Clinical trial NCT02620787
Conditions: Diabetes Wound Infection Healthy Volunteers
Sponsor: Hartford Hospital
Start date: 2016-02-23; Completion date: 2017-03-01
Enrollment: 18 participants; Allocation: NON_RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This study will determine the tissue penetration of tedizolid (Sivextro, Merck \& Co.), a novel oxazolidinone antibiotic, into the extracellular, interstitial fluid of soft tissue in diabetic patients with lower limb wound infections. Penetration will be compared with a group of healthy volunteer control participants.

Detailed description:
This study will enroll 10 patients with diabetes who are admitted with a lower limb wound infection and 6 healthy volunteer control participants. The study will take place in an inpatient unit at Hartford Hospital for all patients and in the Clinical Research Center at Hartford Hospital for all healthy volunteers. All participants will receive 3 to 6 doses of oral tedizolid 200mg once daily. A microdialysis probe (Mdialysis Inc., N. Chelmsford, MA) will be inserted into the subcutaneous soft tissue near the margin of the wound (patients) or in the thigh (healthy volunteers). The microdialysis probe is perfused with lactated Ringer's solution and samples are collected for the 24 hours following the final dose (i.e., 48-72 hours). A peripheral intravenous catheter will be inserted into an arm vein to collect blood samples simultaneously with microdialysis samples. Concentrations in tissue are compared with blood to determine percent penetration.

Arms: arm 1: Participants with a documented medical history of Type 1 or Type 2 diabetes and a mild to moderate (Grade 2 or 3) wound infection of the lower limb will receive 3 to 6 doses of oral tedizolid 200mg once daily, followed by sampling of interstitial tissue fluid at the margin of the wound by a microdialysis probe over 24 hours following the last dose (e.g., 48-72 hours). arm 2: Participants will be male or female healthy adult volunteers with no significant medical or medication history. Participants will receive 3 to 6 doses of oral tedizolid 200mg once daily, followed by sampling of interstitial tissue fluid at the margin of the wound by a microdialysis probe over 24 hours following the last dose (e.g., 48-72 hours).
Interventions: intervention 1: Tedizolid intervention 2: Microdialysis Catheter Insertion
Intervention descriptions: intervention 1: None intervention 2: A 20 kila-Dalton microdialysis probe (63 MD catheter; MDialysis Inc., N. Chelmsford, MA) will be inserted into the subcutaneous tissue at the margin of the wound (patient group) or in the thigh tissue (healthy volunteers). The probe will be left in place for the final dose and all tissue sampling procedures thereafter. This probe is perfused with a physiologic solution to collect interstitial fluid samples. The probe will then be removed after completion of sample collection.

Protocol documents:
Prot_SAP_000.pdf: 
       
1 
Protocol Version Date: June 27, 2016 
 
 
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Requirements for Submitting a Full Proposal 
 
Section #1 - MISP Protocol Identification 
 
Study Title: 
Comparative Assessment of Tedizolid Tissue Penetration and Pharmacokinetic Profile Between 
Diabetic Patients With Wound Infections and Healthy Volunteers via In Vivo Microdialysis 
 
Request Date: 
26-AUG-2015 
Protocol Version 
Date: 
11-JAN-2017 
Institution Name 
Center for Anti-Infective Research and Development 
Hartford Hospital 
Investigator 
Contact 
Information: 
- Full address  
- Phone No. 
- Fax  No. 
- e-mail address 
David P. Nicolau, PharmD, FCCP, FIDSA 
Center for Anti-Infective Research and Development 
Hartford Hospital 
80 Seymour Street 
Hartford, CT 06102 
Tel: 860.972.3941 
Fax: 860.545.3992 
Email: david.nicolau@hhchealth.org 
 


       
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Protocol Version Date: June 27, 2016 
 
Section #2- Core Protocol 
 
2.1 Objectives & 
Hypotheses  
 
 
 
 
2.1.1 Primary Objectives:   
To describe the pharmacokinetic profile of oral tedizolid in the plasma and 
subcutaneous tissue of diabetic patients with ongoing wound infections of the lower 
extremities, i.e., below the knee, (study group) and compare it to the profile in 
healthy volunteers (control group) using in vivo microdialysis. 
 
