Conditions: Tuberculosis, Pulmonary
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 112
Healthy volunteers: no

Brief summary:
The overall goal of this exploratory proof-of-concept study is to determine whether, in participants with pulmonary tuberculosis caused by M. tuberculosis (MTB) with or without rifampin resistance-conferring rpoB-gene mutations, the combination of meropenem and amoxicillin/clavulanate with rifampin has greater early bactericidal activity (EBA) than the combination of meropenem and amoxicillin/clavulanate without rifampin. Funding Source- FDA OOPD.

Detailed description:
This is a proof-of-concept study to determine whether, in humans infected with M. tuberculosis that is resistant or susceptible to rifampin based on conventional drug susceptibility testing, the combination of meropenem, amoxicillin/clavulanate, and rifampin has activity that is sufficiently promising to proceed with further drug development along these lines. Rifampin has an incompletely understood but critical role in eradication of M. tuberculosis persisters and consequently the shortening of the duration of treatment for 'rifampin susceptible' tuberculosis (TB). For Multi-Drug Resistant (MDR) / Extensively Drug Tuberculosis (XDR) TB, the ability to recoup rifampin's antituberculosis activity through rational combination with a carbapenem and a β-lactamase inhibitor with or without amoxicillin could transform the treatment of this disease.

This proof-of-concept study is designed such that a negative outcome would refute the hypothesis that the combination of a carbapenem and amoxicillin/clavulanate with rifampin will have greater activity than either component alone against M. tuberculosis strains having Minimum Inhibitory Concentrations (MIC) in the range considered resistant to rifampin. A positive study outcome would catalyze further research to identify optimal dosing strategies for all regimen components as well as development of carbapenems optimized for TB treatment with respect to targets of activity, stability against hydrolysis, and oral formulation.

The study hypothesis cannot be tested satisfactorily in traditional animal models of tuberculosis chemotherapy due to the rapid inactivation of carbapenems (as well as other beta-lactams) by dehydropeptidases that are expressed at high levels in mouse, rabbit, and guinea pig tissues. However, all of the study drugs are Food and Drug Administration (FDA) -approved for various infectious disease indications, are in routine clinical use, and have good safety profiles, such that proceeding with the proposed clinical trial based on in vitro data is justified.

This study will also characterize the relationship between meropenem exposure (in combination with amoxicillin/clavulanate) and early bactericidal activity in order to identify the pharmacokinetic drivers of activity and pharmacokinetic targets for desired effects. This will inform the identification of more feasible meropenem dosing strategies in the near term, as well as the dose selection for novel oral carbapenems that may be available for tuberculosis treatment in the future. The proportion of the dosing interval for which free drug concentrations exceed MIC (T\>MIC) is the pharmacokinetic (PK) / pharmacodynamic(PD) parameter most closely correlated with efficacy of carbapenems against common fast-growing bacteria such as Enterobacteriaceae that cause infections for which meropenem is currently approved. A commonly accepted target for efficacy in these infections is 40% T\>MIC, which requires multiple daily doses to achieve. Whether this PK/PD parameter and target value is optimal for carbapenem treatment of infections with M. tuberculosis, which has a much longer doubling time, is unknown. In the trial by Diacon et al, meropenem 2 grams thrice daily plus amoxicillin/clavulanate resulted in a median T\>MIC of 76% \[90% Confidence Interval (CI): 66-93\] whereas faropenem sodium 600 mg thrice daily plus amoxicillin/clavulanate resulted in T\>MIC of 13% (90% CI: 0-33), indicating that if T\>MIC is the single parameter most strongly linked to efficacy in tuberculosis, then the target for bactericidal effect is between 13% and 76%, and lower and/or less frequent doses (or use of oral carbapenems with lower bioavailability) may still have significant efficacy. If T\>MIC is not the efficacy-linked PK/PD parameter, less frequent administration of the same total dose is likely to remain equally effective.

Arms:
arm 1: Participants with the presence of rifampin resistance-conferring rpoB mutations in M. tuberculosis who will receive RIFAMPIN 20mg/kg once daily (QD), MEROPENEM 2 grams (G) thrice daily (TID) intravenously, Amoxicillin/Clavulanate Potassium 500 milligrams (MG)-125 MG Oral Tablet once daily for 14 days arm 2: Participants with the presence of rifampin resistance-conferring rpoB mutations in M. tuberculosis who will receive MEROPENEM 2 grams TID (thrice daily) intravenously, Amoxicillin/Clavulanate Potassium 500 MG-125 MG Oral Tablet once daily for 14 days arm 3: Participants without the presence of rifampin resistance-conferring rpoB mutations in M. tuberculosis who will receive RIFAMPIN 20mg/kg once daily, MEROPENEM 2 grams TID (thrice daily) intravenously, Amx/Clv orally at a dose of 500 mg/125 mg thrice daily for 14 days arm 4: Participants without the presence of rifampin resistance-conferring rpoB mutations in M. tuberculosis who will receive MEROPENEM 2 grams TID intravenously, Amoxicillin/Clavulanate Potassium 500 MG-125 MG Oral Tablet once daily for 14 days arm 5: Participants without the presence of rifampin resistance-conferring rpoB mutations in M. tuberculosis who will receive MEROPENEM 1 gram TID intravenously, Amoxicillin/Clavulanate Potassium 500 MG-125 MG Oral Tablet once daily for 14 days arm 6: Participants without the presence of rifampin resistance-conferring rpoB mutations in M. tuberculosis who will receive MEROPENEM 3 grams QD intravenously, Amoxicillin/Clavulanate Potassium 875 MG-125 MG Oral Tablet once daily for 14 days

Interventions: intervention 1: Rifampin intervention 2: MEROPENEM 2 grams TID intervention 3: MEROPENEM 1 gram TID intervention 4: MEROPENEM 3 grams QD intervention 5: Amoxicillin/Clavulanate Potassium 500 MG-125 MG Oral Tablet intervention 6: Amoxicillin/Clavulanate Potassium 875 MG-125 MG Oral Tablet
Intervention descriptions: intervention 1: Oral administration of rifampin at a dosage of 20 mg/kg daily intervention 2: Intravenous administration at a dosage of 2 grams thrice daily intervention 3: Intravenous administration at a dosage of 1 gram thrice daily intervention 4: Intravenous administration at a dosage of 3 grams once daily intervention 5: Amx/Clv will be administered orally at a dose of 500 mg/125 mg thrice daily intervention 6: Amx/Clv will be administered orally at a dose of 875 mg/125 mg once daily

Protocol document:
Prot_SAP_000.pdf: 
PI:  KE Dooley, A Diacon 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724         
         Version 3.0, 08 November 2016 
Page 1 of 48
A Phase 2a Study of the Early Bactericidal Activity of Rifampin in 
Combination with Meropenem plus Amoxicillin/Clavulanate Among Adults 
with Rifampin-Resistant or Rifampin-Susceptible Pulmonary Tuberculosis 
FDA Protocol No: 
FD-R-05724 
Protocol Chairs:  
Kelly E. Dooley – Johns Hopkins University 
Andreas Diacon – Stellenbosch University 
Protocol Co-Chair: 
Eric Nuermberger – Johns Hopkins University 
Funding Source: 
Office of Orphan Products Development Grants Program of the U.S. Food & 
Drug Administration under grant R01FD005724  
Version Number 3.0 
08 November 2016 
NCT03174184


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 2 of 48 
 
 
STUDY TEAM 
Investigators 
 
Kelly E. Dooley, MD, PhD (Protocol Chair) 
Associate Professor of Medicine, Pharmacology & Molecular Sciences 
Divisions of Clinical Pharmacology and Infectious Diseases 
Johns Hopkins University Center for Tuberculosis Research 
600 N. Wolfe Street, Osler 527 
Baltimore, MD 21287 
Phone 443-287-0517 
Fax 410-614-9978 
Email kdooley1@jhmi.edu 
 
Andreas Diacon, MD (Protocol Chair) 
Task Applied Science and Stellenbosch University 
PO Box 19063 
Tygerberg, 7505 
South Africa 
Phone: +27-21-938-9392 
FAX: +27-21-938-9476 
E-Mail: ahd@sun.ac.za 
Eric Nuermberger, MD (Protocol co-Chair) 
Associate Professor of Medicine and International Health 
Johns Hopkins University Center for Tuberculosis Research 
1550 Orleans Street 
Baltimore, MD 21231 
Phone 410-502-0580 
Fax 410-614-8173 
Email enuermb@jhmi.edu 
 
Susan E. Dorman, MD (Investigator) 
Professor of Medicine and International Health 
Johns Hopkins University Center for Tuberculosis Research 
1550 Orleans Street, Room 1M-06 
Baltimore, MD 21231 
Phone 410-502-2717 
Fax 410-955-0740 
Email dsusan1@jhmi.edu 
 
 
 
 
 
 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 3 of 48 
 
 
Sub-Investigators 
 
Gyanu Lamichhane, PhD (Sub-Investigator) 
Associate Professor of Medicine 
Johns Hopkins University Center for Tuberculosis Research 
1550 Orleans Street 
Baltimore, MD 21231 
Phone 410-929-4760 
Fax 410-614-8173 
Email treat@jhu.edu 
Nikhil Gupte, MSc, MPhil, PhD (Biostatistician) 
Center for Global Health and Education, Johns Hopkins University School of Medicine & 
BJ Medical College and Sassoon General Hospitals 
Jai Prakash Narayan Road 
Pune, India 411001 
Phone +91 98220-70853 
Email ngupte1@jhmi.edu 
 
Grace L. Barnes, RN, MSN, MPH (Study Coordinator) 
Johns Hopkins University Center for Tuberculosis Research 
1550 Orleans Street 
CRB-2, 1M 
Baltimore, MD 21287-0014 
Phone 410-925-1116 
Email glbarnes@jhmi.edu 
 
 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 4 of 48 
 
 
TABLE OF CONTENTS 
 
 
Page 
Study Team 
2 
Table of Contents 
4 
1 Protocol Summary 
6 
2 Study Goal and Objectives 
9 
2.1 Goal 
9 
2.2 Primary Objectives 
9 
2.3 Secondary Objectives 
9 
3 Introduction 
10 
3.1 Scientific Background 
10 
3.2 Study Rationale 
13 
3.3 Rationale for selection of doses and regimens 
14 
3.4 Potential risks and benefits 
15 
4 Study Drugs 
16 
4.1 Rifampin 
16 
4.2 Meropenem 
17 
4.3 Amoxicillin/clavulanate 
18 
5 Design 
20 
5.1 Treatment Regimens 
20 
5.2 Endpoints 
20 
5.3 Randomization 
21 
6 Population 
22 
6.1 General Considerations 
22 
6.2 Special Populations 
22 
6.3 Eligibility Criteria 
22 
7 Study Schedule 
24 
7.1 Screening Visit 
24 
7.2 Enrollment (Day -1) 
24 
7.3 Day 0 
25 
7.4 Study Days 1, 2, 3, and 4 
25 
7.5 Study Days5, 6, 7, 8, 9, 10, 11, and 12 
25 
7.6 Study Day 13 
26 
7.7 Study Day 14 
26 
7.8 Study Day 15 
26 
7.9 Study Day 28 
26 
7.10 Early Withdrawal 
27 
8 Study Treatment 
28 
8.1 Regimens, Administration, and Duration 
28 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 5 of 48 
 
8.2 Study Product Formulation and Preparation 
28 
8.3 Study Product Accountability 
29 
8.4 Concomitant Medications 
29 
8.5 Adherence Assessment 
29 
9 Study Procedures 
30 
9.1 Informed Consent Process 
30 
9.2 Clinical and Laboratory Evaluations 
30 
9.3 Compensation of Study Participants 
32 
10 Assessment of Safety and Tolerability 
33 
10.1 Safety and tolerability endpoints 
33 
10.2 Safety Evaluation 
33 
10.3 Study Treatment Discontinuation Criteria 
33 
10.4 Adverse Events 
33 
10.5 Clinical Management of Adverse Events 
36 
11 Data Analysis and Statistical Considerations 
37 
11.1 Hypotheses 
37 
11.2 Data Analysis 
37 
11.3 Sample Size 
38 
12 Pharmacology Study Design 
39 
12.1 Methods and Timing for Assessing, Recording, and Analyzing 
PK Outcome Measures 
39 
12.2 PK Evaluations 
39 
12.3 PK Blood Collection, Processing, Storage 
39 
12.4 Laboratory Performing the Assays 
39 
13 Human Subjects Protection 
40 
13.1 Institutional Review Board Involvement 
40 
13.2 Informed Consent 
40 
13.3 Confidentiality 
40 
13.4 Special Populations 
40 
13.5 Ethical Issues in Doing this Trial in South Africa 
41 
13.6 Future Use of Stored Specimens 
41 
14 Monitoring and Data Handling 
42 
15 References 
43 
Appendix A: Schedule of Events 
47 
 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 6 of 48 
 
1 
PROTOCOL SUMMARY 
Title: 
A Phase 2a Study of the Early Bactericidal Activity of Rifampin in Combination with 
Meropenem plus Amoxicillin/Clavulanate Among Adults with Rifampin-Resistant or 
Rifampin-Susceptible Pulmonary Tuberculosis 
 
Goal: 
The overall goal of this exploratory proof-of-concept study is to determine whether, in 
participants with pulmonary tuberculosis caused by M. tuberculosis with or without 
rifampin resistance-conferring rpoB mutations, the combination of meropenem and 
amoxicillin/clavulanate with rifampin has greater early bactericidal activity (EBA) than 
the combination of meropenem and amoxicillin/clavulanate without rifampin.   
 
