Clinical trial NCT03910673
Conditions: Bacterial Infection Multiple-drug Resistance Pathogen Resistance
Keywords: Adults Fosfomycin Disodium Healthy Intrapulmonary Intravenous Pharmacokinetics Phase 1 ZTI-01
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)
Start date: 2019-06-27; Completion date: 2020-12-17
Enrollment: 39 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This is a Phase 1, open-label, multiple-dose trial conducted at a single center. The treatment period will consist of three 6 g doses (18 g) of ZTI-01 as a 1-hour intravenous (IV) infusion (+10 minute window). A total of 30 enrolled subjects will be randomized to undergo a single standardized bronchoscopy with bronchoalveolar lavage (BAL) at one of five sampling times. A total of 6 subjects will be assigned to each BAL-sampling time. Up to ten additional enrolled subjects will act as alternates to obtain 30 evaluable subjects. An evaluable subject is defined as a subject who receives all doses of ZTI-01, undergoes BAL at the randomized sampling timepoint with BAL return volume adequate for testing, and undergoes at least the one blood sampling timepoint that is concurrent with the assigned BAL sampling timepoint, with blood sampling volume that is adequate for testing. The objectives of the study are to assess safety and pharmacokinetics (PK) for a multiple dose regimen of IV-infused ZTI-01.

Detailed description:
This is a Phase 1, open-label, multiple-dose trial conducted at a single center. The treatment period will consist of three 6 g doses (18 g) of ZTI-01 as a 1-hour intravenous (IV) infusion (+10 minute window). A total of 30 enrolled subjects will be randomized to undergo a single standardized bronchoscopy with bronchoalveolar lavage (BAL) at one of five sampling times. A total of 6 subjects will be assigned to each BAL-sampling time. Up to ten additional enrolled subjects will act as alternates to obtain 30 evaluable subjects. An evaluable subject is defined as a subject who receives all doses of ZTI-01, undergoes BAL at the randomized sampling timepoint with BAL return volume adequate for testing, and undergoes at least the one blood sampling timepoint that is concurrent with the assigned BAL sampling timepoint, with blood sampling volume that is adequate for testing. The objectives of the study are to assess safety and pharmacokinetics (PK) for a multiple dose regimen of IV-infused ZTI-01.

Arms: arm 1: ZTI-01 administered as 1-hour IV infusions (+10 minute window) given every 8 hours for three doses. Each dose comprised of 200 mL (6 g) of fosfomycin disodium. Bronchoscopy and bronchoalveolar lavage (BAL) performed 2 hours after start of third infusion dose. n = 6 arm 2: ZTI-01 administered as 1-hour IV infusions (+10 minute window) given every 8 hours for three doses. Each dose comprised of 200 mL (6 g) of fosfomycin disodium. Bronchoscopy and bronchoalveolar lavage (BAL) performed 30 minutes after start of third infusion dose. n = 6 arm 3: ZTI-01 administered as 1-hour IV infusions (+10 minute window) given every 8 hours for three doses. Each dose comprised of 200 mL (6 g) of fosfomycin disodium. Bronchoscopy and bronchoalveolar lavage (BAL) performed 5 hours after start of third infusion dose. n = 6 arm 4: ZTI-01 administered as 1-hour IV infusions (+10 minute window) given every 8 hours for three doses. Each dose comprised of 200 mL (6 g) of fosfomycin disodium. Bronchoscopy and bronchoalveolar lavage (BAL) performed 75 minutes after start of third infusion dose. n = 6 arm 5: ZTI-01 administered as 1-hour IV infusions (+10 minute window) given every 8 hours for three doses. Each dose comprised of 200 mL (6 g) of fosfomycin disodium. Bronchoscopy and bronchoalveolar lavage (BAL) performed 8 hours after start of third infusion dose. n = 6
Interventions: intervention 1: Fosfomycin disodium
Intervention descriptions: intervention 1: Fosfomycin (a phosphonic acid derivative) formulated as a disodium salt.

Protocol documents:
ICF_000.pdf: 
Consent to Participate in a Research Study
A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of 
ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects
DMID# 16-0058
Version 8.0, 21SEP2020
Page 1 of 12
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You are being asked to take part in this research study as a normal, healthy, adult volunteer. Research 
studies are voluntary and include only people who choose to take part.  Please read this consent form 
carefully and take your time making your decision. As your study doctor or study staff discusses this 
consent form with you, please ask him/her to explain any words or information that you do not clearly 
understand.  We encourage you to talk with your family and friends before you decide to take part in this 
research study.  The nature of the study, risks, inconveniences, discomforts, and other important 
information about the study are listed below.
Please tell the study doctor or study staff if you are taking part in another research study.
Funding from the National Institutes of Health (NIH) will sponsor this study. Portions of 
 
 and their research team’s salaries will be paid by this funding.
WHO WILL BE MY DOCTOR ON THIS STUDY?
If you decide to participate, 
 and 
 will be your doctors for the 
study and will be in contact with your regular health care provider throughout the time that you are in 
the study and afterwards, if needed.
CONCISE SUMMARY
The purpose of this study is to determine the safety of a study drug called ZTI-01 (intravenous fosfomycin 
disodium) and to determine how well this study drug gets from the blood into the lungs. Fosfomycin is an 
antibiotic that is already available in oral form to treat serious urine or kidney infections. It may be able to 
treat serious pneumonias that are resistant to other common antibiotics.
If you agree to participate, you will stay at Duke for three days, during which you will receive three doses 
of the study drug with close monitoring of your medical status before and after all of the doses. You will 
have your blood drawn multiple times during the study to determine the blood levels of the drug, and to 
determine whether it has caused any side effects. After the third dose, you will undergo a bronchoscopy, 
which is a procedure to look at your lungs and air passages by inserting a tube through your mouth and 
down your throat to reach your lungs. This is done under conscious sedation to obtain samples from inside 
your lungs. After you leave Duke, you will be called the next day to find out how you are doing and after 
that call your participation in the study will be over. 
If you participate, there will be no direct benefit to you. There are risks involved in receiving an 
experimental drug. In prior studies of ZTI-01, some participants had decreased heart rate or blood pressure, 
headaches, stomach upset, and changes in some of their blood lab values. There are also risks involved in 
having your blood drawn (like pain) and in undergoing bronchoscopy (like coughing and discomfort). 
These risks will be discussed in more detail below. 
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IRB REFERENCE DATE: 09/28/2020
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Consent to Participate in a Research Study
A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of 
ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects
DMID# 16-0058
Version 8.0, 21SEP2020
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WHY IS THIS STUDY BEING DONE?
This is a study of an investigational drug, ZTI-01. Investigational means that it is a study drug, still 
being tested in research studies and not approved by the United States Food and Drug Administration 
(FDA). ZTI-01 is intravenous fosfomycin disodium. Intravenous, or IV for short, refers to a way of 
giving a drug or other substance through a catheter inserted into a vein. 
Fosfomycin is an antibiotic and was approved by the FDA in 1996 in an oral form (meaning taken by 
mouth), at a lower dose, to treat urinary infections. ZTI-01 is an intravenous (IV) form of fosfomycin 
that may be able to treat serious pneumonia infections that are resistant to most available antibiotics. The 
IV form of fosfomycin is approved for use outside the United States (in Europe and Japan) and has been 
tested in people in other studies in the U.S., but is not approved by the U.S. FDA. 
There are two main purposes of this study. The first is to understand the safety and side effects of this 
dosing regimen of ZTI-01 in healthy people. The second is to measure how well the study drug gets into 
the bloodstream and the lungs, and how long it lasts in each place. 
HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY?
Approximately 125 people will take part in this study at Duke.
WHAT IS INVOLVED IN THE STUDY?
Participation in this study is completely voluntary, and if you decide not to participate there will be no 
penalty or loss of benefits to which you are otherwise entitled. 
If you agree to be in this study, you will be asked to sign and date this consent form.  You will have the 
following tests and procedures to make sure that you are eligible: 

Physical exam and medical history

Vital signs, height, and weight

Blood (about 2 tablespoons will be drawn) and urine tests

Breath test to detect alcohol

Electrocardiogram (EKG), a tracing of the electrical activity of the heart
As part of this eligibility testing, you will be tested for COVID-19 (SARS-CoV-2). You will be notified 
of the results of the testing, and counseled as to the meaning of the results, whether they are positive or 
negative. If the test indicates that you are infected with COVID-19, you will receive additional 
counseling about the significance of your care and possible risks to other people. We are required to 
report all positive results to the North Carolina Division of Public Health. The test results will be kept 
confidential to the extent permissible under the law. If you do not want to be tested for COVID-19, then 
you should not agree to participate in this study.
DUHS IRB
IRB NUMBER: Pro00101916
IRB REFERENCE DATE: 09/28/2020
IRB EXPIRATION DATE: 03/06/2021


Consent to Participate in a Research Study
A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of 
ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects
DMID# 16-0058
Version 8.0, 21SEP2020
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As part of this eligibility testing, you will be tested for HIV (human immunodeficiency virus, which is 
the virus that causes the acquired immunodeficiency syndrome [AIDS]). You will be notified of the 
results of the testing, and counseled as to the meaning of the results, whether they are positive or 
negative. If the test indicates that you are infected with HIV, you will receive additional counseling 
about the significance of your care and possible risks to other people. We are required to report all 
positive results to the North Carolina Division of Public Health. The test results will be kept confidential 
to the extent permissible under the law. If you do not want to be tested for HIV, then you should not 
agree to participate in this study.
If you are eligible and you agree to participate, we will schedule a time for you to come to Duke for an 
admission period of three days. During that admission period, you will be required to stay inside the unit 
but you will be free to walk around, and there will be television and games for your entertainment. Food 
will be provided during your stay except during the period of time when you will need to fast (not eat) 
prior to the bronchoscopy. You will be randomized to a specific time for your bronchoscopy procedure; 
the time assignments will be random, like drawing numbers out of a hat.
You will be asked to avoid non-prescription medications, vitamins, dietary or herbal supplements, 
caffeine, and consumption more than twice per week of products containing genuine licorice for 7 days 
prior to the admission period, and to avoid alcohol for 48 hours prior to the admission period. 
If you are a female of childbearing potential, you will have a urine pregnancy test the day you come in 
for admission. You must use an acceptable contraceptive method for 30 days prior to the first dose of the 
study drug and for at least 30 days after the last dose of the study drug. The study team will discuss the 
acceptable methods with you.
If you are a male whose partner is of childbearing age, you must be willing to use condoms throughout 
the study, including for a full day after you leave the confinement unit. 
When you come to Duke for your admission period, you will stay for three days. Before being given any 
of the study drug, you will have the following tests and procedures:

Physical exam and medical history

Vital signs and weight

Blood (just under 2 teaspoons will be drawn) and urine tests

Breath test to detect alcohol 

COVID-19 test (SARS-CoV-2)

Placement of two peripheral IV lines in your veins, most likely one in each of your arms
Then, you will have the following procedures and tests over the course of one to two days:

You will be given the study drug through your IV, one dose every eight hours for a total of three 
doses
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IRB NUMBER: Pro00101916
IRB REFERENCE DATE: 09/28/2020
IRB EXPIRATION DATE: 03/06/2021


Consent to Participate in a Research Study
A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of 
ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects
DMID# 16-0058
Version 8.0, 21SEP2020
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
Vital signs (like blood pressure, temperature, heart rate, oxygen level) before, during, and several 
times after each dose

EKG before the first dose and after the last dose of study drug

Blood draws 18 different times before, during, and after the doses of the study drug; a total of 
just under 6 tablespoons of blood will be drawn

Bronchoscopy either during or after the last dose of study drug, depending on your time 
assignment 

Urine tests after the last dose of study drug

Physical exam and measurement of weight before leaving the admission unit
A bronchoscopy is an exam of the lungs using a long tube with a light on the end, which will be passed 
through your nose or mouth into your breathing tubes and lungs. Once it is in your lungs, a small 
amount of sterile saline solution will be squirted into a localized area of one of your lungs, then 
suctioned back up through the bronchoscope, and that fluid will be used for testing. Before the exam 
begins, medicines will be given through your IV to make you relaxed and sleepy. The drugs used most 
often are fentanyl and midazolam. This is a routine part of this exam. Lidocaine, a numbing medicine, 
will also be sprayed into your mouth, throat, and lungs. The bronchoscopy itself usually takes around 10 
minutes. It may take longer than that to gradually give you the sedation medicine, and to allow you to 
wake up from the sedation. 
The day after your bronchoscopy, you will be called by phone to ask about how you feel and any new 
medicines you are taking. If you are not having any concerning symptoms or complaints, your 
participation in the study will end after the follow-up phone call. If you are having any concerning 
symptoms or complaints, or if there are abnormalities with the testing that was done during the 
admission period, you may be asked to return to Duke for evaluation. In that case, your participation in 
the study will end when the symptoms or abnormalities are resolved or no longer require medical 
follow-up. 
If you begin the study but choose not to continue or complete it for any reason, or if the study doctors 
determine that you should not continue or complete the study, then you will have the following 
procedures and tests before you leave the admission unit. This is for your safety, to check for any side 
effects of the drug:

Physical exam and weight measurement

Blood (about 1 tablespoon will be drawn) and urine tests
If there are no abnormalities observed on these procedures and tests, then your participation in the study 
will end at that time. If, however, there are abnormalities that the study doctors believe to be significant 
to your health, then additional follow-up visits may be scheduled so that you can be monitored 
appropriately.
DUHS IRB
IRB NUMBER: Pro00101916
IRB REFERENCE DATE: 09/28/2020
IRB EXPIRATION DATE: 03/06/2021


Consent to Participate in a Research Study
A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of 
ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects
DMID# 16-0058
Version 8.0, 21SEP2020
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The total amount of blood drawn for this study will be up to 122.4 ml (about 8 tablespoons).
HOW LONG WILL I BE IN THIS STUDY?
You will be in the study from the time that you are found to be eligible and agree to participate, which 
could be up to 30 days before the admission period. Within those 30 days, you will be asked to avoid 
non-prescription medications, vitamins, dietary or herbal supplements, caffeine, and consumption more 
than twice per week of products containing genuine licorice for just the 7 days prior to the admission 
period, and to avoid alcohol for just the 48 hours prior to the admission period. The admission period for 
this study is three days. Then, you will continue in the study for one day after the admission period, up 
until the time that you receive the follow-up phone call. If significant abnormalities develop after you 
receive the study drug, then you may need to follow up with the study doctors until those abnormalities 
resolve or become stable. 
You can choose to stop participating at any time without penalty or loss of any benefits to which you are 
entitled. However, if you decide to stop participating in the study, we encourage you to talk to the study 
doctor 
 first.
WHAT ARE THE RISKS OF THE STUDY?
The risks of this study include side effects of the study drug itself, risks of the procedures that are done 
as part of the study, and the potential risk of loss of confidentiality. 
Risks of the Study Drug
If you participate in the study, you may be at risk for the following side effects of ZTI-01. You should 
discuss these with the study doctor and your regular health care provider if you choose. ZTI-01 may 
cause some, all, or none of the side effects listed below.
More Likely

Headache

Decreased blood calcium (could cause muscle cramps, confusion, stiff achy muscles, 
tingling of lips, fingers and feet)

Increased liver enzymes (could cause easy bruising, enlargement of abdomen, fluid 
retention)

Decreased blood potassium (could cause weakness or, in extreme cases, abnormal heart 
rhythm)

Decreased blood phosphorus (could cause weakness or, in extreme cases, confusion, 
trouble breathing, or trouble swallowing)

Stomach upset, including nausea, vomiting, or diarrhea

Swelling and pain at the IV site

A change in your electrocardiogram (EKG, an electronic snapshot of the heart's electrical 
activity) called a prolonged QT interval, which usually does not cause any symptoms or 
problems but, in very rare or severe cases, can potentially cause fast or erratic heart beats
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IRB REFERENCE DATE: 09/28/2020
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Consent to Participate in a Research Study
A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of 
ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects
DMID# 16-0058
Version 8.0, 21SEP2020
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Less Likely 

Decreased blood pressure (could cause dizziness or weakness)

A severe form of diarrhea called colitis that is known to occur with nearly any antibiotic 
medicine

Allergic reactions, including rash, face or mouth swelling, or anaphylaxis, which is a 
severe and potentially life-threatening allergic reaction

Kidney injury

Liver injury

Decreased appetite or change in the way things taste

Dizziness or spinning sensation (vertigo)

Shortness of breath or asthma attack

Fatigue or confusion

Vision changes

Rapid heart rate

Swelling in legs or body

Increased blood sodium (could cause thirst or, in extreme cases, confusion)

Decreases in the red blood cells, white blood cells, or platelets, which can, respectively, 
lead to fatigue or shortness of breath, risk of fever or infection, or risk of bleeding
You will be monitored closely for all of the above risks and appropriate medical care will be provided in 
the event that any of them occur.
Drug and Food Interactions
For your safety, you must tell the study doctor or nurse about all the prescribed medical foods and drugs, 
herbal products, over-the-counter (OTC) drugs, vitamins, natural remedies, products containing genuine 
licorice, and alcohol that you are taking before you start the study and before starting to take any of 
these products while you are on the study.
Risks of Blood Draws and IV Insertion
Risks associated with drawing blood from your arm and/or inserting an IV line include momentary 
discomfort and/or bruising. Infection, excess bleeding, clotting, or fainting are also possible, although 
unlikely.
Risks of EKG
Possible side effects of the EKG are skin irritation, itching and redness from the EKG electrode pads.
Risks of Bronchoscopy
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A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of 
ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects
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Although the bronchoscopy exam is not painful, common side effects are throat numbness, cough, and a 
sore throat. Some people experience brief gagging. Fevers or chills may occur after the bronchoscopy. 
Rarely, there can be chest pain, cough with phlegm containing blood, nosebleed, and temporary 
vomiting. The lidocaine liquid or spray to numb your mouth and throat has an awful taste and causes a 
strange feeling in the mouth. It can make you have trouble swallowing for 30-60 minutes after the 
bronchoscopy, so you will not be allowed to eat or drink during that time. Finally, any invasive 
procedure like bronchoscopy can result in stress on the heart or lungs. 
The bronchoscopy exam includes moderate sedation, which is the use of drugs to make you relaxed and 
sleepy. The drugs used most often are fentanyl and midazolam. Midazolam may cause some people to 
feel drowsy, tired, or weak for 1 or 2 days after it has been given. It may also cause problems with using 
your hands or feet and your ability to think. Midazolam may make you dizzy, cause headache, low 
oxygen levels and low blood pressure. Common side effects of fentanyl are feeling dizzy, faint, or 
lightheaded, feeling tired or weak or having a hard time catching your breath or feeling out of breath. 
Less common side effects are feeling anxious, confused, decrease in the amount of urine you make and 
the number of times you urinate; having to urinate less, feeling drowsy, nervous, having a false sense of 
well-being, and seeing, hearing, or feeling things that are not there. Do not drive, use machines, sign 
legal documents, or do anything else that could cause you or someone else harm if you are not alert 
until the effects of these drugs have gone away or until the day after you receive this drug, whichever 
period of time is longer. You will be watched closely during the bronchoscopy exam and we will treat 
you if any of these side effects occur. If you are scheduled to leave the confinement unit on the same day 
as your bronchoscopy exam, someone will need to drive you home. Otherwise, you will be welcome to 
stay an extra night in the confinement unit so that the effects of the sedative drugs have fully worn off.
To protect against these risks, you will be given oxygen and your vital signs and heart rhythm will be 
monitored continuously during the bronchoscopy. The doses of all medications given to you for 
bronchoscopy will be carefully monitored, with safe limits set. Care and monitoring will be provided 
before, during, and after the bronchoscopy by nursing staff with oversight by the study doctors.
Risk of Loss of Confidentiality
Every effort will be made your keep your information confidential; however, this cannot be fully 
guaranteed.
Reproductive Risks
For women: The effects of the study drug on a developing pregnancy or breastfeeding infant are 
unknown.  Therefore, women who are pregnant, planning a pregnancy, or breastfeeding are excluded 
from this study. 
If you are a woman who could possibly become pregnant (you have not completed menopause, or you 
have not had a hysterectomy and/or both tubes and/or both ovaries removed) and you have a partner 
who is able to father children, a blood pregnancy test will be done (using 1 teaspoon of blood drawn 
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ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects
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from a vein by needle-stick), and it must be negative before you can continue in this study. In women 40 
years old and older, blood pregnancy tests may sometimes give a false positive or indeterminate result, 
and additional testing may be required.  A urine pregnancy test will also be performed the day of your 
admission.  
You and your partner must agree to either abstain completely from vaginal intercourse for the duration 
of the study and for 30 days after discharge, or agree to use an effective method of contraception for the 
same length of time.   Effective methods include (a) partner vasectomy, (b) bilateral tubal ligation, (c) 
intrauterine devices (IUDs), (d) hormonal methods (birth control pills, implants, injections, patches, 
vaginal rings, or (e) barrier methods (condoms, diaphragms, cervical caps) when used with a spermicide.  
If you are not using one of these methods, your doctor will discuss options with you, given your medical 
condition, your personal preferences, and the level of protection required by this study.  Because no 
method is 100% effective, you should notify your study doctor immediately if you think there is any 
chance you could be pregnant. 
For men: The effects of the study drug on developing pregnancies that began while the father was 
taking the drug are not known.  In addition, the drug may be transmitted in semen to a partner during 
sexual activity.   If your partner is a woman who could possibly become pregnant (she has not 
completed menopause, or has not had a hysterectomy and/or both tubes and/or both ovaries removed), 
you and your partner must agree to either abstain completely from vaginal intercourse for the duration of 
the study and until the follow-up phone call the day after your bronchoscopy, or use condoms each time 
you have vaginal intercourse for the same length of time.  This is true even if you have had a vasectomy 
(because vasectomy does not prevent transmission of drug in seamen).  If your partner is currently 
pregnant or breastfeeding, you must use a condom for all types of sexual activity.  You should inform 
your partner about the possible risks of this study, and that you will need to report a pregnancy that 
occurs during the study to your study doctor. 
There may be risks, discomforts, drug interactions or side effects that are not yet known.
ARE THERE BENEFITS TO TAKING PART IN THE STUDY?
If you agree to take part in this study, there will be no direct medical benefit to you. We hope that in the 
future the information learned from this study will benefit other people with infections caused by 
bacteria that are resistant to common antibiotics.
WILL MY INFORMATION BE KEPT CONFIDENTIAL?
Participation in research involves some loss of privacy. We will do our best to make sure that 
information about you is kept confidential, but we cannot guarantee total confidentiality. Your personal 
information may be viewed by individuals involved in this research and may be seen by people 
including those collaborating, funding, and regulating the study. We will share only the minimum 
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ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects
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necessary information in order to conduct the research. Your personal information may also be given out 
if required by law. 
As part of the study, results of your study-related laboratory tests and procedures may be reported to the 
NIH and its affiliates, but this would be without the inclusion of any information that identifies you. In 
addition, your records may be reviewed in order to meet federal or state regulations. Reviewers may 
include representatives from the Food and Drug Administration, representatives and affiliates of the 
NIH, the Duke University Health System Institutional Review Board, the company that manufactures 
the study drug, and others as appropriate. If any of these groups review your research record, they may 
also need to review your entire medical record.
The Department of Health and Human Services (HHS) has issued a Certificate of Confidentiality to 
further protect your privacy. With this Certificate, the investigators may not disclose research 
information that may identify you in any Federal, State, or local civil, criminal, administrative, 
legislative, or other proceedings, unless you have consented for this use. Research information protected 
by this Certificate cannot be disclosed to anyone else who is not connected with the research unless:  
1) there is a law that requires disclosure (such as to report child abuse or communicable 
diseases but not for legal proceedings); 
2) you have consented to the disclosure, including for your medical treatment; or 
3) the research information is used for other scientific research, as allowed by federal 
regulations protecting research subjects. 
Disclosure is required, however, for audit or program evaluation requested by the agency that is funding 
this project or for information that is required by the Food and Drug Administration (FDA).
You should understand that a Confidentiality Certificate does not prevent you or a member of your 
family from voluntarily releasing information about yourself or your involvement in this research. If you 
want your research information released to an insurer, medical care provider, or any other person not 
connected with the research, you must provide consent to allow the researchers to release it. This means 
that you and your family must also actively protect your own privacy.
Finally, you should understand that the investigator is not prevented from taking steps, including 
reporting to authorities, to prevent serious harm to yourself or others.
All of the blood, urine, bronchoscopy and EKG studies are being done only because you are in this 
study. The study results will not be provided to you OR sent to your physician.
Your information and samples that are collected as part of the research, even if identifiers are removed, 
will not be used or distributed for future research studies.
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IRB EXPIRATION DATE: 03/06/2021


Consent to Participate in a Research Study
A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of 
ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects
DMID# 16-0058
Version 8.0, 21SEP2020
Page 10 of 12
Subject Initials
DUKE UNIVERSITY HEALTH SYSTEM
Form
M0345
We are required to report all positive results of the HIV test to the North Carolina Division of Public 
Health. The test results will be kept confidential to the extent permissible under the law. If you do not 
want to be tested for HIV, then you should not agree to participate in this study.
The study results will be retained in your research record for at least six years after the study is 
completed. At that time either the research information not already in your medical record may be 
destroyed or information identifying you will be removed from such study results at DUHS.  Any 
research information in your medical record will be kept indefinitely.
This information may be further disclosed by the sponsor of this study.  If disclosed by the sponsor, the 
information is no longer covered by federal privacy regulations.  If this information is disclosed to 
outside reviewers for audit purposes, it may be further disclosed by them and may not be covered by 
federal privacy regulations.
While the information and data resulting from this study may be presented at scientific meetings or 
published in a scientific journal, your name or other personal information will not be revealed.
Some people or groups who receive your health information might not have to follow the same privacy 
rules. Once your information is shared outside of DUHS, we cannot guarantee that it will remain private. 
If you decide to share private information with anyone not involved in the study, the federal law 
designed to protect your health information privacy may no longer apply to the information you have 
shared.  Other laws may or may not protect sharing of private health information.
A representative from the sponsor may be present at certain study visits/procedures. 
WHAT ARE THE COSTS TO YOU?
There will be no cost to you associated with taking part in this study.
WHAT ABOUT COMPENSATION?
You will be reimbursed up to $1225 for your expenses related to your participation (parking, gas, and 
time). You will receive $100 for the screening visit, $250 for Day -1 visit, $250 for Day 1 visit, $600 for 
the Day 2/Bronchoscopy visit and $25 for the follow-up phone call visit.
Payment received as compensation for participation in research is considered taxable income to the 
research subject.  If payment to an individual exceeds $600 in any one calendar year, Duke University is 
required to report this information to the Internal Revenue Service (IRS).  Research subject payments to 
a non-employee of Duke University exceeding $600 during any calendar year will result in a 1099 
(Miscellaneous Income) form being issued to the individual and a copy sent to the IRS.
DUHS IRB
IRB NUMBER: Pro00101916
IRB REFERENCE DATE: 09/28/2020
IRB EXPIRATION DATE: 03/06/2021





SAP_002.pdf: 
CLINICAL RESEARCH IN INFECTIOUS DISEASES 
 
 
 
STATISTICAL ANALYSIS PLAN 
for 
DMID Protocol: 16-0058 
Study Title: 
A Phase 1 Safety and Intrapulmonary 
Pharmacokinetics Study of ZTI-01 (Intravenous 
Fosfomycin Disodium) in Healthy Adult Subjects 
 
NCT03910673 
 
Version 1.0 
 
DATE: 20-FEB-2020 
 
THIS COMMUNICATION IS PRIVILEGED AND CONFIDENTIAL  
 
 


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STUDY TITLE 
Protocol Number Code: 
DMID Protocol: 16-0058 
Development Phase: 
Phase 1 
Products: 
Intravenous (IV) fosfomycin disodium (ZTI-01) 
Form/Route: 
Intravenous infusion 
Indication Studied: 
Microbial Infection 
Sponsor: 
Division of Microbiology and Infectious Diseases 
National Institute of Allergy and Infectious Diseases 
National Institutes of Health 
Clinical Trial Initiation Date: 
11JUN2019 
Clinical Trial Completion Date: 
DDMMMYYYY 
Date of the Analysis Plan: 
20FEB2020 
Version Number: 
1.0 
This study was performed in compliance with Good Clinical Practice. 
Information contained in this publication is the property of Division of Microbiology and Infectious Diseases and is confidential. This 
information may not be disclosed to third parties without written authorization from Division of Microbiology and Infectious Diseases. This 
report may not be reproduced, stored in a retrieval system or transmitted in any form or by any means - electronic, mechanical, recording or 
otherwise - without the prior authorization from Division of Microbiology and Infectious Diseases. This document must be returned to Division 
of Microbiology and Infectious Diseases upon request. 
 


