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    Clinical Trial Results:
    A PHASE 3, MULTICENTER, RANDOMIZED, DOUBLE BLIND, ACTIVE CONTROLLED STUDY TO EVALUATE THE EFFICACY AND SAFETY OF DELAFLOXACIN COMPARED WITH VANCOMYCIN + AZTREONAM IN PATIENTS WITH ACUTE BACTERIAL SKIN AND SKIN STRUCTURE INFECTIONS

    Summary
    EudraCT number
    2012-001767-71
    Trial protocol
    HU   LV   ES   BG   HR  
    Global end of trial date
    21 Jun 2014

    Results information
    Results version number
    v1(current)
    This version publication date
    07 Jul 2018
    First version publication date
    07 Jul 2018
    Other versions
    Summary report(s)
    Delafloxacin 302 JAC Manuscript

    Trial information

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    Trial identification
    Sponsor protocol code
    RX-3341-302
    Additional study identifiers
    ISRCTN number
    -
    US NCT number
    NCT01811732
    WHO universal trial number (UTN)
    -
    Other trial identifiers
    IND: 76096
    Sponsors
    Sponsor organisation name
    Melinta Therapeutics
    Sponsor organisation address
    300 George Street, Suite 301, New Haven, United States, 06511
    Public contact
    Sue Cammarata, Melinta Therapeutics, 1 3127249401, scammarata@melinta.com
    Scientific contact
    Sue Cammarata, Melinta Therapeutics, 1 3127249401, scammarata@melinta.com
    Paediatric regulatory details
    Is trial part of an agreed paediatric investigation plan (PIP)
    No
    Does article 45 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Does article 46 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Results analysis stage
    Analysis stage
    Final
    Date of interim/final analysis
    04 Nov 2015
    Is this the analysis of the primary completion data?
    Yes
    Primary completion date
    21 Jun 2014
    Global end of trial reached?
    Yes
    Global end of trial date
    21 Jun 2014
    Was the trial ended prematurely?
    No
    General information about the trial
    Main objective of the trial
    To assess the clinical efficacy of delafloxacin compared with vancomycin + aztreonam in patients with Acute Bacterial Skin and Skin Structure Infections (ABSSSIs) at the Follow-up Visit (Day 14 +/- 1).
    Protection of trial subjects
    This study was conducted in compliance with the protocol and all regulatory requirements, in accordance with GCP, including International Conference on Harmonisation (ICH) guidelines, and in general conformity with the most recent version of the Declaration of Helsinki.
    Background therapy
    Patients who had received 1 dose of either a single, potentially effective, short-acting antimicrobial drug or regimen for treatment of the ABSSSI under study in the 14 days before study entry were limited to no more than 25% of total randomized patients.
    Evidence for comparator
    The comparator selected for this study was vancomycin + aztreonam based on activity against gram-positive and gram-negative bacteria, respectively. Vancomycin is a glycopeptide antibiotic that has been in clinical use for the prophylaxis and treatment of infections caused by gram-positive bacteria for nearly 50 years. Aztreonam is a monobactam antibiotic with activity against gram-negative bacteria. Since delafloxacin has activity against both gram-positive and gram-negative pathogens and vancomycin is only active against gram-positive pathogens, aztreonam was given to patients for gram-negative coverage.
    Actual start date of recruitment
    15 Apr 2013
    Long term follow-up planned
    No
    Independent data monitoring committee (IDMC) involvement?
    No
    Population of trial subjects
    Number of subjects enrolled per country
    Country: Number of subjects enrolled
    Spain: 2
    Country: Number of subjects enrolled
    Croatia: 2
    Country: Number of subjects enrolled
    Hungary: 3
    Country: Number of subjects enrolled
    Latvia: 30
    Country: Number of subjects enrolled
    Ukraine: 57
    Country: Number of subjects enrolled
    United States: 542
    Country: Number of subjects enrolled
    Israel: 24
    Worldwide total number of subjects
    660
    EEA total number of subjects
    37
    Number of subjects enrolled per age group
    In utero
    0
    Preterm newborn - gestational age < 37 wk
    0
    Newborns (0-27 days)
    0
    Infants and toddlers (28 days-23 months)
    0
    Children (2-11 years)
    0
    Adolescents (12-17 years)
    0
    Adults (18-64 years)
    614
    From 65 to 84 years
    39
    85 years and over
    7