 
Phase: 
2a 
 
Design: 
Open-label, randomized clinical trial examining the bactericidal activity of meropenem 
plus amoxicillin/clavulanate with versus without rifampin 
 
Population: 
Adults with sputum smear positive pulmonary tuberculosis caused by M. tuberculosis with 
or without rifampin resistance-conferring rpoB mutations 
 
Number of sites: 
 
One enrollment site located in South Africa 
Study duration: 
 
Approximately 30 days for each participant 
Intervention: 
 
 
 
Regimen 
Number 
per arm 
Regimen components 
Rifampin 
resistant 
A 
24 
Rifampin 
Meropenem 
2 grams thrice daily 
Amx/Clv 
B 
16 
- 
Meropenem 
2 grams thrice daily 
Amx/Clv 
Rifampin 
susceptible 
C 
12 
Rifampin 
Meropenem 
2 grams thrice daily 
Amx/Clv 
D 
12 
- 
Meropenem 
2 grams thrice daily 
Amx/Clv 
E 
12 
- 
Meropenem 
1 gram thrice daily 
Amx/Clv 
F 
12 
- 
Meropenem 
3 grams once daily 
Amx/Clv 
Abbreviation:Amx/Clv, amoxicillin/clavulanate 
 
 
Objectives: 
Primary 
• 
Among participants with pulmonary TB caused by M. tuberculosis with or without 
rifampin resistance-conferring rpoB mutations: to estimate the 14-day EBA, based 
on colony forming unit counts, of the combination of meropenem and 
amoxicillin/clavulanate, without versus with rifampin 
 
• 
To compare the magnitude of the effect on 14-day EBA, based on colony forming 
units, of the addition of rifampin to meropenem and amoxicillin/clavulanate in 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 7 of 48 
 
participants with pulmonary TB caused by M. tuberculosis with vs. without 
rifampin resistance-conferring rpoB mutations.  
 
• 
To determine the association between the area under the concentration-time curve 
divided by minimum inhibitory concentration (AUC/MIC) of rifampin and the 
antimycobacterial activity of the study treatments, adjusting for other factors 
known to affect treatment response 
 
• 
To characterize the exposure-response relationship of meropenem (in combination 
with amoxicillin/clavulanate) on 14-day EBA in participants with pulmonary TB 
 
Secondary 
• 
To describe the safety and tolerability of the study regimens, administered for 14 
days 
 
• 
Estimate the 14-day antimycobacterial activity, based on liquid culture time-to-
positivity, of the study treatments 
 
• 
Determine the steady state pharmacokinetics of rifampin and meropenem 
 
• 
Determine the MICs of the study drugs, alone and in combination, for participant’s 
M. tuberculosis isolates 
 
• 
Estimate the 2-day antimycobacterial activity, based on colony forming unit 
counts and also based on liquid culture time-to-positivity 
 
Endpoints: 
Primary 
• 
Mean daily fall in log10CFU of M. tuberculosis per mL sputum over14 days of 
treatment (EBA0-14(CFU) 
 
• 
Steady state PK and PK/PD parameters (including AUC0-24,maximum 
concentration (Cmax), MIC against M. tuberculosis; time above MIC) for 
rifampin and meropenem 
 
Secondary 
• 
Grade 2 or higher drug-related adverse clinical or laboratory events 
 
• 
Change in time-to-positivity in MGIT liquid media over 14 days of treatment 
(EBA0-14(TTP)) 
 
• 
Mean daily fall in log10CFU of M. tuberculosis per mL sputum over2 days of 
treatment (EBA0-2(CFU) 
 
 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 8 of 48 
 
Schema 
 
 
 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 9 of 48 
 
2 
STUDY GOAL AND OBJECTIVES 
2.1 
Goal 
The overall goal of this exploratory proof-of-concept study is to determine whether, in participants 
with pulmonary tuberculosis caused by M. tuberculosis with or without rifampin resistance-
conferring rpoB mutations, the combination of meropenem and amoxicillin/clavulanate with 
rifampin has greater early bactericidal activity (EBA) than the combination of meropenem and 
amoxicillin/clavulanate without rifampin.   
 
2.2 
Primary Objectives 
 
2.2.1 
Among participants with pulmonary TB caused by M. tuberculosis with or without rifampin 
resistance-conferring rpoB mutations: to estimate the 14-day EBA, based on colony forming unit 
counts, of the combination of meropenem and amoxicillin/clavulanate, without versus with 
rifampin 
 
2.2.2 
To compare the magnitude of the effect on 14-day EBA, based on colony forming units, of the 
addition of rifampin to meropenem and amoxicillin/clavulanate in participants with pulmonary TB 
caused by M. tuberculosis with vs. without rifampin resistance-conferring rpoB mutations. 
 
2.2.3 
To determine the association between the area under the concentration-time curve divided by 
minimum inhibitory concentration (AUC/MIC) of rifampin and the antimycobacterial activity of 
the study treatments, adjusting for other factors known to affect treatment response 
 
2.2.4 
To characterize the exposure-response relationship of meropenem (in combination with 
amoxicillin/clavulanate) on 14-day EBA in participants with pulmonary TB 
 
 
2.3 
Secondary Objectives 
 
2.3.1 
To describe the safety and tolerability of the combination of the study regimens, administered for 
14 days 
 
2.3.2 
Estimate the 14-day antimycobacterial activity, based on liquid culture time-to-positivity, of the 
study treatments 
 
2.3.3 
Determine the steady state pharmacokinetics of rifampin and meropenem 
 
2.3.4 
Determine the MICs of the study drugs, alone and in combination, for participant’s M. tuberculosis 
isolates 
 
2.3.5 
Estimate the 2-day antimycobacterial activity, based on colony forming unit counts and also based 
on liquid culture time-to-positivity 
 
 
 
 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 10 of 48 
 
3 
INTRODUCTION 
 
3.1  
Scientific background 
 
3.1.1 
Drug-resistant tuberculosis (TB) as a global health problem: the need for novel treatment regimens 
Mycobacterium tuberculosis has just surpassed HIV as the single greatest killer by an infectious pathogen 
on the planet. The World Health Organization (WHO) estimates that over 9 million new cases and 1.54 
million deaths due to tuberculosis (TB) occurred in 2013 [WHO 2013a and 2013b]. Multidrug-resistant 
(MDR) TB,i.e. TB resistant to isoniazid and rifampin, is a growing public health threat, with an estimated 
480,000 cases in 2013, and extensively drug-resistant (XDR) TB, i.e. TB resistant to isoniazid, rifampin, 
fluoroquinolones, and injectable anti-TB drugs, has been found in every country in which it has been sought 
[WHO 2013b]. TB resistant to all currently available anti-TB drugs is now a reality and threatens a return 
to the pre-antibiotic era [Klopper 2013; Loewenberg 2012; Slomski 2013; Udwadia 2012]. Therapeutic 
options for highly drug-resistant TB are limited in availability, acceptability and efficacy. For example, 
only 1 in 5 patients diagnosed with MDR-TB is started on treatment [WHO 2013b]. Current treatment for 
MDR-TB requires 18-24 months of multidrug therapy, including at least 6 months of an injectable agent, 
and yet is successful in only 48% of patients [WHO 2011; Ahuja 2012].  For select patients, a seven drug 
9-12 month “short course” regimen is now available in some settings [WHO 2016].  Current regimens, 
whether short course or standard duration, for the treatment of highly drug-resistant TB are poorly-tolerated 
and have significant toxicities. Several drugs with novel mechanisms of action recently have been approved 
or are in advanced phase clinical trials, but the drug pipeline is not robust and new drugs must be combined 
with other effective antituberculosis drugs to prevent acquired drug resistance and optimize the likelihood 
of cure.  Therefore improved treatments of drug-resistant TB are critical to improve patient cure rates and 
to alleviate suffering related to the common severe side effects of standard drug-resistant TB regimens. 
 
3.1.2 
Optimizing the use of existing antibiotics is a rational strategy for improving the treatment of drug-
resistant TB. 
There are two approaches that can be taken to developing new treatments for TB and drug-resistant TB.  
The first is the development of new chemical entities with antituberculosis activity but without cross-
resistance to existing antibiotics.  Bedaquiline and delamanid are examples of new chemical entities with 
novel mechanisms of action.  The second approach is the optimization of the use of existing drugs or 
combinations of drugs.  By virtue of rifampin’s unique treatment-shortening effect in modern short-course 
TB regimens, resistance of an infecting M. tuberculosis strain to rifampin is primarily responsible for the 
prolonged treatment duration required to treat MDR-TB.  Strategies that restore rifampin susceptibility, 
even partially, may have important treatment-shortening effects on MDR-TB regimens.   
  
3.1.3 
M. tuberculosis has intrinsic resistance to β-lactam antibiotics 
 
β-lactam antibiotics inhibit bacterial cell wall synthesis by binding to and consequently inactivating the 
transpeptidases that cross-link peptidoglycan chains to form the cell wall.  The antibacterial activity of 
penicillins and cephalosporins are mediated mainly through their inactivation of classical D,D-
transpeptidases.  Historically, β-lactam antibiotics have seldom been considered for TB treatment due to 
the perception that M. tuberculosis is intrinsically resistant to β-lactams due to the constitutive production 
of the chromosomally-encoded broad-spectrum β-lactamase, BlaC.  
 
3.1.4 
Clavulanate stably inactivates M. tuberculosis BlaC β-lactamase 
Clavulanate is a β-lactam drug that functions as a β-lactamase inhibitor.  Clavulanate itself has negligible 
intrinsic antimicrobial activity, but it functions as a suicide inhibitor of β-lactamases by covalently bonding 
to the active site of bacterially-encoded β-lactamases, thereby inactivating those enzymes and restoring the 
antimicrobial activity of β-lactam antibiotics.  Clavulanate is marketed in combination with amoxicillin and 
also in combination with ticarcillin for the treatment of certain bacterial infections.  Clavulanate has been 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 11 of 48 
 
shown to irreversibly inhibit the M. tuberculosis BlaC β-lactamase.  Clavulanate reacts with the BlaC β-
lactamase quickly to form hydrolytically stable, inactive forms of the enzyme [Hugonnet 2007].  
Tazobactam and sulbactam also inhibit the BlaC gene product, but the covalent adduct generated is unstable 
and is hydrolyzed.  Thus, among the FDA-approved β-lactamase inhibitors, clavulanate appears to be the 
most promising with respect to activity against M. tuberculosis.  
 
3.1.5 
Carbapenems, which are relatively poor substrates for the M. tuberculosis BlaCβ-lactamase, have 
intrinsic activity against M. tuberculosis in vitro; this activity is potentiated by clavulanate and 
further potentiated by amoxicillin/clavulanate 
Carbapenems are members of the β-lactam class of antibiotics. However, unlike penicillins and 
cephalosporins, carbapenems are relatively poor substrates for the M. tuberculosis BlaC β-lactamase.  
Meropenem, a carbapenem approved by the FDA for use in certain bacterial infections, has activity against 
M. tuberculosis in vitro, and this activity is potentiated by clavulanate [Hugonnet 2009, Kaushik 2015].  
The combination of meropenem and clavulanate has an observed MIC of < 1 ug/mL against M. tuberculosis, 
sterilizes aerobically grown cultures within 14 days, and has inhibitory activity against anaerobically grown 
cultures used to model a persistent state of M. tuberculosis[Hugonnet 2009].Clavulanate is not available 
for human use except in combination with amoxicillin or ticarcillin.  Gonzalo and Drobniewski recently 
studied 28 M. tuberculosis strains including MDR and XDR strains to assess if meropenem/clavulanate was 
active at concentrations achievable in vivo and to determine whether there was inhibition of 
meropenem/clavulanate activity in the presence of amoxicillin.  They found that the addition of clavulanate 
to meropenem reduced the MIC of meropenem by an average of over 1.8 dilutions, while the addition of 
amoxicillin to meropenem/clavulanate reduced the MIC of meropenem by an average of 3.2 dilutions 
[Gonzalo 2013].  The mechanism is not clear, but may be through inhibition of different transpeptidases by 
meropenem vs. amoxicillin.  Thus, in vitro studies provide rationale for further study of the combination of 
meropenem and amoxicillin/clavulanate for TB treatment. 
3.1.6 
Carbapenems inhibit non-classical L,D-transpeptidases that are critical for M. tuberculosis cell 
wall biosynthesis and bacterial persistence 
Until recently it was thought that D,D-transpeptidases (penicillin binding proteins) were the only enzymes 
involved in the final step of peptidoglycan cell wall biosynthesis.  However, it was recently shown that M. 
tuberculosis contains L,D-transpeptidases that catalyzes3->3 linkages (as opposed to the 4->3 linkages 
catalyzed by classical D,D-transpeptidases) and are critical for cell wall biosynthesis[Gupta 2010; Erdemli 
2012; Schoonmaker 2014].  In M. tuberculosis the majority of transpeptide linkages in the peptidoglycan 
are of the 3->3 type.  Moreover, the M. tuberculosisL,D-transpeptidase is expressed as the organism enters 
the persistent state, with corresponding changes in the structure of the peptidoglycan [Lavollay 2008]. Loss 
of L,D-transpeptidase  activity through mutation leads to reduced survival of M. tuberculosis during the 
chronic phase of infection in mice and increased susceptibility to amoxicillin/clavulanate[Gupta 2010; 
Schoonmaker 2014].Thus, the M. tuberculosis L,D-transpeptidases are an attractive target for drug 
development.  
 
