Phage therapy is the
therapeuticuse of bacteriophages to treat pathogenic bacterialinfections. Although extensively used and developed mainly in former Soviet Unioncountries for about 90 years, this method of therapy is still being tested elsewhere for treatmentof a variety of bacterial and poly-microbial biofilminfections, and has not yet been approved in countries other than Georgia. Phage therapy has many potential applications in human medicineas well as dentistry, veterinary science, and agriculture. [McAuliffe et al. "The New Phage Biology: From Genomics to Applications" (introduction) in Mc Grath, S. and van Sinderen, D. (eds.) "Bacteriophage: Genetics and Molecular Biology" Caister Academic Press ISBN 978-1-904455-14-1. [http://www.highveld.com/pages2/phage.html reprint] ] If the target host of a phage therapy treatment is not an animal, however, then the term " biocontrol" (as in phage-mediated biocontrol of bacteria) is sometimes employed rather than "phage therapy".
An important theoretical benefit of phage therapy is that bacteriophages can be much more specific than more common drugs, so can be chosen to be harmless to not only the host
organism(human, animal, or plant), but also other beneficial bacteria, such as gut flora, reducing the chances of opportunistic infections. They also have a high therapeutic index, that is, phage therapy gives rise to few if any side effects, as opposed to drugs, and does not stress the liver. Because phages replicate " in vivo", a single, small dose is sometimes sufficient. Fact|date=December 2007 On the other hand, this specificity is also a disadvantage: A phage will only kill a bacterium if it is a match to the specific strain. Thus, phage mixtures are often applied to improve the chances of success, or samples can be taken and an appropriate phage identified and grown.
Phages are currently being used therapeutically to treat bacterial infections that do not respond to conventional antibiotics, particularly in the country of Georgia.BBC Horizon: Phage - The Virus that Cures] cite journal |author=Parfitt T |title=Georgia: an unlikely stronghold for bacteriophage therapy |journal=Lancet |volume=365 |issue=9478 |pages=2166–7 |year=2005 |pmid=15986542|doi=10.1016/S0140-6736(05)66759-1] cite journal
title =Old dogma, new tricks—21st Century phage therapy
journal =Nature Biotechnology
publisher =Nature Publishing Group
location =London UK
month =January | year =2004
accessdate =2007-12-15] They tend to be more successful than antibiotics where there is a
biofilmcovered by a polysaccharidelayer, which antibiotics typically cannot penetrate. Fact|date=December 2007 In the West, no therapies are currently authorized for use on humans, although phages for killing food poisoningbacteria (" Listeria") are now in use.cite journal |author=Pirisi A |title=Phage therapy—advantages over antibiotics? |journal=Lancet |volume=356 |issue=9239 |pages=1418 |year=2000 |pmid=11052592 |doi=10.1016/S0140-6736(05)74059-9]
Following the discovery of bacteriophages by
Frederick Twortand Felix d'Hérellecite journal |author=Shasha SM, Sharon N, Inbar M |title= [Bacteriophages as antibacterial agents] |language=Hebrew |journal=Harefuah |volume=143 |issue=2 |pages=121–5, 166 |year=2004 |pmid=15143702 |doi=] in 1915 and 1917, phage therapy was immediately recognized by many to be a key way forward for the eradication of bacterial infections. A Georgian, George Eliava, was making similar discoveries. He travelled to the Pasteur Institutein Paris where he met d'Hérelle, and in 1926 he founded the Eliava Institutein Tbilisi, Georgia, devoted to the development of phage therapy.
In neighbouring countries including
Russia, extensive research and development soon began in this field. In the USA during the 1940s, commercialization of phage therapy was undertaken by the large pharmaceutical company, Eli Lilly.