2.1.2 Secondary Objectives:   
To describe the safety and tolerability of oral tedizolid in diabetic patients 
with diabetic foot infections and in healthy volunteers 
2.2 Background & 
Rationale, 
Significance of 
Selected Topic & 
Preliminary Data  
 
The annual incidence of foot ulcers among diabetics has been estimated at 
between 6% to 11.5%, and 10 to 15% of those with diabetes will have at least one 
foot ulcer during their lifetime.1 The majority (upwards of 60%) of these diabetic 
ulcers become infected.2 Treatment of these complicated diabetic wound infections 
primarily involve surgical intervention, topical antiseptics, and systemic antibiotic 
therapy.3 However, despite advances in these areas, outcomes from such infections 
remain poor and often lead to limb amputation in 15% to 20% of participants within 5 
years.4    
Gram-positive organisms, particularly Staphylococcus aureus, are the main 
pathogens found in diabetic wound infections.3 As antibiotic resistance rates have 
risen, methicillin-resistant S. aureus (MRSA) has also become more frequent in 
acute bacterial skin and skin structure infections (ABSSSI).5  Additionally, diabetic 
wound infections caused by MRSA are associated with worse outcomes compared 
with other pathogens.5,6 As a result, antibiotics targeting MRSA are often prescribed 
for the treatment of diabetic wound infections either as monotherapy, or in 
combination with other antibiotics to cover Gram-negative and anaerobic bacteria 
that also may be present. 
Tedizolid (Sivextro®, Cubist Pharmaceuticals Inc., Lexington, MA), the active 
moiety of the prodrug tedizolid phosphate, is an oxazolidinone antibiotic approved by 
the FDA for the treatment of ABSSSI caused by S. aureus (including MRSA), 
Streptococcus pyogenes, Streptococcus agalactiae, and Enterococcus faecalis.7 A 
6-day course of tedizolid was well-tolerated and non-inferior to 10-day course of 
linezolid in Phase II and Phase III clinical trials of ABSSSI.8,9,10 
The pharmacokinetic profile of tedizolid has been described in numerous 
patient populations.11 However, the penetration into tissue during an active infection 
has yet to be elucidated. The most accurate method to calculate overall penetration 
is to evaluate the entire drug exposure, or AUC, in the tissue of interest and compare 
this with the overall AUC in blood. In the setting of clinical infection, our group has 
successfully applied a technique called in vivo microdialysis to assess the interstitial 
(i.e., extracellular) concentration profile of antimicrobials in comparison to their 
systemic exposures.12,13,14,15 This approach involves placing a probe with a semi-
permeable membrane at the tip into tissue and constantly perfusing the probe with a 
physiologic solution via a pump; this approach allows for the continuous collection of 
extracellular fluid from the tissue and enables assessment of drug concentration over 
a specified time period (i.e., the entire dosing interval). Using this methodology, the 
penetration of a single 600 mg oral dose of tedizolid into muscle and subcutaneous 
adipose tissue of the thigh was assessed in 12 healthy volunteers.16 Tedizolid 
demonstrated an AUCtissue/AUCplasma ratio of 1.1 and 1.2 for adipose tissue and 
muscle, respectively, indicating excellent tissue penetration for the oral route of the 
drug administration into healthy volunteers. Although these data are promising, the 


       
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Protocol Version Date: June 27, 2016 
tissue penetration into actively infected tissue may vary from that of healthy 
volunteers.  Furthermore, the dose tested was three-fold greater than the currently 
approved dosage of tedizolid. Because ABSSSI are very common in the diabetic 
patient and tedizolid may be a suitable oral therapeutic option, a study examining the 
tissue penetration of oral tedizolid in this population with ongoing infection is required 
to provide a more complete understanding of the pharmacokinetic profile of this 
novel compound. Hence a more comprehensive assessment of the interstitial fluid 
concentrations at the site of infection will serve as the pharmacologic basis for the 
clinical utility of tedizolid in the infected diabetic patient. 
 
2.3 Study Design 
 
2.3.1 Sites  
The study will be conducted at Hartford Hospital, Hartford, CT. For participants 
enrolled in the study group (i.e., infected diabetic patients), all study interventions will 
occur while admitted as a Hartford Hospital inpatient.  For participants enrolled in the 
control group (i.e., healthy adult volunteers), study interventions will occur in a study 
physician’s office (baseline screening), at a local clinical laboratory (baseline 
laboratory screening), and in the Clinical Research Center (CRC) at Hartford 
Hospital. 
 
2.3.2 Inclusion Criteria 
2.3.2.1 Study Group 
Participants with a documented medical history of Type 1 or Type 2 diabetes (for 
which they are receiving insulin or oral anti-hyperglycemic agents), and a suspected 
complicated skin and skin structure infection will be included. The suspected 
infection will be an ongoing and infection will be defined as mild or moderate by the 
Infectious Diseases Society of America,17 or as Grade 2 or 3 by the International 
Consensus on the Diabetic Foot (Table 1).18 Other anti-infective agents besides the 
study drug, except linezolid, will be permitted for the purposes of treatment. 
 
