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    Clinical Trial Results:
    A Multi-center, Randomized, Double-blind, Comparative Study to Evaluate the Safety and Efficacy of ZTI-01 Versus Piperacillin/Tazobactam in the Treatment of Complicated Urinary Tract Infections, Including Acute Pyelonephritis, in Hospitalized Adults

    Summary
    EudraCT number
    2015-003372-73
    Trial protocol
    CZ   HU   LT   LV   SK   PL   EE   GR   BG   RO   HR  
    Global end of trial date
    12 Jan 2017

    Results information
    Results version number
    v1(current)
    This version publication date
    29 Sep 2018
    First version publication date
    29 Sep 2018
    Other versions

    Trial information

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    Trial identification
    Sponsor protocol code
    ZTI-01-200
    Additional study identifiers
    ISRCTN number
    -
    US NCT number
    NCT02753946
    WHO universal trial number (UTN)
    -
    Sponsors
    Sponsor organisation name
    Zavante Therapeutics, Inc. (a Nabriva Therapeutics, plc entity)
    Sponsor organisation address
    11750 Sorrento Valley Road, Suite 250, San Diego, CA 92121, United States,
    Public contact
    David Skarinsky, Zavante Therapeutics, Inc. (a Nabriva Therapeutics, plc entity), 001 8582994921, David.Skarinsky@nabriva.com
    Scientific contact
    Evelyn J. Ellis-Grosse, Zavante Therapeutics, Inc. (a Nabriva Therapeutics, plc entity), 001 8582994921, Evelyn.Ellis.Grosse@nabriva.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
    31 Jan 2018
    Is this the analysis of the primary completion data?
    Yes
    Primary completion date
    12 Jan 2017
    Global end of trial reached?
    Yes
    Global end of trial date
    12 Jan 2017
    Was the trial ended prematurely?
    No
    General information about the trial
    Main objective of the trial
    The primary objective of this study was to demonstrate that ZTI-01 was non-inferior to Piperacillin-Tazobactam (PIP-TAZ) in overall success (clinical cure and microbiologic eradication) in the microbiologic Modified Intent-to-Treat (m­MITT) Population at the Test-of-Cure (TOC) Visit
    Protection of trial subjects
    The study was conducted in full compliance with the principles of the Declaration of Helsinki, International Conference on Harmonisation (ICH) guidelines, and all of the applicable United States (US) Code of Federal Regulations (CFR), 21 CFR Parts 50 & 312. Prior to the beginning of the study, the Investigator was to have the IRB/IECs’ written approval of the written informed consent form and any other information to be provided to patients. Before undertaking any study-related procedures with patients, the purpose and nature of the study, as well as possible adverse effects, were explained to the patients in understandable terms and written informed consent was obtained from each individual. Each informed consent was to be appropriately signed and dated by the patient and the person obtaining consent. Each patient was to receive a copy of the signed informed consent.
    Background therapy
    -
    Evidence for comparator
    -
    Actual start date of recruitment
    21 Jun 2016
    Long term follow-up planned
    No
    Independent data monitoring committee (IDMC) involvement?
    Yes
    Population of trial subjects
    Number of subjects enrolled per country
    Country: Number of subjects enrolled
    Poland: 22
    Country: Number of subjects enrolled
    Romania: 8
    Country: Number of subjects enrolled
    Slovakia: 24
    Country: Number of subjects enrolled
    Croatia: 8
    Country: Number of subjects enrolled
    Bulgaria: 10
    Country: Number of subjects enrolled
    Czech Republic: 14
    Country: Number of subjects enrolled
    Estonia: 10
    Country: Number of subjects enrolled
    Hungary: 9
    Country: Number of subjects enrolled
    Latvia: 29
    Country: Number of subjects enrolled
    Lithuania: 13
    Country: Number of subjects enrolled
    Belarus: 70
    Country: Number of subjects enrolled
    Georgia: 25
    Country: Number of subjects enrolled
    Russian Federation: 78
    Country: Number of subjects enrolled
    Ukraine: 144
    Country: Number of subjects enrolled
    United States: 1
    Worldwide total number of subjects
    465
    EEA total number of subjects
    147
    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)
    314
    From 65 to 84 years
    140
    85 years and over
    11

    Subject disposition

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    Recruitment
    Recruitment details
    -

    Pre-assignment
    Screening details
    Screening procedures were performed within 48 hours prior to randomization on Day 1.