3.1.7 
The combination of meropenem plus amoxicillin/clavulanate has antituberculosis activity in 
humans 
The combination of meropenem plus amoxicillin/clavulanate has entered clinical practice for the treatment 
of highly drug-resistant TB based on the above in vitro data, the general safety and tolerability of these 
three drugs, and the paucity of other therapeutic options.  To date, anecdotal reports and small case series 
support the efficacy and safety/tolerability of meropenem plus amoxicillin/clavulanate in combination with 
other agents in salvage regimens for drug-resistant TB [Yew 1995, Dauby 2011; Paven 2012; Palmero 
2015, De Lorenzo 2013].  De Lorenzo and colleagues reported on an observational case-control study of 
37 MDR/XDR-TB patients treated with meropenem plus amoxicillin/clavulanate in addition to a linezolid-
containing regimen (cases) and 61 controls treated with a linezolid-containing regimen [De Lorenzo 2013].  


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 12 of 48 
 
Five 
of 
37 
(13.5%) 
of 
cases 
had 
adverse 
events 
potentially 
attributed 
to 
meropenem/amoxicillin/clavulanate.  Two of these five cases experienced elevated liver transaminases - 
one patient had successful rechallenge with meropenem/amoxicillin/clavulanate and was able to continue 
this combination without problems, while the other patient experienced worsening of transaminases on re-
challenge and was discontinued from meropenem/amoxicillin/clavulanate.  The three other cases 
experienced diarrhea that did not require drug withdrawal.  In spite of the higher clinical severity of the 
case group treated with meropenem plus amoxicillin/clavulanate, at 3 months the case group had a higher 
proportion of sputum smear converters than controls (28/32 [87.5%] vs. 9/16 [56.3%], p=0.02) and a higher 
proportion of culture converters (31/37 [83.8%] vs. 15/24 [62.5%], p=0.06).  
 
Diacon and colleagues recently conducted a randomized controlled study of the 14-day early bactericidal 
activity of meropenem plus amoxicillin/clavulanate in adults with newly diagnosed sputum smear-positive 
drug-susceptible pulmonary TB[Diacon, 2016].  Participants randomized to the meropenem plus 
amoxicillin/clavulanate arm received meropenem 2 grams thrice daily by intravenous bolus, with 
amoxicillin 500 mg/clavulanate 125 mg administered orally thrice daily, for 14 days.  Participants 
randomized to the control arm received standard antituberculosis therapy with daily oral isoniazid, rifampin, 
pyrazinamide, and ethambutol according to South African National Treatment Programme guidelines.  
Meropenem plus amoxicillin/clavulanate reduced the mean mycobacterial load by 0.11 (95% CI 0.09 to 
0.13) log10colony forming units per mL of sputum per day and thereby exhibited robust 14-day early 
bactericidal activity (reference control regimen reduced mean mycobacterial load by 0.17 (95% CI 0.15 to 
0.19)).  Mild diarrhea that did not require dose adjustment was the most common adverse event among 
participants receiving meropenem plus amoxicillin/clavulanate regimen (10/15 [67%] participants).  
Despite proof-of-concept having been achieved, thrice daily intravenous meropenem administration is 
unlikely to be feasible in most settings of tuberculosis clinical care.  Less frequent dosing of meropenem or 
another carbapenem suitable for intramuscular injection would increase feasibility significantly.  A 
carbapenem formulated for oral administration would have the greatest impact on feasibility provided 
adequate drug exposures can be reached.  To this end, Diacon et al also randomized participants in another 
arm of the same trial to receive faropenem sodium 600 mg with amoxicillin 500 mg/clavulanate 125 mg, 
each administered orally thrice daily, for 14 days.  In contrast to meropenem, faropenem plus 
amoxicillin/clavulanate did not reduce the mean mycobacterial load at all (0.00, 95% CI 0.09 to 0.13 log10 
colony forming units per mL of sputum per day).  A better understanding of the pharmacokinetic drivers of 
activity and the optimal as well as minimal pharmacokinetic targets may inform the development of more 
feasible meropenem dosing strategies in the short term, as well as appropriate dosing strategies for novel 
oral carbapenems used for tuberculosis treatment in the medium and longer term. 
3.1.8 
The Combination of a Carbapenem plus Beta-Lactamase Inhibitor Restores the Activity of 
Rifampin Against ‘Rifampin-Resistant’ M. tuberculosis in vitro 
Lamichhane and colleagues recently conducted a series of studies aimed at establishing whether 
carbapenems plus isoniazid or rifampin exhibited synergy, antagonism, or indifference in vitro against M. 
tuberculosis [Kaushik 2015].  Using checkerboard titration assays, the combination of meropenem and 
rifampin exhibited synergy against drug-susceptible M. tuberculosis strains, with a fractional inhibitory 
concentration (FIC) index of 0.4.  Moreover, the MIC of rifampin against multiple rifampin-resistant M. 
tuberculosis strains was at least 10-100 times lower in the presence of a sub-inhibitory concentration of 
meropenem (Table 1).  


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
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The rifampin and meropenem concentrations are readily achievable clinically.  For example a 600 mg oral 
dose of rifampin typically achieves a free drug level of approximately 1.5 µg/mL. 
3.2 
Study rationale 
This is a proof-of-concept study to determine whether, in humans infected with M. tuberculosis that is 
resistant or susceptible to rifampin based on conventional drug susceptibility testing, the combination of 
meropenem, amoxicillin/clavulanate, and rifampin has activity that is sufficiently promising to proceed 
with further drug development along these lines.  Rifampin has an incompletely understood but critical role 
in eradication of M. tuberculosis persisters and consequently the shortening of the duration of treatment for 
‘rifampin susceptible’ TB.  For MDR-/XDR-TB, the ability to recoup rifampin’s antituberculosis activity 
through rational combination with a carbapenem and a β-lactamase inhibitor with or without amoxicillin 
could transform the treatment of this disease.   
This proof-of-concept study is designed such that a negative outcome would refute the hypothesis that the 
combination of a carbapenem and amoxicillin/clavulanate with rifampin will have greater activity than 
either component alone against M. tuberculosis strains having MICs in the range considered resistant to 
rifampin.  A positive study outcome would catalyze further research to identify optimal dosing strategies 
for all regimen components as well as development of carbapenems optimized for TB treatment with respect 
to targets of activity, stability against hydrolysis, and oral formulation.   
The study hypothesis cannot be tested satisfactorily in traditional animal models of tuberculosis 
chemotherapy due to the rapid inactivation of carbapenems (as well as other beta-lactams) by 
dehydropeptidases that are expressed at high levels in mouse, rabbit, and guinea pig tissues.  However, all 
of the study drugs are FDA-approved for various infectious disease indications, are in routine clinical use, 
and have good safety profiles, such that proceeding with the proposed clinical trial based on in vitro data is 
justified.   
This study will also characterize the relationship between meropenem exposure (in combination with 
amoxicillin/clavulanate) and early bactericidal activity in order to identify the pharmacokinetic drivers of 
activity and pharmacokinetic targets for desired effects.  This will inform the identification of more feasible 
meropenem dosing strategies in the near term, as well as the dose selection for novel oral carbapenems that 
may be available for tuberculosis treatment in the future. The proportion of the dosing interval for which 
free drug concentrations exceed MIC (T>MIC) is the PK/PD parameter most closely correlated with efficacy 
of carbapenems against common fast-growing bacteria such as Enterobacteriaceae that cause infections for 
which meropenem is currently approved.  A commonly accepted target for efficacy in these infections is 
40% T>MIC, which requires multiple daily doses to achieve.  Whether this PK/PD parameter and target value 
is optimal for carbapenem treatment of infections with M. tuberculosis, which has a much longer doubling 
time, is unknown.  In the trial by Diacon et al, meropenem 2 grams thrice daily plus amoxicillin/clavulanate 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
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resulted in a median T>MIC of 76% (90% CI: 66-93) whereas faropenem sodium 600 mg thrice daily plus 
amoxicillin/clavulanate resulted in T>MIC of 13% (90% CI: 0-33), indicating that if T>MIC is the single 
parameter most strongly linked to efficacy in tuberculosis, then the target for bactericidal effect is between 
13% and 76%, and lower and/or less frequent doses (or use of oral carbapenems with lower bioavailability) 
may still have significant efficacy.  If T>MIC is not the efficacy-linked PK/PD parameter, less frequent 
administration of the same total dose is likely to remain equally effective. 
3.3 
Rationale for selection of doses and regimens 
For this proof-of-concept clinical trial that is based on in vitro data and the recently demonstrated EBA of 
the combination of meropenem with amoxicillin/clavulanate, the selection of regimens and study drug 
doses aims to balance answering the key scientific question expeditiously and reducing risk.  For 
participants with drug-resistant TB, the number of regimens has been restricted intentionally to the 
minimum required to determine whether or not, and to what degree, rifampin efficacy can be restored by 
combining high-dose rifampin with a potent carbapenem while reducing as best as possible the potential 
risk to study participants (in whom initiation of definitive treatment for tuberculosis will be delayed) and 
to study staff (since some participants will have drug-resistant TB).  Accordingly, the dose of meropenem 
(2 grams every 8 hours) is that which has already been shown to have measurable, significant activity 
against M. tuberculosis when administered in combination with amoxicillin/clavulanate to patients with 
TB; the dose of 2 grams every 8 hours has regulatory approval for non-TB indications.  The dose of 
rifampin, 20 mg/kg daily, chosen for this study is based on recent clinical trials in drug-susceptible TB and 
substantial routine clinical practice demonstrating that this dose is safe and well-tolerated [Boeree 2015].  
Further, the EBA of 1200 mg of rifampin is measurable and higher than that of 600 mg in patients with 
drug-susceptible TB [Diacon 2007; Boeree 2015].  The tolerability of rifampin at doses higher than 20 
mg/kg daily is not well-established.  Clinical trials have also shown supraproportional increases in exposure 
with increases in rifampin dose, such that doubling the rifampin dose increases drug concentrations 3- to 4-
fold.  According to experiments performed in a validated in vitro pharmacodynamics system (hollow fiber) 
model, a rifampin AUC/MIC of 24 h*mg/L is the target that maximizes bacterial kill.  The median steady-
state AUC0-24 for rifampin at a dose of 600 mg is 26 h*mg/L (range 21-41) and it is 113 h*mg/L (range 78-
162) for a dose of 1200 mg [Boeree 2015].  With a co-administered cell wall synthesis inhibitor, cell wall 
permeability may theoretically increase, resulting in even higher intracellular concentrations.  It is also 
known that rifampin has a prolonged post-antibiotic effect. In the current study, if a rifampin dose of 10 
mg/kg were selected but did not augment the activity of meropenem and amoxicillin/clavulanate against 
M. tuberculosis isolates with rpoB mutations and phenotypic resistance, then there would remain legitimate 
uncertainty as to whether the negative result was simply due to insufficient rifampin dose and exposure – 
an issue that could be overcome with relative ease. Even with a single dose level of rifampin, exposures 
will be highly variable, and the MIC range for isolates from patients with drug-susceptible and drug-
resistant TB will range widely, allowing for robust PK-PD analyses.  The dose of amoxicillin/clavulanate 
(500 mg/125 mg) three times daily has regulatory approval for other non-TB indications and is used widely 
in routine clinical practice with a good safety record; this dose in combination with meropenem has been 
shown to have substantial EBA against M. tuberculosis [Diacon 2016].  In this study 
amoxicillin/clavulanate is used mainly for the beta-lactamase inhibition conferred by clavulanate, which is 
not currently available as a single component drug for use in humans.  However, the exposure of study 
participants to concomitant amoxicillin is justified by a) in vitro data showing that the addition of 
amoxicillin to meropenem/clavulanate reduces the minimum inhibitory concentration of meropenem 
substantially beyond that of clavulanate alone [Gonzalo 2013], and b) considerable clinical experience with 
the use of meropenem with amoxicillin/clavulanate for treatment of highly drug-resistant TB.  
Additionally, this study will characterize the relationship between meropenem exposure (in combination 
with amoxicillin/clavulanate) and early bactericidal activity in order to identify the PK/PD parameter most 
closely linked to efficacy and target parameter value for the desired effect.  In participants with drug-


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
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susceptible TB, the combination of meropenem plus amoxicillin/clavulanate (without rifampin) will be 
administered intravenously at three different dosages: meropenem two grams thrice daily, meropenem one 
gram thrice daily, and meropenem three grams once daily.  To identify the PK/PD parameter most closely 
linked to efficacy, the same three gram total daily dose will be administered as three grams once daily or 
as one gram thrice daily.  The dose fractionation methodology will enable a quantitative analysis to 
determine which PK/PD parameter is most closely correlated with EBA.  The dose-ranging thrice daily 
arms will enable a quantitative analysis to determine the target value of that parameter associated with 
bactericidal effect.  These results will inform the identification of more feasible dosing strategies for 
meropenem (e.g. 3 grams once daily) and other marketed carbapenems for tuberculosis patients in the near 
term, as well as the dosage selection for novel oral carbapenems that may be available for tuberculosis 
treatment in the future.   As described below, meropenem dosages of 2 grams thrice daily and 1 gram thrice 
daily are approved by the US FDA for certain indications.  Once daily administration of meropenem 3 
grams is investigational, and there is limited published information on use of this dosage for treatment of 
respiratory infections in adults [Etemadi 2011, Darley 2000].  
3.4 
Potential Risks and Benefits 
There are several potential risks to study participants.  There is a risk of clinically significant TB disease 
progression while on investigational study drugs.  To reduce this risk, severely ill individuals will not be 
enrolled in this study, and in addition the investigational treatment is restricted to 14 days.  There is a risk 
of toxicity of the investigational drugs.  To reduce this risk, eligibility parameters are such that individuals 
having meaningfully abnormal results for key hematology and/or chemistry parameters will not be enrolled. 
In addition, participants will be monitored closely for adverse events.  There are minimal medical risks 
associated with drawing blood and obtaining sputum.   
There is no direct benefit to study participants.  This study will benefit society by contributing to the 
understanding of optimal strategies for treatment of TB.   
 