Whilst knowledge was being accumulated regarding the biology of phages and how to use phage cocktails correctly, early uses of phage therapy were often unreliable. When
antibioticswere discovered in 1941 and marketed widely in the USA and Europe, Western scientists mostly lost interest in further use and study of phage therapy for some time.cite journal |author=Hanlon GW |title=Bacteriophages: an appraisal of their role in the treatment of bacterial infections |journal=Int. J. Antimicrob. Agents |volume=30 |issue=2 |pages=118–28 |year=2007 |pmid=17566713 |doi=10.1016/j.ijantimicag.2007.04.006 |url=http://linkinghub.elsevier.com/retrieve/pii/S0924-8579(07)00203-8]
Isolated from Western advances in antibiotic production in the 1940s, Russian scientists continued to develop already successful phage therapy to treat the wounds of
soldiers in field hospitals. During World War II, the Soviet Union used bacteriophages to treat many soldiers infected with various bacterial diseases e.g. dysentery and gangrene. The success rate was as good as, if not better than any antibiotic.Fact|date=March 2007 Russian researchers continued to develop and to refine their treatments and to publish their research and results. However, due to the scientific barriers of the Cold War, this knowledge was not translated and did not proliferate across the world. [ "Stalin's Forgotten Cure" " Science (magazine)" 25 October 2002v.298 [www.sciencemag.org] [http://www.phage-biotech.com/images/Science-phagetherapy.pdf reprint] ] cite journal |author=Summers WC |title=Bacteriophage therapy |journal=Annu. Rev. Microbiol. |volume=55 |issue= |pages=437–51 |year=2001 |pmid=11544363 |doi=10.1146/annurev.micro.55.1.437] There is an extensive library and research center at the Eliava Institute in Tbilisi, Georgia. Phage therapy is today a widespread form of treatment in neighbouring countries. For 80 years Georgian doctors have been treating local people, including babies and newborns, with phages.
As a result of the development of antibiotic resistance since the 1950s and an advancement of scientific knowledge, there is renewed interest worldwide in the ability of phage therapy to eradicate bacterial infections and chronic polymicrobial biofilm, along with other strategies.
Phages have been explored as means to eliminate pathogens like "
Campylobacter" in raw foodcite journal |author=Mangen MJ, Havelaar AH, Poppe KP, de Wit GA |title=Cost-utility analysis to control Campylobacter on chicken meat: dealing with data limitations |journal=Risk Anal. |volume=27 |issue=4 |pages=815–30 |year=2007 |pmid=17958494 |doi=10.1111/j.1539-6924.2007.00925.x |url=http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0272-4332&date=2007&volume=27&issue=4&spage=815] and " Listeria" in fresh food or to reduce food spoilage bacteria.cite book | author = Mc Grath S and van Sinderen D (editors). | title = Bacteriophage: Genetics and Molecular Biology | edition = 1st ed. | publisher = Caister Academic Press | year = 2007 | url=http://www.horizonpress.com/phage | id = [http://www.horizonpress.com/phage ISBN 978-1-904455-14-1 ] ] In agricultural practice phages were used to fight pathogens like " Campylobacter", " Escherichia" and " Salmonella" in farm animals, " Lactococcus" and " Vibrio" pathogens in fish from aquaculture and " Erwinia" and " Xanthomonas" in plants of agricultural importance. The oldest use was, however, in human medicine. Phages were used against diarrheal diseases caused by " E. coli", " Shigella" or " Vibrio" and against wound infections caused by facultative pathogens of the skin like staphylococciand streptococci. Recently the phage therapy approach has been applied to systemic and even intracellular infections and the addition of non-replicating phage and isolated phage enzymes like lysinsto the antimicrobial arsenal. However, definitive proof for the efficiency of these phage approaches in the field or the hospital is only provided in a few cases.cite book | author = Mc Grath S and van Sinderen D (editors). | title = Bacteriophage: Genetics and Molecular Biology | edition = 1st ed. | publisher = Caister Academic Press | year = 2007 | url=http://www.horizonpress.com/phage | id = [http://www.horizonpress.com/phage ISBN 978-1-904455-14-1 ] ]
Some of the interest in the West can be traced back to 1994, when Soothill demonstrated (in an animal model) that the use of phages could improve the success of skin grafts by reducing the underlying "