    Period 1
    Period 1 title
    Overall Trial (overall period)
    Is this the baseline period?
    Yes
    Allocation method
    Randomised - controlled
    Blinding used
    Double blind
    Roles blinded
    Investigator, Monitor, Data analyst, Carer, Subject, Assessor

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    ZTI-01
    Arm description
    -
    Arm type
    Experimental

    Investigational medicinal product name
    Fosfomycin for injection
    Investigational medicinal product code
    ZTI-01
    Other name
    Disodium fosfomycin
    Pharmaceutical forms
    Powder for solution for infusion
    Routes of administration
    Intravenous use
    Dosage and administration details
    6 g ZTI-01 in water for injection intravenously (IV) administered every 8 hours infused over 1 hour.

    Arm title
    PIP-TAZ
    Arm description
    -
    Arm type
    Active comparator

    Investigational medicinal product name
    Piperacillin [PIP]/Tazobactam [TAZ]
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Powder for solution for infusion
    Routes of administration
    Intravenous use
    Dosage and administration details
    4.5 g PIP-TAZ (4 g PIP/0.5 g TAZ) IV administered every 8 hours infused over 1 hour.

    Number of subjects in period 1
    ZTI-01 PIP-TAZ
    Started
    233
    232
    Completed
    221
    230
    Not completed
    12
    2
         Consent withdrawn by subject
    8
    1
         Adverse event, non-fatal
    1
    1
         Lost to follow-up
    3
    -

    Baseline characteristics

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    Baseline characteristics reporting groups
    Reporting group title
    ZTI-01
    Reporting group description
    -

    Reporting group title
    PIP-TAZ
    Reporting group description
    -

    Reporting group values
    ZTI-01 PIP-TAZ Total
    Number of subjects
    233 232 465
    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)
    159 155 314
        From 65-84 years
    67 73 140
        85 years and over
    7 4 11
    Age continuous
    Units: years
        arithmetic mean (standard deviation)
    49.5 ± 20.55 50.8 ± 20.87 -
    Gender categorical
    Units: Subjects
        Female
    151 146 297
        Male
    82 86 168

    End points

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    End points reporting groups
    Reporting group title
    ZTI-01
    Reporting group description
    -

    Reporting group title
    PIP-TAZ
    Reporting group description
    -

    Primary: Proportion of patients with an overall success (clinical cure and microbiologic eradication) in the m-MITT Population at the Test-of-Cure (TOC) Visit.

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    End point title
    Proportion of patients with an overall success (clinical cure and microbiologic eradication) in the m-MITT Population at the Test-of-Cure (TOC) Visit.
    End point description
    End point type
    Primary
    End point timeframe
    The timeframe for the primary end point was the TOC Visit, that was completed on Day 19 (+2 Days).
    End point values
    ZTI-01 PIP-TAZ
    Number of subjects analysed
    184
    178
    Units: percent
        number (not applicable)
    64.7
    54.5
    Statistical analysis title
    Proportion of Responders
    Statistical analysis description
    Percentages were calculated using the number of patients in the microbiologic Modified Intent-to-Treat (m-MITT) Population as the denominator. a. Treatment difference was the difference in the overall success rate between the 2 treatment groups (ZTI-01/PIP-TAZ). The 95% confidence interval (CI) (2-sided) was computed using a continuity-corrected Z-statistic. b. Overall success was defined as clinical cure and microbiologic eradication.
    Comparison groups
    ZTI-01 v PIP-TAZ
    Number of subjects included in analysis
    362
    Analysis specification
    Pre-specified
    Analysis type
    non-inferiority
    Method
    Cochran-Mantel-Haenszel
    Parameter type
    Mean difference (net)
    Point estimate
    10.2
    Confidence interval
         level
    95%
         sides
    2-sided
         lower limit
    -0.4
         upper limit
    20.8
    Variability estimate
    Standard error of the mean

