Clinical trial NCT03959527
Conditions: Gonorrhea
Sponsor: Global Antibiotics Research and Development Partnership
Start date: 2019-11-06; Completion date: 2023-09-18
Enrollment: 1011 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This trial is a multi-center, open label, randomized controlled, non-inferiority phase III trial evaluating the safety and efficacy of a 3 g oral dose of zoliflodacin compared to a combination of a single intra-muscular 500 mg dose of ceftriaxone and a single 1 g oral dose of azithromycin for the treatment of uncomplicated gonorrhoea.

Detailed description:

Arms: arm 1: Participant in this arm will receive a single dose of zoliflodacin. arm 2: Participant in this arm will receive a single dose of comparators combination (ceftriaxone and azithromycin).
Interventions: intervention 1: zoliflodacin intervention 2: ceftriaxone intervention 3: azithromycin
Intervention descriptions: intervention 1: Dose: 3g, oral administration intervention 2: Dose: 500mg, Intra-Muscular (IM) administration intervention 3: Dose: 1g, oral administration

Protocol documents:
ICF_003.pdf: 
Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 1 of 19 
 
 
 
 
INFORMED CONSENT FORM (ICF) 
 
 
 
Product Code/Name 
Zoliflodacin, ceftriaxone and azithromycin 
 
Protocol Title 
A multi-center, randomized, open-label, non-inferiority 
trial to evaluate the efficacy and safety of a single, oral 
dose of zoliflodacin compared to a combination of a 
SINGLE intramuscular dose of ceftriaxone and a 
SINGLE oral dose of azithromycin in the treatment of 
patients with uncomplicated gonorrhoea. 
 
Protocol Number 
Version/Date 
STI_Zoli001 / v4.0 / 22 October 2021 
 
ClinicalTrials.gov identifier:   NCT0395927 
 
Principal Investigator 
Enter Name and Address of Principal Investigator at 
relevant trial site 
 
Sponsor 
Global 
Antibiotic 
Research 
and 
Development 
Partnership (GARDP), Geneva, Switzerland 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 2 of 19 
 
 
Why have I been given this form? 
 
You are being invited to take part in a clinical research study on gonorrhoea. This form 
is called an informed consent form; it describes the purpose of the study, the study 
procedures, the risks, the benefits and the alternatives to participating in this study that 
are available to you.  
 
You are invited to take part in this study because: 
• you may have gonorrhoea 
• you are at least twelve (12)-years-old and weigh more than thirty-five (35) 
kilograms <<Insert for US sites only: (77 pounds)>> 
• if you are a female, you are not pregnant or intend to be in the next thirty (30) 
days. You are on highly effective contraception and agree to remain on such 
contraception and use a condom until the end of your participation in the study. 
• if you are a male, you agree to use a condom and delay conception with a 
female partner until the end of your participation in the study. 
Please note you cannot participate in this study if: 
• you have undergone sex reassignment surgery involving your penis or vagina 
• you were involved in a clinical study where you received an experimental drug 
within the past 30 days 
• you have already participated in this research study and been assigned 
treatment. 
 
It is not obligatory for you to take part in this research, your participation in this research 
study is free and completely voluntary. If you decide not to participate in this research 
study, you will be offered the treatment that is routinely offered in this hospital/clinic for 
gonorrhoea infection. You can also start the study and change your mind later and decide 
to stop participating at any time; this will not affect your ongoing treatment at this 
hospital/clinic.  
 
There may be words that you do not understand. Please ask as many questions as you 
have to the study doctor or the medical staff before making any decision, to help you to 
decide whether you want to take part in the study and please take as long as you need 
to decide whether to participate. We will ask you additional questions to check if we have 
explained everything to you clearly. 
 
If you do agree to participate in this study, you will be asked to write your name, sign and 
personally date the page at the end.  
 
If you have a personal insurance policy, review its terms and restrictions carefully to 
confirm that study participation does not interfere with the policy you have.    
 
We will provide you with an original signed copy of this form to keep.  
 
You do not give up any legal rights by signing this form. 
 
 
What is the purpose of the study? 
 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 3 of 19 
Gonorrhoea is a sexually transmitted disease from bacterial origin that is transmitted 
through unprotected oral, anal, or vaginal sex. Uncomplicated gonorrhoea infects the 
urethra (the tube inside the penis that drains urine from the urinary bladder), the female 
reproductive tract, eyes, throat, vagina, and anus. Gonorrhoea can cause: discharge in 
your genital tract, pelvic or testicular pain, burning sensation when urinating, pain during 
sexual intercourse, and/or vaginal bleeding. It can also cause problems in your rectum 
and throat if they are infected and finally, it can also be asymptomatic. Women who have 
gonorrhoea can pass the disease on to their baby during delivery. Untreated gonorrhoea 
can also increase the risk of acquiring and transmitting HIV. Gonorrhoea can also be 
complicated: it means the infection has spread to other organs and/or your blood 
circulation. Complicated gonorrhea is not evaluated in this study. 
 
The standard treatment for uncomplicated gonorrhoea is antibiotics: ceftriaxone and 
azithromycin are the most commonly used. When this treatment is effective, symptoms 
should improve within 2-3 days. However, antibiotics treatments are increasingly failing 
to cure gonorrhoea because the bacteria responsible for the disease has learned to resist 
to them. This is called antimicrobial resistance. This resistance can spread rapidly and 
there is a high risk that one day, a reliable treatment won’t be available to cure 
gonorrhoea.  
 
The Global Antibiotic Research and Development Partnership (GARDP) Foundation is a 
not-for-profit organization that works on discovering new antibiotic treatments. You are 
being invited to take part in this study from GARDP which evaluates if a new antibiotic 
called zoliflodacin is a suitable treatment for gonorrhoea. Your participation is likely to 
help GARDP provide the necessary evidence to support use of zoliflodacin to treat 
gonorrhea. To know if zoliflodacin is approximately as good and safe as the currently 
recommended therapies, we need to compare both treatments. Therefore, if you 
participate in this study, you will be given either zoliflodacin or a combination of 
ceftriaxone and azithromycin, a standard treatment for uncomplicated gonorrhoea. 
 
This research study has been reviewed and approved by an accredited research ethics 
committee, which is a committee whose task is to make sure research participants are 
protected from harm.  
 
 
What is the size and duration of the study? 
 
Approximately 1092 participants from the Netherlands, Belgium, South Africa, Thailand 
and the USA will be recruited into this study, of which <<enter expected number of 
patients to be enrolled in the relevant country>> will be recruited in <<enter name of 
relevant country>>. The study will last until the required number of participants are 
recruited.  
 
 
How long will my participation in the study last for? 
 
If you decide to take part in the study, your participation in the trial will consist of one (1) 
day of treatment (today), followed by one (1) phone call in one (1) or two (2) days and 
two (2) follow-up visits at the hospital/clinic over a total of thirty (30) days. 
Today’s visit should take approximately <<enter time of relevant site>>, and each follow-
up visit to the hospital/clinic should take approximately <<enter time of relevant site>>. 
The phone call should last approximately <<enter time of relevant site>>, 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 4 of 19 
In total your participation will last approximately 30 days. 
 
<<insert if site participates to PK sub-study: If you agree to participate in this study, you 
could also be invited to participate in a sub-study which will investigate how much time 
it takes for zoliflodacin (the study drug) to be absorbed into your body and how long it 
stays in your body after it has been absorbed. Please discuss it further with your doctor 
if you are interested.>> 
 
What are my responsibilities during the study? 
 
If you take part in this study, you are committing to follow the study procedures: 
 
• You must make every effort to attend all the study visits and answer to the phone 
call.  
 
• You must report any health problems you experience to the medical staff  
 
• You must report all medication you take (name of drug, dose taken, when it was 
taken) to the medical staff. 
 
• You must not take any drug that is forbidden during the study. The medical staff 
will explain to you which drugs are not allowed. 
 
• You must agree not to have anal, oral or vaginal sex, or to protect yourself using 
a condom during all anal, oral or vaginal sexual contacts during the 30 days of the 
study. This is important to minimize risk of being infected again and to avoid 
getting pregnant or getting your partner pregnant whilst you are in the study 
because the risks of zoliflodacin on pregnancy have not been tested yet, and there 
is limited data on the impact of ceftriaxone and azithromycin on pregnancy. The 
medical staff will discuss the appropriate contraception methods with you. 
 
• If you or your partner become pregnant during the study, you must tell the medical 
staff immediately. This is important to check the health of both you and your 
unborn baby. The medical staff will ask your permission to obtain information on 
your pregnancy and on your baby from the doctor following your pregnancy. 
 
• You are prohibited from participating simultaneously in another clinical study in 
which medications are prescribed. 
 
• You are prohibited from participating in this same study at a different 
hospital/clinic, or in this study again after you have already completed it at this 
hospital. 
 
 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 5 of 19 
What are the procedures during the study? 
 
 
Today (and 
possibly 
tomorrow)  
Clinic visit 
Day 2 or 3  
Phone call 
Between Day 
4 and 8  
Clinic visit 
Between 
Day 27 and 
33  
Clinic visit 
Discussion with 
doctor/medical 
staff 
X 
X 
X 
X 
Pregnancy test 
(for females) 
X 
 
X 
X 
HIV test (if you 
agree) 
X 
 
 
 
Physical 
examination 
X 
 
X 
X 
Blood tests 
X 
 
X 
X 
Swab tests 
X 
 
X 
X 
Drug treatment 
X 
 
 
 
 
Day 1: today 
 
1. Screening 
 
The first step will be to evaluate if you qualify to participate in the study. 
 
• You will be asked questions about your life situation such as your age, sex at birth, 
gender and ethnicity. You will also be asked questions about your medical history, 
sexual history and about medical treatment you have received over the past 30 
days. We will also ask you to provide us with your contact details. Your answers 
will be kept confidential. 
 
 
• Trained medical staff will conduct a physical examination to assess your general 
health and will ask you if you are currently taking any medication. The examination 
includes: temperature, weight, skin examination, oral examination, rectal 
examination and external genital examination (including pelvic examination for 
females). 
 
• If you are a female that can have children, you will be asked to give a urine sample 
for a pregnancy test. 
 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 6 of 19 
2.Tests 
 
Medical staff will then proceed to a series of tests to learn about your health.  
 
• HIV test 
If you agree, the medical staff will test you for HIV infection, except if your HIV status or 
HIV treatment regimen is known and documented, or if you received testing directly prior 
to being asked to participate in the study. <<insert if site participates to PK sub-study: If 
you don’t want to be tested for HIV, you can still participate in the study, but you will not 
be able to participate to the PK sub-study.>>  
This test will usually give a result in 15-60 minutes.  
A positive result from an HIV test always needs to be confirmed by a different laboratory 
test. This result is usually available in <<insert time at specific site>> days, and this will 
not affect your participation in the study. If you are confirmed HIV positive, the 
hospital/clinic staff will make sure that you will be followed up as per standard guidelines 
in your country and that you access appropriate care. HIV treatment is not part of the 
research study and the cost will not be covered by GARDP. If you have HIV infection, 
you will still be able to participate in this study. 
If you agree to be tested for HIV, the medical staff will <<Choose one of the following as 
appropriate: take a maximum of 5 mL of blood through venous blood draw OR collect a 
few drops of blood by pricking one of your fingers OR use a small sample of a blood tube 
collected from you for other blood tests>>. 
 
• Blood tests 
Medical staff will take a maximum of 15 mL (about 3 teaspoons) of blood through blood 
draw using a needle in your arm.  A bandage will be put on your arm that will need to 
stay in place for a short time (approximately 15 minutes). 
 
Three types of tests will be performed with your blood sample:  
o A full blood count: this is a very common test measuring cells in your blood such 
as red blood cells, white blood cells and platelets to help the doctor rule out serious 
health problems, 
o Liver function tests which will tell us how well your liver is working, 
o Kidney function tests that will tell us how well your kidneys are functioning. 
 
• Swab tests 
Swab tests are normal routine procedures to detect bacterial infections. In this study, 
swab samples will be collected for Neisseria gonorrhoeae and Chlamydia trachomatis 
testing, which are two bacteria that cause sexually transmitted diseases. The medical 
staff will use a sterile << insert type of kit e.g.: plastic loop, polyester swab…>> to collect: 
o two samples from your throat << insert if applicable: (to minimize the risk of 
COVID-19 transmission, you might be asked to collect this sample yourself under 
guidance and supervision of the study staff’),>> 
o two samples from your rectum, 
o two samples from your urethra if you have a penis (if you have a discharge, the 
tip is gently placed into the top of the penis to collect bacteria. If you don’t have a 
discharge, the tip will be inserted 2 to 4 cm inside your penis and rotated for 3 to 
5 seconds), 
o OR two samples from your uterine cervix during the pelvic exam (with help of a 
speculum inserted into your vagina) if you have a cervix. 
 
 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 7 of 19 
3.Study treatment 
 
Neither the doctor, nor you will choose which treatment you will receive. You will be 
assigned by chance (like flipping a coin) by a computer program, to a group of participants 
that will receive zoliflodacin (group 1) or to a group of participants that will receive 
ceftriaxone plus azithromycin (group 2). You will have 2 out of 3 chances to receive 
zoliflodacin, and 1 out of 3 chances to receive the ceftriaxone plus azithromycin 
treatment. This process is called ‘unequal randomisation’. Both you and the medical staff 
will know which treatment you are getting. 
 
The study staff will check that you have eaten before you take/receive the study 
treatment. If you have not eaten, you will be asked to take a snack/light meal, which will 
be provided by the study staff. This will help make sure the treatment is effective.   
Then, you will be given the study treatment in one dose and you will need to stay in the 
hospital/clinic for 30 minutes after taking the medicine. 
• For group 1 (zoliflodacin 3 grams [g]), the treatment will be granules mixed into 
potable water which you will have to drink. 
• For group 2 (ceftriaxone and azithromycin), you will have to swallow four (4) 
tablets of 250 mg azithromycin with water. Then you will receive an injection of 2 
mL containing 500 mg of ceftriaxone with a needle into your muscle. Ceftriaxone 
will be mixed with a drug (lidocaine) which numbs the area of injection. 
  
NOTE: if there is no time to do everything mentioned above on the first day you visit the 
clinic, if your physician deems this is appropriate and if you agree, you might undergo 
some of the above-mentioned procedures today and the rest, including taking the blood 
and swab tests as well as receiving the study treatment tomorrow morning. 
 
Day 3 (-1 day): phone call 
You will receive a phone call from the hospital/clinic one (1) or two (2) days from today 
to ask if you have experienced any health problems and if you have been taking other 
medications. You will also be asked about your sexual behaviour since your previous visit 
to the hospital/clinic. 
 
Day 6 (+/- 2 days): clinic visit 
You will be asked to verify your contact information that was collected on Day 1. 
• The medical staff will ask you how you are feeling and if you have had any health 
problems and if you have been taking other medications since the first visit. They 
will also discuss with you about your sexual behavior. 
• The medical staff will: 
o perform a physical examination 
o collect a blood sample about a maximum of 15 mL (about 3 teaspoons) for 
full blood count, liver function tests and kidney function tests 
o depending on the results of the swab tests taken at your first visit and/or if 
some of the results have not yet been received, the medical staff will: 
▪ collect a maximum of two urethral (if you have a penis) or cervical (if 
you have a cervix) samples 
▪ collect a maximum of two throat samples << insert if applicable: (to 
minimise the risk of COVID-19 transmission, you might be asked to 
collect this sample yourself under guidance and supervision of the 
study staff)>> 
▪ collect a maximum of two rectal samples. 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 8 of 19 
 
• if you are a female that can have children, the medical staff will also perform a 
urine pregnancy test. 
 
If your test results for Chlamydia trachomatis from Day 1 show that you have a 
chlamydia infection, and you were assigned to the group of participants that received 
zoliflodacin (Group 1), you will be treated for chlamydia infection according to standard 
of care. If you were assigned to ceftriaxone and azithromycin (Group 2), there is no 
need to treat as azithromycin works against Chlamydia trachomatis.  
 
Day 30 (+/- 3 days): clinic visit 
You will be asked to verify your contact information. 
• The medical staff will ask you how you are feeling and if you have had any health 
problems and if you have been taking other medications since the previous visit. 
They will also discuss with you about your sexual behavior. 
• The medical staff will: 
o perform a physical examination 
o collect a blood sample of a maximum of 15 mL (about 3 teaspoons) for full 
blood count, liver function tests and kidney function tests 
o depending on the results of the swab tests taken at your previous visit 
and/or if you have symptoms, the medical staff will: 
▪ collect a maximum of two urethral (if you have a penis) or cervical (if 
you have a cervix) samples 
▪ collect a maximum of two throat samples << insert if applicable: (to 
minimise the risk of COVID-19 transmission, you might be asked to 
collect this sample yourself under guidance and supervision of the 
study staff)>> 
▪ collect a maximum of two rectal samples  
• If you are a female that can have children, the medical staff will also perform a 
urine pregnancy test. 
 
NOTE: The maximum amount of blood that will be drawn during the study is 50 mL (about 
10 teaspoons). 
 
 
May I withdraw, at a future date, my consent for participation in this research 
study? 
 
You may decide to stop your participation in the study before the end at any time without 
providing any justification.   
 
If you decide to withdraw your participation in this study, it will not affect the quality of 
your care. Information collected up to your withdrawal cannot be removed from the study 
data. This includes samples collected up until the date of withdrawal which will be kept 
and analyzed. However, you have the right to request that bacterial isolates from 
previously collected samples meant for storage and future analysis are destroyed.  
No new information will be collected from you or added to existing data or database 
unless you agree to it. 
 
The medical staff also have the right to withdraw you from the study if: 
• in their opinion the study would impose a health risk to you, 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 9 of 19 
• you fail to follow your responsibilities, 
• the study is stopped. 
In the case of your withdrawal from the study by a study doctor, you will be treated 
according to standard of care in this hospital/clinic.  
In this event, you will be asked to come back one last time to the hospital/clinic to make 
sure that you are safe with the treatment you already took, if you agree; this is called an 
early withdrawal visit. 
 
Early withdrawal visit: 
 
• You will be asked if you had any health problems since the beginning of the 
treatment, if you have been taking other medications. They will also discuss with 
you about your sexual behavior.  
• The medical staff will perform a physical examination. 
The medical staff will collect a blood sample of a maximum of 15 mL (about 3 
teaspoons) for full blood count, liver function tests and kidney function tests. 
• If you are a female that can have children, a urine pregnancy test will be 
performed.  
 
If you wish to withdraw at the time of the first or second follow-up visit, you will discuss 
with your study doctor whether you agree that the planned samples for assessing the 
infections are taken.  
 
Sometimes during the course of a research project, new information becomes available 
about the treatment/drug that is being studied. If this happens, the medical staff will tell 
you about it and discuss whether you want to, or should, continue in the study. If you 
decide not to carry on, the medical staff will make arrangements for your care to continue. 
If you decide to continue in the study, you will be asked to sign an updated consent form. 
 
 
What will happen with my samples and the results of my tests? 
 
You have the possibility to discuss with the medical staff the use of the collected data at 
any time. 
 
• Blood tests 
The blood samples will be sent to a local laboratory. When these results are available, 
the medical staff will discuss them with you if an abnormality is detected. They will assess 
the best treatments for you or refer you to a doctor/hospital if needed. The blood samples 
will be destroyed as per local standard practices.  
 
• Swab tests 
The swabs will be sent to local laboratories to see if bacteria are present, and if the 
bacteria are likely to be gonorrhoea. If so, these bacteria will be sent to a laboratory in 
the USA to confirm if they are gonorrhoea, and to learn if the bacteria are resistant to 
common antibiotics. This will be very useful information for the researchers to compare 
if zoliflodacin kills the bacteria as well as ceftriaxone and azithromycin do, and learn more 
about how the disease is evolving.  
The bacteria will also be sent to a laboratory in Sweden after the end of the study to study 
their genetic code to try and understand why the bacteria may have become resistant to 
antibiotics.  


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 10 of 19 
No blood or urine samples will be sent for genetic analyses; only bacteria will be shipped 
and analysed. No genetic analyses will be performed on your DNA. 
Results from the analyses performed in Sweden will not be made available to the medical 
staff as they are intended for research purposes only and will not impact your clinical 
care. 
 
Throughout the study, and until the end, some of the bacteria collected from your samples 
(called bacterial isolates) will be stored in a local laboratory as a back-up (in case some 
shipments to the central laboratory in the USA get lost or destroyed). Bacterial isolates 
will also be stored in the central laboratories in the USA and in Sweden until completion 
of all study analyses.  
<< Insert for SA and Thailand where long term storage in US or Sweden is not allowed: 
After the end of the study, the bacteria collected from your samples that will be sent to 
the USA and Sweden will be destroyed. The bacteria collected from your samples that 
will be kept in a local laboratory will also be destroyed at the end of the study, except if 
you agree to long term storage of those bacterial isolates.>> 
<< Insert for US, South Africa and NL: They will be destroyed at the end of the study, 
except if you agree to long-term storage of those bacterial isolates.>> 
<< Insert if long term storage is to be included in main ICF: If you agree, bacterial isolates 
will be kept for a maximum of 5 years after the end of the study for future research on 
gonorrhoea. Please check this box to certify that you agree to this      >>  
 
Swabs will also be analyzed to see if you have another common sexually transmitted 
infection Chlamydia trachomatis.  
 
 
What are the possible risks of taking part in this study? 
 
• Social risks 
<< To remove or keep sentences below as required at country level>> 
Although the clinic staff will make every effort to ensure the confidentiality of your 
records, it is possible that your participation in this study could become known to 
others, and that a social impact may result of it.  
During the study visits, you may also feel embarrassed or uncomfortable with some of 
the questions you will be asked, some of the procedures that will be done, or some of the 
test results that you will receive. The questions you will be asked about your sexual 
behavior may make you feel uneasy. However, you do not have to answer any questions 
that you do not want to, and you can stop answering the questions at any time. 
Study staff will help you deal with any feelings or questions you have.  
 
• Risks associated with zoliflodacin 
As of today, five clinical studies in healthy participants and one clinical study in 
participants with gonorrhoea have been conducted with zoliflodacin. In completed studies 
as of as of 5th September 2021, 324 people have received at least one dose of 
zoliflodacin, most of them receiving at least one dose ≥3 g, the dose that is given in this 
study. Most commonly reported side effects of zoliflodacin were headache, diarrhoea, 
and nausea. Vomiting was reported by one participant receiving zoliflodacin. Unpleasant 
taste was commonly reported in healthy participants when the drug was previously 
presented as a powder rather than granules. 
 
 
 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 11 of 19 
• Risks associated with ceftriaxone and azithromycin 
Ceftriaxone: The main risk is severe allergic reactions, which can occur in around 3 % 
of people and can be fatal. The most frequently reported side effects for ceftriaxone are 
abnormal counts of some blood cells, loose stools or diarrhea, rash, and effect on liver 
function. Ceftriaxone will be mixed with a drug (lidocaine) which has the property to numb 
the area of injection. 
Possible reactions to lidocaine include flushing, redness of skin, small red or purple spots 
on the skin, hives, swelling at the site of injection or unusually warm skin. A reaction such 
as itching, bruising, burning, pain, or bleeding at the site of injection is very common. 
 
Azithromycin: Rare serious allergic reactions such as skin rash and liver damage 
(hepatotoxicity) have been reported. The most frequently reported side effects when 
taking a single dose are diarrhea/loose stools, nausea, abdominal pain, vomiting and 
indigestion.  
 
• There is a risk that your disease will not get better after treatment. In that case, 
you will receive additional treatment after Day 6, in accordance with the local standard 
of care. 
 
• Risks associated with medical procedures 
Physical examination: It is rare to have a problem during a physical examination. You 
may feel uncomfortable or feel some pressure during examination of your genital area. If 
you need a pelvic exam, this could be uncomfortable due to the speculum. 
 
Blood sampling (venepuncture): You may feel a slight discomfort or even feel like 
fainting when the needle is inserted to your vein. You may have a small bruise where the 
needle went in. Bruises can be painful but are usually harmless and fade over the next 
few days.  A risk of infection is possible where the needle is inserted, though very rare. 
 
Swab tests: There may be some mild discomfort associated with taking vaginal, throat 
or rectal swab. If there is no discharge, urethral swab << is a painful procedure OR can 
cause slight discomfort – choose one option as required as per local standard>>. 
 
• Risks associated with exposure during pregnancy  
If you are a female participant: 
Zoliflodacin has not been studied in pregnant females, and there is limited data on 
ceftriaxone and azithromycin in pregnancy. Therefore, it is important that you do not 
become pregnant during the study. 
If you may be able to have children, you will be given a pregnancy test at screening. If 
the result is positive, you will not be able to participate in the study. If you are 
breastfeeding, you cannot participate in the study. 
Your partner(s) or you must use an accepted form of birth control throughout the study 
until at least 28 days after receiving treatment, so you do not become pregnant. 
Acceptable forms of birth control include: 
- 
For yourself: combined (estrogen and progestogen containing) hormonal 
contraception, or progestogen-only hormonal contraception, or mechanical 
products, such as an intrauterine device.  
- 
For your male partner(s): vasectomy. 
These methods must be combined with a condom to avoid being re-infected during the 
study. The medical staff will discuss with you methods of birth control. 
If you become pregnant during the course of the study, please contact the medical staff 
immediately.  


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 12 of 19 
The medical staff must make every effort to follow up and document the course and the 
outcome of all pregnancies until delivery and until the newborn child reaches 2 years old, 
even if you withdraw from the study or if the study has finished, if you agree to this. 
 
If you are a male participant: 
If you have (a) female partner(s) that is (are) able to have children, you must inform them 
that the effects of the investigational products on sperm are unknown. Your partner(s) 
and yourself must agree to delay conception for at least 28 days. This is best achieved 
by using an accepted form of birth control until at least 28 days after receiving treatment. 
Acceptable forms of birth control include: 
- 
For yourself: condom, vasectomy  
- 
For your female partner(s): combined (estrogen and progestogen containing) 
hormonal contraception, or progestogen-only hormonal contraception, or 
mechanical products, such as an intrauterine device.  
These methods must be combined with a condom to avoid being re-infected during the 
study.  
The medical staff will discuss with you appropriate methods of birth control for you and 
your partner. 
If your partner(s) become pregnant during the course of the study, please contact the 
medical staff immediately. 
The medical staff must make every effort to follow up and document the course and the 
outcome of all pregnancies until delivery and until the newborn child reaches 2 years old. 
They will ask your partner if they agree to this. 
 
 
• Unknown risks 
In addition, there may be uncommon or previously unknown risks that might occur. You 
should report any problems to the medical staff immediately. Contact details are provided 
at the end of this form. 
 
 
What are the benefits to participating in this study? 
 
• By participating into the study, you will benefit from close and frequent medical 
care.  
• If you are found to be positive for HIV or chlamydia, you will be rapidly referred 
for treatment and follow up according to the standard of care in your country. 
Treatment will not be provided by GARDP. 
• Since antibiotic resistance to the standard treatment already exists and may 
rapidly grow, new antibiotics are crucially needed. Your participation will help 
determine if zoliflodacin can be used in future to treat gonorrhoea. This will be of 
benefit for future patients.  
 
 
What about confidentiality? 
 
Your identity, medical records and your participation in this research study will be strictly 
confidential. Your name will not be mentioned on any sample leaving the hospital/clinic, 
nor on any data collected during the study, except in records here at the hospital/clinic. 
Upon enrollment in the study, you will be attributed a unique number, which will be used 
to identify the samples and data collected from you. The number list will be kept secure 
at the hospital/clinic. 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 13 of 19 
 
Your data will only be collected by and shared with personnel authorized at GARDP and 
GARDP’s representatives (study team, monitors, auditors). None of this data will allow to 
identify you. At the end of the study, we will write a report about the results of the study 
and publish the results of this study on publicly available databases and in medical 
journals so that other doctors can learn about it. These reports will not include any 
information relating to you personally (for example name or where you live). We ask your 
permission for authorised medical staff, clinical monitors or auditors and ethics committee 
to have access to your information to ensure that the study is being conducted correctly. 
 
GARDP may also give your data  to the US Food and Drug Administration (FDA) (the 
USA Health Agency), and other governmental health agencies in the USA and other 
countries involved in the trial or in which an approval for zoliflodacin may be sought. This 
may be part of the process to try to get the treatment approved by the FDA and/or foreign 
government authorities. Each of these organisations will be under an obligation to keep 
data confidential. 
 
Your data will be used as long as is needed for the study and may be retained for longer, 
wherever required by law. GARDP will retain data from clinical trials for up to 25 years. 
 
You have the possibility to access your personal information by asking your medical 
doctors, and you have the right to correct the data collected from you if there is an error. 
 
A description of this clinical trial will be available on http://www.clinicaltrials.gov as 
required by U.S. law. This Website will not include information that can identify you. The 
Website will include a summary of the final study results. You can access this Website 
at any time.  
 
<<Insert for Europe sites only: If your data is transferred, we will always ensure 
appropriate measures will be taken to protect your personal information. Along with 
coding your personal information as detailed above with a unique number, we also make 
sure we have contracts and other protections in place before we share your personal 
information. These measures comply with data protection and privacy laws.  
Your data may be transferred to trusted persons in other countries. Data protection and 
privacy laws may not be as strong in these countries as the laws in your home country. 
When personal information is transferred, GARDP makes sure that appropriate and 
suitable safeguards are used.  
Your coded personal information may be transmitted to:  
• GARDP who is based in Switzerland 
• the ICON GPHS group to help us complete the study, which is based in the USA  
• laboratories or clinical facilities which help us to conduct analysis on samples you 
give us as part of the study  
• couriers or transport companies to enable us to deliver the samples to external 
laboratories.  
For questions or requests regarding how your personal information is handled, or if you 
required additional information, please contact Insert DPO contact >> 
 
<<Insert for US sites only: There are United States federal laws and regulations related 
to privacy. These laws can be found under the Health Insurance Portability and 
Accountability Act of 1996 (HIPAA). These laws apply to certain personal health 
information collected in connection with this study. Your permission to use this 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 14 of 19 
information is required. In addition to this form, you will be asked to give your permission 
to use your personal health information. This is done by signing the HIPAA Authorization 
Form attached to this form. Please ask the study site if you have any questions about the 
HIPAA Authorization Form.>> 
 
 
How much will it cost you if you are participating in this study?  
 
The medical treatments and tests that you get as part of this study will be provided free 
of charge.  There will be no cost to you for taking part in the study. If you have a private 
insurance, your insurance will not be billed for any of the study procedures.  
In the event that you suffer an injury or illness related to participating in this trial, GARDP 
will pay all costs relating to treatment of the injury or illness. GARDP have subscribed 
appropriate clinical trial insurance to cover for such event. If you wish to find out more 
about the insurance, the medical staff will be happy to provide more information. 
 
 
Will you be paid if you decide to participate in this study? 
 
If you agree to participate in the study, you will receive << to adapt per country/site >> 
per visit to the hospital/clinic to compensate for your time and travel to and from the 
hospital/clinic. 
  
 
 
Contact persons  
 
For further information regarding the study or in the event of a study related injury, 
please contact: 
 
1. Insert name, address and tel of study site investigator  
 
If you have any questions on your rights as study participant, please contact: 
 
2. Insert name, address and tel of someone independent of the study (e.g. Ethics 
Committee Chair, patient’s representative) 
 
 
You will be given an original of this information to keep. 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 15 of 19 
Site Number: 
<<Insert Site Identifier>> 
Participant Identification Number for this trial:  
 
CONSENT FORM 
 
Product Code/Name 
Zoliflodacin, ceftriaxone and azithromycin 
Protocol Title 
A multi-center, randomized, open-label, non-inferiority 
trial to evaluate the efficacy and safety of a single, oral 
dose of zoliflodacin compared to a combination of a 
SINGLE intramuscular dose of ceftriaxone and a 
SINGLE oral dose of azithromycin in the treatment of 
patients with uncomplicated gonorrhoea. 
Protocol Number 
Version/Date 
STI_Zoli001 v4.0 22 October 2021 
Name of Investigator: <<Insert>> 
 
I have read the information in this form, or it has been read to me in a language that I 
understand well. I have had the opportunity to ask questions about it and all my questions 
have been answered to my satisfaction.  
I know that I can refuse to participate in the study without penalty or loss of benefits to 
which I would have been otherwise entitled, or that if I agree to participate, I can withdraw 
at any time without losing benefits or services to which I or my family are entitled. 
I agree to participate in the study. By signing this form, I agree that the personal 
information collected about me will be accessible to GARDP’s representatives (study 
team, monitors, auditors), ethics committees or the Food and Drug Administration or 
other regulatory agencies. 
 
Name of Participant: _____________________ 
 
Signature: ________________Date:_____________Time:__________ 
I have explained the study to the participant and answered all of his/her questions. I 
believe that he/she understands the information described in this form and freely 
consents to participate. A copy of this form has been provided to the participant.  
 
Name of Investigator/Clinic staff_____________________ 
 
Signature:__________________Date:__________________Time:______________ 
 
If applicable: 
I have witnessed the accurate reading of the form to the participant. I confirm that the 
participant has had the opportunity to ask questions. I confirm that the participant 
agrees to be part of the study.  
 
Name of Impartial Witness<<*>>: _______________________ 
 
Signature: ____________________Date:______________Time:________ 
 
<<If applicable locally: add this definition: *A witness is a person who is independent from the research 
team or any team member and who was not involved in obtaining consent.>> 
Be reminded that two originals of the form have to be signed (depending of country requirements). Once 
completed and signed, one original is for the participant and the other one is to be kept as source 
documentation. (e.g.: investigator site file) 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 16 of 19 
Site Number: 
<<Insert Site Identifier>> 
Participant Identification Number for this trial:  
 
PARENT/GUARDIAN CONSENT FORM (FOR MINORS) 
 
Product Code/Name 
Zoliflodacin, ceftriaxone and azithromycin 
Protocol Title 
A multi-center, randomized, open-label, non-inferiority 
trial to evaluate the efficacy and safety of a single, oral 
dose of zoliflodacin compared to a combination of a 
SINGLE intramuscular dose of ceftriaxone and a 
SINGLE oral dose of azithromycin in the treatment of 
patients with uncomplicated gonorrhoea. 
Protocol Number 
Version/Date 
STI_Zoli001 v4.0 22 October 2021 
Name of Investigator: <<Insert>> 
 
I, as the parent / guardian of <<Insert minor participant name>> have read the information 
in this form, or it has been read to me in a language that I understand well. I have had 
the opportunity to ask questions about it and all my questions have been answered to my 
satisfaction. 
I know that I can refuse to allow my child/ward to participate in the study without suffering 
any penalty or loss. If I agree to their participation, they can be withdrawn at any time 
without losing benefits or services to which they or my family are entitled. 
I agree that my child / ward can participate in the study. By signing this form, I agree that 
the personal information about my child/ward will be accessible to GARDP, GARDP’s 
representatives (study team, monitors, auditors), ethics committees or the Food and Drug 
Administration or other US or foreign regulatory agencies. 
 
Parent/Guardian’s full name: ___________________________________ 
 
Signature: _____________________Date: ____________Time:______________ 
I have explained the study to the participant and answered all of his/her questions.  I 
believe that he/she understands the information described in this form and freely 
consents to participate. A copy of this form has been provided to the participant.  
 
Name of Investigator/Clinic staff: _____________________  
 
Signature: __________________Date: _______Time:__________ 
 
If applicable: 
I have witnessed the accurate reading of the form to the participant. I confirm that the 
participant has had the opportunity to ask questions. I confirm that the participant 
agrees to be part of the study.  
Name of impartial witness<<*>>: _______________________ 
 
Signature: ____________________Date:______________Time: _____________ 
 
<<If applicable locally: add this definition: *A witness is a person who is independent from the research 
team or any team member and who was not involved in obtaining consent.>> 
 Be reminded that two originals of the form have to be signed (depending on country requirements). Once 
completed and signed, one original is for the participant and the other original is to be kept as source 
documentation. (e.g.: investigator site file) 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 17 of 19 
Site Number: 
<<Insert Site Identifier>> 
Patient Identification Number for this trial:  
 
ASSENT FORM (FOR MINORS) 
 
(To be completed in addition to the parental consent for minors. This may not always be 
required, but it is good practice and should be included in the ethics submission for their 
review) 
 
Product Code/Name 
Zoliflodacin, ceftriaxone and azithromycin 
Protocol Title 
A multi-center, randomized, open-label, non-inferiority 
trial to evaluate the efficacy and safety of a single, oral 
dose of zoliflodacin compared to a combination of a 
SINGLE intramuscular dose of ceftriaxone and a 
SINGLE oral dose of azithromycin in the treatment of 
patients with uncomplicated gonorrhoea. 
Protocol Number 
Version/Date 
STI_Zoli001 v4.0 22 October 2021 
Name of Investigator: <<Insert>> 
 
I have had chance to read or had read to me the information in this form and the study 
has been explained to me in a language that I understand. I have been able to ask all the 
questions I wanted to and my questions have been answered to my satisfaction. 
I know I do not have to take part in the study and that I can change my mind at any time 
during the study if I want to. I know that if I don’t take part in the study, I will still receive 
the best treatment available at the site. 
I agree to participate. 
 