    Subject disposition

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    Recruitment
    Recruitment details
    A total of 660 patients were enrolled at 54 global sites in Europe (118 patients) and the United States (542 patients). The first patient was enrolled on 25 April 2013, the last patient was enrolled on 10 May 2014, and the final study visit was conducted on 24 June 2014.

    Pre-assignment
    Screening details
    Eligibility criteria included age ≥18 years, and a diagnosis of ABSSSI, defined as cellulitis/erysipelas, wound infection, major cutaneous abscess, or burn infection with ≥75 cm2 of erythema and ≥2 signs of systemic infection.

    Period 1
    Period 1 title
    Overall Study (overall period)
    Is this the baseline period?
    Yes
    Allocation method
    Randomised - controlled
    Blinding used
    Double blind
    Roles blinded
    Subject, Investigator, Monitor, Data analyst, Carer, Assessor
    Blinding implementation details
    This was a double-blind study. An unblinded pharmacist obtained treatment assignments and provided blinded treatment to the blinded investigator for administration to the patient. A placebo infusion was given in the same manner as aztreonam to patients receiving delafloxacin. All personnel who evaluated patient efficacy and safety were blinded, with the exception of an unblinded statistician who was responsible for generating tables for the bioanalytical staff.

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    Delafloxacin
    Arm description
    Delafloxacin Treatment Group
    Arm type
    Experimental

    Investigational medicinal product name
    Delafloxacin Powder for Solution for Intravenous Infusion
    Investigational medicinal product code
    RX-3341-83
    Other name
    ABT-492, Abbott-319492
    Pharmaceutical forms
    Powder for solution for infusion
    Routes of administration
    Intravenous use
    Dosage and administration details
    Delafloxacin for Injection, 300 mg/vial, is formulated as a sterile, nonpyrogenic, light yellow to tan-colored lyophilized cake. Patients received delafloxacin, 300 mg IV, every 12 hours for 10 to 28 doses. Patients randomly assigned to the delafloxacin treatment arm received a blinded placebo infusion in place of the aztreonam given to the vancomycin patients from the unblinded pharmacist or unblinded designee, which was discontinued as soon as possible if a gram-negative organism was not identified in baseline cultures.

    Arm title
    Vancomycin + Aztreonam
    Arm description
    Vancomycin + Aztreonam Treatment Group
    Arm type
    Active comparator

    Investigational medicinal product name
    Vancomycin
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Powder for solution for infusion
    Routes of administration
    Intravenous use
    Dosage and administration details
    Sterile vancomycin hydrochloride was supplied as an off-white lyophilized powder containing vancomycin hydrochloride equivalent of 1 g vancomycin activity. Patients randomized to vancomycin received IV doses for the entire course of treatment. The recommended starting dose of vancomycin was 15 mg/kg based on actual body weight or as per local standard of care. All study sites were to monitor vancomycin therapeutic drug levels on Day 2 (+1 day, after at least 3 doses of study drug have been administered) and Day 6 (+/-1 day) and that adjustments in vancomycin dose be made with the intent of maintaining a minimum trough concentration of >15 ug/mL up to a maximum trough concentration of 20 ug/mL.

