Conditions: Diabetes Wound Infection Healthy Volunteers
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 16
Healthy volunteers: yes

Brief summary:
This study will determine the tissue penetration of ceftolozane/tazobactam (Zerbaxa, Merck \& Co.), a novel β-lactam/β-lactamase combination antibiotic, into the extracellular, interstitial fluid of soft tissue in diabetic patients with lower limb wound infections. Penetration will be compared with a group of healthy volunteer control participants.

Detailed description:
This study will enroll 10 patients with diabetes who are admitted with a lower limb wound infection and 6 healthy volunteer control participants. The study will take place in an inpatient unit at Hartford Hospital for all patients and in the Clinical Research Center at Hartford Hospital for all healthy volunteers. All participants will receive at least 3 doses of ceftolozane/tazobactam 1.5g every 8 hours. A microdialysis probe (Mdialysis Inc., N. Chelmsford MA) will be inserted into the subcutaneous soft tissue near the margin of the wound (patients) or in the thigh (healthy volunteers). The microdialysis probe is perfused with lactated Ringer's solution and samples are collected each hour for 8 hours after the final dose. A peripheral intravenous catheter will be inserted into an arm vein to collect blood samples simultaneously with microdialysis samples. Concentrations in tissue are compared with blood to determine percent penetration.

Arms:
arm 1: Participants with a documented history of Type 1 or Type 2 diabetes and a mild to moderate (Grade 2 or 3) wound infection of the lower limb will receive at least 3 doses of intravenous ceftolozane/tazobactam 1.5g every 8 hours, followed by sampling of interstitial tissue fluid at the margin of the wound by a microdialysis probe over 8 hours. arm 2: Participants will be male or female healthy adult volunteers with no significant medical or medication history. Participants will receive at least 3 doses of intravenous ceftolozane/tazobactam 1.5g every 8 hours, followed by sampling of interstitial tissue fluid in the thigh by a microdialysis probe over 8 hours.

Interventions: intervention 1: Ceftolozane/tazobactam intervention 2: Microdialysis Catheter Insertion
Intervention descriptions: intervention 1: 3 or more doses of ceftolozane/tazobactam intravenously administered over 60 minutes every 8 hours intervention 2: A 20 kila-Dalton microdialysis probe (63 MD catheter; MDialysis Inc., N. Chelmsford, MA) will be inserted into the subcutaneous tissue at the margin of the wound (patient group) or in the thigh tissue (healthy volunteers). The probe will be left in place for the final dose and all tissue sampling procedures thereafter. This probe is perfused with a physiologic solution to collect interstitial fluid samples. The probe will then be removed after completion of sample collection.

Protocol document:
Prot_SAP_000.pdf: 
       
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Version Date: 06/27/16 
 
 
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Requirements for Submitting a Full Proposal 
 
Section #1 - MISP Protocol Identification 
 
Study Title: 
Tissue Penetration of Ceftolozane/Tazobactam in Diabetic Patients with Lower Limb 
Infections 
 
Request Date: 
04-SEP-2015 
Version Date: 
27-JUN-2016 
Institution Name 
Center for Anti-Infective Research and Development 
Hartford Hospital 
Investigator 
Contact 
Information: 
- Full address  
- Phone No. 
- Fax  No. 
- e-mail address 
 
 
David P. Nicolau, PharmD, FCCP, FIDSA 
80 Seymour Street, Hartford, CT 06102 
Tel: 860.972.3941 
Fax: 860.545.3992 
Email: david.nicolau@hhchealth.org 
 


       
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Section #2- Core Protocol 
 
2.1 Objectives & 
Hypotheses  
 
 
 
 
2.1.1 Primary Objectives:   
 
To describe the pharmacokinetic profile of intravenous ceftolozane/tazobactam in the 
plasma and subcutaneous tissue of diabetic patients with ongoing wound infections 
of the lower extremities (i.e., below the knee) using in vivo microdialysis and 
compare the profile with that of a control group of healthy volunteer participants. 
 
2.1.2 Secondary Objectives:   
 
To describe the safety and tolerability of intravenous ceftolozane/tazobactam in 
diabetic patients with diabetic foot infections and in healthy participants. 
 