Table 1. Clinical Classification of Infections 
Clinical manifestations of infection 
Infection severitya 
PEDIS 
gradeb 
Wound lacking purulence or any 
manifestations of inflammation 
Uninfected 
1 
Presence of ≥2 manifestations of 
inflammation (purulence, or erythema, pain, 
tenderness, warmth, or induration), but any 
cellulitis/erythema extends ≤2 cm around the 
ulcer, and infection is limited to the skin or 
superficial subcutaneous tissues; no other 
local complications or systemic illness 
 
Mild 
2 
Infection (as above) in a participant who is 
systemically well and metabolically stable 
but which has ≥1 of the following 
characteristics: cellulitis extending >2 cm, 
lymphangitic streaking, spread beneath the 
superficial fascia, deep-tissue abscess, 
gangrene, and involvement of muscle, 
tendon, joint or bone 
 
Moderate 
3 
Infection in a participant with systemic 
toxicity or metabolic instability (e.g., fever, 
Severe 
4 


       
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Protocol Version Date: June 27, 2016 
chills, tachycardia, hypotension, confusion, 
vomiting, leukocytosis, acidosis, severe 
hyperglycemia, or azotemia) 
a Infectious Diseases Society of America; b International Consensus on the Diabetic 
Foot; PEDIS, perfusion, extent/size, depth/tissue loss, infection, and sensation 
 
2.3.2.2 Control Group 
Male or female healthy adult (≥ 18 years of age) volunteers who will be identified via 
hospital and local advertisements (newspaper, postings, and internet) in the Greater 
Hartford, Connecticut region would be eligible to be enrolled. 
 
2.3.3 Exclusion Criteria 
Participants in the study or control group will be excluded if any of the 
following criteria are met:   
1. Less than 18 years of age 
2. History of hypersensitivity to tedizolid or linezolid 
3. History of hypersensitivity to lidocaine or lidocaine derivatives 
4. Pregnant or breastfeeding 
5. Presence of anemia, thrombocytopenia, or leukopenia as defined by 
hematocrit, platelet, or white blood cell count < 75% of the lower limit of 
normal7 
6. Concomitant receipt of linezolid 
7. Any other reason felt by the investigator to potentially affect the 
outcomes of the study 
 
2.3.3.1 Additional Exclusion Criteria for Study Group 
1. Participants likely to require multiple surgical interventions during the 
study period, which therefore could affect placement of the microdialysis 
catheter 
 
2.3.3.2 Additional Criteria for Control Group 
1. Positive urine drug screen (cocaine, THC, opiates, benzodiazepines, 
and amphetamines). 
2. History of regular alcohol consumption exceeding 7 drinks/week for 
females or 14 drinks/week for men (1 drink = 5 ounces of wine or 12 
ounces of beer or 1.5 ounces of hard liquor) within 6 months of 
screening. 
3. Use of tobacco- or nicotine-containing products in excess of the 
equivalence of 5 cigarettes per day. 
4. Use of prescription or nonprescription drugs, vitamins, or dietary 
supplements within 7 days or 5 half-lives (whichever is longer) prior to 
the first dose of study medication, with the exception of acetaminophen 
at doses of ≤ 1 g/day. Herbal supplements, hormonal methods of 
contraception (including oral and transdermal contraceptives, injectable 
progesterone, progestin subdermal implants, progesterone-releasing 
IUDs, postcoital contraceptive methods), and hormone replacement 
therapy must be discontinued at least 14 days prior to the first dose of 
study medication. Depo-Provera® must be discontinued at least 6 
months prior to the first dose of study medication. 
 
2.4 Study Flowchart 
 


       
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Protocol Version Date: June 27, 2016 
2.5 Study 
Procedures 
2.5.1 Screening Procedure 
2.5.1.1 Study Group 
Electronic medical records of admitted diabetic patients who are being followed by 
podiatrists for infections of the lower limbs will be pre-screened to identify patients 
eligible for study enrollment through evaluating each patient’s profile for the meeting 
of inclusion and exclusion criteria. Pre-screening will involve accessing patient’s 
medical record to determine eligibility.  If eligible, written informed consent will be 
obtained (see 2.5.2) followed by complete screening, which will include a physical 
exam, medical, surgical, and medication history and collection of blood and urine for 
laboratory assessment (see 2.5.5.1).  Screening will occur within 24 hours of the first 
dose of tedizolid.  
 