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TABLE OF CONTENTS 
STUDY TITLE ............................................................................................................................... II 
TABLE OF CONTENTS ...............................................................................................................III 
LIST OF ABBREVIATIONS ....................................................................................................... VI 
1. 
PREFACE .....................................................................................................................1 
2. 
INTRODUCTION ........................................................................................................2 
2.1. 
Purpose of the Analyses ................................................................................................2 
3. 
STUDY OBJECTIVES AND ENDPOINTS ................................................................3 
3.1. 
Study Objectives ...........................................................................................................3 
3.2. 
Endpoints ......................................................................................................................3 
3.3. 
Study Definitions and Derived Variables .....................................................................4 
3.3.1. 
Fosfomycin Concentrations in ELF and AM ................................................................4 
3.3.2. 
Definition of AEs ..........................................................................................................4 
4. 
INVESTIGATIONAL PLAN .......................................................................................7 
4.1. 
Overall Study Design and Plan .....................................................................................7 
4.2. 
Discussion of Study Design, Including the Choice of Control Groups ........................7 
4.3. 
Selection of Study Population ......................................................................................7 
4.3.1. 
Subject Inclusion Criteria .............................................................................................7 
4.3.2. 
Subject Exclusion Criteria ............................................................................................8 
4.4. 
Treatments ..................................................................................................................10 
4.4.1. 
Treatments Administered ............................................................................................10 
4.4.2. 
Identity of Investigational Product(s) .........................................................................10 
4.4.3. 
Method of Assigning Subjects to BAL Sampling Timepoint Groups 
(Randomization) .........................................................................................................10 
4.4.4. 
Selection of Doses in the Study ..................................................................................11 
4.4.5. 
Selection and Timing of Dose for Each Subject .........................................................11 
4.4.6. 
Blinding ......................................................................................................................11 
4.4.7. 
Prior and Concomitant Therapy ..................................................................................11 
4.4.8. 
Treatment Compliance ................................................................................................12 
4.5. 
Safety and PK Variables .............................................................................................12 
4.5.1. 
Safety Variables ..........................................................................................................12 
4.5.2. 
Pharmacokinetics Variables ........................................................................................13 


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5. 
SAMPLE SIZE CONSIDERATIONS .......................................................................14 
6. 
GENERAL STATISTICAL CONSIDERATIONS ....................................................15 
6.1. 
General Principles .......................................................................................................15 
6.2. 
Timing of Analyses .....................................................................................................15 
6.3. 
Analysis Populations ..................................................................................................15 
6.3.1. 
Safety Population ........................................................................................................15 
6.3.2. 
Pharmacokinetics Population......................................................................................15 
6.4. 
Covariates and Subgroups ..........................................................................................15 
6.5. 
Missing Data ...............................................................................................................15 
6.6. 
Interim Analyses and Data Monitoring ......................................................................15 
6.7. 
Multicenter Studies .....................................................................................................15 
6.8. 
Multiple Comparisons/Multiplicity ............................................................................16 
7. 
STUDY SUBJECTS ...................................................................................................17 
7.1. 
Disposition of Subjects ...............................................................................................17 
7.2. 
Protocol Deviations ....................................................................................................17 
8. 
EFFICACY EVALUATION ......................................................................................18 
9. 
SAFETY EVALUATION ..........................................................................................19 
9.1. 
Demographic and Other Baseline Characteristics ......................................................19 
9.1.1. 
Prior and Concurrent Medical Conditions ..................................................................19 
9.1.2. 
Prior and Concomitant Medications ...........................................................................19 
9.2. 
Measurements of Treatment Compliance ...................................................................19 
9.3. 
Adverse Events ...........................................................................................................19 
9.3.1. 
Unsolicited Adverse Events ........................................................................................20 
9.4. 
Deaths, Serious Adverse Events and other Significant Adverse Events ....................20 
9.5. 
Pregnancies .................................................................................................................20 
9.6. 
Clinical Laboratory Evaluations .................................................................................20 
9.7. 
Vital Signs and Physical Evaluations .........................................................................22 
9.8. 
ECG Assessments .......................................................................................................23 
10. 
PHARMACOKINETICS ...........................................................................................24 
10.1. 
Analysis Population and Handling of Missing Timepoints ........................................24 
10.2. 
Dosing and Pharmacokinetic Sampling Summary .....................................................24 
10.3. 
Definition and Estimation of Individual PK Parameters ............................................25 


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10.3.1. 
PK Parameters ............................................................................................................25 
10.3.2. 
Noncompartmental Analysis Population AUC and Percent Penetration 
Estimation ...................................................................................................................27 
10.4. 
Descriptive Statistics ..................................................................................................28 
10.4.1. 
Pharmacokinetic Parameter Summaries for Plasma ...................................................28 
10.4.2. 
Pharmacokinetic Parameter Summaries for ELF and AM .........................................28 
10.4.3. 
Analysis of Noncompartmental Analysis Parameters and Percent Penetration .........28 
10.5. 
Exploratory Population PK Modeling ........................................................................29 
11. 
IMMUNOGENICITY ................................................................................................30 
12. 
OTHER ANALYSES .................................................................................................31 
13. 
REPORTING CONVENTIONS ................................................................................32 
14. 
TECHNICAL DETAILS ............................................................................................33 
15. 
SUMMARY OF CHANGES IN THE CONDUCT OF THE STUDY OR 
PLANNED ANALYSES ............................................................................................34 
16. 
REFERENCES ...........................................................................................................35 
17. 
LISTING OF TABLES, FIGURES, AND LISTINGS ..............................................36 
APPENDICES ...............................................................................................................................37 
APPENDIX 1. TABLE MOCK-UPS..........................................................................................38 
APPENDIX 2. FIGURE MOCK-UPS ........................................................................................89 
APPENDIX 3. LISTINGS MOCK-UPS ...................................................................................111 
 


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LIST OF ABBREVIATIONS 
AE 
Adverse Event 
ALP 
Phosphorus, Alkaline Phosphatase 
ATC 
Anatomical Therapeutic Classification  
ALT 
Alanine Aminotransferase 
AM 
Alveolar Macrophage  
aPTT 
Partial Thromboplastin Time  
AST 
Aspartate Aminotransferase 
AUC(0-inf) 
AUC Extrapolated To Infinity 
AUC(0-t) 
AUC From Time Of Dosing To Time T. 
AUMC 
Area Under First Moment Curve 
BAL 
Bronchoalveolar Lavage 
BLQ 
Below Quantification Limit 
BMI 
Body Mass Index 
BP 
Blood Pressure  
BSV 
Between Subject Variability 
BUN 
Blood Urea Nitrogen 
C 
Degree(S) Celsius 
CI 
Confidence Interval 
Cmax 
Maximum Measured Plasma Concentration  
CPK 
Creatine Phosphokinase  
CRF 
Case Report Form 
CSR 
Clinical Study Report  
CV 
Coefficient Of Variation 
DCC 
Data Coordinating Center 
DMID 
Division Of Microbiology And Infectious Diseases 
DSMB 
Data And Safety Monitoring Board 
ECG 
Electrocardiogram 
ELF 
Epithelial Lining Fluid  
GM 
Geometric Mean 


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GSD 
Geometric SD  
h 
Hour(S) 
hCG 
Human Chorionic Gonadotropin 
HCV 
Hepatitis C Virus 
HIV 
Human Immunodeficiency Virus 
ICH 
International Conference On Harmonisation 
IRB 
Institutional Review Board 
ISM 
Independent Safety Monitor  
IV 
Intravenous 
L 
Liter 
LDH 
Lactate Dehydrogenase 
LLN 
Lower Limit Of Normal 
LLOQ 
Lower Limit Of Quantification  
max 
Maximum 
mcg 
Microgram 
MedDRA 
Medical Dictionary For Regulatory Activities  
mEq 
Milliequivalent 
mg 
Milligram 
MH 
Medical History 
min 
Minimum 
mL 
Milliliter 
MOP 
Manual Of Procedures 
N 
Number (Typically Refers To Subjects) 
NCA 
Noncompartmental Analysis 
NIH 
National Institutes Of Health 
PI 
Principal Investigator 
PK 
Pharmacokinetics 
PT 
Prothrombin Time 
RBC 
Red Blood Cell 
RCD 
Reverse Cumulative Distribution  
RV 
Residual Variability 


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SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan  
SD 
Standard Deviation 
SDCC 
Statistical And Data Coordinating Center 
SDTM 
Standard Data Tabulation Model 
SMC 
Safety Monitoring Committee 
SOC  
System Organ Class 
SOP 
Standard Operating Procedures 
t1/2 
Terminal Elimination Half-Life  
TEAE 
Treatment Emergent Adverse Event 
TFLs 
Tables, Figures, And Listings 
tmax 
Time To Peak Concentration  
U 
Units 
ULN 
Upper Limit Of Normal 
Vd 
Volume Of Distribution  
VPC 
Visual Predictive Checks 
WBC 
White Blood Cell 
WHO 
World Health Organization 
λz 
Terminal-Phase Elimination Rate Constant  
ZTI-01 
Intravenous Fosfomycin Disodium 
 


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1. 
PREFACE 
The Statistical Analysis Plan (SAP) for “A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of 
ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult Subjects” (DMID Protocol 16-0058) describes 
and expands upon the statistical information presented in the protocol. 
This document describes all planned analyses and provides reasons and justifications for these analyses. It 
also includes sample tables, listings, and figures planned for the final analyses. Regarding the final analyses 
and Clinical Study Report (CSR), this SAP follows the International Conference on Harmonisation of 
Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) Guidelines, as indicated in 
Topic E3 (Structure and Content of Clinical Study Reports), and more generally is consistent with Topic E8 
(General Considerations for Clinical Trials) and Topic E9 (Statistical Principles for Clinical Trials). The 
structure and content of the SAP provides sufficient detail to meet the requirements identified by the FDA and 
ICH, while all work planned and reported for this SAP will follow internationally accepted guidelines 
published by the American Statistical Association and the Royal Statistical Society for statistical practice.  
Any deviation from this SAP will be described and justified in protocol amendments and/or in the CSR, as 
appropriate. The reader of this SAP is encouraged to also review the study protocol for details on conduct of 
the study and the operational aspects of clinical assessments. 


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2. 
INTRODUCTION 
This is a Phase 1, open-label, multiple-dose trial conducted at a single center. The treatment period will 
consist of three 6 g doses of ZTI-01 as a 1 h IV infusion. A total of 30 enrolled subjects will be randomized. 
Six additional enrolled subjects will act as alternates. An evaluable subject is defined as a subject who 
receives all doses of ZTI-01, undergoes bronchoalveolar lavage (BAL) at the randomized sampling timepoint 
with BAL return volume adequate for testing, and undergoes at least the one blood sampling timepoint that is 
concurrent with the assigned BAL sampling timepoint, with blood sampling volume that is adequate for 
testing. 
2.1. 
Purpose of the Analyses 
These analyses will assess the safety and plasma and intrapulmonary pharmacokinetics (PK) of three 6 g 
doses of ZTI-01 administered as three 1 h IV infusions.  


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3. 
STUDY OBJECTIVES AND ENDPOINTS 
3.1. 
Study Objectives 
Safety: 
• Determine the safety of multiple doses of ZTI-01 (6 g dose every 8 hours, administered as a 1-hour 
IV infusion, for a total of 18 g in three doses). 
Pharmacokinetic: 
• Determine the plasma and intrapulmonary PK (epithelial lining fluid (ELF) and alveolar 
macrophage (AM) concentrations of ZTI-01) after multiple doses of ZTI-01 (6 g dose every 8 
hours, administered as a 1-hour IV infusion, for a total of 18 g in three doses). 
3.2. 
Endpoints 
Safety: 
• The safety outcome measure will be the occurrence of adverse events (AEs), summary of physical 
exam findings, vital signs, clinical laboratory tests, and electrocardiogram (ECGs) at any time 
from the start of study drug administration through the end of subject follow-up. 
• All subjects who receive at least one dose of study drug will be included in the safety outcome 
measure. AEs will be collected from the time of dosing on Day 1 through the telephone follow-up 
interview on Day 3. Treatment Emergent Adverse Events (TEAEs) will be assessed by severity 
and relationship to the study drug as determined by the investigator. 
Pharmacokinetics: 
• The pharmacokinetic outcome measures will be plasma and intrapulmonary concentrations of ZTI-
01 by validated bioassays.  
• Plasma PK parameters will be derived from the plasma concentration vs. time curves after the third 
dose of study drug. The parameters include, but are not limited to:   
o Maximum measured plasma concentration (Cmax) 
o Area under the concentration vs. time curve (AUC0-8 and AUC0-inf) 
o Time to peak concentration (tmax) 
o Terminal elimination half-life (t1/2) 
o Terminal-phase elimination rate constant (λz) 
o Volume of distribution (Vd)  
o Clearance (CL) 
Intrapulmonary PK parameters will be derived from the ratios of drug concentrations in ELF and AMs to 
simultaneous drug concentrations in plasma for each subject and summarized for each sampling time. The 
median concentrations of fosfomycin from the BAL sampling times will be used to estimate the AUC0-8 of 
plasma, ELF, and AM. The ratios of AUC0-8 of ELF-to-plasma and AM-to-plasma will be calculated to 
determine the percent lung penetration. 


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3.3. 
Study Definitions and Derived Variables  
3.3.1. 
Fosfomycin Concentrations in ELF and AM 
Concentration of Fosfomycin in ELF 
The volume of ELF recovered in the BAL samples will be estimated using the urea dilution method [1]. The 
estimated concentration of fosfomycin in ELF (FosfomycinELF) will be calculated as follows:  
FosfomycinELF = FosfomycinBAL × (UreaPlasma/UreaBAL) 
Where FosfomycinBAL is the measured fosfomycin concentration in the BAL sample and UreaPlasma and 
UreaBAL are the measured concentrations of urea in plasma and BAL fluid, respectively.  
3.3.2. 
Definition of AEs 
Adverse Events 
ICH E6 defines an AE as any untoward medical occurrence in a patient or clinical investigation subject 
administered a pharmaceutical product, and that does not necessarily have a causal relationship with this 
treatment. An AE can therefore be any unfavorable and unintended sign (including a clinically significant 
laboratory abnormality), symptom, or disease temporally associated with use of the study drug, whether or not 
it is deemed related to the study drug. The occurrence of an AE may come to the attention of study personnel 
during study visits and interviews of a study subject presenting for medical care, or upon review by a study 
monitor.  
All AEs including local and systemic reactions not meeting the criteria for serious adverse events (SAEs) will 
be captured on the appropriate case report form (eCRF). Information to be collected includes event 
description, time of onset, clinician’s assessment of severity, relationship to study drug (assessed only by 
those with the training and authority to make a diagnosis), outcome, action taken, and time of 
resolution/stabilization of the AE. All AEs occurring while on study will be documented appropriately 
regardless of relationship. All AEs will be followed until they adequately resolve or are determined by the PI 
to be medically stable (stable or improving over two assessments and no further intervention required). Any 
medical condition that is present at the time that the subject is screened will be considered as a baseline 
finding and not reported as an AE. However, if its Grade increases at any time during the trial such that it 
meets the AE definition specified above, it will be recorded as an AE. 
All systemic and laboratory AEs will be graded using the Adverse Event Toxicity Grading Scale (See 
Protocol v6.0 Appendix B). Laboratory toxicity grading will be determined by using these tables as modified 
for the study to accommodate the reference range of the Central Laboratory and the acceptable ranges used in 
determining eligibility. If a subject was enrolled in the trial with a laboratory value that is outside the 
reference range, but within the acceptable range, an AE will be recorded if it otherwise meets the definition of 
AE in Protocol v6.0 Section 9.3 (occurred after the start of infusion of the first dose of study product) and the 
on-study value is higher (if initially high) or lower (if initially low) than the screening value. 
Treatment Emergent Adverse Event (TEAE) 
A TEAE is defined as an AE with an onset or increase in either severity or frequency after study drug 
administration. Since the reporting period for AEs in this protocol is from the time of dosing on Day 1 
through the Telephone Follow-up Interview on Day 3, all recorded AEs are by definition TEAEs.  


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Severity of Event 
All AEs will be assessed by the clinician using the protocol-defined grading system. 
Changes in the severity of an AE will be documented to allow an assessment of the duration of the AE at each 
level of intensity to be performed. AEs characterized as intermittent require documentation of onset and 
duration of each episode. 
Relationship to Study Products:  
The clinician’s assessment of an AE's relationship to the study drug is part of the documentation process, but 
it is not a factor in determining what is or is not reported in the trial. If there is any doubt as to whether a 
clinical observation is an AE, it will be reported. All AEs will have their relationship to the study drug 
assessed using the terms “related” or “not related.” In a clinical trial, the study drug must always be suspect. 
To help assess relatedness, the following guidelines are used. 
• Related: There is a reasonable possibility that the study drug caused the AE. Reasonable 
possibility means that there is evidence to suggest that the study drug caused the AE. 
• Not Related: There is not a reasonable possibility that the study drug caused the AE.  
Serious Adverse Events (SAE) 
An AE or suspected AE is considered “serious” if, in the view of either the investigator or Sponsor, it results 
in any of the following outcomes:  
• Death, 
• a life-threatening AE,  
• An adverse event is considered life-threatening if, in the view of either the site principal 
investigator or sponsor, its occurrence places the patient or subject at immediate risk of death. It 
does not include an adverse event that, had it occurred in a more severe form, might have caused 
death. 
• inpatient hospitalization or prolongation of existing hospitalization,  
• a persistent or significant incapacity or substantial disruption of the ability to conduct normal life 
functions, or  
• a congenital anomaly/birth defect.   
• Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical judgment they 
may jeopardize the subject and may require medical or surgical intervention to prevent one of the 
outcomes listed in this definition.  Examples of such medical events include allergic bronchospasm 
requiring intensive treatment in an emergency room or at home, blood dyscrasias or convulsions 
that do not result in inpatient hospitalization, or the development of drug dependency or drug 
abuse. 
All SAEs will be: 
• Assessed for severity and relationship to the study drug and alternate etiology, 
• Recorded on the appropriate SAE data collection form and eCRF, 
• Followed through resolution, 


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• Reviewed and evaluated by the Independent Safety Monitor (ISM) (as deemed necessary), Safety 
Monitoring Committee (SMC) (periodic review unless related), DMID, and IRB. 


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4. 
INVESTIGATIONAL PLAN 
4.1. 
Overall Study Design and Plan 
This is a Phase 1, open-label, multiple-dose trial conducted at a single center. The treatment period will 
consist of three 6 g doses of ZTI-01 as a 1 h IV infusion. A total of 30 enrolled subjects will be randomized. 
Six additional enrolled subjects will act as alternates. An evaluable subject is defined as a subject who 
receives all doses of ZTI-01, undergoes BAL at the randomized sampling timepoint with BAL return volume 
adequate for testing, and undergoes at least the one blood sampling timepoint that is concurrent with the 
assigned BAL sampling timepoint, with blood sampling volume that is adequate for testing. Subjects who 
initiate the Treatment Phase but are not evaluable will be replaced with an alternate at the sample BAL 
sampling timepoint. 
Each subject will complete Screening, Baseline, Treatment, and Follow-up Phases. A diagram of the overall 
study design is shown in Figure 1. The Screening Phase will be conducted on an outpatient basis within 30 
days of the Baseline Phase. The Baseline Phase will consist of admission to DEPRU on the day before the 
first dose (Day -1) for pre-dosing assessments. The Treatment Phase (Day 1 to Day 2) will include dosing 6 g 
of ZTI-01, administered as a 1-hour IV infusion, every 8 hours for a total 18 g in 3 doses, followed by post-
treatment safety assessments, and BAL and blood sample collections for PK measurements. Each subject will 
undergo a single standardized bronchoscopy with BAL after the start of the last IV infusion of ZTI-01. Blood 
samples for PK measurements will be collected before each dose, up to 8 hours after the start of the first IV 
infusion of ZTI-01, and up to 12 hours after the start of the third IV infusion. 
Subjects will remain in DEPRU during the Treatment Phase and will be discharged at least 12 hours after the 
start of the third IV infusion (if safety parameters are acceptable to the investigator). Safety assessments will 
be conducted during the entire Treatment Phase. The Follow-Up Phase will consist of a telephone interview 
on Day 3 for symptom-driven safety assessments. 
4.2. 
Discussion of Study Design, Including the Choice of Control Groups 
As the main focus of this protocol is to evaluate the safety and pharmacokinetics of multiple doses of ZTI-01, 
there is no control group and all subjects receive the same dose of ZTI-01with the same PK blood collection 
timepoints. Subjects will be randomized to one of five BAL sampling timepoints with a total of 6 subjects 
assigned to each BAL sampling time.  
4.3. 
Selection of Study Population 
The study population for this trial is 36 healthy male and female adults aged 18-45 years, inclusive, with BMI 
18-30 kg/m2, inclusive, and body weight >50 kg (110 lbs.). Only subjects who meet all inclusion criteria and 
no exclusion criteria will be eligible for enrollment into the trial. No exemptions are granted on 
Inclusion/Exclusion Criteria in DMID-sponsored trials. 
4.3.1. 
Subject Inclusion Criteria 
To be considered for study enrollment, subjects must meet all of the following inclusion criteria: 
1. Healthy1 men and women aged 18-45 years with no clinically significant findings2 at Screening and 
Baseline (Day -1 to Day 1)2 
1Healthy is defined by the absence of any medical condition described in the exclusion criteria in a 
subject with a normal physical exam including vital signs. If the subject has another current, ongoing 


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medical condition, the condition cannot meet any of the following criteria: 1) first diagnosed within 3 
months of enrollment; 2) is worsening in terms of clinical outcome in the last 6 months; or 3) involves 
need for medication.  
2Including findings on medical history, physical exam, vital signs, 12-lead ECG, or clinical laboratory 
tests.  
2. Body Mass Index (BMI) = 18-30 kg/m2, inclusive, and body weight >50 kg (110 lbs) 
3. Females who have been surgically sterilized via bilateral oophorectomy and/or hysterectomy at least 
90 days prior to Screening are considered lacking childbearing potential and will be eligible3 
3Postmenopausal females are not eligible, as the definition of menopause would require age >45, and 
all subjects in this study are age ≤45. 
4. Females of childbearing potential must have a negative serum pregnancy test at Screening, a negative 
urine pregnancy test at Baseline (Day -1 to Day 1), and must use acceptable contraception4 
4Acceptable contraception methods are restricted to surgical sterilization (bilateral tubal ligation) or 
successful Essure placement (permanent, non-surgical, non-hormonal sterilization with documented 
radiological confirmation at least 90 days after the procedure), use of long-acting reversible 
contraceptive devices (progestin-releasing subdermal implants [Nexplanon and Implanon, Merck], 
copper intrauterine devices [Paragard, Teva], and levonorgestrel-releasing intrauterine devices 
[Mirena, Bayer; Skyla, Bayer; Liletta, Allergan/Medicines360]), licensed hormonal products such as 
injectables or oral contraceptives, barrier methods such as condoms or diaphragms with spermicidal 
agents, and abstinence from sexual intercourse with a male partner. 
Subjects must have used the above-listed method for a minimum of 30 days prior to the first dose of 
study drug and be willing to use the method for at least 30 days after the final dose of study drug. 
5. Male subjects5 whose partners are of childbearing age or pregnant must be willing to use condoms 
during the study and through the Day 3 follow-up call. 
5including men who have had vasectomies 
6. Able to abstain from alcoholic beverages within 48 hours before Baseline (Day -1 to Day 1) and 
throughout the Treatment Phase 
7. Able to abstain from caffeine use within 7 days before Baseline (Day -1 to Day 1) and throughout the 
inpatient period 
8. Willing to remain in DEPRU during the Baseline and Treatment Phases  
9. Have a high probability for compliance and completion of the trial  
10. Sign a dated, witnessed, written ICF 
11. Have adequate venous access for infusions and blood draws 
4.3.2. 
Subject Exclusion Criteria 
Subjects must meet none of the following exclusion criteria: 
1. Any surgical or medical condition that in the opinion of the investigator could interfere with drug 
absorption, distribution, metabolism, or excretion. 
2. Any surgical or medical condition that in the opinion of the investigator may place the subject at 
increased risk while participating in the trial.  