2.2 Background & 
Rationale, 
Significance of 
Selected Topic & 
Preliminary Data  
 
The annual incidence of foot ulcers among diabetics has been estimated to be  
between 6% to 11.5%, and 10 to 15% of those with diabetes will have at least one 
foot ulcer during their lifetime.1 The majority (upwards of 60%) of these diabetic 
ulcers become infected.2 Treatment of these complicated diabetic wound infections 
primarily involves surgical intervention, topical antiseptics, and systemic antibiotic 
therapy.3 However, despite advances in these areas, outcomes from such infections 
remain poor and often lead to limb amputation in 15% to 20% of participants within 
5 years.4    
 
Different pathogens are implicated in diabetic wound infections, and infections due 
to antibiotic-resistant pathogens are on the rise. Such pathogens include methicillin-
resistant Staphylococcus aureus (MRSA), extended-spectrum β-lactamase (ESBL)–
producing Gram-negative bacilli, as well as highly resistant Pseudomonas 
aeruginosa.5 Other pathogens also isolated from these infections include 
Streptococcus spp.  Therefore, antibiotics targeting these pathogens are often 
prescribed either as monotherapy or in combination. The emergence of resistance in 
pathogens causing diabetic wound infections challenges treatment since limited 
treatment options are available. 
 
Ceftolozane/tazobactam (Zerbaxa, Cubist Pharmaceuticals Inc., Lexington, MA), is 
a β-lactam antibiotic and member of the cephalosporin class that demonstrates potent 
activity against antibiotic-resistant Enterobacteriaceae, P. aeruginosa, and 
Streptococcus spp.6  
 
The pharmacokinetic profile of ceftolozane/tazobactam has been described in healthy 
adult volunteers with some studies being focused on pulmonary penetration of the 
drug.7 However, penetration into skin tissue of an active infection has yet to be 
elucidated. The most accurate method to calculate overall penetration is to evaluate 
the entire drug exposure, or AUC, in the tissue of interest and compare this with the 
overall AUC in blood. In the setting of clinical infection, our group has successfully 
applied a technique called in vivo microdialysis to assess the interstitial (i.e., 
extracellular) concentration profile of antimicrobials in comparison with their 
systemic exposures.8-11  This approach involves placing a probe (with a semi-
permeable membrane at the tip) into tissue and constantly perfusing the probe with a 
physiologic solution via a pump; this approach allows for the continuous collection 


       
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of extracellular fluid from the tissue and enables assessment of drug concentration 
over a specified time period (i.e., the entire dosing interval). Because foot infections 
are very common in the diabetic patients and given the in vitro potency of 
ceftolozane/tazobactam against Enterobacteriaceae, P. aeruginosa, and 
Streptococcus spp., a study examining the tissue penetration of the drug in this 
patient population would be beneficial to understand its pharmacokinetics in the 
inflamed tissue of the diabetic foot, and hence provide a basis for future clinical 
studies on the drug’s efficacy for this type of infection.  A control group of healthy 
volunteer participants will be used to compare penetration and tissue exposure. 
 
2.3 Study Design 
 
2.3.1 Sites  
The study will be conducted at Hartford Hospital, Hartford, CT. The Study Group 
will be admitted to an inpatient unit while the Control Group will be studied in the 
Clinical Research Center at Hartford Hospital. 
 
2.3.2 Inclusion Criteria 
 
2.3.2.1 Study Group 
Participants with a documented medical history of Type 1 or Type 2 diabetes (for 
which they are receiving insulin or oral anti-hyperglycemic agents), and a suspected 
complicated skin and skin structure infection will be included. The suspected 
infection will be an ongoing and infection will be mild or moderate or Grade 2 or 3 
as defined by the Infectious Diseases Society of America (Table 1).5 Other anti-
infective agents besides the study drug will be permitted for the purposes of 
treatment except members of the β-lactam group of antibiotics. 
 