 
 
 
 
 
 
 
 
 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
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4 
STUDY DRUGS 
 
4.1 
Rifampin 
 
Rifampin is a semi-synthetic rifamycin derivative that is highly active against mycobacteria, most gram-
positive bacteria, and some gram-negative bacteria. It is bactericidal for both intracellular and extracellular 
microorganisms. By inhibiting prokaryotic DNA-dependent RNA polymerase, it suppresses the early 
elongation of the nucleotide chain in RNA synthesis. 
 
Dose and indications: Rifampin is indicated in the treatment of all forms of tuberculosis [Rifadin package 
insert]. The recommended dose of rifampin for the treatment of TB in adults is 10 mg/kg in a single daily 
administration, not to exceed 600 mg/day.  Higher doses of rifampin (900 mg daily to 1200 mg daily) have 
been used in other infections such as brucellosis, leishmaniasis, legionnaires’ disease, and bone/joint 
infections without apparent safety or tolerability problems [Solera 1995; Kochar 2000; Edelstein 1984; 
Kissling 1981; Zimmerli 2004]. Higher doses of rifampin, up to 35 mg/kg daily, are under investigation for 
treatment of tuberculosis based on in vitro, animal, and clinical trial evidence that higher doses of rifampin 
may be more effective against M. tuberculosis [Gumbo 2007; Jayaram 2003; Rosenthal 2012;Jindani 1980; 
Jindani 2003; Diacon 2007; Ruslami 2007; Boeree 2015].  Rifampin is available in 150 mg or 300 mg 
capsules. In this study, rifampin will be provided at a dose of 20 mg/kg daily. 
 
Pharmacokinetics:  After 1.5 to 2 hours, a 600 mg dose yields a peak blood level of 6-10 mg/L, while a 
1200 mg dose yields a Cmax of 16-32 mg/L [Boeree 2015].  The steady-state AUC0-24 for rifampin at a dose 
of 600 mg is 26 h*mg/L (range 21-41) and it is 113 h*mg/L (range 78-162) for a dose of 1200 mg.  Rifampin 
is normally absorbed completely when taken orally, but food delays absorption. The half-life of rifampin 
varies from 2 to 5 hours, and it is shortened by approximately 20-40% after the first week of daily treatment 
because of the induction of hepatic microsomal enzymes. The half-life is unaffected by renal impairment 
but is increased by liver disease or biliary obstruction. Rifampin is deacetylated to an enterohepatically 
recirculated active metabolite, and 50% to 60% is excreted in the feces. Up to 30% of a dose is excreted in 
the urine. Approximately 85% of circulating rifampin is bound to plasma proteins, and is widely distributed 
throughout the body.  
 
Drug-drug interactions:  Rifampin is an inducer of a number of hepatic enzymes involved in the 
metabolism of drugs and some hormones. This enzyme induction causes more rapid elimination (and 
potential loss of efficacy) of many drugs. Medications for which concomitant rifampin is contraindicated 
include: HIV-1 protease inhibitors (other than ritonavir), delavirdine, cyclosporine, tacrolimus, 
itraconazole, and ketoconazole. For many other medications, the dose can be increased to compensate for 
the effect of rifampin. 
 
Toxicity and Tolerability:  In the usual daily dose of 600 mg, rifampin is well tolerated. It often causes 
harmless but disconcerting red-orange discoloration of tears, sweat, saliva, feces, and urine. Less than 4% 
of TB patients experience significant adverse reactions to rifampin. Gastrointestinal AEs are the most 
common, and they include epigastric distress, anorexia, nausea, vomiting, cramps, and diarrhea. Hepatitis 
rarely occurs in persons who have normal baseline hepatic function. The incidence of hepatitis may be 
increased for older persons and those who have chronic liver disease or alcoholism, but remains 
substantially lower than that for pyrazinamide or isoniazid. Rifampin administered intermittently can cause 
a flu-like syndrome of fever, chills, and myalgia, although this is uncommon using the 600 mg dose given 
daily. In a very small proportion of patients the flu-like syndrome is associated with interstitial nephritis, 
acute tubular necrosis, thrombocytopenia, hemolytic anemia, and shock. There may be changes in 
menstruation.  For the treatment of tuberculosis, a rifampin dose of 20 mg/kg daily administered for 5 days 
was safe and well-tolerated (Diacon 2007).  A recent dose-ranging trial showed that two weeks of rifampin 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
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up to 35 mg/kg daily (the highest dose studied) was safe and well-tolerated (Boeree 2015); preliminary data 
from a study using a dose of 35 mg/kg daily for 12 weeks similarly showed that this dose was safe and 
well-tolerated (personal communication, M. Boeree).   
 
4.2 
Meropenem 
 
Meropenem is a broad-spectrum carbapenem antibiotic that is active against Gram-positive and Gram-
negative bacteria.  Meropenem readily penetrates the cell wall of most Gram-positive and Gram-negative 
bacteria and inhibits cell wall synthesis through inhibition of both classical D, D-transpeptidases as well as 
recently discovered non-classical L, D transpeptidases including those of M. tuberculosis.   
 
Dose and indications: Meropenem is indicated for treatment of complicated skin and skin structure 
infections caused by susceptible bacteria, treatment of complicated appendicitis and peritonitis caused by 
susceptible bacteria, and meningitis caused by susceptible bacteria [Merrem package insert].  The 
recommended dose of meropenem, administered intravenously, is 500 mg given every 8 hours for skin and 
skin structure infections, 1 gram every 8 hours for intra-abdominal infections, and up to 2 grams every 8 
hours for meningitis [Merrem package insert]. Meropenem administered at a dosage of 3 grams once daily 
has been used in a limited number of adults for the treatment of respiratory infections.  Darley and 
colleagues administered meropenem3 grams as a single intravenous dose once every 24 hours, for up to 10 
days, to nine ambulatory adults (4 males and 5 females, average age 60 years) with infective exacerbations 
of bronchiectasis; 8 of 9 patients were effectively treated, and the meropenem is described as being well-
tolerated although no safety information is reported [Darley 2000].   Etemadi and colleagues described the 
use of a once daily intravenous infusion of 3 grams of meropenem for treatment of aspiration pneumonia 
in 31 elderly patients (17 males, 14 females, average age 85 years) in long-term care facilities; this treatment 
was described as being clinically effective and tolerable, although no safety details are provided [Etemadi 
2011]. In the here-in proposed trial, meropenem will be administered by intravenous infusion at the 
approved dosages of 2 grams every 8 hours and 1 gram every eight hours; in addition meropenem will be 
administered at the investigational dose of 3 grams once every 24 hours.   
 
Pharmacokinetics: Meropenem is administered intravenously as an infusion or bolus injection.  Meropenem 
rapidly and substantially penetrates most tissues including pulmonary tissues (Byl 1999).  At the end of a 
30-minute intravenous infusion of a single dose of meropenem in healthy volunteers, mean peak plasma 
concentrations are approximately 23 ug/mL (range 14-26) for a 500 mg dose, and 49 ug/mL (range 39-58) 
for a 1 gram dose.  A 5-minute intravenous bolus injection in healthy volunteers results in mean peak plasma 
concentrations of 45 ug/mL (range 18-65) for a 500 mg dose and 112 ug/mL (range 83-140) for a 1 gram 
dose.  In adults with normal renal function, the elimination half-life of meropenem is approximately one 
hour.  Approximately 70% of the intravenously administered dose is recovered as unchanged meropenem 
in the urine over 12 hours.  Plasma protein binding of meropenem is approximately 2%.  There is one 
metabolite that is microbiologically inactive.  In patients with renal insufficiency the plasma clearance of 
meropenem correlates with creatinine clearance.  There is no detectable effect of liver disease on the 
pharmacokinetics of meropenem. 
 
Drug-drug interactions: Probenecid competes with meropenem for active tubular secretion and inhibits the 
renal excretion of meropenem, leading to substantial increases in the elimination half-life of meropenem 
and in the extent of systemic exposure.  Meropenem may reduce serum levels of valproic acid to 
subtherapeutic levels.  Unlike many other candidate antimycobacterial compounds, meropenem has no 
interactions with rifampin. 
 
Toxicity and Tolerability: Meropenem is contraindicated in patients with known hypersensensitivity to 
other carbapenems and in patients who have demonstrated anaphylactic reactions to beta-lactams.  Seizures 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 18 of 48 
 
and other adverse central nervous system experiences have been reported during meropenem treatment, but 
are rare and have occurred mostly in patients with pre-existing central nervous system disorders or with 
bacterial meningitis and/or renal insufficiency.  During clinical investigations 2904 immunocompetent 
adults were treated with meropenem for infections outside the central nervous system – seizures occurred 
in 20 (0.7%) of patients, all of whom had pre-existing contributing factors including prior history of 
seizures, or central nervous system abnormality and concomitant medications with seizure potential.  
During clinical investigations of 2904 immunocompetent adults the following adverse reactions were 
reported, irrespective of the relationship to therapy with meropenem, in greater than 1.0% of patients:  
diarrhea (4.8%), nausea/vomiting (3.6%), inflammation at the injection site (2.4%), headache (2.3%), rash 
(1.9%), sepsis (1.6%), constipation (1.4%), apnea (1.3%), shock (1.2%), and pruritis (1.2%).  
Pseudomembranous colitis due to Clostridium difficile has been reported with nearly all antibacterial 
agents, including meropenem.   
 
4.3 
Amoxicillin/clavulanate 
 
Amoxicillin/clavulanate (abbreviated as Amx/Clv) is an oral antibacterial combination consisting of 
amoxicillin and clavulanate potassium.  Amoxicillin is a semisynthetic analog of ampicillin.  Amoxicillin 
is susceptible to degradation by beta-lactamases and therefore its clinical spectrum of activity does not 
include organisms which produce these enzymes.  Clavulanate is a beta-lactam that inactivates a wide 
variety of beta-lactamases by blocking the active sites of these enzymes.  Thus, the formulation of 
amoxicillin and clavulanate protects amoxicillin from degradation by beta-lactamases and effectively 
extends the antibiotic spectrum of amoxicillin. 
 
Dose and indications: Amx/Clv is indicated for treatment of lower respiratory tract infections, otitis media, 
and sinusitis caused by beta-lactamase-producing strains of Haemophilus influenza and Moraxella 
catarrhalis, as well as skin and skin structure infections caused by beta-lactamase-producing strains of 
Staphylococcus aureus, Escherichia coli, and Klebsiellaspp; and urinary tract infections caused by beta-
lactamase-producing strains of E. coli, Klebsiella spp., and Enterobacterspp [Augmentin package insert].  
In adults, the recommended dose of Amx/Clv for treatment of severe infections and infections of the 
respiratory tract is one 500 mg tablet (500 mg amoxicillin/125 mg clavulanate) every 8 hours or one 875 
mg tablet (875 mg amoxicillin/125 mg clavulanate) every 12 hours.  For this clinical trial, Amx/Clv will be 
administered at a dose of one 500 mg tablet every 8 hours or one 875 mg tablet once daily, depending on 
treatment assignment.  
 
Pharmacokinetics:  Amoxicillin and clavulanate potassium each are well-absorbed from the gastrointestinal 
tract after oral administration.  While the absorption of clavulanate potassium is greater when taken with 
food relative to the fasted state, the safety and efficacy of the Amx/Clv combination has been established 
in clinical trials where it was taken without regard to food.  Amoxicillin serum concentrations achieved 
with Amx/Clv are similar to those produced by oral administration of equivalent doses of amoxicillin alone.  
After oral administration of Amx/Clv the elimination half-life of amoxicillin is 1.3 hours and that of 
clavulanate potassium is 1.0 hour. Approximately 50-70% of amoxicillin and approximately 25-40% of the 
clavulanate potassium are excreted unchanged in the urine during the first 6 hours after administration. 
Serum protein binding has been estimated at approximately 18% for amoxicillin and approximately 25% 
for clavulanate potassium.  Amoxicillin and clavulanate each diffuse readily into most tissues except brain 
and spinal fluid.  
 