Name of Minor:_______________________________ 
 
Minor's Signature (If able):_______________Date:___________Time:__________ 
I have explained the study to the participant and answered all of his/her questions.  I 
believe that he/she understands the information described in this form and freely 
consents to participate. A copy of this form has been provided to the participant.  
 
Name of Investigator/Clinic staff: _____________________ 
 
Signature:_____________________Date:______________Time:______________ 
 
If applicable: 
I have witnessed the accurate reading of the form to the participant. I confirm that the 
participant has had the opportunity to ask questions. I confirm that the participant 
agrees to be part of the study.  
 
Name of Impartial Witness<<*>>:_______________________ 
 
Signature:__________________________Date:_____________Time:____________ 
<<If applicable locally: add this definition: *A witness is a person who is independent from the research 
team or any team member and who was not involved in obtaining consent.>> 
Be reminded that two originals of the form have to be signed (depending on country requirement). Once 
completed and signed, one original is for the participant and the other original is to be kept as source 
documentation (e.g.: investigator site file) 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 18 of 19 
<<For US sites only>> 
 
Site Number: 
<<Insert Site Identifier>> 
Patient Identification Number for this trial:  
 
HIPAA Research Authorization 
 
Authorization to Use and Disclose Health Information 
 
I agree to permit [Name of Institution] and any of my doctors or other health care 
providers (together “Providers”), study doctor, and [his/her/their/its] collaborators and 
medical staff (together “Researchers”), to obtain, use, and disclose health information 
about me as described below.  
 
The health information that may be used and disclosed includes:  
 
1. All information collected during the research and procedures described in the 
Informed Consent Form (the “Research”); and  
2. Personal health information in my medical records that is relevant to the 
Research, which includes my past medical history, medical information from 
my primary care physician, and other medical information relating to my 
participation in the study.  
The Providers may disclose health information in my medical records to:  
 
1. The Researchers;  
2. Representatives of government agencies, review boards, and other persons 
who watch over the safety, effectiveness, and conduct of research; and  
3. Global Antibiotic Research and Development Partnership, and its affiliates, 
agents and contractors assisting in the conduct or completion of the study 
(together, “Sponsor”).  
 
The Researchers may use and share my health information:  
 
1. Among themselves, with the Sponsor, and with the other participating 
Researchers to conduct the Research; and  
2. As permitted by the Informed Consent Form.  
The Sponsor may use and share my health information for purposes of the Research 
and as permitted by the Informed Consent Form.  
 
Once my health information has been disclosed to a third party, federal privacy laws 
may no longer protect it from further disclosure.  
 
Please note that: 
 
1. You do not have to sign this Authorization, but if you do not, you may not 
participate in the Research.  If you do not sign this Authorization, your right to 
other medical treatment will not be affected. 


Informed Consent Form  
STI_Zoli001 protocol v4.0 of 22 October 2021 
 
 Zoliflodacin 
Master ICF v 4.0 of 26 October 2021 
Page 19 of 19 
2. You may change your mind and revoke (take back) this Authorization at any 
time for any reason.  To revoke this Authorization, you must write to the study 
team at: 
NAME: 
 
ADDRESS: 
 
PHONE: 
 
 
3. However, if you revoke this Authorization, you will not be allowed to continue 
taking part in the Research.  Also, even if you revoke this Authorization, the 
Providers, Researchers, and the Sponsor may continue to use and disclose 
the information they have already collected to protect the integrity of the 
Research or as permitted by the Informed Consent Form. 
4. While the Research is in process, you may not be allowed to see your health 
information that is created or collected during the course of the Research.  
After the Research is finished, however, you may inspect and obtain a copy 
of this information. 
5. The expiration date for this Authorization is 25 years after the study is 
completed. 
6. You will be given a copy of this Authorization after you have signed it. 
  
 
Signature of Participant or authorized representative* 
 
Date 
Time (hh:mm) 
Printed Name of Participant or authorized representative 
Date 
Time (hh:mm) 
 
*If this Authorization is signed by an authorized representative, please describe the basis 
of your authority to act for the Participant: 
 

Prot_000.pdf: 
Protocol number STI_Zoli001
Zoliflodacin
Protocol version 5.0 of 12 July 2023
Confidential 
Page 1 of 74
A MULTI-CENTER, RANDOMIZED, OPEN-LABEL, NON-INFERIORITY 
TRIAL TO EVALUATE THE EFFICACY AND SAFETY OF A SINGLE, ORAL 
DOSE OF ZOLIFLODACIN COMPARED TO A COMBINATION OF A 
SINGLE INTRAMUSCULAR DOSE OF CEFTRIAXONE AND A SINGLE 
ORAL DOSE OF AZITHROMYCIN IN THE TREATMENT OF PATIENTS 
WITH UNCOMPLICATED GONORRHOEA
Clinical Trial Protocol
Short title
Zoliflodacin in uncomplicated gonorrhoea
Name of products
Zoliflodacin, ceftriaxone and azithromycin
Drug Class
Antibiotic
Phase
Phase III
Indication
Uncomplicated gonorrhoea
Trial Protocol Number
STI_Zoli001 
EudraCT
2019-000990-22
IND number
139,105
Sponsor
GARDP, Chemin Camille-Vidart, 15, 1202 
Geneva, Switzerland; 
Phone: +41 22 555 19 90
Protocol chair
Prof Edward Hook, University of Alabama at 
Birmingham, United States of America
Clinical Trial Protocol Version / Date
Version 5.0 of 12 July 2023
Clinical Trial Protocol Template 
Version/Date
Version 1.2 of 2 June 2014
Protocol Amendment Number / Date
Amendment 4 / 12 July 2023
The information contained in this document is confidential. It is to be used by investigators, potential 
investigators, consultants, or applicable independent ethics committees. It is understood that this information 
will not be disclosed to others without written authorisation from GARDP, except where required by applicable 
local laws
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Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 2 of 74 
 
CLINICAL TRIAL PROTOCOL SIGNATURE PAGE 
 
STI Project  Lead 
 
Signature 
 
 
  
 
 
 
 Date of Signature 
(MM/DD/YYYY) 
Name  
 
Pierre Daram 
Title 
 
Project Lead 
Institution 
 
Global Antibiotics Research and Development Partnership (GARDP)  
Address 
 
Chemin Camille-Vidart, 15, 1202 Geneva, Switzerland 
 
GARDP STI Medical Lead  
 
Signature 
 
  
 
 
 Date of Signature 
(MM/DD/YYYY) 
Name  
Alison Luckey 
Title 
Senior Medical Lead 
Institution 
Global Antibiotics Research and Development Partnership (GARDP)  
Address 
Chemin Camille-Vidart, 15, 1202 Geneva, Switzerland 
 
Protocol Chair 
 
Signature 
 
  
 
 
 Date of Signature 
(MM/DD/YYYY) 
Name  
Edward Hook 
Title 
Emeritus Professor of Infectious Disease 
Departments of Medicine 
Institution 
University of Alabama at Birmingham 
Address 
240 Zeigler Research Building, 703 19th St. South, Birmingham, AL 35294-
0006, USA 
 
 
 
 
 
 
 
 
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Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 3 of 74 
 
Scientific Advisory Panel 
People listed in the table below contributed to the initial trial design and protocol v1.0 
writing.  
 
Name 
Affiliation 
Teodora Wi 
Department of Reproductive Health and Research, World Health 
Organization (WHO) 
Carolyn Deal 
National Institute of Allergy and Infectious Diseases, Washington, USA 
David Lewis 
Western Sydney Sexual Health Center, Sydney, Australia 
Sinead Delany 
Wits Reproductive Health and HIV Institute, University of the 
Witwatersrand, Johannesburg, South Africa 
Magnus Unemo 
WHO Collaborating Centre for Gonorrhoea and other sexually 
transmitted infections (STIs) Örebro University Hospital, Sweden  
Suba Srinivasan 
GARDP, Geneva, Switzerland, (formerly Entasis Therapeutics, 
Waltham, USA) 
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Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 4 of 74 
 
INVESTIGATOR SIGNATURE PAGE 
I have read this protocol and agree that it contains all necessary details for carrying out this 
trial. I will conduct the trial as outlined herein and in compliance with GCP/GCLP, the principles 
outlined in the Declaration of Helsinki, all applicable regulatory requirements and local 
regulations. I will complete the trial within the time designated. 
I will provide copies of the protocol and all pertinent information to all individuals responsible 
to me who assist in the conduct of this trial. I will discuss this material with them to ensure 
they are fully informed regarding the investigational product and the conduct of the trial. 
I will use only the informed consent form approved by the sponsor or its representative and 
will fulfill all responsibilities for submitting pertinent information to the Institutional Review 
Board/Independent Ethics Committee (IRB/IEC) responsible for this trial if required by national 
law. 
I agree that the sponsor or its representatives shall have access to any source documents from 
which case report form information may have been generated. 
 
Principal investigator at each trial site 
 
Investigator 
signature 
 
  
 
 
 Date of Signature 
(DD/mmm/YY) 
Name  
 
Title 
 
Institution 
 
Address 
 
 
 
 
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Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 5 of 74 
 
PROTOCOL REVISIONS 
 
Version / 
Date 
Changes 
Sections 
impacted 
V 1.0 / 8 April 
2019 
Original version 
 
V2.0 / 9 
August 2019 
 
 
Addition of methylene blue test as possible NG diagnostic test in inclusion 
criterion #3  
Summary, 4.1 
Clarification on barrier contraception required during participation  in the 
study only 
Summary, 4.1 
Update of exclusion criterion #22 as per SmPC of new source of 
ceftriaxone 
Summary, 4.2 
Exclusion criterion #28 reworded into « previous randomisation in this 
clinical trial » to allow for re-screening 
Summary, 4.2 
Clarification of treatment of participants diagnosed a posteriori as 
infected with CT at baseline 
3.1 
Correction of stratification made on sex at birth 
3.3 
Collection of full date of birth 
5.1, 5.2.1 
Clarifications on clinical assessment of gonorrhoea 
5.1, 5.2.1, 5.2.4, 
5.2.5 
Removal of use of participant diary card 
5.1, 5.2.1, 5.2.4, 
5.2.5, 8.6 
Clarification of collection of microbiological samples 
5.1, 5.2.1, 5.2.5, 
7.4 
Collection of date/time of last meal taken prior to dosing for all 
participants 
5.2.1 
Reference to the MOP for assessment of clinical cure 
5.2.4 
Reference to pharmacy manual for study treatment storage and 
preparation 
6.5, 6.6 
Clarification of physical examination of pharynx required 
7.1 
Correction of total blood volume collected in accordance with ICF 
7.2.1 
Clarification on collection of ART last dose for PK participants 
7.3 
Correction of allowed PK sample processing time 
7.3 
Infant follow up by paediatrician made optional 
8.4 
Renaming of clinical ITT population into clinical cure population  
11.2.2 
Removal of sexual behaviour questionnaire from protocol as provided to 
regulatory authorities and ethics committees as a standalone document 
for review 
5.1, 5.2.1, 5.2.3, 
5.2.4, 5.2.5, 
Appendices 
Correction of typographical errors and abbreviations 
All 
V3.0 / 22 
November 
2019 
Head of Clinical Affairs (A. Janin) replaced by Study Medical Lead (M. 
Heep) 
Protocol 
Signature Page 
Removal of CYP3A4 inhibitors group in PK sub-study 
Summary,2 7.3 
Addition of justification for CYP3A4 exclusion 
3.2.4 
Inclusion age of participants lowered to 12 years old  
Summary, 2, 
4.1, 7.3 
Clarification on methylene blue /gentian violet stain 
Summary, 4.1 
Addition of exclusion criterion for CYP3A4 inhibitors 
Summary,4.2 
Correction of unblinding procedure in case of SUSAR 
3.4 
Clarification on HIV testing as per local practice 
5.1, 5.2.1 
Clarification of capture of last food intake prior to dosing 
5.1, 5.2.1 
Introduction of flexibility on timing of Visit 3 
5.1, 5.2.3 
Correction of assessments to be performed at early withdrawal visits 
5.1, 5.2.6 
Clarification of handling of unscheduled visits 
5.3 
Update of total number of subjects exposed to zoliflodacin 
6.1.2 
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Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 6 of 74 
 
Version / 
Date 
Changes 
Sections 
impacted 
Addition of forbidden concomitant CYP3A4 inhibitors 
6.9 
Clarification on contacting medical monitor regarding newly diagnosed 
HIV positive participants 
6.9 
Addition of nature of food intake around dosing time for PK participants 
7.3  
V4.0 / 22 
October 2021 
Correction of typos, minor edits and clarifications, updating of 
abbreviations 
Throughout 
protocol 
Administrative changes: Updates of study team members and sponsor 
address, Advisory panel role clarification, Simplification of protocol 
signatures to follow to GARDP Standard Operating Procedure (SOP) 
Clinical trial 
protocol 
signature page 
Contingency measure due to COVID-19 pandemic: 
Deletion of Chlamydia trachomatis (CT) assessment at Day 30 visit 
(exploratory endpoint)  
Protocol 
summary, 2, 
3.1, 5.1, 7.4, 
11.4.2 
Contingency measure due to COVID-19 pandemic: 
Deletion of Mycoplasma genitalium (MG) assessment (exploratory 
endpoint) 
Protocol 
summary, 2, 
3.1, 5.1, 5.2.1, 
7.4, 11.4.2 
Clarification of contraception requirements prior to inclusion in the trial 
(Inclusion criteria 5)  
Protocol 
summary, 4.1, 
8.4, Appendix 1 
Clarification of HIV testing requirements for study participation (Inclusion 
criteria 8) 
Protocol 
summary, 4.1, 
5.1, 5.2.1, 7.2.1 
Clarification of treatment of concomitant infections with systemic 
antibiotics with activity against Neisseria gonorrhoeae (NG) (Exclusion 
criteria 13) 
Protocol 
summary, 4.2  
Clarification of selection of participants 
Protocol 
summary, 4, 
11.1 
Background information literature is updated to reflect most recent 
surveillance data on gonorrhoea infections 
1.1 
Addition of recent in vitro data supporting the 3g dose and rewording of 
most common AE 
1.2, 3.2.2 
Update of section 1.3 with latest information on gepotidacin clinical 
development and NABOGO trials preliminary results 
1.3 
Update text to reflect the updated US Centers for Disease Control and 
Prevention (CDC) guidelines for treatment of uncomplicated gonorrhoea. 
References to national treatment guidelines are updated when 
applicable. 
3.2.3 
Update of the clarification of CYP3A4 exclusion and mention of planned 
study STIZoli_003  
 
Contingency measure due to COVID-19 pandemic: 
Addition of Section 3.2.5 Impact of COVID-19 pandemic on trial conduct 
and contingency measures in trial design justification  
3.2.5 
Clarification of how randomisation is performed 
3.3 
Clarification of section on blinding 
3.4 
Update of overall trial duration 
3.5 
Duration of Day 1 visit: Allowing Day 1 visit to happen over 2 days under 
specific conditions 
5.1 and 5.2.1 
Addition of mandatory food intake before dosing 
5.1 and 5.2.1 
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Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 7 of 74 
 
Version / 
Date 
Changes 
Sections 
impacted 
V4.0 / 22 
October 2021 
Clarification of procedure to follow if microbiological assessments results 
are not back in time for the test of cure (TOC) visit 
5.1, 5.2.4 
Addition of sexual history questionnaire assessment at early withdrawal 
visits 
5.1, 5.2.6  
Clarification that direct bilirubin is only required to be performed when 
total bilirubin is out of normal range. 
5.1, 7.2.1 
Addition of text to highlight that those participants who miss the TOC visit 
are considered treatment failure for primary endpoint analysis 
5.2.4 
Contingency measure due to COVID-19 pandemic 
Clarification on handling of out-of-window visits and unscheduled visits 
5.3 
Removal of summary of zoliflodacin non-clinical and clinical experience and 
referral to the Investigator Brochure (IB) 
6.1.2 
Reference is added to the ceftriaxone and azithromycin United States 
prescribing information (USPI) in addition to the summaries of product 
characteristics (SmPC) as applicable. 
6.2.1 
Contingency measure due to COVID-19 pandemic: 
Flexibilities for pharyngeal swab collection  
7.2.2 
Contingency measure due to COVID-19 pandemic: 
NAAT testing allowed with other platforms than Hologic   
7.2.2 
Clarification on food intake recommendations in the pharmacokinetic (PK) 
sub-study 
7.3 
Clarification of section 8.1.1 adverse events (AE) 
1. Assessment whether laboratory/procedures abnormalities should 
be considered as an AE  
2. Clarification of AE definition 
3. Clarification of special cases for AE occurring during screening 
period  
8.1.1 
Minor clarification of the end of the AE reporting period 
8.1.2 
Deletion of duplicated information and clarification of sponsor team in 
section 8.3.1 Reporting of SAEs to sponsor  
8.3.1 
Clarification of events to be reported in an expedited manner 
8.3.2 
Clarification of Exposure during pregnancies section 
8.4 
Clarification of AE follow up 
8.5 
Addition of new analysis population and additional sensitivity analysis 
11.2, 11.2.3, 
11.4.2 
Clarification of definition of microbiological failure 
11.4.1 
Contingency measure due to COVID-19 pandemic: 
Addition of flexibility around monitoring visit format 
13.1 
Addition of the trial clinicaltrials.gov number. 
17.1 
V5.0 / 12 July 
2023 
Administrative changes: Updates of study team members 
Protocol 
Signature Page 
Increase of pre-specified non-inferiority margin to 12% for primary 
endpoint with rationale and re-estimation of evaluable patient population 
for microITT based on blinded pooled data analysis of study performance 
vs baseline assumptions 
 
Summary, 3.2.1, 
4, 11.1, 11.4.2 
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Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 8 of 74 
 
Version / 
Date 
Changes 
Sections 
impacted 
V5.0 / 12 July 
2023 
Clarification that randomisation can occur on Day -1 and trial treatment 
administration the next calendar day (Day 1) to accommodate logistics of 
PK sampling  
(Incorporation in protocol amendment of Note-to-file from 7 July 2022) 
5.1 (Table 3),  
5.2.1 
Reference to UAB central laboratory deleted to reflect change of central 
lab vendor  
(Incorporation in protocol amendment of Note-to-file from 30 January 
2023) 
7.2.2, 11.7 
Correction of error around TOC results in Table 4 Assessments and use for 
clinical management; clarification of anatomical sites and indication for 
sampling at post-baseline visits  
(Incorporation in protocol amendment of Note-to-file from 7 July 2022) 
7.4 (Table 4) 
Minor clarification to definition of trial populations included in the 
analysis to align with Statistical Analysis Plan 
11.2, 11.2.4 
Clarification of contraceptive requirements for male participants to 
reflect how the protocol was conducted 
(Incorporation in protocol amendment of Note-to-file from 7 July 2022) 
16.6 
Inclusion of additional references and correction of error in references 
11.1, 11.7, 
References 
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Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 9 of 74 
 
TABLE OF CONTENTS 
 
TABLE OF CONTENTS ............................................................................................. 9 
ABBREVIATIONS – GLOSSARY OF TERMS ........................................................ 12 
PROTOCOL SUMMARY .......................................................................................... 15 
1. 
BACKGROUND AND TRIAL RATIONALE .................................................. 22 
1.1. 
Background information ................................................................................................... 22 
1.2. 
Zoliflodacin development .................................................................................................. 23 
1.3. 
Overall rationale for the trial ............................................................................................. 24 
2. 
TRIAL OBJECTIVES AND ENDPOINTS ...................................................... 25 
3. 
TRIAL DESIGN.............................................................................................. 27 
3.1. 
Design ................................................................................................................................. 27 
3.2. 
Rationale ............................................................................................................................. 28 
3.2.1. 
Justification for trial design ...................................................................................... 28 
3.2.2. 
Justification for investigational drug dose selection ................................................ 28 
3.2.3. 
Justification for comparator selection ...................................................................... 29 
3.2.4. 
Justification for exclusion of CYP3A4 inhibitors ...................................................... 32 
3.2.5. 
Impact of COVID-19 pandemic on trial conduct and contingency measures ......... 32 
3.3. 
Randomization.................................................................................................................... 33 
3.4. 
Blinding ............................................................................................................................... 33 
3.5. 
Trial duration ...................................................................................................................... 33 
4. 
SELECTION OF PARTICIPANTS ................................................................. 34 
4.1. 
Inclusion criteria ................................................................................................................ 34 
4.2. 
Exclusion criteria ............................................................................................................... 34 
5. 
SCHEDULE OF EVENTS .............................................................................. 36 
5.1. 
Table of assessments ........................................................................................................ 36 
5.2. 
Schedule of assessments ................................................................................................. 36 
5.2.1. 
Visit 1: Day 1 (-1 day) .............................................................................................. 39 
5.2.2. 
Visit 2: Day 2 - PK sub-study .................................................................................. 39 
5.2.3. 
Visit 3: Day 3 (-1 day) .............................................................................................. 40 
5.2.4. 
Visit 4: Day 6 (+/-2 days) ......................................................................................... 40 
5.2.5. 
Visit 5: Day 30 (+/-3 days) ....................................................................................... 40 
5.2.6. 
Early withdrawal ...................................................................................................... 40 
5.3. 
Unscheduled and out-of-window visits ........................................................................... 41 
5.3.1. Out-of-window visits .......................................................................................................... 41 
5.3.2. Unscheduled visits ............................................................................................................ 41 
6. 
INVESTIGATIONAL PRODUCTS ................................................................. 41 
6.1. 
Zoliflodacin treatment ........................................................................................................ 41 
6.1.1. 
Product description and dosage ............................................................................. 41 
6.1.2. 
Summary of non-clinical and clinical experience .................................................... 41 
6.2. 
Comparator trial treatment ................................................................................................ 42 
6.2.1. 
Product description and dosage ............................................................................. 42 
6.2.1. 
Summary of non-clinical and clinical experience .................................................... 42 
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6.3. 
Labelling and packaging ................................................................................................... 42 
6.4. 
Shipment ............................................................................................................................. 42 
6.5. 
Storage ................................................................................................................................ 43 
6.6. 
Preparation and administration of trial treatments ........................................................ 43 
6.7. 
Accountability..................................................................................................................... 43 
6.8. 
Blinding and procedures for un-blinding ........................................................................ 43 
6.9. 
Concomitant treatments .................................................................................................... 43 
6.10. 
Escape treatments ............................................................................................................. 44 
7. 
TRIAL PROCEDURES/EVALUATIONS ....................................................... 44 
7.1. 
Clinical evaluations ............................................................................................................ 44 
7.2. 
Laboratory evaluations ...................................................................................................... 45 
7.2.1. 
Clinical laboratory evaluations ................................................................................ 45 
7.2.2. 
Microbiological evaluations ..................................................................................... 45 
7.3. 
Pharmacokinetic evaluations............................................................................................ 46 
7.4. 
Clinical management of participants ............................................................................... 47 
8. 
ASSESSMENT OF SAFETY ......................................................................... 48 
8.1. 
Definitions ........................................................................................................................... 48 
8.1.1. 
Adverse event ......................................................................................................... 48 
8.1.2. 
Adverse Event reporting period .............................................................................. 49 
8.1.3. 
Serious adverse event ............................................................................................ 49 
8.1.4. 
Overdose ................................................................................................................. 50 
8.1.5. 
Grading of AE severity ............................................................................................ 50 
8.1.6. 
AE causality assessment ........................................................................................ 50 
8.2. 
Detection and recording of AEs ....................................................................................... 51 
8.3. 
Expedited reporting of SAEs ............................................................................................ 51 
8.3.1. 
Reporting of SAEs to sponsor ................................................................................. 51 
8.3.2. 
Reporting of SAEs to national regulatory authorities and ethics committees ......... 52 
8.4. 
Exposure during pregnancies .......................................................................................... 52 
8.5. 
AE follow up........................................................................................................................ 53 
8.6. 
Safety assessments ........................................................................................................... 53 
9. 
WITHDRAWALS ........................................................................................... 53 
10. 
DATA COLLECTION AND MANAGEMENT ................................................. 53 
10.1. 
Source data ......................................................................................................................... 53 
10.2. 
Electronic data capture system ........................................................................................ 54 
11. 
DATA ANALYSIS AND STATISTICAL METHODS ...................................... 55 
11.1. 
Sample size determination ................................................................................................ 55 
11.2. 
Definition of trial populations included in the analysis ................................................. 56 
11.2.1. 
Micro-ITT population ............................................................................................... 57 
11.2.2. 
Clinical cure population ........................................................................................... 57 
11.2.3. 
Evaluable population ............................................................................................... 57 
11.2.4. 
PP population .......................................................................................................... 57 
11.2.5. 
Safety population .................................................................................................... 57 
11.2.6. 
PK population .......................................................................................................... 58 
11.3. 
Baseline characteristics .................................................................................................... 58 
11.4. 
Efficacy analysis ................................................................................................................ 58 
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Protocol version 5.0 of 12 July 2023 
 
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Page 11 of 74 
 
11.4.1. 
Definitions................................................................................................................ 58 
11.4.2. 
Specification of efficacy analysis ............................................................................ 58 
11.5. 
Safety analysis ................................................................................................................... 60 
11.6. 
Pharmacological endpoints .............................................................................................. 60 
11.7. 
Missing values .................................................................................................................... 61 
12. 
DATA SAFETY MONITORING BOARD ....................................................... 61 
13. 
QUALITY ASSURANCE AND QUALITY CONTROL PROCEDURES ......... 62 
13.1. 
Monitoring, audits and inspections ................................................................................. 62 
13.2. 
Audits and inspections ...................................................................................................... 63 
13.3. 
Laboratory framework ....................................................................................................... 63 
14. 
TRIAL DOCUMENTATION ........................................................................... 63 
14.1. 
Confidentiality and retention of trial documents ............................................................ 63 
14.2. 
Protocol amendment ......................................................................................................... 63 
14.3. 
Final trial reports ................................................................................................................ 64 
15. 
EARLY TERMINATION OF THE TRIAL ....................................................... 64 
16. 
ETHICS .......................................................................................................... 65 
16.1. 
Trial conduct ....................................................................................................................... 65 
16.2. 
Regulatory and ethical approval....................................................................................... 65 
16.3. 
Informed consent process ................................................................................................ 65 
16.4. 
Justification for selection of trial population .................................................................. 66 
16.5. 
Community engagement ................................................................................................... 66 
16.6. 
Risks and benefits ............................................................................................................. 66 
16.7. 
HIV status and voluntary counselling and testing.......................................................... 67 
16.8. 
Compensation .................................................................................................................... 68 
16.9. 
Insurance and liability ....................................................................................................... 68 
16.10. Post-trial access ................................................................................................................. 68 
17. 
REPORTING AND PUBLICATION ............................................................... 68 
17.1. 
International registry of clinical trials .............................................................................. 68 
17.2. 
Publication .......................................................................................................................... 68 
REFERENCES ......................................................................................................... 69 
APPENDIX 1: CONTRACEPTION METHODS CONSIDERED AS HIGHLY 
EFFECTIVE .............................................................................................................. 74 
 
 
 
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Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 12 of 74 
 
ABBREVIATIONS – GLOSSARY OF TERMS 
 
 
ADL 
Activities of daily living 
ADME 
Absorption, distribution, metabolism, excretion 
AE 
Adverse event 
ALT 
Alanine transaminase 
AMR 
Antimicrobial resistance 
API 
Active pharmaceutical ingredient 
ART 
Anti-retroviral therapy 
AUC 
Area under the time-concentration curve 
BA 
Bioavailability 
BID 
Twice a day 
BV 
Bacterial vaginosis 
CFR 
CT 
Code of Federal Regulations 
Chlamydia trachomatis 
CI 
Confidence interval 
CIOMS 
CKD-EPI 
Council for International Organizations of Medical Sciences 
Chronic kidney disease - epidemiology collaboration 
CL/F 
Apparent total clearance of the drug after oral administration 
Cmax 
Maximum plasma drug concentration 
Cmin 
Minimum plasma drug concentration 
CRF 
CTCAE 
Case report form 
Common Terminology Criteria for Adverse Events  
CV 
CYP3A4 
Coefficient of variation 
Cytochrome P450 family 3 subfamily A member 4 
DMID 
DNA 
Division of Microbiology and Infectious Diseases 
Deoxyribonucleic acid 
DNDi 
Drugs for neglected diseases initiative 
DoH 
Department of Health 
DSMB 
Data and safety monitoring board 
eCRF 
Electronic case report form 
EDC 
eGFR 
Electronic data capture 
Estimated glomerular filtration rate 
EMA 
European Medicines Agency 
EOT 
End of trial 
ESC 
Extended spectrum cephalosporines 
EU 
European Union 
FBC 
Full blood count 
FDA 
Food and Drug Administration 
FPFV 
First participant first visit 
fT>MIC 
Period over which free drug concentrations exceed MIC 
FWA 
g 
Federal-wide assurance 
Gram 
GARDP 
Global Antibiotics Research & Development Partnership 
GCLP 
Good clinical laboratorial practice 
GCP 
Good clinical practice 
GI 
Gastrointestinal 
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Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
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Page 13 of 74 
 
GM 
Geometrical mean 
GMP 
GSD 
H 
HCl 
Good manufacturing practice 
Geometrical standard deviation 
Hour  
Hydrochloric acid 
HFIM 
Hollow fibre infection model 
HIC 
HIV 
High income country 
Human immunodeficiency virus 
HLGT 
HPLC 
High level group term 
High performance liquid chromatography 
IB 
Investigator brochure 
ICF 
Informed consent form 
ICH 
International Conferences on Harmonization of Technical Requirements for 
Registration of Pharmaceuticals for Human Use 
ICMJE 
International committee of medical journal editors 
IEC 
Independent ethics committee 
IM 
IMP 
Intramuscular 
Investigational medicinal product 
IRB 
Independent review board 
ITT 
Intention to treat 
IV 
Ke 
Kg 
L 
Intravenous 
Elimination rate 
Kilogram 
Litre 
LFT 
Liver function tests 
LPLV 
MAR 
Last participant last visit 
Missing at random 
MDR 
Multi drug resistant 
MedDRA 
mEq 
mg 
Medical Dictionary for Regulatory Activities 
Milli-equivalent 
Milligram 
MIC 
MIC90 
Minimum inhibitory concentration 
Minimum inhibitory concentration required to inhibit the growth of 90 % of 
organisms 
Micro-ITT 
mL 
MNAR 
Microbiologic – intention to treat 
Millilitre 
Missing not at random 
MoH 
Ministry of Health 
MOP 
Manual of procedures 
MoPH 
MS 
μg 
Ministry of Public Health 
Mass spectroscopy 
Microgram 
NAAT 
Nucleic acid amplification test 
NBTI 
Novel bacterial topoisomerase inhibitors 
NCE 
ng 
NG 
New chemical entity 
Nanogram 
Neisseria gonorrhoeae 
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Protocol version 5.0 of 12 July 2023 
 
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NIH 
National Institute of Health 
NRA 
PCI 
National regulatory authorities 
Packaging Coordinators Inc. 
PD 
Pharmacodynamics 
PI 
Principal investigator (see note Section 13) 
PID 
Pelvic inflammatory disease 
PK 
Pharmacokinetics 
PO 
Per os 
PP 
Per protocol 
PT 
Preferred term 
PV 
Pharmacovigilance 
QC 
QTc 
Quality control 
Corrected QT interval 
rBA 
Relative bioavailability 
RDT 
RNA 
rRNA 
S. aureus 
Rapid diagnostic test 
Ribonucleic acid 
Ribosomal ribonucleic acid 
Staphylococcus aureus 
SAD 
Single ascending dose 
SAE 
Serious adverse event 
SAPHRA 
South Africa Health Products Regulatory Authority 
SD 
Standard deviation 
SmPC 
Summary of product characteristics 
SOC 
System organ class 
SOP 
Standard operating procedures 
STI 
Sexually transmitted infections 
SUSAR 
Suspected unexpected serious adverse reaction 
t1/2 
Elimination half life 
Thai-FDA 
tlast 
tmax 
Thailand Food and Drug Administration 
Time to last measurable drug concentration following drug administration  
Time to reach Cmax following drug administration 
TOC 
Test of cure 
UD 
Urethral discharge 
ULN 
USA 
Upper limit of normal 
United States of America 
US-CDC 
United States Centers for Disease Control and Prevention 
US-FDA 
VCT 
VZ/F 
United States – Food and Drug Administration 
Voluntary counselling and testing 
Apparent volume of distribution during terminal phase 
USPI 
United States Prescribing Information 
WBC 
WGS 
White blood cell 
Whole genome sequencing 
WHO 
World Health Organization 
WNL 
wt 
Within normal limits 
weight 
 
 
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Protocol number STI_Zoli001 
 
Zoliflodacin 
Protocol version 5.0 of 12 July 2023 
 
Confidential  
Page 15 of 74 
 
PROTOCOL SUMMARY 
 
Trial title 
A multi-center, randomized, open-label, non-inferiority trial to 
evaluate the efficacy and safety of a single, oral dose of 
zoliflodacin compared to a combination of a single 
intramuscular dose of ceftriaxone and a single oral dose of 
azithromycin in the treatment of patients with uncomplicated 
gonorrhoea 
Protocol number 
STI_Zoli001 
Phase of development 
Phase III 
Design 
Non-inferiority, parallel, open-label 
Primary objective  
To assess the efficacy of a single, oral, 3 grams (g) dose of 
zoliflodacin compared to a combination of a single 
intramuscular (IM) 500 milligram (mg) dose of ceftriaxone and a 
single 1 g oral dose of azithromycin for the treatment of 
uncomplicated urogenital gonorrhoea 
Secondary objectives 
x To assess the safety and tolerability of a single, oral, 3 g 
dose of zoliflodacin compared to a combination of a 
single IM 500 mg dose of ceftriaxone and a single 1 g oral 
dose of azithromycin in participants with uncomplicated 
gonorrhoea 
x To determine microbiological cure rate of pharyngeal 
gonorrhoea after administration of a single, oral, 3 g 
dose of zoliflodacin compared to a combination of a 
single IM 500 mg dose of ceftriaxone and a single 1 g oral 
dose of azithromycin 
x To determine microbiological cure rate of rectal 
gonorrhoea after administration of a single, oral, 3 g 
dose of zoliflodacin compared to a combination of a 
single IM 500 mg dose of ceftriaxone and a single 1 g oral 
dose of azithromycin 
x To determine the clinical cure rate of symptomatic 
gonorrhoea in male participants after administration of a 
single, oral, 3 g dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of ceftriaxone 
and a single 1 g oral dose of azithromycin 
x To determine the microbiological cure rate of urogenital 
gonorrhoea among women and men, after 
administration of a single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 500 mg dose 
of ceftriaxone and a single 1 g oral dose of azithromycin 
x To determine the microbiological cure rate of Neisseria 
gonorrhoeae (NG) at urethral or cervical sites in the 
subset of participants with pre-existing resistance to 
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antibiotics commonly used for NG treatment (including 
to ceftriaxone alone, to azithromycin alone, and to both) 
x To determine the antimicrobial susceptibility profile of 
gonococcal strains isolated from participants with 
uncomplicated gonorrhoea at baseline and the test of 
cure (TOC) (day 6 ±2) visit 
x To determine the eradication rate of NG nucleic acid 
from urethral, cervical, rectal, pharyngeal specimens 
after administration of a single, oral, 3 g dose of 
zoliflodacin compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin 
PK (pharmacokinetics) 
objective (sub-study 
only) 
To evaluate the plasma PK of a single, oral, 3 g dose of 
zoliflodacin: 
x in adult participants (≥ 18 years old) with uncomplicated 
gonorrhoea who are human immunodeficiency virus 
(HIV) negative or HIV positive 
x in HIV negative adolescent participants (≥ 12 and < 18 
years old) with uncomplicated gonorrhoea 
Exploratory objectives 
x To determine the late eradication rate of NG nucleic 
acids from urethral, cervical, rectal, pharyngeal 
specimens after administration of a single, oral, 3 g dose 
of zoliflodacin compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin 
x To determine the late relapse/re-infection rate of NG 
from urethral, cervical, rectal, pharyngeal specimens 
after administration of a single, oral, 3 g dose of 
zoliflodacin compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin 
x To investigate relationships between pre-treatment and 
post-treatment NG isolates within those participants 
whose cultures at TOC (day 6 ±2) are found positive for 
NG and identify possible determinants of zoliflodacin 
resistance 
Primary endpoint 
Microbiological cure as determined by culture at urethral or 
cervical sites at TOC (day 6 ±2) 
Secondary endpoints 
x 
Incidence, severity, causality, and seriousness of 
treatment-emergent adverse events and the evaluation 
of changes from baseline in safety laboratory test results 
and physical examinations 
x Proportion of participants with microbiological cure as 
determined by culture at pharyngeal sites at TOC (day 6 
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±2) 
x Proportion of participants with microbiological cure as 
determined by culture at rectal sites at TOC (day 6 ±2) 
x Proportion of male participants with clinical cure at TOC 
(day 6 ±2) 
x Proportion of female and male participants with 
microbiological cure as determined by culture at cervical 
or urethral site at TOC (day 6 ±2) 
x Proportion of participants with microbiological cure as 
determined by culture at urethral or cervical sites at TOC 
and for whom the baseline antimicrobial susceptibility 
profile indicated pre-existing resistance to antibiotics 
commonly used for NG treatment (including to 
ceftriaxone alone, to azithromycin alone, and to both) 
x Antimicrobial susceptibility profile of gonococcal strains 
isolated at baseline and at TOC (day 6 ±2) 
x Proportion of participants with a negative NG nucleic 
acid amplification test (NAAT) from urethral or cervical 
sites at TOC (day 6 ±2) 
x Proportion of participants with a negative NG NAAT from 
oropharyngeal sites at TOC (day 6 ±2) 
x Proportion of participants with a negative NG NAAT from 
rectal sites at TOC (day 6 ±2) 
Exploratory endpoints 
x Out of participants with a positive NG NAAT test and a 
negative NG culture at TOC, the below will be 
determined: 
o Proportion of participants with a negative NG 
NAAT and culture from urethral or cervical sites 
at the end of the trial (day 30 +/- 3 days) 
o Proportion of participants with a negative NG 
NAAT and culture from oropharyngeal sites at the 
end of the trial (day 30 +/- 3 days) 
o Proportion of participants with a negative NG 
NAAT and culture from rectal sites at the end of 
the trial (day 30 +/- 3 days) 
x Out of participants with symptoms at end of the trial 
(day 30 +/- 3 days), the following will be determined: 
o Proportion of patients with positive NAAT and/or 
culture at each anatomical site respectively at 
end of the trial (day 30 +/- 3 days)  
o Antimicrobial susceptibility profile of gonococcal 
strains isolated at the end of the trial (day 30 +/- 
3 days 
x Whole genome sequencing (WGS) of NG isolates from 
the TOC and end of trial (EOT) visits plus all baseline 
isolates (urogenital, pharyngeal and rectal) from the 
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same patients with possible microbiological failure 
Pharmacological 
endpoints 
 