Table 1. Clinical Classification of Infections 
Clinical manifestations of infection 
Infection severity 
PEDIS 
grade 
No symptoms or signs of infection present, as defined 
by the presence of at least 2 of the following items: 
• 
Local swelling or induration 
• 
Erythema 
• 
Local tenderness or pain 
• 
Local warmth 
• 
Purulent discharge (thick, opaque to white or 
sanguineous secretion) 
 
 
Uninfected 
 
1 
Local infection involving only the skin and the 
subcutaneous tissue (without involvement of deeper 
tissues and without systemic signs as described below). 
If erythema, must be > 0.5 cm to ≤ 2 cm around the 
ulcer 
 
Mild 
2 
Local infection (as described above) with erythema > 2 
cm, or involving structures deeper than skin and 
subcutaneous tissues (e.g., abscess, osteomyelitis, 
septic arthritis, fasciitis), and no systemic inflammatory 
response signs (as described below) 
 
Moderate 
3 
Local infection (as described above) with the signs of 
SIRS, as manifested by ≥ 2 of the following: 
• 
Temperature > 38°C or < 36°C 
• 
Heart rate > 90 beats/min 
• 
Respiratory rate > 20 breaths/min or 
• 
PaCO2 < 32 mm Hg 
• 
White blood cell count > 12,000 or < 4,000 
cells/µL or ≥ 10% immature (band) forms 
Severe 
4 
 


       
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2.3.2.2 Control Group 
Male or female healthy adult (≥ 18 years of age) volunteer participants who will be 
identified via hospital and local advertisements (newspaper, postings, and internet) in 
the Greater Hartford area, Connecticut region will be eligible for enrollment. 
 
2.3.3 Exclusion Criteria 
 
2.3.3.1 General Criteria 
 
         Participants will be excluded if any of the following criteria are met:   
1. Less than 18 years of age 
2. History of any reported hypersensitivity or allergy to 
ceftolozane/tazobactam, piperacillin/tazobactam, or any β-lactam 
antibiotic 
3. History of hypersensitivity to lidocaine or lidocaine derivatives 
4. Females who are pregnant or breastfeeding 
5. Concomitant receipt of any β-lactams antibiotic 
6. Concomitant receipt of probenecid 
7. Reduced kidney function defined as creatinine clearance of ≤ 50 
mL/min, as calculated by Cockroft-Gault 
8. Any other reason felt by the investigator to potentially affect the 
outcomes of the study 
 
2.3.3.2 Additional Exclusion Criteria for Study Group 
 
1. Participants likely to require multiple surgical interventions during the 
study period, which therefore could affect placement of the 
microdialysis catheter 
 
2.3.3.3 Additional Exclusion Criteria for Control Group 
 
1. Positive urine drug screen (cocaine, THC, opiates, benzodiazepines, and 
amphetamines) 
2. History of regular alcohol consumption exceeding 7 drinks/week for 
females or 14 drinks/week for men (1 drink = 5 ounces of wine or 12 
ounces of beer or 1.5 ounces of hard liquor) within 6 months of 
screening. 
3. Use of tobacco- or nicotine-containing products in excess of the 
equivalence of 5 cigarettes per day. 
4. Use of prescription or nonprescription drugs, vitamins, or dietary 
supplements within 7 days or 5 half-lives (whichever is longer) prior to 
the first dose of study medication, with the exception of acetaminophen 
at doses of ≤ 1 g/day. Herbal supplements, hormonal methods of 
contraception (including oral and transdermal contraceptives, injectable 
progesterone, progestin subdermal implants, progesterone-releasing 
IUDs, postcoital contraceptive methods), and hormone replacement 
therapy must be discontinued at least 14 days prior to the first dose of 
study medication. Depo-Provera® must be discontinued at least 6 
months prior to the first dose of study medication. 
 


       
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2.4 Study Flowchart 
2.5 Study 
Procedures 
 
2.5.1 Screening Procedure 
 
2.5.1.1 Study Group 
Electronic medical records of admitted diabetic patients who are being followed by 
podiatrists for infections of the lower limbs will be screened to identify patients 
eligible for study enrollment through evaluating each patient’s profile for the 
meeting of inclusion and exclusion criteria. Screening will involve accessing 
patient’s age, past medical history, physician’s notes, laboratory and imaging data, 
and medication administration record. 
 