Drug-drug interactions: Probenecid decreases the renal tubular secretion of amoxicillin and can result in 
increased and prolonged blood levels of amoxicillin.  Amx/Clv may reduce the efficacy of oral 
contraceptives. Amx/Clv has no clinically meaningful drug-drug interactions with rifampin.  
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 19 of 48 
 
Toxicity and Tolerability: Amx/Clv is contraindicated in patients with a history of allergic reactions to any 
penicillin and in patients with a previous history of cholestatic jaundice/hepatic dysfunction associated with 
Amx/Clv.  Pseudomembranous colitis due to Clostridium difficile has been reported with nearly all 
antibacterial agents, including Amx/Clv.  Hepatic dysfunction, including severe cholestatic hepatitis, has 
rarely been reported with Amx/Clv.  Amx/Clv is generally well-tolerated.  The majority of side effects 
observed in clinical trials of Amx/Clv were mild and transient; less than 3% of patients discontinued therapy 
because of drug-related side effects.  In the original premarketing studies that included both adults and 
children, the most frequently reported adverse effects were diarrhea/loose stools (9%), nausea (3%), skin 
rashes and urticarial (3%), vomiting (1%), and vaginitis (1%).  Serum sickness-like reactions, erythema 
multiforme, exfoliative dermatitis, hepatitis, interstitial nephritis, and convulsions each have been reported 
with ampicillin-class antibiotics but are rare.  
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
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5 
DESIGN 
 
This will be a prospective, randomized, open label phase 2a clinical trial.  This study will enroll two groups 
of participants, namely participants with the presence of rifampin resistance-conferring rpoB mutations in 
M. tuberculosis(Group 1) and participants without the presence of rifampin resistance-conferring rpoB 
mutations in M. tuberculosis(Group 2).  Within Group 1, participants will be randomized to receive one of 
the two treatment regimens. Within Group 2, participants will be randomized to receive one of the four 
treatment regimens. 
 
5.1 
Treatment Regimens 
 
Thetreatment regimens are shown below.  Regimens A and C are comprised of meropenem plus 
amoxicillin/clavulanate with rifampin.  Regimens B, D, E, and F are comprised of meropenem plus 
amoxicillin/clavulanate without rifampin. 
 
In study arms A, B, C, and D, meropenem will be administered intravenously at a dosage of 2 grams thrice 
daily.  In arms E and F, a total of 3 grams of meropenem will be administered each day; in arm E the 
meropenem will be administered in divided doses (1 gram thrice daily), and in arm F the meropenem will 
be administered as a single once daily dose of 3 grams.  
 
Rifampin will be administered orally at a dose of 20 mg/kg once daily (arms A and C). Amx/Clv will be 
administered orally at a dose of 500 mg/125 mg thrice daily, except in arm F in which Amx/Clv will be 
administered orally at a dose of 875 mg/125 mg once daily. 
 
Study treatment will be administered for 14 days.  Additional details are in Section 8.1. 
 
 
Regimen 
Number 
per arm 
Regimen components 
Rifampin 
resistant 
A 
24 
Rifampin 
Meropenem 
2 grams thrice daily 
Amx/Clv 
B 
16 
- 
Meropenem 
2 grams thrice daily 
Amx/Clv 
Rifampin 
susceptible 
C 
12 
Rifampin 
Meropenem 
2 grams thrice daily 
Amx/Clv 
D 
12 
- 
Meropenem 
2 grams thrice daily 
Amx/Clv 
E 
12 
- 
Meropenem 
1 gram thrice daily 
Amx/Clv 
F 
12 
- 
Meropenem 
3 grams once daily 
Amx/Clv 
Abbreviation: Amx/Clv, amoxicillin/clavulanate 
 
5.2 
Endpoints 
 
5.2.1 
Primary Endpoints 
• 
Mean daily fall in log10CFU of M. tuberculosis per mL sputum over14 days of treatment (EBA0-
14(CFU) 
 
• 
Steady state PK and PK/PD parameters (including AUC0-24, maximum concentration (Cmax), 
MIC against M. tuberculosis; time above MIC) for rifampin and meropenem 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 21 of 48 
 
5.2.2 
Secondary Endpoints 
• 
Grade 2 or higher drug-related adverse clinical or laboratory events 
 
• 
Change in time-to-positivity in MGIT liquid media over 14 days of treatment (EBA0-14(TTP)) 
 
• 
Mean daily fall in log10CFU of M. tuberculosis per mL sputum over2 days of treatment (EBA0-
2(CFU) 
 
5.3 
Randomization  
Participants will be assigned to the ‘Rifampin Resistant’ group (Group 1) or the ‘Rifampin Susceptible’ 
group (Group 2) based on the presence or absence, respectively, of a rifampin resistance-conferring 
mutation identified using Xpert MTB/RIF rapid testing at study screening.  Participants in the Rifampin 
Resistant group will be randomized 3:2 to study arms A and B.  Participants in the Rifampin Susceptible 
group will be randomized 1:1:1:1 to study arms C, D, E, and F.  Randomization will be computer-generated.  
 
Once accrual into a group (i.e. the Rifampin Resistant group or the Rifampin Susceptible group) is 
completed, enrollment into that group will be closed and participants who are found eligible for that group 
based on Xpert MTB/RIF rifampin DST results will not be randomized into the trial.  
 
This will be an open-label trial in which neither the subjects nor the study staff will be blinded as to rifampin 
resistance/susceptibility group status or treatment assignment after randomization.  However, 
microbiologists performing mycobacterial EBA cultures will be blinded both to rifampin 
resistance/susceptibility group status and treatment assignment after randomization.  Statisticians will be 
blinded as to treatment assignment of individual patients. 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 22 of 48 
 
6. 
POPULATION 
 
6.1 General Considerations 
 
Study entry is open to males and females age 18 years to 65 years of any ethnic background who meet study 
eligibility criteria. Historically, approximately 60% of patients with TB at clinical sites are males. The 
gender, ethnicity, and socioeconomic background of study subjects are expected to mirror that of the 
population served by the study site, and that of the population most affected by TB.  Study subjects will be 
recruited from clinics in Cape Town, South Africa.  
 
6.2 Special Populations 
 
6.2.1 
Children, Pregnant Women, and Breast-Feeding Women 
Children will not be enrolled in this exploratory EBA study because of differences in the typical disease 
presentation in children versus adults; study participants must be able to produce a 16-hour sputum 
specimen daily for seven days and few children can do this.  Pregnant women or breast-feeding women will 
not be enrolled since a 14-day delay in initiation of definitive TB treatment could increase the risk of TB 
transmission to the fetus/newborn.  In addition, pregnancy may affect study drug pharmacokinetics and 
introduce a source of variability that cannot be adequately addressed in this small PK and safety study.   
 
6.2.2 
Prisoners 
This study will not enroll prisoners.  
 
6.2.3 
HIV-Positive Individuals  
HIV-infected individuals with CD4 >100 cells/cu mm as well as HIV-uninfected individuals will be 
included in this study.  HIV is a risk factor for TB and drug-resistant TB, and therefore the identification of 
improved TB treatment strategies that can be used in people living with HIV/AIDS is important.  HIV-
infected adults with severe immunosuppression (for this study defined as CD4 < 100 cells/cu mm) and 
concomitant TB have high early mortality rates, and therefore prompt definitive therapy for both TB and 
HIV is warranted; such individuals will not be eligible for study participation.  Rifampin has clinically 
significant drug-drug interactions with some antiretroviral drugs, and thus HIV-infected individuals 
receiving treatment with certain antiretroviral drugs will not be eligible for study participation.  
 
6.3 Eligibility Criteria 
 
6.3.1 
Inclusion criteria for participation in this study 
• 
New or recurrent pulmonary TB with one or both of the following: 
o sputum positive for acid-fast bacilli on direct microscopy of at least grade 1+ 
(International Union Against Tuberculosis and Lung Disease [IUATLD] scale) on at 
least one pre-treatment sputum sample 
 
o sputum positive for M. tuberculosis by Xpert MTB/RIF testing, with semiquantitative 
result of ‘medium’ or ‘high’ on at least one pre-treatment sputum sample 
 
• 
Age ≥18 and ≤65 years at study screening 
 
• 
Ability and willingness to provide informed consent 
 
• 
Body weight 40 kg to 90 kg, inclusive 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
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• 
Laboratory values obtained within 30 days prior to or at study screening: 
o Absolute neutrophil count (ANC) >750 cells/mm3 
o Hemoglobin ≥7.0 g/dL 
o Platelet count ≥50,000/mm3 
o Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤3 X upper 
limit of normal (ULN) 
o Total bilirubin ≤2.5 X ULN 
o Creatinine< 1.5 X ULN 
 
• 
HIV infection must be documented as either absent or present 
 
• 
For HIV-positive candidates only: CD4+ cell count of ≥ 100 cells/cu mm, performed within 30 
days prior to or at study screening 
 
• 
For females of reproductive potential, negative serum or urine pregnancy test within 7 days 
prior to or at study screening. Female participants who are participating in sexual activity that 
could lead to pregnancy must agree to use one reliable non-hormonal method of contraception 
(condoms or an IUD), or another method (diaphragm or cervical cap) if it is approved by the 
national regulatory authority and used according to package insert, while receiving study 
medications.   
 
• 
Willingness to be hospitalized for a minimum of 16 consecutive days 
 
• 
Ability to produce an overnight sputum sample of sufficient quality and quantity.  As a 
guideline, this should be10 ml or more during a 16-hour collection period. Volume is clinically 
estimated from a spot sample provided at screening and verified upon the first overnight 
collection (which can be repeated upon retraining).  
 
• 
Xpert MTB/RIF result performed on sputum within 14 days prior to or at study screening that 
shows EITHER ‘Rifampin resistance detected’ OR ‘Rifampin resistance not detected’.   
 
6.3.2 
Exclusion Criteria 
• 
Treatment with any drug active against M. tuberculosis within the 3 months prior to study 
screening. 
 
• 
Breast-feeding 
 
• 
Known allergy or sensitivity to any of the study drugs 
 
• 
Participants receiving valproate sodium or probenecid 
 
• 
Karnofsky score < 60 OR poor general condition such that, in the opinion of the investigator at 
screening, any delay in initiation of definitive TB treatment cannot be tolerated 
 
• 
Known current neurological TB or seizure disorder 
 
• 
Any condition as determined by physical examination, medical history, laboratory data, or 
chest x-ray which, in the opinion of the investigator, would interfere with safety or endpoint 
assessments in the study. 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 24 of 48 
 
7. STUDY SCHEDULE 
 
Appendix A contains a table of the Schedule of Events. 
 
7.1 Screening Visit 
 
Subjects with a presumptive diagnosis of sputum smear positive pulmonary TB will be invited to 
participate.  
 
Informed written consent, using IRB-approved consent forms, will be obtained by trained study personnel 
prior to performing any study-specific procedures.  Informed consent is a process that will be initiated prior 
to the individual’s agreeing to participate in the study and will continue throughout the individual’s study 
participation.  The informed consent process is described in detail in the “Study Procedures” section.   
 
The screening period will be kept as short as possible, with a maximum duration of 7 days. Enrollment 
sputum collections can be started before all screening results are available.  
 
The following will be performed after obtaining written informed consent: 
• 
Participants will be asked questions related to demographics. 
• 
Medical history 
• 
Medication history 
• 
Assessment of signs, symptoms, and diagnoses 
• 
Complete physical examination 
• 
Height 
• 
Weight 
• 
Karnofsky score 
• 
Complete blood count with differential 
• 
Complete blood chemistry profile 
• 
Pregnancy test (women) 
• 
CD4+ count (HIV-infected participants) 
• 
Chest X-ray (unless results of a chest X-ray performed within 14 days prior to screening are 
available) 
• 
Spot sputum collection for AFB smear microscopy and Xpert MTB/RIF 
• 
Counseling about study procedures 
• 
Hospitalisation (at the discretion of the investigator) 
 
7.2 
Enrollment (Day -1) 
 
Procedures to be performed at Enrollment: 
• 
Concomitant medication assessment / review of eligibility criteria with respect to medication use 
• 
Enrollment of individuals who meet eligibility criteria 
• 
Assignment to Group 1 (rifampin resistant) or Group 2 (rifampin susceptible)* 
• 
Randomization* 
• 
Hospitalization 
• 
Spot sputum collection for culture, with cultivated M. tuberculosis then tested using a commercially 
available rapid molecular test for resistance/susceptibility to isoniazid, rifampin, fluoroquinolones, 
and second-line injectable drugs; b) phenotypic DST; c) MIC determination 
• 
Overnight sputum collection 
• 
Counseling about study procedures 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 25 of 48 
 
 
Participants who do not meet eligibility criteria or are not enrolled will be referred to a local source of TB 
care.  *Group assignment and randomization may be performed either on Day -1 or on Day 0, depending 
on when rifampin resistance results are available.  
 