Pseudomonas aeruginosa" infection.cite journal |author=Soothill JS |title=Bacteriophage prevents destruction of skin grafts by Pseudomonas aeruginosa |journal=Burns |volume=20 |issue=3 |pages=209–11 |year=1994 |pmid=8054131|doi=10.1016/0305-4179(94)90184-8] Recent studies have provided additional support for these findings.cite journal |author=McVay CS, Velásquez M, Fralick JA |title=Phage therapy of Pseudomonas aeruginosa infection in a mouse burn wound model |journal=Antimicrob. Agents Chemother. |volume=51 |issue=6 |pages=1934–8 |year=2007 |pmid=17387151 |doi=10.1128/AAC.01028-06 |url=http://aac.asm.org/cgi/pmidlookup?view=long&pmid=17387151]
Recently, the use of phages as delivery mechanisms for traditional antibiotics has been proposed.cite journal |author=Yacoby I, Bar H, Benhar I |title=Targeted drug-carrying bacteriophages as antibacterial nanomedicines |journal=Antimicrob. Agents Chemother. |volume=51 |issue=6 |pages=2156–63 |year=2007 |pmid=17404004 |doi=10.1128/AAC.00163-07 |url=http://aac.asm.org/cgi/pmidlookup?view=long&pmid=17404004] cite journal |author=Yacoby I, Shamis M, Bar H, Shabat D, Benhar I |title=Targeting antibacterial agents by using drug-carrying filamentous bacteriophages |journal=Antimicrob. Agents Chemother. |volume=50 |issue=6 |pages=2087–97 |year=2006 |pmid=16723570 |doi=10.1128/AAC.00169-06 |url=http://aac.asm.org/cgi/pmidlookup?view=long&pmid=16723570] The use of phages to deliver antitumor agents has also been described, in preliminary "in vitro" experiments for cells in tissue culture.cite journal |author=Bar H, Yacoby I, Benhar I |title=Killing cancer cells by targeted drug-carrying phage nanomedicines |journal=BMC Biotechnol. |volume=8 |issue= |pages=37 |year=2008 |pmid=18387177 |doi=10.1186/1472-6750-8-37 |url=http://www.biomedcentral.com/1472-6750/8/37]
A potential benefit of phage therapy is freedom from the severe adverse effects of antibiotics. Also it would possibly be fast-acting, once the exact bacteria are identified and the phages administered. Another benefit of phage therapy is that although
bacteriaare able to develop resistance to phages the resistance might be easier to overcome.
Bacteriophages are often very specific, targeting only one or a few strains of bacteria.cite journal |author=Duckworth DH, Gulig PA |title=Bacteriophages: potential treatment for bacterial infections |journal=BioDrugs |volume=16 |issue=1 |pages=57–62 |year=2002 |pmid=11909002 |doi=] Traditional antibiotics usually have more wide-ranging effect, killing both harmful bacteria and useful bacteria such as those facilitating food digestion. The specificity of bacteriophages might reduce the chance that useful bacteria are killed when fighting an infection.
Increasing evidence shows the ability of phages to travel to a required site — including the brain, where the
blood brain barriercan be crossed — and multiply in the presence of an appropriate bacterial host, to combat infections such as meningitis. However the patient's immune system can, in some cases mount an immune response to the phage (2 out of 44 patients in a Polish trial ["Non-antibiotic therapies for infectious diseases." by Christine F Carson, and Thomas V Riley "Communicable Diseases Intelligence" Volume 27 Supplement - May 2003 [http://www.aodgp.gov.au/internet/wcms/publishing.nsf/Content/cda-pubs-cdi-2003-cdi27suppl-htm-cdi27supab.htm Australian Dept of health website] ] ). This might possibly be therapeutically significant.
Development and production is faster than
antibiotics, on condition that the required recognition molecules are known. Fact|date=May 2008
Research groups in the West are engineering a broader spectrum phage and also target
MRSAtreatments in a variety of forms - including impregnated wound dressings, preventative treatment for burn victims, phage-impregnated sutures. Enzobiotics are a new development at Rockefeller University that create enzymes from phage. These show potential for preventing secondary bacterial infections e.g. pneumonia developing with patients suffering from flu, otitis etc..Fact|date=May 2008
Some bacteria such as multiply resistant
Klebsiella pneumoniaehave no non toxic antibiotics available, and yet killing of the bacteria via intraperitoneal, intravenous or intranasal of phages in vivo has been shown to work in laboratory tests. [ [http://www.ncbi.nlm.nih.gov/pubmed/1882608?dopt=Abstract] ]
In its simplest form, phage treatment works by collecting local samples of water likely to contain high quantities of bacteria and bacteriophages, for example
effluentoutlets, sewageand other sources. They can also be extracted from corpses. The samples are taken and applied to the bacteria that are to be destroyed which have been cultured on growth medium.