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3. History or presence of cardiovascular disease including coronary artery disease and chronic 
hypertension (systolic pressure >140 mmHg or diastolic pressure >90 mmHg) 
4. Abnormal ECG at screening, as determined by the investigator to be clinically significant 
5. History or presence of renal impairment or chronic renal disease 
6. History or presence of liver disease (ALT, AST, or total bilirubin above the upper limit of normal) 
7. History or presence of chronic pulmonary disease, including asthma, requiring use of medication in 
the year before screening 
8. History of intolerance or hypersensitivity to phosphonic acid derivative antibiotics or any of its 
constituents (i.e., oral or IV fosfomycin) 
9. Have cancer or have a history of cancer within the past 5 years, with the exception of non-
melanomatous skin cancer, treated, without evidence of recurrence 
10. Any medical condition that prevents a subject from undergoing bronchoscopy with BAL 
11. Serum creatinine  above the upper limit of normal, or estimated creatinine clearance (CrCl) <60 
mL/min as determined by Cockcroft-Gault equation6 
6Cockcroft-Gault equation where age is in years, weight is in kilograms, and serum Cr is in mg/dL 
units: 
Males: CrCl (mL/min) = (140 – age) x Weight / (72 x Cr) 
Females: CrCl (mL/min) = [(140 – age) x Weight / (72 x Cr)] x 0.85 
12. History of regular alcohol consumption within 6 months of Baseline (Day -1 to Day 1)7  
7History of regular alcohol consumption is defined as an average weekly intake of >14 drinks for 
males or >7 drinks for females. One drink is equivalent to 12 g of alcohol: 12 ounces (360 mL) of 
beer, 5 ounces (150 mL) of wine, or 1.5 ounces (45 mL) of 80 proof distilled spirits.   
13. History of ≥10 pack-years smoking, or history of any nicotine use8 in the 6 months before Baseline 
(Day -1 to Day 1) or positive urine cotinine screen at Baseline (Day -1 to Day 1)9.   
8Including cigarettes, pipe, cigar, chewing tobacco, nicotine patch 
9A positive urine cotinine at screening is allowed if negative at baseline 
14. History of illicit drug use within 6 months of Baseline (Day -1 to Day 1)10 
10Use of cannabinoids with 1 month of Baseline (Day -1 to Day 1) is excluded, but other use of 
cannabinoids within 6 months is permitted 
15. Use of any prescription drugs, except acceptable contraception methods listed above, within 30 days 
of Baseline (Day -1 to Day 1) 
16. Involvement in other investigational studies of any type (drugs, devices, procedures) within 30 days of 
Baseline (Day -1 to Day 1) 
17. Blood or blood products donation within 30 days of Baseline (Day -1 to Day 1) 
18. Planning egg or sperm donation any time before Day 3 follow-up call 
19. Use of any non-prescription medications, vitamins, consumption >2 times/week of products 
containing genuine licorice, caffeine, or dietary or herbal supplements within 7 days of Baseline (Day 
-1 to Day 1).11  


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11Excluded from this list is intermittent use of acetaminophen at doses ≤2 g/day. Herbal supplements 
must be discontinued 7 days before the initial dose of study drug on Day 1. 
20. Presence of any acute illness, including febrile illness with temperature >37.8°C (>100.0°F), within 7 
days of Baseline (Day -1 to Day 1)  
21. Currently pregnant or breastfeeding as determined by subject report 
22. Positive tests for human immunodeficiency virus (HIV) 1 and 2 antibodies, hepatitis B surface antigen 
(HBsAg), or hepatitis C virus (HCV) antibody 
23. Positive urine drug or positive breathalyzer test for alcohol at Screening or Baseline (Day -1 to Day 1) 
or positive cotinine at Baseline (Day -1 to Day 1) 
24. Weight loss or gain of >10% within 30 days of Baseline (Day -1 to Day 1)  
25. Any laboratory value at screening or enrollment that is Grade 2 or more (Protocol Appendix B). A 
laboratory value that is Grade 1 will be allowed if not considered to be clinically significant by the 
investigator.12 
12Excluded from this list of permissible Grade 1 laboratory values are ALT, AST, or Total bilirubin 
per Exclusion Criteria 6; serum creatinine per Exclusion Criteria 11; and serum electrolytes 
including sodium, potassium, calcium, phosphorus and magnesium.  
4.4. 
Treatments 
4.4.1. 
Treatments Administered  
Each subject will receive three 6 g doses of ZTI-01, administered as a 1-hour IV infusion, every 8 hours for a 
total 18 g in 3 doses.  
4.4.2. 
Identity of Investigational Product(s) 
The non-US commercial drug product that will be used in the trial is a single vial of ZTI-01 disodium powder 
(4 g presentations with recrystallized succinic acid, in a Type 1 glass vials).  
Each Type 1, glass vial of ZTI-01 contains sterile white powder consisting of 5.28 g of fosfomycin disodium 
(equivalent to 4 g of fosfomycin and 1.28 g of sodium) and the inactive ingredient: recrystallized succinic 
acid. Each gram of ZTI-01 contains 330 mg of sodium. A total of two 4 g vials are required to prepare the 6 g 
dose. 
Vials will be labeled with protocol number, product identity – 4 g of ZTI-01 (fosfomycin for injection), lot 
number, expiry date, and the IND caution statement “New Drug – Limited by Federal Law to Investigational 
Use Only,” a statement to store at controlled room temperature, and a statement that each vial is for 
intravenous, single use only. 
4.4.3. 
Method of Assigning Subjects to BAL Sampling Timepoint Groups (Randomization) 
Subjects will be randomized to a single standardized bronchoscopy with BAL sampling timepoint upon study 
enrollment using an assignment schedule as follows: 30 subjects will be randomized 1:1:1:1:1 to one of the 
five BAL sampling timepoints (30 minutes, 75 minutes, 2 hours, 5 hours, or 8 hours after the start of the third 
IV infusion of ZTI-01). Up to six (6) subjects will be enrolled as alternates. Alternates will arrive at DEPRU 
on Day -1 to Day 1 and will adopt the planned BAL sampling timepoint of any other enrolled subject who 
fails to present for check-in or who fails to meet inclusion/exclusion criteria on Day -1 to Day 1. If all 


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scheduled subjects present for check-in and meet Day -1 to Day 1 inclusion/exclusion criteria, then alternates 
will not undergo any further study procedures at that time. In that case, alternates may be assigned to a new 
bronchoscopy time on a future date, alternate status for a future date, or as replacement subjects. 
Subjects will be enrolled online using the enrollment module of AdvantageEDCSM software. The 
randomization code will be prepared by DCC statisticians and included in the enrollment module for this 
study. AdvantageEDC will assign each subject to a sampling timepoint after the demographic and eligibility 
data have been entered. 
4.4.4. 
Selection of Doses in the Study 
The dosage selection was directly influenced by applying PK-PD principles of anti-infective agents. Recent 
studies have provided useful information for modernizing and optimizing fosfomycin dosing regimens. 
VanScoy et al found that the PK-PD parameter that most strongly associated with efficacy was the percentage 
of fosfomycin concentrations above the resistance inhibitory concentration (RIC) [% T>RIC] during the 
dosing interval [2]. The proposed magnitude % T>RIC associated with net bacterial stasis and a 1-log10 and 2-
log10 colony forming unit (CFU) reduction in bacterial density over 24 hours was 11.8, 20.9, and 32.7%, 
respectively. Total daily fosfomycin doses of 8 g and 32 g resulted in a rapid reduction in bacterial density 
without amplification of a drug-resistant subpopulation. A subsequent study suggested that the lowest 
fosfomycin dosing regimen that did not amplify a drug-resistant bacterial subpopulation was 4 g administered 
every 8 hours [3]. An in-vivo study performed in a neutropenic murine thigh model [4] used dose 
fractionation to assess PK-PD targets and survival. This study demonstrated ZTI-01 potency against E. coli, 
K. pneumoniae, and P. aeruginosa, including ESBL-producing and carbapenem-resistant phenotypes in vivo. 
In this 24-hour model, the index AUC/MIC was most closely linked with efficacy. Notably, targets for 
AUC/MIC and T>Threshold were similar between organism groups. Enterobacteriaceae stasis was noted at 
AUC/MIC exposures of ~20 and maximal survival was observed at exposures similar to stasis endpoints. 
4.4.5. 
Selection and Timing of Dose for Each Subject 
This trial will evaluate a single dose sequence of ZTI-01: three 6-g doses of fosfomycin, administered as a 1-
hour IV infusion, every 8 hours. Refer to Section 4.4.4 for additional details regarding the selection for the 
dose timing schedule. 
4.4.6. 
Blinding 
This is an open-label, unblinded study. Blinding (masking) is not needed. 
4.4.7. 
Prior and Concomitant Therapy  
Medications to treat any AEs the subject experiences during the trial are permitted. All information on 
concomitant medications will be recorded on the subject’s eCRF and will include the name of the procedure 
or drug and duration of the treatment (start/stop times), dosages, and route. The intermittent intake of 
acetaminophen (maximum 2 g/day) is permitted throughout the trial if approved by the Site PI. Subjects are 
required to refrain from the use of all prescription medications for at least 30 days before administration of the 
first dose of study drug on Day 1 until the last PK sample is taken.  
Herbal supplements and over-the-counter meds (except acetaminophen at doses ≤2 g/day) must be 
discontinued 7 days before the first dose of study drug until completion of the Treatment Phase. The use of 
illegal drugs is prohibited within the 6 months prior to Baseline (Day -1 to Day 1) and is not permitted while 
subjects are enrolled in this study. A urine drug screen will be performed at Screening. If a subject is unable to 


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comply with the restrictions described above, the subject’s continued participation in the trial will be re-
evaluated by the investigator. 
4.4.8. 
Treatment Compliance 
Study staff will be present for and during all study drug administrations. Visual inspection by study staff of 
the complete infusion will be appropriately recorded in the eCRF. All interruptions or premature terminations 
of infusion will be documented. 
4.5. 
Safety and PK Variables 
The following section describes the variables related to the safety and PK endpoints collected throughout the 
study. For a detailed schedule of procedures refer to Table 1. 
4.5.1. 
Safety Variables 
The type, incidence, relatedness, and severity of TEAEs and SAEs will be recorded from time of first dosing 
on day 1 through the follow-up call on Day 3. Refer to Section 3.3 for definitions of AEs, TEAEs, SAE, 
severity and relatedness.  
The following safety laboratory parameters and vital signs will be summarized for baseline and each post-
dose timepoint collected. Change from baseline will be summarized for all post dose timepoints. The most 
recent measurement prior to start of infusion of the first ZTI-01 dose will be regarded as baseline. For 
parameters with multiple pre-dose measurements, screening values prior to the baseline measurement will be 
listed only.  
Serum chemistry:  
- 
Albumin, glucose, blood urea nitrogen (BUN), potassium, magnesium, calcium, sodium, total protein, 
creatinine, triglycerides, total cholesterol, creatine phosphokinase (CPK), phosphorus, alkaline 
phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, 
direct bilirubin, and lactate dehydrogenase (LDH) will be collected at Screening and Day 2 before 
discharge. Albumin, random glucose, BUN, potassium, magnesium, calcium, sodium, phosphorus, 
total protein, creatinine, CPK, ALP, AST, ALT, and total bilirubin will be collected at Baseline (Day -
1 to Day 1). Sodium, potassium, magnesium, calcium, and phosphorus will be collected approximately 
2 hours prior to the assigned bronchoscopy timepoint. 
Hematology:  
- 
Hemoglobin, hematocrit, platelet count, white blood cell (WBC) count, neutrophils, lymphocytes, 
monocytes, eosinophils, basophils will be collected at Screening and Day 2 before discharge.  
Coagulation: 
- 
Prothrombin time (PT) and activated partial thromboplastin time (aPTT) will be collected at Screening 
and Day 2 before discharge. 
Urinalysis:  
- 
Leukocyte esterase, blood, pH, specific gravity, glucose, protein. A microscopic test will be performed 
if urinalysis is abnormal. The microscopic urinalysis result for the presence of blood will supersede the 
dipstick urinalysis result. Urinalyses performed at Screening and Day 2 before discharge.  


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Vital signs including heart rate, systolic blood pressure, diastolic blood pressure, temperature, respiratory rate, 
and peripheral oxygen saturation, are obtained for the following timepoints: Screening, Baseline (Day -1 to 
Day 1), immediately prior (within 10 minutes) to each of three doses of Study Drug, and at approximately 0.5, 
1, 2, and 5 hours after the start of infusion for each dose, and before discharge from DEPRU. Change from 
baseline will be summarized for all post dose timepoints. The most recent measurement prior to start of 
infusion of the first ZTI-01 dose will be regarded as baseline. 
ECGs including QTc interval, PR Interval, and QRS Duration will be obtained at Screening, Baseline (Day -1 
to Day 1), and Day 2 within 2 hours of the third (last) dose of study drug. In case of premature discontinuation 
of study drug, ECG is to be performed before discharge. 
Physical exam: overall physical assessment (to include vital signs [temperature, blood pressure, respiratory 
rate, heart rate, peripheral oxygen saturation], skin, head and neck, lungs, heart, liver, spleen, extremities, 
lymph nodes, and nervous system) and weight will be collected at Screening, Baseline (Day -1 to Day 1) and 
Day 2 prior to Discharge. Height will be measured and BMI will be calculated at screening only.  
4.5.2. 
Pharmacokinetics Variables  
Blood (plasma) for PK samples will be drawn for all subjects at the following timepoints relative to each 
dose:   
- 
Dose 1: Within 10 minutes before starting the 1-hour infusion and at 30 minutes (±5 minutes), 1 hour 
(0 to 5 minutes from end of infusion), 1 hour 15 minutes (±5 minutes), 2 hours (±5 minutes), 5 hours 
(±15 minutes) from the start time of the first infusion of ZTI-01 
- 
Dose 2: Within 10 minutes before starting the second 1-hour infusion.  
Note: This PK sample will be reported as the 8 hours post Dose 1 PK sample 
- 
Dose 3: Within 10 minutes before starting the 1-hour infusion and at 30 minutes (±5 minutes), 1 hour 
(0 to 5 minutes from end of infusion), 1 hour 15 minutes (±5 minutes),  2 hours (±5 minutes), 5 hours 
(±15 minutes), 8 hour (±15 minutes), and 12 hours (±15 minutes) from the start time of the third (last) 
infusion of ZTI-01 
A standardized bronchoscopy with BAL sampling will be performed at ±15 minutes of the single assigned 
timepoint based on each subject’s schedule assignment: 30 minutes, 1 hour 15 minutes, 2, 5, or 8 hours after 
the start time of the third (last) infusion of ZTI-01. 


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5. 
SAMPLE SIZE CONSIDERATIONS 
Since statistical analyses are not intended to serve as a basis of definitive conclusions, statistical power 
considerations for determination of sample size were not performed. The sample size for this study was 
selected as adequate for determining the safety and PK of ZTI-01. The sample size is based on clinical 
experience and judgment relative to study design and objectives.   


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6. 
GENERAL STATISTICAL CONSIDERATIONS 
6.1. 
General Principles 
All continuous variables will be summarized using the following descriptive statistics: N (non-missing sample 
size), mean, standard deviation (SD), median, maximum (max) and minimum (min). The frequency and 
percentages (based on the non-missing sample size) of observed levels will be reported for all categorical 
measures. When 95% confidence intervals (CIs) are given for a percent, exact (Clopper-Pearson) CIs will be 
used unless otherwise noted. 
In general, all data will be listed. All summary tables will be annotated with the total population size relevant 
to that table, including any missing observations. 
6.2. 
Timing of Analyses 
The final analysis will be performed after database lock. There are no planned interim analyses 
6.3. 
Analysis Populations 
6.3.1. 
Safety Population 
All subjects who receive any amount of ZTI-01 (start first infusion) will be included in the Safety Population 
6.3.2. 
Pharmacokinetics Population 
The pharmacokinetic analyses will be performed using the population of evaluable subjects. An evaluable 
subject is defined as a subject who receives all doses of ZTI-01, undergoes BAL at the randomized sampling 
timepoint with BAL return volume adequate for testing, and undergoes at least the one blood sampling 
timepoint that is concurrent with the BAL sampling timepoint, with blood sampling volume that is adequate 
for testing. 
6.4. 
Covariates and Subgroups  
The protocol does not define any formal subgroup analyses.  
6.5. 
Missing Data 
All attempts will be made to collect all data per protocol. No imputation will be performed for missing safety 
values and outliers will not be excluded from the safety analysis. The amount of missing data and reasons for 
missingness if available will be summarized in the body of the analysis report. 
6.6. 
Interim Analyses and Data Monitoring 
No interim analyses are planned. A safety summary report will be generated for review by the Safety 
Monitoring Committee (SMC) if a halting rule (see Protocol v6.0 Section 9.5) is met. 
6.7. 
Multicenter Studies 
This is a single site study. 


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6.8. 
Multiple Comparisons/Multiplicity 
Safety and PK analyses will not be adjusted for multiple comparisons.  


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7. 
STUDY SUBJECTS 
7.1. 
Disposition of Subjects 
The disposition of subjects in the study will be tabulated for all subjects and by BAL sampling timepoint 
(Table 5). The table shows the total number of subjects screened, enrolled and randomized, enrolled as an 
alternate, received any study product, completed infusion of study product, completed all PK blood draws, 
completed bronchoscopy with BAL, completed all plasma urea samples, completed at least one PK blood 
draw concurrent with BAL timepoint, completed follow-up on Study Day 3 and the number of subjects 
determined to be PK evaluable. 
A flowchart showing the disposition of study subjects will be included (Figure 2). This figure will present the 
number of subjects screened, enrolled, lost to follow-up, and analyzed. A listing of subjects who did not 
receive all three treatment infusions or terminated from study follow-up including the reason for treatment 
discontinuation or termination will be included in Listing 1. 
The composition of the Safety and PK analysis populations, including reasons for subject exclusion, are 
presented in Table 6. Although there may be multiple reasons for exclusion, only one reason will be counted 
when summarizing reasons for exclusion from analysis populations in the table. The order that reasons will be 
considered are the same as the order shown in the table shell. Subjects who were excluded from any analysis 
population will be listed along with reason for exclusion (Listing 4).  
Table 7 will present a summary of the reasons that subjects were screened but not enrolled summarized by 
inclusion and exclusion criteria. 
7.2. 
Protocol Deviations 
A summary of subject-specific protocol deviations will be presented by the reason for the deviation, the 
deviation category, and BAL Sampling Timepoint group for all subjects (Table 2). All deviations will be 
reviewed for possible subject exclusion from the PK population, including but not limited to incomplete 
infusion of study product, missing PK blood draws at PK timepoints, missing BAL at BAL sampling 
timepoint, and PK or BAL samples not processed per the MOP. All subject-specific protocol deviations and 
non-subject specific protocol deviations will be listed (Listing 2 and Listing 3, respectively). 


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8. 
EFFICACY EVALUATION 
There are no efficacy endpoints for this protocol. 


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9. 
SAFETY EVALUATION 
All safety analyses will be presented using the Safety Population. 
When calculating the incidence of AEs and SAEs (i.e., on a per subject basis), each subject will be counted 
once and any repetitions within a subject will be ignored for events coded in the same category by the 
Medical Dictionary for Regulatory Activities (MedDRA®). The denominators for percent values will be 
indicated within the table or table header and denominators will consist of the maximal size of the Safety 
Population in the indicated observation period. 
9.1. 
Demographic and Other Baseline Characteristics 
Summaries of age, weight, height, BMI, sex, ethnicity, and race will be presented by BAL sampling timepoint 
and for all subjects (Table 8, Table 9). Ethnicity is categorized as Hispanic or Latino, not Hispanic or Latino, 
Not Reported, and Unknown. In accordance with NIH reporting policy, subjects may self-designate as 
belonging to more than one race or may refuse to identify a race, the latter reflected in the CRF as “No” to 
each racial option. 
Individual subject listings will be presented for all demographics (Listing 5). 
9.1.1. 
Prior and Concurrent Medical Conditions 
All current illnesses and past pre-existing medical conditions will be coded using MedDRA dictionary version 
20.1 or higher. Summaries of subjects’ pre-existing medical conditions by MedDRA system organ class 
(SOC) and BAL sampling timepoints will be presented in Table 10. Individual subject listings will be 
presented for all medical conditions (Listing 6). 
9.1.2. 
Prior and Concomitant Medications  
Prior (30 days before administration of the first dose) and Concomitant medications will be coded to the 
Anatomical Therapeutic Classification (ATC) using the WHO Drug Dictionary. The use of prior or 
concomitant medications during the study will be summarized by ATC1 and ATC2 code and BAL sampling 
timepoint for the Safety Population (separately in Table 33 for prior medications and Table 34 for 
concomitant medications). Individual subject listings will be presented for all prior and concomitant 
medications (separately in Listing 18 for prior medications and Listing 19 for concomitant medications).  
Drugs will be listed and summarized as prior medications when the end date for the medication is before the 
first dose of study product and listed and summarized as concomitant medications otherwise. 
9.2. 
Measurements of Treatment Compliance 
The infusion start and end dates and times for each dose of study product will be listed (Listing 7). 
9.3. 
Adverse Events 
TEAEs will be collected from the start of the first infusion on Day 1 through the Telephone Follow-Up 
Interview on Day 3. When calculating the incidence of AEs (i.e., on a per subject basis), each subject will 
only be counted once at the highest severity recorded and any repetitions of AEs within a subject will be 
ignored. Denominators for percentages are the number of subjects in the Safety Population. 


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9.3.1. 
Unsolicited Adverse Events 
A brief overall summary of AEs will be shown in Table 11, including the number of subjects with at least 1 
TEAE of any severity, the number of subjects with at least 1 related TEAE of each severity, and the number 
of subjects with at least 1 SAE. 
The following summaries for unsolicited TEAEs will be presented by MedDRA system organ class (SOC) 
and Preferred Term: 
• The total number of TEAEs and the number and percentage of subjects reporting at least one AE, 
regardless of severity or relationship to study product. 95% CI intervals will be presented for 
proportions (Table 12), following start of each infusions and for any time from the start of infusion 
for Dose 1 through the Telephone Follow-Up Interview on Day 3. 
• The total number of TEAEs and the number and percentage of subjects reporting at least one AE 
by severity and relationship to study product (Table 13), for all AEs occurring from the start of 
infusion for Dose 1 through the Telephone Follow-Up Interview on Day 3. 
• Bar chart displaying the incidence (number of subjects) of related TEAEs by severity and 
MedDRA SOC (Figure 3); 
• Bar chart displaying the frequency (number of occurrences) of related TEAEs by severity and 
MedDRA SOC (Figure 4); 
AEs by subject will be presented in Listing 8. A subject listing of non-serious AEs of moderate or greater 
severity will be reported (Table 15). 
9.4. 
Deaths, Serious Adverse Events and other Significant Adverse Events 
A listing of SAEs by subject will be presented in Table 14. The listing will include Subject ID, Adverse Event 
Description, Adverse Event Onset Date/End Date, Days Post Dose, Reason Reported as an SAE, Relationship 
to Treatment, Alternate Etiology if not Related, action taken with study treatment, whether subject 
discontinued due to AE, outcome, MedDRA SOC, and MedDRA Preferred Term. 
9.5. 
Pregnancies 
For any subjects in the Safety Population who became pregnant during the study, every attempt will be made 
to follow these subjects to completion of pregnancy to document the outcome, including information 
regarding any complications with pregnancy and/or delivery. If any pregnancies occur, listings of pregnancies 
and outcomes will be presented (Listing 20, Listing 21, Listing 22, Listing 23, and Listing 24). 
9.6. 
Clinical Laboratory Evaluations 
Chemistry, Hematology, Coagulation, and Urinalysis laboratory parameters will be collected at Screening, 
Baseline and Day 2 before discharge as described in Section 4.5.1. Sodium, potassium, magnesium, calcium, 
and phosphorus chemistry parameters will also be collected approximately 2 hours prior to the assigned 
bronchoscopy timepoint. The grading scale used for clinical laboratory evaluations is presented in Table 3.  
Baseline will be defined as the most recent measurement prior to start of infusion of the first ZTI-01 dose. For 
parameters with multiple pre-dose measurements, screening values prior to the baseline measurement will be 
listed only. 
The following parameters will be presented (in order): 


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• Chemistry: Sodium, Potassium, Magnesium, Calcium, Phosphorus, Albumin, Random Glucose, 
BUN, Total Protein, Creatinine, Triglycerides, Total Cholesterol, CPK, ALP, AST, ALT, Total 
Bilirubin, Direct Bilirubin, and LDH 
• Hematology: Hemoglobin, Hematocrit, Platelet Count, WBC Count, Neutrophils, Lymphocytes, 
Monocytes, Eosinophils, Basophils 
• Coagulation: PT and aPTT 
• Urinalysis:  
o By dipstick: Leukocyte Esterase, Blood, pH, Specific Gravity, Protein, Glucose.  
o By microscopic evaluation: WBC in urine, Red Blood Cells (RBC) in urine, Bacteria, and Casts.  
Laboratory results will be summarized by parameter and severity for baseline and all post-dose timepoints 
(including maximum severity post-baseline) and presented in Table 20, Table 22, Table 24, and Table 26. At 
baseline, measurements will be summarized according to the grading scale in Table 3. For post-dose 
measurements, if a value is outside the normal range but did not meet the definition for an AE due to the value 
being less than or equal to the measurement at baseline, it will be categorized as “Outside Normal Range.” All 
other values will be summarized according to the grading scale in Table 3. 
Laboratory parameters that have grading criteria for both decreases (result lower than normal range and 
baseline measurement) and increases (result higher than normal range and baseline measurement) will be 
summarized separately by direction of change. For example, sodium will be summarized separately as 
“Sodium, Decrease” and “Sodium, Increase.” For the summary of the Urinalysis laboratory parameters, the 
denominator for WBC in urine and RBC in urine by microscopic evaluation will be the number of subjects 
with a urinalysis result (dipstick or microscopic evaluation) for the visit, not only the number of subjects with 
microscopic evaluation. 
Abnormal laboratory results, Grade 1 severity or higher, will be listed in Table 16, Table 17, Table 18, and 
Table 19. 
For continuous laboratory parameters, descriptive statistics including mean, SD, median, min and max values 
by timepoint and change from baseline all post-dose measures will be presented by laboratory parameter in 
Table 21, Table 23, Table 25, and Table 27.  
Data will be visualized using box plots showing the change from baseline at each post dose timepoint.  
- 
Chemistry Parameters: Beginning at Figure 5 and continuing through Figure 23 
- 
Hematology Parameters: Beginning at Figure 24 and continuing through Figure 32 
- 
Coagulation Parameters: Figure 33, Figure 34 
- 
Urinalysis: Figure 35, Figure 36 
Only laboratory parameters reported as continuous values will be included in tables of summary statistics and 
in box plots for change from baseline. Continuous parameters from the urine microscopic evaluation will not 
be visualized but will be summarized in the tables of summary statistics.  
Listing 9, Listing 10, Listing 11, and Listing 12 will provide a complete listing of individual clinical 
laboratory results with applicable reference ranges. 
Baseline serology screening results (Listing 13), urine toxicology and alcohol screening results (Listing 14) 
will be listed. 


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9.7. 
Vital Signs and Physical Evaluations 
Vital sign measurements include systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, 
peripheral oxygen saturation, and temperature. Vital signs will be assessed at Screening and Baseline visits, 
immediately prior (within 10 minutes) to each of three doses of study drug, at approximately 0.5, 1, 2, and 5 
hours after the start of infusion for each dose, and before discharge on Study Day 2.  
The grading scale for vital sign evaluations is presented in Table 4. Summaries of vital signs by severity will 
be tabulated by timepoint and presented by parameter in Table 28. Vital signs that have grading criteria for 
both decreases (result lower than normal range and baseline measurement) and increases (result higher than 
normal range and baseline measurement) will be summarized separately by direction of change.  
Descriptive statistics including mean, SD, median, min and max values by timepoint and change from 
baseline for each post dose timepoint will be presented by parameter in Table 29. The baseline measurement 
used for all post-dose timepoints will be the most recent measurement prior to start of infusion of the first 
ZTI-01 dose. Any pre-dose measurements from Screening or Baseline prior to the baseline value will be 
listed. 
Data will be visualized using box plots showing the change from baseline at all post dose study timepoints 
with lines connecting the median, first quartile, and third quartile of the change from baseline at each 
timepoint (Figure 37, Figure 38, Figure 39, Figure 40, Figure 41 and Figure 42).  
Vital signs results will be listed (Listing 15). Unplanned vital signs measurements will be included in the 
listing, but excluded from tabular and graphical summaries, except when calculating the maximum severity 
post-baseline. 
The study protocol allows measurements of vital signs to be repeated in the case of an abnormal 
measurement. Repeat readings may be obtained up to twice more for a maximum of 3 measurements 
including the initial measurement. The following rules will be used to decide which measurement to include 
in summaries if more than one replicate was entered into the clinical database. 
• If the first replicate is normal, then it will be used for analysis 
• If the first replicate is abnormal, and the second replicate is also abnormal, then the first replicate 
will be used if has a severity equal to or greater to the second replicate, or the second replicate will 
be used if the second replicate has a higher severity than the first replicate. 
• If the first replicate is abnormal, the second replicate is normal, and a third replicate measurement 
was not performed, then the first replicate will be used in the analysis. 
• If the first replicate is abnormal, the second replicate is normal, and the third replicate is normal, 
then the second replicate will be used in the analysis. 
• If the first replicate is abnormal, the second replicate is normal, and the third replicate is abnormal, 
then the first replicate will be used if has a severity equal to or greater to the third replicate, or the 
third replicate will be used if the third replicate has a higher severity than the first replicate. 
Vital signs replicates not used in the analysis will not be listed. 
A physical exam will be performed at Screening, Baseline (Day -1 to Day 1) and Day 2 (day of discharge) as 
described in Section 4.5, as well as the SAE follow-up as needed. Results of physical examinations, scheduled 
and unscheduled, will be presented in Listing 16. 