    Adverse events

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    Adverse events information
    Timeframe for reporting adverse events
    From baseline to Day 26 (+/- 2 days; Late Follow-up Visit).
    Assessment type
    Systematic
    Dictionary used for adverse event reporting
    Dictionary name
    MedDRA
    Dictionary version
    19.0
    Reporting groups
    Reporting group title
    ZTI-01
    Reporting group description
    -

    Reporting group title
    PIP-TAZ
    Reporting group description
    -

    Serious adverse events
    ZTI-01 PIP-TAZ
    Total subjects affected by serious adverse events
         subjects affected / exposed
    5 / 233 (2.15%)
    6 / 231 (2.60%)
         number of deaths (all causes)
    0
    0
         number of deaths resulting from adverse events
    0
    0
    Neoplasms benign, malignant and unspecified (incl cysts and polyps)
    Metastatic gastric cancer
         subjects affected / exposed
    1 / 233 (0.43%)
    0 / 231 (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
    Haematuria
         subjects affected / exposed
    0 / 233 (0.00%)
    1 / 231 (0.43%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Renal impairment
         subjects affected / exposed
    0 / 233 (0.00%)
    1 / 231 (0.43%)
         occurrences causally related to treatment / all
    0 / 0
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Infections and infestations
    Urinary tract infection
         subjects affected / exposed
    1 / 233 (0.43%)
    1 / 231 (0.43%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Otitis media acute
         subjects affected / exposed
    1 / 233 (0.43%)
    0 / 231 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Prostatic abscess
         subjects affected / exposed
    1 / 233 (0.43%)
    0 / 231 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Pyelonephritis acute
         subjects affected / exposed
    0 / 233 (0.00%)
    1 / 231 (0.43%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Renal abscess
         subjects affected / exposed
    0 / 233 (0.00%)
    1 / 231 (0.43%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Septic embolus
         subjects affected / exposed
    0 / 233 (0.00%)
    1 / 231 (0.43%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Metabolism and nutrition disorders
    Hypokalaemia
         subjects affected / exposed
    1 / 233 (0.43%)
    0 / 231 (0.00%)
         occurrences causally related to treatment / all
    1 / 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
    ZTI-01 PIP-TAZ
    Total subjects affected by non serious adverse events
         subjects affected / exposed
    96 / 233 (41.20%)
    73 / 231 (31.60%)
    Investigations
    Alanine aminotransferase increased
         subjects affected / exposed
    20 / 233 (8.58%)
    6 / 231 (2.60%)
         occurrences all number
    22
    11
    Aspartate aminotransferase increased
         subjects affected / exposed
    17 / 233 (7.30%)
    6 / 231 (2.60%)
         occurrences all number
    17
    8
    Nervous system disorders
    Headache
         subjects affected / exposed
    6 / 233 (2.58%)
    5 / 231 (2.16%)
         occurrences all number
    6
    5
    General disorders and administration site conditions
    Infusion site phlebitis
         subjects affected / exposed
    2 / 233 (0.86%)
    6 / 231 (2.60%)
         occurrences all number
    2
    6
    Gastrointestinal disorders
    Nausea
         subjects affected / exposed
    10 / 233 (4.29%)
    3 / 231 (1.30%)
         occurrences all number
    11
    3
    Diarrhoea
         subjects affected / exposed
    9 / 233 (3.86%)
    11 / 231 (4.76%)
         occurrences all number
    9
    12
    Vomiting
         subjects affected / exposed
    9 / 233 (3.86%)
    1 / 231 (0.43%)
         occurrences all number
    9
    1
    Metabolism and nutrition disorders
    Hypokalaemia
         subjects affected / exposed
    14 / 233 (6.01%)
    3 / 231 (1.30%)
         occurrences all number
    15
    3

