confirmed 
Negative, Not Done. 
 Indication for Index Surgery: Cancer, Crohn's Disease, Inflammatory Bowel 
Disease (IBD), Other (categorical) 
The following baseline factors are identified as prognostic factors that may be associated 
with primary outcome for which group balance will be reviewed: age, gender, comorbid 
conditions (Yes/No) associated with increased risk of SSI (as listed in section 6.5), 
Charlson co-morbidity index, indication for index surgery. If any of these baseline factors 
are deemed imbalanced then the factor will be included as an extra adjusting covariate in 
the relevant sensitivity analysis models for the primary and key secondary efficacy 
endpoints. 
 
6.4. 
Stratification Factors for Randomization 
Stratification factors for randomization will be summarized by treatment group and overall 
using ITT population. Summaries will be presented with the appropriate descriptive 
statistics as specified in section 5.1 above. 
The following will be provided: 
 Type of Prophylactic Standard of Care: IV antibiotics With Mechanical Bowel 
Preparation, IV antibiotics Without Mechanical Bowel Preparation (categorical) 
 Region: USA, Europe+ Israel (categorical) 
To note, errors in randomization (selecting the wrong category of the factor) are not 
possible for the Region factor, however, are possible for the type of prophylactic SoC 
factor. If these happen, the corrected factor (as presented in the CRF) will be presented as 
well. 
 
6.5. 
Medical History 
Medical history data will be summarized by treatment group and overall using Safety 
population. All medical history terms will be coded using the Medical Dictionary for 
Regulatory Activities (MedDRA, version 23.1). The number and percentage of subjects 
with at least one medical history term will be summarized by System Organ Class (SOC) 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 30 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
and by Preferred Term (PT) within SOC for each treatment group and overall. The number 
of events will also be summarized. The table will be sorted by overall descending frequency 
of SOC and then, within a SOC, by overall descending frequency of PT.  
Additional summary table will be provided for the following comorbid conditions 
(associated with increased risk of SSI): Diabetes, Chronic Obstructive Pulmonary Disease 
(COPD)/Smoking, Obesity/Overweight, Hypertension, and Peripheral Vascular Disease 
(PVD). The number and percentage of subjects will be presented for each comorbid 
condition by treatment group and overall. 
All medical history data will be listed. 
 
6.6. 
Physical Examination 
Physical examination findings at baseline (Normal, Abnormal CS, Abnormal NCS, 
Missing) will be summarized by treatment group and overall using Safety population. 
Summaries will be presented with the appropriate descriptive statistics as specified in 
section 5.1 above. 
 
6.7. 
Protocol Deviations  
All protocol deviations in the study will be listed. Summary of deviations according to pre-
defined categories will also be provided by treatment group and overall. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 31 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
7. 
EFFICACY ANALYSES 
7.1. 
General 
The analysis of the primary and key secondary efficacy endpoints will be performed on the 
ITT, mITT and PP populations, with the ITT population serving as the primary analysis 
population. General additional secondary efficacy endpoints will be analysed using the ITT 
and mITT populations, unless otherwise noted for a specific endpoint. SSI related 
additional secondary efficacy endpoints will be analysed on the sub-population of subjects 
who experienced at least one adjudicated SSI within 30 days post index surgery. 
Summaries will be presented by treatment group, unless otherwise noted. 
 
7.2. 
Primary Efficacy Analysis 
The primary objective of the study is to assess the anti-infective efficacy of DPLEX+SOC 
over a period of 30 days post operation, by preventing surgical site infection (SSI), defined 
as superficial and/or deep infection, in the index (target) incision, compared to the SoC 
alone control arm. 
 
7.2.1. 
Primary Analysis 
The primary efficacy analysis will be based on the ITT population and will compare the 
proportions of treatment failures (as defined in section 3.2.1 above) between D-PLEX+SoC 
and SoC alone treatment groups. 
The number and percentage of subjects, defined as treatment failures, will be presented by 
treatment group. A 95% confidence interval (based on the Clopper-Pearson method) will 
be constructed for each proportion. A Cochran–Mantel–Haenszel (CMH) test will compare 
the proportions of treatment failure between the two groups, using the study stratification 
factors used for randomization (as specified in section 3.4.1 above), and corresponding risk 
difference estimate will be presented with 95% confidence interval (using the method of 
Mantel–Haenszel stratum weights, as applied in the COMMONRISKDIFF option in the 
SAS FREQ procedure). The following generic SAS syntax will be used: 
ODS OUTPUT CommonPdiff=cmh_pdiff(WHERE=(method="Mantel-Haenszel")) 
 