2.5.1.2 Control Group 
Adult healthy volunteers will be identified via hospital and local advertisements 
(newspaper, postings, and internet) and will be initially pre-screened via phone 
interview.  If eligible, all volunteers will be screened by a study physician within 28 
days of the scheduled study period to confirm that inclusion and exclusion criteria 
are met after providing written informed consent (see 2.5.2).  This will include a 
physical exam, medical, surgical, and medication history and collection of blood and 
urine for laboratory assessment (see 2.5.5.1).   
 
2.5.2 Informed Consent 
Prior to study enrollment, patients and healthy volunteers identified as eligible for the 
study will be approached for consenting, where they will be provided with written 
informed consent that will document their election and agreement to participate in 
the study. The consenting process will be conducted by the principal investigator, co-
investigators, or trained research staff members. A copy of the signed consent will 
be provided to the participant and placed in the medical record (study group only). 
Screening and Informed Consent 
Study Group: Within 24 hours of first tedizolid dose 
Control Group: Within 28 days of first tedizolid dose 
Administration of tedizolid phosphate 
Study Group: 200mg orally q24h x 3-6 doses 
Control Group: 200mg orally q24h x 3 doses  
Blood sample collection around final dose  
(0, 1, 2, 2.5, 3, 3.5, 4, 6, 8, 12, 16, 20, and 24 hours) 
Dialysate sample collection around final dose  
(0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 16, 20, and 24 hours) 
At 
steady 
state 
Data Analysis 
Final Report 
Study Exit Physical and Labs 


       
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Protocol Version Date: June 27, 2016 
 
2.5.3 Study Drug 
All participants will receive tedizolid phosphate 200 mg orally every 24 hours. The 
study group will receive 3-6 doses, to allow flexibility in sample collection among 
other medical/surgical interventions required during his/her hospitalization.  The 
control group will receive 3 doses to achieve steady-state before sample collection. 
All participants in the study group will also receive standard intravenous or oral 
antibiotic therapy to treat their diabetic foot infections. 
 
2.5.4 Summary of Interventions 
• 
Screening physical exam and baseline blood and urine laboratory 
assessment 
• 
Administration of oral tedizolid phosphate to achieve steady-state 
• 
Insertion of microdialysis probe by study physician (see 2.5.5.3) 
• 
Collection of blood samples 
• 
Collection of dialysate samples 
• 
End of study physical exam and blood and urine laboratory assessment 
 
 
2.5.5 Procedures 
2.5.5.1 Baseline Participant Evaluations 
At screening, eligibility will be verified using inclusion/exclusion criteria. A general 
physical examination, including pedal pulses (study group only), a 
medical/surgical/medication history and vital signs (temperature, blood pressure, 
heart rate, respiratory rate) will be conducted by the study physician. Clinical 
laboratory tests, including serum electrolyte panel, serum creatinine, liver function 
panel, complete blood count with differential, glycosylated hemoglobin 
(HbA1c)(study group only), albumin, and microscopic urinalysis will be performed 
unless drawn within the last three days and the participant is clinically stable. Urine 
pregnancy tests will be required for women of childbearing potential. Concomitant 
medications will be recorded. A blood sample for screening of common drugs of 
abuse (cocaine, tetrahydrocannabinol (THC), opiates, benzodiazepines, and 
amphetamines) will be collected (control group only). 
 
Study group participants will be screened within 24 hours of first dose of tedizolid.  
Control group participants will be screened within 28 days of first dose of tedizolid.   
 
2.5.5.2 Clinical Research Center (CRC) – (Control group only) 
Once enrolled and confirmed eligible at baseline screening, control group 
participants will be admitted to the CRC at Hartford Hospital on the evening of Study 
Day -1.  A second screening of selected control group participants, which will include 
a brief physical exam, vital signs, medical history, and repeat of all labs tested in 
2.5.5.1 except for drugs of abuse screening, will take place.  This is to confirm study 
eligibility is maintained. Study drug will be administered on Study Days 1, 2, and 3.  
A microdialysis catheter (see 2.5.5.3) will be inserted on Study Day 3, followed by 
blood and dialysate collection (see 2.5.5.5 and 2.5.5.6).  A final end of study physical 
exam and collection of blood and urine for laboratory assessment will be conducted 
on Study Day 4 before discharge.  On Study Days 1 and 2 (only), participants are 
permitted to leave the CRC for work/school or at discretion of the Principal 
Investigator after oral dosing and a 4 hour monitoring period. Participants must 
return to the CRC for dinner time (7pm) on the same day. During the remainder of 
the study (Day 3 and Day 4), participants will not be permitted to leave the CRC. 
Lunch and Dinner will be provided for participants while they are in the CRC. 
Participants must refrain from consuming caffeinated and alcoholic beverages during 
the study (Day -1 to Day 4).. 
 