2.5.1.2 Control Group 
Adult healthy volunteer participants will be identified via hospital and local 
advertisements (newspaper, postings, and internet) and will be initially screened via 
phone interview and if eligible all interested volunteers will be screened by a study 
physician within 28 days of the scheduled study period to confirm that inclusion and 
exclusion criteria are met after providing written informed consent. 
 
2.5.2 Informed Consent 
 
Prior to study enrollment, healthy volunteer participants and patients identified as 
eligible for the study will be approached for consenting, where they will be provided 
with written informed consent that will document their election and agreement to 
participate in the study. The consenting process will be conducted by the principal 
investigator, co-investigators, or trained research staff members. 
 
Screening 
Consenting 
Administration of cefolozane/tazobactam (not less 
than 3 doses will be administered) 
Blood samples collection (0, 1, 2, 3, 4, 5, 6, 7 and 8 hours) 
 
Dialysate samples collection (0, 1, 2, 3, 4, 5, 6, 7 and 8 
hours) 
Storage of samples until analyzed 
At 
steady 
state 
Analysis of samples 
Data analysis 


       
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2.5.3 Study Drug 
 
All participants will receive intravenous ceftolozane/tazobactam 1.5 gram (g) every 8 
hours to achieve steady-state prior to the initiation of the pharmacokinetic study.   
Admitted patients will receive between 3 and 9 doses (1 – 3 days) prior to 
pharmacokinetic sampling; this is to permit flexibility with microdialysis catheter 
insertion and sampling while minimizing interference with standard clinical care. 
Effort will be made to complete the pharmacokinetic sampling as soon as clinically 
feasible after the third dose.  This is not a treatment study; all patients will also 
receive standard intravenous antibiotic therapy to treat their diabetic foot infections. 
All healthy volunteer participants will receive exactly 3 doses of 
ceftolozane/tazobactam, which is sufficient to achieve steady-state.  
Ceftolozane/tazobactam will be provided by Merck & Co. 
 
 
2.5.4 Procedures 
 
2.5.4.1 Baseline Participant Evaluations 
At screening, eligibility will be verified using inclusion/exclusion criteria. A general 
physical examination, including pedal pulses, a medical history and vital signs will 
be conducted by the study physician. Clinical laboratory tests, including serum 
electrolyte panel, serum creatinine, liver function panel, complete blood count, 
glycosylated hemoglobin (HbA1c), albumin, and urinalysis will be performed unless 
drawn within the last three days and the participant is clinically stable. Urine or 
serum pregnancy tests will be required for women of childbearing potential. 
Concomitant medications will be recorded. 
 
 
2.5.4.2 Microdialysis Procedure 
Prior to the final scheduled dose, a microdialysis probe (63 MD catheter; MDialysis 
Inc., N. Chelmsford, MA) with a membrane length of 30 mm and molecular cut-off 
of 20 kDa will be inserted into subcutaneous tissue near the margin of the wound 
(study group) or healthy thigh tissue (control group) via a guidance cannula, 
following a local injection of lidocaine 0.5% solution to minimize pain.8 Specifically, 
a puncture hole will be made 10 cm away from the margin of the wound, in order to 
place the semi-permeable probe at the tip of the catheter within 5 cm of the wound 
(i.e., peri-ulcer area).13 The guidance cannula will be removed, leaving the 
microdialysis probe implanted subcutaneously. 
 
The microdialysis system will be connected and constantly perfused with lactated 
Ringer’s solution (perfusate) at a flow rate of 2 µL/min with a microinfusion pump 
(CMA 107 microdialysis pump, CMA Microdialysis AB, Solna, Sweden). After a 
30-minute baseline period, sampling of the interstitial fluid will begin before the start 
of the final dose of intravenous ceftolozane/tazobactam for baseline values. At the 
beginning of the final dose, sampling will occur as noted in section 5.3.6. Once 
dialysate sampling is complete, the probe will be calibrated by the retrodialysis 
technique over a 1-hour interval to assess recovery of the antibiotic through the 
dialysis membrane. A calibration standard concentration of ceftolozane/tazobactam 
300/150 µg/mL will be added to the perfusate and its rate of disappearance through 
the membrane will determine the recovery rate by obtaining a dialysate sample. 
Recovery of ceftolozane/tazobactam via retrodialysis will be calculated as follows:  
% Recovery = 100 – (Concentrationdialysate / Concentrationperfusate × 100). 