    CMH=cmh_pval(WHERE=(AltHypothesis="Row Mean Scores Differ")); 
PROC FREQ DATA=eff ORDER=internal; 
TABLES STRATAA*STRATAB*TRTP*AVALC / CMH COMMONRISKDIFF(COLUMN=2);  
RUN; 
 
The following hypotheses will be tested for a significant difference in the treatment-failure 
proportions between D-PLEX+SOC (PDPLEX) and SoC alone (PSoC) treatments: 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 32 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
H0: PDPLEX = PSoC 
vs. 
H1: PDPLEX ≠ PSoC 
For final analysis, the interim analysis adjusted significance level will be used for this test, 
refer to section 5.35.3 for details. In the case of small number of events (less than 5 events 
in any treatment group), the Fisher's exact test will be used. 
In addition, the number and percentage of each of the failure types comprising the primary 
efficacy endpoint will be presented by treatment group. The denominator for percentages 
will be the number of ITT subjects in each treatment group. The mutually exclusive failure 
type categories are: 
1. Death 
1.1. Death and Adjudicated DSSI Event 
1.2. Death and Adjudicated SSSI Event 
1.3. Death and Adjudicated Re-intervention 
1.4. Death, without Adjudicated SSI Event or Adjudicated Re-intervention 
2. Adjudicated SSI Event (Total) 
2.1. Adjudicated DSSI Event 
2.2. Adjudicated SSSI Event 
3. Adjudicated Re-intervention 
4. Missing Day 30 SSI Assessment. 
Subjects experiencing more than one type of treatment failure event will be counted only 
in the highest in the hierarchy type (based on the above order). To note, adjudicated DSSI 
and SSSI events, all-cause mortality, and adjudicated re-interventions will be analysed 
further as a part of the additional secondary efficacy analyses. 
 
7.2.2. 
Sensitivity and Supportive Analyses 
Sensitivity and supportive analyses for the primary endpoint analysis will address the 
following aspects: 
1) Repeat the primary analysis using the mITT and PP populations. 
2) To account for the possibility of errors in values of stratification factors used for 
randomization, the primary analysis will supportively be repeated using the correct 
values. 
3) Difference between the treatment groups when controlling for possible imbalance 
in important baseline factors (as obtained from the analyses described in 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 33 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
section 6.3) will be analysed by evaluating the odds ratio obtained from estimating 
a multiple logistic regression model.  
4) Sensitivity analyses for the imputation of missing data due to other reasons than 
death (please refer to section 5.45.4.1). 
5) Descriptive statistics of the incidence of re-interventions at the target incision site 
due to other reasons than suspected SSI or due to poor wound healing (including 
wound dehiscence), within 30 days post abdominal index surgery. Sensitivity 
analysis where these events are considered also as treatment failure (in addition to 
the primary endpoint treatment failure events, as detailed in section 3.2.1) will also 
be performed. 
All analyses of the primary endpoint are based on the blinded and independent adjudication 
committee decisions. The investigator assessment of SSI will be described and listed, as 
detailed in section 8.5. 
 
7.3. 
Secondary Efficacy Analyses 
7.3.1. 
Key Secondary Efficacy Analyses 
7.3.1.1. 
First Key Secondary: SSI Rate within 30 Days Post Index Surgery 
The number and percentage of subjects with at least one SSI event (as defined in 
section 3.2.2.1, item 1) will be presented by treatment group. A 95% confidence interval 
(based on the Clopper-Pearson method) will be constructed for each proportion. A 
Cochran–Mantel–Haenszel (CMH) test will compare the proportions of subjects with at 
least one SSI event between the two groups, using the study stratification factors used for 
randomization (as specified in section 3.4.1 above), and corresponding risk difference 
estimate will be presented with 95% confidence interval (using the method of Mantel–
Haenszel stratum weights, as applied in the COMMONRISKDIFF option in the SAS 
FREQ procedure, generic SAS syntax detailed in section 7.2.1 above). In the case of small 
number of events (less than 5 events in any treatment group), the Fisher's exact test will be 
used. 
This first key secondary efficacy endpoint will be formally tested only if the primary 
efficacy endpoint analysis showed statistically significant difference between the groups 
in the favor of D-PLEX+SoC, using two-sided 5% significance level (per section 5.3). 
 