7.3 Day 0 
 
The participant will remain hospitalized.  Procedures to be performed on Day 0: 
• 
Group assignment and randomization, if not already performed on Day -1 
• 
Targeted physical examination 
• 
Weight 
• 
Assessment of signs, symptoms, and diagnoses 
• 
Concomitant medication assessment 
• 
Pregnancy test (women) 
• 
Overnight sputum collection 
• 
Counseling about study procedures 
• 
Blood and urine retention sample collection 
 
7.4 Study Days 1, 2, 3, and 4 
 
The participant will remain hospitalized and will receive assigned study treatment starting on Day 1.  The 
following procedures will be performed on each of days 1, 2, 3, and 4: 
• 
Administration of assigned study treatment 
• 
Targeted physical examination 
• 
Weight 
• 
Assessment of signs, symptoms, and diagnoses 
• 
Adverse events assessment 
• 
Concomitant medication assessment 
• 
Overnight sputum collection  
• 
Counseling about study procedures 
• 
IN ADDITION, blood and urine retention sample collection on day 3 
 
7.5 Study Days 5, 6, 7, 8, 9, 10, 11, and 12 
 
The participant will remain hospitalized and will receive assigned study treatment.  The following 
procedures will be performed on each day: 
• 
Administration of assigned study treatment 
• 
Targeted physical examination 
• 
Weight 
• 
Assessment of signs, symptoms, and diagnoses 
• 
Adverse events assessment 
• 
Concomitant medication assessment 
• 
Counseling about study procedures 
• 
IN ADDITION, overnight sputum collection will occur on days 6, 8, 10, and 12 
• 
IN ADDITION, a complete blood count with differential and a complete chemistry profile will be 
performed on day 7 
• 
IN ADDITION, blood and urine retention sample collection on day 7 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 26 of 48 
 
7.6  Study Day 13 
 
The participant will remain hospitalized.  The following procedures will be performed: 
• 
Administration of assigned study treatment 
• 
Targeted physical examination 
• 
Weight 
• 
Assessment of signs, symptoms, and diagnoses 
• 
Adverse events assessment 
• 
Concomitant medication assessment 
• 
Counseling about study procedures 
• 
Pharmacokinetic sampling 
 
7.7 Study Day 14 
 
The participant will remain hospitalized.  The following procedures will be performed: 
• 
Administration of assigned study treatment 
• 
Targeted physical examination 
• 
Weight 
• 
Assessment of signs, symptoms, and diagnoses 
• 
Adverse events assessment 
• 
Concomitant medication assessment 
• 
Pregnancy test (women) 
• 
Complete blood count with differential 
• 
Complete blood chemistry profile 
• 
Overnight sputum collection  
• 
Counseling about study procedures 
• 
Blood and urine retention sample collection 
 
7.8 Study Day 15 
 
The following procedures will be performed: 
• 
Targeted physical examination 
• 
Weight 
• 
Assessment of signs, symptoms, and diagnoses 
• 
Adverse events assessment 
• 
Concomitant medication assessment 
• 
The participant will be discharged from the hospital 
 
7.9 Study Day 28 (Visit window +/- 3 days) 
 
The following procedures will be performed: 
• 
Targeted physical examination 
• 
Weight 
• 
Assessment of signs, symptoms, and diagnoses 
• 
Adverse events assessment 
• 
Concomitant medication assessment 
• 
Complete blood count with differential 
• 
Complete blood chemistry profile 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 27 of 48 
 
7.10 
Early withdrawal 
 
In case of early withdrawal during the study treatment period the following information will be collected 
and procedures performed: 
• 
Targeted physical examination 
• 
Weight 
• 
Assessment of signs, symptoms, and diagnoses 
• 
Adverse events assessment 
• 
Concomitant medication assessment 
• 
Complete blood count with differential 
• 
Complete blood chemistry profile 
• 
Blood and urine retention sample collection 
 
 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 28 of 48 
 
8. STUDY TREATMENT 
 
8.1 Regimens, Administration, and Duration 
 
The treatment regimens are shown below.  Regimens A and C are comprised of meropenem plus 
amoxicillin/clavulanate with rifampin.  Regimens B, D, E, and F are comprised of meropenem plus 
amoxicillin/clavulanate without rifampin.   
 
In study arms A, B, C, and D, meropenem will be administered intravenously at a dosage of 2 grams thrice 
daily, with infusion duration approximately 30 minutes.  In arms E and F, a total of 3 grams of meropenem 
will be administered each day; in arm E the meropenem will be administered in divided doses (1 gram 
thrice daily, infusion duration approximately 30 minutes for each dose), and in arm F the meropenem will 
be administered as a single once daily dose of 3 grams (infusion duration approximately 60 minutes for 
each dose).   
 
Rifampin will be administered orally at a dose of 20 mg/kg once daily (arms A and C only).  
Amx/Clv will be administered orally at a dose of 500 mg/125 mg thrice daily in arms A, B, C, D, and E.  
In arm F, Amx/Clv will be administered orally at a dose of 875 mg/125 mg once daily. 
Oral study drugs will be administered at the time that the meropenem infusion starts.   
 
Study treatment will be administered for 14 days. 
 
 
Regimen 
Number 
per arm 
Regimen components 
Rifampin 
resistant 
A 
24 
Rifampin 
Meropenem 
2 grams thrice daily 
Amx/Clv 
B 
16 
- 
Meropenem 
2 grams thrice daily 
Amx/Clv 
Rifampin 
susceptible 
C 
12 
Rifampin 
Meropenem 
2 grams thrice daily 
Amx/Clv 
D 
12 
- 
Meropenem 
2 grams thrice daily 
Amx/Clv 
E 
12 
- 
Meropenem 
1 gram thrice daily 
Amx/Clv 
F 
12 
- 
Meropenem 
3 grams once daily 
Amx/Clv 
Abbreviation: Amx/Clv, amoxicillin/clavulanate 
 
8.2 Study Product Formulation and Preparation 
 
Rifampin will be supplied as Rifadin® (rifampin capsules USP) by Sanofi-Aventis.   
 
Meropenem will be supplied as Merrem® I.V. (meropenem for injection), 1 gram infusion vials, by 
AstraZeneca.  Infusion vials will be constituted with sodium chloride 0.9%.  Details of constitution are 
provided in the Manual of Procedures.  
 
Amoxicillin/clavulanate will be supplied by GlaxoSmithKline as Augmentin® 500 mg tablets (containing 
500 mg amoxicillin and 125 mg clavulanate) for Arms A, B, C, D, and E and as Augmentin 875 mg 
tablets (containing 875 mg amoxicillin and 125 mg clavulanate) for Arm F. 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 29 of 48 
 
8.3 Study Product Accountability 
 
The site pharmacist will maintain records of all study products received, dispensed to study participants, 
and final disposition of all study products.  These records will include the lot number and expiration date 
as well as the start and stop dates for usage of that lot number.  
 
8.4 Concomitant Medications 
 
The use of all non-study drugs including over-the-counter products from 14 days before study screening to 
completion of the final study visit will be monitored and recorded.   
 
8.4.1 Prohibited Medications 
Use of anti-tuberculosis medications (other than assigned study treatment) is prohibited from screening 
until after the final dose of study medications.  A list of prohibited anti-tuberculosis medications is provided 
in the Manual of Procedures.   
 
Use of the following drugs is prohibited from screening until after the final dose of study medications: 
probenecid, chloramphenicol, macrolide antibiotics, sulfonamides, tetracycline antibiotics, tramadol, 
ketoconazole, antacids. 
 
Antiretroviral drugs are prohibited except for efavirenz, nucleoside reverse transcriptase inhibitors, and 
nucleotide reverse transcriptase inhibitors, which are allowed if, at the time of study screening, the 
participant has already been started on those drugs and is stable on them.  Antiretroviral drugs including 
efavirenz, nucleoside reverse transcriptase inhibitors, and nucleotide reverse transcriptase inhibitors should 
not be newly initiated between screening and the final dose of study medications. 
 
8.5 Adherence Assessment 
 
Study doses will be observed during hospitalization and adherence will be documented by study staff.   
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 30 of 48 
 
9. STUDY PROCEDURES 
 
9.1 Informed Consent Process 
 
Informed written consent, using IRB-approved consent forms, will be obtained by trained study personnel 
prior to performing study-specific procedures.  Potential subjects will receive information about risks and 
possible benefits of study participation, study objectives and procedures, potential toxicities, and the 
informed consent process.  Informed consent requires the signature or mark of the subject.  A copy of the 
signed and dated informed consent document will be given to the subjects for their records.  The rights and 
welfare of the 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 this study, and that they may withdraw consent 
at any time.  Individuals who choose not to participate in the study will be referred to local sources of TB 
care.  
 
9.2 Clinical and Laboratory Evaluations 
 
9.2.1 
Instructions for Clinical Evaluations 
 
Medical History 
The medical history should include clinical diagnoses and events, as well as allergies to 
medications.  
 
Medication History 
TB treatment should be recorded on the CRF.   
 
The following medications, if administered/taken within 14 days prior to study screening, 
should be recorded on the study CRF:  antiretroviral medications, prescription drugs for 
treatment of opportunistic infections, prescription drugs for prophylaxis of opportunistic 
infections, other prescription drugs, alternative therapies, dietary supplements.  
 
Complete Physical Examination 
A complete physical examination will include at a minimum an examination of the skin, head, 
mouth, neck and lymph nodes; auscultation of the chest; cardiac exam; abdominal exam; 
examination of the lower extremities for edema. The complete physical exam will also include 
signs and symptoms, diagnoses, and vital signs (temperature, pulse, respiration rate, and blood 
pressure). 
 
Targeted Physical Examination 
A targeted physical examination will include vital signs (temperature, pulse, respiration rate, 
and blood pressure). The targeted physical examination is to be driven by any previously 
identified or new signs or symptoms, including diagnoses that the participant has experienced 
since the last visit.  
 
Karnofsky Score 
Karnofsky score will be recorded at screening.  
 
Height 
Height will be recorded once at screening.  
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 31 of 48 
 
Weight 
Weight will be recorded at all study visits except as noted in the Schedule of Events.   
 
Signs and Symptoms 
At screening all grades of signs and symptoms that occurred within 7 days prior to screening 
must be recorded.  Post-screening, only signs and symptoms of Grade 2 or higher must be 
recorded.  In addition, all signs and symptoms that lead to a change in study treatment must be 
recorded, regardless of grade.  
 
Diagnoses 
Record all diagnoses identified for clinical events and other diseases.  
 
Concomitant Medications 
All concomitant medications started or stopped since the last study visit must be recorded on 
the CRF.   
 
TB Medications 
Except for assigned study medications, TB treatment should not be administered on Days 0 
through the completion of the overnight sputum collection on Day 15.  After completion of the 
overnight sputum collection on Day 15, and no later than Day 18, the participant should be 
started on TB treatment according to local norms. The start date and initial doses should be 
recorded.   
 
Antiretroviral Medications 
Record all modifications, including start/stop dates, initial doses, participant-initiated and/or 
health care provider-mandated modifications, and any temporary holds or permanent 
discontinuations.  
 
9.2.2 
Instructions for Laboratory Evaluations 
 
Complete Blood Count with Differential 
Complete all values regardless of grade for hemoglobin, platelet count, white blood cell count, 
absolute neutrophil count.  
 
Complete Blood Chemistry Profile 
Record all values regardless of grade for AST, ALT, alkaline phosphatase, total bilirubin, 
creatinine, potassium, and albumin. 
 
CD4+ Count (HIV-infected participants) 
For participants who are HIV-infected, a CD4+ cell count determination performed within 30 
days prior to or at study screening must be recorded.   
 
Pregnancy Test 
For women with reproductive potential: serum or urine beta-HCG.  A urine test, if used, must 
have a sensitivity of 15-25 mIU/mL. 
 
Chest X-ray 
A chest X-ray will be performed at screening, unless the results of a chest X-ray performed 
within 14 days prior to screening are available.  
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 32 of 48 
 
9.2.3 
Instructions for Sputum Samples 
Details of laboratory procedures will be described in the Manual of Operations. 
 
Spot Sputum 
This will be collected under supervision at the study site.  A sample as close to 5 mL should be 
produced if possible.  
 
Overnight Sputum Collection 
Sputum will be collected over approximately 16 hours each night beginning at around 4 pm +/- 
one hour in an appropriate clean container in hospitalized individuals.  This sputum will be 
used for EBA analysis. Start and stop times, sputum volume collected and sputum quality will 
be recorded.  
 
Solid Culture CFU Determination and Liquid MGIT Culture TTP 
For the determination of drug activity, sputum will be cultured on solid medium and CFU 
counts will be determined.  Sputum will also be cultured in MGIT liquid medium using an 
automated detection system; daily TTP, measured in hours, will be performed.  
 
Other Mycobacteriology Testing 
Cultured M. tuberculosis from the Enrollment Day spot sputum or the first positive sputum 
culture will be subjected to drug susceptibility testing using the following methods: a) 
commercially available rapid molecular test that includes testing for isoniazid, rifampin, 
fluoroquinolones, and second-line injectable agents (e.g. Hain Genotype MTBDRplus and 
Genotype MTBDRsl); b) phenotypic rifampin susceptibility test using MGIT culture; and c) 
determination of MICs to study drugs.  DNA sequencing of the M. tuberculosis rpoB gene may 
be performed in order to correlate rpoB mutations with rifampin MICs. 
 
9.2.4 
Pharmacokinetic Sampling 
Details of sampling procedures will be provided in the Manual of Operations.  Blood samples 
for study drug concentrations may be collected from an indwelling catheter, or, if a catheter 
cannot be placed or maintained successfully, by direct venipuncture.  
 
9.2.5 
Blood and urine retention sampling 
The blood and urine retention sampling methodology and requirements will be described in a 
separate document, the Biomarker Manual, which will be provided prior to the trial start. These 
samples will be collected in addition to the trial safety laboratory evaluations on days 0, 3, 7, 
and 14 and Early Withdrawal. The samples will be stored for potential future analysis of 
biomarkers related to tuberculosis and its treatment (e.g. biomarkers as novel surrogate markers 
of efficacy). These samples will not be used for genetic testing. 
 
9.2.6 
Hospitalization 
At the discretion of the investigator, a participant may be hospitalized during the screening 
period if necessary for the safety of the participant or to decrease risk of tuberculosis 
transmission to others.  All participants who receive study treatment will be hospitalized from 
Day -1 to Day 15.  The period from screening to treatment will be kept as short as logistically 
possible to minimize the period of participants remaining without TB treatment.  
 