       
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2.5.4.3 Study Drug Administration 
Ceftolozane/tazobactam 1.5 g will be administered by the intravenous route every 8 
hours, with each dose  infused over 1 hour. The doses will be administered by the 
nursing staff with a record log of the date and time. 
 
2.5.4.4 Plasma Collection and Concentration Determination 
Blood samples to assess ceftolozane/tazobactam concentrations will be conducted 
over an 8-hour period after the administration of the final dose. Blood samples of 10 
mL each will be collected through a Jelco® catheter or a peripherally inserted central 
catheter (PICC), if available, at pre-determined time points.  Blood sample times will 
be at 0 (just before administration of the final dose), 1, 2, 3, 4, 5, 6, 7, and 8 hours. 
Blood samples will be collected in a 10-mL BD Vacutainer containing sodium 
heparin (green top). All blood samples will be immediately centrifuged (2,000 × g 
for 10 min) to collect the separated plasma, which will be stored in amber-colored 
polypropylene tubes to protect from light at -80 °C until concentration determination. 
 
Concentrations of both ceftolozane and tazobactam in plasma will be assessed using 
a validated high performance liquid chromatography (HPLC) at the Center for Anti-
Infective Research and Development of Hartford Hospital. 
 
 
2.5.4.5 Dialysate Collection and Concentration Determination 
Interstitial fluid concentrations of the soft tissue in the lower extremity will be 
assessed by in vivo microdialysis. Participants will refrain from excessive movement 
during the sampling process. After catheter insertion, the probe will be perfused with 
lactated Ringer’s solution for 30 minutes prior to sampling. A baseline dialysate 
sample (120 µL) will be taken over an hour after placement of the microdialysis 
catheters just before the administration of the final dose. Further dialysate samples of 
approximately 120 µL each will be collected at 0 (just before administration of the 
final dose of ceftolozane/tazobactam), 1, 2, 3, 4, 5, 6, 7, and 8 hours. After sampling 
is complete, recovery of the antibiotic through the dialysis filter will be assessed by 
the retrodialysis technique over a 1-hour interval (Section 2.5.4.2). All dialysate 
samples will be collected in 200 µL microvials (CMA Microdialysis AB, Solna, 
Sweden), which will be additionally stored within amber-colored polypropylene 
tubes at -80 °C to protect against light and evaporation until concentration 
determination.  The catheter will then be removed by trained study personnel. 
 
Both ceftolozane and tazobactam concentrations in dialysate will be assessed using 
HPLC at the Center for Anti-Infective Research and Development of Hartford 
Hospital. 
 
2.5.4.6 Protein Binding Analysis and Determination 
Protein binding studies will be conducted by a minimum of three independent tests 
using Centrifree® Ultrafiltration devices (Millipore Corporation, Billerica, MA) with 
30 kDa molecular cut-off filters, as per the manufacturer's package insert. 
Ultrafiltration of an aqueous standard will be performed to assess binding of the drug 
to the ultrafiltration membrane. An additional blood sample of 10 mL will be 
collected at the peak concentration (1 hour after final dose administration) into a 10-
mL BD Vacutainer containing sodium heparin (green top). Samples will be 
immediately centrifuged to collect the separated plasma. Exactly 0.9 mL of plasma 


       
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will be transferred into three separate ultrafiltration devices and centrifuged for 45 
minutes at 25 °C at 2,000 × g to generate an ultrafiltrate volume of approximately 
250 µL.  
 
Drug concentration in the initial aliquot of plasma and ultrafiltrates will be 
determined by HPLC at the Center for Anti-Infective Research and Development. In 
addition, non-specific protein binding of ceftolozane/tazobactam will be determined 
in aqueous fluid using a concentration that is similar to the peak concentration of the 
compound. 
 
Individual protein binding percentages will be applied to each participant’s data at all 
time points to determine free plasma concentrations. The percentage of protein 
binding will be calculated using the following formula: % Protein Binding = 100 – 
(Concentrationultrafiltrate / Concentrationplasma × 100). 
 