7.3.1.2. 
Second Key Secondary: ASEPSIS>20 Rate 
The second key secondary efficacy endpoint (as defined in section 3.2.2.1, item 2) will be 
analysed using the same methods as described for the first key secondary efficacy endpoint 
(refer to section 7.3.1.1 above). 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 34 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
This second key secondary efficacy endpoint will be formally tested only if the first key 
secondary efficacy endpoint showed statistically significant difference between the groups 
in the favor of D-PLEX+SoC, using two-sided 5% significance level. 
 
The same sensitivity analyses as defined for the primary endpoint will be performed for 
the two key secondary efficacy endpoints. Sensitivity analyses for missing data in these 
endpoints are described in section 5.4.2. 
 
7.3.2. 
Additional Secondary Efficacy Analyses 
The current section describes the analyses to be performed on the additional secondary 
efficacy endpoints, as defined in section 3.2.2.2. 
General additional secondary efficacy endpoints will be analysed using the ITT and mITT 
populations, unless otherwise noted for a specific endpoint. No other sensitivity analyses 
are planned for these endpoints. The following analyses will be provided: 
 Incidence of SSSI within 30 days post index surgery. 
This endpoint will be analysed using the same methods as described for the first 
key secondary efficacy endpoint (refer to section 7.3.1.1 above). 
 Incidence of DSSI within 30 days post index surgery. 
This endpoint will be analysed using the same methods as described for the first 
key secondary efficacy endpoint (refer to section 7.3.1.1 above). 
 All-cause mortality rate within 30 days post randomization. 
In case there are no subjects with unknown survival status at 30 days post 
randomization, this endpoint will be analysed using the same methods as described 
for the first key secondary efficacy endpoint (refer to section 7.3.1.1 above). 
Otherwise, time to event survival analysis methods will be employed in which 
subjects with unknown survival status will be censored on the last date of known 
to be alive. In this later case, Day 30 mortality rates, along with 95% confidence 
intervals, will be estimated from Kaplan-Meier curves and Z test will be used to 
compare these rates between the treatment groups. 
 All-cause mortality rate within 60 days post randomization. 
This endpoint will be analysed using the same methods as described above for the 
all-cause mortality rate within 30 days post randomization endpoint, while 
changing 30 days to 60 days. 
 Time to adjudicated SSI within 30 days post index surgery. 
Time to adjudicated SSI will be estimated using Kaplan-Meier (KM) method. A 
graphical representation of the data will be done using KM curves. The 
corresponding restricted mean times (by day 30) with 95% confidence intervals will 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 35 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
be estimated. In addition, the number of censored observations will be provided by 
treatment group. The treatment groups will be compared with a stratified log rank 
test, using the study stratification factors used for randomization (as specified in 
section 3.4.1 above). In addition, cumulative incidence plot, treating death as 
competing event, will be provided. 
 Number (percentage) of subjects, re-admitted within 30 days post index surgery 
(for any reason) and experienced adjudicated SSI during this re-admission. 
This endpoint will be analysed using the same methods as described for the first 
key secondary efficacy endpoint (refer to section 7.3.1.1 above). 
 Number (percentage) of subjects who experienced at least one adjudicated surgical 
re-intervention within 30 days post index surgery. 
This endpoint will be analysed using the same methods as described for the first 
key secondary efficacy endpoint (refer to section 7.3.1.1 above). 
 Number (percent) of subjects who experienced at least 1 surgical re-intervention 
during 30 days post index surgery. 
This endpoint will be analysed using the same methods as described for the first 
key secondary efficacy endpoint (refer to section 7.3.1.1 above). 
 