       
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Protocol Version Date: June 27, 2016 
2.5.5.2 Microdialysis Procedure 
A microdialysis probe (63 MD catheter; MDialysis Inc., N. Chelmsford, MA) with a 
membrane length of 30 mm and molecular cut-off of 20 kDa will be inserted into 
subcutaneous tissue near the margin of the wound (study group) or healthy thigh 
tissue (control group) via a guidance cannula, following a local injection of lidocaine 
0.5% solution to minimize pain.12 Specifically, for the study population a puncture 
hole will be made 10 cm away from the margin of the wound, in order to place the 
semi-permeable probe at the tip of the catheter within 5 cm of the wound (i.e., peri-
ulcer area).19 The microdialysis probe will be inserted just prior to the final planned 
tedizolid dose in all participants.  The guidance cannula will then be removed, 
leaving the microdialysis probe implanted subcutaneously. 
The microdialysis system will be connected and constantly perfused with lactated 
Ringer’s solution (perfusate) at a flow rate of 2 µL/min with a microinfusion pump 
(CMA 107 microdialysis pump, CMA Microdialysis AB, Solna, Sweden). After a 30-
minute baseline sampling period, sampling of the interstitial fluid will begin before the 
start of the final dose of oral tedizolid for baseline values. At the beginning of the final 
dose, sampling will occur as noted in section 2.5.5.6. Once dialysate sampling is 
complete, the probe will be calibrated by the retrodialysis technique over a 1-hour 
interval to assess recovery of the antibiotic through the dialysis membrane. A 
calibration standard concentration of tedizolid 100 µg/mL will be added to the 
perfusate and its rate of disappearance through the membrane will determine the 
recovery rate by obtaining a dialysate sample. Recovery of tedizolid via retrodialysis 
will be calculated as follows:  % Recovery = 100 – (Concentrationdialysate / 
Concentrationperfusate × 100). 
 
2.5.5.4 Study Drug Administration 
Tedizolid 200 mg will be administered by the oral route every 24 hours for 3-6 doses 
(study group only) or for 3 days (control group only). The doses will be administered 
by the nursing staff on the morning of the study days with a glass of water. Each 
dose will be preceded by an 8-hour fast and followed by a 4-hour fast. A record log 
of the date and time of administration will be maintained.  
 
2.5.5.5 Plasma Sample Collection 
Blood samples to assess tedizolid concentrations will be collected over a 24-hour 
period after the final dose. Blood samples of 10 mL each will be collected through a 
Jelco® catheter at pre-determined time points.  Blood sample times will be at 0 (just 
before administration of the final dose), 1, 2, 2.5, 3, 3.5, 4, 6, 8, 12, 16, 20, and 24 
hours. Blood samples will be collected in a 10-mL BD Vacutainer containing sodium 
heparin (green top). All blood samples will be immediately centrifuged (2,000 × g for 
10 min) to collect the separated plasma, which will be stored in amber-colored 
polypropylene tubes to protect from light at -80 °C until concentration determination. 
 
2.5.5.6 Dialysate Sample Collection 
Interstitial fluid concentrations of the soft tissue in the lower extremity will be 
assessed by in vivo microdialysis. Participants will refrain from excessive movement 
during the sampling process. After catheter insertion, the probe will be perfused with 
lactated Ringer’s solution for 30 minutes prior to sampling. A baseline dialysate 
sample (120 µL) will be taken over an hour after placement of the microdialysis 
catheters just before the administration of the final dose. Further dialysate samples 
of approximately 120 µL each will be collected at 0 (just before administration of 
tedizolid dose), 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 16, 20, and 24 hours. After all 
sampling is complete, recovery of the antibiotic through the dialysis filter will be 
assessed by the retrodialysis technique over a 1-hour interval. All dialysate samples 
will be collected in 200 µL microvials (CMA Microdialysis AB, Solna, Sweden), which 
will be additionally stored within amber-colored polypropylene tubes at -80 °C to 
protect against light and evaporation until concentration determination. 