Plasma PK parameters of zoliflodacin in HIV negative and HIV 
positive participants (≥ 18 years old) 
Plasma PK parameters of zoliflodacin in HIV negative 
adolescents (≥12 and <18 years old) 
 
Inclusion criteria 
 
1. ≥ 12 years old (if enrolment of minors is in agreement 
with local regulations and ethics guidance) 
2. ≥ 35 kilogram (kg) 
3. Signs and symptoms consistent with urethral or cervical 
gonorrhoea  
OR 
Urethral or cervical uncomplicated gonorrhoea as 
determined by either a positive culture or NAAT or Gram 
stain or methylene blue/gentian violet stain in the past 
14 days prior to screening  
OR 
Unprotected sexual contact with an individual confirmed 
to be infected with NG in the past 14 days prior to 
screening (positive NAAT, Gram stain, methylene 
blue/gentian violet stain or culture) 
4. For females of child-bearing potential, a negative urine 
pregnancy test at screening 
5. For females of child-bearing potential, use of a highly 
effective method of contraception at the time of IMP 
administration on Day 1 (see Appendix 1: Contraception 
methods considered as highly effective and required 
duration) and until at least 28 days after treatment. 
Females on oral contraceptives must also use a barrier 
contraception method during participation in the study. 
6. For males with a female partner of child-bearing age, 
willingness to delay conception during the trial and for 
28 days after treatment 
7. Willingness to comply with trial protocol 
8. For participants in the PK sub-study: Willingness to 
undergo HIV testing 
9. Willingness to abstain from sexual intercourse or use 
condoms for vaginal, anal and oral sex from enrolment 
until the end of trial (EOT) visit 
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10. Willingness and ability to give written informed consent 
or be consented by a legal representative, or provide 
assent and parental consent (for minors, as appropriate) 
Exclusion criteria 
11. Confirmed or suspected complicated or disseminated 
gonorrhoea  
12. Pregnant or breastfeeding females 
13. Known concomitant infection which would require 
immediate additional systemic antibiotics with activity 
against NG 
14. Use of any systemic or intravaginal antibiotics with 
activity against NG within 30 days prior to screening 
15. Use of systemic corticoid drugs or other 
immunosuppressive therapy within 30 days prior to 
screening 
16. Use of moderate or strong CYP3A4 inducers (e.g.  
efavirenz, rifampicin, carbamazepine, phenobarbital) 
within 30 days or five half-lives of the drug, whichever is 
greater, prior to screening (see Section 6.9) 
17. Cytotoxic or radiation therapy within 30 days prior to 
screening 
18. Known chronic renal, hepatic, hematologic impairment 
or other condition interfering with the absorption, 
distribution or elimination of the drug, based on medical 
history and physical examination 
19. History of urogenital sex-reassignment surgery 
20. Immunosuppression as evidenced by medical history, 
clinical examination or a recent (≤1 month) CD4 count 
below 200 cells/microliter (μL) 
21. Known clinically relevant cardiac pro-arrhythmic 
conditions such as cardiac arrhythmia, congenital or 
documented QT prolongation   
22. Known history of severe allergy to cephalosporin, 
penicillin, monobactams, carbapenems, or macrolide 
antibiotics 
23. Known or suspected allergies or hypersensitivities to 
lidocaine, methylparaben, lactose or any of the 
components of the study drugs (refer to the zoliflodacin 
investigator brochure (IB) and summaries of product 
characteristics (SmPC) for the comparator treatments) 
24. Receipt or planned receipt of an investigational product 
in a clinical trial within 30 days or five half-lives of the 
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drug, whichever is greater prior to screening until end of 
participation to this clinical trial 
25. History of alcohol or drug abuse in the 12 months prior 
to screening which would compromise trial participation 
in the judgement of the investigator 
26. Severe medical or psychiatric condition that, in the 
opinion of the investigator, may increase the risk 
associated with trial participation or may interfere with 
the interpretation of trial results or affect the individual’s 
ability to provide informed consent 
27. Individuals whom, in the judgement of the investigator, 
are unlikely or unable to comply with this trial protocol 
28. Previous randomisation in this clinical trial 
29. Use of moderate or strong CYP3A4 inhibitors within 30 
days or five half-lives of the drug, whichever is greater, 
prior to screening (see Section 6.9) 
 
Target sample size 
(estimated) 
696 evaluable trial participants (464 in interventional group and 
232 in control group) including 20-30 adolescents (≥12 and < 18 
years old). The estimated randomised sample size is up to 
approximately 928 trial participants, and the estimated number 
of participants enrolled will be approximately 1092 taking into 
account screen failures. 
Intervention 
Single oral 3 g dose of zoliflodacin granules as oral suspension 
Comparator 
Combination of a single intramuscular 500 mg dose of 
ceftriaxone and a single oral 1 g dose of azithromycin 
Statistical analysis 
The microbiological intent-to-treat (micro-ITT) population will 
be used as the primary analysis population for the assessment 
of microbiological cure. The micro-ITT population will include all 
randomized participants who receive a dose of drug, who have 
urogenital NG isolated at baseline and who are not infected with 
a strain that shows resistance to both ceftriaxone and 
azithromycin at baseline.  
The primary efficacy analysis will claim that zoliflodacin is non-
inferior to the ceftriaxone-azithromycin combination if the 
upper bound of the 2-sided 95% confidence interval (CI) for the 
microbiological cure rate of the combination therapy minus 
zoliflodacin will be 12% or less (prespecified non-inferiority 
margin for the primary endpoint).  
Complementary 
activities 
Microbiological bacterial isolates collected will be stored for 
long-term (no longer than 5 years, with the exception of the 
Netherlands where bacterial isolates will be kept up to 15 years 
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as per local regulations) after the end of the trial analysis (e.g. 
genotyping) for use in future research in relation to diagnosis 
and treatment of gonorrhoea. 
 
 
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1. Background and trial rationale 
1.1. Background information 
Bacterial sexually transmitted infections (STI) are a major public health concern globally, 
affecting over 357 million people every year (1). Neisseria gonorrhoeae (NG), the etiological 
agent of gonorrhoea, is estimated to have caused 78 million infections in 2012.  The Western 
Pacific and African regions have the highest incidence of gonococcal infections worldwide, 
with 89 and 50 cases per 100’000 population respectively. Rates of male urethral discharge 
(UD), which is primarily due to NG or Chlamydia trachomatis (CT), are also highest for these 
two regions, amounting to 567 per 100’000 in Africa and 141 per 100’000 in the Western 
Pacific. In high income countries (HIC), gonorrhoea is also raising significant concerns. In the 
United States of America (USA) it is the second most frequently reported notifiable infectious 
diseases, with over 600’000 infections reported per year (2). NG has been included as one of 
three organisms presenting an urgent threat due to progressive antimicrobial resistance by 
the US Centers for Disease Control and Prevention (US CDC) (3). 
Gonorrhoea affects both men and women. In men, infections commonly manifest as 
urethritis. Symptoms develop in 75% of the men within four to eight days of genital infection 
and in 80 to 90% within two weeks (4). UD is the most frequent presenting symptom and is 
often undistinguishable from non-gonococcal urethritis (e.g. CT infections). Acute unilateral 
epididymitis can be a complication of gonococcal infection, although it is more common with 
CT infections (5, 6). In women, gonococcal infections are often (≥50% of the cases) 
asymptomatic. Genital infections, in particular cervical infections, are the most common 
infections. When symptomatic, cervical infection typically manifests as mucopurulent 
discharge. If left untreated, NG infections can ascend to involve the uterus and fallopian tubes. 
Gonorrhoea is associated with significant morbidity and if not treated appropriately, can have 
serious consequences on reproductive health. Pelvic inflammatory disease (PID), ectopic 
pregnancies, abortions, neonatal conjunctivitis and blindness are among the possible 
complications. Studies have also shown that gonorrhoea enhances the transmission of human 
HIV by three to five-fold (7-9). 
Most individuals with gonorrhoea are managed in the community, and clinical management 
is often empiric and syndromic: treatment is based on the presence of easily recognized signs 
(e.g. urethral or vaginal discharge), and the provision of antibiotics that deal with the majority 
of, or the most serious, organisms responsible for the syndrome. Extended spectrum 
cephalosporins (ESC) constitute the mainstay of gonorrhoea treatment. However, with 
increasing resistance to ESC emerging globally, and in particular to cefixime, several countries 
switched around 2013 from ESC monotherapy to a dual therapy that includes an injectable 
ESC – ceftriaxone- and azithromycin (10, 11), the underlying, unproven, assumption being that 
a dual therapy would slow down resistance emergence.  
Over the past few years, the World Health Organization (WHO) and others have raised 
concerns over the spread of gonococcal antimicrobial resistance (AMR), warning that 
infections due to NG may soon become untreatable (12-14). Reports of treatment failures 
with ESC and azithromycin monotherapy have multiplied over the past few years, and clinical 
failures to dual therapy have been reported (15-17). Despite this, the drug development 
pipeline for NG remains insufficient. In 2012, the WHO launched a global action plan to control 
the spread and impact of AMR in NG. Identifying new treatment options for multi-drug 
resistant (MDR) gonorrhoea is a key element of the WHO global action plan, and has long been 
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called for by clinicians and microbiologists (18, 19). 
1.2. Zoliflodacin development 
Zoliflodacin (ETX0914) belongs to a new class of antibiotics that inhibit bacterial 
deoxyribonucleic acid (DNA) replication. It shows in vitro antibacterial activity against several 
Gram-positive pathogens such as Staphylococcus spp. and Streptococcus spp. as well as 
fastidious Gram-negative pathogens such as Haemophilus influenzae, Moraxella catarrhalis 
and NG (20). Minimum inhibitory concentration required to inhibit the growth of 90% of 
organisms (MIC90) values for NG range from 0.125 to 0.25 μg/mL.   
A complete program of both oral and intravenous (IV) toxicity studies was performed in the 
rat and dog. Data collected included clinical observations, body weight changes, food 
consumption, clinical pathology and histopathology. Also completed was a battery of genetic 
toxicology studies and single dose safety pharmacology studies to assess cardiovascular, 
central nervous system, renal, respiratory and gastrointestinal endpoints.  
Studies performed in the Staphylococcus aureus (S. aureus) neutropenic thigh model, which 
was the surrogate pathogen model available at the time, indicated that the ratio between the 
area under the concentration-time curve (AUC) and the MIC was the driver of log kill. Those 
studies also supported a predicted efficacious mean AUC in humans of 49 μg*hour(h)/mL. 
Overall, the preclinical data supported progression to phase I trials (20, 21). More recently, 
dose-ranging studies using a hollow fibre infection model (HFIM) for NG confirmed the 
exposure-response previously generated with S. aureus that, accounting for PK variability in 
human, zoliflodacin should be administered as a single oral dose of 3g to provide effective 
killing of NG while suppressing emergence of resistance (22). 
Detailed results of these pre-clinical evaluations are summarized in the investigator brochure 
(IB).  
Zoliflodacin is being developed as an oral, single dose treatment. Final data is available from 
six clinical trials : a phase I single-ascending dose (SAD) trial, a phase I absorption, distribution, 
metabolism, excretion (ADME) trial (23), a phase II trial involving participants with confirmed 
urogenital gonococcal infection (24), a phase I relative bioavailability (rBA) trial 
(clinicaltrials.gov NCT03404167), a phase I food effect trial with healthy volunteers to assess 
the effect of food on the PK characteristics of a newly developed formulation (clinicaltrials.gov 
NCT03718806) and a thorough QT/QTc (TQT) trials (25). The SAD and ADME trials showed that 
zoliflodacin was well tolerated at all doses tested (200 mg- 4’000 mg). The most frequently 
reported AEs in both healthy volunteers and patients with uncomplicated gonorrhoea were 
headache, nausea and diarrhea. Dysgeusia, which is the preferred term for ‘unpleasant taste’ 
in the Medical Dictionary for Regulatory Activities (MedDRA), was reported by healthy 
volunteers receiving an old zoliflodacin formulation, which is not the formulation used in this 
trial.  
In the phase II, 96% (95%CI: 88-100%) cure rates were observed with both the 2 g and the 3 g 
doses in the micro-ITT population at the urogenital site (55 out of 57 and 54 out of 56 
participants respectively) compared to 100% (95% CI:88-100) in the comparator arm of 
ceftriaxone 500 mg IM (24). All participants with concomitant rectal infections were cured 
with either dose of zoliflodacin, while for those with concurrent oropharyngeal infections, 
cure rates were lower (2 g 50% [95%CI: 16-84]; 3 g 82% [95%CI: 48-98]) compared to 100% 
(95%CI: 40-100) for ceftriaxone. The small number of participants with concurrent 
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oropharyngeal infections included in the phase II (8 participants in the 2 g arm, 11 participants 
in the 3 g arm and 4 in the ceftriaxone arm) however precludes any firm conclusion about 
efficacy at this site. In the phase II, the safety profile of zoliflodacin was generally similar to 
ceftriaxone; the most common adverse events (excluding infection-related AEs) were 
diarrhoea, headache, and nausea. The drug was overall generally well tolerated. 
1.3. Overall rationale for the trial 
Despite growing concerns over progressive antimicrobial resistance, the development 
pipeline for uncomplicated gonorrhoea remains relatively empty with only two new chemical 
entities (NCE) currently in development: zoliflodacin and gepotidacin. Gepotidacin, for which 
with single dose treatment a few microbiological failures occurred in phase 2, especially in 
isolates with high baseline MICs (26), is being tested in phase III as a 2-dose treatment for 
uncomplicated gonorrhoea. As fluoroquinolone resistance is already extremely prevalent 
globally (27), the use of gepotidacin will have to be restricted to cases where the antimicrobial 
susceptibility pattern of the infecting strain is known. Zoliflodacin (AZD0914) on the other 
hand, has shown extremely good activity against a large collection of isolates (standard and 
clinical), from different geographical origins, including multi-drug resistant (MDR) and 
extremely drug resistant (XDR) strains (28-31). In vitro studies clearly show the absence of 
cross-resistance between zoliflodacin and pre-existing fluoroquinolone and cephalosporin 
resistance mechanism (32). The frequency of spontaneous resistance to zoliflodacin in vitro 
was found to be low and comparable to frequencies reported for fluoroquinolones (1.5x10-8 
to 5.2x10-9 at 4x MIC) (33-35). 
The utility of commercialized readily-available drugs as new treatments for uncomplicated 
gonorrhoea has been investigated in a few trials. For example, a 4-arm trial (NABOGO) was 
conducted in the Netherlands to formally evaluate ertapenem, fosfomycin and gentamicin 
compared to ceftriaxone (36). Preliminary data shows that ertapenem , but not gentamicin 
nor fosfomycin, was non-inferior to ceftriaxone. Nevertheless, ertapenem must also be 
administered intramuscularly, like ceftriaxone. In case resistance to the currently 
recommended therapies reaches the critical threshold of 5% set by WHO and other public 
health agencies, it could have some utility before a new molecule comes to market. However, 
it does not provide a long-term solution and have well-known drawbacks as the MIC of 
ertapenem is affected by the ESC resistance determinants (37). In contrast, zoliflodacin has 
proven to be an excellent clinical candidate both in terms of efficacy and safety. The drug is 
well tolerated, can be administered orally and has shown high rates of cure for urethral, 
cervical and rectal gonococcal infection in phase II (24). 
In summary, zoliflodacin is a new promising option to address the risk posed by the threat of 
drug-resistant gonorrhoea. The purpose of this phase III multi-center, randomized, open-label, 
non-inferiority trial is to confirm the efficacy and safety outcomes observed in the phase II 
trial and to generate the necessary evidence to support a marketing authorization application 
in the USA, the European Union (EU), South Africa and Thailand.  
 
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2. Trial objectives and endpoints 
Table 1: objectives and endpoints 
OBJECTIVES 
ENDPOINTS 
PRIMARY 
To assess the efficacy of a single, oral, 3 g 
dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of 
ceftriaxone and a single 1 g oral dose of 
azithromycin for the treatment of 
uncomplicated urogenital gonorrhoea 
Microbiological cure as determined by 
culture at urethral or cervical sites at TOC 
(day 6 ±2) 
SECONDARY 
To assess the safety and tolerability of a 
single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g 
oral dose of azithromycin in participants 
with uncomplicated gonorrhoea 
Incidence, severity, causality, and 
seriousness of treatment-emergent adverse 
events and the evaluation of changes from 
baseline in safety laboratory test results 
and physical examinations 
To determine microbiological cure rate of 
pharyngeal gonorrhoea after 
administration of a single, oral, 3 g dose of 
zoliflodacin compared to a combination of 
a single IM 500 mg dose of ceftriaxone and 
a single 1 g oral dose of azithromycin 
Proportion of participants with 
microbiological cure as determined by 
culture at pharyngeal sites at TOC (day 6 
±2) 
To determine microbiological cure rate of 
rectal gonorrhoea after administration of a 
single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g 
oral dose of azithromycin 
Proportion of participants with 
microbiological cure as determined by 
culture at rectal sites at TOC (day 6 ±2) 
To determine the clinical cure rate of 
symptomatic gonorrhoea in male 
participants after administration of a single, 
oral, 3 g dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of 
ceftriaxone and a single 1 g oral dose of 
azithromycin 
Proportion of male participants with clinical 
cure at TOC (day 6 ±2) 
To determine the microbiological cure rate 
of urogenital gonorrhoea among women 
and men, after administration of a single, 
Proportion of female and male participants 
with microbiological cure as determined by 
culture at cervical or urethral site at TOC 
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OBJECTIVES 
ENDPOINTS 
oral, 3 g dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of 
ceftriaxone and a single 1 g oral dose of 
azithromycin 
(day 6 ±2) 
To determine the microbiological cure rate 
of NG at urethral or cervical sites in the 
subset of participants with pre-existing 
resistance to antibiotics commonly used for 
NG treatment (including to ceftriaxone 
alone, to azithromycin alone and to both) 
Proportion of participants with 
microbiological cure as determined by 
culture at urethral or cervical sites at the 
TOC visit and for whom the baseline 
antimicrobial susceptibility profile indicated 
pre-existing resistance to antibiotics 
commonly used for NG treatment 
(including to ceftriaxone alone, to 
azithromycin alone and to both) 
To determine the antimicrobial 
susceptibility profile of gonococcal strains 
isolated from participants with 
uncomplicated gonorrhoea at baseline and 
the TOC visit 
Antimicrobial susceptibility profile of 
gonococcal strains isolated at baseline and 
at TOC (day 6 ±2) 
To determine the eradication rate of NG 
nucleic acid from urethral, cervical, rectal, 
pharyngeal specimens after administration 
of a single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g 
oral dose of azithromycin 
x Proportion of participants with a 
negative NG NAAT from urethral or 
cervical sites at TOC (day 6 ±2) 
x Proportion of participants with a 
negative NG NAAT from 
oropharyngeal sites at TOC (day 6 
±2) 
x Proportion of participants with a 
negative NG NAAT from rectal sites 
at TOC (day 6 ±2) 
PK sub-study only 
To evaluate the plasma PK profile after a 
single, oral, 3 g dose of zoliflodacin: 
x in adult participants (≥ 18 years old) 
with uncomplicated gonorrhoea  
who are HIV negative or HIV positive 
x in HIV negative adolescent 
participants (≥ 12 and < 18 years 
old) with uncomplicated 
gonorrhoea 
 
 
x Plasma PK parameters of 
zoliflodacin in HIV negative and HIV 
positive adult participants  
x Plasma PK parameters of 
zoliflodacin in HIV negative 
adolescents (≥ 12 and < 18 years 
old) 
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OBJECTIVES 
ENDPOINTS 
EXPLORATORY 
To determine the late eradication rate of 
NG nucleic acid from urethral, cervical, 
rectal, pharyngeal specimens after 
administration of a single, oral, 3 g dose of 
zoliflodacin compared to a combination of 
a single IM 500 mg dose of ceftriaxone and 
a single 1 g oral dose of azithromycin 
Out of participants with a positive NG NAAT 
test and a negative NG culture at TOC, the 
below will be determined: 
x Proportion of participants with a 
negative NG NAAT and culture from 
urethral or cervical sites at the end 
of the trial (day 30 +/- 3 days) 
x Proportion of participants with a 
negative NG NAAT and culture from 
oropharyngeal sites at the end of 
the trial (day 30 +/- 3 days) 
x Proportion of participants with a 
negative NG NAAT and culture from 
rectal sites at the end of the trial 
(day 30 +/- 3 days) 
To determine the late relapse/re-infection 
rate of NG from urethral, cervical, rectal, 
pharyngeal specimens after administration 
of a single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 
500 mg dose of ceftriaxone and a single 1 g 
oral dose of azithromycin 
Out of participants with symptoms at end 
of the trial (day 30 +/- 3 days), the following 
will be determined: 
x Proportion of patients with positive 
NAAT and/or culture at each 
anatomical site respectively at end 
of the trial (day 30 +/- 3 days)  
x Antimicrobial susceptibility profile 
of gonococcal strains isolated at the 
end of the trial (day 30 +/- 3 days) 
To investigate relationships between pre-
treatment and post-treatment NG isolates 
within those participants whose cultures at 
TOC and EOT are found positive for NG and 
identify possible determinants of 
zoliflodacin resistance 
WGS of NG isolates from the TOC and EOT 
visits plus all baseline isolates (urogenital, 
pharyngeal and rectal) from the same 
patients with possible microbiological 
failure  
 
3. Trial design  
3.1. Design 
This trial will be a multi-center, open label, randomized controlled, non-inferiority phase III 
trial evaluating the safety and efficacy of a 3 g oral dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin for the treatment of uncomplicated gonorrhoea.  
A schematic of the trial schedule is presented in Figure 1. Participants presenting to the clinic 
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will be assessed for eligibility after informed consent is signed on Day 1. Should eligibility be 
confirmed, they will be randomised to either the zoliflodacin group or the ceftriaxone-
azithromycin combination group, undergo baseline assessments and dosed with the trial
treatment. Those participants who are assigned to the zoliflodacin group and who will also 
have consented to be enrolled in the PK sub-study will undergo blood sampling on Day 1 and 
return to the clinic on Day 2 for further blood sampling. Site staff will call all participants on 
Day 3 for safety monitoring purposes and to enquire about sex behaviour since the previous 
clinic visit. Participants will return to the clinic on Day 6 for the TOC visit, involving safety and 
efficacy assessments (primary endpoint for the trial will be assessed at the TOC visit). Those 
participants that will a posteriori have been diagnosed with a CT infection via NAAT at baseline 
and who were randomised to the zoliflodacin arm will then be treated for the CT infection as 
per standard of care. All participants will be asked to return to the clinic for the EOT visit on 
Day 30 for final safety and efficacy assessments. For further details on the schedule of 
assessments refer to Section 5. 
Figure 1: Trial design schematic 
CT: Chlamydia trachomatis; HIV: human immunodeficiency virus; NAAT: nucleic acid amplification test; NG: Neisseria 
gonorrhoeae; PK: pharmacokinetics. 
Note: Culture and NAAT assessments at visits 4 and 5 are conditional to results at previous visits as per the schedule of 
assessments (Section 5).
3.2. Rationale 
3.2.1. Justification for trial design
The choice of a non-inferiority trial design is based on the fact that an efficacious treatment 
already exists for uncomplicated gonorrhoea, although not all participants achieve 
microbiological cure. Given the high cure rate achieved with the ceftriaxone/azithromycin 
combination (≥95%) it would be unethical to conduct a placebo-controlled trial. It would also 
be unfeasible to show superiority of zoliflodacin. On the other hand, zoliflodacin offers some 
advantages over the ceftriaxone/azithromycin combination: it has in-vitro activity against 
azithromycin-, cefixime- and ceftriaxone- resistant strains and it is an oral treatment while 
ceftriaxone is an injectable treatment. A non-inferiority design is therefore justified and is 
consistent with the US Food and Drug Administration (FDA) guidance for industry (38).
Justification for the non-inferiority margin is available in Section 11.1.
3.2.2. Justification for investigational drug dose selection 
Pharmacokinetic/pharmacodynamic (PK/PD) targets have not been developed or established 
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specifically for NG in animal or human studies. Because of spontaneous eradication of the 
bacteria, proven adequate animal models of gonococcal infection do not exist and a mouse S. 
aureus neutropenic thigh model was used as a surrogate to determine the human dose for 
zoliflodacin (20). Based on the S. aureus trial, the highest MIC observed to date (0.25 mg/litre 
[L]) and data from the SAD phase I trial, doses of 2 g and 3 g were investigated in the phase II 
trial. The key assumption behind dose selection was that the PK/PD index best associated with 
clinical efficacy was AUC/MIC (20). In the phase II trial, high cure rates were achieved with 
both a 2 g and a 3 g dose. In the primary analysis of the micro-ITT population, 55 of 57 (96.5%, 
CI: [87.8%, 99.6%]) infected participants in the zoliflodacin 2 g arm achieved microbiological 
cure at the urethral/cervical site. Of the 56 infected participants in the zoliflodacin 3 g arm, 54 
(96.4%, CI: [87.7%, 99.6%]) achieved microbiological cure and of the 28 infected participants 
in the ceftriaxone arm, all 28 (100%, CI: [87.7%, 100%]) achieved microbiological cure. In the 
secondary analysis of the per protocol (PP) population, 48 of 49 (98.0%, CI: [89.2%, 99.9%]) 
infected participants in the zoliflodacin 2 g arm achieved microbiological cure at the 
urethral/cervical site. Of the 47 infected participants in the zoliflodacin 3 g arm, all 47 (100%, 
CI: [92.5%, 100%]) achieved microbiological cure. Of the 21 infected participants in the 
ceftriaxone arm, all 21 (100%, CI: [83.9%, 100%]) achieved microbiological cure. 
Microbiological cures at the rectal and pharyngeal sites were also investigated in the Phase II 
trial. Further details are available in the IB. The phase II trial used a compounded suspension 
of active pharmaceutical ingredient (API) in an aqueous vehicle containing standard 
excipients. This formulation was not commercially viable, hence a granule for oral suspension 
formulation has been developed for further testing in clinical trials and commercialization. 
The rBA trial (clinicaltrials.gov NCT03404167) and the final data from the food effect trial 
(Clinicaltrials.gov NCT 03718806) showed that the exposure achieved with granule 
formulation is comparable to that achieved with the aqueous suspension formulation. The PK 
characteristics measured during these trials may be found in the IB.  
PK/PD modelling suggests that a 3 g dose of the granule formulation will result in an AUC of 
30500 ng•h/mL (5%-95% quantile bounds: 9960 - 78400 ng•h/mL) and 53600 ng•h/mL (5%-
95% quantile bounds: 22400 - 107000 ng•h/mL) in fasted and fed subjects respectively. These 
values are comparable to the AUC achieved with a 3 g dose of the previous aqueous 
suspension formulation. Additional information can be found in the IB. 
Based on those results, to maximize cure rates both at urogenital and extra-genital sites and 
to cover isolates with higher MICs, a 3 g dose was selected as the final dose for the phase III 
trial. This dose was well tolerated in both phase I and II studies. To further support a 3 g dose, 
results of dose-ranging HFIM experiments with NG recently confirmed that, accounting for PK 
variability in human, a 3 g dose provides effective killing of NG while suppressing emergence 
of resistance (22). It thus appears that the 3 g dose provides the best benefit/risk ratio.  
3.2.3. Justification for comparator selection 
The present trial will be the first global trial investigating a new antimicrobial that aims at 
addressing a global public health need. The Global Antibiotic Research and Development 
Partnership (GARDP) overarching goal is to conduct a single phase III trial that meets the 
regulatory requirements of the US FDA, the South African Health Products Regulatory 
Authority (SAHPRA), the Thai Food and Drug Administration (Thai FDA) and the European 
Medicines Agency (EMA), and that enables registration and roll out of zoliflodacin in those 
countries. However, a major challenge is to choose a unique comparator against which 
zoliflodacin can be evaluated in a scientifically robust way.  
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The comparator for this trial is a single combination of an IM dose of 500 mg ceftriaxone and 
a 1 g oral dose of azithromycin. The rationale for use of this combination is to compare 
zoliflodacin to the first line treatment recommended by most current national and 
international guidelines (see Table 2). With regards to the dose of ceftriaxone, a 500 mg dose 
was chosen for the following reasons: 
1) Dosages of ceftriaxone up to 1 g have proven safe and are approved for use in various 
indications by all regulatory agencies cited above. A dose of 500 mg ceftriaxone is 
recommended for first line treatment of uncomplicated gonorrhoea in the US and the 
EU and for re-treatment/treatment failure by WHO guidelines for the treatment of NG 
(39-41). 
2) There is currently no firm clinical evidence to support (or to oppose) a 500 mg versus 
a 250 mg dose of ceftriaxone for treatment of gonorrhoea. However, modelling data 
suggests a higher dose may achieve higher log kill, in particular in situation where MICs 
are in the upper range (40, 42). It is generally assumed that the clinical efficacy of β-
lactam antibiotics relates to fT > MIC and experiments conducted by Jaffe and 
colleagues found that penicillin efficacy in male urethritis was predicted by total (i.e. 
serum-bound plus free) penicillin levels at least four times above the MIC for at least 
10 h, roughly corresponding to an fT > MIC of 7–10 h (43). For cephalosporins, 
Chisholm et al. postulated that an fT > MIC of 20–24 h is needed for efficacy with 
cephalosporins (42). This is unlikely to be achieved by a 250 mg dose while it is very 
likely by a 500 mg dose. 
3) At the moment the ceftriaxone MICs are still largely within the susceptible range 
(≤0.125 μg/ml) and 250 mg dose is likely to achieve sufficient exposure to cover most 
isolates. However, MIC "creep" is being observed in several countries, including in 
South Africa and Thailand, and reports of treatment failures have been published from 
several countries internationally (28, 44, 45). In the WHO Southeast Asian Region, 
decreased susceptibility or resistance to ceftriaxone was noted by 50% (3/6) of the 
countries (Bhutan, India, and Indonesia) reporting ceftriaxone susceptibility data in 
2014; 33% (2/6; India and Indonesia) reported ≥ 5% decreased susceptibility or 
resistance (27). From 2009 to 2014, 83% (5/6) of countries reported isolates with 
decreased susceptibility or resistance to ceftriaxone, and 50% (3/6) reported ≥ 5% 
decreased susceptibility or resistance (27). The latest estimates from China also show 
that between 9.7% and 12.2% of the isolates have decreased susceptibility to ESC (46). 
In essence, this means that by the time zoliflodacin is licensed it is likely that the WHO-
recommended dosage of ceftriaxone will have also increased. Several countries 
already use 500 mg to 1 g of ceftriaxone (e.g. China, Germany, The Netherlands, Japan 
and the US). Comparing zoliflodacin to 500 mg dose of ceftriaxone during the phase III 
will therefore bring more meaningful data to support registration.  
4) Based on the assumption above, showing non-inferiority of zoliflodacin to 500 mg of 
ceftriaxone + 1 g azithromycin will be more conservative, as well as more widely 
applicable than if a 250 mg ceftriaxone dose + 1 g azithromycin was used as a 
comparator. 
5) This dosage was used in other gonorrhoea trials, including the zoliflodacin phase II trial, 
and achieved high cure rates and excellent safety profile.  
6) The combination of ceftriaxone with azithromycin is the standard of care in many 
countries (See Table 2). 
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Table 2: Summary of currently recommended regimens for the treatment of uncomplicated 
gonorrhoea 
 
Uncomplicated urogenital 
infections due to NG 
Uncomplicated urogenital 
infections due to CT  
Reference 
WHO 
250 mg ceftriaxone, IM, single 
dose + 1 g azithromycin, oral, 
single dose 
Or 
400 mg cefixime1 oral single 
dose +1 g azithromycin, oral, 
single dose 
 
1 g azithromycin, oral, single 
dose 
Or 
100 mg doxycycline, oral, twice 
a day (BID) for 7 days 
(39, 47) 
US CDC 
From December 2020: 500 mg 
ceftriaxone, IM, single dose 
 
From December 2020: 100 mg 
doxycycline, oral, BID for 7 days 
 
(40) 
 
Before December 2020:  
250 mg ceftriaxone, IM, single 
dose + 1 g azithromycin, oral, 
single dose 
Before December 2020:  
1 g azithromycin oral, single 
dose or 100 mg doxycycline, 
oral, BID for 7 days 
(48) 
 
South Africa 
national 
guidelines 
 
 
No differentiation between NG and CT infections 
(49) 
250 mg ceftriaxone + 1 g azithromycin 
 
Thailand 
national 
guidelines 
500 mg ceftriaxone, IM, single 
dose  
Or 
400 mg cefixime1,2 oral, single 
dose 
 
1 g azithromycin, oral, single 
dose 
Or 
100 mg doxycycline, oral, BID 
for 14 days 
 
(50) 
Europe 
guidelines  
 
 
 
Netherlands 
guidelines 
500 mg ceftriaxone, IM, single 
dose 
 + 2 g azithromycin oral, single 
dose 
 
500 mg ceftriaxone, IM, single 
dose 
 
1 g azithromycin oral, single 
dose 
Or 
100 mg doxycycline, oral, BID 
for 7 days 
 
1 g azithromycin, oral, single 
dose 
Or 
100 mg doxycycline, oral, BID 
for 7 days 
(41) 
 
 
 
 
(51) 
 
CT: Chlamydia trachomatis; IM: intramuscular; NG: Neisseria gonorrhoeae; US-CDC: United States Centers for 
Disease Control and Prevention; WHO: World health Organisation. 
1. Provided recent local resistance data shows susceptibility to the antibiotic 
2. Azithromycin is not a requirement for treatment of uncomplicated gonorrhoea but recommended for 
the empiric treatment of symptomatic individuals 
 
 
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3.2.4. Justification for exclusion of CYP3A4 inhibitors 
In the initial development of zoliflodacin a physiologically-based PK (PBPK) model 
incorporating physicochemical properties, absorption, distribution, metabolism, and 
excretion of zoliflodacin was developed to investigate the systemic exposure of the drug after 
oral administration to healthy adults and determine the potential for drug-drug interactions 
(DDIs) (see IB for details). Based on the output of these simulations using data derived from 
the original amorphous formulation, the totality of the data indicated that zoliflodacin has low 
potential for significant DDIs across a broad range of CYP P450s and transporters except 
CYP3A4. Strong CYP3A4 inhibitors were predicted to have a modest impact on zoliflodacin 
(~1.3 fold increase on Cmax and a 2.4 - 2.6 fold increase in AUC) while moderate to strong 
CYP3A4 inducers have the potential to reduce zoliflodacin exposure below what is required 
for efficacy.  
The increase in AUC predicted by physiologically-based PK model in zoliflodacin in the 
presence of strong inhibitors (ketoconazole and ritonavir) was used directly to adjust the 
typical value estimate of clearance (tvCL) in the population PK model. The population PK 
model was then used to conduct Monte Carlo simulations of a virtual patient population. In 
this manner the potential effect of a strong CYP3A4 inhibitor on the simulated PK could be 
considered across fed/fasted status and body weight range. 
In light of the substantive food effect observed in the recent Phase I Food Effect study 
(DNDi/GARDP STI_Zoli002) of the new immediate release formulation ("Phase III 
formulation"), the Sponsor has undertaken further in silico evaluation of the potential impact 
of CYP3A4 inhibition on zoliflodacin exposure using the refined population PK model used to 
extrapolate exposure in lower body weight ranges of 35 to 50 kg; for these analyses, the 
potential effect of a strong CYP3A4 inhibitor on zoliflodacin concentrations was considered by 
reducing the tvCL value in the model by 2.37 and 2.61 fold based upon mean predicted fold 
changes in AUC (derived from SimCYP simulations) with ketoconazole and ritonavir as 
inhibitors. 
Output of Monte Carlo simulations for a 3000 mg dose utilizing these predicted fold changes 
in AUC of zoliflodacin in the presence of each strong CYP3A4 inhibitor suggested the highest 
mean Cmax achieved in the lowest bodyweight of 35 kg (weight cut-off limit in the ongoing 
Phase III study GARDP STI_Zoli001), would be nearly equivalent to the maximum 
concentration that has been observed clinically; i.e. mean geometric mean Cmax of 37.5 
μg/mL in subjects administered a 4000 mg (“Phase III formulation”) with a high fat meal.  
Based on this analysis, the Sponsor concluded that it was prudent to prohibit concomitant 
dosing of zoliflodacin with moderate/strong CYP3A4 inhibitors until further clinical and PK 
data are available from PK subset groups in the present Phase III study and from a planned 
study that is investigating drug-drug interactions and food effect (STIZoli_003, EudraCT 
number 2020-000379-19). 
 