SSI related additional secondary efficacy endpoints will be analysed on the sub-population 
of subjects who experienced at least one adjudicated SSI within 30 days post index surgery. 
The following analyses will be provided: 
 Number (percentage) of subjects who had at least one bacteria resistant to 
Doxycycline grown during the bacteriological tests. 
This endpoint will be tabulated by treatment group, presenting the number and 
percentage of subjects in each category ("Yes" / "No"). Chi square test (or Fisher's 
exact test, as applicable) will be used to compare the treatment groups, and 
corresponding risk difference estimate will be presented with 95% confidence 
interval. 
 Number (percentage) of bacteria resistant to Doxycycline out of all bacteria grown 
during the bacteriological tests. 
This endpoint will be tabulated by treatment group, presenting the number and 
percentage of bacteria in each category ("Yes" / "No"). 
 Number (percentage) of subjects who received IV antibiotic as a treatment for their 
adjudicated SSI. 
This endpoint will be analysed using the same methods as described above for the 
number (percentage) of subjects who had at least one bacteria resistant to 
Doxycycline grown during the bacteriological tests endpoint. 
 Number of IV antibiotic treatment days. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 36 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
This endpoint will be summarized by treatment group, using the appropriate 
descriptive statistics as specified in section 5.1 above. A Wilcoxon Rank Sum Test 
will be conducted to assess for treatment group differences. 
 Average of subjects' cumulative ASEPSIS assessment score (AUC). 
This endpoint will be summarized by treatment group, using the appropriate 
descriptive statistics as specified in section 5.1 above. A Wilcoxon Rank Sum Test 
will be conducted to assess for treatment group differences. 
 Number (percentage) of subjects with at least one score of ASEPSIS > 20. 
This endpoint will be analysed using the same methods as described above for the 
number (percentage) of subjects who had at least one bacteria resistant to 
Doxycycline grown during the bacteriological tests endpoint. 
Bacteria- related additional descriptive analysis: 
 Number (percentage) of bacteria resistant to any antibiotics (any, exactly 1, exactly 
2, exactly 3 and more than 3 antibiotics) out of all bacteria grown during the first 
and all bacteriological tests based on the safety analysis population (regardless of 
confirmed SSI status). 
 
7.4. 
Sub-group Analysis 
The primary and key secondary efficacy endpoints will be analysed by incision length with 
the following categories: ">10 – ≤ 20 cm" and "> 20 cm". Subgroup analyses will be 
performed using the same methods specified for the primary and key secondary analyses. 
The primary and the first key secondary efficacy endpoints will also be analysed by 
mechanical bowel preparation received (“Yes/No”). As mechanical bowel preparation is a 
stratification variable, crude analyses will be applied in each subgroup. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 37 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
8. 
SAFETY ANALYSES 
8.1. 
General 
Safety analyses will be based on Safety population, unless otherwise noted. All summaries 
will be presented by treatment group and overall, unless otherwise noted.  
 
8.2. 
Adverse Events 
All adverse events (AEs) will be coded using the Medical Dictionary for Regulatory 
Activities (MedDRA, version 23.1). Only Treatment Emergent Adverse Events (TEAEs) 
will be summarized. TEAEs are defined as all AEs that start on or after the date of the 
index surgery. If the AE start date is incomplete, unless it is clear that the date is prior to 
index surgery, it will be conservatively imputed as follows for the purpose of determining 
TEAE flag:  
 If the start date is completely missing, the start date will be equal to the date of the 
index surgery. However, if the stop date is not missing and is before the date of the 
index surgery, then the stop date will be used instead. 
 If the start day is missing, but the month and year are not missing and are equal to 
the month and year of the index surgery, then the day of the index surgery will be 
used. 
 If the start day is missing, but the month and year are not missing and are not equal 
to the month and year of the index surgery, then the first day of the month will be 
used. 
 If the start day and month are missing, then the day and the month of the index 
surgery will be used. 
Please note, AE summary tables will include also all suspected SSI Events, reported by 
investigator on Suspected SSI Events form. 
Every AE will be graded by the investigator as mild, moderate, or severe and will be 
assessed by the investigator for its relationship to the IP (related, possibly related, unlikely 
related, not related), and for relationship to other causes (concurrent illness, surgical 
intervention, other, none). AEs assessed for relationship to the IP as "Unlikely Related" or 
"Not Related" will be summarized under "Not Related" category; AEs assessed for 
relationship to the IP as "Related" or "Possibly Related" will be summarized under 
"Related" category; AEs with missing assessment for relationship to the IP will be 
conservatively included in "Related" category.  
When reporting by System Organ Class (SOC) and PT, the reports will present the SOC in 
alphabetical order; while PTs within the SOC will be presented in order of overall 
decreasing frequency of occurrence. A patient with multiple AEs (different PTs) coded to 
the same SOC will be counted only once for that SOC, but will be counted each time for 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 38 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
different PTs within that SOC. A patient with separate events of the same PT will be 
counted only once in the frequency tables for that PT. 
The following summaries will be provided: 
 An overall summary of TEAEs, presenting the overall incidence (number and 
percentage) of subjects, by treatment group, for the following categories: 
o Subjects with at least one TEAE 
o Subjects with at least one severe TEAE  
o Subjects with any IP related TEAE  
o Subjects with any other-causes relationship TEAE 
o Subjects with at least one serious TEAE 
o Subjects with any TEAE resulting in death 
o Subjects with any TEAE with action taken marked as Surgical re-
Intervention 
o Subjects with any TEAE with action taken marked as Surgical re-
Intervention with same incision as in the Index Surgery. 
 Tabulations of the number and percentage of subjects with at least one TEAE, as 
well as the number of events, summarized for each treatment group by System 
Organ Class (SOC) and by Preferred Term (PT) within SOC, will be provided for 
the following events: 
o All TEAEs 
o Serious TEAEs 
o Treatment-Related TEAEs 
o TEAEs resulting in death 
o TEAEs with action taken marked as Surgical re-Intervention with same 
incision as in the Index Surgery 
o TEAEs by maximal Severity (Mild, Moderate, Severe) 
o TEAEs by maximal relationship to Treatment (Not Related, , Related) 
In addition, all AEs will be listed, regardless of whether they were treatment emergent. In 
addition, a listing of all SAEs will be provided. If there are any death, a by-patient listing 
of deaths will also be provided. 
 