    Investigational medicinal product name
    Aztreonam
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Powder for solution for infusion
    Routes of administration
    Intravenous use
    Dosage and administration details
    Aztreonam for Injection is a sterile, nonpyrogenic, sodium-free, lyophilized, off-white to slightly yellow solid. Until a baseline culture confirmed no gram-negative pathogens, the unblinded pharmacist or unblinded designee provided a blinded infusion of aztreonam for patients in the vancomycin group and a blinded placebo infusion in place of the aztreonam for patients in the delafloxacin group. For patients in the vancomycin treatment arm the aztreonam dose was 2 g BID.

    Number of subjects in period 1
    Delafloxacin Vancomycin + Aztreonam
    Started
    331
    329
    Completed
    276
    271
    Not completed
    55
    58
         Adverse event, serious fatal
    1
    1
         Noncompliance with Study Drug
    2
    2
         Randomized in error
    -
    1
         Physician decision
    2
    -
         Consent withdrawn by subject
    15
    9
         Adverse event, non-fatal
    3
    9
         Lost to follow-up
    24
    30
         Noncompliance with Study
    5
    5
         Lack of efficacy
    3
    1

    Baseline characteristics

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    Baseline characteristics reporting groups
    Reporting group title
    Delafloxacin
    Reporting group description
    Delafloxacin Treatment Group

    Reporting group title
    Vancomycin + Aztreonam
    Reporting group description
    Vancomycin + Aztreonam Treatment Group

    Reporting group values
    Delafloxacin Vancomycin + Aztreonam Total
    Number of subjects
    331 329 660
    Age categorical
    Units: Subjects
        In utero
    0 0 0
        Preterm newborn infants (gestational age < 37 wks)
    0 0 0
        Newborns (0-27 days)
    0 0 0
        Infants and toddlers (28 days-23 months)
    0 0 0
        Children (2-11 years)
    0 0 0
        Adolescents (12-17 years)
    0 0 0
        Adults (18-64 years)
    305 309 614
        From 65-84 years
    23 16 39
        85 years and over
    3 4 7
    Age continuous
    Units: years
        arithmetic mean (standard deviation)
    46.3 ( 13.91 ) 45.3 ( 14.44 ) -
    Gender categorical
    Units: Subjects
        Female
    125 120 245
        Male
    206 209 415
    Subject analysis sets

    Subject analysis set title
    ITT
    Subject analysis set type
    Intention-to-treat
    Subject analysis set description
    The ITT analysis set included all patients who were randomly assigned to treatment. Patients were analyzed according to the treatment they were assigned at randomization.

    Subject analysis set title
    CE
    Subject analysis set type
    Per protocol
    Subject analysis set description
    All patients in the ITT analysis set who met criteria specified in the SAP including 1) received the correct study drug, 2) received at least 80% of expected doses, 3) had required clinical assessments at the Follow up Visit (Day 14 +/- 1 day) or patient was considered a clinical failure, 4) did not receive any concomitant systemic antibacterials, and 5) had no protocol deviations that would affect efficacy.

    Subject analysis sets values
    ITT CE
    Number of subjects
    660
    484
    Age categorical
    Units: Subjects
        In utero
    0
    0
        Preterm newborn infants (gestational age < 37 wks)
    0
    0
        Newborns (0-27 days)
    0
    0
        Infants and toddlers (28 days-23 months)
    0
    0
        Children (2-11 years)
    0
    0
        Adolescents (12-17 years)
    0
    0
        Adults (18-64 years)
    614
    455
        From 65-84 years
    39
    28
        85 years and over
    7
    1
    Age continuous
    Units: years
        arithmetic mean (standard deviation)
    45.8 ( 14.18 )
    46.3 ( 13.98 )
    Gender categorical
    Units: Subjects
        Female
    245
    165
        Male
    415
    319

    End points

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    End points reporting groups
    Reporting group title
    Delafloxacin
    Reporting group description
    Delafloxacin Treatment Group

    Reporting group title
    Vancomycin + Aztreonam
    Reporting group description
    Vancomycin + Aztreonam Treatment Group

    Subject analysis set title
    ITT
    Subject analysis set type
    Intention-to-treat
    Subject analysis set description
    The ITT analysis set included all patients who were randomly assigned to treatment. Patients were analyzed according to the treatment they were assigned at randomization.