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9.8. 
ECG Assessments 
An ECG will be performed at Screening, Baseline and within 1-2 hours of the last dose (3rd dose) of study 
drug and include the following parameters: QTc Interval, PR Interval, and QRS Duration. The grading scale 
for ECG evaluations is included in Table 4. 
ECG change in overall interpretation from Baseline to Post Dose 3 will be shown in Table 30. Summaries of 
ECG results by severity for each parameter will be tabulated by timepoint and presented in Table 31.  
Summary statistics of ECG results including mean, SD, median, min and max values by timepoint and change 
from baseline for the Post Dose 3 timepoint will be tabulated and presented by parameter for baseline and 
each post dose timepoint (Table 32). Data will be visualized using box plots showing the change from 
baseline at post Dose 3 (Figure 43, Figure 44, Figure 45 ). 
Individual data listings of ECG results will be presented (Listing 17).  
 


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10. 
PHARMACOKINETICS 
10.1. 
Analysis Population and Handling of Missing Timepoints 
The pharmacokinetic analyses will be performed using the population of evaluable subjects as defined in 
Section 6.3.2.  
Timepoints below the lower limit of quantification (LLOQ), referred to as below quantification limit (BQL), 
preceding the first PK concentration above the LLOQ will be imputed as 0. All other PK sample 
concentrations below the LLOQ will not be included in graphical displays or analyses.  
All protocol deviations will be reviewed by the statistician. Major deviations such as receiving an incomplete 
dose, subject dosed but not meeting eligibility criteria, etc. may result in exclusion of a subject from PK 
analysis with approval from the sponsor. Statistical outlier concentrations will not be excluded from analysis 
unless associated with a protocol deviation that could plausibly explain the outlier.  
Missing PK sample concentrations will not be imputed for the NCA.  
10.2. 
Dosing and Pharmacokinetic Sampling Summary 
Subject infusion start and end times (including interruptions) for all infusions received will be presented for 
each subject (Listing 7). If infusion of the drug is interrupted, the start and end times of the interruption will 
be recorded. Regardless of the amount of study product received, all scheduled blood draws will be attempted 
to be collected within a window based on the start of the administration. Special cases that potentially affect 
the analysis will be discussed in the final report. Actual infusion duration will be used for NCA analysis. If 
actual infusion duration time is missing, a duration of 1 h will be imputed.  
Fosfomycin concentrations in plasma will be listed by subject and infusion dose number, with BQL and out of 
sample time window samples indicated (Listing 25). Fosfomycin concentrations in BAL and cell pellet 
samples concentrations will be listed by subject with out of sample time window samples indicated 
(Listing 27). The listings will also indicate the nominal and actual time associated with the sample.  
Nominal time is defined as the time in hours since the start of infusion of either Dose 1 or Dose 3 as shown 
below: 
Dose 1 
• Timing of PK sample = “Pre-Dose for Dose 1”, Nominal Time = 0 h 
• Timing of PK sample = “30 minutes after starting the first dose”, Nominal Time = 0.5 h 
• Timing of PK sample = “1 hour after starting the first dose”, Nominal Time = 1 h 
• Timing of PK sample = “1 hour 15 minutes after starting the first dose”, Nominal Time = 1.25 h 
• Timing of PK sample = “2 hours after starting the first dose”, Nominal Time = 2 h 
• Timing of PK sample = “5 hours after starting the first dose”, Nominal Time = 5 h 
• Timing of PK sample = “Pre-Dose for Dose 2”, Nominal Time = 8 h 
Dose 3 
• Timing of PK sample = “Pre-Dose for Dose 3”, Nominal Time = 0 h 
• Timing of PK sample = “30 minutes after starting the third dose”, Nominal Time = 0.5 h 


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• Timing of PK sample = “1 hour after starting the third dose”, Nominal Time = 1 h 
• Timing of PK sample = “1 hour 15 minutes after starting the third dose”, Nominal Time = 1.25 h 
• Timing of PK sample = “2 hours after starting the third dose”, Nominal Time = 2 h 
• Timing of PK sample = “5 hours after starting the third dose”, Nominal Time = 5 h 
• Timing of PK sample = “8 hours after starting the third dose”, Nominal Time = 8 h 
• Timing of PK sample = “12 hours after starting the third dose”, Nominal Time = 12 h 
Important protocol deviations related to dosing or PK sampling will be described. Possible bioanalytical 
errors and their effect on the PK analysis will be discussed. 
10.3. 
Definition and Estimation of Individual PK Parameters 
PK parameters will be estimated through a NCA using Phoenix® WinNonlin® version 8.0 or later (Pharsight 
Corporation, Cary, NC) using plasma concentrations collected after start of the first infusion. Actual post-dose 
time will be used for the estimation of PK parameters instead of nominal time. 
Phoenix WinNonlin® NCA will use the following settings to compute parameters from serum and pulmonary 
PK data: 
• Linear Up Log Down calculation method 
• Uniform weighting 
• IV Infusion 
• Lambda Z Acceptance Criteria 
o Rsq_adjusted ≥ 0.90 
o Span ≥ 3.0 half-lives 
o Includes at least 3 timepoints after Tmax 
10.3.1. 
PK Parameters 
Cmax 
Maximum concentration (Cmax) for Dose 1 is defined as the maximum observed ZTI-01 concentration 
observed over all PK sample concentrations following Dose 1 and prior to Dose 2 and Cmax for Dose 3 is 
defined as the maximum observed ZTI-01 concentration observed over all PK sample concentrations 
following Dose 3.  It will be obtained from the Cmax parameter calculated by WinNonlin®. If there is no 
measurable concentration in the subject’s PK profile, then Cmax will be missing for that subject. Cmax will be 
reported in units of µg/mL. 
Tmax 
Time of maximum concentration (Tmax) will be calculated separately for Dose 1 and for Dose 3. For Dose 1, 
Tmax is defined as the time at which the maximum concentration occurs for PK sample concentrations 
following Dose 1 and prior to Dose 2.  For Dose 3, Tmax is defined as the time at which the maximum 
concentration occurs for PK sample concentrations following Dose 3. These will be obtained from the Tmax 
parameter calculated by WinNonlin®. If there is no measurable Cmax in the subject’s PK profile, then Tmax 
will be missing for that subject. Tmax will be reported in units of h. 


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λz  
The elimination rate constant (λz) is defined as the first-order rate constant describing the rate of decrease of 
drug concentration in the terminal phase (defined as the region of the PK curve where absorption and 
distribution are no longer significant, and drug concentration follows first-order elimination kinetics). λz will 
be computed as the slope of a terminal region consisting of at least 3 successive points in the plot of log-
transformed concentration data versus time. λz will be estimated using uniform weighting.  
Time points used in the estimation of λz will be initially selected using the WinNonlin® automatic algorithm. 
Manually chosen time points may be used at the discretion of the PK analyst after examination of the 
automatically chosen points in the context of the semi-log profile. The set of points chosen will be that which 
maximizes the Pearson correlation (r) while satisfying the following. Computation of λz for a subject requires 
the use of at least three consecutive timepoints after Tmax with evaluable concentrations above the LLOQ and 
for which the absolute value of the Pearson correlation (R2) of log-transformed concentrations with time is 
greater than 0.8. If deemed necessary and appropriate, the observation collected at Tmax may be used in the 
calculation of λz. The range of timepoints used to estimate λz must span at least 1.5 half-lives (definition 
below). Estimates of λz that use the timepoint at Tmax will be clearly specified and justified in the analysis 
report. Drug concentrations used to calculate λz will be indicated in Listing 25. This parameter will be 
obtained from the Lambda_z parameter calculated by WinNonlin® and will be reported in units of /hours 
t½ 
The apparent terminal elimination half-life (t½) is defined as the time required for the drug concentration to 
decrease by a factor of one-half in the terminal phase. The apparent terminal elimination half-life (t½) will be 
estimated as ln(2) / λz. It will be obtained from the HL_Lambda_z parameter calculated by WinNonlin®. 
Half-life will be reported in units of h. 
AUC 
AUC(0-8)  for Dose 1 is defined  as the area under the concentration-time curve from dosing for Dose 1 ( Dose 
1 Nominal Time=0 h ) to 8 hrs post start of infusion, 12 hours post start of Dose 3 infusion, and the time of 
the last measured concentration, respectively.  
AUC(0-8)  and AUC(0-12) will be estimated using the Linear Up Log Down calculation method. AUC(0-last) will 
be estimated using the Linear Up Log Down calculation method and obtained from the AUClast parameter 
calculated by WinNonlin®. 
AUC(0-∞) for Dose 3 is defined as the total area under the concentration-time curve from start of infusion for 
Dose 3 (Nominal Time=0 h ) taken to the limit as the end time becomes arbitrarily large. AUC(0-∞) will be 
estimated by adding the Dose 3 AUC(0-last) to an extrapolated value equal to the last measured concentration 
greater than the LLOQ divided by λz: 
AUC(0−∞) = AUC(0−last) + Clast
Ke
, 
where Clast is the last measured concentration ≥ LLOQ. AUC(0-inf) will be obtained from the AUCINF_obs 
parameter calculated by WinNonlin®. If the amount extrapolated portion of AUC(0-∞) is >20%, the estimated 
AUC(0-∞) value will be flagged when listed in the report (Listing 26) and will be excluded from statistical 
summaries of parameter estimates and downstream calculations. 
All AUCs will be reported in units of h*µg/mL. 


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CL 
Clearance (CL) is defined as the volume of plasma completely cleared of drug per unit time and is estimated 
in trials of an IV-administered drug as the dose divided by the AUC(0-∞). It will be obtained from the Cl_obs 
parameter calculated by WinNonlin®. If the amount extrapolated portion of AUC(0-∞) is >20%, the estimated 
CL value will be flagged when listed in the report and will be excluded from statistical summaries of 
parameter estimates and downstream calculations. CL will be reported in units of L/h. 
Vd 
Volume of distribution (Vd) will be estimated as the apparent volume of distribution at steady state (Vss) in 
trials of an IV-administered drug. This value will be calculated using the AUC and area under the first 
moment curve (AUMC). It will be obtained from the Vss_obs parameter calculated by WinNonlin®. If the 
amount extrapolated portion of AUC(0-inf) is >20%, the estimated Vss value will be flagged when listed in the 
report and will be excluded from statistical summaries of parameter estimates and downstream calculations. 
Vd at steady state will be reported in units of L. 
AR 
The observed accumulation ratio (AR) is defined as the ratio of exposure parameters following multiple 
dosing. AR will be calculated using AUC0-8 and Cmax for Dose 1 and Dose 3: 
AR = AUC0-8,  Dose 3
AUC0-8, Dose 1
 
AR = Cmax,  Dose 3
Cmax, Dose 1
 
When λZ is estimable, AR will also be estimated using the elimination rate λz from Dose 3: 
AR = 
1
1-e-λZτ 
where τ is the length of the dosing interval, 8 h. 
Shift in Tmax 
Shift in Tmax between Dose 1 and Dose 3 will be calculated by the subtraction of Tmax for Dose 1 from Tmax 
for Dose 3. Point estimates of the shift and associated 95% CIs derived from the inversion of the Sign Test 
will be reported. The 95% CIs will be calculated using the CIPCTLDF option in PROC Univariate.   
10.3.2. 
Noncompartmental Analysis Population AUC and Percent Penetration Estimation 
The median concentrations of fosfomycin from the BAL sampling times will be used to estimate the 
population average AUC0-8 of plasma, ELF, and AM will be estimated using the Linear Up Log Down 
calculation method.  
The ratios of population average AUC0-8 of ELF-to-plasma and AM-to-plasma will be calculated to determine 
estimates of the percent penetration by dividing the AUC0-8 for ELF or AM by the geometric mean Plasma 
AUC0-8.  


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10.4. 
Descriptive Statistics  
Summary statistics for all continuous PK measures and parameters will include mean, SD, min, max, median, 
coefficient of variation as a percent (CV%), GM, and geometric SD (GSD), unless otherwise specified. CV% 
will not be calculated for Tmax and Tlast since those variables are not log-normal.  
The CV% will be calculated using the method for log-normally distributed data.:  
CV% =  ඥexp(σ2) −1 ∗100% , where σ2 is the variance of the log-transformed data [5]. 
10.4.1. 
Pharmacokinetic Parameter Summaries for Plasma 
Plasma fosfomycin concentrations and summary statistics will be listed and summarized by nominal 
timepoint for Dose 1 (Table 35) and for Dose 3 (Table 36) and presented graphically:  
• Figure 46 will plot all plasma PK profiles plots for Dose 1 and Dose 3 as linear plots and Figure 47 
will plot all subject plasma PK profiles plots for Dose 1 and Dose 3 as semilogarithmic plots 
• Linear plots of plasma mean concentration curves will be shown in Figure 48 for Dose 1 and Dose 
3, with error bars representing +/- 1 standard SD. 
• Semi-logarithmic plots of GM plasma concentration curves will be shown in Figure 49 Dose 1 and 
Dose 3. 
PK Estimates for Dose 1 will include Cmax, Tmax, Tlast, AUC(0-8)  and will be presented in Table 37. PK 
Estimates for Dose 3 will include Cmax, Tmax, Tlast, AUC(0-8), AUC(0-last) and AUC(0-inf), λz,t1/2, CL, and Vd and 
will be presented in Table 38.  
Shift in Tmax will be summarized for Dose 3 compared to Dose 1 in Table 39 . AR for Cmax and AUC(0-8) will 
be summarized for Dose 3 compared to Dose 1 in Table 40. 
10.4.2. 
Pharmacokinetic Parameter Summaries for ELF and AM 
ELF fosfomycin concentrations will be calculated as described in Section 3.3. Serum and BAL urea levels, 
volume of fosfomycin concentrations in BAL, the derived Fosfomycin concentrations in ELF, and fosfomycin 
concentrations in AM will be presented by BAL sampling timepoint and subject in Listing 27.   
Statistical summaries by BAL sampling point for ELF fosfomycin concentrations and the concentration ratio 
of ELF to plasma fosfomycin concentrations will be presented in Table 41. Statistical summaries by BAL 
sampling point for AM fosfomycin concentrations and the concentration ratio of AM to Plasma fosfomycin 
concentrations will be presented in Table 42 respectively.  
10.4.3. 
Analysis of Noncompartmental Analysis Parameters and Percent Penetration 
The NCA population average AUC0-8 of plasma, ELF, and AM using the median concentrations of 
fosfomycin from the BAL sampling times will be presented in Table 43 along with the calculated percent 
penetration for ELF to plasma and AM to plasma.  
Data will be presented graphically in the following figures:  
- 
Box plot showing BAL sampling timepoint on the x-axis and the distribution of subject fosfomycin 
concentrations in ELF, AM, and plasma at matching BAL timepoint on the y-axis (Figure 50). 
- 
Linear plots showing the population median fosfomycin concentrations by compartment (plasma, 
ELF, and AM) across each of the BAL sampling timepoints (Figure 51).  


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- 
Semi-logarithmic plots showing the population median fosfomycin concentrations by compartment 
(plasma, ELF, and AM) across each of the BAL sampling timepoints (Figure 52).  
10.5. 
Exploratory Population PK Modeling  
In addition to analysis of penetration of ZTI-01 into the lung using NCA, an exploratory analysis of 
penetration using the population PK approach will be performed as described in [6], where observed 
concentrations in both the central and peripheral compartment will be used simultaneously to fit a 2- or 3-
compartment model. Between subject variability (BSV) for all PK parameters will be included using an 
exponential model, where the random errors have a N(0, ω2) distribution. 
If fitting both concentration types simultaneously does not produce an adequate model, then plasma PK and 
lung PK will be modeled sequentially as described in [7]. In this approach, plasma concentrations will first be 
modeled using a 2-compartment or 3-compartment model and ELF or AM concentrations will be 
subsequently modeled using approaches akin to treating ELF or AM concentrations as a response in a PK/PD 
analysis. Specifically, the following models would be considered for ELF or AM concentrations (referred to 
here generally as Clung). 
1) Direct Response: 𝐶𝐶𝑙𝑙𝑙𝑙𝑙𝑙𝑙𝑙= 𝛽𝛽𝐶𝐶𝑝𝑝 
2) Time −varying proportion: 𝐶𝐶𝑙𝑙𝑙𝑙𝑙𝑙𝑙𝑙= 𝛽𝛽𝑗𝑗𝐶𝐶𝑝𝑝, 𝑗𝑗= 1,2,3,4,5 
3) Effect Site Equilibration: 𝑑𝑑𝑑𝑑𝑙𝑙𝑙𝑙𝑙𝑙𝑙𝑙
𝑑𝑑𝑑𝑑
= −𝑄𝑄× 𝐶𝐶𝑙𝑙𝑙𝑙𝑙𝑙𝑙𝑙+ 𝑄𝑄× 𝐶𝐶𝑝𝑝 
Model selection will be based on diagnostic plots and AIC. Other models such as use of an Emax link function 
to describe a nonlinear relationship between Clung and Cp may be considered if none of the above models are 
adequate. BSV for all PK parameters will be included using an exponential model. The final model will 
include estimation of all off-diagonal estimates of the BSV covariance matrix, if feasible. Residual variability 
(RV) will be included using a combined multiplicative and additive model. The FOCE-ELS calculation 
method in Phoenix v8.0 or higher NLME will be used for model fitting. Model performance will be evaluated 
using visual predictive checks (VPCs). Parameter estimates for the final model will be presented with 
estimates of BSV (CV) where relevant. 
Median values and 95% prediction intervals for penetration will be obtained by simulating 1,000 8-hour 
plasma and ELF/AM profiles with BSV and without RV, computing individual AUC0-8 values using the 
predicted concentrations via NCA with the Linear Up Log Down calculation method, computing individual 
penetration using AUC ratios, and taking the 2.5th and 97.5th percentiles of the ratio as the bounds for the 
prediction intervals. 


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11. 
IMMUNOGENICITY 
There are no immunogenicity endpoints for this protocol. 


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12. 
OTHER ANALYSES 
There are no other analyses. 


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13. 
REPORTING CONVENTIONS 
P-values ≥0.001 and ≤0.999 will be reported to 3 decimal places; p-values less than 0.001 will be reported as 
“<0.001” The mean, standard deviation, and other statistics will be reported to 1 decimal place greater than 
the original data. The minimum and maximum will use the same number of decimal places as the original 
data. Proportions will be presented as 2 decimal places; values greater than zero but <0.01 will be presented as 
“<0.01”. Percentages will be reported to the nearest whole number; values greater than zero but < 1% will be 
presented as “<1”; values greater than 99% but less than 100% will be reported as >99%. Estimated 
parameters, not on the same scale as raw observations (e.g. regression coefficients) will be reported to 3 
significant figures. 
For PK, AUCs will be reported as whole numbers (or using 3 significant digits if less than 100). t1/2, Tmax, CL, 
and Vd (Vss) values will be reported to one decimal place (or to 2 significant digits if less than 1). λz values 
will be reported to 3 significant digits. Cmax will be reported with the same number of significant digits as the 
measurement.  
Listings of individual subject data include a Subject ID column. The subject identifiers assigned by site staff 
are replaced throughout this report with the SDTM variable USUBJID to protect the confidentiality of those 
who volunteered to participate in this protocol. USUBJID has been created as a composite of the 3-letter EDC 
platform code followed by a numeric identifier assigned chronologically to enrolled subjects as well as 
screening failures across all sites and protocols in the EDC platform. Any data sharing activities will include 
the USUBJID and not the subject identifiers assigned at the site. 
 


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14. 
TECHNICAL DETAILS 
SAS version 9.4 or above will be used to generate all tables, figures, and listings. 


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15. 
SUMMARY OF CHANGES IN THE CONDUCT OF THE STUDY OR 
PLANNED ANALYSES 
If there are changes to the planned analysis prior to final data lock and after finalization of the SAP, they may 
be added to the SAP as an addendum. The SAP will not be amended after final data lock. 


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16. 
REFERENCES 
1. Rennard, S. I., et al. "Estimation of volume of epithelial lining fluid recovered by lavage using urea as 
marker of dilution." Journal of applied physiology 60.2 (1986): 532-538. 
2. VanScoy BD, McCauley J, Ellis-Grosse EJ, Okusanya OO, Bhavnani SM, Forrest A, Amborse PG.  
Exploration of the pharmacokinetic-pharmacodynamic relationships for fosfomycin efficacy using an in 
vitro infection model.  Antimicrob Agents Chemother 2015;59:7170–7. 
3. VanScoy BD, McCauley J, Bhavnani SM, Ellis-Grosse EJ, Amborse PG.  Relationship between 
fosfomycin exposure and amplification of Escherichia coli subpopulations with reduced susceptibility in a 
hollow-fiber infection model.  Antimicrob Agents Chemother 2016;60:5141–5. 
4. Lepak AJ, Zhao M, Vanscoy B, Taylor DS, Ellis-Grosse E, Ambrose PG, and Andes DR. In vivo 
Pharmacokinetics and Pharmacodynamics of ZTI-01 (Fosfomycin for Injection) in the Neutropenic 
Murine Thigh Infection Model against E. coli, K. pneumoniae, and P. aeruginosa.  Antimicrob. Agents 
Chemother. AAC.00476-17; Accepted manuscript posted online 10 April 2017 
5. Canchola, J. A., et al. "Correct use of percent coefficient of variation (% CV) formula for log-transformed 
data." MOJ Proteomics Bioinform 6.4 (2017): 316-317. 
6. Lodise, Thomas P., et al. "Telavancin penetration into human epithelial lining fluid determined by 
population pharmacokinetic modeling and Monte Carlo simulation." Antimicrobial agents and 
chemotherapy 52.7 (2008): 2300-2304. 
7. Dimelow, Richard, et al. "Population pharmacokinetic modelling of ceftazidime and avibactam in the 
plasma and epithelial lining fluid of healthy volunteers." Drugs in R&D 18.3 (2018): 221-230. 
 


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17. 
LISTING OF TABLES, FIGURES, AND LISTINGS  
Table, figure, and listing shells are presented in Appendices 1, 2, and 3. 
 


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APPENDICES 


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APPENDIX 1. TABLE MOCK-UPS 
LIST OF TABLES 
Table 1: 
Schedule of Study Procedures ....................................................................................40 
Table 2: 
Distribution of Protocol Deviations by Category, Type, and BAL Sampling 
Timepoint Group ........................................................................................................42 
Table 3: 
Laboratory Adverse Event Grading Scale ..................................................................44 
Table 4: 
Clinical Adverse Event Definition and Grading Scale ...............................................46 
Table 5: 
Subject Disposition by BAL Sampling Timepoint Group ..........................................49 
Table 6: 
Analysis Populations by BAL Sampling Timepoint Group .......................................50 
Table 7: 
Ineligibility Summary of Screen Failures ...................................................................51 
Table 8: 
Summary of Categorical Demographic and Baseline Characteristics by BAL 
Sampling Timepoint Group ........................................................................................52 
Table 9: 
Summary of Continuous Demographic and Baseline Characteristics by BAL 
Sampling Timepoint Group ........................................................................................53 
Table 10: Summary of Subjects with Pre-Existing Medical Conditions by MedDRA 
System Organ Class and BAL Sampling Timepoint Group .......................................54 
Table 11: Overall Summary of Adverse Events .........................................................................55 
Table 12: Summary of Unsolicited Adverse Events by MedDRA System Organ Class 
and Preferred Term, and Timepoint ............................................................................56 
Table 13: Unsolicited Adverse Events by MedDRA System Organ Class and Preferred 
Term, Maximum Severity and Relationship ...............................................................57 
Table 14: Listing of Serious Adverse Events .............................................................................58 
Table 15: Listing of Non-Serious, Unsolicited, Moderate or Severe Adverse Events ...............59 
Table 16: Listing of Abnormal Laboratory Results – Chemistry ...............................................61 
Table 17: Listing of Abnormal Laboratory Results – Hematology ............................................62 
Table 18: Listing of Abnormal Laboratory Results – Coagulation ............................................63 
Table 19: Listing of Abnormal Laboratory Results – Urinalysis ...............................................64 
Table 20: Chemistry Laboratory Results by Parameter, Severity, and Timepoint .....................65 
Table 21: Chemistry Laboratory Summary Statistics by Parameter and Timepoint ..................66 
Table 22: Hematology Laboratory Results by Parameter, Severity, and Timepoint ..................67 
Table 23: Hematology Laboratory Summary Statistics by Parameter and Timepoint ...............68 
Table 24: Coagulation Laboratory Results by Parameter, Severity, and Timepoint ..................69 
Table 25: Coagulation Laboratory Summary Statistics by Parameter and Timepoint ...............70 


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Table 26: Urinalysis Laboratory Results by Parameter, Maximum Severity, and 
Timepoint ....................................................................................................................71 
Table 27: Urinalysis Laboratory Summary Statistics by Parameter and Timepoint ..................72 
Table 28: Vital Signs by Assessment, Maximum Severity, and Timepoint ...............................73 
Table 29: Vital Signs Summary Statistics and Change from Baseline by Assessment 
and Timepoint .............................................................................................................74 
Table 30: ECG Overall Interpretations, Post Dose 3 Compared to Baseline .............................75 
Table 31: ECG Results by Parameter, Severity, Timepoint and Assessment .............................76 
Table 32: ECG Results - Summary Statistics by Parameter and Timepoint...............................77 
Table 33: Number and Percentage of Subjects with Prior Medications by WHO Drug 
Classification and BAL Sampling Timepoint .............................................................78 
Table 34: Number and Percentage of Subjects with Concurrent Medications by WHO 
Drug Classification and BAL Sampling Timepoint ...................................................79 
Table 35: Individual Concentrations and Summary Statistics by for Plasma 
Fosfomycin Concentration (µg/mL) by Nominal Time - Dose 1 ...............................80 
Table 36: Individual Concentrations and Summary Statistics by for Plasma 
Fosfomycin Concentration (µg/mL) by Nominal Time - Dose 3 ...............................81 
Table 37: Summary Statistics for Plasma Fosfomycin PK Parameters, Dose 1 .........................82 
Table 38: Summary Statistics for Plasma Fosfomycin PK Parameters, Dose 3 .........................83 
Table 39: Summary of Shift in Tmax, Comparing Dose 1 and Dose 3 ......................................84 
Table 40: Summary Statistics for Accumulation Ratios Comparing Dose 1 and Dose 3 ...........85 
Table 41: Summary Statistics for ELF Fosfomycin Concentration (µg/mL) and ELF to 
Plasma Concentration Ratio by BAL Sampling Timepoint .......................................86 
Table 42: Summary Statistics for AM Fosfomycin Concentration (µg/mL) and AM to 
Plasma Concentration Ratio by BAL Sampling Timepoint .......................................87 
Table 43: Noncompartmental Analysis Population Average AUC0-8 of Fosfomycin in 
Plasma, ELF, and AM and Percent Penetration .........................................................88 
 


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9.1 
Overall Study Design and Plan Description 
9.5.1 Pharmacokinetic and Safety Measurements Assessed and Flow Chart 
Table 1: 
Schedule of Study Procedures 
Activities 
Screening 
Visit 
Baseline  
Visit 
Treatment 
Phase 
Discharge Visit 
Telephone 
Follow-Up 
Early Termination 
Unscheduled Visit 
Day 
-30 to -1 
Day 
-1 to 1 
Days 
1 to 2 
Day 2 
Day 3 
Informed Consent 
X 
 
 
 
 
 
 
Review Eligibility Criteria 
X 
X 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
Admission to DEPRU 
 
X 
 
 
 
 
 
Medical History 
X 
Xa 
 
 
 
 
 
Counsel on Birth Control 
X 
 
 
X 
 
X 
 
Counsel on non-prescription medications 
X 
 
 
 
 
 
 
Prior/Concomitant Medication Review 
X 
X 
X 
X 
X 
X 
X 
Collect and Record AEs/SAEsb 
 
 
X 
X 
X 
X 
X 
Height / BMI 
X 
 
 
 
 
X 
 
Vital Signsc 
X 
X 
X 
X 
 
X 
X 
Physical Exam (including weight) 
X 
X 
 
X 
 
X 
Xd 
Alcohol and Tobacco Historye 
X 
 
 
 
 
 
 
ECG (12-lead)f 
X 
X 
X 
 
 
 
X 
HIV Antibody, Hepatitis B Ag, Hepatitis C Antibody  
X 
 
 
 
 
 
 
Hem-Coag-UAg 
X 
 
X 
X 
 
X 
 
Chemistryg 
X 
X 
X 
X 
 
X 
 
Lipids, LDHg 
X 
 
X 
X 
 
X 
 
Pregnancy Testsh 
X 
X 
 
 
 
 
 
Urine & Breath Tox Screensi  
X 
X 
 
 
 
 
 
Place Two Peripheral IVs 
 
X 
 
 
 
 
 
Study Drug Administrationj 
 
 
X 
 
 
 
 
Blood for Urea Assayk 
 
 
X 
 
 
 
 
Blood PK Samplesl 
 
 
X 
 
 
 
 
Bronchoscopy and BALm 
 
 
X 
 
 
 
 
Discharge from DEPRU 
 
 
 
X 
 
 
 
a Update medical history as appropriate since screening including non-pharmacologic treatments/procedures within 72 hours before enrollment 
in the eCRF 
b Collect and record AEs and SAEs from the time the start of treatment (Day 1) through Day 3. 