8.3. 
Physical Examination 
Physical examinations (PE) will be performed at screening, Day 30 and Day 60 visits. As 
noted in the protocol, any abnormal finding with respect to baseline, assessed by the 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 39 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
Investigator as clinically significant, should be recorded as an Adverse Event in the 
relevant eCRF section. 
In order to display any changes in body system findings over time, PE findings (Normal, 
Abnormal and not clinically significant, Abnormal and clinically significant, Missing) will 
be summarized using the appropriate descriptive statistics as specified in section 5.1 above, 
presenting: 
 By-visit summary table; 
 Shift table from baseline to each post-baseline scheduled visit. 
In addition, all abnormal physical examination results will be listed. 
 
8.4. 
Vital Signs 
Vital signs(body temperature, systolic blood pressure, diastolic blood pressure and heart 
rate) are collected at screening and at Day 0 (before surgery, unless they were taken for 
screening occurring on the same day), Day 1, Day 5, Day 14, Day 30 and Day 60 
(termination) visits. It should also be collected at unscheduled (UN) visits. 
Each measurement will be assessed by the investigator as clinically significant (CS) or not 
clinically significant (not CS).  
Vital signs measurements will be summarized using the appropriate descriptive statistics 
as specified in section 5.1 above, as follows: 
 By-visit summaries will be presented on the raw and change from baseline values 
for each vital sign parameter (continuous).  
 The number and percentage of subjects with not CS and CS values will be tabulated 
by visit, for each parameter. In addition, the number and percentage of subjects with 
not CS and CS values will be tabulated per parameter for any time during study 
time point, where a subject may be counted both as having CS value and as having 
not CS value, if experienced both events during the study. 
Results obtained at unscheduled visit will not be included in by-visit summaries, but will 
be included in any time during study summaries, and data listings. 
In addition, all clinically significant vital signs data will be listed. 
 
8.5. 
Incisional Wound Healing 
Incisional wound healing will be assessed by a blinded investigator, using visual 
examination (as a part of Surgical Site Assessment form and Surgical Site Assessment 
questionnaire form) and Modified Vancouver Scar Scale questionnaire. Assessment is 
scheduled at Day 1, Day 5, Day 14, Day 30 and Day 60 (termination) visit. Assessment 
will also be performed at UN visits.  
 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 40 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
Data will be summarized using the appropriate descriptive statistics as specified in 
section 5.1 above. The following will be provided: 
 By-visit summaries for the following visual examination items: 
o Is the wound healing as expected: Yes, No, Not Applicable (categorical, 
based on Surgical Site Assessment form) 
o Was the wound suspected to be infected: Yes, No (categorical, based on 
Surgical Site Assessment form) 
o Final Assessor Decision (based on Surgical Site Assessment questionnaire 
form): 
 Superficial Surgical Site Infection: Yes, No (categorical) 
 Deep Surgical Site Infection: Yes, No (categorical) 
 By-visit summaries for responses to the Modified Vancouver Scar Scale 
questionnaire (categorical). 
In addition, all incisional wound healing data will be listed. Only scheduled visits will be 
summarized in by-visit analysis, but unscheduled visits will be presented in data listings. 
 