3.2.5. Impact of COVID-19 pandemic on trial conduct and contingency measures 
The COVID-19 pandemic is providing unprecedented challenges to all healthcare workers 
and patients in general and for recruitment and running of clinical trials.  
GARDP therefore took, and continues to take, contingency measures to mitigate the impact 
of the pandemic on the trial, to support site staff and patients, and to minimise risks to 
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them, while being able to continue recruitment to the trial and to guarantee data quality 
and integrity.  
Contingency measures are described in a separate COVID-19 mitigation plan.  
  
3.3. Randomization 
The randomization sequence will be obtained by computer-generated random numbers and 
provided to each trial site through a web-based randomization system. Trial participants will 
be assigned to receive either zoliflodacin or a ceftriaxone/azithromycin combination in a 2:1 
allocation ratio. Unequal randomization has been chosen to increase the number of 
individuals from which safety data is gathered. Randomisation will be performed using 
random permutated blocks of 3, 6, and 9 with stratification by sex at birth and with each block 
maintaining the 2:1 randomisation. At each trial site, a dedicated pharmacist or designated 
clinician will be responsible for monitoring drug storage and for dispensing trial drugs in 
accordance with the treatment allocation. 
3.4. Blinding 
This will be an open-label trial. With a double-dummy design, participants would have to 
receive an IM injection and a tablet as well as an oral sachet, which would be likely to decrease 
their willingness to participate in the trial. Moreover, placebo injections might not be 
acceptable from an ethical perspective, and as a consequence the majority of gonorrhoea 
trials conducted over the past 30 years that included ceftriaxone treatment arm have been 
unblinded trials.  
Nevertheless, the laboratory staff who performs assessment of the primary outcome will be 
blinded to treatment allocation. This is achievable as the treatment allocation will not be 
mentioned on the trial specimen sent to the laboratory. Samples collected throughout the 
trial will be anonymized and a unique participant identifier will be used for sample tracking 
and result reporting. Laboratory results will be entered in the electronic case report form 
(eCRF) by site staff, or reported directly to data management as per pre-determined data 
specifications. For sites participating in the PK sub-study, it will be ensured that trial personnel 
handling PK samples are different from the laboratory personnel handling microbiological 
samples.  
With the exception of medical monitors and country specific personnel who interact regularly 
and are required to advise unblinded site teams, the sponsor remains blinded as detailed in 
the Blinding convention document. All the data will remain blinded to the sponsor until 
database lock, except in case of expedited reporting of suspected unexpected serious adverse 
reaction (SUSAR). 
3.5. Trial duration  
The planned total duration for individual participants will be 30 days (± 3 days). The trial 
treatment will be a single dose of either the investigational treatment or the comparator 
treatment. The duration of the follow-up period will be 29 days (± 3 days). The end of the trial 
is defined as the last participant’s last visit. Overall and taking into consideration an evaluation 
of the impact of the COVID-19 pandemic on recruitment, recruitment into the trial is expected 
to last for approximately 3.5 years. 
 
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4. Selection of participants 
The target sample size is 696 evaluable participants: 464 in the zoliflodacin group and 232 in 
the comparator group, with an estimated randomisation sample size of up to approximately 
928. Details of the sample size calculation can be found in Section 11.1. Accounting for 
anticipated screening failures, the enrolment sample size is estimated to be around 1092. 
Only participants who meet ALL inclusion criteria and NONE of the exclusion criteria will be 
eligible for enrolment into the trial. All relevant medical and non-medical conditions should 
be taken into consideration when deciding whether this protocol is suitable for a particular 
participant. Eligibility criteria must not be waived by the investigator nor by the sponsor. 
4.1. Inclusion criteria 
Participants must meet ALL the following inclusion criteria to be eligible for enrollment into 
the trial:  
1. Age ≥ 12 years old (if enrolment of minors is in agreement with local regulations and 
ethics guidance) 
2. Weight ≥ 35 kg 
3. Signs and symptoms consistent with urethral or cervical gonorrhoea  
OR 
Urethral or cervical uncomplicated gonorrhoea as determined by either a positive 
culture or NAAT or Gram stain or methylene blue/gentian violet stain in the past 14 
days prior to screening 
OR 
Unprotected sexual contact with an individual reported to be infected with NG in the 
past 14 days prior to screening (confirmation by a positive NAAT, Gram stain, 
methylene blue/gentian violet stain or culture) 
4. For females of child-bearing potential, a negative urine pregnancy test at screening 
5. For females of child-bearing potential, use of a highly effective method of 
contraception at the time of IMP administration on Day 1 (see Appendix 1: 
Contraception methods considered as highly effective and required duration) and 
during at least 28 days after treatment. Females on oral contraceptives must also use 
a barrier contraception method during participation in the trial 
6. For males with a female partner of child-bearing age, willingness to delay conception 
for 28 days after treatment 
7. Willingness to comply with trial protocol 
8. For participants in PK sub-study: Willingness to undergo HIV testing 
9. Willingness to abstain from sexual intercourse or use condoms for vaginal, anal and 
oral sex until the EOT visit 
10. Willingness and ability to give written informed consent or be consented by a legal 
representative or provide assent and parental consent (for minors, as appropriate). 
4.2. Exclusion criteria 
The presence of any of the following will exclude a potential participant from trial enrolment: 
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11. Confirmed or suspected complicated or disseminated gonorrhoea  
12. Pregnant or breastfeeding women 
13. Known concomitant infection which would require immediate additional systemic 
antibiotics with activity against NG 
14. Use of any systemic or intravaginal antibiotics with activity against NG within 30 days 
prior to screening 
15. Use of systemic corticoid drugs or other immunosuppressive therapy within 30 days 
prior to screening 
16. Use of moderate or strong CYP3A4 inducers (e.g. efavirenz, rifampicin, carbamazepine, 
phenobarbital) within 30 days or five half-lives of the drug, whichever is greater, prior 
to screening (see Section 6.9) 
17. Cytotoxic or radiation therapy within 30 days prior to screening 
18. Known chronic renal, hepatic, hematologic impairment or other condition interfering 
with the absorption, distribution or elimination of the drug based on medical history 
and physical examination 
19. History of urogenital sex-reassignment surgery 
20. Immunosuppression as evidenced by medical history, clinical examination or a recent 
(≤ 1 month) CD4 count <200 cells/μL 
21. Know clinically relevant cardiac pro-arrhythmic conditions such as cardiac arrhythmia, 
congenital or documented QT prolongation   
22. Known history of severe allergy to cephalosporin, penicillin, monobactams, 
carbapenems or macrolide antibiotics  
23. Known or suspected allergies or hypersensitivities to lidocaine, methylparaben, lactose 
or any of the components of the study drugs (refer to the zoliflodacin IB and SmPC for 
the comparators treatments)  
24. Receipt or planned receipt of an investigational product in a clinical trial within 30 days 
or five half-lives of the drug, whichever is greater, prior to screening until end of 
participation to this clinical trial 
25. History of alcohol or drug abuse within 12 months prior to screening which would 
compromise trial participation in the judgment of the investigator 
26. Severe medical or psychiatric condition which, in the opinion of the investigator, may 
increase the risk associated with trial participation or may interfere with the 
interpretation of trial results or affect the individual’s ability to provide informed 
consent 
27. Individuals whom, in the judgement of the investigator, are unlikely or unable to 
comply with this trial protocol 
28. Previous randomisation in this clinical trial 
29. Use of moderate or strong CYP3A4 inhibitors (see manual of operating procedures 
[MOP]) within 30 days or five half-lives of the drug, whichever is greater, prior to 
screening (see Section 6.9) 
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5. Schedule of events  
5.1. Table of assessments 
The trial investigational schedule is shown in Table 3. 
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Table 3: Trial investigational schedule 
Visit number 
11 
2 
3 
4 
5 
 
Timing (window) 
Day 1 (- 1 
day) 
Day 1 
Day 2 
Day 3 (-1 
day) 
Day 6 (± 2 
days)2 
Day 30 (± 3 
days) 
 
Visit type 
Screening 
Baseline 
Dosing 
PK 
Phone 
call 
Test of 
cure 
(TOC) 
End of trial 
(EOT) 
Early 
withdrawal / 
unscheduled 
visit3 
Screening assessments 
 
 
 
 
 
 
 
 
Informed consent4 
X 
 
Demographics5 
X 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
Sexual history6 
X 
 
 
 
X 
X 
X 
X 
Targeted physical examination7 
X8 
 
 
 
 
X 
X 
X 
Pregnancy test 
X 
 
X 
X 
X 
Assessment of eligibility 
X 
 
 
 
 
 
 
 
 
 
 
Randomization  
X17 
 
 
 
 
 
 
 
 
 
 
Laboratory investigations   
 
HIV testing9 
 
X 
 
 
 
 
 
 
Full blood count (FBC) and differentials 
X 
 
X 
X 
X 
Liver function tests (LFTs)10 
X 
 
X 
X 
X 
Creatinine and estimated glomerular filtration rate (eGFR) 
X 
 
X 
X 
X 
Urethral/endocervical Gram stain and microscopy 
examination11   
X 
 
 
 
 
 
 
 
 
 
 
Efficacy outcomes    
 
Urogenital NG culture and NAAT 
X 
 
X12 
X13 
Rectal NG culture and NAAT 
X 
 
X12 
X13 
Pharyngeal NG culture and NAAT 
X 
 
X12 
X13 
Antimicrobial susceptibility testing14 
X 
 
X 
X 
NAAT for CT (urogenital) 
 
X 
 
 
 
 
 
 
NAAT for CT (rectal) 
X 
 
NAAT for CT (pharyngeal) 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Pharmacokinetic sampling15 
X 
 
X 
 
 
 
 
 
 
 
 
 
Food intake16 
 
 
X 
 
 
 
 
 
Trial treatment administration 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse events 
Å--------------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------¦ 
Prior / concomitant medications 
Å--------------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------¦ 
CT: Chlamydia trachomatis; HIV: human immunodeficiency virus;  NAAT: nucleic acid amplification test; NG: Neisseria gonorrhoeae.PK: pharmacokinetics. 
1. 
Assessments for Visit 1 can be performed over 2 days as long as ALL Baseline assessments and Dosing are performed on the 2nd day. Day 1 is the day of dosing. For details see Section 5.2.1. 
2. 
In case ANY of the NG microbiological test results for a specific anatomical site is not available prior to the collection of the TOC visit specimens, both NG culture and NAAT microbiology specimens should 
be collected for that particular anatomical site and microbiological evaluations should be performed.  
3. 
If a participant has completed scheduled visits as per protocol and returns to the clinic on an additional occurrence on a day that does not correspond to a scheduled trial visit, site staff should handle them 
as per their routine practice. In this case no assessment is mandated as per protocol. See Section 5.3 for details. 
4. 
Including counselling on sexual risk behaviour, and partner(s) notification and treatment 
5. 
Including date of birth, gender, sex at birth, ethnicity 
6. 
Using sexual history questionnaires provided 
7. 
Including clinical assessment of gonorrhoea 
8. 
Screening physical examination will act as baseline too 
9. 
HIV testing is mandatory only for participants to the PK sub-study. For all other participants, HIV testing is proposed, but not mandatory for inclusion in the study. An HIV test result obtained on the day of 
enrolment may be used as baseline assessment. Participants with a documented positive HIV diagnosis or documented prescription of ART also do not need to be tested again. 
10. Alanine transaminase (ALT) and total and direct bilirubin (direct bilirubin only required if total bilirubin is elevated) 
11. A Gram stain result obtained on the day of enrolment may be used as baseline assessment 
12. In cases where both baseline NG NAAT and NG culture results are negative, no further samples should be taken at subsequent visits. This applies to each anatomical site respectively. 
13. Only take sample if: 
- symptoms at any anatomical site are present. If symptoms at any anatomical site are observed, take samples from all 3 anatomical sites. 
- a negative culture and a positive NG NAAT results were obtained at TOC. This applies to each anatomical site respectively. 
14. Only for culture samples with confirmed identification of NG 
15. Only for participants who consent to participate in the PK sub-study. The PK sub-study will take place in select sites only. See Section 7.3 for time points.  
16. Food must be taken before trial treatment. Details on timing of food intake in relation with dosing time and required food content are available in the MOP.   
17. For participants of the PK sub-study only, randomisation can occur on Day -1 (Screening) once eligibility has been confirmed and participants can return to complete baseline assessments and receive study 
treatment the following calendar day, to assist with scheduling of the visit. 
 
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5.2. Schedule of assessments
Changes in health and concomitant medications will be recorded from signature of the 
informed consent until the EOT visit. See Section 8 for further details on adverse events.
5.2.1. Visit 1: Day 1 (-1 day)
Assessments for Visit 1 can be performed over 2 days as long as ALL Baseline assessments 
and Dosing are performed on the 2nd day. The day that is considered Day 1 is the day of 
Dosing. 
Screening Day 1 (-1 day)
After signing the informed consent, participants will be asked demographic information, 
including date of birth (only year of birth and age will be reported in the eCRF), gender, sex at 
birth and ethnicity. Eligibility criteria will be reviewed, and a complete medical history, and 
sexual history over the past 3 months will be obtained as part of this process. A targeted 
physical examination will be performed (the physical examination performed at screening will 
be regarded as the baseline), including a clinical assessment of gonorrhoea, as well as a urine 
pregnancy test for females of child-bearing potential.
For participants taking part in the PK sub-study, randomization can occur on Day -1 (Screening) 
once eligibility has been confirmed, and participants can return to complete Day 1 baseline 
assessments and receive study treatment the following calendar day, to assist with scheduling 
of the visit.
Baseline (Day 1) 
Eligible participants will be randomised to either the zoliflodacin or the comparator group. 
They will then undergo baseline assessments, including safety laboratory tests and HIV rapid 
testing if applicable. HIV testing is mandatory only for participants to the PK sub-study. For all 
other participants, HIV testing is proposed, but not mandatory for inclusion in the study. An 
HIV test result obtained on the day of enrolment may be used as baseline assessment. 
Participants with a documented positive HIV diagnosis or documented prescription of ART do 
not require repeat testing. Swabs will also be taken for microbiology outcomes (1 swab for NG 
culture and 1 swab for NG/CT NAAT evaluations) from the urethra or cervix, rectum and 
pharynx. 
Absorption of zoliflodacin and tolerability of azithromycin tablets are improved when patients 
are fed, and not fasted. Therefore, food must be taken before trial treatment. Details on 
timing of food intake in relation with dosing time and required food content are available in 
the MOP. The date and time of last food intake prior to trial treatment administration will be 
captured.
Once ALL baseline assessments are completed, participants will receive trial treatment.
Blood samples for PK analysis will be taken as per schedule described in Section 7.3 from those 
participants who will have signed the PK sub-study informed consent.
5.2.2. Visit 2: Day 2 - PK sub-study
Visit 2 is for participants enrolled in the PK sub-study only. See Section 7.3 for further details.
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5.2.3. Visit 3: Day 3 (-1 day) 
On day 3, the medical staff will call participants on the phone to enquire about their health 
condition and sexual history since the last visit. This day is not a clinic visit. 
5.2.4. Visit 4: Day 6 (+/-2 days) 
At the TOC visit, participants will undergo safety lab assessments, a physical examination 
including a clinical assessment of gonorrhoea, and females of child-bearing potential will 
perform a urine pregnancy test. Males at birth will be assessed for clinical cure as per guidance 
in the MOP. Sexual history since the previous visit will also be assessed. The medical staff will 
enquire with the participant whether they experienced any potential AE and took any 
medication since the last visit. 
Swabs will be collected for microbiology outcomes (1 swab for NG culture and 1 swab for NG 
NAAT evaluations) from each anatomical site (urogenital, rectal and pharyngeal), unless both 
NG culture and NG NAAT results at that specific anatomical site were negative at baseline. 
In case ANY of the NG microbiological test results for a specific anatomical site is not available 
prior to the collection of the TOC visit specimens, both NG culture and NAAT microbiology 
specimens should be collected for that particular anatomical site and microbiological 
evaluations should be performed. 
Once all specimens are collected, participants randomised to the zoliflodacin arm with a 
positive CT NAAT at baseline will be treated for CT infection as per local standard of care.  
If a participant returns for a TOC visit outside the allowed time window, the primary TOC 
assessments will be considered missed and the participant will therefore be regarded as a 
treatment failure for primary endpoint analysis. It is therefore of crucial importance to ensure 
all participants have a TOC visit within the allowed time window (Day 6 +/- 2 days). 
5.2.5. Visit 5: Day 30 (+/-3 days) 
At the EOT visit, participants will undergo safety lab assessments, a physical examination 
including a clinical assessment of gonorrhoea, and females of child-bearing potential will 
perform a urine pregnancy test. Sexual history since the previous visit will also be assessed. 
The medical staff will enquire with the participant whether they experienced any potential AE 
and took any medication since the last visit. 
Swabs will be collected for microbiology outcomes as per Table 4 in Section 7.4.  
5.2.6. Early withdrawal 
In case a participant is withdrawn or withdraws consent prior to Visit 5 (EOT), they will be 
asked to return to the clinic to undergo safety lab assessments, a physical examination and a 
urine pregnancy test if they are a female of child-bearing potential, as well as the sexual 
history questionnaire, should they agree.  The medical staff will enquire with the participant 
whether they experienced any potential AE and took any medication since the last visit. 
If a participant withdraws during the timeframe for Visit 4 or Visit 5, trial staff should attempt 
to collect samples as per the schedule of assessment at that visit, should the participant agree. 
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5.3. Unscheduled and out-of-window visits 
5.3.1. Out-of-window visits 
Protocol-specified visits that occur outside of the protocol-specified time windows will be 
considered out-of-window visits. Results of assessments and procedures for these should be 
documented in the eCRF pages for the intended visit and a protocol deviation must be 
documented. In case of doubt or question on which visit should be performed, the Investigator 
should contact the medical monitor. 
 
5.3.2. Unscheduled visits 
Unscheduled visits can occur at any time during study participation.  Assessments are not 
mandated per protocol but if a participant has completed scheduled visits as per protocol 
and returns to the clinic on an additional occurrence on a day that does not correspond to a 
scheduled trial visit, site staff should handle them as per their routine practice. No 
assessments are mandated as per protocol, but can be performed and recorded for safety 
reasons as relevant to the study (e.g. follow-up safety laboratory tests). Site staff will take 
the opportunity to question the participant about any potential adverse event or medication 
taken. In case of identification of either, this must be recorded in source notes and 
transcribed into the eCRF into the adverse event and concomitant medication forms 
respectively.  
6. Investigational products 
6.1. Zoliflodacin treatment  
6.1.1. Product description and dosage 
Zoliflodacin is a first-in-class drug (spiropyrimidinetrione) with a specific mode of action 
against bacterial topoisomerase II distinct from the fluoroquinolone class of antibiotics. The 
chemical name for zoliflodacin is (2R,4S,4aS)-11-fluoro-2,4-dimethyl-8-[(4S)-4-methyl-2-oxo-
1,3-oxazolidin-3-yl]-1,2,4,4a-tetrahydro-2'H,6H-spiro[1,4-oxazino[4,3-a][1,2]oxazolo[4,5-g] 
quinoline-5,5'-pyrimidine]-2',4',6'(1'H,3'H)-trione. Zoliflodacin is presented as white granules 
for oral suspension, packaged in a single sachet. Each sachet contains 3 g amorphous 
zoliflodacin, co-formulated with mannitol, microcrystalline cellulose, croscarmellose sodium, 
colloidal silicon dioxide, xanthan gum, talc, and magnesium stearate. Zoliflodacin is active 
against several STI pathogens, including NG, CT and Mycoplasma genitalium (33, 52).  It shows 
excellent in vitro activity against all clinical NG isolates tested so far, including isolates that 
were resistant to fluoroquinolones, azithromycin, and ESC, and several reference strains such 
as the XDR H401 strain (28, 32, 53).  
6.1.2. Summary of non-clinical and clinical experience 
Please refer to the zoliflodacin IB for full descriptions of the zoliflodacin properties, non-
clinical and clinical data available to date and identified and potential risks associated with 
zoliflodacin. 
 
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6.2. Comparator trial treatment 
6.2.1. Product description and dosage 
Ceftriaxone is a sterile, semi-synthetic, broad-spectrum cephalosporin antibiotic. The 
chemical name of ceftriaxone sodium is (6R, 7R)-7-[2-(2-Amino-4-thiazolyl) glyoxylamido]-8-
oxo-3-[[(1,2,5,6-tetrahydro-2-methyl-5,6-dioxo-as-triazin-3-yl)thio]methyl]-5-thia-1 
azabicyclo [4.2.0]oct-2-ene-2-carboxylic acid, 72-(Z)-(O-methyloxime), disodium salt, 
sesquaterhydrate. The bactericidal activity of ceftriaxone results from the inhibition of cell 
wall synthesis and is mediated through binding to penicillin binding proteins. Ceftriaxone is a 
white to yellowish sterile powder in a clear glass vial. For the purpose of this trial, a single dose 
of ceftriaxone 500 mg, dissolved in lidocaine hydrochloride (HCl) 1% will be used for IM 
injection. Lidocaine is a local anaesthetic that will be used to numb the area of injection and 
therefore limit injection pain.  
Azithromycin is a macrolide antibacterial, for oral administration. The chemical name of 
azithromycin monohydrate is (2R,3S,4R,5R,8R,10R,11R,12S,13S,14R)-13-[(2,6-dideoxy-3-C-
methyl-3-O-methyl-α-L-ribohexopyranosyl) oxy]-2-ethyl- 3,4,10-trihydroxy-3,5,6,8,10,12,14-
heptamethyl-11-[[3,4,6- 
trideoxy-3-(dimethylamino)-β-D-xylo-hexopyranosyl]oxy]-1-oxa-6-
azacyclopentadecan-15-one monohydrate. Azithromycin acts by binding to the 23S ribosomal 
ribonucleic acid (rRNA) of the 50S ribosomal subunit of susceptible microorganisms inhibiting 
bacterial protein synthesis and impeding the assembly of the 50S ribosomal subunit. 
Azithromycin will be supplied as oral tablets containing 250 mg azithromycin.  
6.2.1. Summary of non-clinical and clinical experience 
Please refer to the ceftriaxone and azithromycin summaries of product characteristics (SmPC) 
or United States Prescribing Information (USPI), as applicable, for full descriptions of the 
identified and potential risks associated with ceftriaxone and azithromycin. 
6.3. Labelling and packaging 
The labelling and secondary packaging of zoliflodacin sachets and comparators treatments will 
be performed by Packaging Coordinators Inc. (PCI) Pharma Services on behalf of the sponsor. 
All trial treatments, including those used in the comparator group, will be labelled in 
compliance with applicable regulatory requirements.  
6.4. Shipment  
All necessary documentation, including favourable opinion from independent review boards 
(IRB) /independent ethics committees (IEC) and national regulatory authorities (NRAs), and 
import authorizations, will be obtained prior to shipment of trial treatments to trial sites. 
Upon receipt, trial treatments and their packaging shall be inspected by the pharmacist or 
designee in charge at the trial site. All suspected defects or deterioration are to be reported 
to the sponsor as per the procedure outlined in the MOP. Suspected defective products are 
to be placed in a secure quarantine area pending investigation and further advice from the 
sponsor. 
In the event of a batch recall, the sponsor will be responsible for informing all principal 
investigators and, in collaboration with trial site pharmacists, of facilitating collection of 
recalled batches and delivery of alternative batches to trial sites. All movements will be 
documented in the drug accountability forms (see Section 6.7).  
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6.5. Storage 
All trial treatments will be stored in the trial site pharmacy, separated and secured, accessible 
only to the trial site staff. All drugs should be stored in accordance with the pharmacy manual.  
The trial site pharmacist or designee will be responsible for monitoring and recording the 
storage temperature and ensuring appropriate measures are in place to protect the trial 
treatments from damage and/or destruction.  
6.6. Preparation and administration of trial treatments 
Trial treatments will only be dispensed and administered to individuals enrolled in the trial 
and who have been randomised. Participants randomized to the zoliflodacin group will receive 
a single 3 g per os (PO) dose (one sachet) of zoliflodacin reconstituted with water. Detailed 
information on the preparation and administration of zoliflodacin can be found in the 
pharmacy manual. Participants randomized to the comparator group will receive ceftriaxone 
as a 500 mg IM injection and azithromycin as four 250 mg oral tablets. The 500 mg ceftriaxone 
vial will be reconstituted with lidocaine HCl 1%. Detailed information on the preparation and 
administration of ceftriaxone can be found in the pharmacy manual. 
6.7. Accountability 
The principal investigator at each site is responsible for the distribution and disposition of the 
trial treatments and has ultimate responsibility for accountability of trial treatments. He/she 
may delegate this responsibility to a trial site pharmacist or nurse. Adequate records on 
receipt, use, return, loss, or other disposition of trial treatments must be maintained. 
Administration of trial treatments will be directly observed and documented in appropriate 
forms by the responsible trial staff. The investigator or site staff are not authorised to supply 
trial treatment to other investigators or sites, or allow trial treatments to be used other than 
as instructed by this protocol without prior written authorisation of GARDP. At the end of the 
trial, unused drugs will be either be destroyed or returned as per sponsor instruction. 
6.8. Blinding and procedures for un-blinding 
As this is an open-label trial, procedures for un-blinding by the investigator in case of medical 
emergency are not applicable. 
6.9. Concomitant treatments 
Medications taken before or after dosing through EOT visit or early termination whichever 
occurs first will be reported as prior medications or concomitant medications, respectively. 
Prior medication taken over the 30 days prior to screening will be recorded as part of the 
screening process (Visit 1). This will also include over-the-counter drugs as well as vitamins, 
herbals and supplements. 
Zoliflodacin should not be co-administered with strong (such as carbamazepine, 
enzalutamine, mitotane, phenytoin, rifampin, or St. John's wort) or moderate (such as 
efavirenz, bosentan, etravirine, modafinil, or nafcillin) inducers of CYP3A4. These drugs should 
not be taken for 30 days before dosing and during the whole trial period.  
Zoliflodacin should not be co-administered with strong or moderate inhibitors of CYP3A4. See 
MOP for examples of such inhibitors. These drugs should not be taken for 30 days before 
dosing and during the whole trial period.  
If a participant is newly diagnosed as HIV positive in the trial and needs to start ART as per 
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local standard of care, or if a participant needs post exposure prophylaxis with a prohibited 
ART, the medical monitor should be contacted immediately to discuss each instance on a case-
by-case basis. Depending on the timing of the required administration of the ART, its 
administration may either be approved, or the participant may be withdrawn from the trial.  
In addition, medications that might interfere with the evaluation of the investigational product 
(e.g. antibiotics with activity against NG) should not be used until the TOC visit. Any 
circumstances that require urgent use of an antibiotic with activity against NG should be 
discussed with the medical monitor.  
Following dosing, any drug (e.g., non-prescription medications, herbal supplements, vitamins, 
or prescription medications) or vaccine or blood/blood products used by the participant 
during the trial will be recorded in the participant’s source documents and on the appropriate 
eCRF.  
Any antacids if taken must be administered more than 1 hour before administration of 
azithromycin. 
Participants who receive trial treatment and are subsequently diagnosed with a concomitant 
infection requiring systemic antibiotics (e.g. bacterial vaginosis [BV]) or infections due to CT, 
Mycoplasma genitalium or Trichomonas vaginalis) will receive treatment according to the 
local clinic’s standard protocols. Whenever possible, additional treatment with antibiotics 
with activity against NG should be deferred up until the TOC visit.  
6.10. Escape treatments 
Participants with persisting signs and symptoms or with a positive NG culture at the TOC visit 
will be treated in accordance with national or local guidelines for treatment failures. 
Treatment received will be recorded in the eCRF. 
7. Trial procedures/evaluations 
Detailed instructions on procedures as well as collection, processing and shipment of samples 
may be found in the laboratory manual and the MOP. 
7.1. Clinical evaluations 
x 
Complete medical history will be obtained by interview of the participants at Visit 1 and 
will be updated at each clinic visit. Participants will be queried regarding a history of 
significant medical disorders of the head, eyes, ears, nose, throat, mouth, cardiovascular 
system, lungs, gastrointestinal tract, liver, pancreas, kidney, urologic system, nervous 
system, blood, lymph nodes, endocrine system, musculoskeletal system, skin, and 
genital/reproductive tract. A history of any allergies, cancer, immunodeficiency, 
psychiatric illness, substance abuse, and autoimmune disease will be solicited. At follow-
up visits, an interim medical history will be obtained by interview of the participants 
noting any changes since the previous visit.  
x 
Sexual history over the past 3 months including sexual orientation will be obtained by 
interview of the participants at Visit 1.  Participants will be queried at Visit 3, Visit 4 and 
Visit 5 regarding sexual activity and condom use since the previous clinic visit. 
Questionnaires to assess sexual behaviour will be provided. 
x 
A targeted physical examination including height and weight and examination of the 
pharynx and genitals (including pelvic exam for women) will be performed on Visit 1, Visit 
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4 and Visit 5. In particular, presence of signs and symptoms of gonorrhoea (e.g. UD, 
dysuria, dyspareunia, visible discharge from urethra and/or anus) will be assessed as per 
the MOP. All physical examinations will be performed by a trial clinician licensed to make 
medical diagnoses. The physical examination performed at screening will act as a baseline 
for subsequent visits . 
x 
A phone interview will be conducted at Visit 3 to check for any changes in health and any 
new medication taken. Participants will also be asked about their sexual activity since the 
previous visit and be reminded about the mandatory sexual behaviour recommendations 
during their involvement in the trial. 
x 
Any changes in health or concomitant medications taken during the trial will be enquired 
and recorded. 
7.2. Laboratory evaluations 
7.2.1. Clinical laboratory evaluations 
x 
A urine pregnancy test will be performed at Visit 1, Visit 4, Visit 5 and early withdrawal on 
all female participants of child-bearing potential. 
x 
HIV testing will be performed at Visit 1 according to standard local practise. HIV testing is 
mandatory only for participants to the PK sub-study. For all other participants, HIV testing 
is proposed, but not mandatory. Participants with a documented positive HIV diagnosis 
or documented prescription for ARTs are considered to be HIV positive and therefore do 
not need to undergo a test. A maximum of 5 ml of venous blood might be collected for 
this test depending on local practice. Any discordant results should be followed up as per 
standard local practice. Further details may be found in the MOP. 
x 
Venous blood samples (a maximum of 15 mL) for haematology and chemistry will be 
collected at Visit 1, Visit 4 and Visit 5. FBC, ALT, direct and total bilirubin (direct bilirubin 
only required if total bilirubin is elevated), and creatinine will be measured. eGFR will be 
calculated using the chronic kidney disease - epidemiology collaboration (CKD-EPI) 
formula. A total volume of a maximum of 50 ml will be taken from each participant during 
the course of the trial (with the exclusion of the PK sub-study). 
7.2.2. Microbiological evaluations 
x 
Microbiological evaluations (Gram stain, culture and NAAT) will be based on the collection 
of appropriate clinical specimen (i.e. a urethral swab for male participants or an 
endocervical swab for female participants for urogenital swabs, a pharyngeal swab or a 
rectal swab) and in accordance with the laboratory manual and MOP. Specimens are 
collected by trained study staff, except pharyngeal specimens which can be self-collected, 
where permitted and as detailed in the MOP. A specific swab for NG culture will be taken 
followed by bedside inoculation of NG selective agar plates. 
x 
Assessment of efficacy in the present trial follows recommendations from the US FDA 
(38). All cultures will be performed in certified national or state/provincial or local 
reference laboratories (see the laboratory manual for a complete list). Local laboratories 
will perform presumptive NG identification, while confirmatory NG identification will be 
carried out by the central laboratory also assessing antimicrobial susceptibility testing. 
x 
Detection of nucleic acid will be based on collection of swabs as above and use of  NAAT. 
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A single swab using the applicable manufacturer’s recommended collection kits will be 
taken to assess the presence of NG and/or CT from the same clinical specimen to minimise 
patient discomfort. Acceptable NAAT platforms/systems and assays are listed in the 
laboratory manual. Detailed methods for NAAT performance can be found in the trial 
laboratory manual. 
x 
Presumed positive cultures will be processed and frozen bacterial isolates will be sent to 
the central laboratory for confirmatory identification and antimicrobial susceptibility 
testing. Aliquots of these frozen bacterial isolates will be stored at a local laboratory for 
future research up to 5 years after the end of the trial, should participants agree (with the 
exception of the Netherlands where bacterial isolates will be kept up to 15 years as per 
standard local practice). 
x 
The MIC, defined as the lowest concentration of an antimicrobial that inhibited the visible 
growth of a microorganism after overnight incubation, will be determined for the 
following antibiotics: zoliflodacin, azithromycin, cefixime, ceftriaxone, ciprofloxacin, 
gentamicin, tetracycline and spectinomycin. Detailed methods for MIC determination can 
be found in the trial laboratory manual. Confirmatory identification of NG by the central 
lab will constitute data for the primary outcome of the trial. 
x 
WGS will be conducted on all NG isolates cultured at the TOC and EOT visits, as well as on 
pre-treatment isolates from the respective participants and on baseline isolates with 
zoliflodacin MIC >0.25 μg/mL. The main objective is to investigate relationships between 
pre-treatment and post-treatment NG isolates within those participants whose cultures 
at TOC are found positive for NG, evaluate the likelihood of re-infection vs treatment 
failure and identify possible genetic determinants of zoliflodacin resistance. The analyses 
will be performed at the microbiology laboratory of the University of Örebro in Sweden.  
7.3. Pharmacokinetic evaluations 
The PK sub-study will be run at select sites (see MOP for list).  
The plasma concentration of zoliflodacin will be determined in the following subsets of 
participants: 
x HIV negative participants and HIV positive participants (≥ 18 years old) 
x HIV negative adolescents (≥12 and <18 years old) 
Each group will include approximately 20 to 30 participants, with PK assessed at five time-
points: 
x 15 min – 1 h post treatment 
x 2 h – 2.5 h post treatment 
x 4.5 h – 5 h post treatment 
x 10 h - 12 h post treatment 
x 24 h - 36 h post treatment 
The time periods will cover Cmax and at least a 10-fold decline in plasma concentration from 
this, this decline being adequately defined as mono-exponential. Sampling time post dose 
will be accurately recorded in the eCRF. Plasma concentrations of zoliflodacin will be 
determined by K-CAS laboratories using a validated high-performance liquid 
chromatography (HPLC) – mass spectroscopy (MS)/MS method. 
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At each time point, a 4 ml venous blood sample will be collected. Samples will be centrifuged 
to allow for extraction of plasma. Plasma should be frozen at about – 70 °C within a 
maximum of 60 minutes after collection of the blood samples. Further details are available in 
the MOP.  
The same food intake recommendations detailed in Section 5.2.1 apply to the participants to 
the PK sub-study. 
7.4. Clinical management of participants 
Assessments performed at site level will be used for patient management. This includes HIV 
and pregnancy testing. Safety laboratory results will be communicated to sites in a timely 
manner to ensure appropriate management of any laboratory finding that is out-of-normal 
range (see laboratory manual for details).  
Table 4 highlights how microbiology test results should dictate clinical management of 
participants and sampling schedule in the trial.  
Table 4: Assessments and use for clinical management 
 