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c Vital signs (heart rate, blood pressure, temperature, respiratory rate, and peripheral oxygen saturation), measured with subject in the supine or 
semi-recumbent position, will be obtained at the following timepoints: Screening, Baseline (Day -1), immediately prior (within 10 minutes) 
to each of three doses of Study Drug, at approximately 0.5, 1, 2, and 5 hours (each ± 10 minutes) as after the start of infusion for each dose, 
and before discharge from DEPRU. If vital signs are abnormal, repeated readings will be obtained up to twice more, 5 to 10 minutes apart. If 
they remain abnormal, unscheduled vital signs will be repeatedly obtained until they normalize (at investigator’s discretion). Since changes 
in vital signs are expected during bronchoscopy, when a vital sign timepoint is scheduled during a subject’s bronchoscopy, that timepoint 
will be measured immediately before the start of bronchoscopy. 
d At unscheduled visits, weight may be performed as part of the physical exam but is not required  
e Alcohol history within past 6 months, lifetime tobacco history 
f ECGs will be performed in the supine or semi-recumbent position (after rest for at least 10 min) at 3 timepoints: at Screening, Day 1 (before 
first dose of Study Drug), and within 1-2 hours of the last dose (3rd dose) of study drug. In case of premature discontinuation of study drug, 
ECG is to be performed before discharge. 
g At Screening, and before discharge (Day 2), obtain hematology labs (white blood cell count, hemoglobin, hematocrit, and platelet count, 
neutrophils, lymphocytes, monocytes, eosinophils, basophils); coagulation tests (aPTT and PT), chemistry labs (albumin, glucose, blood urea 
nitrogen (BUN), potassium, magnesium, calcium, sodium, phosphorus, total protein, creatinine, triglycerides, total cholesterol, CPK, 
phosphorus, AST, ALT, total bilirubin, direct bilirubin, ALP, LDH), and urinalysis (leukocyte esterase, blood, glucose, protein, pH, and 
specific gravity via dipstick with addition of urine microscopy if dipstick abnormal). At Baseline (Day -1 to Day 1) obtain albumin, glucose, 
BUN, potassium, magnesium, calcium, sodium, phosphorus, total protein, creatinine, CPK, AST, ALT, total bilirubin, and ALP. 
Approximately two hours prior to bronchoscopy (Day 2) obtain sodium, potassium, magnesium, calcium, and phosphorus. 
h Serum pregnancy test for women of childbearing potential at screening, and urine pregnancy test for women of childbearing potential at 
Baseline (Day -1 to Day 1) 
i Alcohol Breathalyzer test, Urine cotinine, and Urine drug screen at Screening and Baseline (Day -1 to Day 1/admission to DEPRU). Cotinine 
will be reported qualitatively as positive/negative. Urine drug screen will consist of: barbiturates, benzodiazepines, THC, cocaine, opiates, 
and amphetamine/methamphetamine.  
j Subjects will receive a total of three doses of ZTI-01 (fosfomycin disodium) 6g, administered every 8 hours, as 1-hour intravenous infusion 
k Blood sample to determine plasma urea concentration will be obtained just before or during the scheduled bronchoscopy 
l PK blood samples will be collected at 15 timepoints: before (within 10 minutes) the first, second, and third doses of study drug, at 30 minutes 
(during infusion), 1 hour (within 5 minutes after the end of infusion), 1 hour 15 minutes, 2, and 5 hours from the start time of the first dose of 
ZTI-01, and at 30 minutes (during infusion), 1 hour (within 5 minutes after the end of infusion), 1 hour 15 minutes, 2, 5, 8, and 12 hours 
from the start time of the third (last) infusion of ZTI-01. Blood PK samples will be drawn for all subjects within the following windows: -1 
to -10 minutes for scheduled samples at pre-dose; +/- 5 minutes for scheduled samples at 30 minutes, 1 hour 15 minutes, and 2 hours; +0-5 
minutes after end of infusion for the scheduled sample at 1 hour; +/- 15 minutes for scheduled samples at 5, 8, and 12 hours. Actual times for 
dosing and sample will be recorded. 
m Bronchoscopy with BAL at 30 minutes (during the 1-hr infusion), 1 hr 15 minutes, 2, 5, or 8 hours from T0 (defined as the start time of the 
last [third] infusion of ZTI-01). BAL PK samples will be obtained within +/- 15 minutes of scheduled timepoint. Actual times for dosing and 
sample will be recorded.  
 


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10.2 
Protocol Deviations 
Table 2: 
Distribution of Protocol Deviations by Category, Type, and BAL Sampling Timepoint Group 
Category 
Deviation Type 
30 minute BAL 
(N=X) 
75 minute BAL 
(N=X) 
2 hour BAL 
(N=X) 
5 hour BAL 
(N=X) 
8 hour BAL 
(N=X) 
All Subjects 
(N=X) 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
Eligibility/enrollment 
Any type 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Did not meet inclusion criterion 
 
 
 
 
 
 
 
 
 
 
 
 
 
Met exclusion criterion 
 
 
 
 
 
 
 
 
 
 
 
 
 
ICF not signed prior to study procedures 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment administration schedule 
Any type 
 
 
 
 
 
 
 
 
 
 
 
 
 
Out of window visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Missed visit/visit not conducted 
 
 
 
 
 
 
 
 
 
 
 
 
 
Missed treatment administration 
 
 
 
 
 
 
 
 
 
 
 
 
 
Delayed treatment administration 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other 
 
 
 
 
 
 
 
 
 
 
 
 
Follow-up visit schedule 
Any type 
 
 
 
 
 
 
 
 
 
 
 
 
 
Out of window visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Missed visit/visit not conducted 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol procedure/assessment 
Any type 
 
 
 
 
 
 
 
 
 
 
 
 
 
Incorrect version of ICF signed 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood not collected 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine not collected 
 
 
 
 
 
 
 
 
 
 
 
 
 
BAL not collected 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other specimen not collected 
 
 
 
 
 
 
 
 
 
 
 
 
 
Specimen result not obtained 
 
 
 
 
 
 
 
 
 
 
 
 


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Category 
Deviation Type 
30 minute BAL 
(N=X) 
75 minute BAL 
(N=X) 
2 hour BAL 
(N=X) 
5 hour BAL 
(N=X) 
8 hour BAL 
(N=X) 
All Subjects 
(N=X) 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
No. of 
Subj. 
No. of 
Dev. 
 
Required procedure not conducted 
 
 
 
 
 
 
 
 
 
 
 
 
 
Required procedure done incorrectly 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study product temperature excursion 
 
 
 
 
 
 
 
 
 
 
 
 
 
Specimen temperature excursion 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment administration 
Any type 
 
 
 
 
 
 
 
 
 
 
 
 
 
Required procedure done incorrectly 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study product temperature excursion 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other 
 
 
 
 
 
 
 
 
 
 
 
 
 


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12.2.2 Displays of Adverse Events 
12.4.1 Individual Laboratory Measurements and Abnormal Laboratory Values 
Table 3: 
Laboratory Adverse Event Grading Scale 
LABORATORY ADVERSE EVENTS 
  
  
  
BLOOD, SERUM, PLASMA  
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 3) 
Sodium – Hyponatremia mEq/L 
132 – <LLN 
130 – <132 
<130 
Sodium – Hypernatremia mEq/L 
>ULN – 148 
>148 – 150  
>150 
Potassium – Hyperkalemia mEq/L 
>ULN – 5.2 
>5.2 - 5.4 
>5.4 
Potassium – Hypokalemia mEq/L 
3.1-<LLN 
3.0-<3.1 
<3.0 
Glucose – Hypoglycemia mg/dL 
65 - 69 
55 - <65 
<55 
Glucose – Hyperglycemia 
Fasting – mg/dL 
>ULN - 120 
>120 - 130 
>130 
Glucose – Hyperglycemia 
Random – mg/dL 
141 - 159 
>159 – 200 
>200 
Blood Urea Nitrogen mg/dL 
21-26 
>26 – 31 
> 31 
Creatinine – mg/dL 
>ULN – 1.7 
>1.7 – 2.0 
>2.0 
Calcium – hypocalcemia mg/dL 
8.0 – <LLN 
7.5 – <8.0 
<7.5 
Calcium – hypercalcemia mg/dL 
>ULN – 11.0 
>11.0 – 11.5 
>11.5 
Magnesium – hypomagnesemia mg/dL 
1.3 – 1.7 
1.1 – <1.3 
<1.1 
Phosphorous – hypophosphatemia mg/dL 
2.1 – 2.2 
1.9 – <2.1 
<1.9 
CPK – mg/dL 
221-1000 
>1000-1500 
>1500 
Albumin – Hypoalbuminemia g/dL 
2.8 – 3.4 
2.5 – <2.8 
< 2.5 
Total Protein – Hypoproteinemia g/dL 
5.2 – <LLN 
5.0 – <5.2 
< 5.0 
Alkaline phosphatase (ALP) – U/L 
111 - 240 
>240– 360 
>360 
AST U/L 
42 – 105 
>105-175 
>175 
ALT U/L (Female) 
>ULN - 105 
>105-175 
>175 
ALT U/L (Male) 
>ULN – 105 
>105-175 
>175 
Bilirubin (serum total) - mg/dL 
1.6 - 2.5 
>2.5 - 3.0 
> 3.0  
Direct bilirubin – mg/dL 
0.7-2.0 
>2.0-3.5 
>3.5 
Total cholesterol – mg/dL 
301 – 400 
>400-500 
>500 
Triglycerides – mg/dL 
>500 – 750 
>750 – 1000 
>1000 
Lactate dehydrogenase – U/L  
>200-500 
>500-800 
>800 
Hemoglobin (Female) - g/dL 
11.0 – 11.9 
9.5 – <11.0 
< 9.5  
Hemoglobin (Male) - g/dL 
12.0 – 13.6 
10.0 – <12.0 
<10.0 
WBC Increase - cell/mm3 
9900 – 15,000 
>15,000 – 20,000 
> 20,000 
WBC Decrease - cell/mm3 
2,500 – 3100 
1,500 – <2,500 
< 1500 
Lymphocytes Decrease - cell/mm3 
500 – <600 
400 - <550 
< 400 
Neutrophils Decrease - cell/mm3 
1,500 - < 2000 
1000 - <1500 
< 1000 


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LABORATORY ADVERSE EVENTS 
  
  
  
Eosinophils - cell/mm3 
> 700 - 750 
>750 - 1500 
> 1500 
Platelets Decreased - cell/mm3 
120,000 – < 149,000 
100,000 – <120,000 
<100,000 
PT – seconds (prothrombin time) 
> ULN – 14.4 
>14.4 – 15.7 
> 15.7 
aPTT – seconds (activated partial thromboplastin time) 
> ULN – 42.1 
>42.1 – 50.0 
> 50.0 
URINE  
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 3) 
Protein 
1+ 
2+ 
>2+ 
Glucose 
1+ 
2+ 
>2+ 
Blood (microscopic) - red blood cells per high power 
field (rbc/hpf) 
5-10* 
>10-50*  
> 50 and/or gross blood* 
 


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Table 4: 
Clinical Adverse Event Definition and Grading Scale 
Clinical Adverse Events 
 
 
 
 
VITAL SIGNS  
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 3) 
Fever (°C) * 
38.0 – 38.4 
38.5 – 38.9 
≥39.0 
* Oral temperature; no 
recent hot or cold 
beverages or smoking.   
             (°F) * 
100.4 – 101.1 
101.2 – 102.0 
≥102.1  
Tachycardia - beats per minute 
101 – 115 and >25% 
change from baseline 
116 – 130 and >25% 
change from baseline 
> 130 or ventricular 
dysrhythmias and >25% 
change from baseline 
 
Bradycardia - beats per minute  
50 – 54 or 45 - 49 bpm 
if baseline <60 bpm - 
Subject is 
asymptomatic; no 
treatment required 
45 – 49 or 40 -44 if 
baseline <60 bpm -  
 Subject is asymptomatic; 
no treatment required; 
Site PI/sub-investigator 
may confirm with ECG 
or 12-lead Holter 
monitors to rule out 
arrhythmia or advanced 
heart block. 
< 45 or <40 bpm if 
baseline <60 bpm - 
Subject is symptomatic 
and/or requires 
treatment; Site PI/sub-
investigator should 
confirm with ECG or 
12-lead Holter monitors 
to rule out arrhythmia or 
advanced heart block 
 
 Hypertension (systolic)- mm Hg 
141-150 
151-160 
> 160 
Assuming supine 
position, 10 min at rest 
conditions, not 
sleeping subjects 
measurements on the 
same arm and several 
concordant results.  
Hypertension (diastolic) - mm Hg 
91-95 
96-100 
> 100 
 
Hypotension (systolic) - mm Hg 
85-89 
80-84 
< 80 
Tachypnea – breaths per minute 
23-25 
26-30 
>30 
CARDIOVASCULAR 
Grade 1  
Grade 2  
Grade 3  
Hemorrhage, Blood Loss  
Estimated blood loss < 
100 mL  
Estimated blood loss > 
100 mL, no transfusion  
required 
Transfusion required  
QTc interval (prolonged) 
QTc 450-480 msec 
 
QTc 481-500 msec 
 
QTc >500 msec 
 
 
PR Interval (prolonged) 
PR 200-250 msec and 
>25% change from 
baseline 
PR >250 msec and >25% 
change from baseline 
AV block 2nd degree 
Type II or higher OR 
ventricular pause >3 sec 
 
QRS Interval (prolonged) 
QRS 120-150 msec 
and >25% change 
from baseline 
QRS 150-180 msec and 
>25% change from 
baseline 
New bundle branch 
block 
 
RESPIRATORY    
Grade 1  
Grade 2  
Grade 3  
 
Cough  
Transient- no 
treatment  
Persistent cough;  
Interferes with daily 
activities 
Bronchospasm, Acute 
Transient; no 
treatment; 71% - 80% 
FEV1 of peak flow  
Requires treatment; 
normalizes with 
bronchodilator; FEV1 
No normalization with 
bronchodilator; FEV1 
<60% of peak flow 


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Clinical Adverse Events 
 
 
 
 
60% - 70% (of peak 
flow)  
Dyspnea   
Does not interfere with 
usual and social 
activities 
Interferes with usual and 
social activities, no 
treatment 
Prevents daily and usual 
social activity or 
requires treatment 
GASTROINTESTINAL   
Grade 1  
Grade 2  
Grade 3  
 
Nausea  
No interference with 
activity 
Some interference with 
activity 
Prevents daily activities 
Vomiting  
No interference with 
activity or 1 - 2 
episodes/24 hours 
Some interference with 
activity or > 2 
episodes/24 hours 
Prevents daily activity or 
requires IV hydration 
Diarrhea  
2 - 3 loose or watery 
stools or < 400 gm/24 
hours 
4 - 5 loose or watery 
stools or 400 - 800 gm/24 
hours 
6 or more loose or 
watery stools or > 
800gms/24 hours or 
requires IV hydration 
 
REACTOGENICITY 
  
  
LOCAL REACTIONS 
Grade 1  
Grade 2  
Grade 3  
Pain 
Does not interfere with 
activity 
Repeated use of non-
narcotic pain reliever > 
24 hours or interferes 
with activity 
Any use of narcotic pain 
reliever or prevents daily 
activity 
Tenderness 
 Discomfort only to 
touch 
Discomfort with 
movement 
Significant discomfort at 
rest 
Erythema/Redness ** 
2.5 - 5 cm 
5.1 - 10 cm 
> 10 cm 
** In addition to 
grading the measured 
local reaction at the 
greatest single 
diameter, the 
measurement should be 
recorded as a 
continuous variable. 
Induration/Swelling *** 
2.5 - 5 cm and does 
not interfere with 
activity 
5.1 - 10 cm or interferes 
with activity 
> 10 cm or prevents 
daily activity 
***Induration/Swelling 
should be evaluated 
and graded using the 
functional scale as well 
as the actual 
measurement 
SYSTEMIC  
Grade 1  
Grade 2  
Grade 3  
Allergic Reaction  
 pruritus without rash  
 localized urticaria  
 generalized urticaria; 
angioedema or 
anaphylaxis  
Headache  
No interference with 
activity 
Repeated use of non-
narcotic pain reliever > 
24 hours or some 
interference with activity 
Significant; any use of 
narcotic pain reliever or 
prevents daily activity 
Fatigue  
No interference with 
activity 
Some interference with 
activity 
Significant; prevents 
daily activity 
Myalgia 
No interference with 
activity 
Some interference with 
activity 
Significant; prevents 
daily activity 
 


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Clinical Adverse Events 
 
 
 
 
ALL OTHER CONDITIONS 
Grade 1 
Grade 2 
Grade 3 
Illness or clinical adverse event 
(as defined according to 
applicable regulations) 
No interference with 
activity 
Some interference with 
activity not requiring 
medical intervention 
Prevents daily activity 
and requires medical 
intervention 
 


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Table 5: 
Subject Disposition by BAL Sampling Timepoint Group 
Subject 
Disposition  
30 minute BAL 
(N=X) 
75 minute BAL 
(N=X) 
2 hour BAL 
(N=X) 
5 hour BAL 
(N=X) 
8 hour BAL 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Screened 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
x 
-- 
Total Enrolled 
x 
100 
x 
100 
x 
100 
x 
100 
x 
100 
x 
100 
Enrolled and Randomized 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
Enrolled as Replacement 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
Began Infusion of Dose 1  
 
 
 
 
 
 
 
 
 
 
 
 
Completed Dose 1  
 
 
 
 
 
 
 
 
 
 
 
 
Completed Dose 2  
 
 
 
 
 
 
 
 
 
 
 
 
Completed Dose 3  
 
 
 
 
 
 
 
 
 
 
 
 
Completed All Scheduled Treatmentsa 
 
 
 
 
 
 
 
 
 
 
 
 
Completed All PK Blood Draws 
 
 
 
 
 
 
 
 
 
 
 
 
Completed Bronchoscopy with BAL 
 
 
 
 
 
 
 
 
 
 
 
 
Completed All Plasma Urea Samples 
 
 
 
 
 
 
 
 
 
 
 
 
At Least One PK Blood Draw Concurrent with BAL 
Timepoint 
 
 
 
 
 
 
 
 
 
 
 
 
Completed Follow-up (Study Day 3)a 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluableb,c 
 
 
 
 
 
 
 
 
 
 
 
 
Note: N= number of subjects enrolled 
a Refer to Listing 1 for reasons subjects discontinued or terminated early. 
b Refer to Listing 4 for reasons subjects are excluded from the Analysis populations. 
c An evaluable subject is defined as a subject who receives all doses of ZTI-01, undergoes BAL at the randomized sampling timepoint with BAL return volume adequate for testing, and undergoes at 
least the one blood sampling timepoint that is concurrent with the assigned BAL sampling timepoint, with blood sampling volume that is adequate for testing. Refer to Listing 4 for reasons subjects are 
not considered evaluable. 
 


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Table 6: 
Analysis Populations by BAL Sampling Timepoint Group 
Analysis Populations 
Reason Subjects Excluded a 
30 minute BAL 
(N=X) 
75 minute BAL 
(N=X) 
2 hour BAL 
(N=X) 
5 hour BAL 
(N=X) 
8 hour BAL 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Safety Population 
Any Reason 
xx 
x 
xx 
xx 
x 
xx 
xx 
x 
xx 
xx 
x 
xx 
 
Did not receive any amount of study product 
 
 
 
 
 
 
 
 
 
 
 
 
PK Population 
Any Reason 
 
 
 
 
 
 
 
 
 
 
 
 
 
Did not receive all 3 doses of study product 
 
 
 
 
 
 
 
 
 
 
 
 
 
Did not undergo BAL at Sampling Timepoint 
 
 
 
 
 
 
 
 
 
 
 
 
 
BAL return volume not adequate for testing 
 
 
 
 
 
 
 
 
 
 
 
 
 
Missing PK sample from blood sampling timepoint 
concurrent with BAL sampling timepoint 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood sampling volume PK sample at timepoint concurrent 
with BAL sampling timepoint inadequate for testing 
 
 
 
 
 
 
 
 
 
 
 
 
Note: N= number of subjects enrolled 
a Refer to Listing 4 for reasons subjects are excluded from the Analysis populations. 
 


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Table 7: 
Ineligibility Summary of Screen Failures 
Inclusion/Exclusion Category 
Inclusion/Exclusion Criterion 
na 
%b 
Inclusion and Exclusion 
Number of subjects failing any eligibility criterion 
x 
100 
Inclusion 
Any inclusion criterion 
x 
xx 
 
[inclusion criterion 1] 
x 
xx 
 
[inclusion criterion 2] 
x 
xx 
 
[inclusion criterion 3] 
x 
xx 
Exclusion 
Any exclusion criterion 
x 
xx 
 
[exclusion criterion 1] 
x 
xx 
 
[exclusion criterion 2] 
x 
xx 
 
[exclusion criterion 3] 
x 
xx 
a More than one criterion may be marked per subject. 
b Denominator for percentages is the total number of screen failures. 
 
 


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Table 8: 
Summary of Categorical Demographic and Baseline Characteristics by BAL Sampling Timepoint Group 
Variable 
Characteristic 
30 minute BAL 
(N=X) 
75 minute BAL 
(N=X) 
2 hour BAL 
(N=X) 
5 hour BAL 
(N=X) 
8 hour BAL 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Sex  
Male 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
Female 
 
 
 
 
 
 
 
 
 
 
 
 
Ethnicity  
Not Hispanic or Latino 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
Hispanic or Latino 
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Reported 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
Race  
American Indian or Alaska Native 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
 
Asian 
 
 
 
 
 
 
 
 
 
 
 
 
 
Native Hawaiian or Other Pacific 
Islander 
 
 
 
 
 
 
 
 
 
 
 
 
 
Black or African American 
 
 
 
 
 
 
 
 
 
 
 
 
 
White 
 
 
 
 
 
 
 
 
 
 
 
 
 
Multi-Racial 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
Note: N=Number of subjects in the Safety Population 
 


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Table 9: 
Summary of Continuous Demographic and Baseline Characteristics by BAL Sampling Timepoint Group 
Variable 
Statistic 
30 minute BAL 
(N=X) 
75 minute BAL 
(N=X) 
2 hour BAL 
(N=X) 
5 hour BAL 
(N=X) 
8 hour BAL 
(N=X) 
All Subjects 
(N=X) 
Age 
Mean 
xx 
xx 
xx 
xx 
xx 
xx 
 
Standard Deviation 
xx 
xx 
xx 
xx 
xx 
xx 
 
Median 
x 
x 
x 
x 
x 
x 
 
Minimum 
x 
x 
x 
x 
x 
x 
 
Maximum 
x 
x 
x 
x 
x 
x 
Height 
Mean 
 
 
 
 
 
 
 
Standard Deviation 
 
 
 
 
 
 
 
Median 
 
 
 
 
 
 
 
Minimum 
 
 
 
 
 
 
 
Maximum 
 
 
 
 
 
 
Weight 
Mean 
 
 
 
 
 
 
 
Standard Deviation 
 
 
 
 
 
 
 
Median 
 
 
 
 
 
 
 
Minimum 
 
 
 
 
 
 
 
Maximum 
 
 
 
 
 
 
BMI 
Mean 
 
 
 
 
 
 
 
Standard Deviation 
 
 
 
 
 
 
 
Median 
 
 
 
 
 
 
 
Minimum 
 
 
 
 
 
 
 
Maximum 
 
 
 
 
 
 
Note: N=Number of subjects in the Safety Population 
 
 


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Table 10: 
Summary of Subjects with Pre-Existing Medical Conditions by MedDRA System Organ Class and BAL Sampling Timepoint 
Group 
MedDRA System Organ Class 
30 minute BAL 
(N=X) 
75 minute BAL 
(N=X) 
2 hour BAL 
(N=X) 
5 hour BAL 
(N=X) 
8 hour BAL 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Any SOC 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
[SOC 1] 
 
 
 
 
 
 
 
 
 
 
 
 
[SOC 2] 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: N=Number of subjects in the Safety Population 
 


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14.3 
Safety Data 
Table 11: 
Overall Summary of Adverse Events 
 
All Subjects 
(N = x) 
Subjectsa with 
n 
% 
At least one TEAE 
x 
x 
 
 
 
At least one related TEAE 
x 
x 
     Mild (Grade 1) 
x 
x 
     Moderate (Grade 2)  
x 
x 
     Severe (Grade 3)  
x 
x 
 
 
 
At least one severe (Grade 3) unsolicited TEAE 
x 
x 
     Related  
x 
x 
     Unrelated 
x 
x 
 
 
 
At least one SAEb 
x 
x 
At least one related, SAE 
x 
x 
At least one adverse event leading to early terminationc  
x 
x 
Note: N = Number of subjects in the Safety Population 
a Subjects are counted once for each category regardless of the number of events. 
b A listing of Serious Adverse Events is included in Table 14. 
c As reported on the Adverse Event eCRF. 


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14.3.1.2 
Unsolicited Adverse Events 
Table 12: 
Summary of Unsolicited Adverse Events by MedDRA System Organ Class and Preferred Term, and Timepoint 
MedDRA System 
Organ Class 
MedDRA 
Preferred Term 
Start of Infusion 1 – 
Pre-Dose 2  
(N=X) 
Start of Infusion 2 – 
Pre-Dose 3  
(N=X) 
Start of Infusion 3 – 
Follow-Up 
(N=X) 
Any Time Post Start of Infusion 
(N=X) 
n 
% 
95% CI 
Events 
n 
% 
95% CI 
Events 
n 
% 
95% CI 
Events 
n 
% 
95% CI 
Events 
Any SOC 
Any PT 
x 
xx 
xx, xx 
x 
x 
xx 
xx, xx 
x 
x 
xx 
xx, xx 
x 
x 
xx 
xx, xx 
x 
[SOC 1] 
Any PT 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 2] 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[SOC 2] 
Any PT 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[PT 2] 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Notes: N = Number of subjects in the Safety Population who started the specified infusion. This table presents number and percentage of subjects and the number of events. For the number of subjects 
(n) and corresponding percent (%), a subject is only counted once per Preferred Term and timepoint. 
 