8.6. 
Laboratory Tests 
Laboratory hematology and chemistry Blood Tests are collected at each scheduled visit 
and are to be collected also at unscheduled visit, if performed. Urinalysis and coagulation 
tests are performed at Screening/pre surgery only. Hematology and chemistry tests are 
analyzed by a central laboratory. Any abnormal finding with respect to baseline, assessed 
by the Investigator as clinically significant, should be recorded as Adverse Events in the 
relevant eCRF form. List of laboratory parameters can be found in the study protocol 
(section 9.1.11 and 9.1.12). 
The following will be provided for each laboratory parameter, and will be summarized 
using the appropriate descriptive statistics, as specified in section 5.1, and presented by 
treatment group: 
 By-visit summaries on the raw and change from baseline values (continuous).  
 Shift tables presenting the changes in laboratory values from baseline to each post-
baseline scheduled visit, and overall (any time during study). For this purpose each 
measurement will be classified as below normal / within normal / above normal, 
according to the specified normal ranges for that parameter. Patient counts and 
percentages will be used to summarize the shifts. In shift analysis to any time 
during study, the worst outcome in both directions (below normal, above normal) 
will be considered. i.e. a subject may be counted both as a shift to below normal 
and as a shift to above normal, if experienced both events during the study. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 41 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
Results obtained at unscheduled visit will not be included in by-visit summaries, but will 
be included in any time during treatment summaries, and data listings. For coagulation and 
urinalysis, baseline data will be described. 
In addition, all laboratory data will be listed. A separate listing of abnormal tests will also 
be provided. 
 
8.7. 
Other Safety Measures 
8.7.1. 
Concomitant Medications 
Per the protocol, all currently used concomitant medications, as well as all medications 
taken/prescribed to the subject throughout the study will be recorded in the electronic Case 
Report Form (eCRF). 
All medications will be classified using the Anatomical Therapeutic Chemical (ATC) 
classification codes and preferred terms (PT) from the World Health Organization Drug 
Dictionary (WHO-DD, WHODrug-Global-B3). Medications with start date or stop date on 
or after the date of index surgery or ongoing at study completion will be considered 
concomitant medications. In case of partial or missing dates, the following imputation rules 
will be applied.  
If the medication start date is incomplete, then it will be imputed as follows for the purpose 
of determining concomitant use:  
 If the start date is completely missing, the start date will be equal to the date of 
index surgery. However, if the stop date is not missing and is before the date of 
index surgery, then the stop date will be used instead. 
 If the start day is missing, the first day of the month will be used.  
 If the start day and month are missing, then the first day of the first month (January) 
will be used. 
If the medication stop date is incomplete, then it will be imputed as follows for the purpose 
of determining concomitant use:  
 If the stop date is completely missing and the medication is not ongoing, the stop 
date will be equal to the date of completion/withdrawal.  
 If the stop day is missing, the last day of the month will be used.  
 If the stop day and month are missing, then the last day of the last month 
(December) will be used. 
All concomitant medications data will be summarized by treatment group and overall using 
Safety population. The number and percentage of subjects with at least one medication 
term will be summarized by ATC Level 4 category and by PT within an ATC Level 4 for 
each treatment group and overall. The table will be sorted by overall descending frequency 
of ATC Level 4 and then, within an ATC Level 4, by overall descending frequency of PT. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 42 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
In addition, summaries of antibiotics that were taken prior to and after the index surgery 
will be provided: 
 Two separate tables will be produced (one for antibiotics taken prior to the index 
surgery and the other for antibiotics taken after the index surgery) in the same 
format as for all concomitant medications table, described above. 
 An overall summary table of antibiotics, summarized by treatment group and 
overall, presenting the incidence (number and percentage) of subjects with 
antibiotics taken prior to and after the index surgery, overall and by route of 
administration. 
 
All concomitant medications data will be listed. 
 
8.7.2. 
Surgery Characteristics 
Surgery characteristics will be summarized using both ITT and Safety analysis population. 
The summaries will be provided by treatment group and overall, using the appropriate 
descriptive statistics as specified in section 5.1 above. The following will be provided: 
 Preoperative IV Antibiotic Given Prior to Surgery: Yes, No (categorical) 
 Surgery Performed: Yes, No (categorical) 
 Type of Surgery: Right Hemicolectomy, Left Hemicolectomy, Transverse 
Colectomy, Sigmoid Colectomy, Subtotal Colectomy, Total Colectomy, 
Proctocolectomy, Low Anterior Resection, Rectum Resection, Other (categorical) 
 Length of Surgical Index Incision (cm) (continuous) 
 Length of Surgical Index Incision: >10 – ≤ 20 cm, > 20 cm (categorical) 
 Anastomosis Performed: Yes, No (categorical) 
 Type of Anastomosis Performed: Ileocolonic, Ileorectal, Ileoanal, Colocolonic, 
Colorectal, Coloanal, Other (categorical) 
 Surgery Included Stoma: Yes, No (categorical) 
 Any Complications Encountered During the Surgery: Yes, No (categorical). 
All surgery characteristics data will be listed. 
 