       
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Protocol Version Date: June 27, 2016 
 
2.5.5.7Protein Binding Analysis and Determination 
Protein binding studies will be conducted using Centrifree® Ultrafiltration devices 
(Millipore Corporation, Billerica, MA).. An additional blood sample of 20 mL will be 
collected at the estimated peak concentration (3 hours after the dose was 
administered) into two 10-mL BD Vacutainer tubes containing sodium heparin 
(green top). Samples will be immediately centrifuged to collect the separated 
plasma. Approximately 0.9 mL of plasma will be transferred into six separate 
ultrafiltration devices, three devices per filter type, and centrifuged for 45 minutes at 
25 °C at 2,000 × g to generate an ultrafiltrate volume of approximately 250 µL. In 
addition, an aliquot of plasma will be retained for total drug concentration 
determinations and will be kept frozen at -80°C.  
 
In addition, non-specific binding to the ultrafiltration membrane will be determined at 
a single tedizolid concentration similar to the peak observed in patients.  For these 
studies, an aqueous standard of tedizolid will be prepared in accordance to 
manufacturer’s recommendation and ultrafiltration will be performed as outlined 
above for both ultrafiltration devices.. 
 
Individual protein binding percentages will be applied to each participant’s data at 
each  time point to determine free plasma concentrations. The percentage of protein 
binding will be calculated using the following formula: % Protein Binding = 100 – 
(Concentrationultrafiltrate / Concentrationplasma × 100). 
 
2.5.5.8 Study Exit Evaluation 
After completion of all sampling and removal of microdialysis catheters, an end of 
study exit evaluation will occur.  This will include a full physical examination, 
including vital signs.  Blood and urine will be collected to repeat all labs tested in 
2.5.5.1, except for the pregnancy test and drugs of abuse screening.  All abnormal 
determinations will be followed until resolution unless follow-up is determined to be 
unnecessary by the study physician.  For the control group, participants will be 
discharged from the study after a 4 hour monitoring period from removal of 
microdialysis catheters. 
 
2.5.5.9 Determination of Tedizolid Concentrations 
Tedizolid concentrations in plasma, dialysate fluid, and aqueous standards will be 
assessed using validated high performance liquid chromatography (HPLC) assays at 
the Center for Anti-Infective Research and Development of Hartford Hospital. 
 
2.6 Study Duration 
IRB Submissions and Approval  
 
 
 
2 months 
Enrollment and Sampling of 10 Patients  
 
 
6-12 months 
Enrollment and Sampling of 6 Healthy Volunteers 
 
4 months 
Tedizolid HPLC  
 
 
 
 
 
1 month 
Pharmacokinetic Analysis 
 
 
 
 
1 month 
Final Report 
 
 
 
 
 
 
2 months  
2.7 Statistical 
Analysis and 
Sample Size 
Justification  
2.7.1 Data Validation and Analysis 
The Principal Investigator will be responsible for the review, validation, and analysis 
of these data as collected and recorded by the study staff. 
 
2.7.2 Primary Endpoint: 
The primary endpoints of the study are to assess the penetration of tedizolid 
into infected skin tissue and compare it to the penetration into healthy skin tissue, as 
well as to assess the pharmacokinetics of tedizolid in plasma of both study 
populations. 
 
 


       
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Protocol Version Date: June 27, 2016 
2.7.2.1 Primary Endpoint Definition: 
Percentage of tissue penetration of tedizolid will be defined based on the 
AUC in plasma and tissue and will be calculated as: AUCtissue / freeAUCplasma × 100. 
Plasma pharmacokinetic parameters that will be estimated including: AUC0-24 (plasma), 
elimination rate constant (Ke), half-life (t½), total plasma clearance (CLT), and Volume 
of distribution (Vd). 
 
2.7.3 Statistical Analysis 
Non-compartmental pharmacokinetic analyses for tedizolid will be conducted using 
Phoenix (version 6.3, Pharsight Corporation, Mountain View, CA). Pharmacokinetic 
parameters for plasma will be determined using each individual’s plasma 
concentration-time profile. The maximum concentration (Cmax) for each participant 
will be estimated by visual inspection of the concentration-time profiles. The log-
linear trapezoidal method will be used to determine AUC0-24 (plasma) for each 
participant.  The elimination rate constant (Ke) will be estimated by the slope of the 
terminal portion of the concentration-time profile; half-life (t½) will be calculated by 
0.693/Ke. Total plasma clearance (CLT) will be calculated by Dose/AUC0-24 (plasma). 
Volume of distribution (Vd) will be calculated by CLT/Ke.   
 