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Table 13: 
Unsolicited Adverse Events by MedDRA System Organ Class and Preferred Term, 
Maximum Severity and Relationship 
MedDRA System 
Organ Class 
Preferred Term 
Severity 
All Subjects 
(N = X) 
Related 
Not Related 
n 
% 
Events 
n 
% 
Events 
Any SOC 
Any PT 
Any Severity 
x  
x  
x  
x  
x  
x  
 
 
Mild 
x  
x  
x  
x  
x  
x  
 
 
Moderate 
x  
x  
x  
x  
x  
x  
 
 
Severe 
x  
x  
x  
x  
x  
x  
SOC 1 
PT 1 
Any Severity 
x  
x  
x  
x  
x  
x  
 
 
Mild 
x  
x  
x  
x  
x  
x  
 
 
Moderate 
x  
x  
x  
x  
x  
x  
 
 
Severe 
x  
x  
x  
x  
x  
x  
 
PT 2 
Any Severity 
x  
x  
x  
x  
x  
x  
 
 
Mild 
x  
x  
x  
x  
x  
x  
 
 
Moderate 
x  
x  
x  
x  
x  
x  
 
 
Severe 
x  
x  
x  
x  
x  
x  
Note: N = Number of subjects in the Safety Population.  
 
 


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14.3.2 Listing of Deaths, Other Serious and Significant Adverse Events 
Table 14: 
Listing of Serious Adverse Events 
Adverse 
Event 
Associated 
with Dose 
No. 
No. of Hours Post 
Associated Dose 
(Duration) 
Study Day Event 
Became Serious 
Reason 
Reported 
as an 
SAE 
Severity 
Relationship 
to Study 
Treatment 
If Not 
Related, 
Alternative 
Etiology 
Action 
Taken 
with 
Study 
Treatment 
Subject 
Discontinued 
Due to AE 
Outcome 
MedDRA 
System 
Organ 
Class 
MedDRA 
Preferred 
Term 
BAL Sampling Timepoint: , Subject ID: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
 
 
Comments: 
 
BAL Sampling Timepoint: ,Subject ID: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
 
 
Comments: 
 
 


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Table 15: 
Listing of Non-Serious, Unsolicited, Moderate or Severe Adverse Events 
Adverse 
Event 
Associated 
with Dose No. 
No. of Hours 
Post 
Associated 
Dose 
(Duration) 
Severity 
Relationship 
to Study 
Treatment 
If Not 
Related, 
Alternative 
Etiology 
Action Taken 
with Study 
Treatment 
Subject 
Discontinued 
Due to AE 
Outcome 
MedDRA 
System Organ 
Class 
MedDRA 
Preferred 
Term 
BAL Sampling Timepoint: , Subject ID: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
Comments: 
 
BAL Sampling Timepoint: , Subject ID: ,  AE Number:  
 
 
 
 
 
 
 
 
 
 
 
Comments: 
 


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14.3.3 Narratives of Deaths, Other Serious and Significant Adverse Events 
(not included in SAP, but this is a placeholder for the CSR) 
 


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14.3.4 Abnormal Laboratory Value Listings (by Subject) 
Table 16: 
Listing of Abnormal Laboratory Results – Chemistry 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint, Laboratory Parameter (follow order specified in Section 9.6)] 
BAL Sampling 
Timepoint 
Subject 
ID 
Sex 
Age 
(years) 
Planned 
Timepoint 
Actual 
Study Day 
Laboratory 
Parameter 
(Units) 
Result 
(Severity) 
Relationship to 
Treatment 
If Not Related, 
Alternate 
Etiology 
Action Taken 
with Study 
Treatment 
Subject 
Discontinued 
Due to Result? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Table 17: 
Listing of Abnormal Laboratory Results – Hematology 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint, Laboratory Parameter (follow order specified in Section 9.6)] 
BAL 
Sampling 
Timepoint 
Subject 
ID 
Sex 
Age 
(years) 
Planned 
Timepoint 
Actual 
Study Day 
Laboratory 
Parameter 
(Units) 
Result 
(Severity) 
Relationship to 
Treatment 
If Not Related, 
Alternate 
Etiology 
Action Taken 
with Study 
Treatment 
Subject 
Discontinued 
Due to Result? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Table 18: 
Listing of Abnormal Laboratory Results – Coagulation 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint, Laboratory Parameter (follow order specified in Section 9.6)] 
BAL 
Sampling 
Timepoint 
Subject 
ID 
Sex 
Age 
(years) 
Planned 
Timepoint 
Actual 
Study Day 
Laboratory 
Parameter 
(Units) 
Result 
(Severity) 
Relationship to 
Treatment 
If Not Related, 
Alternate 
Etiology 
Action Taken 
with Study 
Treatment 
Subject 
Discontinued 
Due to Result? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Table 19: 
Listing of Abnormal Laboratory Results – Urinalysis 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint, Laboratory Parameter (follow order specified in Section 9.6)] 
BAL 
Sampling 
Timepoint 
Subject 
ID 
Sex 
Age 
(years) 
Planned 
Timepoint 
Actual 
Study Day 
Laboratory 
Parameter 
(Units) 
Result 
(Severity) 
Relationship to 
Treatment 
If Not Related, 
Alternate 
Etiology 
Action Taken 
with Study 
Treatment 
Subject 
Discontinued 
Due to Result? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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14.3.5 Displays of Laboratory Results 
14.3.5.1 
Chemistry Results 
Table 20: 
Chemistry Laboratory Results by Parameter, Severity, and Timepoint  
[Implementation Note: If there are no subjects with an early termination visit, then that row will not be included in the table. If no values are missing for 
any parameter then that column will not be included in the table. If no values meet the criteria for the “Outside Normal Range” column then exclude 
column and corresponding footnote. Only Sodium, potassium, magnesium, calcium, and phosphorus are collected at the 2 hours prior to the assigned 
bronchoscopy timepoint, summaries for all other parameters will not include the “2 hours prior to the assigned bronchoscopy” row ] 
Chemistry Parameter 
Timepoint 
N 
None 
Outside Normal 
Range a 
Mild/ 
Grade 1 
Moderate/ 
Grade 2 
Severe/ 
Grade 3 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Chemistry - Any Parameter 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
2 hours prior to the assigned bronchoscopyb 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Prior to Discharge (Day 2) 
 
 
 
 
 
 
 
 
 
 
 
 
 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sodium - Increase 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
2 hours prior to the assigned bronchoscopyb 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Prior to Discharge (Day 2) 
 
 
 
 
 
 
 
 
 
 
 
 
 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sodium - Decrease 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
2 hours prior to the assigned bronchoscopyb 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
… 
 
 
 
 
 
 
 
 
 
 
 
 
 
Notes: N = Number of subjects in the Safety Population with clinical safety labs results at the respective study timepoint. Baseline = The most recent measurement prior to start of infusion of the first 
ZTI-01 dose. The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any timepoint post baseline, including unscheduled assessments. 
a Post-dose measurements that were outside the normal range but did not meet the definition for an AE due to the value being less than or equal to the measurement at baseline will be categorized as 
“Outside Normal Range” 
b Only Sodium, potassium, magnesium, calcium, and phosphorus are collected at the 2 hours prior to the assigned bronchoscopy timepoint. 


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Table 21: 
Chemistry Laboratory Summary Statistics by Parameter and Timepoint 
 
 
Measurement 
Change from Baseline 
Timepoint 
N 
Mean 
SD 
Median 
Min, Max 
Mean 
SD 
Median 
Min, Max 
Sodium (mEq/L) 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
2 hours prior to the assigned bronchoscopy 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Prior to Discharge (Day 2) 
 
 
 
 
 
 
 
 
 
Potassium (mEq/L) 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
2 hours prior to the assigned bronchoscopy 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Prior to Discharge (Day 2) 
 
 
 
 
 
 
 
 
 
Magnesium (mg/dL) 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
2 hours prior to the assigned bronchoscopy 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Prior to Discharge (Day 2) 
 
 
 
 
 
 
 
 
 
Calcium (mg/dL) 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
2 hours prior to the assigned bronchoscopy 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Prior to Discharge (Day 2) 
 
 
 
 
 
 
 
 
 
Phosphorus (mg/dL) 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
2 hours prior to the assigned bronchoscopy 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Prior to Discharge (Day 2) 
 
 
 
 
 
 
 
 
 
Albumin (g/dL) 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Prior to Discharge (Day 2) 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Random Glucose (mg/dL) 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
… 
 
 
 
 
 
 
 
 
 
Notes: N = Number of subjects in the Safety Population with clinical safety labs results at the respective study timepoint. Baseline = The most recent measurement prior to start of infusion of the first 
ZTI-01 dose. 
 


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14.3.5.2 
Hematology Results 
Table 22: 
Hematology Laboratory Results by Parameter, Severity, and Timepoint  
[Implementation Note: If there are no subjects with an early termination visit, then that row will not be included in the table. If no values are missing for 
any parameter then that column will not be included in the table. If no values meet the criteria for the “Outside Normal Range” column then exclude 
column and corresponding footnote.] 
Hematology Parameter 
Timepoint 
N 
None 
Outside Normal 
Range a 
Mild/ 
Grade 1 
Moderate/ 
Grade 2 
Severe/ 
Grade 3 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Hematology - Any Parameter 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
Prior to Discharge (Day 2) 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemoglobin - Increase 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
Prior to Discharge (Day 2) 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hematocrit - Increase 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
… 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Notes: N = Number of subjects in the Safety Population with clinical safety labs results at the respective study timepoint. Baseline = The most recent measurement prior to start of infusion of the first 
ZTI-01 dose. The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any timepoint post baseline, including unscheduled assessments. NA = Not applicable. 
a Post-dose measurements that were outside the normal range but did not meet the definition for an AE due to the value being less than or equal to the measurement at baseline will be categorized as 
“Outside Normal Range” 


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Table 23: 
Hematology Laboratory Summary Statistics by Parameter and Timepoint  
 
 
Measurement 
Change from Baseline 
Timepoint 
N 
Mean 
SD 
Median 
Min, Max 
Mean 
SD 
Median 
Min, Max 
Hemoglobin (g/dL) 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Prior to Discharge (Day 2) 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Hematocrit (%) 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
… 
 
 
 
 
 
 
 
 
 
Notes: N= Number of subjects in the Safety Population with clinical safety labs results at the respective study timepoint. Baseline = The most recent measurement prior to start of infusion of the first 
ZTI-01 dose. 
 


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14.3.5.3 
Coagulation 
Table 24: 
Coagulation Laboratory Results by Parameter, Severity, and Timepoint  
[Implementation Note: If there are no subjects with an early termination visit, then that row will not be included in the table. If no values are missing for 
any parameter then that column will not be included in the table. If no values meet the criteria for the “Outside Normal Range” column then exclude 
column and corresponding footnote.] 
Coagulation Parameter 
Timepoint 
N 
None 
Outside Normal 
Range a 
Mild/ 
Grade 1 
Moderate/ 
Grade 2 
Severe/ 
Grade 3 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Coagulation - Any Parameter 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
Prior to Discharge (Day 2) 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
 
 
PT - Increase 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
Prior to Discharge (Day 2) 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
 
 
aPPT - Increase 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
Prior to Discharge (Day 2) 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
 
 
Notes: N = Number of subjects in the Safety Population with clinical safety labs results at the respective study timepoint. Baseline = The most recent measurement prior to start of infusion of the first 
ZTI-01 dose. The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any timepoint post baseline, including unscheduled assessments. 
a Post-dose measurements that were outside the normal range but did not meet the definition for an AE due to the value being less than or equal to the measurement at baseline will be categorized as 
“Outside Normal Range” 
 


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Table 25: 
Coagulation Laboratory Summary Statistics by Parameter and Timepoint  
 
 
Measurement 
Change from Baseline 
Timepoint 
N 
Mean 
SD 
Median 
Min, Max 
Mean 
SD 
Median 
Min, Max 
PT 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Prior to Discharge (Day 2) 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
aPTT 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Prior to Discharge (Day 2) 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Notes: N = Number of subjects in the Safety Population with clinical safety labs results at the respective study timepoint. Baseline = The most recent measurement prior to start of infusion of the first 
ZTI-01 dose. 


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14.3.5.3 
Urinalysis Results 
Table 26: 
Urinalysis Laboratory Results by Parameter, Maximum Severity, and Timepoint 
[Implementation Note: If there are no subjects with an early termination visit, then that row will not be included in the table. If no values are missing for 
any parameter then that column will not be included in the table. If no values meet the criteria for the “Outside Normal Range” column then exclude 
column and corresponding footnote.] 
Urinalysis Parameter 
Timepoint 
N 
None 
Outside Normal 
Range a 
Mild/ 
Grade 1 
Moderate/ 
Grade 2 
Severe/ 
Grade 3 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Urinalysis - Any Parameter 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
Prior to Discharge (Day 2) 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protein 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
Prior to Discharge (Day 2) 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
 
 
Glucose 
Baseline 
x 
x 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
x 
Prior to Discharge (Day 2) 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
 
 
Notes: N = Number of subjects in the Safety Population with clinical safety labs results at the respective study timepoint. Baseline = The most recent measurement prior to start of infusion of the first 
ZTI-01 dose. The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any timepoint post baseline, including unscheduled assessments. 
a Post-dose measurements that were outside the normal range but did not meet the definition for an AE due to the value being less than or equal to the measurement at baseline will be categorized as 
“Outside Normal Range” 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 27: 
Urinalysis Laboratory Summary Statistics by Parameter and Timepoint  
[Implementation Note: If there are no subjects with microscopic evaluation then the rows for WBC in Urine, RBC in Urine, and Casts will not be 
included in table] 
 
 
Measurement 
Change from Baseline 
Timepoint 
N 
Mean 
SD 
Median 
Min, Max 
Mean 
SD 
Median 
Min, Max 
pH 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Prior to Discharge (Day 2) 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Specific Gravity 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Prior to Discharge (Day 2) 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
WBC in Urine 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Prior to Discharge (Day 2) 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
RBC in Urine 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Prior to Discharge (Day 2) 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Casts 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Prior to Discharge (Day 2) 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Notes: N = Number of subjects in the Safety Population with clinical safety labs results at the respective study timepoint. Baseline = The most recent measurement prior to start of infusion of the first 
ZTI-01 dose. 


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14.3.6 Displays of Vital Signs 
Table 28: 
Vital Signs by Assessment, Maximum Severity, and Timepoint 
[Implementation Note: If there are no subjects with an early termination visit, then that row will not be 
included in the table. If no values are missing for any parameter then that column will not be included in the 
table] 
Timepoint 
N 
None 
Mild/ 
Grade 1 
Moderate/ 
Grade 2 
Severe/ 
Grade 3 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Systolic Blood Pressure, Decrease 
Baseline 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
Dose 1, 30 min Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 1, 1 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 1, 2 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 1, 5 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 2, ≤10 min Pre-Infusion 
 
 
 
 
 
 
 
 
 
 
 
Dose 2, 30 min Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 2, 1 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 2, 2 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 2, 5 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 3, ≤10 min Pre-Infusion 
 
 
 
 
 
 
 
 
 
 
 
Dose 3, 30 min Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 3, 1 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 3, 2 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 3, 5 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Prior to Discharge (Day 2) 
 
 
 
 
 
 
 
 
 
 
 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
Systolic Blood Pressure, Increase 
Baseline 
 
 
 
 
 
 
 
 
 
 
 
Dose 1, 30 min Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
Dose 1, 1 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
 
 
… 
 
 
 
 
 
 
 
 
 
 
 
Notes: N = number of subjects in the Safety Population. Baseline = The most recent measurement prior to start of infusion of the first ZTI-01 
dose. The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any timepoint post baseline, including 
unscheduled assessments.  
 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 29: 
Vital Signs Summary Statistics and Change from Baseline by Assessment and Timepoint 
 
 
Measurement 
Change from Baseline 
Timepoint 
N 
Mean 
SD 
Median 
Min, Max 
Mean 
SD 
Median 
Min, Max 
Systolic Blood Pressure (mmHg) 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Dose 1, 30 min Post Infusion Start 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Dose 1, 1 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
Dose 1, 2 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
Dose 1, 5 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
Dose 2, ≤10 min Pre-Infusion 
 
 
 
 
 
 
 
 
 
Dose 2, 30 min Post Infusion Start 
 
 
 
 
 
 
 
 
 
Dose 2, 1 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
Dose 2, 2 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
Dose 2, 5 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
Dose 3, ≤10 min Pre-Infusion 
 
 
 
 
 
 
 
 
 
Dose 3, 30 min Post Infusion Start 
 
 
 
 
 
 
 
 
 
Dose 3, 1 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
Dose 3, 2 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
Dose 3, 5 h Post Infusion Start 
 
 
 
 
 
 
 
 
 
Prior to Discharge (Day 2) 
 
 
 
 
 
 
 
 
 
Diastolic Blood Pressure (mmHg) 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Dose 1, 30 min Post Infusion Start 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
… 
 
 
 
 
 
 
 
 
 
Notes: N = Number of subjects in the Safety Population with vital signs at the respective study timepoint. Baseline = The most recent measurement prior to start of infusion of the first ZTI-01 dose.  
 


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Table 30: 
ECG Overall Interpretations, Post Dose 3 Compared to Baseline 
[Implementation Note: If there are no subjects with an early termination visit, then that row will not be included in the table. If no values are missing for 
any parameter then that column will not be included in the table] 
ECG Interpretation at Baseline (N = X) 
ECG Post Dose 3 
Normal 
n (%) 
Abnormal, NCS 
n (%) 
Abnormal, CS 
n (%) 
Missing 
n (%) 
Normal 
x (x) 
x (x) 
x (x) 
x (x) 
Abnormal, NCS 
x (x) 
 
 
 
Abnormal, CS 
x (x) 
 
 
 
Clinically significant change from baseline 
x (x) 
 
 
 
Missing 
x (x) 
 
 
 
Notes: N = number of subjects in the Safety Population. Baseline = The most recent measurement prior to start of infusion of the first ZTI-01 dose. CS = clinically significant; NCS = not clinically 
significant.  
 


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Table 31: 
ECG Results by Parameter, Severity, Timepoint and Assessment 
[Implementation Note: If there are no subjects with an early termination visit, then that row will not be included in the table. If no values are missing for 
any parameter then that column will not be included in the table] 
Timepoint 
N 
None 
Mild/ 
Grade 1 
Moderate/ 
Grade 2 
Severe/ 
Grade 3 
Missing 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
QTc Interval 
Baseline 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
Xx 
Post Dose 3 
 
 
 
 
 
 
 
 
 
 
 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
PR Interval 
Baseline 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
Xx 
Post Dose 3 
 
 
 
 
 
 
 
 
 
 
 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
QRS Duration 
Baseline 
x 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
Xx 
Post Dose 3 
 
 
 
 
 
 
 
 
 
 
 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
 
 
Max Severity Post Baseline 
 
 
 
 
 
 
 
 
 
 
 
Notes: N = number of subjects enrolled that received any study product and ECG results at the respective study timepoint. Baseline = The most recent measurement prior to start of infusion of the first 
ZTI-01 dose. The “Max Post Baseline” rows indicate the maximum severity experienced by each subject at any timepoint post baseline, including unscheduled assessments.  
 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 32: 
ECG Results - Summary Statistics by Parameter and Timepoint  
[Implementation Note: If there are no subjects with an early termination visit, then that row will not be included in the table.] 
 
 
Measurement 
Change from Baseline 
Timepoint 
N 
Mean 
SD 
Median 
Min, Max 
Mean 
SD 
Median 
Min, Max 
QTc Interval 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Post Dose 3 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
PR Interval 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Post Dose 3 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
QRS Duration 
Baseline 
x 
x.x 
x.x 
x.x 
x.x, x.x 
- 
- 
- 
- 
Post Dose 3 
x 
x.x 
x.x 
x.x 
x.x, x.x 
x.x 
x.x 
x.x 
x.x, x.x 
Early Termination Visit 
 
 
 
 
 
 
 
 
 
Notes: N= Number of subjects in the Safety Population with ECG results at the respective study timepoint. Baseline = The most recent measurement prior to start of infusion of the first ZTI-01 dose. 
 


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14.4 
Summary of Concomitant Medications 
Table 33: 
Number and Percentage of Subjects with Prior Medications by WHO Drug Classification and BAL Sampling Timepoint 
WHO Drug Code 
Level 1, Anatomic Group 
WHO Drug Code 
Level 2, Therapeutic Subgroup 
30 minute BAL 
(N=X) 
75 minute BAL 
(N=X) 
2 hour BAL 
(N=X) 
5 hour BAL 
(N=X) 
8 hour BAL 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Any Level 1 Codes 
Any Level 2 Codes 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
[ATC Level 1 - 1] 
Any [ATC 1 – 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC 2 - 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC 2 - 2] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC 2 - 3] 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC Level 1 – 2] 
[ATC 2 - 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC 2 - 2] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC 2 - 3] 
 
 
 
 
 
 
 
 
 
 
 
 
Notes: N = Number of subjects in the Safety Population. n=Number of subjects reporting taking at least one medication in the specific WHO Drug Class. 
 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 34: 
Number and Percentage of Subjects with Concurrent Medications by WHO Drug Classification and BAL Sampling Timepoint 
WHO Drug Code 
Level 1, Anatomic Group 
WHO Drug Code 
Level 2, Therapeutic Subgroup 
30 minute BAL 
(N=X) 
75 minute BAL 
(N=X) 
2 hour BAL 
(N=X) 
5 hour BAL 
(N=X) 
8 hour BAL 
(N=X) 
All Subjects 
(N=X) 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
n 
% 
Any Level 1 Codes 
Any Level 2 Codes 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
x 
xx 
[ATC Level 1 - 1] 
Any [ATC 1 – 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC 2 - 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC 2 - 2] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC 2 - 3] 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC Level 1 – 2] 
[ATC 2 - 1] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC 2 - 2] 
 
 
 
 
 
 
 
 
 
 
 
 
 
[ATC 2 - 3] 
 
 
 
 
 
 
 
 
 
 
 
 
Notes: N = Number of subjects in the Safety Population. n=Number of subjects reporting taking at least one medication in the specific WHO Drug Class. 
 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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14.4 
Pharmacokinetics 
Table 35: 
Individual Concentrations and Summary Statistics by for Plasma Fosfomycin 
Concentration (µg/mL) by Nominal Time - Dose 1 
Subject ID 
Plasma Fosfomycin Concentration (µg/mL) by Nominal Timea After Dose 1 
0 h 
0.5 h 
1b h 
1.25 h 
2 h 
5 h 
8c h 
SST.00101 
x 
x 
x 
x 
x 
x 
x 
SST.00102 
x 
x 
x 
x 
x 
x 
x 
SST.00102 
x 
x 
x 
x 
x 
x 
x 
… 
x 
x 
x 
x 
x 
x 
x 
Statistics 
x 
x 
x 
x 
x 
x 
x 
Nd 
x 
x 
x 
x 
x 
x 
x 
Mean 
x.x 
x 
x 
x 
x 
x 
x 
SD 
x.x 
x 
x 
x 
x 
x 
x 
Min 
x.x 
x 
x 
x 
x 
x 
x 
Median 
x.x 
x 
x 
x 
x 
x 
x 
Max 
x.x 
x 
x 
x 
x 
x 
x 
CV%e 
x 
x 
x 
x 
x 
x 
x 
GM 
x 
x 
x 
x 
x 
x 
x 
GSD 
x 
x 
x 
x 
x 
x 
x 
a Times are relative to time of start of infusion of Dose 1.  
b 0-5 minutes from end of infusion for Dose 1. 
c Pre-dose for Dose 2 
d Number of data points used to compute the summary statistics. For calculation of summary statistics, BQL values were imputed as 0 if they did 
not come after a PK sample concentration that is above the LLOQ and treated as missing otherwise. 
e CV% =  √(exp(σ2)-1)  * 100% , where σ2 is the variance of the log-transformed data 
 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 36: 
Individual Concentrations and Summary Statistics by for Plasma Fosfomycin 
Concentration (µg/mL) by Nominal Time - Dose 3 
Subject ID 
Plasma Fosfomycin Concentration (µg/mL) by Nominal Timea After Dose 3 
0 h 
0.5 h 
1 b h 
1.25 h 
2 h 
5 h 
8 h 
12 h 
SST.00101 
x 
x 
x 
x 
x 
x 
x 
x 
SST.00102 
x 
x 
x 
x 
x 
x 
x 
x 
SST.00102 
x 
x 
x 
x 
x 
x 
x 
x 
… 
x 
x 
x 
x 
x 
x 
x 
x 
Statistics 
x 
x 
x 
x 
x 
x 
x 
x 
Nc 
x 
x 
x 
x 
x 
x 
x 
x 
Mean 
x 
x 
x 
x 
x 
x 
x 
x 
SD 
x 
x 
x 
x 
x 
x 
x 
x 
Min 
x 
x 
x 
x 
x 
x 
x 
x 
Median 
x 
x 
x 
x 
x 
x 
x 
x 
Max 
x 
x 
x 
x 
x 
x 
x 
x 
CV% 
x 
x 
x 
x 
x 
x 
x 
x 
GM 
x 
x 
x 
x 
x 
x 
x 
x 
GSD 
x 
x 
x 
x 
x 
x 
x 
x 
a Times are relative to time of dosing. Times are relative to time of start of infusion of Dose 3. Blood PK samples will be drawn within the 
following windows: -10 to -1 minute for scheduled samples at 0h; ±5 minutes for scheduled samples at 0.5h, 1.25h, and 2h; +0-5 minutes from 
end of infusion for the scheduled sample at 1h; and ±15 minutes for scheduled samples at 5h, 8h and 12h. 
b 0-5 minutes from end of infusion for Dose 3. 
c Number of data points used to compute the summary statistics. For calculation of summary statistics, BQL values were imputed as 0 if they did 
not come after a PK sample concentration that is above the LLOQ and treated as missing otherwise. 
d CV% =  √(exp(σ2)-1)  * 100% , where σ2 is the variance of the log-transformed data. 
 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 37: 
Summary Statistics for Plasma Fosfomycin PK Parameters, Dose 1 
Statistic 
Cmax 
(µg/mL) 
Tmax 
(h) 
Tlast 
(h) 
AUC(0-8) 
(h*µg/mL) 
N 
x 
x 
x 
x 
Mean 
x 
x 
x 
x 
SD 
x 
x 
x 
x 
Min 
x 
x 
x 
x 
Median 
x 
x 
x 
x 
Max 
x 
x 
x 
x 
CV% 
x 
NA 
NA 
x 
GM 
x 
x 
x 
x 
GSD 
x 
x 
x 
x 
Notes: N=Number of data points used to compute the summary statistics. NA = Not applicable. 
 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 38: 
Summary Statistics for Plasma Fosfomycin PK Parameters, Dose 3 
Statistic 
Cmax 
(µg/mL) 
Tmax 
(h) 
Tlast 
(h) 
AUC(0-8) 
(h*µg/mL) 
AUC(0-12) 
(h*µg/mL) 
AUC(0-inf) 
(h*µg/mL) 
λz 
(/h) 
t1/2 
(h) 
CL 
(L/h) 
Vss 
(L) 
N 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Mean 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
SD 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Min 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Median 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Max 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
CV% 
x 
NA 
NA 
x 
x 
x 
x 
x 
x 
x 
GM 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
GSD 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Notes: N = Number of data points used to compute the summary statistics. NA = Not applicable. 
 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 39: 
Summary of Shift in Tmax, Comparing Dose 1 and Dose 3 
Median Tmax (h) 
Median Difference in Tmax (h) 
95% CI of Estimated Median 
Difference (h)a 
Dose 1 
Dose 3 
x.x 
x.x 
x.x 
(x.x, x.x) 
a 95% CI derived from inversion of the Sign Test 
 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 40: 
Summary Statistics for Accumulation Ratios Comparing Dose 1 and Dose 3 
Statistic 
Cmax AR   
AUC(0-8) AR  
N 
x 
x 
Mean 
x 
x 
SD 
x 
x 
Min 
x 
x 
Median 
x 
x 
Max 
x 
x 
GM 
x 
x 
GSD 
 
 
Note: N=Number of data points used to compute the summary statistics. 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 41: 
Summary Statistics for ELF Fosfomycin Concentration (µg/mL) and ELF to Plasma 
Concentration Ratio by BAL Sampling Timepoint 
Statistic 
ELF Fosfomycin Concentration (µg/mL) at BAL Sampling 
Timepoint 
Concentration Ratio ELF to Plasma at BAL Sampling 
Timepoint 
0.5 h 
1.25 h 
2 h 
5 h 
8 h 
0.5 h 
1.25 h 
2 h 
5 h 
8 h 
N 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Mean 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
SD 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Min 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Median 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Max 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
CV% 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
GM 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
GSD 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Notes: times are relative to time of start of infusion of Dose 3. N = Number of data points used to compute the summary statistics.  