 
Action(s) if result is: 
 
 
Positive 
Negative 
Baseline 
results1, 4 
NG culture and 
NG NAAT 
If either culture and/or NAAT is/are 
positive, take further swabs for 
both culture and NAAT at TOC 
If both NG culture and NG NAAT are 
negative, no further swabs to be 
taken for NG in the trial 
CT NAAT 
 
o Treat as per standard of care at 
TOC after collection of all 
specimens if participant was 
randomised to zoliflodacin 
group 
o No further swabs to be taken 
for CT (except if participant is 
symptomatic at day 30) 
No further swabs to be taken for CT 
(except if participant is symptomatic 
at day 30) 
 
TOC 
results 
NG culture and 
NG NAAT 
o If NG culture is positive, treat 
as per standard of care 
o No further swabs to be taken 
for NG2 
If both NG culture and NG NAAT are 
negative, no further swabs to be 
taken for NG in the trial (except if 
participant is symptomatic at day 
30)1, 3 
o 
If NG culture is negative and NG NAAT is positive at TOC, both NG 
culture and NG NAAT to be done at day 301 
Day 30 
results3 
NG culture and 
NG/CT NAAT 
Treat as per standard of care if any 
of the test results is positive 
 
CT: Chlamydia trachomatis; NAAT: nucleic acid amplification test; NG: Neisseria gonorrhoeae. 
1 Applies to each of the three anatomical sites independently. 
2 If NG culture is positive in any of the three anatomical sites, no further swabs need be taken from any site at 
day 30, except if participant is symptomatic at day 30. 
3 If a participant presents with signs and/or symptoms of an NG infection at Day 30, swabs for NG culture and 
NG/CT NAAT should be collected from all three anatomical sites. 
4 In the event that Baseline results are not available at the time of the TOC visit, all swabs from each of the 
three anatomical sites should be taken. 
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Antimicrobial susceptibility testing will be performed in batches during the trial and 
therefore will not be available to sites for clinical management. WGS is exploratory in nature 
and will moreover be analysed in batches. As a consequence, results are not to be used for 
clinical management. 
8. Assessment of safety  
8.1. Definitions 
8.1.1. Adverse event 
An AE is defined as any untoward medical occurrence in a clinical trial participant administered 
a medicinal product and which does not necessarily have a causal relationship with this 
treatment. 
An AE can therefore be any unfavourable and unintended sign (including an abnormal 
laboratory finding or a procedure abnormality that are deemed clinically significant by the 
investigator), symptom, or disease temporally associated with the use of a medicinal product, 
whether or not considered related to the medicinal product. 
Furthermore, the definition of an AE includes worsening (in severity and frequency) of pre-
existing conditions ("medical history") after trial drug administration and abnormalities of 
procedures (i.e. electrocardiogram, X-ray…) or laboratory results which are assessed as 
“clinically significant”. 
What laboratory/procedures abnormalities should be considered as an AE? 
All treatment-emergent laboratory/procedures abnormalities (or worsening in severity or 
frequency of pre-existing abnormalities) assessed as “clinically significant” must be reported 
as an AE. 
When reporting an abnormal laboratory/procedure result, a clinical diagnosis should be 
recorded rather than the abnormal value itself, if available (for example, “anaemia” rather 
than “decreased red blood cell count”).  
What is not an AE? 
• Medical conditions or abnormal safety laboratory results present at the initial trial 
visit that do not worsen in severity or frequency during the trial are NOT considered 
as AE and should be documented as medical history if significant. 
x Symptoms, exacerbation or worsening of the studied disease will NOT be considered 
as AE and will not be captured in the AE page of the eCRF if consistent with the 
anticipated natural progression of the disease (overall and for this given participant). 
• Lack of efficacy of the trial treatment is NOT considered as AE. 
Special Cases: screening period: 
With the exception of abnormal safety laboratory findings detected at baseline (which are 
assumed to have been present prior to informed consent), events occurring after informed 
consent but prior to study treatment administration must be reported as adverse events using 
the applicable form in the eCRF, but will not be classified as treatment-emergent adverse 
events.  
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8.1.2. Adverse Event reporting period 
The adverse events reporting period begins upon participant enrolment in the trial (after 
signature of informed consent) and ends at an EOT or early withdrawal visit.  
All adverse events that occur during the adverse event reporting period specified in the 
protocol must be reported, whether the event is considered medication related or not. In 
addition, any adverse event that occurs after the adverse event reporting period that the 
investigator assesses as possibly related to the investigational medication should also be 
reported as an adverse event. 
Special Cases: screening failures:  
For screening failure participants, events and updates must be recorded in the eCRF and using 
the AE or serious adverse event (SAE) forms (as appropriate) until the date the participant was 
determined to be a screening failure. Beyond that date, only serious or medically relevant 
protocol-related events will be followed-up. The date and time of screening failure will also 
be recorded in the source notes and the eCRF. 
8.1.3. Serious adverse event 
An AE is defined as serious if it:  
x results in death 
x is life-threatening: in this context refers to an AE in which the participant was at risk of 
death at the time of the AE; it does not refer to an AE that hypothetically might have 
caused death if more severe 
x requires or prolongs hospitalization, i.e. the AE requires at least an overnight admission 
or prolongs a hospitalisation beyond the expected length of stay. Hospital admissions 
for social reasons and respite care in the absence of any deterioration in the 
participant’s general condition, as well as hospitalisation for elective surgery or for 
normal disease management (including treatment adjustment) are NOT to be 
considered as SAE according to this criterion  
x results in persistent or significant disability, i.e. the AE resulted in a substantial 
disruption of the participant’s ability to conduct normal activities 
x is a congenital anomaly/birth defect, i.e. an AE outcome in a child or foetus of a 
participant exposed to the IMP before conception or during pregnancy 
x is an important medical event.  
Medical and scientific judgment should be exercised in deciding whether other situations 
should be considered serious events, such as important medical events that might not be 
immediately life-threatening or result in death or hospitalisation but might jeopardise the 
participant or might require intervention to prevent one of the other outcomes listed above. 
Examples of such events include, but are not limited to, intensive treatment in an emergency 
room or at home for allergic bronchospasm; blood dyscrasias or convulsions that do not result 
in hospitalization. In addition, any suspected transmission via a medicinal product of an 
infectious agent is also considered a serious adverse event/reaction.  
Although exposure during pregnancy and overdose are not always serious by regulatory 
definition, these events must be handled as defined in Section 8.4 for reporting trial treatment 
exposure during pregnancies and Section 8.1.4 for overdose. 
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8.1.4. Overdose 
An overdose is defined as a dose greater than the dose evaluated in the present trial as 
described in Sections 6.1 and 6.2 of the protocol.  
All overdoses should be reported in the eCRF. If the overdose is associated with an AE, then 
the AE should also be reported.  
In the event of an overdose of trial treatment, the investigator should use clinical judgment in 
treating the overdose and contact the sponsor medical monitor. The investigator should refer 
to the IB for detailed information regarding warnings, precautions, contraindications, AEs, and 
other significant data pertaining to zoliflodacin. Investigators should refer to ceftriaxone and 
azithromycin SmPCs respectively in case of overdose with either comparator treatment. 
Trial treatment dosing errors made by the research facility staff that result in a possible 
overdose (as well as all dosing errors) of trial treatment must be documented as protocol 
deviations and reported to the sponsor and the IRB/IEC in accordance with the IRB/IEC 
requirements.  
8.1.5. Grading of AE severity 
The severity is used to describe the medical intensity of a specific event. In this clinical trial, 
the severity of AEs must be primarily assessed by investigators according to the Common 
Terminology Criteria for Adverse Events (CTCAE) (54) tables as a guide in the grading of the 
severity of AEs (grades 1-5). The tables will be provided in the MOP.  
Whenever the AE grading is not detailed in the CTCAE tables, the investigator should use the 
following grading for that specific AE: 
MILD: The participant is aware of the event or symptom, but the event or symptom is easily 
tolerated. Does not interfere with the trial participant’s activities of daily living (ADL). 
MODERATE: The participant experiences sufficient discomfort to interfere with or reduce his 
or her usual level of ADL. 
SEVERE: Significant impairment of functioning: the participant is unable to carry out usual ADL 
and/or the participant’s life is at risk from the event.  
LIFE-THREATENING: The participant’s life is at significant risk; extreme limitation in ADL, 
significant assistance required; significant medical intervention/therapy required, 
hospitalization or hospice care probable. 
The investigator should continue using the above grading for all other subsequent evaluations 
of this particular AE for that participant and all others. When the intensity of an AE changes 
over time, each change in intensity will be recorded in the source documents until the event 
resolves. However, only one AE and the maximum intensity will be recorded in the eCRF for 
each separate event. If the AE resolves but then recurs, each will be recorded as a separate 
AE, with the appropriate start and stop dates and times. 
8.1.6. AE causality assessment 
For both serious and non-serious AEs, the investigator is required to assess if there is a causal 
relationship between the AE and the trial treatments, ie. to determine whether there exists a 
reasonable possibility that the trial treatments caused or contributed to the AE. 
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The following categories for relationship to each trial treatment will be used during AE 
reporting: 
RELATED: There is at least a reasonable possibility of causal relationship between the AE and 
the trial treatment. This means that there are facts (evidence) or arguments to suggest a 
causal relationship. 
NOT RELATED: There is no reasonable possibility that the AE is related to the trial treatment. 
8.2. Detection and recording of AEs 
The investigator is required to report all directly observed adverse events and all adverse 
events spontaneously reported by the trial participant using concise medical terminology. In 
addition, at each visit the participant will be questioned about the occurrence of adverse 
events, with a generic question such as “Since last visit have you felt any health problem?”. 
AEs can be spontaneously reported by trial participants or elicited through open-ended 
questioning, examination, or evaluation of trial participants during trial visits. The investigator 
should also review all results of assessments performed as part of the trial, such as laboratory 
assessment results and physical examinations, and assess them for clinically relevant changes 
compared to baseline (Section 8.1.1). 
All AEs occurring during the trial must be recorded in the AE section of the eCRF. AE recording 
applies to both investigational and control group. AEs (including lab or procedures 
abnormalities) should be described using a diagnosis whenever possible, rather than 
individual underlying signs and symptoms. When a clear diagnosis cannot be identified, each 
sign or symptom should be reported as a separate AE.  
As far as possible, each AE should be evaluated to determine: 
x The severity grade based on the CTCAE (54) Grade 1-5 (Section 8.1.5) or on grading scale 
described above (only for those AEs not described in CTCAE) 
x Its duration (start and end dates or if continuing at the end-of-trial visit) 
x Its relationship to each trial treatment (causality; see Section 8.1.6) 
x Action taken with respect to each trial treatment (treatment maintained, dose reduced, 
permanently discontinued, temporarily discontinued, not applicable) 
x Whether medication or therapy was taken/given in relation to the AE 
x Whether it is serious (see Section 8.1.3). 
AE recording shall begin upon signature of the informed consent form (ICF) and should 
continue until the participant’s last visit. 
8.3. Expedited reporting of SAEs 
8.3.1. Reporting of SAEs to sponsor 
Every SAE occurring in a trial participant during the trial (whether or not the event is 
considered trial treatment related) must be reported by the investigator to the sponsor on 
SAE e-mail address (mentioned below) within 24 hours of learning of its occurrence, 
preferably using an SAE report form in English (dated, signed and scanned). All relevant 
information concerning the SAE must be obtained from the appropriate points of contact, 
such as description of the event, onset date and type, duration, severity, relationship to each 
trial treatment, outcome, actions taken, emergency room records, laboratory testing and 
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treatment of the SAE, and all other relevant clinical and laboratory data as soon as possible. 
SAE email address: SAESTI_Zoli001@gardp.org 
The original copy of the SAE report form and the confirmation of receipt email must be kept 
with the participant medical file at the trial site. 
Recurrent episodes, complications, or progression of the initial SAE must be reported as 
follow-up to the original episode within 24 hours of the investigator receiving the follow-up 
information.  
Alike non-serious AEs, information about all SAEs should also be collected and recorded in the 
AE section of the eCRF.  
8.3.2. Reporting of SAEs to national regulatory authorities and ethics committees 
Related SAEs and SUSARs will be reported in an expedited manner to the national regulatory 
authorities (NRA), ethics committees and any other relevant institutions/bodies as per local 
safety reporting regulations. Further details will be provided in the trial safety management 
plan. 
8.4. Exposure during pregnancies 
The effect of zoliflodacin administration has not been studied in pregnant women. Therefore, 
all eligible women of reproductive age must not be pregnant and have a negative pregnancy 
test before they can be included in the trial. All female participants must also agree on using  
a highly effective method of contraception at the time of IMP administration on Day 1 (see 
Appendix 1 for acceptable methods and required duration) and until at least 28 days after 
administration of the trial treatment.  
All participants must be instructed to inform the investigator immediately if there is a 
suspicion of pregnancy. If following trial treatment, it is subsequently discovered that a trial 
participant, or the female partner of a trial participant, is pregnant or may have been pregnant 
at the time of investigational drug exposure, the sponsor must be notified immediately (within 
24 hours). The principal investigator must report all cases of exposure to study treatment 
during pregnancies using the “pregnancy surveillance form”. This must be done irrespective 
of whether an adverse event has occurred. The information submitted should include the 
anticipated date of delivery. 
The investigator must follow the women exposed during pregnancy from day of awareness of 
pregnancy until completion of the pregnancy at definite intervals (at 3 months, 6 months, at 
9 month/child birth) or until pregnancy termination (i.e., induced / spontaneous abortion). 
The investigator will provide pregnancy outcome information as a follow up to the initial 
pregnancy surveillance form.  
Stillbirth infants should be seen by a doctor as soon as possible to assess the cause of death. 
In the case of a live birth, a doctor (preferably a paediatrician if possible) should assess the 
infant at the time of birth and submit a child surveillance report to the sponsor. 
Follow-up of children exposed to drug in utero is proposed to the parents by the Investigator, 
until the children reach 2 years of age. If an event presented by a child exposed to drug in 
utero during child monitoring is identified as meeting a seriousness criterion (e.g. congenital 
anomaly or death), it shall be reported using the SAE form (in addition to the “Child 
Surveillance form”) within the same timelines as for SAE reporting (see timelines in Section 
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8.1.2).  
8.5. AE follow up 
All AEs should be treated appropriately by the investigator. Once an AE is detected, it should 
be followed until its resolution or until stabilization. Assessment should be made at each visit 
(or more frequently, if necessary) of any changes in severity, suspected relationship to the 
trial regimen, interventions required to treat it, and outcome. For AEs that have not resolved 
at the end of the trial, it is the responsibility of the principal investigator to ensure that 
participants are appropriately referred to their treating physician or to an adequate specialist. 
In addition, all serious adverse events and those non-serious events assessed by the 
investigator as related to the investigational drug must continue to be followed even after the 
subject participation in the trial is over. Such events should be followed until they resolve or 
until the investigator assesses them as “chronic” or “stable”. 
8.6.  Safety assessments 
Safety assessments include physical examination, safety lab assessment and review of 
potential AEs. They will be performed at each visit, as per the schedule of events (Section 5).  
 
9. Withdrawals 
At any point in time, participants may withdraw consent. Participants who withdraw from the 
trial will benefit from the same conditions of care as those who remain in the trial. Samples 
collected up until the date of withdrawal will be kept and analyzed, and this will be explained 
in the ICF. 
The investigator is responsible for completing a final assessment form in the eCRF at the time 
of the participant’s withdrawal. The investigator should make a reasonable effort to ascertain 
the reason(s) for consent withdrawal, while fully respecting the participant's rights.  
If a participant does not return for a scheduled visit, every effort should be made to contact 
him/her. In any circumstance, every effort (a minimum of 2 phone calls, documented in the 
source documents) should be made to document participant outcome, if possible. 
The investigator may also decide to withdraw a participant from the trial at any time without 
penalty and for any reason without prejudice to his or her future medical care. Participants 
may be withdrawn for non-compliance with trial procedures or trial drug administration.  
In all cases, the date and reason(s) for withdrawal (including the primary reason) must be 
recorded in the source documents and the eCRF. If a participant is prematurely withdrawn 
from the trial for any reason, the investigator must make every effort to perform the 
evaluations in accordance with Section 5.2.6. Every effort will be made to follow up 
participants who prematurely discontinue from the trial to determine final outcome. 
10. Data collection and management 
10.1. Source data 
According to the International Council on Harmonization of Technical Requirements for 
Registration of Pharmaceuticals for Human Use (ICH), source documents are “original 
documents, data and records (e.g. hospital records, clinical and office charts, laboratory notes, 
memoranda, participant’s diaries or checklists, pharmacy dispensing records, recorded data 
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from automated instruments, microfiches, photographic negatives, microfilms or magnetic 
media, X-rays, participant files, and records kept at the pharmacy at the laboratory and at 
medico-technical departments involved in the clinical trial)” (ICH E6, 1.52) 
According to the ICH, source data are “all information in original records and certified copies 
of original records of clinical findings, observations, or other activities in a clinical trial 
necessary for the reconstruction and evaluation of the trial. Source data are contained in 
source documents (original records or certified copies)” (ICH E6, 1.51). 
In the present trial, all trial data will be first recorded in source documents before being 
transcribed in the eCRF or data provided to PV.  
The source documents must remain available at the trial site after data have been transcribed 
in the eCRF/data or forms sent to PV, to allow retrospective checks that source data have been 
accurately and completely transcribed in the eCRF/data sent to PV. The investigator will allow 
the monitors, the persons responsible for the audit, the representatives of the ethics 
committees, and of the regulatory authorities to have direct access to source data and 
documents in order to analyse, examine, verify and reproduce any report and record that is 
important for the evaluation of the trial. 
10.2. Electronic data capture system 
An eCRF will be designed to record all the data to be collected as per the protocol. An eCRF 
will be completed for each participant. The eCRF, together with all trial related forms and logs 
will be produced by the sponsor before being distributed to investigators. The eCRFs have 
been built using Clinical Studio, a fully validated secure web-enabled software that conforms 
to 21 CFR Part 11 requirements.  
The designated investigator staff will enter the data required by the protocol into the eCRF. 
The principal investigator will be responsible for assuring that the data entered into the eCRF 
is complete, accurate, consistent with the source documents and that entry and updates are 
performed in a timely manner (including in consistency with data sent to PV). Corrections and 
alterations of data on the eCRF or source documents must be made by the investigator or by 
the designated person from his/her team and must be dated and signed. Investigator site staff 
will not be given access to the electronic data capture (EDC) system until they have been 
adequately trained.  
Medical history/current medical conditions and adverse events will be coded using the 
MedDRA terminology. Prior and concomitant medications will be coded using WHO-DRUG 
dictionary. 
ICON GPHS data management will review the eCRF data entered by investigator staff for 
completeness and accuracy. Electronic data queries stating the nature of the problem and 
requesting clarification will be created for discrepancies and missing values and sent to the 
investigational site via the EDC system. Designated investigator site staff are required to 
respond promptly to queries and to make any necessary changes to the data. 
Protocol deviations will be detected through appropriate monitoring (see Section 13 quality 
assurance and quality control). These should be appropriately documented and upon 
conclusion of the trial, the list of deviations will be communicated to ICON GPHS data 
management and statistics. Once the trial data has been verified for completeness and 
accuracy, the database will be locked.  
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11. Data analysis and statistical methods 
11.1. Sample size determination 
The efficacy of the combination therapy 500 mg IM ceftriaxone and 1 g oral azithromycin in 
the SOLITAIRE-U trial was initially used as the cure rate reference (55, 56). This trial had 
assessed the non-inferiority of a single dose of 1 g oral solithromycin in comparison with the 
combination therapy in uncomplicated urogenital gonorrhoea; it reported 84.5% (95% CI, 72.4 
to 87.1%) microbiological cure rate under the combination therapy (56). In addition, the trial 
observed 14% of participants with indeterminate outcome (participants who did not return 
for TOC assessment).  
For this study, the initial assumption was that there would be no treatment difference 
between the parenteral comparator ceftriaxone and azithromycin) and zoliflodacin. A 10% 
non-inferiority margin was initially selected, based on the US FDA guidelines on drug 
development for NG (38). An unequal allocation ratio was chosen to provide sufficient data 
on the safety of zoliflodacin (57). The initial hypothesis was that a single oral 3 g of zoliflodacin 
would be non-inferior to a combination of a single IM 500 mg dose of ceftriaxone and a single 
1 g oral dose of azithromycin if the upper bound of the 2-sided 95% CI for the microbiological 
cure rate of the combination therapy minus zoliflodacin was 10% or less (prespecified non-
inferiority margin for the primary endpoint). Based on an 85% cure rate in the comparator 
arm (combination therapy), and a non-inferiority margin of 10%, it was calculated that 603 
participants (402 in the intervention group and 201 in the control group, with a two-sided α 
of 5% and 2:1 allocation ratio) would provide 90% power to show that a single oral 3 g dose 
of zoliflodacin was non-inferior to a combination of a single IM 500 mg dose of ceftriaxone 
and a single 1 g oral dose of azithromycin with respect to microbiological cure rate at TOC. 
Taking into account criteria for inclusion in the micro-ITT population (see Section 11.2.1), it 
was estimated that a maximum of 35% of the randomized population would be potentially 
ineligible for inclusion in the micro-ITT population. Therefore, it was anticipated that up to 
approximately 928 participants would be randomized into the trial in order to achieve the 
target sample size of 603 in the micro-ITT population. Accounting for anticipated screening 
failures, the enrolment sample size was estimated to be around 1092. 
During the study however, GARDP reassessed the cure rates of all recent Phase 2 and 3 trials 
investigating the efficacy of a new oral investigational product for uncomplicated gonorrhoea 
(24, 26, 56, 58). This indicated that when comparing an oral therapy (even with 100% 
susceptibility) against a parenteral combination that rarely fails, a true underlying treatment 
difference of at least -4% should be assumed, rather than the assumption of equal underlying 
cure rates used in the initial sample size calculation. This is hypothesized to be due to intrinsic 
differences in the bioavailability of an oral versus parenteral drug. Under these assumptions, 
the oral therapy would still be estimated to yield a true cure rate of over 95% which is 
acceptable for single dose oral therapy for gonorrhoea as stated in the CDC criteria (59, 60). 
In addition, Mitrani-Gold et al. published in 2022 a systematic literature review and meta-
analysis (using a weighted, non-iterative random-effects model) to estimate the 
microbiological response rate and 95% CIs for ceftriaxone and proxy-for-placebo (61). The 
analysis proposed that by reviewing data from more recent studies, a non-inferiority margin 
of 15% was shown to robustly preserve estimated ceftriaxone treatment effect in a Phase 3 
microbiologically evaluable population. Using the same methodology, GARDP conducted a 
conservative analysis in a microbiologically evaluable population comparing ceftriaxone 
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treatment effect in the micro-ITT population with the proxy-for-placebo estimate, which 
showed a margin of 12% would preserve 57% of the estimated ceftriaxone treatment effect.  
Therefore in a Type C interaction with the US FDA held in October 2022 wherein GARDP 
requested consideration by the Agency of an increase in the non-inferiority margin, taking into 
account the -4% treatment difference, the published meta-analysis (61) and the unmet public 
health need for new drugs active against ceftriaxone-resistant NG (see Section 1.3), the US 
FDA indicated that a wider non-inferiority margin of 12% for the primary endpoint could be 
acceptable. In the Appendix ‘Justification for noninferiority margin’, the US FDA guidance (38) 
estimates the benefit of an effective treatment over placebo to be 11.9%, but this is 
acknowledged by the US FDA to be a conservative estimate due to the limitation of the data 
included in the meta-analysis. Additionally, the Agency added that, dependent on 
demonstrated efficacy, consideration would be given for a broad or limited population 
indication for the treatment of uncomplicated gonorrhoea. 
Consequently, it will be considered that a single oral 3 g of zoliflodacin will be non-inferior to 
a combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin if the upper bound of the 2-sided 95% CI for the microbiological cure rate of the 
combination therapy minus zoliflodacin would be 12% or less (prespecified non-inferiority 
margin for the primary endpoint). 
Keeping in mind the trial was conducted for the most part during the high peaks of the COVID-
19 pandemic, monitoring of blinded pooled data was conducted to assess the performance of 
the study against assumptions used in the sample size determination described above in these 
higher risk circumstances. When approximately 70% of participants were enrolled, the 
proportion of participants ineligible for the micro-ITT population were estimated to be 
approximately 20% (vs 35% in original assumptions), and the proportion of nonassessable 
outcomes due to missed TOC assessments at 10% (foreseen at 15% in original assumptions).  
Based on these estimations, a blinded pooled data analysis was performed taking into account 
as well the-4% treatment difference and a 12% non-inferiority margin. It was concluded that 
696 participants evaluable for the micro-ITT analysis set (464 in the intervention group and 
232 in the control group, with a two-sided α of 5% and 2:1 allocation ratio) would provide 
approximately 90% power to show that a single oral 3 g dose of zoliflodacin is non-inferior to 
a combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin with respect to microbiological cure rate at TOC. Taking into account criteria for 
inclusion in the micro-ITT population (see Section 11.2.1) and blinded analysis of study 
conduct, it is estimated conservatively that a maximum of 25% of the randomized population 
would be potentially ineligible for inclusion in the micro-ITT population. Therefore, up to 
approximately 928 participants are to be randomized into the trial in order to achieve the 
target sample size of 696 in the micro-ITT population (remains unchanged). Similarly, 
accounting for anticipated screening failures, the enrolment sample size remains estimated to 
be around 1092. 
11.2. Definition of trial populations included in the analysis 
For each microbiological outcome and anatomical site (see Section 2), there will be three 
analysis population types used for the efficacy analysis: the micro-ITT, the evaluable and the 
PP population. The micro-ITT will be the primary analysis population while the evaluable and 
PP population will be the secondary. For clinical outcomes, the clinical cure and PP populations 
will be used.  
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11.2.1. Micro-ITT population 
The micro-ITT population will include all randomized participants who had a positive NG 
culture at baseline and whose baseline antimicrobial susceptibility testing result showed no 
pre-existing resistance to both ceftriaxone and azithromycin. It will include participants who 
do not comply with trial treatment, those who are lost-to-follow-up, those who are 
nonassessable for microbiological outcome, or who receive antibacterial therapy with activity 
against NG prior to the TOC visit. A participant’s eligibility for the micro-ITT population will 
depend on the particular anatomical site in question.  
Resistance will be defined as per local standards. Further details may be found in the SAP. 
Participants who receive the trial treatment and are found to have a negative NG culture at 
the urethral or cervical site at baseline (visit 1) will be excluded from the micro-ITT population 
and thus of the primary efficacy endpoint analysis and secondary analyses corresponding to 
the urethral or cervical sites. Participants who receive trial product and are found to be NG 
culture negative at the rectal or pharyngeal site at visit 1 will be excluded from the micro-ITT 
population for the corresponding secondary efficacy endpoint analyses at the rectal or 
pharyngeal sites. 
The modified micro-ITT population will include all randomized participants who had a positive 
NG culture at baseline. 
11.2.2. Clinical cure population 
For the efficacy analyses of clinical cure, the clinical cure population will include all male at 
birth participants included in the micro-ITT population and who had at least one sign or 
symptom of urethral gonorrhoea at baseline.  
11.2.3. Evaluable population 
The evaluable population will include all randomized participants who have a positive NG 
culture at baseline and whose baseline antimicrobial susceptibility testing result showed no 
pre-existing resistance to both ceftriaxone and azithromycin, who do not vomit within 30 
mins of administration of zoliflodacin or azithromycin and who have a NG culture result at 
the TOC visit. 
11.2.4. PP population 
The PP efficacy population will include all participants in the micro-ITT population who meet 
all inclusion/exclusion criteria, complied with trial treatment, did not vomit within 30 mins of 
administration of zoliflodacin or azithromycin, did not receive any systemic antibiotic with 
known activity against NG prior to TOC visit, did not receive any of the prohibited medications, 
abstained from sexual intercourse and used condoms for vaginal, anal and oral sex prior to 
TOC and returned to the trial site for the TOC visit within the specified window (Visit 4, trial 
day 6±2).  
The clinical-PP population will include male participants in the PP population with at least one 
sign or symptom of gonorrhoea at baseline and with an evaluable clinical cure outcome. 
11.2.5. Safety population 
The safety population will include all randomized participants who have received trial 
treatment. 
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11.2.6. PK population 
The PK population will include all participants randomized to the zoliflodacin group who 
consent to participate to the PK sub-study and from whom at least one valid PK sample post 
treatment is obtained. 
11.3. Baseline characteristics 
Baseline demographics and clinical characteristics will be described overall and by treatment 
group and trial site. Demographic data will include age, gender, sex at birth and ethnicity. 
Baseline clinical data will include initial clinical presentation, sexual history, previous or 
coexisting sexually transmitted infections, results of laboratory investigations including results 
of culture, NAAT and Gram stain, and antibiotics susceptibility testing where available. 
Summary tables will present descriptive statistics: for continuous variables, mean ± standard 
deviation or median and range (whichever is most appropriate); for categorical variables, 
frequency counts and percentage of participants within each category.  
Any missing data pattern will be investigated and reasons for missing data obtained and 
summarised where possible. A second table summarising baseline characteristics of 
participants by trial groups with no missing outcome will be presented to assess whether these 
characteristics were balanced between the treatment groups when only participants with 
non-missing outcomes are considered. 
11.4. Efficacy analysis 
11.4.1. Definitions 
x Microbiological cure: a participant with a positive NG culture at baseline and a negative 
NG culture at the TOC visit. A positive NG culture is defined as a culture with confirmed 
microbiological identification by the central laboratory. 
x Microbiological failure: a participant with a positive NG culture at baseline and at the 
TOC visit and for whom there is no supportive evidence of a re-infection or a 
participant experiencing an intercurrent event before the TOC visit which is possibly 
related to a lack of efficacy of the study treatment. Supportive evidence of re-infection 
includes re-exposure to an untreated sex partner or a NG strain genotype different 
from the strain identified at baseline and/or history of unprotected sex. A participant 
with a positive NG culture at baseline and who is nonassessable for microbiological 
outcome at TOC (e.g. who has a missing microbiological outcome at the TOC due to a 
missed visit or a lost/damaged microbiological specimen) is also considered a failure. 
x Clinical cure: a male at birth participant experiencing resolution of signs and symptoms 
of urogenital gonococcal infection that were present at enrolment. Further details on 
assessment of clinical cure are included in the MOP. 
x Lost-to-follow-up: a participant who has missed his/her appointment after completing 
treatment and cannot be traced until and including the end of the expected follow-up 
period (30 days± 3 days) 
x Non-evaluable for microbiological outcome: a participant who did not have a 
urogenital positive culture result for NG at baseline (visit 1). 
11.4.2. Specification of efficacy analysis 
Efficacy endpoints are defined in Section 2. The primary efficacy endpoint is defined as a 
negative culture to NG at urethral or cervical sites at TOC (day 6 ±2) among patients included 
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in the micro-ITT population.  
The difference in the proportions of participants, in the micro-ITT population, with negative 
culture at the TOC visit will be estimated between the ceftriaxone/azithromycin and the 
zoliflodacin groups and a 2-sided 95% CI will be calculated. The primary efficacy analysis will 
claim zoliflodacin as non-inferior to the ceftriaxone/azithromycin combination if the upper 
bound of the 2-sided 95% CI for the microbiological cure rate of the combination therapy 
minus zoliflodacin lies below the 12% prespecified non-inferiority margin. The primary analysis 
will be conducted on the micro-ITT analysis, which includes participants who are non-
assessable for microbiological outcome or who are lost-to-follow-up.  
To include all randomized participants, missing outcomes will be replaced using multiple 
imputation (62). Sensitivity analyses will also be performed to explore departures from 
assumptions about missing data. To take into account the possibility that missing outcomes 
are not completely at random, a pattern mixture model will be fitted under missing at random 
(MAR) and it will be expanded to allow for the context of missing not at random (MNAR) (62). 
Results of sensitivity analyses will be presented graphically by an estimation of the treatment 
effect (microbiological cure rate) in the combination therapy group, in the zoliflodacin group 
and in both groups depending on the departures from assumptions about missing data (62).  
This efficacy analysis will also be performed on the PP and evaluable population as part of the 
secondary objectives.  
For secondary efficacy endpoints, Chi-2 or Fisher exact tests will be performed, depending on 
applicability criteria, for the comparison of: 
1) The proportions of microbiological cure at TOC between both trial groups at 
pharyngeal and rectal sites  
2) The proportions of clinical cure at TOC between both trial groups.  
These analyses will be conducted in the micro-ITT population and repeated in the modified 
micro-ITT, the evaluable and PP populations, unless stated otherwise. In particular, the 
proportion of clinical cure will be assessed in the clinical cure population. All statistical tests 
will be 2-sided with a level of significance set at 5%. In addition, the following comparison will 
be made 
3) The proportions of participants with a negative NG NAAT from urethral or cervical sites 
at TOC between both trial groups 
4) The proportions of participants with a negative NG NAAT from oropharyngeal sites at 
TOC between both trial groups 
5) The proportions of participants with a negative NG NAAT from rectal sites at TOC 
between both trial groups 
These analyses will be conducted among participants that have a positive NG NAAT from the 
corresponding site at baseline. 
Regarding the antimicrobial susceptibility testing profile of gonococcal isolates, all analyses 
will be descriptive. The MIC breakpoint plus the median, 90th percentile, 50th percentile, modal 
MIC and range of MICs will be reported by treatment group and by site of infection. The 
proportion of isolates at or above MIC breakpoint (n/N) at baseline and TOC (if applicable) will 
also be reported by treatment group and by site of infection. Moreover, changes in 
antimicrobial susceptibility testing between the baseline and TOC isolates will be reported for 
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all participants with microbiological failure without any statistical comparison.  
A descriptive analysis of participants with baseline isolates resistant to ceftriaxone, to 
azithromycin and to both will also be reported. Sensitivity analyses will also be performed. 
In addition, the following exploratory, comparative analyses will be conducted using Mann-
Whitney non-parametric test: 
x Antimicrobial susceptibility testing profile (MIC distribution) of baseline and TOC 
isolates for participants with multiple sites of infection vs participants with unique site 
of infection. 
x Antimicrobial susceptibility testing profile (MIC distribution) of baseline and TOC 
isolates for isolates that are resistant to fluoroquinolones at baseline vs isolates that 
are fluoroquinolone-sensitive. 
x Antimicrobial susceptibility testing profile (MIC distribution) of baseline and TOC 
isolates for isolates that are resistant to other antibiotics commonly used for NG 
treatment (e.g. azithromycin and ceftriaxone) at baseline vs isolates that are sensitive 
to those antibiotics. 
x Antimicrobial susceptibility testing profile (MIC distribution) of baseline isolates of 
participants with subsequent microbiological failure vs microbiological cure. 
11.5. Safety analysis 
Safety endpoints are defined in Section 2. All safety analyses will be descriptive, and endpoints 
will be reported by trial group.  
AEs will be coded using the latest version of the MedDRA. All AEs and SAEs occurring after trial 
drug dosing will be summarized using frequency counts and percentages and their exact 95% 
CI in the following groups: 
x Overall (i.e., regardless of severity or relationship to treatment); 
x By severity grade (mild, moderate, or severe); 
x By relationship to trial drug; 
x By MedDRA level hierarchy (system organ class [SOC], higher level group term [HLGT], 
and preferred term [PT]). 
Descriptive statistics (mean, standard deviation, 95% CI or median and interquartile range, 
whichever is appropriate) will be used to summarize clinical laboratory data at baseline and 
during follow-up visits. Changes in laboratory results pre- and post-treatment will be 
examined and those that are clinically significant will be highlighted and reported as AE. 
11.6. Pharmacological endpoints  
The following PK parameters will be estimated for zoliflodacin: 
x AUC(0-last): Area under the concentration time-curve from time zero to the last 
concentration above the lower limit of quantitation 
x AUC(0-∞): Area under the concentration time-curve from time zero to infinity  
x AUC(0-t): Area under the concentration time-curve from time zero to time t 
x Cmax: Maximum observed concentration 
x Tmax: Time of maximum observed concentration 
x Ke: Elimination rate constant 
x t1/2: Terminal elimination half-life 
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x CL/F: Apparent total clearance of the drug after oral administration 
x Vz/F: Apparent volume of distribution 
The PK analysis will be addressed in a separate report. 
11.7. Missing values 
Prior to analysis, any missing data will be investigated and reasons for missing data obtained 
and summarised where possible. All attempts will be made to avoid any missing outcome data 
and to correct for it. Because the definition of the micro-ITT includes participants who are non-
assessable for microbiological outcome or who are lost-to-follow-up, we will replace missing 
outcomes using multiple imputation (as described under 11.4). The missing data will be 
imputed with predicted values from a multivariable logistic regression model that will include 
these observed participant data and that will be adjusted for baseline covariates (e.g. trial 
centre, age, history of unprotected sex). The multivariable model will yield a probability of a 
Bernoulli process that is used to generate values for the outcome data. The probability will be 
used to impute the missing outcome value by rounding it to the nearest integer (0 or 1) or by 
sampling from a Bernoulli distribution. To avoid any bias, the imprecision due to imputation 
will be accounted for by means of multiple imputation (M=20 imputations). Hence, multiple 
datasets with imputed outcomes will be generated and results will be pooled by using 
standard techniques taking into account the variation between imputed data sets (62). To take 
into account the possibility that missing outcomes are not completely at random, we will also 
fit a pattern mixture model under MAR that will be expanded to allow for the context of MNAR 
(62). For those participants with a missing primary outcome from the central laboratory  but 
with existing outcome from the local microbiology laboratory, the local laboratory data will 
be used, and a sensitivity analysis will be performed. A sensitivity analysis measuring the 
impact of the different reasons for missing values will also be performed. 
 