2.5.4.7 Study Exit Evaluation 
A full physical examination, including vital signs and clinical lab tests will be 
performed on the last day of the study. All abnormal determinations will be followed 
until resolution unless follow-up is determined to be unnecessary by the study 
physician. 
 
2.6 Study Duration 
IRB Submissions and Approval  
 
 
 
2 months 
Enrollment and Sampling of 10 Patients  
 
 
6-12 months 
Enrollment and Sampling of 6 Healthy Volunteers 
 
4 months 
Ceftolozane/Tazobactam HPLC                       
 
 
1 month 
Pharmacokinetic Analysis 
 
 
 
 
1 month 
Final Report 
 
 
 
 
 
 
2 months  
2.7 Statistical 
Analysis and 
Sample Size 
Justification  
 
2.7.1 Data Validation and Analysis 
The PI will be responsible for the review, validation, and analysis of these data as 
collected and recorded by the study staff. 
 
2.7.2 Primary Endpoint 
The primary endpoints of the study are to assess the penetration of 
ceftolozane/tazobactam into infected skin tissue and compare it with the penetration 
into healthy skin tissue. 
 
2.7.2.1 Primary Endpoint Definition 
Percentage of tissue penetration of ceftolozane/tazobactam will be defined based on 
the AUC in tissue and in plasma. This will be calculated as: AUCtissue / freeAUCplasma 
× 100. Plasma pharmacokinetic parameters that will be estimated include AUC0-8 
(plasma), elimination rate constant (Ke), half-life (t½), total plasma clearance (CLT), and 
Volume of distribution (Vd). 
 
2.7.3 Statistical Analysis 
This is a descriptive pharmacokinetics study to evaluate the exposure and penetration 
ratio of ceftolozane/tazobactam into the interstitial fluid of infected tissue of diabetic 
patients compared with healthy volunteer participants. 
             
Pharmacokinetic analyses for ceftolozane/tazobactam will be conducted using 
Phoenix (version 6.3, Pharsight Corporation, Mountain View, CA). Non-
compartmental pharmacokinetics analysis will be used. Pharmacokinetic parameters 


       
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for plasma will be determined using each individual’s plasma concentration-time 
profile. The maximum concentration (Cmax) for each participant will be estimated by 
visual inspection of the concentration-time profiles. The log-linear trapezoidal 
method will be used to determine AUC0-24 (plasma) for each participant.  The 
elimination rate constant (Ke) will be estimated by the slope of the terminal portion 
of the concentration-time profile; half-life (t½) will be calculated by 0.693/Ke. Total 
plasma clearance (CLT) will be calculated by Dose/AUC0-24 (plasma). Volume of 
distribution (Vd) will be calculated by CLT/Ke.   
            
All microdialysis concentrations will be corrected for recovery before 
pharmacokinetic analysis as follows:  Concentrationtissue = 100 × (Concentrationsample 
/ % in vivo recovery).  The AUC0-24 (tissue) will be assessed by the log-linear 
trapezoidal rule. Percentage of penetration into tissue will be calculated as follows:  
AUCtissue / freeAUCplasma × 100. 
 
Student’s t-test will be used to compare the penetration ratio and pharmacokinetic 
parameter values of ceftolozane and tazobactam between study and control groups. 
 
2.7.4 Sample Size Determination 
Ten patients with diabetic foot infection and six healthy volunteers are to be enrolled 
in the study. This is primarily a descriptive, controlled study to observe the exposure 
and penetration ratio of ceftolozane/tazobactam into the interstitial fluid of infected 
tissue of diabetic patients and compare it to that of healthy volunteers. In similar 
study designs, 10 study patients were sufficient to describe the central tendency of 
these penetration estimates and some confidence of dispersion.  Given reduced 
variability in healthy participants, 6 volunteers will be utilized. 
  
2.8 Specific Drug 
Supply 
Requirements  
Ceftolozane/tazobactam 1.5 g vials will be provided by Merck & Co. as an open 
label supply. 
2.9 Adverse 
Experience 
Reporting 
Participants will be monitored for any sign or symptom of adverse events throughout 
the course of the study. Unanticipated, life-threatening or fatal adverse events will be 
reported to the IRB, the manufacturer, and the Food and Drug Administration 
according to federal guidelines. All adverse events requiring medical attention will 
be treated by the study physician and will be recorded by the investigator. 
 