    More information

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    Substantial protocol amendments (globally)

    Were there any global substantial amendments to the protocol? Yes
    Date
    Amendment
    03 Dec 2015
    Amendment 1: -The study was changed from a Phase 2 study to a Phase 2/3 study. -The primary objective was changed to the demonstration that ZTI-01 is non-inferior to PIP-TAZ in overall success in the treatment of cUTI or AP, and secondary objectives were added to include the comparison of the clinical cure rates and microbiologic eradication of the 2 treatment groups. -The population for the study was increased from approximately 200 patients to 460 patients to increase the power of the study. -Elevated WBC count was eliminated as a sign or symptom of cUTI or AP. -The duration of contraception requirements for study participants was shortened based on toxicity studies. -The threshold for the thrombocytopenia exclusion criterion was lowered from 60,000 platelets/mm3 to 50,000 platelets/mm3. -The 4 g ZTI-01 treatment group was eliminated, and the ratio of patients randomized to the 2 treatment groups was changed to 1:1. -The duration of treatment was changed to 7 days for all patients unless deemed a treatment failure, and the TOC Visit was changed to Day 12 (+2 days). -A DMC was added to assess safety and evaluability during the study. -Outcome definitions were clarified. -The secondary efficacy analyses at the LFU Visit were made additional efficacy analyses to support the primary and secondary outcomes. -The statistical efficacy analyses were updated to reflect the changes in the primary and secondary objectives and efficacy analyses. -The sample size rationale was updated to reflect the increased sample size and power of the study. -The number of sites was increased from 60 to 100 to 115. -An unblinded site monitor was added to ensure the blind was maintained throughout the study. -Infusion of 5% dextrose to maintain the blind was added in situations where patients may not be safely administered free WFI. -The 12-lead ECG in triplicate was changed to a single reading. -Changes were also made for clarity and/or consistency.
    29 Mar 2016
    Amendment 2: -Changes were made to inclusion and exclusion criteria; -Procedures for dosing in patients with renal insufficiency were specified; -The duration of treatment was changed to 7 to 14 days, the TOC Visit was changed to Day 19, and the LFU Visit was changed to Day 26; -Urine isolate growth criteria was changed to >1x10^3 CFU/mL for laboratory analysis; -Baseline urine and blood samples submitted to the central laboratory were specified; -Patient treatment in cases of non-susceptibility to study drug was provided; -Determination of serum creatinine within 24 hours of first dose of study drug was specified; -Proportion of patients with a response of clinical cure in the MITT and m-MITT -Populations at Day 5 were added as an additional efficacy endpoint; -Per-pathogen microbiologic eradication rate in the m-MITT and ME-TOC -Populations at the TOC Visit was added as an additional efficacy endpoint; -Treatment failure, per-patient clinical improvement, and recommended minimum duration for clinical evaluation were added to premature discontinuation of study drug; -Staff responsible for documenting and maintaining logs for study drug receipt, storage, preparation, and dispensing were identified; -Procedures for study drugs that experienced a temperature excursion during shipment were provided; -Screening and randomization procedures were clarified, and determination of serum creatinine results within 24 hours of first dose of study drug was added to procedures; -Daily determination of CrCl and daily assessment of vital signs were added to procedures performed during the Treatment Period; -Definition of an adverse event was clarified; -Determination of whether an adverse event was related/not related to study drug was clarified; -PIP-TAZ vial formulation for use in the United States was added; -Changes were also made for clarity and/or consistency.

    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
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