12. Data safety monitoring board 
An independent data and safety monitoring board (DSMB), composed of 3 members 
independent of the investigators and sponsor, will be constituted prior to trial 
implementation. Its role will be to monitor the accumulated trial data for participants’ safety.  
Depending on this evaluation, the DSMB will make recommendations to the sponsor 
concerning the continuation, modification or termination of the trial. There will be no planned 
interim analysis in this trial. 
The DSMB will consist of at least one STI clinical expert. Support from an independent 
statistician will be provided by ICON GPHS. An unblinded statistician will be available should 
specific requests requiring an unblinded statistician from the data safety monitoring board 
arise. Prior to trial start, a DSMB charter and SOP will be established and the schedule for 
subsequent, interim meetings will be determined. The format of DSMB reports will also be 
discussed.  
During the trial, the sponsor will be responsible for timely communicating to the DSMB all 
SAEs. In addition, the sponsor will communicate quarterly progress reports to the DSMB that 
will include safety listings and Council for International Organizations for Medical Science 
(CIOMS) reports.  
The DSMB will be responsible for interpreting the information communicated by the sponsor 
and for determining: 
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x whether the overall incidence, seriousness and severity of AEs jeopardizes 
participants’ safety 
x whether the investigational drug poses significant, new, safety concern compared to 
the reference information. 
 
13. Quality assurance and quality control procedures 
13.1. Monitoring, audits and inspections 
Prior to trial start, a monitoring plan will be developed. The site principal investigator will allow 
the monitors to visit the site and facilities where the trial will take place in order to verify 
compliance with the trial protocol, ICH-good clinical practice (GCP) and WHO-good clinical 
laboratory practice (GCLP) for laboratories. Training sessions on GCP, GCLP and on protocol 
implementation will be organised for the investigators and all trial staff prior to recruitment 
start. A MOP will be distributed to all the trial centres and a laboratory manual will be 
distributed to all laboratories.  
Trial monitoring will be carried out by dedicated monitors at ICON GPHS at regular intervals, 
depending on the recruitment rate, to verify data quality and trial integrity. When travel of 
monitors and/or access to clinics is limited due to COVID-19 restrictions, remote monitoring 
is allowed to ensure continuity of monitoring where permitted and feasible locally.  
The principal investigator must allow the monitor to: 
x inspect the site, the laboratories, the facilities, the equipment and the material used 
for the trial, 
x meet all members of his/her team involved in the trial, 
x consult all of the documents relevant to the trial, including those filled by the trial 
nurse and trial pharmacist 
x check that the eCRF has been correctly completed 
x review the completion and accuracy of pharmacovigilance documentation and 
consistency with the eCRF 
x directly access source documents for comparison of data therein with the data in the 
eCRF/data or forms sent to PV, 
x verifying that randomization has been conducted in accordance with the 
corresponding SOP and that no breach occurred in allocation concealment 
x verify the collection, transport, storage and shipment of biological samples 
x verify that the trial is carried out in compliance with the protocol and national 
regulatory requirements 
x verify the proper handling and management of trial treatments 
At the end of each monitoring visit, and based on monitoring visit reports, the sponsor will be 
responsible for controlling: 
x recruitment rates, ineligibility, non-compliance, protocol violations and dropouts 
overall and in each trial centre 
x completeness and timeliness of data 
x compliance with GCP, GCLP and applicable regulations  
x any protocol deviations as defined in the monitoring plan. 
A final monitoring visit will be conducted at the end of the trial, after the last participant last 
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visit (LPLV), and once the database is locked. 
13.2. Audits and inspections 
In addition to the monitoring activities foreseen above, the trial may be evaluated by external 
auditors appointed by the sponsor and by representatives from national regulatory authorities 
or ethics committees who must be allowed access to eCRFs, source documents, trial files, and 
trial facilities. 
13.3. Laboratory framework 
All laboratory activities will be carried out according to the trial laboratory manual. The 
laboratory manual compiles all procedures that are relevant to the evaluation of trial 
outcomes, and encompass pre-analytical, analytical and post-analytical phases. 
Most laboratory investigations to be performed during the trial are already in use in the trial 
sites. Hence existing quality control (QC) procedures will be followed for all laboratory 
investigations. Additional quality assurance activities will be implemented as necessary to 
meet GCLP standards, and oversight will be provided by the sponsor. Details can be found in 
the trial laboratory manual. 
14. Trial documentation 
14.1. Confidentiality and retention of trial documents 
Due to the social harm and stigma that is often associated with STIs, all trial sites are 
accustomed to maintaining strict confidentiality with regards to their patients. Most sites are 
dedicated STI clinics. All trial-related information will be stored securely at the trial sites. All 
participant information will be stored in locked file cabinets in areas with access limited to site 
staff.  
All laboratory specimens, reports, trial data collection, process, and administrative forms will 
be identified by a coded number only to maintain participant confidentiality. All records that 
contain names or other personal identifiers, such as locator forms and informed consent 
forms, will be stored separately from trial records identified by code number. All local 
databases will be secured with password-protected access systems. Forms, lists, logbooks, 
appointment books, and any other listings that link participant ID numbers to other identifying 
information will be stored in a separate, locked file in an area with limited access. 
Participant’s trial information will not be released without the written permission of the 
participant, except as necessary for monitoring by the sponsor, the DSMB, the NRAs or 
IRBs/IECs. The principal investigator should agree to provide access to all trial information and 
documents to sponsor representatives, auditors and inspector mandated by NRAs. The 
information will be treated in compliance with professional secrecy. 
The investigators must arrange for the retention of all information relevant to the trial, 
including a copy of the eCRF along with audit trail and essential documents listed in Section 8 
of ICH-GCP, for at least 15 years after completion or termination of the trial. After that period 
of time, the documents may be destroyed with prior permission from the sponsor, subject to 
local regulations. Should the investigator wish to assign the trial records to another party or 
move them to another location, the sponsor must be notified in advance. 
14.2. Protocol amendment 
If the protocol must be altered after it has been signed, the modification or amendment must 
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be discussed and approved by the sponsor. The protocol amendment must be drafted and 
signed by both parties. All amendments must be submitted to the relevant ethics committees 
and NRAs. Administrative amendments can be implemented immediately but amendments 
that affect other aspects can only be implemented after a favourable opinion of the ethics 
committee and NRA has been obtained and local regulatory requirements have been complied 
with. An amendment needed to eliminate immediate hazards to the participants in the trial is 
exempted from this rule. When the submission is performed by the principal investigator, the 
latter must transmit a copy of ethics committee’s new written opinion to the sponsor, 
immediately upon receipt. 
When a protocol amendment results in revised informed consent forms, after IRB/EC 
approval, re-consent will be obtained from participants currently enrolled into the trial in a 
timely manner at or before the participant’s next trial visit. This will allow sufficient time and 
information to make a decision about continued participation in the research trial. 
14.3. Final trial reports 
A final trial report summarising the trial outcome will be drafted by the investigators and 
provided to the local IEC/IRB.  
A clinical trial report will be prepared by the sponsor with input from investigators as 
appropriate. One copy of the final trial report must be dated and signed by the sponsor’s 
medical monitor, principal investigators, trial statistician and the clinical trial manager before 
being transmitted to the IRB/IECs and NRAs. 
 
15. Early termination of the trial 
Both the sponsor and the investigators reserve the right to terminate the trial at any time prior 
to inclusion of the intended number of participants, but they intend to exercise this right only 
for valid scientific or administrative reasons. Should this be necessary, both parties will 
arrange the procedures after review and consultation. In terminating the trial, the sponsor 
and the investigators will ensure that adequate consideration is given to the protection of the 
participants’ interests. 
Reasons for early termination of the trial by the sponsor may include but are not limited to:  
x enrolment rate too low 
x protocol violations 
x inaccurate or incomplete data 
x unsafe or unethical practices 
x questionable safety of the test article 
x following the recommendation of the DSMB or IEC 
x administrative decision 
Reasons for early termination of the trial by the investigators may be: 
x insufficient time or resource to conduct the trial 
x lack of eligible participants. 
In the event that the trial is terminated early, the investigator has to: 
x complete the eCRF to the greater extent possible 
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x answer all questions of the sponsors or their representatives related to data of 
participants enrolled at the site prior to trial termination 
x ensure that participants enrolled in the trial who had not yet reached a follow up time 
point are informed promptly and followed up with the necessary medical care 
x provide in writing the reasons for their decision to the IEC/IRB and the sponsor 
x follow end of trial procedures as per the protocol and MOP. 
 
16. Ethics 
16.1. Trial conduct 
The trial will be conducted in accordance with the ethical principles laid down in the 
declaration of Helsinki 1964, as revised in Fortaleza in 2013, the ICH-GCP, the WHO-GCLP and 
with all applicable national regulations. 
16.2. Regulatory and ethical approval  
The trial protocol, the participant ICF, the eCRF, up-to-date versions of the IB or SmPC, as well 
as principal investigators qualifications will be submitted to appropriate IRBs/IECs.  
The trial will not start in any centre before written approval by these IRBs/IECs has been 
obtained, the local regulatory requirements have been complied with, and the signature of 
the clinical trial protocol of each contractual party involved has been obtained. 
16.3. Informed consent process 
An ICF in clear, simple language complying with new Common Rule (45 CFR part 46 subpart A) 
requirements will be provided to the participant. The investigator or designee is to collect 
written consent from each participant before any trial-specific procedure is conducted. Two 
original ICFs must be completed, dated and signed personally by the participant and by the 
investigator or designated trial staff. The participant should be given one signed original form; 
the second original should be kept by the investigator. 
Adolescent participants (≥ 12 and < 18 years old) will be consented according to the practice 
in use in their country of origin. If required by local research ethics guidelines, assent will be 
sought from participants and consent will be sought from a legal representative in addition. 
In countries that recognize the status of emancipated minors, consent will be sought from the 
participant directly.  
If the participant is unable to read, a relative or an impartial witness should be present during 
the informed consent discussion. The participant must give consent orally and, if capable of 
doing so, complete, sign (or thumbprint) and personally date the information and consent 
form. The witness must then complete, sign and date the form to testify of the participant’s 
understanding of the trial information and his/her willingness to participate, together with the 
investigator. 
The ICF will be provided to the principal investigators by the sponsor. Any changes to the ICF 
suggested by the principal investigator must be agreed to by the sponsor before submission 
to the IRB/IEC, and a copy of the approved version must be provided to the sponsor after 
IRB/IEC approval. Any change to the ICF after the initial approval constitutes an amendment 
and must be submitted for approval to the IRB/IEC, and to the NRA. 
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16.4. Justification for selection of trial population 
The inclusion of minors in the present trial is justified from an ethical perspective by the fact 
that prevalence of STIs among adolescents is usually high and zoliflodacin given as a single 
dose appears to be safe based on non-clinical and clinical studies (see IB). This vulnerable 
group will benefit from the knowledge and intervention generated by the present trial. 
Gathering of PK data from adolescents, who usually have lower body weights, is key to inform 
dosing adjustment if necessary. 
HIV positive participants will be eligible for inclusion in the trial, as long as their ART does not 
contain any of the prohibited medications.  
16.5. Community engagement 
Prior to trial start, relevant communities, such as women’s group, youth, men who have sex 
with men (MSM) groups, and other key populations in trial sites will be informed. Community 
meetings will be held to inform these groups of the trial prior to the trial. Feedback on the trial 
concept will also be gathered through community meetings wherever possible. Follow-up 
meetings will also be done to provide progress of the trial. Moreover, results of the trial will 
be disseminated to these communities. During these meeting the communities will be assured 
of maintaining confidentiality and reducing stigma.  
16.6. Risks and benefits 
Clinical findings with zoliflodacin:  
To date, zoliflodacin as a single dose has been well tolerated by both healthy subjects and 
patients included in the clinical development program. Most commonly reported AEs included 
excluding infection-related AEs were mild gastro-intestinal events (nausea and diarrhoea) and 
headache. There were no AEs reported at a frequency of ≥5%  
Non-clinical findings with zoliflodacin:  
Mild testicular degenerations were observed in rat and dog studies, and reprotoxicity studies 
in rodent showed a slight adverse effect on male and female fertility as well as embryofoetal 
development after multiple dosing for 14-28 days. Zoliflodacin has not been studied in 
pregnant women, and hence all women participants of child bearing potential should not be 
pregnant or have a negative pregnancy test at enrolment and use effective contraceptive 
methods for 30 days after receipt of zoliflodacin. Male participants with female partners of 
child bearing potential must agree to delay conception for 28 days after treatment, and 
conduct abstinence/use effective barrier contraceptive methods to avoid exposure during 
pregnancy for 30 days after receipt of zoliflodacin. As with all antibiotics, allergic and 
hypersensitivity reactions are a potential risk. Please refer to section 6.1.2 of this protocol and 
to the latest version of the IB for a full description of the identified and potential risks 
associated with zoliflodacin.  
Potential risks associated with ceftriaxone: 
The main risk associated with ceftriaxone is the risk of anaphylaxis, and ceftriaxone is contra-
indicated in individuals with known severe allergy to cephalosporins or penicillin. In clinical 
trials, the most frequently reported AEs for ceftriaxone are eosinophilia, leukopenia, 
thrombocytopenia, diarrhoea, rash, and hepatic enzymes increased. Injection site reaction at 
site of intramuscular injection are expected and the use of concomitant lidocaine will mitigate 
risk of severe injection site pain. Please refer to the ceftriaxone SmPC for a full description of 
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the identified and potential risks associated with ceftriaxone. 
Potential risks associated with azithromycin: 
As with erythromycin and other macrolides, rare serious allergic reactions including 
angioneurotic oedema and anaphylaxis (rarely fatal), dermatologic reactions including acute 
generalised exanthematous pustulosis, Stevens Johnson syndrome, toxic epidermal necrolysis 
(rarely fatal) and drug reaction with eosinophilia and systemic symptoms have been reported. 
If an allergic reaction occurs, appropriate therapy should be instituted. Physicians should be 
aware that reappearance of the allergic symptoms may occur when symptomatic therapy is 
discontinued. Please refer to the azithromycin SmPC for a full description of the identified and 
potential risks associated with azithromycin. 
Potential risks associated with lidocaine: 
Lidocaine is a local anaesthetic of the amide type that is approved for use as a diluent for 
ceftriaxone. Reactions to lidocaine include cutaneous lesions, urticaria, oedema or 
anaphylactoid reactions. Pruritis, burning, oedema, erythema, purpura, and bleeding may 
occur at the local injection site. Allergic reactions may occur as a result of sensitivity to local 
anaesthetic agents or to the methylparaben used as a preservative in multiple dose vials. 
Allergic reactions as a result of sensitivity to lidocaine are extremely rare. 
Risks associated with trial participation: 
Trial procedures related risks include risks associated with some of the trial procedures. For 
instance, venepuncture causes transient discomfort and may cause fainting. Bruising at the 
site of venepuncture may occur. Infection at the site is possible but highly unlikely as aseptic 
technique will be used.  
It is possible that participants' involvement in the trial could become known to others, and 
that a social impact may result. For example, participants could be treated unfairly, or could 
have problems being accepted by their families and/or communities. In the event that a 
participant reports a social impact, every effort will be made by trial staff to provide 
appropriate care and counselling to the participant as necessary, and/or referral to 
appropriate resources for the safety of the participant.  
Benefits from trial participation: 
Participants in this trial will benefit from having a comprehensive STI case management 
including laboratory tests for NG and CT resulting in faster and better-informed treatment of 
STIs.  
If positive, the trial will benefit future patients with gonorrhoea by providing the necessary 
evidence to support introduction of a new antibiotic against drug sensitive and drug-resistant 
gonorrhoea. Given the pace at which resistance to ESC is emerging and spreading globally, it 
is likely that the incidence of treatment failures to the currently-recommended treatment will 
increase in the near future. At the same time the 5% resistance threshold set by WHO, US-
CDC and other organizations will soon be reached, and alternative treatment options are 
urgently required.   
16.7. HIV status and voluntary counselling and testing 
HIV positive participants are eligible for inclusion in this trial. Participants without a 
documented positive HIV diagnosis or documented prescription of ART will undergo voluntary 
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counselling and testing (VCT) for HIV as part of the trial baseline assessments, and as per local 
routine procedures. All HIV positive individuals will be offered counselling, referred for HIV 
care and treatment, in line with routine practice in trial sites. This may either be done at the 
same time as consent is obtained for inclusion in the trial or at a later date according to 
hospital practice. Participants who are found to be HIV positive will be referred onwards for 
treatment, surveillance and follow up according to the national protocol for HIV positive 
participants. Participants on pre- or post- exposure prophylaxis for HIV infection may enrol in 
the trial provided they meet all inclusion criteria and none of the exclusion criteria including 
those pertinent to disallowed concomitant medications. 
16.8. Compensation 
All trial treatments and diagnostic test costs will be supported by the sponsor. Participants will 
receive compensation for their time spent for trial participation as per local standards.  
16.9. Insurance and liability 
As sponsor of the trial, GARDP is liable for and shall indemnify any claims and damages brought 
by a trial participant suffering from an injury, which arises out of the performance of the trial 
in accordance with the protocol. To this end, GARDP has taken an insurance covering the 
conduct of the trial and all participants. 
16.10. Post-trial access 
If the present trial is successful in demonstrating zoliflodacin is non-inferior to the comparator 
regimen, the sponsor intends to use trial results to support a request for registration in all trial 
countries. In addition, the sponsor will develop a stewardship and access strategy that will 
accompany the roll out of zoliflodacin in target countries and ensure zoliflodacin is promptly 
available to future gonorrhoea patients.  
 
17. Reporting and publication 
17.1. International registry of clinical trials  
The present trial was registered in the clinicaltrials.gov public register prior to start (NCT # 
NCT03959527). 
17.2. Publication 
Upon trial completion and finalisation of the trial report, the results of the trial will be either 
submitted for publication and/or posted in a publicly accessible database of clinical trial 
results. Authorship of any publication will be based on the uniform requirements for 
manuscripts submitted to biomedical journals as defined by the International Committee of 
Medical Journal Editors (ICMJE). 
 
 
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Newman L, Rowley J, Vander Hoorn S, Wijesooriya NS, Unemo M, Low N, et al. Global 
Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted 
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2. 
Centers for Disease Control and Prevention. Sexually Transmitted Disease 
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U.S. Department of Health and Human Services CDC. Antibiotic resistance threats in 
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Harnisch JP, Berger RE, Alexander ER, Monda G, Holmes KK. Aetiology of acute 
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Hawkins DA, Taylor-Robinson D, Thomas BJ, Harris JR. Microbiological survey of acute 
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Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and 
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Cohen MS, Hoffman IF, Royce RA, Kazembe P, Dyer JR, Daly CC, et al. Reduction of 
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Moss GB, Overbaugh J, Welch M, Reilly M, Bwayo J, Plummer FA, et al. Human 
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gonococcal urethritis and CD4 cell depletion. J Infect Dis. 1995;172(6):1469-74. 
10. 
Bignell C, Unemo M, European STI Guidelines Editorial Board. 2012 European 
guideline on the diagnosis and treatment of gonorrhoea in adults. International 
journal of STD & AIDS. 2013;24(2):85-92. 
11. 
Maldonado NG, Takhar SS. Update on Emerging Infections: news from the Centers 
for Disease Control and Prevention. Update to the CDC's Sexually Transmitted 
Diseases Treatment Guidelines, 2010: Oral cephalosporins no longer a recommended 
treatment for gonococcal infections. Annals of emergency medicine. 2013;61(1):91-5. 
12. 
Tapsall JW, Ndowa F, Lewis DA, Unemo M. Meeting the public health challenge of 
multidrug- and extensively drug-resistant Neisseria gonorrhoeae. Expert review of 
anti-infective therapy. 2009;7(7):821-34. 
13. 
Unemo M, Golparian D, Shafer WM. Challenges with gonorrhea in the era of multi-
drug and extensively drug resistance - are we on the right track? Expert review of 
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Protocol version 5.0 of 12 July 2023 
 
Confidential  
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anti-infective therapy. 2014;12(6):653-6. 
14. 
Unemo M, Nicholas RA. Emergence of multidrug-resistant, extensively drug-resistant 
and untreatable gonorrhea. Future Microbiology. 2012;7(12):1401-22. 
15. 
Fifer H, Natarajan U, Jones L, Alexander S, Hughes G, Golparian D, et al. Failure of 
Dual Antimicrobial Therapy in Treatment of Gonorrhea. N Engl J Med. 
2016;374(25):2504-6. 
16. 
Department of Health. Multi-drug resistant gonorrhoea. 2018; 
17. 
Public Health England. UK case of Neisseria gonorrhoeae with high-level resistance to 
azithromycin and resistance to ceftriaxone acquired abroad. Vol. 12. 2018. 
18. 
WHO. Global action plan to control the spread and impact of AMR in Neisseria 
gonorrhoeae. Geneva; 2012. 
19. 
Lee H, Lee K, Chong Y. New treatment options for infections caused by increasingly 
antimicrobial-resistant Neisseria gonorrhoeae. Expert Review of Anti-Infective 
Therapy. 2016;14(2):243-56. 
20. 
Basarab GS, Kern GH, McNulty J, Mueller JP, Lawrence K, Vishwanathan K, et al. 
Responding to the challenge of untreatable gonorrhea: ETX0914, a first-in-class agent 
with a distinct mechanism-of-action against bacterial Type II topoisomerases. 
Scientific Reports. 2015;5(11827. 
21. 
Craig WA. Pharmacokinetic/pharmacodynamic parameters: rationale for antibacterial 
dosing of mice and men. Clinical Infectious Diseases. 1998;26(1):1-10; quiz 11-2. 
22. 
Jacobsson S, Golparian D, Oxelbark J, Alirol E, Franceschi F, Gustafsson TN, et al. 
Pharmacodynamic Evaluation of Dosing, Bacterial Kill, and Resistance Suppression for 
Zoliflodacin Against Neisseria gonorrhoeae in a Dynamic Hollow Fiber Infection 
Model. Frontiers in Pharmacology. 2021;12(682135. 
23. 
O'Donnell J, Lawrence K, Vishwanathan K, Hosagrahara V, Mueller JP. Single-Dose 
Pharmacokinetics, Excretion, and Metabolism of Zoliflodacin, a Novel 
Spiropyrimidinetrione Antibiotic, in Healthy Volunteers. Antimicrobial Agents and 
Chemotherapy. 2019;63(1):e01808-18. 
24. 
Taylor SN, Marrazzo J, Batteiger BE, Hook EW, 3rd, Sena AC, Long J, et al. Single-Dose 
Zoliflodacin (ETX0914) for Treatment of Urogenital Gonorrhea. New England Journal 
of Medicine. 2018;379(19):1835-1845. 
25. 
Newman LM, Kankam M, Nakamura A, Conrad T, Mueller J, O'Donnell J, et al. 
Thorough QT Study To Evaluate the Effect of Zoliflodacin, a Novel Therapeutic for 
Gonorrhea, on Cardiac Repolarization in Healthy Adults. Antimicrobial Agents and 
Chemotherapy. 2021;65(12):e0129221. 
26. 
Taylor SN, Morris DH, Avery AK, Workowski KA, Batteiger BE, Tiffany CA, et al. 
Gepotidacin for the Treatment of Uncomplicated Urogenital Gonorrhea: A Phase 2, 
Randomized, Dose-Ranging, Single-Oral Dose Evaluation. Clinical Infectious Diseases. 
2018;67(4):504-512. 
27. 
Wi T, Lahra MM, Ndowa F, Bala M, Dillon JR, Ramon-Pardo P, et al. Antimicrobial 
resistance in Neisseria gonorrhoeae: Global surveillance and a call for international 
collaborative action. PLoS Medicine. 2017;14(7):e1002344. 
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Protocol version 5.0 of 12 July 2023 
 
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28. 
Unemo M, Ringlander J, Wiggins C, Fredlund H, Jacobsson S, Cole M. High in vitro 
susceptibility to the novel spiropyrimidinetrione ETX0914 (AZD0914) among 873 
contemporary clinical Neisseria gonorrhoeae isolates from 21 European countries 
from 2012 to 2014. Antimicrobial Agents and Chemotherapy. 2015;59(9):5220-5. 
29. 
Papp JR, Lawrence K, Sharpe S, Mueller J, Kirkcaldy RD. In vitro growth of multidrug-
resistant Neisseria gonorrhoeae isolates is inhibited by ETX0914, a novel 
spiropyrimidinetrione. International journal of antimicrobial agents. 2016;48(3):328-
30. 
30. 
Su XH, Wang BX, Le WJ, Liu YR, Wan C, Li S, et al. Multidrug-Resistant Neisseria 
gonorrhoeae Isolates from Nanjing, China, Are Sensitive to Killing by a Novel DNA 
Gyrase Inhibitor, ETX0914 (AZD0914). Antimicrobial Agents and Chemotherapy. 
2016;60(1):621-3. 
31. 
Bradford PA, Miller AA, O'Donnell J, Mueller JP. Zoliflodacin: An Oral 
Spiropyrimidinetrione Antibiotic for the Treatment of Neisseria gonorrheae, Including 
Multi-Drug-Resistant Isolates. ACS Infectious Diseases. 2020;6(6):1332-1345. 
32. 
Alm RA, Lahiri SD, Kutschke A, Otterson LG, McLaughlin RE, Whiteaker JD, et al. 
Characterization of the novel DNA gyrase inhibitor AZD0914: low resistance potential 
and lack of cross-resistance in Neisseria gonorrhoeae. Antimicrobial Agents and 
Chemotherapy. 2015;59(3):1478-86. 
33. 
Huband MD, Bradford PA, Otterson LG, Basarab GS, Kutschke AC, Giacobbe RA, et al. 
In vitro antibacterial activity of AZD0914, a new spiropyrimidinetrione DNA 
gyrase/topoisomerase inhibitor with potent activity against Gram-positive, fastidious 
Gram-Negative, and atypical bacteria. Antimicrobial Agents and Chemotherapy. 
2015;59(1):467-74. 
34. 
Jacobsson S, Golparian D, Alm RA, Huband M, Mueller J, Jensen JS, et al. High in vitro 
activity of the novel spiropyrimidinetrione AZD0914, a DNA gyrase inhibitor, against 
multidrug-resistant Neisseria gonorrhoeae isolates suggests a new effective option 
for oral treatment of gonorrhea. Antimicrobial Agents and Chemotherapy. 
2014;58(9):5585-8. 
35. 
Ruiz J, Jurado A, Garcia-Mendez E, Marco F, Aguilar L, Jimenez de Anta MT, et al. 
Frequency of selection of fluoroquinolone-resistant mutants of Neisseria 
gonorrhoeae exposed to gemifloxacin and four other quinolones. The Journal of 
antimicrobial chemotherapy. 2001;48(4):545-8. 
36. 
de Vries H, Jongen V, Heyman T, Wind C, de Korne-Elenbaas J, van Dam A, et al. 
Poster O20.2 Ertapenem is non-inferior to ceftriaxone for the treatment of 
anogenital gonorrhea: the NABOGO randomized double blind non-inferiority trial. 
Sexually Transmitted Infections. 2021;97(Suppl 1):A63. 
37. 
Unemo M, Golparian D, Limnios A, Whiley D, Ohnishi M, Lahra MM, et al. In vitro 
activity of ertapenem versus ceftriaxone against Neisseria gonorrhoeae isolates with 
highly diverse ceftriaxone MIC values and effects of ceftriaxone resistance 
determinants: ertapenem for treatment of gonorrhea? Antimicrobial agents and 
chemotherapy. 2012;56(7):3603-9. 
38. 
US FDA. Uncomplicated Gonorrhea: Developing Drugs for Treatment - Guidance for 
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Industry. Silver Spring; 2015. Available from: 
https://fda.report/media/88904/Uncomplicated-Gonorrhea--Developing-Drugs-for-
Treatment.pdf. 
39. 
WHO. WHO Guidelines for the Treatment of Neisseria gonorrhoeae. Geneva; 2016. 
Available from: 
https://apps.who.int/iris/bitstream/handle/10665/246114/9789241549691-eng.pdf. 
40. 
St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K, et al. Update 
to CDC's Treatment Guidelines for Gonococcal Infection, 2020. Morbidity and 
Mortality Weekly Report. 2020;69(50):1911-6. 
41. 
Unemo M, Ross J, Serwin AB, Gomberg M, Cusini M, Jensen JS. 2020 European 
guideline for the diagnosis and treatment of gonorrhoea in adults. International 
Journal of STD and AIDS. 2020;1-17. 
42. 
Chisholm SA, Mouton JW, Lewis DA, Nichols T, Ison CA, Livermore DM. Cephalosporin 
MIC creep among gonococci: time for a pharmacodynamic rethink? Journal of 
Antimicrobial Chemotherapy. 2010;65(10):2141-8. 
43. 
Jaffe HW, Schroeter AL, Reynolds GH, Zaidi AA, Martin JE, Jr., Thayer JD. 
Pharmacokinetic determinants of penicillin cure of gonococcal urethritis. 
Antimicrobial agents and chemotherapy. 1979;15(4):587-91. 
44. 
Golparian D, Ohlsson A, Janson H, Lidbrink P, Richtner T, Ekelund O, et al. Four 
treatment failures of pharyngeal gonorrhoea with ceftriaxone (500 mg) or cefotaxime 
(500 mg), Sweden, 2013 and 2014. Eurosurveillance. 2014;19(30): 
45. 
Singh AE, Gratrix J, Martin I, Friedman DS, Hoang L, Lester R, et al. Gonorrhea 
Treatment Failures With Oral and Injectable Expanded Spectrum Cephalosporin 
Monotherapy vs Dual Therapy at 4 Canadian Sexually Transmitted Infection Clinics, 
2010-2013. Sexually Transmitted Diseases. 2015;42(6):331-6. 
46. 
Yin YP, Han Y, Dai XQ, Zheng HP, Chen SC, Zhu BY, et al. Susceptibility of Neisseria 
gonorrhoeae to azithromycin and ceftriaxone in China: A retrospective study of 
national surveillance data from 2013 to 2016. PLoS Medicine. 2018;15(2):e1002499. 
47. 
WHO. WHO guidelines for the treatment of Chlamydia trachomatis. Geneva; 2016. 
Available from: 
https://apps.who.int/iris/bitstream/handle/10665/246165/9789241549714-eng.pdf. 
48. 
Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually 
transmitted diseases treatment guidelines, 2015. Morbidity and Mortality Weekly 
Report Recommendations and Reports. 2015;64(RR-03):1-137. 
49. 
Department of Health, Republic of South Africa. Sexually transmitted infections - 
Management guidelines 2018 [Internet]. 2018. [cited 2021 Oct 4]. Available from: 
http://www.health.gov.za/wp-content/uploads/2020/11/sti-guidelines-27-08-19.pdf. 
50. 
Thailand Ministry of Public Health. Guidelines for treatment of gonorrhea (in Thai) 
[Internet]. Bangkok; 2019. [cited 2021 Oct 12]. Available from: 
http://klb.ddc.moph.go.th/dataentry/handbook/form/70. 
51. 
Van Bergen J, Dekker J, Boeke A, Kronenberg E, Van der Spruit R, Burgers J, et al. 
Dutch College of General Practitioners’ guideline STD consultation (NHG standaar: 
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Het soa-consult) v2.0 [Internet]. 2013. [cited 2021 Oct 12]. Available from: 
https://richtlijnen.nhg.org/files/pdf/70_Het%20soa-consult_september-2013.pdf. 
52. 
Waites KB, Crabb DM, Duffy LB, Huband MD. In vitro antibacterial activity of AZD0914 
against human Mycoplasmas and Ureaplasmas. Antimicrobial agents and 
chemotherapy. 2015;59(6):3627-9. 
53. 
Foerster S, Golparian D, Jacobsson S, Hathaway LJ, Low N, Shafer WM, et al. Genetic 
Resistance Determinants, In Vitro Time-Kill Curve Analysis and Pharmacodynamic 
Functions for the Novel Topoisomerase II Inhibitor ETX0914 (AZD0914) in Neisseria 
gonorrhoeae. Frontiers in microbiology. 2015;6(1377. 
54. 
National Institute of Health. Common Terminology Criteria for Adverse Events 
(CTCAE) version 5.0. NIH Publication; 2017. 
55. 
WHO. WHO guidelines for the treatment of Neisseria gonorrhoeae - Annex D 
evidence profiles and evidence-to-decision frameworks. 2016. 
56. 
Chen MY, McNulty A, Avery A, Whiley D, Tabrizi SN, Hardy D, et al. Solithromycin 
versus ceftriaxone plus azithromycin for the treatment of uncomplicated genital 
gonorrhoea (SOLITAIRE-U): a randomised phase 3 non-inferiority trial. The Lancet 
Infectious Diseases. 2019;19(8):833-842. 
57. 
Dumville JC, Hahn S, Miles JN, Torgerson DJ. The use of unequal randomisation ratios 
in clinical trials: a review. Contemporary Clinical Trials. 2006;27(1):1-12. 
58. 
Hook EW, 3rd, Golden MR, Taylor SN, Henry E, Tseng C, Workowski KA, et al. Efficacy 
and Safety of Single-Dose Oral Delafloxacin Compared With Intramuscular 
Ceftriaxone for Uncomplicated Gonorrhea Treatment: An Open-Label, Noninferiority, 
Phase 3, Multicenter, Randomized Study. Sexually Transmitted Diseases. 
2019;46(5):279-286. 
59. 
Hook EW, Newman L, Drusano G, Evans S, Handsfield HH, Jerse AE, et al. 
Development of New Antimicrobials for Urogenital Gonorrhea Therapy: Clinical Trial 
Design Considerations. Clinical Infectious Diseases. 2020;70(7):1495-1500. 
60. 
Moran JS, Levine WC. Drugs of choice for the treatment of uncomplicated gonococcal 
infections. Clinical Infectious Diseases. 1995;20 Suppl 1(S47-65. 
61. 
Mitrani-Gold FS, Fix J, Donald A. Systematic Review and Meta-Analysis to Estimate 
the Treatment Effect and Inform a Non-Inferiority Margin for a Phase 3 Non-
Inferiority Trial in Uncomplicated Urogenital Gonorrhea. Sexually Transmitted 
Diseases. 2022;49(9):635-43. 
62. 
White IR, Royston P, Wood AM. Multiple imputation using chained equations: Issues 
and guidance for practice. Statistics in Medicine. 2011;30(4):377-99. 
 
 
 
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Appendix 1: Contraception methods considered as highly effective 
For the purpose of this trial methods that can achieve a failure rate of less than 1% per year 
when used consistently and correctly are considered as highly effective birth control 
methods. Such methods, and the duration of required adherence prior to IMP 
administration, include:  
- 
combined (estrogen and progestogen containing) hormonal contraception associated 
with inhibition of ovulation:  
x 
oral (required for at least 7 days prior to IMP administration) 
x 
intravaginal (required for at least 7 days prior to IMP administration) 
x 
transdermal (required for at least 7 days prior to IMP administration) 
- 
progestogen-only hormonal contraception associated with inhibition of ovulation:  
x 
oral (required for at least 7 days prior to IMP administration)  
x 
injectable (required for at least 7 days prior to IMP administration) 
x 
implantable (required for at least 7 days prior to IMP administration) 
- 
intrauterine device (IUD) (any time prior to IMP administration) 
- 
intrauterine hormone-releasing system (IUS) (any time prior to IMP administration) 
- 
bilateral tubal occlusion (any time prior to IMP administration) 
- 
vasectomised partner1 (at least 3 months prior to IMP administration and verified by 
partner semen analysis) 
All contraceptive methods must be continued until at least 28 days post IMP administration. 
1 Vasectomised partner is a highly effective birth control method provided that partner is the sole sexual partner of the 
female of child-bearing potential trial participant and that the vasectomised partner has received medical assessment of 
the surgical success.   
 