8.7.3. 
Measures of Treatment Compliance 
D-PLEX treatment will be administered during a single operative session directly 
visualized by the Investigator and recorded in the subject’s source documents. The number 
and percentage of subjects receiving each D-PLEX dose (2 or 3 vials) will be summarized.  


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 43 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
In addition, during the study potential options with IP preparation (Yes/No) and/or IP 
application (Yes/No) will be documented. These outcomes will be summarized. 
All study drug administration data will be listed. Problems with IP preparation r application 
will be listed within Surgery Characteristics (section 8.7.2). 
 
8.7.4. 
Hospitalizations (During Study) 
Hospitalizations during study will be summarized by treatment group using the descriptive 
statistics as specified in section 5.1 above. 
The following will be provided regarding the Index hospitalization: 
 The duration (in days), as recorded in the eCRF (continuous) 
 Was the hospitalization length as expected (Yes/No) 
The following will be provided regarding additional hospitalizations (during study): 
 Any hospitalization (Yes/No) 
 Any readmission due to SSI (Yes/No) 
 Any hospitalization due to Adverse Event (Yes/No) 
 Any elective hospitalization (Yes/No) 
 Any hospitalization in ICU (Yes/No) 
 Total hospitalization days (continuous, according to eCRF). 
In addition, listing of Hospitalizations, including prior hospitalizations, will be provided. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 44 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
9. 
PHARMACOKINETIC (PK) ANALYSES 
The PK population will consist of all subjects who have been treated with D-PLEX, and 
have had PK sampling. All PK data will be listed. Details for PK endpoints and analyses 
will be provided prior to breaking the blind and prior to the database lock. 
 
10. 
STATISTICAL SOFTWARE 
All summary tables, figures, listings and statistical analyses will be generated using SAS® 
software, version 9.3 or later. 
 
11. 
SUMMARY OF CHANGES FROM LAST SAP VERSION 
Version 4 of the SAP incorporate the following additions: 
Section 
Other 
sections 
impacted 
Topic 
Change description and rationale 
5.3 
 
Multiple comparisons 
and multiplicity      
Documenting the interim-analysis 
adjusted alpha level for the primary 
endpoint. 
7.4 
 
Subgroup analysis 
Adding subgroup analysis by 
mechanical bowl preparation 
(Yes/No). 
3.2.2.2 
 
Secondary endpoints 
Adding descriptive statistics 
summary 
Version 3 of the SAP incorporate changes according to the recent protocol amendment 
(version 06), along with the inclusion of further details and clarifications without any major 
change. 
The most significant changes made to the text in this document between this version and 
version 2 are summarized in the table below. For changes made following protocol 
amendment, please refer to the detailed justification therein: 
 
Section 
Other 
sections 
impacted 
Topic 
Change description and rationale 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 45 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
3.2.1  
3.3; 
4.5; 
7.2.1 
Primary efficacy 
endpoint; Handling of 
re-intervention at the 
target site      
In accordance with protocol 
amendment. 
3.2.1; 
 
5.4.1; 
5.5; 
 
An analysis window 
for was valid non-
missing Day-30 
information was 
defined 
In response to the COVID-19 
pandemic, affecting visiting times, 
in accordance with the FDA 
Conduct of Clinical Trials of 
Medical Products During the 
COVID-19 Public Health 
Emergency Guidance from 2020. 
3.2.2.2,  
3.2.3 
7.3.2; 
8.7.4 
The lists of 
Additional Secondary 
efficacy endpoints 
and safety endpoints 
was updated. 
In alignment with the protocol 
3.3.1  
 
Sample Size 
calculation: Update to 
the minimal and 
maximal sample size 
New target numbers to enroll were 
calculated based on the change 
(decrease) in the estimated baseline 
SSI rate, this step was undertaken 
in response to the COVID-19 
pandemic, affecting visiting times, 
in accordance with the FDA 
Conduct of Clinical Trials of 
Medical Products During the 
COVID-19 Public Health 
Emergency Guidance from 2020. 
3.3.2 Interim 
analysis; 
 