The bacteria usually die, and the mixture is centrifuged. The phages collect on the top of the mixture and can be drawn off.
The phage solutions are then tested to see which ones show growth suppression effects (lysogeny) and/or destruction (lysis) of the target bacteria. The phage showing lysis are then amplified on cultures of the target bacteria, passed through a filter to remove all but the phages, then distributed.
Phages are "bacterium specific" and it is therefore necessary in many cases to take a swab from the patient and culture it prior to treatment. Occasionally, isolation of therapeutic phages can typically require a few months to complete, but clinics generally keep supplies of phage cocktails for the most common bacterial strains in a geographical area.
Phages in practice are applied orally, topically on infected wounds or spread onto surfaces, or used during surgical procedures. Injection is rarely used, avoiding any risks of trace chemical contaminants that may be present from the bacteria amplification stage,and recognizing that the immune system naturally fights against viruses introduced into the bloodstream or lymphatic system.
The direct human use of phage might possibly be safe; suggestively, in August 2006, the United States
Food and Drug Administrationapproved spraying meat with phages. Although this initially raised concerns since without mandatory labelingconsumers won't be aware that meat and poultry products have been treated with the spray, [http://www.forbes.com/business/healthcare/feeds/ap/2006/08/18/ap2959720.html] it confirms to the public that, for example, phages against " Listeria" are generally recognized as safe (GRAS status) within the worldwide scientific community and opens the way for other phages to also be recognized as having GRAS status. Phage therapy has been attempted for the treatment of a variety of bacterial infections including: laryngitis, skin infections, dysentery, conjunctivitis, periodontitis, gingivitis, sinusitis, urinary tract infections and intestinal infections, burns, boils, etc. - also poly-microbial biofilms on chronic wounds, ulcers and infected surgical sites. Fact|date=December 2007
In 2007, Phase 2a clinical trials have been reported at the
Royal National Throat, Nose and Ear Hospital, London for " Pseudomonas aeruginosa" infections ( otitis).cite web |url=http://www.bccapital.co.uk/PressNews/tabid/118/Default.aspx |title=Press & News |accessdate=2007-12-13 |format= |work=] .cite web |url=http://www.biocontrol.ltd.uk/STVdoc.htm |title=biocontrol.ltd.uk |accessdate=2007-12-13 |format= |work=] cite web |url=http://www.biocontrol-ltd.com/PressNews/tabid/61/articleType/ArticleView/articleId/9/Scientists-start-germ-warfare-to-beat-illness.aspx |title=biocontrol-ltd.com |accessdate=2008-04-30 |format= |work=] Documentation of the Phase-1 and Phase-2a study is not available at present.
Phase 1 clinical trials are underway in the South West Regional Wound Care Center, Lubbock, Texas for an approved cocktail of phages against bacteria, including "P. aeruginosa", "
Staphylococcus aureus" and " Escherichia coli" (better known as E. coli). Fact|date=December 2007
Reviews of phage therapy indicate that more clinical and microbiological research is needed to meet current standards. [" "Phage therapy: the "Escherichia coli" experience" by Harald Brüssow in "Microbiology" (2005) v. 151, p.2133-2140. [http://mic.sgmjournals.org/cgi/content/full/151/7/2133?view=long&pmid=16000704 publisher site] ]
Phages can usually be freeze dried and turned into pills without materially impacting efficacy. In pill form temperature stability up to 55 C, and shelf lives of 14 months have been shown.Fact|date=December 2007
Other forms of administration can include application in liquid form. These vials are usually best kept refrigerated.Fact|date=December 2007
Oral administration works better when an antacid is included, as this increases the number of phages surviving passage through the stomach.Fact|date=December 2007
Topical administration often involves application to gauzes that are laid on the area to be treated.Fact|date=December 2007
The host specificity of phage therapy may make it necessary for clinics to make different cocktails for treatment of the same infection or disease because the bacterial components of such diseases may differ from region to region or even person to person. Such a process would make it difficult for large scale production of phage therapy. Additionally, patent issues (specifically on living organisms) may complicate distribution for pharmaceutical companies wishing to have exclusive rights over their "invention"; making it unlikely that a for-profit corporation will invest capital in the widespread application of this technology.