 
 
 
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SAP_001.pdf: 
Final Analysis 
Statistical Analysis Plan (SAP) 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
 Page 1 of 44 
Protocol Title: 
A multi-center, randomized, open-label, non-inferiority trial to 
evaluate the efficacy and safety of a single, oral dose of 
zoliflodacin compared to a combination of a single 
intramuscular dose of ceftriaxone and a single oral dose of 
azithromycin in the treatment of patients with uncomplicated 
gonorrhoea 
Protocol Number: 
STI_Zoli001 
Protocol Version, Date 
5.0, 12 July 2023 
Document Version, Date: 
V3.0, 14 September 2023 
Prepared by: 
Plus-Project Partnership 
On behalf of: 
Global Antibiotics Research and Development Partnership (GARDP) 
Confidentiality statement: 
▪
The information provided in this document is strictly confidential.
▪
The recipients of the SAP must not disclose the confidential information contained
within this document or any related information to other persons without the
permission of the sponsor.
▪
In addition, the recipients of the SAP must keep this confidential document in a
controlled environment which prevents unauthorized access to the document.
ClinicalTrials.gov identifier   NCT03959527 


 
Final Analysis 
Statistical Analysis Plan (SAP) 
 
 
 
 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
                                                                         Page 2 of 44 
 
SIGNATURE PAGE 
 
Prepared at Plus-Project by:  
 
 
 
 
 
 
Helen Broadhurst, Senior Statistics Manager 
 
Date  
(DD MMM YYYY) 
 
 
 
 
 
Reviewed at Plus-Project by: 
 
 
 
 
 
 
 
 
 
Phil Rowe, Executive Director, Statistics 
 
Date  
(DD MMM YYYY) 
 
 
 
 
Approved at GARDP by: 
 
 
 
 
 
 
 
 
 
Dr Subasree Srinivasan, Medical Director 
 
Date  
(DD MMM YYYY) 
 
 
 
 
Helen Broadhurst (Sep 14, 2023 10:26 GMT+1)
Helen Broadhurst
Sep 14, 2023
Sep 14, 2023
Subasree Srinivasan (Sep 14, 2023 11:36 GMT+2)
Subasree Srinivasan
Sep 14, 2023


 
Final Analysis  
Statistical Analysis Plan (SAP) 
 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
Page 3 of 44
 
REVISION HISTORY 
 
 
Version/Date 
Version name 
Section 
Changes implemented 
First v1.0/ 
09-Sep-2022 
First version 
N/A 
N/A 
v2.0 / 17-Jul-2023 Second version 
3.1 General Trial Design,  
5 Sample Size and Power, 8.1 
General Statistical Conventions, 
8.6.2 
Analysis 
of 
primary 
efficacy endpoints 
In line with protocol update v5.0/12-Jul-2023;  Number of 
evaluable patients in sample size and NI margin amended to 12%. 
 
 
3.3 
Trial 
treatments 
and 
assessments 
Table 2 randomization schedule clarified in line with protocol 
update v5.0/12-Jul-2023 
 
 
6.8 Per-Protocol population 
Added condition in line with protocol update v5.0/12-Jul-2023 
V3.0 / 14-Sep-
2023 
Third version 
6.2 
Clarified definition of no pre-existing resistance. 
 
 
7.1.2 
Add indeterminate culture outcome to definition of microbiological 
response for clarity. 
 
 
7.2.2 
AE date imputation removed since AE date not allowed to be 
partial. 
 
 
8.1 
Specify exclusion of data at site 710-005 from summary tables and 
figures 
 
 
8.4.2 
Definition of HIV positive status 
 
 
8.4.3 
Add separate summary of  STI from sexual history questionnaire. 
 
 
8.6.4 
Definition on Late Eradication Rate in the context of exploratory 
objectives 
 
 
8.7.2 
Definition of eGFR added. 


 
Final Analysis 
Statistical Analysis Plan (SAP) 
 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
                                                                     Page 4 of 44 
 
TABLE OF CONTENTS 
 
SIGNATURE PAGE ............................................................................................................. 2 
REVISION HISTORY .......................................................................................................... 3 
TABLE OF CONTENTS ...................................................................................................... 4 
LIST OF ABBREVIATIONS ............................................................................................... 6 
1 INTRODUCTION ........................................................................................................... 8 
2 TRIAL OBJECTIVES ..................................................................................................... 9 
2.1 Primary objective(s) ............................................................................................... 9 
2.2 Secondary objective(s) ........................................................................................... 9 
2.2.1 Safety Objective: ........................................................................................ 9 
2.2.2 Efficacy Objectives: ................................................................................... 9 
2.2.3 Pharmacokinetics (PK) objective (sub-trial only): ................................... 10 
2.3 Exploratory objective(s) ....................................................................................... 10 
3 TRIAL DESIGN ............................................................................................................ 11 
3.1 General trial design ............................................................................................... 11 
3.2 Randomization and blinding ................................................................................. 13 
3.3 Trial treatments and assessments .......................................................................... 14 
4 TRIAL ENDPOINTS .................................................................................................... 17 
4.1 Primary Efficacy Endpoint ................................................................................... 17 
4.2 Secondary Endpoint(s) ......................................................................................... 17 
4.2.1 Safety Endpoint: ....................................................................................... 17 
4.2.2 Efficacy Endpoints: .................................................................................. 17 
4.2.3 PK Sub-trial endpoints ............................................................................. 17 
4.3 Exploratory endpoint(s) ........................................................................................ 17 
5 SAMPLE SIZE AND POWER ..................................................................................... 19 
6 ANALYSIS POPULATIONS ....................................................................................... 21 
6.1 Randomized Population ........................................................................................ 21 
6.2 Micro-ITT population ........................................................................................... 21 
6.3 Modified micro-ITT Population ........................................................................... 21 
6.4 Clinical Cure Population ...................................................................................... 22 
6.5 Safety (SAF) Population ....................................................................................... 22 
6.6 PK population ....................................................................................................... 22 
6.7 Evaluable population ............................................................................................ 22 
6.8 Per-Protocol (PP) population ................................................................................ 22 
6.9 Clinical-PP population .......................................................................................... 22 
6.10 Protocol deviations/violations and exclusions from analysis sets ........................ 22 
7 Statistical Considerations and analysis .......................................................................... 24 
7.1 Derived Variables ................................................................................................. 24 
7.1.1 Demographics ........................................................................................... 24 
7.1.2 Efficacy ..................................................................................................... 24 
7.2 Handling of missing data and outliers .................................................................. 25 
7.2.1 Missing data analysis methods for sensitivity analysis ............................ 25 
7.2.2 Handling of missing or incomplete dates ................................................. 25 


 
Final Analysis 
Statistical Analysis Plan (SAP) 
 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
                                                                     Page 5 of 44 
 
8 STATISTICAL METHODS.......................................................................................... 27 
8.1 General statistical conventions ............................................................................. 27 
8.2 Participant disposition .......................................................................................... 29 
8.3 Protocol deviations ............................................................................................... 29 
8.4 Demographics and baseline characteristics .......................................................... 29 
8.4.1 Demographics ........................................................................................... 29 
8.4.2 Baseline and disease characteristics ......................................................... 30 
8.4.3 Medical / Surgical history ........................................................................ 30 
8.4.4 Prior and concomitant medications .......................................................... 30 
8.5 Extent of exposure ................................................................................................ 31 
8.5.1 Treatment duration ................................................................................... 31 
8.5.2 Treatment compliance .............................................................................. 31 
8.6 Efficacy analyses .................................................................................................. 31 
8.6.1 Analysis methods ...................................................................................... 31 
8.6.1.1 Multiplicity ............................................................................................... 32 
8.6.1.2 Treatment by center interaction analysis (multi-center trial) ................... 32 
8.6.2 Analysis of primary efficacy endpoints .................................................... 32 
8.6.2.1 Sensitivity Analyses for primary efficacy endpoint ................................. 33 
8.6.3 Analysis of secondary efficacy endpoints ................................................ 34 
8.6.3.1 Subgroup Analyses ................................................................................... 35 
8.6.4 Analysis of exploratory endpoints ............................................................ 36 
8.7 Safety analyses ..................................................................................................... 37 
8.7.1 Adverse events .......................................................................................... 37 
8.7.2 Clinical laboratory evaluations ................................................................. 39 
8.7.3 Physical examinations .............................................................................. 40 
8.7.4 Electrocardiograms (ECG) ....................................................................... 40 
8.7.5 Pregnancy ................................................................................................. 40 
8.8 Other analysis ....................................................................................................... 40 
8.8.1 Pharmacokinetics (PK) analysis ............................................................... 40 
8.9 Interim analysis .................................................................................................... 40 
8.9.1 Data Safety Monitoring Board (DSMB) .................................................. 40 
9 CHANGES TO PLANNED ANALYSIS FROM TRIAL PROTOCOL ...................... 42 
10 REFERENCES .............................................................................................................. 43 
 
 


 
Final Analysis 
Statistical Analysis Plan (SAP) 
 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
                                                                     Page 6 of 44 
 
LIST OF ABBREVIATIONS 
The following abbreviations will be used within this SAP. 
 
Abbreviation 
or 
special term 
Explanation 
AE 
Adverse Event 
ALT 
Alanine transaminase 
ART 
Anti-retroviral therapy 
AST 
Antimicrobial susceptibility test 
ATC 
Anatomical Therapeutic Chemical 
AUC 
Area under the curve 
BMI 
Body Mass Index 
CI 
Confidence Interval 
CIOMS 
Council for International Organizations for Medical Science 
CKD-EPI 
Chronic Kidney Disease Epidemiology Collaboration 
Clinical-ITT 
Clinical intention to treat 
CTR 
Clinical Trial Report 
CT 
Chlamydia trachomatis 
CTCAE 
Common Terminology Criteria for Adverse Events 
DSMB 
Data and safety monitoring board 
ECG 
Electrocardiogram 
eCRF 
Electronic Case Report Form 
eGFR 
Estimated glomerular filtration rate 
FBC 
Full Blood Count 
FDA 
Food Drug Administration 
GPHS 
Government and Public Health Solutions 
HIV 
Human immunodeficiency virus 
HLGT 
Higher Level Group Term 
ICH  
International Conference on Harmonisation 
IM 
Intramuscular 
IMP 
Investigational Medicinal Product 
KG 
Kilogram 
LFT 
Liver function tests 


 
Final Analysis 
Statistical Analysis Plan (SAP) 
 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
                                                                     Page 7 of 44 
 
LR 
Logistics Regression 
MAR 
Missing at random 
MedDRA 
Medical dictionary for regulatory activities 
MI 
Multiple Imputation 
MIC 
Minimum inhibitory concentration 
Micro-ITT 
Microbiological intention to treat 
Modified micro-ITT 
Modified –microbiological intention to treat 
MNAR 
Missing not at random 
MOP 
Manual of procedures 
MSM 
Men who have sex with Men 
NAAT 
Nucleic acid amplification test 
NG 
Neisseria gonorrhoeae 
NI 
Non-inferiority 
PK 
Pharmacokinetics 
PMM 
Pattern Mixture Model 
PO 
per os 
PP 
Per Protocol 
PrEP 
Pre-exposure prophylaxis 
PT 
Preferred Term 
PV 
Pharmacovigilance 
SAE 
Serious Adverse Event 
SAF 
Safety Population 
SAP 
Statistical Analysis Plan 
SD 
Standard Deviation 
SOC 
System Organ Class 
STI 
Sexually transmitted infections 
SUSAR 
Suspected unexpected serious adverse reaction 
TEAE 
Treatment Emergent Adverse Event 
TFLs 
Tables, Figures and Listings 
TOC 
Test of Cure 
USA 
United States of America 
WGS 
Whole genome sequencing 
WHO 
World Health Organization 


 
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Statistical Analysis Plan (SAP) 
 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
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1 
INTRODUCTION 
The purpose of this Statistical Analysis Plan (SAP) is to provide detailed descriptions of the 
statistical methods, data derivations and data displays for trial protocol STI_Zoli001 Version 
5.0 “A multi-center, randomized, open-label, non-inferiority trial to evaluate the efficacy 
and safety of a single, oral dose of zoliflodacin compared to a combination of a single 
intramuscular dose of ceftriaxone and a single oral dose of azithromycin in the treatment of 
patients with uncomplicated gonorrhoea” dated 12 July 2023 for final analysis. The table of 
contents and templates for the tables, figures, and listings (TFLs) will be produced in a 
separate document. 
Any deviations from this SAP will be described and justified in the Clinical Trial Report 
(CTR). 
The preparation of this SAP has been based on International Conference on Harmonization 
(ICH) E9 guideline (6). 
All data analyses and generation of TFLs will be performed using SAS 9.4® or higher. 
 
 


 
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Version: 3.0, Date: 14 Sep 2023 
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2 
TRIAL OBJECTIVES 
2.1 
Primary objective(s) 
The primary objective of this trial is to assess the efficacy of a single, oral, 3 grams (g) dose of 
zoliflodacin compared to a combination of a single intramuscular (IM) injection of 500 milligram 
(mg) dose of ceftriaxone and a single 1 g oral dose of azithromycin for the treatment of 
uncomplicated urogenital gonorrhoea 
2.2 
Secondary objective(s) 
2.2.1 
Safety Objective: 
• 
To assess the safety and tolerability of a single, oral, 3 g dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin in participants with uncomplicated gonorrhea 
2.2.2 
Efficacy Objectives: 
• 
To determine microbiological cure rate of pharyngeal gonorrhoea after administration  of a 
single, oral, 3 g dose of zoliflodacin compared to a combination of a single IM 500 mg dose 
of ceftriaxone and a single 1 g oral dose of azithromycin 
• 
To determine microbiological cure rate of rectal gonorrhoea after administration  of a single, 
oral, 3 g dose of zoliflodacin compared to a combination of a single IM 500 mg dose of 
ceftriaxone and a single 1 g oral dose of azithromycin 
• 
To determine the clinical cure rate of symptomatic gonorrhoea in male participants after 
administration of a single, oral, 3 g dose of zoliflodacin compared to a combination of a 
single IM 500 mg dose of ceftriaxone and a single 1 g oral dose of azithromycin 
• 
To determine the microbiological cure rate of urogenital gonorrhoea among women and men 
respectively, after administration of a single, oral, 3 g dose of zoliflodacin compared to a 
combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin 
• 
To determine the microbiological cure rate of Neisseria gonorrhoeae (NG) at urethral or 
cervical sites in the subset of participants with pre-existing resistance to antibiotics 
commonly used for NG treatment (including to ceftriaxone alone, to azithromycin alone, and 
to both) 
• 
To determine the antimicrobial susceptibility profile of gonococcal strains isolated from 
participants with uncomplicated gonorrhoea at baseline and the Test of cure (TOC) visit 
• 
To determine the eradication rate of NG nucleic acid from urethral, cervical, rectal, 
pharyngeal specimens after administration of a single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral 


 
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dose of azithromycin 
2.2.3 
Pharmacokinetics (PK) objective (sub-trial only): 
To evaluate the plasma PK profile after a single, oral, 3 g dose of zoliflodacin: 
• 
in adult participants (≥ 18 years old) with uncomplicated gonorrhoea who are HIV negative 
or HIV positive 
• 
in HIV negative adolescent participants (≥ 12 and < 18 years old) with uncomplicated 
gonorrhoea 
2.3 
Exploratory objective(s) 
• 
To determine the late eradication rate of NG nucleic acid from urethral, cervical, rectal, 
pharyngeal specimens after administration of a single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral 
dose of azithromycin 
• 
To determine the late relapse/re-infection rate of NG from urethral, cervical, rectal, 
pharyngeal specimens after administration of a single, oral, 3 g dose of zoliflodacin 
compared to a combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral 
dose of azithromycin 
• 
To investigate relationships between pre-treatment and post-treatment NG isolates within 
those participants whose cultures at TOC (day 6 ±2) and EOT (day 30 ±3) are found positive 
for NG and identify possible determinants of zoliflodacin resistance 
 


 
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Statistical Analysis Plan (SAP) 
 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
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3 
TRIAL DESIGN 
3.1 
General trial design 
This trial is a Phase III, interventional, multi-center, randomized controlled, open label, double-
dummy, non-inferiority trial evaluating the safety and efficacy of a 3 g oral dose of zoliflodacin 
compared to a combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral dose of 
azithromycin for the treatment of uncomplicated gonorrhoea. 
Participants will present to the clinic for assessment of eligibility after informed consent is signed on 
Day 1 (-1 day). Should eligibility be confirmed, they will be randomised to either the zoliflodacin 
group or the ceftriaxone/azithromycin combination group, undergo baseline assessments and dosed 
with the trial treatment on the same or next day.  Assessments for Visit 1 can be performed over 2 
days as long as ALL Baseline assessments and Dosing are performed on the 2nd day. The day that 
is considered Day 1 is the day of Dosing. 
Those participants who are assigned to the zoliflodacin group and who will also have consented to 
be enrolled in the PK sub-trial will undergo blood sampling on Day 1 and return to the clinic on Day 
2 for further blood sampling.  
Sites staff will call participants on Day 3 for safety monitoring purposes and to enquire about sex 
behaviour since the previous clinic visit. Participants will return to the clinic on Day 6 for the TOC 
visit, involving safety and efficacy assessments (primary endpoint for the trial will be assessed at the 
TOC visit). Participants will be asked to return to the clinic for the EOT  visit on Day 30 for final 
safety and efficacy assessments.  
The trial consists of following visits and phone calls: 
 
• 
Screening period/ Randomization (Visit 1, Day 1 [-1 day]) 
• 
Baseline assessments (Visit1, Day 1) 
• 
Dosing (Visit 1, Day 1) 
• 
PK Sampling (Visit 2, Day 2) 
• 
Phone call (Visit 3, Day 3 [-1 day]) 
• 
Test of Cure (Visit 4, Day 6 [±2 days])) 
• 
Follow-up (Visit 5, Day 30 [±3 days])) 
For further details on the schedule of assessments refer to Table 2 below. 
 
 


 
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Figure 1: Trial design schematic 
 
CT: Chlamydia trachomatis; HIV: human immunodeficiency virus; NAAT: nucleic acid amplification test; 
NG: Neisseria gonorrhoeae; PK: pharmacokinetics. 
Note: Culture and NAAT assessments at visits 4 and 5 are conditional to results at previous visits as per the 
schedule of assessments (Table 2). 
 
The target sample size is 696 evaluable participants: 464 in the zoliflodacin group and 232 in the 
comparator group  including 20-30 adolescents (≥12 and < 18 years old), with an estimated 
randomisation sample size of approximately 928. Accounting for anticipated screening failures , the 
maximum enrolment sample size is estimated to be around 1092. 
The total duration for individual participants will be 30 days (± 3 days), unless the participant 
discontinues from the study or withdraws consent (refer to study protocol section 9 for details of 
reasons for study withdrawal). The trial treatment will be a single dose of either the investigational 
treatment or the comparator treatment. The duration of the follow-up period will be 29 days (± 3 
days). The end of trial is defined as the last participant’s last visit. Overall, recruitment into the trial 
is expected to last for approximately 3.5 years. 
The trial is conducted in The Netherlands, Belgium, Thailand, South Africa and United States of 
America (USA).  
 
 


 
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3.2 
Randomization and blinding 
The randomization sequence will be obtained by computer-generated random numbers and provided 
to each trial site through a web-based randomization system (Flex Advantage). Trial participants will 
be assigned to receive either zoliflodacin or a ceftriaxone/azithromycin combination in a 2:1 
allocation ratio. Unequal randomization has been chosen to increase the number of individuals from 
which safety data is gathered. Randomization will be performed using random permutated blocks of 
3, 6, and 9 with stratification by sex at birth. At each trial site, a dedicated pharmacist or designated 
clinician will be responsible for monitoring drug storage and for dispensing trial drugs in accordance 
with the treatment allocation. 
Blinding 
This will be an open-label trial (with measures put in place to keep sponsor global staff blinded where 
feasible, described in a blinding convention). With a double-dummy design, participants would have 
to receive an IM injection and a tablet as well as an oral sachet, which would be likely to decrease 
their willingness to participate in the trial. Moreover, placebo injections might not be acceptable from 
an ethical perspective, and as a consequence the majority of gonorrhoea trials conducted over the 
past 30 years that included ceftriaxone treatment arm have been unblinded trials.  
The laboratory staff who performs assessment of the primary outcome will be blinded to treatment 
allocation. This is achievable as the treatment allocation will not be mentioned on the trial specimen 
sent to the laboratory. Samples collected throughout the trial will be anonymized and a unique 
participant identifier will be used for sample tracking and result reporting. Laboratory results will be 
entered in the eCRF by site staff, or reported directly to data management as per pre-determined data 
specifications. For sites participating in the PK sub-trial, it will be ensured that trial personnel 
handling PK samples are different from the laboratory personnel handling microbiological samples. 
With the exception of medical monitors and country specific personnel who interact regularly and 
are required to advise unblinded site teams, the sponsor remains blinded as detailed in the Blinding 
convention document. All the data will remain blinded to the sponsor until database lock, except in 
case of expedited reporting of suspected unexpected serious adverse reaction (SUSAR). 
An unblinded statistician at ICON plc will be available should specific unblinded requests from the 
data safety monitoring board arise. 
Procedures for unblinding 
As this is an open-label trial, procedure for emergency unblinding is not applicable (in a medical 
emergency where knowledge of the blinded treatment is necessary for the treatment of an adverse 
event).  


 
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Unblinding of SUSARs for safety reporting is described in the Safety Management Plan. 
3.3 
Trial treatments and assessments 
The participants in this trial will be randomized into either the below treatments on Day 1/ Visit 1: 
• 
Trial treatment: zoliflodacin (3 g per os (PO)). 
• 
Comparator treatment: ceftriaxone (500 mg) + azithromycin (1 g). 
Administration of Trial Treatments: 
Trial treatments will only be dispensed and administered to individuals enrolled in the trial and who 
have been randomized. Participants randomized to the zoliflodacin group will receive a single 3 g 
PO dose (one sachet) of zoliflodacin reconstituted with water. Detailed information on the 
preparation and administration of zoliflodacin can be found in the IMP preparation and 
administration instruction.  
Administration of Comparator Trial Treatments: 
Participants randomized to the comparator group will receive ceftriaxone as a 500 mg IM injection 
and azithromycin as four 250 mg oral tablets. Detailed information on the preparation and 
administration of zoliflodacin can be found in the IMP preparation and administration instruction. 
Study Assessments: 
A detailed description of procedures and assessments to be conducted during this trial is summarized 
in the Scheduled of Trial Assessments in Table 2 below. 
 
 
 
 


 
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Table 2: Schedule of Trial Assessments 
 
Visit number 
                11    
2    
3 
4 
5 
Timing (window) 
Day 1 (-1 
day) 
Day 1 
Day2 
Day 3 (-
1 day) 
Day 6 (± 2 
days)2 
Day 30 (± 3 
days) 
 
Visit type 
Screening 
Baseline 
Dosing    PK  
  Phone 
call 
Test of 
cure 
(TOC) 
End of 
trial 
Early 
withdrawal / 
unscheduled 
visit3 
Screening 
assessments 
Informed consent4 
X 
Demographics5 
X 
Medical history 
X 
Sexual history6 
X 
X 
X 
X 
X 
Targeted physical 
examination7 
X8 
X 
X 
X 
Pregnancy test 
X 
X 
X 
X 
Assessment of 
eligibility 
X 
Randomization 
X17 
Laboratory 
investigations 
HIV testing9 
X 
Full blood count 
(FBC) and 
differentials 
X 
X 
X 
X 
Liver function tests 
(LFTs)10 
X 
X 
X 
X 
Creatinine and 
estimated 
glomerular 
filtration rate 
(eGFR) 
X 
X 
X 
X 
Urethral/endocerv
ical Gram stain 
and microscopy 
examination11 
X 
Efficacy outcomes 
Urogenital NG 
culture and NAAT 
X 
X12 
X13 
Rectal NG culture 
and NAAT 
X 
X12 
X13 
Pharyngeal NG 
culture and NAAT 
X 
X12 
X13 
AST14 
X 
X 
X 
NAAT for CT 
(urogenital) 
X 


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


 
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4 
TRIAL ENDPOINTS 
4.1 
Primary Efficacy Endpoint 
• 
Microbiological cure as determined by culture at urethral or cervical sites at TOC (day 6 ±2) 
4.2 
Secondary Endpoint(s) 
The secondary endpoints of this trial are: 
4.2.1 
Safety Endpoint: 
• 
Incidence, severity, causality, and seriousness of treatment-emergent adverse events and the 
evaluation of changes from baseline in safety laboratory test results and physical 
examinations  
4.2.2 
Efficacy Endpoints:  
• 
Proportion of participants with microbiological cure as determined by culture at pharyngeal 
sites at TOC (day 6 ±2) 
• 
Proportion of participants with microbiological cure as determined by culture at rectal sites 
at TOC (day 6 ±2) 
• 
Proportion of male participants with clinical cure at TOC (day 6 ±2) 
• 
Proportion of female and male participants respectively with microbiological cure as 
determined by culture at cervical or urethral site at TOC (day 6 ±2) 
• 
Proportion of participants with microbiological cure as determined by culture at urethral or 
cervical sites at the TOC visit and for whom the baseline antimicrobial susceptibility profile 
indicated pre-existing resistance to antibiotics commonly used for NG treatment (including 
to ceftriaxone alone, to azithromycin alone and to both) 
• 
Antimicrobial susceptibility profile of gonococcal strains isolated at baseline and at TOC 
(day 6 ±2) 
• 
Proportion of participants with a negative NG nucleic acid amplification test (NAAT) from 
urethral or cervical sites at TOC (day 6 ±2) 
• 
Proportion of participants with a negative NG NAAT from oropharyngeal sites at TOC (day 
6 ±2) 
• 
Proportion of participants with a negative NG NAAT from rectal sites at TOC (day 6 ±2) 
4.2.3 
PK Sub-trial endpoints 
• 
Plasma PK parameters of zoliflodacin in HIV negative and HIV positive adult participants 
• 
Plasma PK parameters of zoliflodacin in HIV negative adolescents (≥ 12 and < 18 years old) 
 
4.3 
Exploratory endpoint(s) 
• 
Out of participants with a positive NG NAAT test and a negative NG culture at TOC for 


 
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specified anatomical site, the below will be determined: 
o Proportion of participants with a negative NG NAAT and culture from urethral or 
cervical sites at the end of the trial (day 30 +/- 3 days) 
o Proportion of participants with a negative NG NAAT and culture from 
oropharyngeal sites at the end of the trial (day 30 +/- 3 days) 
o Proportion of participants with a negative NG NAAT and culture from rectal sites at 
the end of the trial (day 30 +/- 3 days) 
• 
Out of participants with symptoms at end of the trial (day 30 +/- 3 days), the following will 
be determined: 
o Proportion of participants with positive NAAT and/or culture at each anatomical site 
respectively at end of the trial (day 30 +/- 3 days) 
o Antimicrobial susceptibility profile of gonococcal strains isolated at the end of the 
trial (day 30 +/- 3 days) 
• 
Whole genome sequencing (WGS) for strain typing and assessment of resistance 
determinants of NG isolates from the TOC and end of trial visits plus all baseline isolates 
(urogenital, pharyngeal and rectal) from the same participants with possible microbiological 
failure 
 
 


 
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5 
SAMPLE SIZE AND POWER 
The efficacy of the combination therapy 500 mg IM ceftriaxone and 1 g oral azithromycin has been 
used as the reference in the SOLITAIRE-U trial. This trial has assessed the non-inferiority of a single 
dose of 1 g oral solithromycin in comparison with the combination therapy in uncomplicated 
urogenital gonorrhoea; it reported 84.5% (95% CI, 72.4 to 87.1%) microbiological cure rate under 
the combination therapy (14). Initially, a 10% non-inferiority (NI) margin for the treatment 
difference in proportion of ceftriaxone/azithromycin combination and  zoliflodacin was selected, 
based on the US Food and Drug Administration (FDA) guidelines on drug development for NG 
(13), and the initial assumption that there would be no treatment difference between the comparator 
(parenteral ceftriaxone and oral azithromycin) and zoliflodacin. An unequal allocation ratio has 
been chosen to provide sufficient data on the safety of zoliflodacin (2). 
During the study however, GARDP assessed the cure rates of all recent Phase 2 and 3 trials 
investigating the efficacy of a new oral investigational product for uncomplicated gonorrhoea (1, 4, 
10,11). This indicated that when comparing an oral therapy (even with 100% susceptibility) against 
a parenteral combination that rarely fails, a true underlying treatment difference of at least -4% 
should be assumed, rather than the assumption of equal underlying cure rates used in the initial 
sample size calculation.  In addition, Mitrani-Gold et al. published in 2022 a systematic literature 
review and meta-analysis (using a weighted, non-iterative random-effects model) to estimate the 
microbiological response rate and 95% CIs for ceftriaxone and proxy-for-placebo (14). The analysis 
proposed that by reviewing data from more recent studies, a NI margin of 15% was shown to 
robustly preserve estimated ceftriaxone treatment effect in a Phase 3 microbiologically evaluable 
population. Using the same methodology, GARDP conducted a conservative analysis in a 
microbiologically evaluable population comparing ceftriaxone treatment effect in the micro-ITT 
population with the proxy-for-placebo estimate, which showed a margin of 12% would preserve 
57% of the estimated ceftriaxone treatment effect.  At a Type C interaction held in October 2022, 
the US FDA indicated that a NI margin of 12% could be acceptable. 
Consequently, it will be considered that a single oral 3 g of zoliflodacin will be non-inferior to a 
combination of a single IM 500 mg dose of ceftriaxone and a single 1 g oral dose of azithromycin 
if the upper bound of the 2-sided 95% CI for the microbiological cure rate of the combination 
therapy minus zoliflodacin would be less than 12% (prespecified NI margin for the primary 
endpoint). 
A blinded pooled data analysis of sample sizing assumptions was also performed.  Considering  the 
expected -4% treatment difference and a NI margin of 12%, it was calculated that 696 participants 
evaluable for the micro-ITT analysis set (464 in the intervention group and 232 in the control group, 
with a two-sided α of 5% and 2:1 allocation ratio) would provide approximately 90% power to show 


 
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that a single oral 3 g dose of zoliflodacin is non-inferior to a combination of a single IM 500 mg 
dose of ceftriaxone and a single 1 g oral dose of azithromycin with respect to microbiological cure 
rate at TOC.  
Taking into account criteria for inclusion in the micro-ITT population (see Section 6.2) and blinded 
assessment of study conduct, it is estimated conservatively that a maximum of 25% of the 
randomized population would be potentially ineligible for inclusion in the micro-ITT population. 
Therefore, up to approximately 928 participants are to be randomized into the trial in order to 
achieve the target sample size of 696 in the micro-ITT population.  Taking into account anticipated 
screening failures, the enrolment sample size remains estimated to be around 1,092. 
 
 
 


 
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6 
ANALYSIS POPULATIONS 
For each microbiological outcome and anatomical site (see Section 2 objectives and Section 4 
endpoints), there will be three analysis population types used for the efficacy analysis: the micro-
ITT, the evaluable and the PP population. The micro-ITT will be the primary analysis population 
while the evaluable and PP population will be the secondary. For clinical outcomes, the clinical cure 
and PP populations will be used. 
6.1 
Randomized Population  
The Randomized population will include all participants who are randomized. 
6.2 
Micro-ITT population 
The micro-ITT population will be defined separately for urogenital, rectal or pharyngeal body site 
populations and will include all randomized participants who had a positive NG culture from the 
relevant anatomical site at baseline and whose baseline AST result showed no pre-existing resistance 
to both ceftriaxone and azithromycin (i.e. participants with ceftriaxone MIC>0.25 µg/mL AND 
azithromycin MIC>1 µg/mL with be excluded from the population). It will include participants who 
do not comply with trial treatment, those who are lost-to-follow-up, those who are nonassessable for 
microbiological outcome, or who receive antibacterial therapy with activity against NG prior to the 
TOC visit. A participant’s eligibility for the micro-ITT population will depend on the particular 
anatomical site in question. 
Resistance to ceftriaxone and azithromycin will be defined as per CLSI [8] standards. 
The micro-ITT population will be derived by anatomical site at baseline.  For example, participants 
who receive the trial treatment and are found to have a negative NG culture at the urethral or cervical 
site at baseline (visit 1) will be excluded from the micro-ITT population and thus of the primary 
efficacy endpoint analysis and secondary analyses corresponding to the urethral or cervical sites. 
Participants who receive trial product and are found to be NG culture negative at the rectal or 
pharyngeal site at visit 1 will be excluded from the micro-ITT population for the corresponding 
secondary efficacy endpoint analyses at the rectal or pharyngeal sites. 
The micro-ITT population will be used for the evaluation of the efficacy assessments. 
6.3 
Modified micro-ITT Population 
The modified micro-ITT population will be defined separately for urogenital, rectal or pharyngeal 
body site populations and will include all randomized participants who had a positive NG culture 
from the relevant anatomical site at baseline (regardless of pre-existing resistance).  


 
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6.4 
Clinical Cure Population  
For the efficacy analyses of clinical cure rate, the clinical cure population will include all male at 
birth participants included in the micro-ITT population and who had at least one sign or symptom of 
urethral gonorrhoea at baseline. 
6.5 
Safety (SAF) Population 
The safety population will include all randomized participants who have received any part of trial 
treatment. 
6.6 
PK population 
The PK population will include all participants randomized to the zoliflodacin group who consent to 
participate to the PK sub-trial and from whom at least one valid PK sample post treatment is obtained. 
6.7 
Evaluable population 
The evaluable population will be defined separately for urogenital, rectal or pharyngeal body site 
populations and will include all randomized participants who have a positive NG culture at baseline 
and whose baseline antimicrobial susceptibility testing result showed no pre-existing resistance to 
both ceftriaxone and azithromycin, who do not vomit within 30 mins of administration of zoliflodacin 
or azithromycin and who have a NG culture result at the TOC visit. 
6.8 
Per-Protocol (PP) population 
The PP population will be defined separately for urogenital, rectal or pharyngeal body site 
populations and will include all participants in the micro-ITT population who meet all 
inclusion/exclusion criteria, complied with trial treatment, did not vomit within 30 mins of 
administration of zoliflodacin or azithromycin, did not receive any systemic antibiotic with known 
activity against NG prior to TOC visit, did not receive any of the prohibited medications, abstained 
from sexual intercourse or used condoms for vaginal, anal and oral sex prior to TOC and returned to 
the trial site for the TOC visit within the specified window (visit 4, trial day 6±2). 
6.9 
Clinical-PP population 
The clinical-PP population will include male at birth participants in the PP population with at least 
one sign or symptom of gonorrhoea at baseline and with an evaluable clinical outcome: 
6.10 Protocol deviations/violations and exclusions from analysis sets 
All violations and exclusions of participants from analysis populations will be identified at the 
Classification Meeting just prior to trial unblinding, through clinical review input provided by 
Sponsor, using the following sources of information: 
• 
Supportive participant listings, provided by the ICON lead statistician ahead of the 
Classification Meeting, based on data recorded on the eCRF.  


 
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• 
Protocol Deviation Logs, provided by ICON. 
Further, deviations from protocol will be classified as important or non-important. 
The important protocol deviations to be identified and to be included in the body of the CSR are: 
• 
Failure to obtain informed consent 
• 
Failure to meet Inclusion/Exclusion Criteria for randomized subjects 
• 
Non-compliance with trial treatment  
• 
Non-compliance with study assessment 
• 
Prohibited medications used up to TOC 
• 
Failure to conduct TOC in specified visit window  
• 
Failure to abstain from sexual intercourse or use condoms up to TOC 


 
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7 
STATISTICAL CONSIDERATIONS AND ANALYSIS 
7.1 
Derived Variables 
The below table provide the list of derived variables for demographic and baseline characteristics, 
baseline derivations and other important derivations of variables applicable for this trial. 
7.1.1 
Demographics 
 
Variables 
Formula 
Demographic and Baseline characteristics 
Age (years) 
Age as collected in eCRF will be used. 
Body mass index (BMI) (kg/m2)   weight (kg)/[height (m)]^2 
Derivation of Duration 
Trial day at any visit 
Date of interest – date of first dose of trial drug. One day is 
added if this difference is ≥ 0 
Baseline Derivations 
Baseline 
The baseline value is defined as the last observation prior to or 
on the date of the trial drug administration. i.e. Day 1/Dose 1 
Value. 
Change from baseline 
Post baseline value – Baseline value 
7.1.2 
Efficacy  
Microbiological cure: 
Microbiological cure is defined as a participant with a positive NG culture at baseline and a negative 
or indeterminate NG culture at the TOC visit for the specified body site. A positive NG culture is 
defined as a culture with confirmed microbiological identification by the central laboratory.  An  
indeterminate culture at TOC is defined as a culture overgrown with normal flora. 
Microbiological failure: 
Microbiological failure is defined as a participant with a positive NG culture at baseline and at the 
TOC visit. A participant with a positive NG culture at baseline and who is nonassessable for 
microbiological outcome at TOC (e.g. who has a missing microbiological outcome at the TOC due 
to a missed visit or a lost/damaged microbiological specimen) is also considered a failure in the 
analysis in the micro-ITT population. 
Clinical cure: 
Clinical cure is defined as a male at birth participant experiencing resolution of ALL signs and 
symptoms of urogenital gonococcal infection that were present at enrolment, and no new symptoms. 