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 42: 
Summary Statistics for AM Fosfomycin Concentration (µg/mL) and AM to Plasma 
Concentration Ratio by BAL Sampling Timepoint 
Statistic 
AM Fosfomycin Concentration (µg/mL) at BAL Sampling 
Timepoint 
Concentration Ratio AM to Plasma at BAL Sampling 
Timepoint 
0.5 h 
1.25 h 
2 h 
5 h 
8 h 
0.5 h 
1.25 h 
2 h 
5 h 
8 h 
N 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Mean 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
SD 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Min 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Median 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Max 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
CV% 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
GM 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
GSD 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Notes: times are relative to time of start of infusion of Dose 3. N = Number of data points used to compute the summary statistics.  
 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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Table 43: 
Noncompartmental Analysis Population Average AUC0-8 of Fosfomycin in Plasma, ELF, 
and AM and Percent Penetration 
 
N 
AUC(0-8)a 
(h*µg/mL) 
Plasma Percent Penetration 
Plasma 
x 
x 
NA 
ELF 
x 
x 
x 
AM 
x 
x 
x 
Note: N = number of data points used to compute used to derive AUC(0-8) 
a AUC(0-8) following Dose 3 
 


Statistical Analysis Plan - DMID Protocol: 16-0058  
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APPENDIX 2. FIGURE MOCK-UPS 
LIST OF FIGURES 
Figure 1: 
Study Design ...............................................................................................................92 
Figure 2: 
CONSORT Flow Diagram .........................................................................................93 
Figure 3: 
Incidence of Related Adverse Events by MedDRA System Organ Class and 
Severity – All Subjects ...............................................................................................94 
Figure 4: 
Frequency of Related Adverse Events by MedDRA System Organ Class and 
Maximum Severity – All Subjects ..............................................................................95 
Figure 5: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Sodium .......................................96 
Figure 6: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Potassium ...................................96 
Figure 7: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Magnesium .................................96 
Figure 8: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Calcium ......................................96 
Figure 9: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Phosphorus .................................96 
Figure 10: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Albumin .....................................97 
Figure 11: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Random Glucose ........................97 
Figure 12: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – BUN ...........................................97 
Figure 13: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Total Protein ...............................97 
Figure 14: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Creatinine ...................................97 
Figure 15: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Triglycerides ..............................97 
Figure 16: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Total Cholesterol ........................97 
Figure 17: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – CPK ............................................97 
Figure 18: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – ALP ............................................97 


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Figure 19: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – AST ............................................97 
Figure 20: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – ALT ............................................97 
Figure 21: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Total Bilirubin ............................97 
Figure 22: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Direct Bilirubin ..........................97 
Figure 23: Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – LDH ...........................................97 
Figure 24: Hematology Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Hemoglobin ................................98 
Figure 25: Hematology Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Hematocrit ..................................98 
Figure 26: Hematology Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Platelet Count .............................98 
Figure 27: Hematology Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – WBC Count ................................98 
Figure 28: Hematology Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Neutrophils .................................98 
Figure 29: Hematology Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Lymphocytes ..............................98 
Figure 30: Hematology Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Monocytes ..................................98 
Figure 31: Hematology Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Eosinophils .................................99 
Figure 32: Hematology Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Basophils ....................................99 
Figure 33: Coagulation Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – PT .............................................100 
Figure 34: Coagulation Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – aPTT .........................................100 
Figure 35: Urinalysis Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – pH .............................................101 
Figure 36: Urinalysis Laboratory Results by Scheduled Timepoints: Box Plot of 
Change from Baseline by Laboratory Parameter – Specific Gravity .......................101 
Figure 37: Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of 
Change from Baseline by Assessment – Systolic Blood Pressure ...........................102 


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Figure 38: Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of 
Change from Baseline by Assessment – Diastolic Blood Pressure ..........................102 
Figure 39: Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of 
Change from Baseline by Assessment – Heart Rate ................................................102 
Figure 40: Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of 
Change from Baseline by Assessment – Respiratory Rate .......................................102 
Figure 41: Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of 
Change from Baseline by Assessment – Peripheral Oxygen saturation ...................102 
Figure 42: Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of 
Change from Baseline by Assessment – Temperature .............................................102 
Figure 43: ECG Change from Baseline by Scheduled Timepoint: Box Plot of Change 
from Baseline by Assessment – QTc Interval (msec) ..............................................103 
Figure 44: ECG Change from Baseline by Scheduled Timepoint: Box Plot of Change 
from Baseline by Assessment – PR Interval .............................................................103 
Figure 45: ECG Change from Baseline by Scheduled Timepoint: Box Plot of Change 
from Baseline by Assessment – QRS Duration ........................................................103 
Figure 46: Concentration Profiles for All Subjects by Time (h) – Dose 1 and Dose 3 ..............104 
Figure 47: Semi-log Concentration Profiles for All Subjects by Time (h) – Dose 1 and 
Dose 3 .......................................................................................................................105 
Figure 48: Mean Plasma Concentration by Nominal Time – Dose 1 ........................................106 
Figure 49: Semi-log Plot of GM Plasma Concentration by Nominal Time – Dose 1 and 
Dose 3 .......................................................................................................................107 
Figure 50: Fosfomycin Concentrations in Plasma, ELF, and AM by Subjects and 
Time(h) – Dose 3 ......................................................................................................108 
Figure 51: Population Median Concentrations in Plasma, ELF, and AM by Time (h) – 
Dose 3 .......................................................................................................................109 
Figure 52: Semi-log Plot of Population Median Concentrations in Plasma, ELF, and 
AM by Time (h) – Dose 3 .........................................................................................110 
 


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9.1 
Overall Study Design and Plan Description 
Figure 1: 
Study Design 
 
 


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10.1 
Disposition of Subjects 
Figure 2: 
CONSORT Flow Diagram 
 
Assessed for Eligibility (n=x) 
Excluded* (n=x) 
♦   [Reason 1] (n=x) 
♦   Concern of potential risk (n=x) 
Randomized (n=x) 
Enrolled as Alternate (n=x) 
Allocation 
Enrollment 
Analysis 
Follow-Up 
Allocated to 30 minute 
BAL (n=x) 
 
♦Received all infusions (n=x) 
Allocated to 2 hour BAL 
(n=x) 
 
♦Received all infusions (n=x) 
Allocated to 8 hour BAL  
(n=x) 
 
♦Received all infusions (n=x) 
Allocated to 5 hour BAL  
(n=x) 
 
♦Received all infusions (n=x) 
Allocated to 75 minute 
BAL (n=x) 
 
♦Received all infusions (n=x) 
Discontinued Intervention 
(n=x) 
[Reason 1] (x), [Reason 2] (x) 
 
 
Early Termination (n=x) 
[Reason 1] (x), [Reason 2] (x) 
Discontinued Intervention 
(n=x) 
[Reason 1] (x), [Reason 2] (x) 
 
 
Early Termination (n=x) 
[Reason 1] (x), [Reason 2] (x) 
Discontinued Intervention 
(n=x) 
[Reason 1] (x), [Reason 2] (x) 
 
 
Early Termination (n=x) 
[Reason 1] (x), [Reason 2] (x) 
Discontinued Intervention 
(n=x) 
[Reason 1] (x), [Reason 2] (x) 
 
 
Early Termination (n=x) 
[Reason 1] (x), [Reason 2] (x) 
Discontinued Intervention 
(n=x) 
[Reason 1] (x), [Reason 2] (x) 
 
 
Early Termination (n=x) 
[Reason 1] (x), [Reason 2] (x) 
Analyzed for safety (n=x) 
♦Excluded from safety 
analyses (n=x) 
[Reason 1] (x), [Reason 2] (x) 
Analysed for PK (n=x) 
♦Excluded from PKanalyses 
(n=x) 
[Reason 1] (x), [Reason 2] (x) 
 
Analyzed for safety (n=x) 
♦Excluded from safety 
analyses (n=x) 
[Reason 1] (x), [Reason 2] (x) 
Analysed for PK (n=x) 
♦Excluded from PKanalyses 
(n=x) 
[Reason 1] (x), [Reason 2] (x) 
 
Analyzed for safety (n=x) 
♦Excluded from safety 
analyses (n=x) 
[Reason 1] (x), [Reason 2] (x) 
Analysed for PK (n=x) 
♦Excluded from PKanalyses 
(n=x) 
[Reason 1] (x), [Reason 2] (x) 
 
Analyzed for safety (n=x) 
♦Excluded from safety 
analyses (n=x) 
[Reason 1] (x), [Reason 2] (x) 
Analysed for PK (n=x) 
♦Excluded from PKanalyses 
(n=x) 
[Reason 1] (x), [Reason 2] (x) 
 
Analyzed for safety (n=x) 
♦Excluded from safety 
analyses (n=x) 
[Reason 1] (x), [Reason 2] (x) 
Analysed for PK (n=x) 
♦Excluded from PKanalyses 
(n=x) 
[Reason 1] (x), [Reason 2] (x) 
 


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14.3.1.2 Unsolicited Adverse Events 
Figure 3: 
Incidence of Related Adverse Events by MedDRA System Organ Class and Severity – 
All Subjects 
[Implementation Note: Show one bar graph, include all subjects] 
 
 


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Figure 4: 
Frequency of Related Adverse Events by MedDRA System Organ Class and Maximum 
Severity – All Subjects 
[Implementation Note: Show one bar graph, include all subjects] 
 
 


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Figure 5: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Sodium  
[Implementation Note: For Laboratory Parameters with more than one timepoint, use lines to connect the 25th 
and 75th percentiles and median. Omit lines if Laboratory Parameter measured only one post dose timepoint] 
 
 
Figures with Similar Format: 
Figure 6: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Potassium  
Figure 7: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Magnesium  
Figure 8: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Calcium 
Figure 9: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Phosphorus 


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Figure 10: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Albumin 
Figure 11: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Random Glucose 
Figure 12: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – BUN 
Figure 13: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Total Protein 
Figure 14: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Creatinine 
Figure 15: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Triglycerides 
Figure 16: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Total Cholesterol 
Figure 17: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – CPK 
Figure 18: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – ALP 
Figure 19: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – AST 
Figure 20: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – ALT 
Figure 21: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Total Bilirubin 
Figure 22: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Direct Bilirubin 
Figure 23: 
Chemistry Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – LDH 


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Figure 24: 
Hematology Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Hemoglobin 
 
 
Figures with Similar Format: 
Figure 25: 
Hematology Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Hematocrit 
Figure 26: 
Hematology Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Platelet Count 
Figure 27: 
Hematology Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – WBC Count 
Figure 28: 
Hematology Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Neutrophils 
Figure 29: 
Hematology Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Lymphocytes 
Figure 30: 
Hematology Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Monocytes 


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Figure 31: 
Hematology Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Eosinophils 
Figure 32: 
Hematology Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Basophils 


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Figure 33: 
Coagulation Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – PT 
 
 
Figure with Similar Format: 
Figure 34: 
Coagulation Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – aPTT 
 


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Figure 35: 
Urinalysis Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – pH 
 
 
Figures with Similar Format: 
Figure 36: 
Urinalysis Laboratory Results by Scheduled Timepoints: Box Plot of Change from 
Baseline by Laboratory Parameter – Specific Gravity 
 
 


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Figure 37: 
Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of Change from 
Baseline by Assessment – Systolic Blood Pressure 
 
 
Figures with Similar Format: 
Figure 38: 
Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of Change from 
Baseline by Assessment – Diastolic Blood Pressure  
Figure 39: 
Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of Change from 
Baseline by Assessment – Heart Rate 
Figure 40: 
Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of Change from 
Baseline by Assessment – Respiratory Rate  
Figure 41: 
Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of Change from 
Baseline by Assessment – Peripheral Oxygen saturation  
Figure 42: 
Vital Signs Change from Baseline by Scheduled Timepoint: Box Plot of Change from 
Baseline by Assessment – Temperature 


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Figure 43: 
ECG Change from Baseline by Scheduled Timepoint: Box Plot of Change from Baseline 
by Assessment – QTc Interval (msec) 
 
Figures with Similar Format: 
Figure 44: 
ECG Change from Baseline by Scheduled Timepoint: Box Plot of Change from Baseline 
by Assessment – PR Interval 
Figure 45: 
ECG Change from Baseline by Scheduled Timepoint: Box Plot of Change from Baseline 
by Assessment – QRS Duration 


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Figure 46: 
Concentration Profiles for All Subjects by Time (h) – Dose 1 and Dose 3 
 
 


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Figure 47: 
Semi-log Concentration Profiles for All Subjects by Time (h) – Dose 1 and Dose 3 
 
 


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Figure 48: 
Mean Plasma Concentration by Nominal Time – Dose 1 
 
 
Note: Error bars give +/- 1 standard deviation. 
 


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Figure 49: 
Semi-log Plot of GM Plasma Concentration by Nominal Time – Dose 1 and Dose 3 
 
 
 


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Figure 50: 
Fosfomycin Concentrations in Plasma, ELF, and AM by Subjects and Time(h) – Dose 3 
[Implementation Note: Use different colors and symbols for Plasma, ELF and AM] 
 
  
 


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Figure 51: 
Population Median Concentrations in Plasma, ELF, and AM by Time (h) – Dose 3 
[Implementation Note: Use different colors for Plasma, ELF and AM] 
 
 
 


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Figure 52: 
Semi-log Plot of Population Median Concentrations in Plasma, ELF, and AM by Time (h) 
– Dose 3 
[Implementation Note: Use different colors for Plasma, ELF and AM] 
 
 
 
 


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APPENDIX 3. LISTINGS MOCK-UPS 
LISTINGS 
Listing 1: Early Terminations or Discontinued Subjects ..........................................................113 
Listing 2: Subject-Specific Protocol Deviations .......................................................................114 
Listing 3: Non-Subject-Specific Protocol Deviations ...............................................................115 
Listing 4: Subjects Excluded from Analysis Populations .........................................................116 
Listing 5: Demographic Data ....................................................................................................117 
Listing 6: Pre-Existing and Concurrent Medical Conditions ....................................................118 
Listing 7: Treatments Administered ..........................................................................................119 
Listing 8: Unsolicited Adverse Events ......................................................................................120 
Listing 9: Clinical Laboratory Results – Chemistry .................................................................121 
Listing 10: Clinical Laboratory Results – Hematology ..............................................................122 
Listing 11: Clinical Laboratory Results – Coagulation ...............................................................123 
Listing 12: Clinical Laboratory Results – Urinalysis ..................................................................124 
Listing 13: Screening Laboratory Results – Serology ................................................................125 
Listing 14: Laboratory Results – Urine Toxicology and Alcohol Testing ..................................126 
Listing 15: Vital Signs ................................................................................................................127 
Listing 16: Physical Exam Findings ...........................................................................................128 
Listing 17: Listing of ECG Interval Measurements ....................................................................129 
Listing 18: Prior Medications ......................................................................................................130 
Listing 19: Concomitant Medications .........................................................................................131 
Listing 20: Pregnancy Reports – Maternal Information .............................................................132 
Listing 21: Pregnancy Reports – Gravida and Para ....................................................................133 
Listing 22: Pregnancy Reports – Live Birth Outcomes ..............................................................134 
Listing 23: Pregnancy Reports – Still Birth Outcomes ...............................................................134 
Listing 24: Pregnancy Reports – Spontaneous, Elective, or Therapeutic Abortion 
Outcomes ..................................................................................................................134 
Listing 25: Subject Level Fosfomycin Concentrations in Plasma ..............................................135 
Listing 26:  Subject-Specific PK Parameters ...............................................................................136 
Listing 27: Subject Level Fosfomycin Concentrations in ELF and in AM Cell Pellet ...............137 
 


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16.1.6 Listing of Subjects Receiving Investigational Product 
(not included in SAP, but this is a placeholder for the CSR) 
 


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16.2 
Database Listings by Subject 
16.2.1 Discontinued Subjects 
Listing 1: 
Early Terminations or Discontinued Subjects 
[Implementation Note: Category will be either “Early Termination” or “Treatment Discontinuation.” In the “Reason” column, concatenate any “specify” 
fields, including AE number and DV number. In the CSR, Subject ID should be USUBJID (not PATID) for purposes of de-identification. Sort order: 
BAL Sampling Timepoint, Subject ID, alphabetically by Category (in the case a subject both terminates early and discontinues treatment).] 
BAL Sampling 
Timepoint 
Subject ID 
Category 
Reason for Early Termination or Treatment 
Discontinuation 
Study Day 
Number of Doses 
Received 
Replaced with 
Alternate 
 
 
 
 
 
 
 
 


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16.2.2 Protocol Deviations 
Listing 2: 
Subject-Specific Protocol Deviations 
[Implementation Note: In the “Deviation” column, concatenate any and all “specify” fields (including visit number, etc.). If “Reason for Deviation” is 
“Other,” concatenate “specify” field, separate by a colon, e.g., “Other: Subject refusal.” In the CSR, Subject ID should be USUBJID (not PATID) for 
purposes of de-identification. Sort order: BAL Sampling Timepoint, Subject ID, DV Number.] 
BAL Sampling 
Timepoint 
Subject ID 
DV Number 
Deviation 
Deviation 
Category 
Study Day 
Reason for 
Deviation 
Deviation 
Resulted in 
AE? 
Deviation Resulted 
in Subject 
Termination? 
Deviation 
Affected 
Product 
Stability? 
Deviation 
Resolution 
Comments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 3: 
Non-Subject-Specific Protocol Deviations 
[Implementation Note: In the “Deviation” column, concatenate any and all “specify” fields (including visit number, etc.). If “Reason for Deviation” is 
“Other,” concatenate “specify” field, separate by a colon, e.g., “Other: Subject refusal.” Sort order: Start Date.] 
Start Date  
Deviation 
End Date 
Reason for 
Deviation 
Deviation Resulted in 
Subject Termination? 
Deviation Affected 
Product Stability? 
Deviation 
Category 
Deviation 
Resolution 
Comments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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16.2.3 Subjects Excluded from the Efficacy Analysis 
Listing 4: 
Subjects Excluded from Analysis Populations 
[Implementation Note: This data in this listing should be congruent with the “Analysis Populations by Study Group” table. The reasons included here 
should match the SAP text that describes who will be excluded from analyses.] 
BAL Sampling 
Timepoint 
Subject ID 
Analyses in which 
Subject is Included 
Analyses from which  
Subject is Excluded 
Results Available? 
Reason Subject Excluded 
 
 
[e.g., Safety, PK] 
[e.g., Safety, PK] 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Notes: “Yes” in the “Results available” column indicates that available data were removed from the analysis. “No” indicates that no data were available for inclusion in the analysis. 
 
 


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16.2.4 Demographic Data 
Listing 5: 
Demographic Data 
[Implementation Note: If a subject is multi-racial, in “Race” column, note “Multiple: (list races, separated by a comma).” In the CSR, Subject ID should 
be USUBJID (not PATID) for purposes of de-identification. Height, weight, and BMI included in this listing will be from the initial screening visit 
Sort order: BAL Sampling Timepoint, Subject ID] 
BAL Sampling 
Timepoint 
 Subject ID 
Sex 
Age at Enrollment (years) 
Ethnicity 
Race 
Height (cm) 
Weight (Kg) 
BMI (kg/m2) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 6: 
Pre-Existing and Concurrent Medical Conditions 
[Sort order: BAL Sampling Timepoint, Subject ID] 
BAL 
Sampling 
Timepoint 
 Subject ID 
MH Number 
Medical History Term 
Condition Start Day  
Condition End Day 
MedDRA System Organ Class 
MedDRA Preferred Term 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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16.2.5 Drug Concentration Data  
Listing 7: 
Treatments Administered 
[Sort order: BAL Sampling Timepoint, Subject ID] 
BAL Sampling  
Timepoint 
Subject ID 
Drug 
Dose Number 
Planned Dose (mg) 
Actual Dose 
(mg) 
Infusion Start 
Date 
Infusion Start 
Time 
(hh:mm) 
Infusion 
End Date 
Infusion End 
Time 
(hh:mm) 
Interruptions 
in study product 
administration 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 8: 
Unsolicited Adverse Events 
[Sort order: BAL Sampling Timepoint, Subject ID, AE Number] 
Adverse 
Event 
Associated 
with Dose 
No. 
No. of hours 
Post 
Associated 
Dose 
(Duration) 
Severity 
SAE? 
Relationship 
to Study 
Treatment 
In Not 
Related, 
Alternative 
Etiology 
Action 
Taken with 
Study 
Treatment 
Subject 
Discontinued 
Due to AE 
Outcome 
MedDRA 
System 
Organ Class 
MedDRA 
Preferred 
Term 
BAL Sampling Timepoint: , Subject ID: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
 
Comments: 
 
 
 
 
 
 
 
 
 
 
 
 
BAL Sampling Timepoint: , Subject ID: , AE Number:  
 
 
 
 
 
 
 
 
 
 
 
 
Comments: 
Note: For additional details about SAEs, see Table: 14. 
 
 


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16.2.8 Individual Laboratory Measurements 
Listing 9: 
Clinical Laboratory Results – Chemistry 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint] 
BAL 
Sampling 
Timepoint 
Subject ID 
Planned 
Timepoint  
Actual 
Timepoint  
Sex  
Age at 
Enrollment 
(years) 
Laboratory Parameter 
(Units) 
Result (Severity 
Grade) 
Reference Range 
Low 
Reference Range 
High 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 10: 
Clinical Laboratory Results – Hematology 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint] 
BAL Sampling 
Timepoint 
Subject ID 
Planned 
Timepoint  
Actual Time Post 
Infusion Dose # 
(h)  
Sex  
Age at 
Enrollment 
(years) 
Laboratory Parameter 
(Units) 
Result (Severity 
Grade) 
Reference Range 
Low 
Reference Range 
High 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 11: 
Clinical Laboratory Results – Coagulation 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint] 
BAL Sampling 
Timepoint 
Subject ID 
Planned 
Timepoint  
Actual Time Post 
Infusion Dose # 
(h)  
Sex  
Age at 
Enrollment 
(years) 
Laboratory Parameter 
(Units) 
Result (Severity 
Grade) 
Reference Range 
Low 
Reference Range 
High 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 12: 
Clinical Laboratory Results – Urinalysis 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint] 
BAL Sampling 
Timepoint 
Subject ID 
Planned 
Timepoint  
Actual Time Post 
Infusion Dose # 
(h)  
Sex  
Age at 
Enrollment 
(years) 
Laboratory 
Parameter (Units) 
Result (Severity 
Grade) 
Reference Range 
Low 
Reference Range 
High 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 13: 
Screening Laboratory Results – Serology 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint] 
BAL Sampling 
Timepoint 
Subject ID 
Planned Timepoint 
Actual Time Post 
Infusion Dose # 
(h)  
HIV 1/2 antigen 
HCV surface antibodies 
HBsAg 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 14: 
Laboratory Results – Urine Toxicology and Alcohol Testing 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint] 
BAL Sampling 
Timepoint 
Subject 
ID 
Planned 
Timepoint 
Actual Time 
Post Infusion 
Dose # (h)  
Amphetamines Methamphetamine 
Barbiturates Benzodiazepines 
THC 
Cocaine 
Opiates 
Cotinine 
Alcohol 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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16.2.9 Vital Signs and Physical Exam Findings 
Listing 15: 
Vital Signs 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint] 
BAL Sampling 
Timepoint 
Subject ID 
Planned 
Timepoint 
Actual Time 
Post Infusion 
Dose # (h)  
Temperature 
(°C) 
Systolic Blood 
Pressure 
(mmHg) 
Diastolic Blood 
Pressure 
(mmHg) 
Heart Rate 
(beats/min) 
Respiratory Rate 
(breaths/min) 
Weight 
(kg) 
Height 
(cm) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 16: 
Physical Exam Findings 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint] 
BAL Sampling 
Timepoint 
Subject ID 
Planned 
Timepoint 
Actual Time 
Post Infusion 
Dose # (h)  
Body System 
Abnormal Finding 
Reported as an AE? 
(AE Description; Number) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 17: 
Listing of ECG Interval Measurements 
[Sort order: BAL Sampling Timepoint, Subject ID, Planned Timepoint] 
 
Interval Measurement 
BAL Sampling 
Timepoint 
Subject ID 
Planned 
Timepoint 
Actual Time Post 
Infusion Dose # 
(h)  
Time of 
Assessment 
(hh:mm) 
QRS duration 
(msec) 
QTc interval 
(msec) 
PR Interval 
(msec) 
Overall Assessment 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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16.2.10 Prior and Concomitant Medications 
Listing 18: 
Prior Medications 
[Sort order: BAL Sampling Timepoint, Subject ID, CM Number] 
BAL Sampling 
Timepoint 
Subject ID 
CM Number 
Medication 
Medication Start Day 
Medication End Day 
Indication 
Taken for a condition on 
Medical History? 
(MH Description; Number) 
ATC Level 1 
(ATC Level 2) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 19: 
Concomitant Medications 
[Sort order: BAL Sampling Timepoint, Subject ID, CM Number] 
BAL 
Sampling 
Timepoint Subject ID 
CM 
Number 
Medication 
Medication Start 
Day 
Medication End 
Day 
Indication 
Taken for an AE? 
(AE Description; 
Number) 
Taken for a condition 
on Medical History? 
(MH Description; 
Number) 
ATC Level 1  
(ATC Level 2) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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16.2.11 Pregnancy Reports 
Listing 20: 
Pregnancy Reports – Maternal Information 
[Sort order: BAL Sampling Timepoint, Subject ID, Pregnancy Number] 
BAL 
Sampling 
Timepoint 
Subject 
ID  
Pregnancy 
Number 
Study Day 
Corresponding 
to Estimated 
Date of 
Conception 
Source of 
Maternal 
Information 
Pregnancy 
Status 
Mother’s 
Pre-
Pregnancy 
BMI 
Mother’s 
Weight 
Gain 
During 
Pregnancy 
Tobacco, 
Alcohol, or 
Drug Use 
During 
Pregnancy? 
Medications 
During 
Pregnancy? 
Maternal 
Complications 
During 
Pregnancy? 
Maternal 
Complications 
During Labor, 
Delivery, or 
Post-Partum? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: Maternal Complications are included in the Adverse Event listing. Medications taken during pregnancy are included in the Concomitant Medications Listing. 
 


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Listing 21: 
Pregnancy Reports – Gravida and Para 
 
 
 
Live Births 
 
 
 
 
 
Subject 
ID 
Pregnancy 
Number 
Gravida 
Extremely 
PBa 
Very 
Early 
PBa 
Early 
PBa 
Late 
PBa 
Early 
TBb 
Full 
TBb 
Late 
TBb 
Post 
TBb 
Still 
Births 
Spontaneous 
Abortion/ 
Miscarriage 
Elective 
Abortions 
Therapeutic 
Abortions 
Major 
Congenital 
Anomaly 
with 
Previous 
Pregnancy? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: Gravida includes the current pregnancy, para events do not. 
a Preterm Birth 
b Term Birth 
 


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Listing 22: 
Pregnancy Reports – Live Birth Outcomes 
Subject 
ID 
Pregnancy 
Number 
Fetus 
Number 
Pregnancy 
Outcome 
(for this 
Fetus) 
Fetal 
Distress 
During 
Labor and 
Delivery? 
Delivery 
Method 
Gestational 
Age at Live 
Birth  
Size for 
Gestational 
Age 
Apgar 
Score, 1 
minute 
Apgar 
Score, 5 
minutes 
Cord pH 
Congenital 
Anomalies? 
Illnesses/ 
Hospitalizations 
within 1 Month of 
Birth? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: Congenital Anomalies are included in the Adverse Event listing. 
Listing 23: 
Pregnancy Reports – Still Birth Outcomes 
Subject 
ID 
Date of 
Initial 
Report 
Fetus 
Number 
Pregnancy 
Outcome 
(for this 
Fetus) 
Fetal Distress 
During 
Labor and 
Delivery? 
Delivery 
Method 
Gestational 
Age at Still 
Birth 
Size for 
Gestational 
Age 
Cord pH 
Congenital 
Anomalies? 
Autopsy 
Performed? 
If Autopsy, Etiology 
for Still Birth 
Identified? 
 