All 
microdialysis 
concentrations 
will 
be 
corrected 
for 
recovery 
before 
pharmacokinetic analysis as follows:  Concentrationtissue = 100 × (Concentrationsample 
/ % in vivo recovery).  The AUC0-24 (tissue) will be assessed by the log-linear trapezoidal 
rule. Percentage of penetration into tissue will be calculated as follows:  AUCtissue / 
freeAUCplasma × 100. 
 
A Student’s t-test will be used to compare the penetration ratio and pharmacokinetics 
of tedizolid between study and control groups. 
2.7.4 Sample Size Determination 
Ten patients with diabetic foot infection (Study Group) and six healthy 
volunteers (Control Group) are to be enrolled in the study. 
 
This is primarily a descriptive, controlled study to observe the exposure and 
penetration ratio of tedizolid into the interstitial fluid of infected tissue of diabetic 
patients and compare it to that of healthy volunteers. In similar study designs, 10 
study patients were sufficient to describe the central tendency of these penetration 
estimates and some confidence of dispersion.  Given reduced variability in healthy 
participants, 6 volunteers will be utilized. 
  
2.8 Specific Drug 
Supply 
Requirements  
Tedizolid phosphate 200 mg tablets will be provided by Merck, Inc. as an open label 
supply. 
2.9 Adverse 
Experience 
Reporting 
Participants will be monitored for any sign or symptom of adverse events throughout 
the course of the study. Unanticipated, life-threatening or fatal adverse events will be 
reported to the IRB, the manufacturer, and the Food and Drug Administration 
according to federal guidelines. All adverse events requiring medical attention will be 
treated by the study physician and will be recorded by the investigator. 
 
 
2.9.1 Definitions 
For the purpose of this study, an adverse event will be defined as any pathologic or 
unintended change in the structure (signs), function (symptoms), or chemistry 
(laboratory values) of the body associated with the use of the study drug, whether or 


       
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Protocol Version Date: June 27, 2016 
not considered drug related, and will be categorized as one of the following:   
• 
MILD – present, but easily tolerated 
• 
MODERATE – discomfort that interferes with usual activities 
• 
SEVERE – incapacitating, inability to work or do usual activities 
A serious adverse event will be defined as any of the above which results in death or 
is immediately life-threatening, requires in-participant hospitalization, or is an 
important medical event that may jeopardize the participant or require medical 
intervention to prevent one of the previously mentioned outcomes.  
 
 
2.9.2 Relationship to Study Medication 
Relationship of the adverse event  to the study medication (i.e., causality) 
will be evaluated according to the investigator’s opinion, as one of the following: 
• 
Concurrent condition – unrelated to study drug 
• 
REMOTE adverse drug event – little or no temporal relationship to study 
drug 
• 
POSSIBLE adverse drug event – temporal relationship to study drug 
• 
PROBABLE adverse drug event – commonly associated with study drug 
• 
DEFINTE adverse drug event – reappeared on re-challenge of study drug 
 
2.9.3 Expectedness of Adverse Event 
As AEs are expected with the study medication, patients will be closely monitored 
throughout the study for any AE occurrence and will be managed accordingly by the 
study physician. All AEs will be recorded by the investigator as described in Section 
2.9.4 below. 
 
2.9.4 Recording and Reporting an Adverse Event 
All adverse events requiring medical attention will be recorded by the investigator as 
such: categorization by severity (mild, moderate, or severe), established time frame 
(start and stop time), complete description of event, all interventions (medical and 
pharmacological), and causality. 
 
2.9.5 Recording and Reporting a Serious Adverse Event (SAE) 
All SAEs will be reported to the Institutional Review Board, sponsor, and the Food 
and Drug Administration according to Federal guidelines. A serious adverse event 
will be defined as any adverse event that results in death, is immediately life-
threatening, requires or prolongs hospitalization, or is an important medical event 
that may jeopardize the participant or may require medical intervention to prevent 
one of the previously mentioned outcomes. 
2.10 References 
1. Margolis D, Malay DS, Hoffstad OJ, et al. Incidence of diabetic foot ulcer and 
lower extremity amputation among Medicare beneficiaries, 2006 to 2008. Data 
Points #2 (prepared by the University of Pennsylvania DEcIDE Center, under 
Contract No.  HHSA29020050041I). Rockville, MD: Agency for Healthcare 
Research and Quality. January 2011. AHRQ Publication No.  10(11)-EHC009-
1-EF   
2. Lipsky BA. New developments in diagnosing and treating diabetic foot 
infections. Diabetes Metab Res Rev 2008; 24 Suppl 1:S66-71.   
3. Lipsky BA. Medical treatment of diabetic foot infections. Clin Infect Dis 2004; 
39:S104-114.   
4. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot 
ulcers in participants with diabetes. Diabetes Care 1999; 22:382-387.   
5. Tentolouris N, Petrikkos G, Vallianou N, et al. Prevalence of methicillin-
resistant Staphylococcus aureus in infected and uninfected diabetic foot 
ulcers. Clin Microbiol Infect 2006; 12:186-189.   
6. Vardakas KZ, Horianopoulou M, Falagas ME. Factors associated with 
treatment failure in participants with diabetic foot infections: an analysis of 