    Subject analysis set title
    CE
    Subject analysis set type
    Per protocol
    Subject analysis set description
    All patients in the ITT analysis set who met criteria specified in the SAP including 1) received the correct study drug, 2) received at least 80% of expected doses, 3) had required clinical assessments at the Follow up Visit (Day 14 +/- 1 day) or patient was considered a clinical failure, 4) did not receive any concomitant systemic antibacterials, and 5) had no protocol deviations that would affect efficacy.

    Primary: Investigator-Assessed Response at Follow-Up Visit

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    End point title
    Investigator-Assessed Response at Follow-Up Visit
    End point description
    The primary efficacy endpoint for the EMA submission was the investigator-assessed response at the FU visit in the ITT analysis set. Cure was defined as the complete resolution of all baseline signs and symptoms of ABSSSI, Improved as some signs and symptoms remained but no additional antimicrobial was required (improved was counted as failure for the primary analysis), and Failure as lack of efficacy after at least 4 doses of study treatment, a treatment-related AE, antibacterial drug therapy required for more than 28 doses, and/or the need for unplanned surgical intervention after study entry except for limited bedside debridement and standard wound care.
    End point type
    Primary
    End point timeframe
    Follow-up (FU) Visit (Day 14 +/- 1 day)
    End point values
    Delafloxacin Vancomycin + Aztreonam ITT CE
    Number of subjects analysed
    331
    329
    660
    484
    Units: Patients
        Cure
    172
    166
    338
    284
        Failure
    159
    163
    322
    200
    Statistical analysis title
    Non-inferiority Hypothesis Test
    Statistical analysis description
    H0: Difference (Delafloxacin treatment group minus Vancomycin + Aztreonam treatment group) of clinical cure rates ≤ -10%
    Comparison groups
    Delafloxacin v Vancomycin + Aztreonam
    Number of subjects included in analysis
    660
    Analysis specification
    Pre-specified
    Analysis type
    non-inferiority
    Method
    Parameter type
    Difference in Cure Rate
    Point estimate
    1.5
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    -6.1
         upper limit
    9.1

    Adverse events

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    Adverse events information
    Timeframe for reporting adverse events
    From first study drug administration to 30 days (+3 ) after last dose of study drug
    Assessment type
    Systematic
    Dictionary used for adverse event reporting
    Dictionary name
    MedDRA
    Dictionary version
    16.1
    Reporting groups
    Reporting group title
    Delafloxacin
    Reporting group description
    -

    Reporting group title
    Vancomycin + Aztreonam
    Reporting group description
    -