 
2.9.1 Definitions 
For the purpose of this study, an adverse event will be defined as any pathologic or 
unintended change in the structure (signs), function (symptoms), or chemistry 
(laboratory values) of the body associated with the use of the study drug, whether or 
not considered drug related, and will be categorized as one of the following:   
• 
MILD – present, but easily tolerated 
• 
MODERATE – discomfort that interferes with usual activities 
• 
SEVERE – incapacitating, inability to work or do usual activities 
 
 
A serious adverse event will be defined as any of the above which results in death or 
is immediately life-threatening, requires in-participant hospitalization, or is an 


       
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important medical event that may jeopardize the participant or require medical 
intervention to prevent one of the previously mentioned outcomes.  
 
2.9.2 Relationship to Study Medication 
Relationship of the AE to the study medication (i.e., causality) will be evaluated 
according to the investigator’s opinion, as one of the following: 
• 
Concurrent condition – unrelated to study drug 
• 
REMOTE adverse drug event – little or no temporal relationship to study 
drug 
• 
POSSIBLE adverse drug event – temporal relationship to study drug 
• 
PROBABLE adverse drug event – commonly associated with study drug 
• 
DEFINTE adverse drug event – reappeared on re-challenge of study drug 
 
2.9.3 Expectedness of AE 
As AEs are expected with the study medication, patients will be closely monitored 
throughout the study for any AE occurrence and will be managed accordingly by the 
study physician. All AEs will be recorded by the investigator as described in Section 
2.9.4 below. 
 
2.9.4 Recording and Reporting an AE 
All adverse events requiring medical attention will be recorded by the investigator as 
such: categorization by severity (mild, moderate, or severe), established time frame 
(start and stop time), complete description of event, all interventions (medical and 
pharmacological), and causality. 
 
2.9.5 Recording and Reporting a SAE 
All serious adverse events will be reported to the Institutional Review Board, 
sponsor, and the Food and Drug Administration according to Federal guidelines. A 
serious adverse event will be defined as any adverse event that results in death, is 
immediately life-threatening, requires or prolongs hospitalization, or is an important 
medical event that may jeopardize the participant or may require medical 
intervention to prevent one of the previously mentioned outcomes. 
2.10 Itemized Study 
Budget  
 
2.10.1 Staff Related Costs 
Principal Investigator 
 
 
 
 
$15,000 
Study Coordinator 
 
 
 
 
$26,250 
Research Assistant (1)  
 
 
 
$13,000 
Research Assistant (2)  
 
 
 
$6,500 
Study Physician 
 
 
 
 
$10,000 
Nursing  
 
 
 
 
 
$7,250 
Phlebotomy 
 
 
 
 
 
$480 
Clinical Research Center Medical Coverage (PA, APRN) $3,600 
 
2.10.2 Participant Fess 
Drug Toxicity Screening  
 
 
 
$3,900 
Patient Payments 
 
 
 
 
$5,000 
Healthy Volunteer Fees  
 
 
 
$6,000 
Healthy Volunteer Housing 
 
 
 
$1,440 
Healthy Volunteer Parking 
 
 
 
$600 
Healthy Volunteer Consumables 
 
 
$3,000 
 
2.10.3 Supplies 
Sample Storage Supplies 
 
 
 
$1,920 


       
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Blood Sampling Supplies 
 
 
 
$4,000 
Peripherally Intserted Central Catheters  
 
$8,000 
Lidocaine 0.5%, 50ml flip top, pack of 25 
 
$60 
Millipore Ultrafiltration Devices  
 
 
$2,880 
CMA 60 Microdialysis Probe ($1950 pack of 4)  
$7,800 
CMA 107 Pump ($3450 per pump, n=2)  
 
$6,900 
CMA 107 Pump Batteries (package of 5) 
 
$700 
CMA 20/107 Sample Collection Vials/Syringes 
 
$2400 
HPLC Analysis of Samples 
 
 
 
$29,120 
Laboratory Services 
 
 
 