3.5.2 
Cancellation of the 
planned blinded SSR 
at 500 subjects; 
inclusion of 
comparative interim 
analysis at 750 
subjects milestone for 
stopping early for 
efficacy or futility, or 
unblinded sample size 
reassessment. 
An interim analysis allowing early 
stopping the study for efficacy or 
futility along with an option to 
upsize sample size the study based 
on informed and rigid statistical 
rules was undertaken in response to 
increasing total enrollment and its 
impact on the study duration 
(where timelines already delayed 
due to the pandemic), in accordance 
with the FDA Conduct of Clinical 
Trials of Medical Products During 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 46 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
the COVID-19 Public Health 
Emergency Guidance from 2020. 
4.2 Analysis 
populations 
 
ITT population 
Addressing unexpected mistakenly 
enrolled patients who were not to 
have abdominal surgery. 
5.3 Multiple 
Comparisons 
and 
multiplicity; 
 
3.3 
7.2.1 
This section was 
updated to detail and 
pre-specify the 
planned method to 
control type 1 error 
due to changes in 
interim analysis plan. 
Following the newly added option 
for stopping early for efficacy or 
futility, or unblinded sample size 
reassessment. 
5.4.2 
7.3.1.2 
For the key secondary 
efficacy endpoints, 
sensitivity analysis for 
missing data due to 
reasons other than 
deaths was detailed. 
 
6.4  
 
 The tabulation of 
corrected values 
(post-randomization) 
in the value of 
stratification factors 
was added. 
 
Prior 
Medications 
 
This section was 
cancelled, as no 
summary tables are 
planned for prior 
medications. 
 
8 Safety 
analyses 
 
Detailed description 
of study collected 
safety data and forms 
was added, along with 
their planned 
descriptive statistics. 
 
Version 2 of the SAP incorporates changes and edits to the previous version of the SAP 
(version 1), aiming to: 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 47 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
 insert greater detail and provide further clarifications in response to the FDA 
recommendations; 
 align with the latest versions of the Clinical Study Protocol (version 04) and the 
Case Report Form.   
The most significant changes made to the text in version 2 relative to version 1 are 
summarized in the table below. 
Topic 
Change Description and Rational 
Second key 
secondary efficacy 
endpoint definition 
In the definition of the second secondary efficacy endpoint 
(number (percentage) of subjects with at least one score of 
ASEPSIS > 20): "any time during the study" had been changed 
to "measured within 30 days post abdominal index surgery", as 
defined in the protocol 
Handling 
withdrawals and 
missing data 
To address FDA recommendation: 
Further clarification had been made to emphasize that, in 
addition to the primary efficacy analyses, in all sensitivity and 
supportive analyses of the primary efficacy endpoint deaths 
and re-interventions in the target incision will be addressed as 
treatment failures. 
Analyses using 
Cochran–Mantel–
Haenszel (CMH) test 
To address FDA recommendation: 
The specific SAS option had been added to further detail on 
how the CMH risk difference estimate (with 95% CI) will be 
computed. 
Primary analysis 
table, summarizing 
treatment failure 
events 
To address FDA recommendation: 
Primary analysis table, summarizing treatment failure events, 
had been rearranged to present first all death cases (and 
possible cases where death occurred along with other types of 
treatment failure). 
Sensitivity and 
supportive analyses 
To address FDA recommendation: 
The following sensitivity analysis had been removed: "Rather 
than treating re-intervention at the target incision site as 
treatment failure, taking the SSI outcome according to the 
determination of the independent adjudication committee". 
Surgery 
characteristics 
To align with the CRF: 
Surgery characteristics section had been updated and further 
detailed to include the CRF information. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 48 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
12. 
LIST OF TABLES, FIGURES AND LISTINGS 
The list of summary tables, figures and listings will be provided in a separate document. 


Statistical Analysis Plan 
Study D-PLEX 311 
______________________________________________________________________________________ 
Page 49 of 49 
Bioforum 
 
PolyPid Ltd. 
Version: 4 
 
Date: 16-JUN-2022 
13. 
REFERENCES 
1. 
Ratitch, B., Lipkovich, I., O’Kelly, M. 2013. “Combining Analysis Results from 
Multiply Imputed Categorical Data.” Proceedings of the Pharmaceutical SAS 
Users Group Conference (PharmaSUG 2013), paper SP03. Cary, NC: SAS 
Institute Inc. 
2. 
Rubin, D.B. 1987. Multiple Imputation for Nonresponse in Surveys. New York: 
John Wiley and Sons.