       
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data from randomized controlled trials. Diabetes Res Clin Pract 2008; 
electronically published ahead of print.   
7. Sivextro® (tedizolid) Prescribing Information, Cubist Pharmaceuticals Inc. 
Lexington, MA. 2014. 
8. Prokocimer P, Bien P, Surber J et al. Phase 2, randomized, double-blind, 
doseranging 
study 
evaluating 
the 
safety, 
tolerability, 
population 
pharmacokinetics, and efficacy of oral torezolid phosphate in participants with 
complicated skin and skin structure infections. Antimicrob Agents Chemother. 
2011; 55:583-92. 
9. Prokocimer P, De Anda C, Fang E et al. Tedizolid phosphate vs. linezolid for 
the treatment of acute bacterial skin and skin structure infections: the 
ESTABLISH-1 randomized trial. JAMA. 2013; 309:559-69. 
10. Moran GJ, Fang E, Corey GR, Das AF, De anda C, Prokocimer P. Tedizolid 
for 6 days versus linezolid for 10 days for acute bacterial skin and skin-
structure infections (ESTABLISH-2): a randomised, double-blind, phase 3, 
non-inferiority trial. Lancet Infect Dis. 2014;14(8):696-705. 
11. Flanagan S, Passarell J, Lu Q, Fiedler-kelly J, Ludwig E, Prokocimer P. 
Tedizolid population pharmacokinetics, exposure response, and target 
attainment. Antimicrob Agents Chemother. 2014;58(11):6462-70. 
12. Müller M, Haag O, Burgdorff T, et al. Characterization of peripheral-
compartment kinetics of antibiotics by in vivo microdialysis. Antimicrob Agents 
Chemother 1996; 40:2703-2709. 
13. Bhalodi AA, Housman ST, Shepard A, Nugent J, Nicolau DP. Tissue 
pharmacokinetics of cefazolin in patients with lower limb infections. Antimicrob 
Agents Chemother. 2013;57(11):5679-83. 
14. Wiskirchen DE, Shepard A, Kuti JL, Nicolau DP. Determination of tissue 
penetration and pharmacokinetics of linezolid in patients with diabetic foot 
infections using in vivo microdialysis. Antimicrob Agents Chemother. 
2011;55(9):4170-5. 
15. Bulik CC, Wiskirchen DE, Shepard A, Sutherland CA, Kuti JL, Nicolau DP. 
Tissue penetration and pharmacokinetics of tigecycline in diabetic patients 
with chronic wound infections described by using in vivo microdialysis. 
Antimicrob Agents Chemother. 2010;54(12):5209-13. 
16. Sahre M, Sabarinath S, Grant M, et al. Skin and soft tissue concentrations of 
tedizolid (formerly torezolid), a novel oxazolidinone, following a single oral 
dose in healthy volunteers. Int J Antimicrob Agents. 2012;40(1):51-4. 
17. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of 
America clinical practice guideline for the diagnosis and treatment of diabetic 
foot infections. Clin Infect Dis. 2012;54(12):e132-73. 
18. Lipsky BA, Berendt AR, Embil J, De Lalla F. Diagnosing and treating diabetic 
foot infections. Diabetes Metab Res Rev 2004; 20:S56-S64. 
19. Walker M, Hadgraft J, Lane ME. Investigation of the permeability 
characteristics of peri-ulcer and whole ischaemic skin tissue. Int J Pharm 
2008; 357(1-2):1-5. 
2.11 Publication 
Plan 
The results of this study would be presented at an international congress such as the 
Interscience Conference on Antimicrobial Agents and Chemotherapy. A final 
publication would be submitted to a peer-reviewed journal such as Antimicrobial 
Agents and Chemotherapy, Journal of Antimicrobial Chemotherapy, or International 
Journal of Antimicrobial Agents. One abstract and one manuscript are anticipated to 
be presented at the conference and published.