 
$16,000 
 
2.10.4 Administrative Fees 
Pharmacy Dispensing Fess 
 
 
 
$3,200 
Institutional Document Preparation and Submission 
$2,000 
Publication Cost (Medical Writing) 
 
 
$4,500 
IRB Fees 
 
 
 
 
 
$2,500 
Meeting-Related Expenses 
 
 
 
$2,500 
 
2.10.5 Overhead Costs 
25% 
(excluding IRB Fees and Meeting-Related Expenses) 
$47,875 
 
Total Direct Cost (Less Overhead)  
 
 
$196,500 
 
TOTAL  
 
 
 
 
 
$244,375
2.11 References 
 
1. Margolis D, Malay DS, Hoffstad OJ, et al. Incidence of diabetic foot ulcer 
and lower extremity amputation among Medicare  beneficiaries, 2006 to 
2008. Data Points #2 (prepared by the University of Pennsylvania DEcIDE 
Center, under Contract No.  HHSA29020050041I). Rockville, MD: Agency 
for Healthcare Research and Quality. January 2011. AHRQ Publication No.  
10(11)-EHC009-1-EF   
2. Lipsky BA. New developments in diagnosing and treating diabetic foot 
infections. Diabetes Metab Res Rev 2008; electronically published ahead of 
print.   
3. Lipsky BA. Medical treatment of diabetic foot infections. Clin Infect Dis 
2004; 39:S104-114.   
4. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of 
foot ulcers in participants with diabetes. Diabetes Care 1999; 22:382-387.   
5. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society 
of America clinical practice guideline for the diagnosis and treatment of 
diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-73. 
6. Zerbaxa® (ceftolozane/tazobactam) Prescribing Information, Cubist 
Pharmaceuticals Inc. Lexington, MA. 2014. 
7. Zhanel GG, Chung P, Adam H, et al. Ceftolozane/tazobactam: a novel 
cephalosporin/β-lactamase inhibitor combination with activity against 
multidrug-resistant gram-negative bacilli. Drugs. 2014;74(1):31-51. 
8. Müller M, Haag O, Burgdorff T, et al. Characterization of peripheral-
compartment kinetics of antibiotics by in vivo microdialysis. Antimicrob 
Agents Chemother 1996; 40:2703-2709.   
9. Bhalodi AA, Housman ST, Shepard A, Nugent J, Nicolau DP. Tissue 
pharmacokinetics of cefazolin in patients with lower limb infections. 
Antimicrob Agents Chemother. 2013;57(11):5679-83.   


       
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10. Wiskirchen DE, Shepard A, Kuti JL, Nicolau DP. Determination of tissue 
penetration and pharmacokinetics of linezolid in patients with diabetic foot 
infections using in vivo microdialysis. Antimicrob Agents Chemother. 
2011;55(9):4170-5.   
11. Bulik CC, Wiskirchen DE, Shepard A, Sutherland CA, Kuti JL, Nicolau DP. 
Tissue penetration and pharmacokinetics of tigecycline in diabetic patients 
with chronic wound infections described by using in vivo microdialysis. 
Antimicrob Agents Chemother. 2010;54(12):5209-13.   
12. Walker M, Hadgraft J, Lane ME. Investigation of the permeability 
characteristics of peri-ulcer and whole ischaemic skin tissue. Int J Pharm 
2008; electronically published ahead of print. 
 
2.12 Publication 
Plan 
 
The results of this study will be presented at an international congress such as the 
Interscience Conference on Antimicrobial Agents and Chemotherapy. A final 
publication would be submitted to a peer-reviewed journal such as Antimicrobial 
Agents and Chemotherapy, Journal of Antimicrobial Chemotherapy, or International 
Journal of Antimicrobial Agents. One abstract and one manuscript are anticipated to 
be presented at the conference and published. 
2.13 Curriculum 
Vitae 
 
A curriculum vita is uploaded online with this submission. 
2.13 Protocol 
Submission for 
Investigator-
Initiated Studies  
U.S. protocols should be submitted by US investigators directly or through the 
Global Research Specialist at  www.merckiisp.com   
 
Non U.S. protocols should be submitted to the MSD office by the investigators.