 
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Lost-to-follow-up: 
For the purpose of the analysis, Lost-to-follow-up is defined as a participant who has missed his/her 
appointment after completing treatment and cannot be traced until and including the end of the 
expected follow-up period (30 days± 2 days). 
 
Non-evaluable for microbiological outcome: 
Non-evaluable for microbiological outcome is defined as a participant who did not have a urogenital 
positive culture result for NG at baseline (visit 1). 
7.2 
Handling of missing data and outliers 
Prior to analysis, any missing data will be investigated and reasons for missing data obtained and 
summarized where possible. All attempts will be made to avoid any missing outcome data and to 
correct for it. In the primary analysis the definition of the micro-ITT includes participants who are 
non-assessable for microbiological outcome or who are lost-to-follow-up as microbiological failures.  
A sensitivity analysis will be performed in which we will replace missing outcomes using multiple 
imputation (MI). 
MI method will be used for sensitivity analysis for primary endpoint to explore departures from 
assumptions about missing data. Otherwise, no imputation will be employed for the descriptive 
summaries and listings. 
7.2.1 Missing data analysis methods for sensitivity analysis 
The following sensitivity analyses of the primary endpoint will be performed using pattern mixture 
model (PMM) to determine the effect on the inference allowing data to be  
• 
missing at random (MAR) 
• 
missing not at random (MNAR) 
Multiple Imputation (MI) using PMM: 
In this approach, multiple imputed datasets will be generated based on the assumption of a monotone 
missing data pattern. The imputation will be performed using the monotone regression model to 
replace the missing values of the primary endpoint.  
Details are provided in Section 8.6.2.1. 
7.2.2 Handling of missing or incomplete dates 
 
Imputation rules for missing or partial medication start/stop dates are defined below: 


 
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Missing or partial medication start date: 
▪ 
If only DAY is missing, use the first day of the month.  
▪ 
If DAY and Month are both missing, use the first day of the year.  
▪ 
If DAY, Month and Year are all missing, use  date the patient was enrolled. 
Missing or partial medication stop date: 
▪ 
If only DAY is missing, use the last day of the month. 
▪ 
If DAY and Month are both missing, use the last day of the year. 
▪ 
If DAY, Month and year are all missing, assign ‘continuing’ status to stop date 
 
 


 
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8 
STATISTICAL METHODS 
8.1 
General statistical conventions 
All statistical procedures will be completed using SAS version 9.4 or higher. 
Unless otherwise stated, all statistical testing will be two-sided and will be performed using a 
significance (alpha) level of 0.05. Two-sided 95% confidence intervals (CI) will be provided when 
relevant. For the primary end point, statistical testing of the NI will be performed at significance 
level of 0.05 with a 12% NI margin in difference of proportions. 
For each microbiological outcome and anatomical site (Section 4 Trial Endpoints), there will be three 
analysis population types used for the efficacy analysis: the micro-ITT, evaluable and the PP 
population. The micro-ITT population will be the primary analysis population while the evaluable 
and PP population will be the secondary. For clinical outcomes, the clinical cure and PP populations 
will be used. 
For all microbiological assessments determining analysis population and efficacy outcome, central 
laboratory results will be used. 
Continuous variables will be summarized using descriptive statistics, including number of 
participants (n), mean, standard deviation (SD), median, minimum and maximum. One additional 
decimal point for mean and median and two additional decimal points for SD will be used in addition 
to the number of decimal points used for the measured values. 
For categorical variables, summaries will include counts of participants and percentages. Percentages 
will be rounded to one decimal place. 
For statistical analyses “baseline” refers to the last observation before treatment, i.e., pre-treatment 
values measured on the treatment day (baseline visit, day 1), and if missing or not evaluated, values 
will not be imputed. A HIV test result obtained post-dose but on the day of enrolment will be 
considered as baseline if no pre-treatment value exists. 
All summaries will be presented by treatment group, unless otherwise specified. Analyses will be 
performed by visit, irrespective of any time window deviations. 
All participant data, including those derived, will be presented in individual participant data listings. 
Unless otherwise stated, unscheduled visit results will be included in date/time chronological order, 
within participant listings only. All listings will be sorted by investigational site, participant number, 
date/time and visit. The treatment group (Test, Reference) as well as participant’s sex and age will 
be stated on each listing. Unless otherwise stated, data listings will be based on the Participant 
Randomized Population. 
Data obtained from participants enrolled at site 710-005 will not be included in any summary tables 
or figures, and will be included in listings only.  This is due to data integrity findings during GARDP 


 
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site audit indicating a serious breach of GCP. 
 
 


 
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8.2 
Participant disposition 
Participant disposition information will be summarized by treatment group and overall. The number 
and percent of participants who are randomized, who took a dose of trial drug, who were randomized 
and not treated, who complete the trial and who withdraw early from the trial will be presented. 
The primary reason for early withdrawal will also be tabulated. 
The number of participants randomized will be used as the denominator for the percentage 
calculation. Participant disposition will be listed. In addition, a listing will be provided to include the 
unmet inclusion/exclusion criteria at Screening/Baseline Visits. 
The number and percent of participants in each analysis population will also be tabulated. 
Screen failures will also be listed with reason for not being randomized. 
Treatment Misallocations: 
If a participant was: 
• 
Randomized but not treated, then they will be reported under their randomized treatment 
group for efficacy analyses. However, they are by definition excluded from the safety 
analyses as actual treatment is missing. 
• 
Randomized but took incorrect treatment, then they will be reported under their randomized 
treatment group for all efficacy analysis, but will be reported under the treatment they 
actually received for all safety analyses. 
8.3 
Protocol deviations 
The number of participants excluded from Randomized, Micro-ITT (urogenital), Micro-ITT 
(pharyngeal), Micro-ITT (rectal), modified Micro-ITT (urogenital), modified Micro-ITT 
(pharyngeal), modified Micro-ITT (rectal), Clinical-cure, SAF, PK, Evaluable (urogenital), 
Evaluable (pharyngeal), Evaluable (rectal), PP and Clinical-PP populations and reasons for exclusion 
will be summarized by treatment group and overall for all screened patients. 
Population membership details will be listed, including reason for exclusion from each population . 
All important protocol deviations identified will be summarized by treatment group and overall. 
A listing will be provided for protocol deviations identified based on data recorded on the eCRF 
and/or protocol deviation Logs from ICON Medical (on Randomized participants). 
8.4 
Demographics and baseline characteristics 
8.4.1 Demographics 
Age, height, weight, body mass index (BMI), sex at birth, gender, race and ethnicity at baseline will 
be summarized using descriptive statistics as described in Section 8.1 by treatment group and overall 
in the Micro-ITT (urogenital), Micro-ITT (pharyngeal), Micro-ITT (rectal) and Randomized 


 
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Populations. 
8.4.2 Baseline and disease characteristics 
The categorical baseline characteristics such as previous or coexisting sexually transmitted 
infections, urine pregnancy test, Human Immunodeficiency virus (HIV) testing and sexual history at 
baseline will be summarized by treatment group for the Micro-ITT (urogenital), Micro-ITT 
(pharyngeal), Micro-ITT (rectal) and Randomized Population.  
There will be additional table which will be summarizing baseline characteristics of participants by 
treatment groups with no missing outcome will be presented to assess whether these characteristics 
were balanced between the treatment groups when only participants with non-missing outcomes are 
considered. 
HIV positive status will include participants who have a positive HIV test at baseline (a HIV test 
result obtained post-dose but on the day of enrolment will be considered as baseline if no pre-
treatment value exists), medical history of HIV, or who are receiving anti-retroviral indicated for 
HIV treatment. 
Gonorrhoea clinical assessment at baseline for males at birth will be summarized in the Clinical-cure 
and Micro-ITT (urogenital) population.  Gonorrhoea clinical assessment at baseline for females at 
birth will be summarized in the Micro-ITT (urogenital) population.   
An individual listing will be provided for demographic and baseline characteristics. 
Presumptive (local lab) evaluations of Neisseria gonorrhoeae (NG) culture, NG-Nucleic Acid 
Amplification Testing (NAAT),  Chlamydia trachomatis NAAT and Mycoplasma genitalium NAAT 
at urogenital, rectal and pharyngeal sites will be summarized.   
Organisms identified by the central lab at baseline will be summarized by body site (although 
Neisseria gonorrhoeae cultures will be isolated and sent to central lab, contaminants or mis-
identification may be possible).  Results of all cultures by the local and central labs at baseline and 
TOC will be listed. 
8.4.3 Medical / Surgical history 
A summary of medical history will be presented by system organ class (SOC) and preferred term 
(PT) using Medical Dictionary for Regulatory Affairs® (MedDRA) Version 23.0 or higher. The table 
will be based on the SAF population. 
The details of medical history findings will be listed by participants and sites. 
A summary of STI history (from the sexual history questionnaire) will be presented by SOC and PT 
similarly.  The table will be based on the SAF population. 
8.4.4 Prior and concomitant medications 
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Organization (WHO) Drug Dictionary Standard or Enhanced and categorized as follows: 
Prior medications: are defined as those medications with a start date/time prior to dose of trial drug. 
Concomitant medications: are defined as those medications with a start date/time on or after dose 
of trial drug, or with start date/time prior to dose and stop date/time after dose of trial drug.  Therefore, 
a medication may be considered both prior and concomitant. 
Prior medications and concomitant medications will be summarized using frequency tables by 
anatomical therapeutic chemical (ATC) class level 1, ATC level 2 and preferred name by treatment 
group on the SAF Population.  
Details for imputing missing or partial start and/or stop dates of medication are described in Section 
7.2.2.  
In addition, prior medications and concomitant medications will be listed with ATC classification 
and preferred term by participants and sites. 
8.5 
Extent of exposure 
8.5.1 Treatment duration 
Since the participants will receive only one dose of trial medication, treatment duration will not be 
calculated. 
An individual listing will be provided to include details of drug administration by participant and 
sites. 
8.5.2 Treatment compliance 
All efforts will be taken to achieve 100% of treatment compliance at each Investigator site by site 
staff.  
Compliance information will not be summarized. 
8.6 
Efficacy analyses 
8.6.1 Analysis methods 
The primary analysis of efficacy will be based on the primary endpoint which is defined as a negative 
culture to NG at urethral or cervical sites at TOC (day 6 ±2) among participants included in the 
micro-ITT population. 
For the primary endpoint analysis, the proportion of participants with negative culture to NG at 
urogenital sites at TOC will be presented by treatment group. The point estimate and 2-sided 95% 
CI with Newcombe score method (9) for the treatment difference in proportion of 
ceftriaxone/azithromycin combination and  zoliflodacin will be presented for the primary endpoint. 
Newcombe 95% CIs for the treatment difference in proportion of ceftriaxone/azithromycin 
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difference with treatment groups based on randomized treatment.  The exact 95% CIs (Clopper-
Pearson method) will be used for the proportion of participants with negative culture within a 
treatment group. 
NI will be concluded if the upper limit of the 95% CI of the treatment difference of ceftriaxone+ 
azithromycin combination minus zoliflodacin is less than the NI margin of 0.12 (or 12%) for the 
primary efficacy endpoint. 
Subgroup analyses will be described in Section 8.6.3.1 
8.6.1.1 Multiplicity 
Multiplicity adjustment will not be done for the primary endpoint because there is only one.  
Statistical testing of secondary endpoints will not adjust alpha for multiplicity, and results should be 
interpreted with caution. 
8.6.1.2 Treatment by center interaction analysis (multi-center trial) 
There will not be any treatment-by-center interaction analysis performed for the endpoints. 
8.6.2 Analysis of primary efficacy endpoints 
The primary objective of this trial is to assess the efficacy of zoliflodacin compared to 
ceftriaxone/azithromycin combination in Microbiological cure as determined by culture at urethral 
or cervical sites at TOC (day 6 ±2). 
The null and alternative hypotheses are expressed as:  
                               H0: P2‒P1≥ 12% versus Ha: P2‒P1< 12%  
where P2 and P1 denote the proportions of negative culture to NG at urethral or cervical sites at TOC 
(day 6 ±2) in ceftriaxone/azithromycin combination and zoliflodacin group respectively. 
The primary endpoint will be summarized with individual proportions and its 95% CI using Clopper-
Pearson method within a treatment. And, the difference in the proportions of participants with 
negative culture to NG at urethral or cervical sites at the TOC visit will be calculated using 
Newcombe method and its 2-sided 95% CIs will be presented in percentages (6).  
The primary efficacy analysis will claim zoliflodacin as non-inferior to the ceftriaxone/azithromycin 
combination if the upper bound of the 2-sided 95% CI for the microbiological cure rate of the 
combination therapy minus zoliflodacin is less than the 12% prespecified NI margin.  
The primary efficacy analysis will be carried out using the participants from the Micro-ITT 
(urogenital) population, which includes participants who are non-assessable for microbiological 
outcome or who are lost-to-follow-up. This efficacy analysis will also be performed on the Modified 
Micro-ITT (urogenital), Evaluable (urogenital) and PP population as part of the secondary objectives. 
A similar analysis of microbiological cure rate at TOC at pharyngeal sites in relevant pharyngeal 


 
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populations, and of microbiological cure rate at TOC in rectal sites in relevant rectal populations, 
will also be performed. 
8.6.2.1 Sensitivity Analyses for primary efficacy endpoint 
The primary analysis will be repeated in the Evaluable (urogenital) population. 
After protocol amendment 3, samples were collected for TOC at an out of window assessment.  A 
sensitivity analysis of the primary analysis will be performed including assessment of TOC samples 
collected out of window. 
In addition, to include all randomized participants and replace missing values of microbiological cure 
at TOC, MI methods will be implemented as a sensitivity analysis.  
To take into account the possibility that missing outcomes are not completely at random and to trial 
the departures from assumptions about missing data at random, PMM will be used for both MAR 
and MNAR mechanisms, and the robustness will be tested using a tipping point analysis.  
Multiple imputed datasets will be generated based on the assumption of a monotone missing data 
pattern. The missing data will be imputed with predicted values from a multivariable logistic 
regression model that will include these observed participant data and that will be adjusted for 
baseline covariates (e.g. trial centre, age, history of unprotected sex). The multivariable model will 
yield a probability of a Bernoulli process that is used to generate values for the outcome data. The 
probability will be used to impute the missing outcome value by rounding it to the nearest integer (0 
or 1) or by sampling from a Bernoulli distribution. To avoid any bias, the imprecision due to 
imputation will be accounted for by means of multiple imputation (M=20 imputations) and seed 
value 1,234. Hence, multiple datasets with imputed outcomes will be generated and results will be 
pooled by using standard techniques taking into account the variation between imputed data sets (5). 
To take into account the possibility that missing outcomes are not completely at random, we will also 
fit a pattern mixture model under MAR that will be expanded to allow for the context of MNAR (5).  
General stepwise procedure for MI: 
➢ Step i) Imputation – Multiple copies of the original dataset will be generated by replacing 
missing values at TOC (Day 6) using Logistic Regression (LR) model (assuming a monotone 
pattern of missing data). Imputed microbiological cure will be used for the analysis. 
Based on the resulting logistic regression equation, a probability is generated for each case 
with missing data and a Bernoulli draw is made for that probability, producing imputed 
values of 0 or 1. 
 
➢ Step ii): Analysis – Risk difference for proportions at TOC (Day 6) will be performed for 
each of the multiple imputed datasets to estimate the relevant standard errors and difference 
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➢ Step iii): Pooling – The results from the multiple imputed datasets will be combined based 
on Rubin’s rules for pooling mean and variance to produce a unique point estimate (Risk 
Difference) and confidence intervals. 
 
Results of sensitivity analyses will be presented graphically by an estimation of the treatment effect 
(microbiological cure rate) in the combination therapy group, in the zoliflodacin group and in both 
groups depending on the departures from assumptions about missing data.  
The efficacy analysis mentioned above will also be performed on the PP population as part of the 
secondary objectives. 
8.6.3 Analysis of secondary efficacy endpoints 
The secondary efficacy endpoints will be analyzed for the comparison of treatment arms.  
For the comparisons of 
• 
The proportions of microbiological cure at TOC between both treatment groups at 
pharyngeal sites (in Micro-ITT (pharyngeal), Modified Micro-ITT (pharyngeal), Evaluable 
(pharyngeal) and PP populations) 
• 
The proportions of microbiological cure at TOC between both treatment groups at rectal sites 
(in Micro-ITT (rectal), Modified Micro-ITT (rectal), Evaluable (rectal) and PP populations) 
• 
The proportions of male at birth participants with clinical cure at TOC between both 
treatment groups (in Clinical Cure population and Clinical-PP populations). 
Two-sided 95% CIs for the proportions and the difference of proportions will be calculated, where 
appropriate (using same methods as for primary endpoint). 
In addition, the following comparison will be made using descriptive statistics only  
• 
The proportions of participants with a negative NG NAAT from urethral or cervical sites at 
TOC between both treatment groups 
• 
The proportions of participants with a negative NG NAAT from oropharyngeal sites at TOC 
between both treatment groups 
• 
The proportions of participants with a negative NG NAAT from rectal sites at TOC between 
both treatment groups 
These analyses will be conducted among participants that have a positive NAAT from the 
corresponding site at baseline. 
To analyse the antimicrobial susceptibility testing (AST) profile, MIC breakpoint (per CLSI criteria 
and EUCAST [3] criteria) for antibiotics other than zoliflodacin will be applied.  In addition the 
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panel by treatment group and site of infection at baseline and TOC. The proportion of isolates at or 
above MIC breakpoint (n/N) at baseline and TOC (if applicable) will also be reported by treatment 
group and by site of infection. Moreover, changes in MIC (changes of ≥2 doubling dilutions) between 
the baseline and TOC isolates will be reported for all participants with microbiological failure 
without any statistical comparison. 
The proportion of participants with microbiological cure at TOC will be presented by body site (in 
micro-ITT analysis set by body site), by MIC (for zoliflodacin, azithromycin and ceftriaxone) at 
baseline and treatment group. 
8.6.3.1 Subgroup Analyses 
To determine consistency of effect, the primary endpoint will be analyzed for subgroups listed below 
using the same analysis as the primary outcome.  Data will be presented in a table and a forest plot.   
• 
Sex at birth (male vs female) (per eCRF) 
• 
Gender (male vs female) 
• 
Age (<18 vs 18-64 vs ≥65) 
• 
Body mass (≤35–≤50kg vs >50–≤75kg vs >75–≤100kg vs >100kg) 
• 
HIV status (negative vs positive vs not collected)  
• 
Race (Black vs White vs Asian vs Other) 
• 
Region (EU vs South Africa vs Asia vs US) 
• 
Fasted status (fed prior to dosing vs fasted (last meal >2 hours) prior to dosing) 
• 
pre-existing resistance status (per CLSI urogenital result) to antibiotics commonly used for 
NG treatment (resistant to ceftriaxone alone vs resistant to azithromycin alone vs resistant to 
both vs susceptible to both) 
• 
Received PrEP medication for HIV at baseline (Yes vs No) 
• 
Risk factor MSM (Yes vs No) 
• 
Sex worker (Never vs Sometimes vs Often) 
Other baseline variables may also be included as subgroups, for example if a baseline imbalance is 
observed between treatment arms.   
The forest plots will be inspected, and the presence of qualitative interactions (a situation where the 
treatment effect is above the NI margin for one subgroup level, and below the NI margin for the 
complement of the subgroup) may be assessed by a global interaction test. 
Subgroup analysis may be repeated for key secondary endpoints. 


 
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8.6.4 Analysis of exploratory endpoints 
All the exploratory analyses will be based on the micro-ITT by body site, unless otherwise stated. 
The exploratory endpoints will be analyzed descriptively, and will not use statistical testing.  
The analysis of the below endpoint will be conducted among participants that have a positive NAAT 
from the corresponding site at baseline. 
Late eradication of NG NAAT is defined as both a negative NG NAAT test and negative NG culture 
at end of trial visit. 
The analysis of the below endpoints will be conducted out of participants with a positive NG NAAT 
test and a negative NG culture at TOC 
• 
Late eradication rate from urethral or cervical sites at the end of the trial (day 30 +/- 3 days) 
• 
Late eradication rate from oropharyngeal sites at the end of the trial (day 30 +/- 3 days) 
• 
Late eradication rate from rectal sites at the end of the trial (day 30 +/- 3 days) 
The analysis of the below endpoints will be conducted out of participants with symptoms at end of 
the trial (day 30 +/- 3 days): 
• 
Rate of positive NG NAAT test and/or positive NG culture at each anatomical site 
respectively at end of the trial (day 30 +/- 3 days) 
• 
Antimicrobial susceptibility profile testing (AST) of gonococcal strains isolated at the end 
of the trial (day 30 +/- 3 days) among those with a positive culture  
For the AST, the following exploratory, descriptive comparisons will be summarized: 
• 
AST profile (MIC distribution) of baseline and TOC isolates for participants with multiple 
sites of infection vs participants with unique site of infection. 
• 
AST profile (MIC distribution) of baseline and TOC isolates for isolates that are resistant to 
fluoroquinolones at baseline vs isolates that are fluoroquinolone-sensitive. 
• 
AST profile (MIC distribution) of baseline and TOC isolates for isolates that are  resistant to 
other antibiotics commonly used for NG treatment (e.g. azithromycin and ceftriaxone, 
tetracyclines) at baseline vs isolates that are sensitive to those antibiotics. 
• 
AST profile (MIC distribution) of baseline isolates of participants with subsequent 
microbiological failure vs microbiological cure (in the micro-ITT and evaluable populations. 
The below exploratory endpoint will be descriptively analyzed in a separate report to the CSR. 
• 
WGS of NG isolates from the TOC and end of trial visits plus all baseline isolates 
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WGS will be conducted on all NG isolates cultured at the TOC and end of trial visits, as well as on 
pre-treatment isolates from the respective participants. The objective of the analysis is to investigate 
relationships between pre-treatment and post-treatment NG isolates within those participants whose 
cultures at TOC or end of trial are found positive for NG, evaluate the likelihood of re-infection vs 
treatment failure and identify possible genetic determinants of zoliflodacin resistance. Percentages 
and frequencies will be presented at TOC and end of trial visit. 
8.7 
Safety analyses 
All the safety analyses will be conducted on the safety population (treated participants). 
All definitions relative to safety endpoints are detailed in the following Sections. 
All safety data will be summarized by treatment group.  
The safety analyses of changes from baseline to a specific time point in safety variables (e.g., 
laboratory parameters, weight) will only include participants from the Safety population who have 
data available for both the baseline and the time point under consideration unless otherwise specified. 
No statistical test will be performed.  
For the continuous safety measures, both actual and change values will be summarized using 
descriptive statistics at baseline and scheduled visit. 
8.7.1 Adverse events 
All Adverse events (AEs) will be classified by Primary System Organ Class (SOC), higher level 
group term (HLGT) and Preferred Term (PT) according to the Medical Dictionary for Regulatory 
Activities (MedDRA) Version 23.0 or higher. 
Adverse events will be sorted alphabetically by SOC and PT. In summaries by PT, AEs will be sorted 
by decreasing frequency according to the total column. 
An AE will be considered as treatment emergent adverse events (TEAE) if it occurs or worsens on 
or after receipt of the trial drug. Details for imputing missing or partial start dates of adverse events 
are described in Section 7.2.2. Imputed Adverse Event dates will be used for determining treatment-
emergence. 
The occurrence of AEs and SAEs will be summarized in terms of incidence, as well as in terms of 
total number of AEs. 


 
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                                                                     Page 38 of 44 
 
An AE overall summary table will be presented by treatment group and overall with the following 
information:   
• 
All AEs  
• 
All TEAEs  
• 
Related TEAE 
• 
Serious AEs (SAEs) 
• 
Related SAEs  
• 
 TEAEs Leading to treatment discontinuation 
• 
TEAEs by maximum severity (Mild, Moderate and Severe) 
• 
TEAEs by maximum severity (CTCAE Grades) 
The incidence of TEAEs will be summarized to include only one occurrence of a preferred term (PT) 
per participant per treatment. If a participant reports multiple occurrences of the same PT and 
treatment, then that preferred term will only be counted once. As with the PT, if a participant reports 
multiple TEAEs within the same system organ class (SOC) and treatment, that SOC will be counted 
only once.  
When reporting adverse events by severity, in addition to providing a summary table based on the 
event selection criteria detailed above, summary table will also be provided based on the most severe 
event during the treatment period - independent of relationship to trial treatment. 
All TEAEs, all TEAES by maximum severity, all TEAEs by maximum relationship, TEAEs leading 
to treatment discontinuation and all SAEs will be summarized by SOC, PT and treatment group using 
frequency counts and percentages (i.e., number and percentage of participants with an event) within 
treatment groups. 
All AEs will be listed, but only treatment-emergent AEs (TEAEs) will be summarized by SOC and 
PT. A summary of SAEs, related SAEs and a summary of non-serious AEs will be presented by SOC 
and PT by treatment group. In addition, all SAEs will be listed by participant.  
A summary of all AEs leading to death will be presented by SOC and PT by treatment group.  
A summary of TEAEs by SOC, PT, and severity will be presented by treatment group. Severity will 
be graded by the investigator according to the Common Terminology Criteria for Adverse Events 
(CTCAE) as “Mild”, “Moderate”, “Severe”, “life-threatening” and “death”. If a participant reports 
multiple occurrences of the same PT/HLGT or SOC, only the most severe will be presented. 


 
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Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
                                                                     Page 39 of 44 
 
8.7.2 Clinical laboratory evaluations 
For the purposes of summarization in both the tables and listings, all laboratory values will be 
presented in SI units. If a lab value is reported using a nonnumeric qualifier e.g., less than (<) a 
certain value,  the given numeric value subtracting (1E-dp) will be used in the summary statistics, 
where dp is the number of decimal places shown in result e.g. if result = "< 0.05" then AVAL = 0.05 
- (1E-2) = 0.04.  Similarly if result is reported using greater than (>) then convert the number in result 
to numeric and add (1E-dp), where dp is the number of decimal places shown in result e.g. if result 
= "> 0.05" then AVAL = 0.05 + (1E-2) = 0.06. 
Descriptive statistics (mean, standard deviation, median, interquartile range, minimum and 
maximum) will be used to summarize clinical laboratory data at baseline and during follow-up visits. 
Changes in laboratory results pre- and post-treatment will be examined. Shift tables showing the 
number of participants with a clinically significant value at baseline as well as at all post baseline 
visits will be presented per parameter.  
Continuous baseline laboratory variables such as Alanine Aminotransferase (ALT) will be 
summarized by descriptive statistics in the same way as continuous demographic variables for the 
Micro-ITT, Clinical-cure and SAF Populations.   
A summary table and box plot by visit and race will be presented in the SAF population for white 
cell count and absolute neutrophil count.  Abbreviated patient profiles of  participants with neutrophil 
count <1.0 x 109/L post-baseline will be presented, including demographic information, medical 
history, STI history, medications, AEs and key laboratory parameters such as neutrophils, platelets, 
red blood cells and white blood cells. 
A table and figure of maximum post-dose ALT vs maximum post-dose total bilirubin, expressed as 
multiples of ULN, will be presented. 
To ensure consistency in the eGFR values presented, eGFR will calculated programmatically from 
laboratory data for presentation in summary tables.   For calculation of eGFR, the following formula 
(CKD-EPI) will be used (15): 
𝑒𝐺𝐹𝑅= 142 × 𝑚𝑖𝑛(𝑆𝑐𝑟𝜅
⁄ , 1)𝛼 × 𝑚𝑎𝑥(𝑆𝑐𝑟𝜅
⁄ , 1)−1.200 × 0.9938𝐴𝑔𝑒 × 1.012[𝑖𝑓 𝑓𝑒𝑚𝑎𝑙𝑒] 
Where Scr is serum creatinine (mg/dL), κ is 0.7 for females and 0.9 for males, α is -0.241 for females 
and -0.302 for males, min indicates the minimum of 𝑆𝑐𝑟𝜅
⁄  or 1, and max indicates the maximum of 
𝑆𝑐𝑟𝜅
⁄  or 1. 
Both calculated eGFR and eGRF as reported by the investigator will be listed.   


 
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Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
                                                                     Page 40 of 44 
 
8.7.3 Physical examinations 
Descriptive statistics for vital sign measurements (weight, BMI) and their changes from baseline, 
when appropriate, at each post-baseline visit will be presented by treatment group and overall. Height 
measurements collected at Day 1/Visit 1 will be carried forward for future visits to calculate BMI. 
Vital signs data will be listed. 
All other physical examination data (General appearance, Head, Eyes, Ears, Nose, Throat (HEENT), 
Neck, Lymph nodes, Cardiovascular/Heart, Pulmonary/Chest, Abdomen, Genitourinary, 
Extremities, Skin, Musculoskeletal and Neurological) will be summarized at each visit with 
percentages and frequencies along with abnormalities by treatment group and overall. 
All physical examination data and abnormalities will be listed (including pre-treatment and post-
treatment results). Shift tables from baseline to Visit 5/Day 30 of normal vs. abnormal assessments 
will be provided by treatment group.  
8.7.4 Electrocardiograms (ECG) 
ECG data are not collected for this trial. 
8.7.5 Pregnancy 
Positive pregnancy tests after dosing will be listed. 
8.8 
Other analysis 
8.8.1 Pharmacokinetics (PK) analysis 
The plasma concentration of zoliflodacin will be retained in SDTM dataset only.   
The analysis of PK parameters will be addressed in a separate report. 
8.9 
Interim analysis 
No formal interim statistical analysis is planned. 
8.9.1 
Data Safety Monitoring Board (DSMB) 
An independent data and safety monitoring board (DSMB), composed of 3 members independent of 
the investigators and sponsor, will be constituted prior to trial implementation. Its role will be to 
monitor the accumulated trial data for participants’ safety. Depending on this evaluation, the DSMB 
will make recommendations to the sponsor concerning the continuation, modification or termination 
of the trial. There will be no planned interim analysis in this trial. 
The DSMB will consist of at least one STI clinical expert. Support from an independent statistician 
will be provided by ICON GPHS. An unblinded statistician will be available should specific requests 
requiring an unblinded statistician from the data safety monitoring board arise. Prior to trial start, a 


 
Final Analysis 
Statistical Analysis Plan (SAP) 
 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
                                                                     Page 41 of 44 
 
DSMB charter and SOP will be established and the schedule for subsequent, interim meetings will 
be determined. The format of DSMB reports will also be discussed. 
During the trial, the sponsor will be responsible for timely communicating to the DSMB all SAEs. 
In addition, the sponsor will communicate quarterly progress reports to the DSMB that will include 
safety listings and Council for International Organizations for Medical Science (CIOMS) reports. 
The DSMB will be responsible for interpreting the information communicated by the sponsor and 
for determining: 
• 
whether the overall incidence, seriousness and severity of AEs jeopardizes participants’ 
safety 
• 
whether the investigational drug poses significant, new, safety concern compared to the 
reference information. 
 


 
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Statistical Analysis Plan (SAP) 
 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
                                                                     Page 42 of 44 
 
9 
CHANGES TO PLANNED ANALYSIS FROM TRIAL 
PROTOCOL 
Clarification that the primary efficacy analysis will claim zoliflodacin as non-inferior to the 
ceftriaxone/azithromycin combination if the upper bound of the 2-sided 95% CI for the 
microbiological cure rate of the combination therapy minus zoliflodacin is less than (not less 
than or equal to) the 12% prespecified NI margin. This is in line with FDA guidance “Non-
Inferiority Clinical Trials to Establish Effectiveness” (12). 
 
 


 
Final Analysis 
Statistical Analysis Plan (SAP) 
 
Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
                                                                     Page 43 of 44 
 
10 
REFERENCES 
 
1. 
Chen MY, McNulty A, Avery A, Whiley D, Tabrizi SN, Hardy D, et al. Solithromycin versus 
ceftriaxone plus azithromycin for the treatment of uncomplicated genital gonorrhoea 
(SOLITAIRE-U): a randomised phase 3 non-inferiority trial. The Lancet Infectious 
Diseases. 2019;19(8):833-842. 
2. 
Dumville JC, Hahn S, Miles JNV, Torgerson DJ. The use of unequal randomisation ratios in 
clinical trials: A review. Contemp Clin Trials [Internet]. 2006 Feb [cited 2018 Jan 
22];27(1):1–12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16236557 
3. 
EUCAST Clinical breakpoints v12.0. 1 Jan 2022  Available from: 
https://www.eucast.org/clinical_breakpoints/ 
4. 
(13)Hook EW, 3rd, Golden MR, Taylor SN, Henry E, Tseng C, Workowski KA, et al. 
Efficacy and Safety of Single-Dose Oral Delafloxacin Compared With Intramuscular 
Ceftriaxone for Uncomplicated Gonorrhea Treatment: An Open-Label, Noninferiority, 
Phase 3, Multicenter, Randomized Study. Sexually Transmitted Diseases. 2019;46(5):279-
286. 
5. 
ICH Topic E3: Structure and Content of Clinical Study Reports (CPMP/ICH/137/95- 
adopted December 1995). 
6. 
ICH Topic E9: Statistical Principles for Clinical Trials (CPMP/ICH/363/96 – adopted March 
1998). 
7. 
(14)Mitrani-Gold FS, Fix J, Donald A. Systematic Review and Meta-Analysis to Estimate 
the Treatment Effect and Inform a Non-Inferiority Margin for a Phase 3 Non-Inferiority Trial 
in Uncomplicated Urogenital Gonorrhea. Sexually Transmitted Diseases. 2022;49(9):635-
43. 
8. 
Performance Standards for Antimicrobial Susceptibility Testing, 30th Edition. CLSI 
supplement M100 (ISBN 978-1-68440-066-9 [Print}; ISBN 978-1-68440-067-6 
[Electronic]). 
Jan 
2020. 
 
Available 
from 
https://www.nih.org.pk/wp-
content/uploads/2021/02/CLSI-2020.pdfClinical and Laboratory Standards Institute, 950 
West Valley Road, Suite 2500, Wayne, Pennsylvania 19087 USA, Jan 2020. 
9. 
Robert Gordon Newcombe. Interval estimation for the difference between independent 
proportions: comparison of eleven methods. Statistics in medicine 1998 
10. 
Taylor SN, Marrazzo J, Batteiger BE, Hook EW, 3rd, Sena AC, Long J, et al. Single-Dose 
Zoliflodacin (ETX0914) for Treatment of Urogenital Gonorrhea. New England Journal of 
Medicine. 2018;379(19):1835-1845. 
11. 
Taylor SN, Morris DH, Avery AK, Workowski KA, Batteiger BE, Tiffany CA, et al. 
Gepotidacin for the Treatment of Uncomplicated Urogenital Gonorrhea: A Phase 2, 
Randomized, Dose-Ranging, Single-Oral Dose Evaluation. Clinical Infectious Diseases. 
2018;67(4):504-512. 
12. 
US FDA. Non-Inferiority Clinical Trials to Establish Effectiveness – Guidance for Industry.  
Silver Spring; 2016 


 
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Statistical Analysis Plan 
Protocol Number: STI_Zoli001 
Version: 3.0, Date: 14 Sep 2023 
                                                                     Page 44 of 44 
 
13. 
US FDA. Uncomplicated Gonorrhea: Developing Drugs for Treatment - Guidance for 
Industry. Silver Spring; 2015. 
14. 
WHO. WHO guidelines for the treatment of Neisseria gonorrhoeae - Annex D evidence 
profiles and evidence-to-decision frameworks. 2016. 
15. 
Inker, Lesley A et al for the Chronic Kidney Disease Epidemiology Collaboration. New 
Creatinine- and Cystatin C-Based Equations to Estimate GFR without Race. N Engl J Med 
2021; 385:1737-1749. 
16. 
 
 
 
 
 
 
 


GARDP_STI_Zoli001_SAP Final_v3.0
Final Audit Report
2023-09-14
Created:
2023-09-14
By:
Human Resources (HumanResources@plus-project.co.uk)
Status:
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Transaction ID:
CBJCHBCAABAAUHjTWlb5LozIjwcA5YVXz19xDMOJJ49y
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