 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 33 of 48 
 
9.3 Compensation of Study Subjects 
 
Study subjects will be compensated for their time and travel to and from study visits as well as for visits 
and for time spent waiting for results while in hospital.  The form and amount of compensation will be in 
accordance with local guidelines. 
 
 
10. ASSESSMENT OF SAFETY AND TOLERABILITY 
 
10.1 
Safety and Tolerability Endpoints 
 
The primary endpoint for analysis of safety and tolerability is Grade 2 or higher adverse events.   
 
10.2 
Safety Evaluation 
 
A Data and Safety Monitoring Board (DSMB) will review the study protocol and oversee progress of the 
trial.  The DSMB will review safety data once 50% of the participants have completed study treatment. 
Since this is an open-label study, the DSMB will have access to treatment group assignment.  The DSMB 
will be comprised of at least the following: an expert in statistics, an expert in clinical trials, and an expert 
in clinical TB.  No early stopping rules will be formally adopted.   
No interim efficacy analyses are planned for this Phase 2 trial.  
10.3 
Study Treatment Discontinuation Criteria 
 
Participants who prematurely discontinue study treatment after having received one or more doses of 
assigned treatment will be replaced.  
 
Study treatment must be immediately discontinued as a result of the following: 
• 
Withdrawal of informed consent. 
• 
Investigator considers it for safety reasons in the best interest of the participant that study 
treatment be stopped.  
• 
Participant becomes pregnant. 
• 
Termination of the study by the sponsor. 
 
All participants withdrawn from treatment will be referred to the local community TB clinics for standard 
antituberculosis chemotherapy according to National Guidelines. The participants will be provided with a 
referral letter to take with them to the TB Clinic.  Participants will be transported by the study staff to the 
clinic, or a follow-up call will be made by the study site staff to the clinic to determine if the participant 
attended the clinic on the date as arranged. Every effort will be made to continue to follow participants who 
discontinue study medicine prematurely until the final study visit, if they are agreeable. 
 
10.4 
Adverse Events 
 
The Investigators are responsible for eliciting adverse events by observing study participants and recording 
all adverse events observed by him/her or reported by study participants during the trial.   
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 34 of 48 
 
10.4.1 Definitions 
Adverse event (AE):  Any untoward medical occurrence in a study participant administered a 
pharmaceutical product and which does not necessarily have a causal relationship with this treatment. An 
adverse event can therefore be any unfavorable and unintended sign (including an abnormal laboratory 
finding), symptom, or disease temporally associated with the use of a medicinal product, whether or not 
related to the medicinal product. 
 
Serious adverse event (SAE): Any untoward medical occurrence that at any dose: 
• 
results in death; 
• 
is life threatening (any event in which the subject was at risk of death at the time of the event; it does 
not refer to an event, which hypothetically might have caused death if it were more severe); 
• 
requires inpatient hospitalization or prolongation of existing hospitalization; 
• 
results in persistent or significant disability/incapacity;  
• 
is a congenital anomaly/birth defect; or 
• 
is a medically important event. 
Note:  
 
Medical and scientific judgment should be exercised in deciding events are “medically important.”  
These events are those that may not be immediately life-threatening or result in death or hospitalization, 
but may jeopardize the study participant or may require medical or surgical intervention to prevent one 
of the outcomes listed above.  Examples of such events are intensive treatment in an emergency room 
or at home for allergic bronchospasm, blood dyscrasias or convulsions that do not result in 
hospitalization, or the development of drug dependency or drug abuse. 
 
Unexpected Adverse Event (UAE):  An adverse reaction, the nature or severity of which is not consistent 
with the applicable product information (e.g., Investigator’s Brochure for an unapproved investigational 
product or package insert/summary of product characteristics for an approved product). 
 
10.4.2 Association and Attribution/causality 
 
An adverse event is considered associated with the use of the drug (Adverse Drug Reaction) if the 
attribution is possible, probable or very likely. 
 
The following definitions for rating attribution/causality will be: 
 
Relatedness Rating 
Definition 
Not Related 
An adverse event, which is not related to the use of the drug. 
Doubtful 
An adverse event for which an alternative explanation is more likely, e.g., 
concomitant drug(s) or concomitant disease(s), and/or the relationship in 
time suggests that a causal relationship is unlikely. 
Possible 
An adverse event, which might be due to the use of the drug.  An 
alternative explanation, e.g., concomitant drug(s) or concomitant 
disease(s), is inconclusive.  The relationship in time is reasonable; 
therefore the causal relationship cannot be excluded. 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 35 of 48 
 
Probable 
An adverse event, which might be due to the use of the drug.  The 
relationship in time is suggestive, e.g., confirmed by dechallenge.  An 
alternative explanation is less likely, e.g., concomitant drug(s) or 
concomitant disease(s). 
Definite 
An adverse event, which is listed as a possible adverse reaction and cannot 
be reasonably explained by an alternative explanation, e.g., concomitant 
drug(s) or concomitant disease(s).   
 
10.4.3 Severity 
 
All symptoms and laboratory findings will be graded according to severity using the Division of AIDS 
Table for Grading Severity of Adult Adverse Events, which is a comprehensive grading scale for patients 
with infectious diseases, including TB or HIV. 
 
10.4.4 Reporting 
 
AE:  Adverse events will be collected by the investigators from the time a study participant receives the 
first dose of study drug through the final study visit. Any AE (serious or non-serious) observed by the 
investigator or reported by the study participant that meets the AE reporting requirements (see below) will 
be recorded on an Adverse Event Case Report Form.  The Investigator will review each AE and assess its 
relationship to drug treatment based on all available information at the time of the completion of the case 
report form.  The following information will be recorded for each Adverse Event reported: 
• 
Diagnosis of the AE, if possible.  In the case where an overall diagnosis cannot be made, each 
specific sign and/or symptom will be recorded as individual AEs; 
• 
Date of onset; 
• 
Stop Date (duration) if applicable; 
• 
Severity;   
• 
Action taken with study drugs; 
• 
Other action taken; 
• 
Outcome; 
• 
Relationship to study drugs; 
• 
Seriousness. 
 
The following adverse events must be reported on an Adverse Event Report Form: 
• 
new medical diagnosis (at the time of enrollment, if the patient already has a medical diagnosis 
whose signs or symptoms worsen during the study to a Grade 3 or 4, this is an adverse event that 
must be reported) 
• 
any grade 2or higher adverse event 
• 
study drug discontinuation due to an adverse event 
• 
pregnancy 
 
SAE:  Any SAE must be recorded and reported by the site investigator to the Johns Hopkins University 
study coordinator within 72 hours and to the local IRB and to regulatory authorities in accordance with 
local requirements and ICH guidelines for Good Clinical Practice.  SAEs will be collected from the time a 
study participant receives the first dose of study drug through the final study visit. 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 36 of 48 
 
The study drugs are rifampin, meropenem, and amoxicillin/clavulanate.  The most common adverse effects 
associated with the study drugs are specified in the "Study Drugs" section. The investigator is responsible 
for monitoring all adverse events that are observed or reported during the study, regardless of whether they 
are related to study drugs.   
In accordance with the FDA’s Code of Federal Regulations, the study sponsor and the participating 
investigators are responsible for reviewing all information relevant to the safety of the study drugs.  
Reporting and monitoring of SAEs is required to alert the FDA, sponsor, institutional review boards, and 
the clinical investigators of real and potential safety issues.  The investigators will carefully review the 
Adverse Event Reports and use this information to monitor the investigational drug's toxicity profile and 
patient safety.  Any adverse experience associated with the use of the drug that is both serious and 
unexpected will be reported to the FDA in the form of a written Safety Report.   
The responsible institutional review boards, FDA and South African Regulatory body (Medicines Control 
Council) will be notified of all SAEs and AEs according to their individual guidelines. 
10.4.5 Pregnancy 
For study purposes, pregnancy must be recorded on an Adverse Event form.   
10.5 
Clinical Management of Adverse Events 
 
For all toxicities that are treatment-emergent and that require the study drugs to be temporarily or 
permanently discontinued, relevant clinical and laboratory tests will be obtained as clinically indicated and 
repeated as needed until final resolution or stabilization of the toxicity.  Toxicities of Grade 2 or higher and 
occurring during study treatment will be documented on the Adverse Event Form.  The maximum level of 
toxicity reached will be clearly indicated.   
 
10.5.1 Grade 1 toxicities 
In general, for grade 1 toxicities, the patient will be followed carefully, and the study drugs will be 
continued.  
10.5.2 Grade 2 toxicities 
For grade 2 toxicities, the patient will be followed more carefully, with additional laboratory and/or clinic 
visits as necessary, and the study drugs temporarily held at the investigator's discretion. 
 
10.5.3 Grade 3 toxicities 
Unless the site investigator has compelling evidence that the Grade 3 AE or toxicity is not related to the 
study drug, the participant should permanently discontinue the study drugs.  
 
10.5.4 Grade 4 toxicities:   
Any patient with grade 4 renal, hepatic, cardiac or hematological toxicity will be immediately discontinued 
from study drugs.   
 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 37 of 48 
 
11. DATA ANALYSIS AND STATISTICAL CONSIDERATIONS 
 
Details of the analyses specified in this section will be contained in a statistical analysis plan. 
 
11.1 
Hypotheses 
 
• 
The 
14-day 
antimycobacterial 
activity 
of 
rifampin 
added 
to 
meropenem 
plus 
amoxicillin/clavulanate will be higher than the 14-day antimycobacterial activity of meropenem 
plus amoxicillin/clavulanate alone, in patients with TB isolates with rifampin resistance-conferring 
rpoB mutations (A vs B) and also in patients with TB isolates without rifampin resistance-
conferring rpoB mutations (C vs D). 
 
• 
The effect of adding rifampin to meropenem plus amoxicillin/clavulanate, as measured by 14-day 
antimycobacterial activity, will be higher among patients with drug-sensitive TB than among 
patients 
with 
drug-resistant 
TB 
(A 
vs 
C). 
 
• 
The effect of 1g meropenem plus amoxicillin/clavulanate, as measured by 14-day 
antimycobacterial activity, will be lower than that of 2g meropenem plus amoxicillin/clavulanate 
(D 
vs 
E). 
 
• 
The effect of 3g meropenem plus amoxicillin/clavulanate once daily, as measured by 14-day 
antimycobacterial activity, will be lower than that of 2g meropenem plus amoxicillin/clavulanate 
three times a day (D vs F). 
 
• 
An AUC/MIC for rifampin that achieves maximal effect when rifampin is added to meropenem 
plus amoxicillin/clavulanate can be determined by PK/PD modeling of combined PK and outcomes 
data from patients with infecting strains of M. tuberculosis that have resistance-conferring rpoB 
mutations and patients with infecting strains of M. tuberculosis that do not have resistance-
conferring rpoB mutations  
 
• 
The combination of meropenem, amoxicillin, clavulanate, and rifampin will be safe and well-
tolerated 
 
11.2 
Data Analysis 
 
Detailed data analysis plans are available in the Statistical Analysis Plan. 
 
Analyses for primary endpoints: 
 
• 
The 14-day EBA, or EBA0-14CFU, as determined by the rate of change in log10 CFU per mL sputum 
over the period of Day 0 to Day 14 will be described with at most three parameters from a linear, 
bi-linear, or non-linear regression of log10 CFU on time. Descriptive statistics of EBA0-14CFU for 
each arm will be reported in a table. Box plots and a plot with confidence intervals will be created. 
 
• 
Equivalence tests will be conducted to examine whether the EBA0-14CFU of Arm A is different 
from the EBA0-14CFU of Arm B.  A similar comparison will be done comparing Arm C to Arm D, 
Arm A to Arm C, Arm D to Arm E, Arm D to Arm F, and Arm E to Arm F.  
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 38 of 48 
 
• 
The relationship between the AUC/MIC for rifampin (value of zero in Arms B and D; 
experimentally determined in Arms A and C) and the EBA will be evaluated with linear or 
nonlinear models, adjusting for other covariates, such as baseline log10 CFU per mL. PK/PD 
modeling will be performed to evaluate the relationship between drug concentrations and rate or 
magnitude of bacterial decline. The distributions of PK/PD parameters will be examined first and 
appropriate transformations will be applied if necessary. Meropenem exposure data (time>MIC, or 
AUC/MIC) may be added to the model, if including these data improves model fit. 
 
• 
PK/PD models will be fit to assess the PK predictor that correlates best with treatment effects, as 
measured by EBA, and define the relationship between that parameter and effect.  This PK/PD 
analysis will be carried out using linear or nonlinear models, adjusting for other covariates.  PK/PD 
modeling will be performed to evaluate the relationships between drug concentrations and rate or 
magnitude of bacterial decline.  The distributions of PK/PD parameters will be examined first and 
appropriate transformations will be applied if necessary.  
 
Analyses for secondary endpoints: 
 
• 
Grade 2 or higher AEs will be reported in a tabular form, by regimen.  
 
 
Descriptive statistics of EBA0-14 TTP(rate of change in TTP in sputum over the period of Day 0 to 
14) as determined by modeling analyses (as for EBA0-14CFU) for each arm will be reported in a 
table. Box plots and a plot with confidence intervals will be created.  
 