 
 
 
 
 
 
 
 
 
 
 
Listing 24: 
Pregnancy Reports – Spontaneous, Elective, or Therapeutic Abortion Outcomes 
Subject 
ID 
Date of Initial 
Report 
Fetus Number 
Pregnancy Outcome 
(for this Fetus) 
Gestational Age at 
Termination 
Abnormality in Product of Conception? 
Reason for Therapeutic 
Abortion 
 
 
 
 
 
 
 
 


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Listing 25: 
Subject Level Fosfomycin Concentrations in Plasma 
[Sort order: BAL Sampling Timepoint, Subject ID, Dose Number  
If Fosfomycin Concentration level below LLOQ report as BQL and include footnote “BQL= Below Quantitative Limit” If no levels are BQL, footnote 
does not need to be included in table.] 
BAL Sampling 
Timepoint 
Subject ID 
Dose 
Number 
Nominal Timea (h) 
Actual Timea (h) 
Actual Dose 
(mg) 
Fosfomycin 
Concentration (µg/mL) 
Sample Within 
Time Window 
Used in λz 
Calculations 
 
 
 
 
yes/no 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: BQL= Below Quantitative Limit 
a Times are relative to start of study product infusion for associated dose. For actual time, out of window times are indicated by an asterisk. 
 


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Listing 26:  
Subject-Specific PK Parameters 
BAL Sampling 
Timepoint 
Subject ID 
Dose 
Number 
Cmax 
(µg/mL) 
Tmax 
(h) 
AUC(0-8)  
(h*µg/mL) 
AUC(0-12)  
(h*µg/mL) 
AUC(0-inf) 
(h*µg/mL) 
λz 
(/h) 
t1/2 
(h) 
CL 
(L/h) 
Vss 
(L) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Listing 27: 
Subject Level Fosfomycin Concentrations in ELF and in AM Cell Pellet 
[Sort order: BAL Sampling Timepoint, Subject ID] 
BAL Sampling 
Timepoint 
Subject ID 
Nominal Timea (h) 
Actual Timea (h) 
BAL Fosfomycin 
Concentration 
(µg/mL) 
(FosfomycinBAL) 
BAL Urea 
Concentration  
(µg/mL) 
(UreaBAL ) 
Plasma Urea 
Concentration 
(µg/mL) 
(UreaPlasma) 
Calculated ELF 
Fosfomycin 
Concentration  
(µg/mL)b 
(FosfomycinELF) 
AM Fosfomycin 
Concentration 
(µg/mL) 
Sample 
Within 
Time 
Window 
 
 
 
 
 
 
yes/no 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
aTimes are relative to start of third dose of study product infusion. For actual time, out of window times are indicated by an asterisk. 
b FosfomycinELF = FosfomycinBAL × (UreaPlasma/UreaBAL) 
 
 

Prot_001.pdf: 
DMID Protocol 16-0058 
Version 9.0 
IV Fosfomycin PK Study 
27 August 2020 
 ________________________________________________________________________________________________________  
 
DMID/NIAID/NIH 
 
 
 
 
 
 
 
 
 
1 
CONFIDENTIAL 
DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
A Phase 1 Safety and Intrapulmonary Pharmacokinetics Study of 
ZTI-01 (Intravenous Fosfomycin Disodium) in Healthy Adult 
Subjects 
DMID Protocol Number: 16-0058 
DMID Funding Mechanism: Vaccine and Treatment Evaluation Unit 
Pharmaceutical Support Provided by: Nabriva Therapeutics, Inc. 
IND Sponsor: NIH/NIAID/DMID 
Principal Investigators: Emmanuel B. Walter, MD, MPH and Loretta G. Que, MD 
DMID Clinical Project Manager: Maureen Mehigan, RN 
DMID Medical Officers: Varduhi Ghazaryan, MD, MPH  
DMID Medical Monitor: Tatiana Beresnev, MD 
Version Number: 9.0 
27 August 2020 
 
 
 


DMID Protocol 16-0058 
Version 9.0 
IV Fosfomycin PK Study 
27 August 2020 
 ________________________________________________________________________________________________________  
 
DMID/NIAID/NIH 
 
 
 
 
 
 
 
 
 
2 
CONFIDENTIAL 
DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
STATEMENT OF COMPLIANCE 
The trial will be carried out in accordance with Good Clinical Practice (GCP) and as required by: 
• 
United States (US) 45 Code of Federal Regulations (CFR) Part 46: Protection of Human Subjects 
• 
Food and Drug Administration (FDA) Regulations, as applicable: 21 CFR Part 50 (Protection of 
Human Subjects), 21 CFR Part 54 (Financial Disclosure by Clinical Investigators), 21 CFR Part 56 
(Institutional Review Boards), and 21 CFR Part 11, 21 CFR Part 312 (Investigational New Drug 
Application). 
• 
International Conference on Harmonization (ICH) E6:GCP; 62 Federal Register 25691 (1997); and 
future revisions 
• 
Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research, 
Report of the National Commission for the Protection of Human Subjects of Biomedical and 
Behavioral Research 
• 
National Institutes of Health (NIH) Office of Extramural Research, Research Involving Human 
Subjects, as applicable 
• 
National Institute of Allergy and Infectious Diseases (NIAID) Clinical Terms of Award, as applicable 
• 
Applicable Federal, State, and Local Regulations and Guidance 
 
 


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27 August 2020 
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DMID/NIAID/NIH 
 
 
 
 
 
 
 
 
 
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CONFIDENTIAL 
DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
SIGNATURE PAGE 
The signature below provides the necessary assurance that the trial will be conducted according to all 
stipulations of the protocol, including all statements regarding confidentiality, and according to local legal 
and regulatory requirements and applicable US federal regulations and ICH E6: GCP guidelines. 
I agree to conduct the study in compliance with GCP and applicable regulatory requirements. 
I agree to conduct the study in accordance with the current protocol and will not make changes to the 
protocol without obtaining the Sponsor’s approval and Institutional Review Board (IRB)/Independent 
Ethics Committee (IEC) approval, except when necessary to protect the safety, rights, or welfare of 
subjects. 
 
Site Investigator Signature: 
 
Signed: 
 
Date: 
 
 
Emmanuel B. Walter, MD, MPH 
Professor of Pediatrics, Duke University 
 
 
 
Site Investigator Signature: 
 
Signed: 
 
Date: 
 
 
 Loretta G. Que, MD 
Professor of Medicine, Duke University 
 
 
 
 


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27 August 2020 
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DMID/NIAID/NIH 
 
 
 
 
 
 
 
 
 
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CONFIDENTIAL 
DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
TABLE OF CONTENTS 
Statement of Compliance .............................................................................................................................. 2 
Signature Page .............................................................................................................................................. 3 
Table of Contents .......................................................................................................................................... 4 
List of Tables ................................................................................................................................................ 8 
List of Figures ............................................................................................................................................... 9 
List of Abbreviations .................................................................................................................................. 10 
Protocol Summary ...................................................................................................................................... 14 
1. 
Key Roles ....................................................................................................................................... 19 
2. 
Background Information and Scientific Rationale ......................................................................... 22 
2.1. 
Background Information ................................................................................................................ 22 
2.2. 
Rationale ........................................................................................................................................ 26 
2.3. 
Potential Risks and Benefits .......................................................................................................... 27 
2.3.1. Potential Risks ............................................................................................................................... 27 
2.3.2. Known Potential Benefits .............................................................................................................. 29 
3. 
Objectives and Outcome Measures ................................................................................................ 30 
3.1. 
Study Objectives ............................................................................................................................ 30 
3.2. 
Study Outcome Measures .............................................................................................................. 30 
4. 
Study Design .................................................................................................................................. 32 
5. 
Study Enrollment and Withdrawal ................................................................................................. 33 
5.1. 
Subject Inclusion Criteria .............................................................................................................. 33 
5.2. 
Subject Exclusion Criteria ............................................................................................................. 34 
5.3. 
Treatment Assignment Procedures ................................................................................................ 37 
5.3.1. Randomization Procedures ............................................................................................................ 37 


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


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DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
8.2.1. Clinical Laboratory Evaluations .................................................................................................... 47 
8.2.2. Bronchoscopy and Bronchoalveolar Lavage (BAL) ...................................................................... 48 
8.2.3. Pharmacokinetic Blood and BAL Samples .................................................................................... 49 
8.2.4. Specimen Preparation, Handling, and Shipping ............................................................................ 51 
9. 
Assessment of Safety ..................................................................................................................... 52 
9.1. 
Specification of Safety Parameters ................................................................................................ 52 
9.2. 
Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters...................... 52 
9.2.1. Adverse Events .............................................................................................................................. 52 
9.2.2. Serious Adverse Events ................................................................................................................. 53 
9.2.3. Procedures to be Followed in the Event of Abnormal Laboratory Test Values or Abnormal 
Clinical Findings ......................................................................................................................................... 54 
9.3. 
Reporting Procedures ..................................................................................................................... 54 
9.3.1. Serious Adverse Events ................................................................................................................. 55 
9.3.2. Regulatory Reporting for Studies Conducted Under DMID-Sponsored IND ............................... 55 
9.3.3. Reporting of Pregnancy ................................................................................................................. 56 
9.4. 
Type and Duration of Follow-up of Subjects after Adverse Events .............................................. 56 
9.5. 
Halting Rules ................................................................................................................................. 56 
9.6. 
Safety Oversight ............................................................................................................................ 56 
9.6.1. Independent Safety Monitor (ISM) ................................................................................................ 57 
9.6.2. Safety Monitoring Committee (SMC) ........................................................................................... 57 
10. 
Clinical Monitoring ........................................................................................................................ 58 
10.1. 
Site Monitoring Plan ...................................................................................................................... 58 
11. 
Statistical Considerations ............................................................................................................... 59 
11.1. 
Study Hypotheses .......................................................................................................................... 59 
11.2. 
Sample Size Considerations ........................................................................................................... 59 


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DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
11.3. 
Final Analysis Plan ........................................................................................................................ 60 
12. 
Source Documents and Access to Source Data/Documents .......................................................... 63 
13. 
Quality Control and Quality Assurance ......................................................................................... 64 
14. 
Ethics/Protection of Human Subjects ............................................................................................ 65 
14.1. 
Ethical Standard ............................................................................................................................. 65 
14.2. 
Institutional Review Board ............................................................................................................ 65 
14.3. 
Informed Consent Process ............................................................................................................. 65 
14.4. 
Exclusion of Women, Minorities, and Children (Special Populations) ......................................... 66 
14.5. 
Subject Confidentiality .................................................................................................................. 66 
14.6. 
Study Discontinuation .................................................................................................................... 67 
14.7. 
Costs, Subject Compensation, and Research Related Injuries ....................................................... 67 
14.8. 
Future Use of Stored Specimens and Data..................................................................................... 68 
15. 
Data Handling and Record Keeping .............................................................................................. 69 
15.1. 
Data Management Responsibilities ................................................................................................ 69 
15.2. 
Data Capture Methods ................................................................................................................... 69 
15.3. 
Types of Data ................................................................................................................................. 69 
15.4. 
Timing/Reports .............................................................................................................................. 70 
15.5. 
Study Records Retention................................................................................................................ 70 
15.6. 
Protocol Deviations ........................................................................................................................ 70 
16. 
Publication Policy .......................................................................................................................... 71 
17. 
Literature References ..................................................................................................................... 72 
18. 
Supplements/Appendices ............................................................................................................... 76 
Appendix A: Schedule of Study Procedures And Evaluations ................................................................... 76 
Appendix B: Adverse event toxicity grading scale ..................................................................................... 79 
Appendix C: Venipuncture schedule and volumes ..................................................................................... 87 


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


DMID Protocol 16-0058 
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IV Fosfomycin PK Study 
27 August 2020 
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DMID/NIAID/NIH 
 
 
 
 
 
 
 
 
 
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CONFIDENTIAL 
DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
LIST OF FIGURES 
Figure 1: Schematic of Study Design ............................................................................................18 
 
 


DMID Protocol 16-0058 
Version 9.0 
IV Fosfomycin PK Study 
27 August 2020 
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CONFIDENTIAL 
DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
LIST OF ABBREVIATIONS 
AE 
Adverse Event/Adverse Experience 
ALT 
 Alanine Aminotransferase 
AM 
Alveolar Macrophage 
ALP 
 Alkaline Phosphatase 
AST 
Aspartate Aminotransferase 
AUC 
Area under the concentration-time curve 
AUC0-t 
AUC calculated to the last measured concentration 
AUC0-inf 
AUC extrapolated to infinity 
BAL 
Bronchoalveolar lavage 
BMI 
Body Mass Index 
Cmax 
Maximum Measured Concentration 
CRF 
Case Report Form 
CDC 
Centers for Disease Control and Prevention 
CFR 
Code of Federal Regulations 
CFU 
Colony Forming Unit 
CL 
Clearance 
CrCl 
Creatinine Clearance 
CRE 
Carbapenem-Resistant Enterobacteriaceae 
CROMS 
Clinical Research Operations and Management Support 
DCC 
Data Coordinating Center 
DEPRU 
Duke Early Phase Research Unit 
DHHS 
Department of Health and Human Services 
DMID 
Division of Microbiology and Infectious Diseases 


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27 August 2020 
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DMID/NIAID/NIH 
 
 
 
 
 
 
 
 
 
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DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
DMID-CMS 
DMID Clinical Materials Services (CMS, Fisher BioServices) 
ECG 
Electrocardiograph 
ELF 
Epithelial Lining Fluid 
ESBL 
Extended-Spectrum Beta-Lactamase 
FDA 
Food and Drug Administration 
FSH 
Follicle-Stimulating Hormone 
FWA 
Federal Wide Assurance 
GCP 
Good Clinical Practice 
GI 
Gastrointestinal 
HBsAg 
Hepatitis B Surface Antigen 
HCV 
Hepatitis C Virus 
IB 
Investigator’s Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonization 
ICMJE 
International Committee of Medical Journal Editors 
IM 
Intramuscular 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ISM 
Independent Safety Monitor 
IV 
Intravenous 
LC-MS/MS 
Liquid chromatography-mass spectrometry/mass spectrometry 
MIC 
Minimum Inhibitory Concentration 
MOP 
Manual of Procedures 
MDR 
Multi-Drug Resistant 
MRSA 
Methicillin Resistant S. aureus 


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


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


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


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


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


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


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Figure 1: Schematic of Study Design 
 


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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5. 
STUDY ENROLLMENT AND WITHDRAWAL 
Subjects will not be enrolled unless they meet the following inclusion and exclusion criteria. The 
investigator or other study personnel will document in the source documents (e.g., the clinical chart) that 
the informed consent form (ICF) was signed and dated before study screening. The time and date that 
informed consent was obtained will be recorded in the source documents and electronic case report form 
(eCRF). The presence of inclusion criteria and the absence of exclusion criteria will be recorded in the 
eCRF. 
5.1. 
Subject Inclusion Criteria 
To be considered for study enrollment, subjects must meet all of the following inclusion criteria: 
1. Healthy1 men and women aged 18-45 years with no clinically significant findings2 at Screening 
and Baseline (Day -1 to Day 1)2 
1Healthy is defined by the absence of any medical condition described in the exclusion 
criteria in a subject with a normal physical exam including vital signs. If the subject has 
another current, ongoing medical condition, the condition cannot meet any of the following 
criteria: 1) first diagnosed within 3 months of enrollment; 2) is worsening in terms of clinical 
outcome in the last 6 months; or 3) involves need for medication.  
2Including findings on medical history, physical exam, vital signs, 12-lead ECG, or clinical 
laboratory tests.  
 
2. Body Mass Index (BMI) = 18-30 kg/m2, inclusive, and body weight >50 kg (110 lbs) 
 
3. Females who have been surgically sterilized via bilateral oophorectomy and/or hysterectomy at 
least 90 days prior to Screening are considered lacking childbearing potential and will be eligible3 
3Postmenopausal females are not eligible, as the definition of menopause would require age 
>45, and all subjects in this study are age ≤45. 
 
4. Females of childbearing potential must have a negative serum pregnancy test at Screening, a 
negative urine pregnancy test at Baseline (Day -1 to Day 1), and must use acceptable 
contraception4 
4Acceptable contraception methods are restricted to surgical sterilization (bilateral tubal 
ligation) or successful Essure placement (permanent, non-surgical, non-hormonal 


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sterilization with documented radiological confirmation at least 90 days after the procedure), 
use of long-acting reversible contraceptive devices (progestin-releasing subdermal implants 
[Nexplanon and Implanon, Merck], copper intrauterine devices [Paragard, Teva], and 
levonorgestrel-releasing intrauterine devices [Mirena, Bayer; Skyla, Bayer; Liletta, 
Allergan/Medicines360]), licensed hormonal products such as injectables or oral 
contraceptives, barrier methods such as condoms or diaphragms with spermicidal agents, 
and abstinence from sexual intercourse with a male partner. 
Subjects must have used the above-listed method for a minimum of 30 days prior to the first 
dose of study drug and be willing to use the method for at least 30 days after the final dose of 
study drug. 
 
5. Male subjects5 whose partners are of childbearing age or pregnant must be willing to use 
condoms during the study and through the Day 3 follow-up call. 
5including men who have had vasectomies 
6. Able to abstain from alcoholic beverages within 48 hours before Baseline (Day -1 to Day 1) and 
throughout the Treatment Phase 
7. Able to abstain from caffeine use within 7 days before Baseline (Day -1 to Day 1) and throughout 
the inpatient period 
8. Willing to remain in DEPRU during the Baseline and Treatment Phases  
9. Have a high probability for compliance and completion of the trial  
10. Sign a dated, witnessed, written ICF 
11. Have adequate venous access for infusions and blood draws 
5.2. 
Subject Exclusion Criteria 
Subjects must meet none of the following exclusion criteria: 
1. Any surgical or medical condition that in the opinion of the investigator could interfere with drug 
absorption, distribution, metabolism, or excretion. 
 
2. Any surgical or medical condition that in the opinion of the investigator may place the subject at 
increased risk while participating in the trial.  
 


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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The Site PI is responsible for informing the IRB of the SAE as per local requirements. DMID will be 
responsible of informing the US Regulatory Authority of the SAE as per federal requirements. 
9.3.1. 
Serious Adverse Events 
Any AE that meets a protocol-defined serious criterion will be submitted immediately (within 24 hours of 
site awareness) on an SAE form to the DMID Pharmacovigilance Group, at the following address:  
DMID Pharmacovigilance Group 
Clinical Research Operations and Management Support (CROMS) 
6500 Rock Spring Drive, Suite 650 
Bethesda, MD 20817, USA 
SAE Hot Line: 1-800-537-9979 (US) or 1-301-897-1709 (outside US) 
SAE FAX Number: 1-800-275-7619 (US) or 1-301-897-1710 (outside US) 
SAE Email Address: PVG@dmidcroms.com 
In addition to the SAE form, select SAE data fields will also be entered into the DCC system (e.g., 
Advantage EDC). Please see the protocol-specific MOP for details regarding this procedure.  
Other supporting documentation of the SAE may be requested by the DMID Pharmacovigilance Group 
and will be provided as soon as possible.  
DEPRU will send a copy of the SAE report(s) to the ISM when they are provided to the DMID 
Pharmacovigilance Group. The DMID Medical Monitor and DMID Clinical Project Manager will be 
notified of the SAE by the DMID Pharmacovigilance Group. The DMID Medical Monitor will review 
and assess the SAE for regulatory reporting and potential impact on subject safety and protocol conduct. 
At any time after completion of the study, if the Site PI or appropriate sub-investigator becomes aware of 
an SAE that is suspected to be related to the study drug, the Site PI or appropriate sub-investigator will 
report the SAE to the DMID Pharmacovigilance Group. 
9.3.2. 
Regulatory Reporting for Studies Conducted Under DMID-Sponsored IND 
Following notification from the investigator, the IND sponsor DMID will report any suspected AE that is 
both serious and unexpected. DMID will report an AE as a suspected adverse reaction only if there is 
evidence to suggest a causal relationship between the study drug and the AE. DMID will notify FDA and 
all participating investigators (i.e., all investigators to whom the Sponsor is providing drug under its INDs 
or under any investigator’s IND) in an IND safety report of potential serious risks from clinical trials or 
any other source, as soon as possible, but in no case later than 15 calendar days after the Sponsor 
determines that the information qualifies for reporting as specified in 21 CFR Part 312.32. DMID will 


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also notify FDA of any unexpected fatal or life-threatening suspected AE as soon as possible but in no 
case later than 7 calendar days after the Sponsor’s initial receipt of the information. Relevant follow-up 
information to an IND safety report will be submitted as soon as the information is available. Upon 
request from FDA, DMID will submit to FDA any additional data or information that the agency deems 
necessary, as soon as possible, but in no case later than 15 calendar days after receiving the request. 
All SAEs designated as “not related” to the study drug will be reported to the FDA at least annually in a 
summary format. 
9.3.3. 
Reporting of Pregnancy 
Pregnancies occurring in study subjects will be reported via AdvantageEDCSM on the Pregnancy Report 
form. All pregnancies occurring during the trial will be followed for information regarding the course of 
pregnancy and any outcome, delivery and condition of the newborn. Follow-up will be provided by the 
investigator to the Medical Monitor (or designee) in a timely manner.  
9.4. 
Type and Duration of Follow-up of Subjects after Adverse Events 
All AEs will be followed until resolution or until determined by the PI to be medically stable 
(stable/improving and no further intervention required). 
9.5. 
Halting Rules 
If any of the halting rules, as outlined below, is met, further enrollment and dosing will be withheld until 
the SMC reviews the safety data and provides its recommendations.  
• 
Two subjects experience any related Grade 3 systemic AE   
• 
Two subjects experience the same related Grade 3 laboratory AE (per Medical Dictionary for 
Regulatory Activities High Level Group Term) 
• 
One subject experiences a related SAE 
A decision to reinitiate the trial and proceed with study drug administration will be made by DMID based 
on the recommendation of the SMC. 
If the following individual halting rule is met, the individual will not undergo further dosing or study 
procedures. 
• 
Subject experiences a grade 2 or higher abnormality in sodium, potassium, magnesium, calcium, or 
phosphorus, when checked approximately 2 hours prior to the bronchoscopy timepoint 
9.6. 
Safety Oversight 
The safety oversight for the trial will be conducted under the direction of DMID.  


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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17. 
LITERATURE REFERENCES 
Albiero J, Sy SKB, Mazucheli J, Caparroz-Assef SM, Costa BB, Alves JLB, Gales AC, Tognim MCB.  
Pharmacodynamic evaluation of the potential clinical utility of fosfomycin and meropenem in 
combination therapy against KPC-2-producing Klebsiella pneumoniaei.  Antimicrob Agents Chemother 
2016;60:4128–39. 
Alemayehu D, Quinn J, Cook J, Kunkel M and Knirsch CA. A Paradigm Shift in Drug Development for 
Treatment of Rare Multidrug Resistant Gram-Negative Pathogens. Clin Infect Dis 2012 Aug;55(4):562-
567. 
Al-Hasan MN, Eckel-Passow JE, Baddour LM. Bacteremia Complicating Gram-Negative Urinary Tract 
Infections: A Population-Based Study. J Infect. 2010 April ; 60(4): 278–285. 
Ambrose PG, Bhavnani SM, Rubino CM, Louie A, Gumbo T, Forrest A, Drusano GL.     
Pharmacokinetics-pharmacodynamics of antimicrobial therapy: It’s not just for mice anymore. Clin Infect 
Dis 2007; 44:79-86. 
Ambrose PG, Bhavnani SM, Ellis-Grosse EJ, Drusano GL.     Pharmacokinetics- pharmacodynamics 
considerations in the design of hospital-acquired or ventilator-associated bacterial pneumonia studies: 
look before you leap! Clin Infect Dis 2010; 51(Suppl 1):S103-S110. 
Asuphon O, Montakantikul P, Houngsaitong J, Kiratisin P, Sonthisombat P.  Optimizing intravenous 
fosfomycin dosing in combination with carbapenems for treatment of Pseudomonas aeruginosa infections 
in critically ill patients based on pharmacokinetic/pharmacodynamics (PK/PD) simulations.  Int J Infect 
Dis 2016;50:23-9. 
Craig WA, Ebert SC. Killing and regrowth of bacteria in vitro: a review. Scand J Infect Dis Suppl 1990; 
74:63–70. 
Dinh A, Salomon J, Bru JP Bernard L. Fosfomycin: efficacy against infections caused by multidrug-
resistant bacteria. Scand J Infect Dis. 2012;44(3):182-189. 
Drusano G. Prevention of Resistance: A Goal for Dose Selection for Antimicrobial Agents. Clin Infect 
Dis 2003; 36(Suppl 1):S42–50. 
Endimiani A, Patel G, Hujer KM, Swaminathan M, Perez F, and Rice LB. In vitro activity of fosfomycin 
against blaKPC-containing Klebsiella pneumoniae isolates, including those non-susceptible to tigecycline 
and/or colistin. Antimicrob Agents Chemother 2010;54:526–529. 
Edwards JR, Peterson KD, Banerjee S, Allen-Bridson K, Morrell G, Dudeck MA, Pollock DA, and Horan 
TC. National Healthcare Safety Network (NHSN) report: Data summary for 2006 through 2008, issued 
December 2009.  Am J Infect Control 2009;37:783-805. 
Falagas ME, Konstatina PG, Kokolakis GN and Rafilidis PI. Fosfomycin: Use Beyond Urinary Tract and 
Gastrointestinal Infections. Clin Infect Dis 2008;46(7):1069-1077. 


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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DMID eCTD Compliant Interventional Protocol Template and Instructions, Version 2.0, Dated August 10, 2017 
APPENDIX C: VENIPUNCTURE SCHEDULE AND VOLUMES 
Table 12: Venipuncture schedule and volumes 
 
Scheduled Laboratory 
Assessments 
Study Days 
Blood 
Volume 
per 
Sample 
(mL) 
Total 
Number of 
Samples 
Total 
Blood 
Volume 
(mL) 
Screening 
(Day -30 to 
Day -1) 
 
Baseline 
(Day -1 to 
Day 1) 
Treatment 
and 
Discharge 
(Days 1-2) 
 
 
 
Chemistry 
X 
X 
X 
9 
3 
27 
Electrolytes (only) 
 
 
X 
4.5 
1 
4.5 
Hematology 
X 
 
X 
4 
2 
8 
Coagulation 
X 
 
X 
2.7 
2 
5.4 
Serum Pregnancy   
X 
 
 
5 
1 
5 
Serologya 
X 
 
 
8.5 
1 
8.5 
Urea Blood Sample 
 
 
X 
4 
1 
4 
PK Blood Samples 
 
 
X 
4 
15 
60 
Total blood volume 
(mL)b 
29.2 
9 
84.2 
 
 
122.4 
 
a Serology is for testing of HIV antibody, Hepatitis B antigen, Hepatitis C antibody. 
b  The total blood volume of 122.4 ml will be collected from each subject; blood volume per study phase is 
reflected at the bottom of each column.