    Serious adverse events
    Delafloxacin Vancomycin + Aztreonam
    Total subjects affected by serious adverse events
         subjects affected / exposed
    12 / 324 (3.70%)
    12 / 326 (3.68%)
         number of deaths (all causes)
    1
    1
         number of deaths resulting from adverse events
    0
    0
    Injury, poisoning and procedural complications
    Overdose
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Stab wound
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Vascular disorders
    Peripheral ischaemia
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Peripheral vascular disorder
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Pregnancy, puerperium and perinatal conditions
    Abortion Spontaneous
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Nervous system disorders
    Cervical radiculopathy
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Gastrointestinal disorders
    Diarrhoea
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Gastric ulcer perforation
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Respiratory, thoracic and mediastinal disorders
    Chronic obstructive pulmonary disease
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Pulmonary embolism
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 1
    Hepatobiliary disorders
    Hepatic cirrhosis
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Skin and subcutaneous tissue disorders
    Pyoderma gangrenosum
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Psychiatric disorders
    Depression
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Major depression
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Polysubstance dependence
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Substance-Induced Mood Disorder
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Renal and urinary disorders
    Renal failure acute
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Musculoskeletal and connective tissue disorders
    Soft tissue necrosis
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Infections and infestations
    Cellulitis
         subjects affected / exposed
    2 / 324 (0.62%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 2
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Hepatitis C
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Infection
         subjects affected / exposed
    1 / 324 (0.31%)
    2 / 326 (0.61%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Peritonitis
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Sepsis
         subjects affected / exposed
    0 / 324 (0.00%)
    1 / 326 (0.31%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Septic shock
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 1
    0 / 0
    Skin bacterial infection
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Staphylococcal sepsis
         subjects affected / exposed
    1 / 324 (0.31%)
    0 / 326 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Frequency threshold for reporting non-serious adverse events: 2%
    Non-serious adverse events
    Delafloxacin Vancomycin + Aztreonam
    Total subjects affected by non serious adverse events
         subjects affected / exposed
    154 / 324 (47.53%)
    193 / 326 (59.20%)
    Investigations
    Alanine aminotransferase increased
         subjects affected / exposed
    12 / 324 (3.70%)
    10 / 326 (3.07%)
         occurrences all number
    12
    10
    Aspartate aminotransferase increased
         subjects affected / exposed
    7 / 324 (2.16%)
    8 / 326 (2.45%)
         occurrences all number
    7
    8
    Nervous system disorders
    Headache
         subjects affected / exposed
    10 / 324 (3.09%)
    25 / 326 (7.67%)
         occurrences all number
    11
    26
    Dizziness
         subjects affected / exposed
    6 / 324 (1.85%)
    7 / 326 (2.15%)
         occurrences all number
    6
    7
    General disorders and administration site conditions
    Infusion site extravasation
         subjects affected / exposed
    28 / 324 (8.64%)
    44 / 326 (13.50%)
         occurrences all number
    44
    66
    Pyrexia
         subjects affected / exposed
    6 / 324 (1.85%)
    8 / 326 (2.45%)
         occurrences all number
    6
    9
    Chills
         subjects affected / exposed
    0 / 324 (0.00%)
    7 / 326 (2.15%)
         occurrences all number
    0
    14
    Pruritus generalised
         subjects affected / exposed
    3 / 324 (0.93%)
    15 / 326 (4.60%)
         occurrences all number
    3
    15
    Gastrointestinal disorders
    Diarrhoea
         subjects affected / exposed
    27 / 324 (8.33%)
    10 / 326 (3.07%)
         occurrences all number
    31
    12
    Nausea
         subjects affected / exposed
    24 / 324 (7.41%)
    28 / 326 (8.59%)
         occurrences all number
    25
    29
    Vomiting
         subjects affected / exposed
    7 / 324 (2.16%)
    10 / 326 (3.07%)
         occurrences all number
    7
    11
    Skin and subcutaneous tissue disorders
    Pruritus
         subjects affected / exposed
    3 / 324 (0.93%)
    11 / 326 (3.37%)
         occurrences all number
    3
    11
    Infections and infestations
    Infection
         subjects affected / exposed
    28 / 324 (8.64%)
    25 / 326 (7.67%)
         occurrences all number
    33
    31

    More information

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    Substantial protocol amendments (globally)

    Were there any global substantial amendments to the protocol? Yes
    Date
    Amendment
    04 Dec 2013
    Changes to the protocol included an update of the sponsor name to Melinta Therapeutics from Rib-X Pharmaceuticals. An FDA secondary objective was updated to include evaluating clinical efficacy in patients with MRSA, and the EMA secondary objectives and endpoints were updated to match those of the FDA. Inclusion and exclusion criteria was clarified, and additionally, an exclusion criteria was added for patients with a history or physical examination finding of peripheral neuropathy.

    Interruptions (globally)

    Were there any global interruptions to the trial? No

    Limitations and caveats

    Limitations of the trial such as small numbers of subjects analysed or technical problems leading to unreliable data.
    None reported

    Online references

    http://www.ncbi.nlm.nih.gov/pubmed/29029278
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