• 
The distribution of rifampin, meropenem, and meropenem plus amoxicillin/clavulanate MIC 
against M. tuberculosis will be reported for participants with drug-sensitive TB (Arms A and B) 
and drug-resistant TB (Arms C and D). 
 
• 
Rifampin and meropenem PK parameters will be estimated using non-compartmental analysis and 
reported using descriptive statistics. 
 
• 
The 2-day EBA and the EBA over other treatment time periods as measured by CFU or by TTP 
will be calculated in the same manner as the 14-day EBA as described above for each treatment 
Arm.  
 
11.3 
Sample size 
For this study, the overall target sample size is 88 analyzable participants, as distributed below.   
 
Per-arm sample sizes of 12 to 16 participants are considered standard for tuberculosis EBA studies [Boeree 
2015; Heinrich 2015; Diacon 2013]. In this study, given that the MIC distribution of rifampin against M. 
tuberculosis in patients with drug-resistant TB is likely to be variable and that exposures to rifampin at a 
dose of 1200 mg are also highly variable, a higher number of participants, n=24, will be enrolled in Arm 
A; 16 participants will be enrolled in Arm B.  12 participants will be enrolled Arm C and 12 participants 
will be enrolled in Arm D – this will provide a sufficient range of MICs and exposures to test hypotheses 
related to activity of rifampin in combination with meropenem plus amoxicillin/clavulanate.  12 participants 
will be enrolled in Arm E and 12 participants will be enrolled in Arm F.    
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
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12 
PHARMACOLOGY STUDY DESIGN 
 
12.1 Methods and Timing for Assessing, Recording, and Analyzing PK Outcome Measures 
 
Intensive PK sampling for rifampin and meropenem will be performed when all study drugs are at steady 
state (day 13, +/- one day). Blood will be collected pre-dose and at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 12 and 24 hours 
post-dose (12 and 24-hour post-dose sample for rifampin measurement only (Arms A and C)). The rifampin 
MIC for M. tuberculosis for each individual will be determined and rifampin AUC/MIC for each study 
participant will be estimated.  
 
12.2 PK Evaluations 
 
PK parameters for rifampin and meropenem will be derived from plasma concentration versus time data. 
Samples will be drawn on a specified study day at optimized sampling times, as per section 12.1. The PK 
parameters to be assessed include: 
• 
AUC0-24 – area under the plasma concentration-time curve in one dosing interval over 24 hours;  
• 
Cmax – maximum observed plasma concentration; 
• 
Cmin – minimum observed plasma concentration; 
• 
Tmax – time of maximum observed plasma concentration; and 
• 
T1/2 
– elimination half-life 
• 
Cl – clearance for meropenem (IV formulation); CL/F, oral clearance for rifampin) 
 
Individual participant PK parameter values will be derived by non-compartmental methods using a 
validated PK program. In addition, PK/PD modeling will be performed to evaluate the relationship between 
drug concentrations and rate or magnitude of bacterial decline. Information about the last 3 study doses 
prior to the PK visit will be collected. Fasted is defined as nothing by mouth except water and study 
medications 2 hours pre-dose and 1 hour post-dose. In addition, information that could explain unusual PK 
values (e.g., vomiting after the dose, not fasting when taken) or reasons for a missed sample (e.g., dropped 
tube, IV stopped working) will be reported. 
 
12.3 Pharmacokinetics: Blood Collection, Processing, and Storage 
 
Blood samples for study drug concentrations will be collected from an indwelling catheter, or, if a catheter 
cannot be placed successfully, by direct venipuncture. If a catheter is used for blood collection, then prior 
to blood sampling, the fluid in the catheter will be completely withdrawn at each sampling time and 
discarded. Each sample will require approximately 4 mL of blood be drawn into one Vacutainer tube. 
Plasma samples will be processed and frozen immediately in an upright position at -70ºC or colder, in 
storage boxes. These samples will be used only for PK studies. Samples will be stored for possible 
measurement of amoxicillin or clavulanate concentrations, should there be scientific interest and support 
for doing this.  
 
12.4 Laboratory Performing the Assays 
 
Plasma rifampin and meropenem concentrations will be determined by a validated high-performance liquid 
chromatography or LC-MS/MS procedure performed according to written standard operating procedures. 
The intraday accuracy and intraday precision will be obtained with quality control samples, which will be 
analyzed concurrently with each set of volunteer samples. Quality control procedures will be in place to 
ensure stability of sample materials. 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 40 of 48 
 
13. 
HUMAN SUBJECTS PROTECTION 
 
13.1 
Institutional Review Board Involvement 
 
This research will be conducted in compliance with the requirements of the US DHHS regulations to protect 
human subjects from research risk (45 CFR Part 46), in compliance with South African regulations 
protecting human subjects, and with oversight by the IRBs of Johns Hopkins University School of Medicine 
(FWA #00005752) and Pharma Ethics (FWA # 00012241).  All study personnel will complete a course in 
protection of human subjects prior to participating in the study.   
 
The investigator will ensure that the purpose of the study is explained to the patient and that written consent 
is obtained prior to participation in the study.  The patient, investigator or designee, and others as required 
by local regulatory guidelines will sign the consent prior to entry into the study.  The patient will receive a 
copy of his/her signed consent form.  The investigator will retain a copy of the signed consent forms, which 
may be inspected at the monitor’s or auditor’s request.  
 
The investigator will promptly report to the Ethics Committee/IRB and regulatory body of all changes in 
the research activity and all unanticipated problems involving risks to human subjects or others, and will 
not make changes in the research without Ethics Committee/IRB and regulatory body approval, except 
where necessary to eliminate apparent immediate hazards to human subjects. 
 
13.2 
Informed Consent 
 
Written informed consent will be obtained by trained study personnel prior to screening for inclusion and 
exclusion criteria.  Informed consent is a process that will be initiated prior to the individual’s agreeing to 
participate in the study and will continue throughout the individual’s study participation.  The informed 
consent process is described in detail in the “Informed Consent Process” section of “Study Procedures” 
(Section 9). 
 
13.3 
Confidentiality 
 
All study records will be managed in a secure and confidential fashion.  Study records will be maintained 
in locked cabinets, and computer records will be password protected.  Access to study records will be 
restricted to specified study team members.  The study monitor(s) or other authorized representatives of the 
sponsor may inspect all documents and records required to be maintained by the investigator.   
 
13.4 
Special Populations 
 
There will be no exclusion based on gender or ethnicity.  Children will not be enrolled in this exploratory 
EBA study because of differences in the typical disease presentation in children versus adults; study 
participants must be able to produce a 16-hour sputum specimen daily for seven days and few children can 
do this.  Pregnant women or breast-feeding women will not be enrolled since a 14-day delay in initiation of 
definitive TB treatment could increase the risk of TB transmission to the fetus/newborn.  In addition, 
pregnancy may affect study drug pharmacokinetics and introduce a source of variability that cannot be 
adequately addressed in this small PK and safety study.  It is anticipated that approximately 40% of study 
subjects will be women, since, historically, approximately 60% of patients with tuberculosis at clinical sites 
are males.  The gender, ethnicity, and socioeconomic background of study subjects are expected to mirror 
that of the population of the hospital and clinics served, and that of the population most affected by 
tuberculosis. This trial will not enroll persons who are incarcerated.  
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 41 of 48 
 
13.5 
Ethical Issues in Doing This Trial in South Africa 
 
The vast majority of the global TB burden occurs in developing countries.  South Africa has an exceedingly 
high TB case rate of approximately 600/100,000 population/year, and ranks #7 in the world based on 
number of incident cases.  New treatment regimens that substantially improve tuberculosis treatment 
(shorten and/or simplify therapy) are critically needed in this setting.  Therefore, it is appropriate to study 
novel treatments for TB and drug-resistant TB in South Africa.  
 
13.6 
Future Use of Stored Specimens 
 
There will be potential future analysis of stored blood and urine specimens. In addition measurements of 
amoxicillin and/or clavulanate on plasma PK samples may be performed if there is scientific interest and 
resources become available.  
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 42 of 48 
 
14. MONITORING AND DATA HANDLING 
 
Site Monitoring will be conducted to ensure that human subject protection, study procedures, laboratory 
procedures, study intervention administration, and data collection processes are of high quality and meet 
sponsor, CGP/ICH, and regulatory guidelines, and that the study is conducted in accordance with the 
protocol and sponsor SOPs.  Site monitoring will performed according to a written monitoring plan. Data 
handling and record keeping will be performed according to procedures that will be developed in a detailed 
Data Management Operations Manual.  A participant’s name will be collected only one time, and this 
information will be kept on a form that does not contain test results, and that is filed separately from forms 
that contain test results.  Each participant will be assigned a unique study ID number.  This number will be 
recorded on each data collection form and clinical specimen.  Names and other obvious identifiers will not 
be used on data collection forms.  All study records will be stored in locked files in a secure area and access 
will be limited to study personnel and designated regulatory personnel.  All forms will be reviewed prior to 
data entry for accuracy, consistency, and completeness by designated study staff.   
 
Source Documents and Access to Source Documents   Appropriate records will be maintained for this trial, 
in compliance with ICH E6 GCP, Section 4.9 and regulatory and institutional requirements for the 
protection of confidentiality of subjects.  The following will have access to study records: members of the 
study team; IRBs that review the study, the Office of Human Research Protections, the FDA, and the MCC.  
Authorized representatives of the sponsor and regulatory agencies will be permitted to examine study 
records for QA reviews, audits, and evaluation of the study safety and progress. 
 
Data Management Responsibilities   The on-site principal investigator and data manager will be responsible 
for accuracy, completeness, and storage of source records and data collection forms. The study team and 
data entry staff will review source documents to ensure accuracy and completeness.  The site administrator 
will maintain logbooks to record dates of completed and upcoming clinic visits and specimen collections.   
 
Data Capture Methods    Hard copy CRFs will be used for data capture purposes.  
 
Reports   The timing of reports will be detailed in the Data Management Operations Manual.  Briefly, safety 
data will be reviewed by the DSMB after 50% of the participants have been enrolled and annually thereafter; 
reports for the DSMB will be prepared for the DSMB according to a schedule determined at the first 
convened DSMB meeting.  Data coding will occur at the time of data collection; ongoing logical data 
queries will be performed. 
 
Study Records Retention    Within 2 years of study completion, identifiers excluding study ID number will 
be deleted from data files.  Study records will be maintained by the investigator for a minimum of 5 years 
following study discontinuation.  The FDA will be notified prior to destruction of study records. 
 
Protocol Deviations   A protocol deviation is any noncompliance with the clinical trial protocol. As a result 
of deviations, corrective actions are to be developed and implemented.  The site will identify and report 
deviations according to the guidelines of the IND sponsor and IRBs. 
 
Quality Management Procedures for quality management will be detailed in a separate Quality Management 
Plan.  The study site will provide direct access to all trial related facilities, source documents, and reports 
for the purpose of monitoring and auditing by the sponsor, and inspection by regulatory authorities. 
Following written procedures, study monitors will verify that the clinical trial is conducted and data are 
generated, documented (recorded), and reported in compliance with the protocol and the applicable 
regulatory requirements. 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 43 of 48 
 
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PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 44 of 48 
 
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infection model of tuberculosis.Antimicrob Agents Chemother. 2003 Jul;47(7):2118-24. 
 
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Kaushik A, Makkar N, Pandey P, Parrish N, Singh U, Lamichhane G.Carbapenems and Rifampin Exhibit 
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Kissling M, Bergamini N.Rifampicin in free combination with other antimicrobial drugs in non-Tb 
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PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
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PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 46 of 48 
 
 
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Trampuz 
A, 
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PE.Prosthetic-joint 
infections.N 
Engl 
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Med. 2004 Oct 
14;351(16):1645-54. 
 
 
 
APPENDIX A:  SCHEDULE OF EVENTS 
 
(SEE NEXT PAGE) 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 47 of 48 
 
Evaluation 
Screening 
Enroll-
ment 
Day -1 
Day 
0 
Study Treatment (Days) 
Dis-
charge 
Final 
Visit 
Early 
withdrawal 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
Day  
15 
Day 28 
+/-3 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Documentation of HIV status 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical/Medication History 
 X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Complete 
Physical 
Examination 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Targeted 
Physical 
Examination 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Karnofsky Score 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Signs/Symptoms/Diagnoses 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse events assessment 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant Medications 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Assignment and randomization 
 
X 
(X) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Complete Blood Count with 
Differential 
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
X 
X 
Complete Blood Chemistry  
X 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
X 
X 
CD4+ 
Count 
(HIV-infected 
participants) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy Test (women) 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
Chest X-ray 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Spot 
Sputum 
for 
smear 
microscopy, Xpert  MTB/RIF 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Spot Sputum Collection for 
culture, phenotypic DST, MIC 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Overnight Sputum Collection 
 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
 
EBA Analysis by Solid Culture 
CFU and Liquid MGIT Culture 
 
X 
X 
X 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
 
Blood and Urine Retention 
Sampling 
 
 
X 
 
 
X 
 
 
 
X 
 
 
 
 
 
 
X 
 
 
X 
Pharmacokinetic Sampling 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
Hospitalization 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Counseling 
about 
study 
procedures 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 


 
PI:  KE Dooley, A Diacon 
 
 
 
 
 
EBA of rifampin, meropenem, Amx/Clv for TB 
Protocol No.:  FD-R-05724                                                                                           Version 3.0, 08 November 2016 
 
Page 48 of 48 
 
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