In addition, due to the specificity of individual phages, for a high chance of success, a mixture of phages is often applied. This means that 'banks' containing many different phages are needed to be kept and regularly updated with new phages, which makes regulatory testing for safety harder and more expensive.
Some bacteria, for example "
Clostridium" and " Mycobacterium", have no known therapeutic phages available as yet.
To work, the virus has to reach the site of the bacteria, and viruses do not necessarily reach the "same" places that antibiotics can reach.
Funding for phage therapy research and clinical trials is generally insufficient and difficult to obtain, since it is a lengthy and complex process to patent bacteriophage products. Scientists comment that 'the biggest hurdle is regulatory', whereas an official view is that individual phages would need proof individually because it would be too complicated to do as a combination, with many variables. Due to the specificity of phages, phage therapy would be most effective with a cocktail injection, which are generally rejected by the FDA. Researchers and observers predict that for phage therapy to be successful the FDA must change its regulatory stance on combination drug cocktails.cite journal |author=Thiel K |title=Old dogma, new tricks—21st Century phage therapy |journal=
Nat. Biotechnol.|volume=22 |issue=1 |pages=31–6 |year=2004 |pmid=14704699 |doi=10.1038/nbt0104-31] Public awareness and education about phage therapy are generally limited to scientific or independent research rather than mainstream media. [Brüssow, H 2007. "Phage Therapy: The Western Perspective". in S. McGrath and D. van Sinderen (eds.) "Bacteriophage: Genetics and Molecular Biology", Caister Academic Press, Norfolk, UK. ISBN 978-1-904455-14-1 ]
The negative public perception of viruses may also play a role in the reluctance to embrace phage therapy.cite journal |author=Verbeken G, De Vos D, Vaneechoutte M, Merabishvili M, Zizi M, Pirnay JP |title=European regulatory conundrum of phage therapy |journal=Future Microbiol |volume=2 |issue=5 |pages=485–91 |year=2007 |pmid=17927471 |doi=10.2217/17460922.214.171.1245 |url=http://www.futuremedicine.com/doi/abs/10.2217/174609126.96.36.1995]
Phage therapy is generally considered safe. As with antibiotic therapy and other methods of countering bacterial infections,
endotoxins are released by the bacteria as they are destroyed within the patient ( Herxheimer reaction). This can cause symptoms of fever, or in extreme cases toxic shock(a problem also seen with antibiotics) is possible. [ [http://www.evergreen.edu/phage/phagetherapy/phagetherapy.htm Evergreen PHAGE THERAPY: BACTERIOPHAGES AS ANTIBIOTICS] ] Janakiraman Ramachandran, a former president of AstraZeneca India who 2 years ago launched GangaGen Inc., a phage-therapy start-up in Bangalore, [ [http://www.phageinternational.com/phagetherapy/stalins_print.htm Stone, Richard. "Stalin's Forgotten Cure." Science Online 282 ( 25 October 2002).] ] argues that this complication can be avoided in those types of infection where this reaction is likely to occur by using genetically engineered bacteriophages; which have had their gene responsible for producing endolysin removed. Without this gene the host bacterium still dies but remains intact because the lysis is disabled. On the other hand this modification stops the exponential growth of phages, so one administered phage means one dead bacterial cell.cite journal
title =Old dogma, new tricks—21st Century phage therapy
journal =Nature Biotechnology
publisher =Nature Publishing Group
location =London UK
month =January | year =2004
accessdate =2007-12-15] Eventually these dead cells are consumed by the normal house cleaning duties of the phagocytes, which utilise enzymes to break the whole bacterium and its contents down into its harmless sub-units of proteins, polysaccharides and lipids. [cite book
first =Stuart Ira
title =Human Physiology -6th ed.
pages = pages: 50,55,448,449
isbn =0-697-34191-7 ]
Care has to be taken in manufacture that the phage medium is free of bacterial fragments and endotoxins from the production process.
Lysogenic bacteriophages are not generally used therapeutically. This group can act as a way for bacteria to exchange DNA, and this can help spread antibiotic resistance or even, theoretically, can make the bacteria pathogenic (see
The lytic bacteriophages available for phage therapy are best kept refrigerated but discarded if the pale yellow clear liquid goes cloudy.
* The novel "Arrowsmith" used phage therapy as a plot point.cite journal |author=Summers WC |title=On the origins of the science in Arrowsmith: Paul de Kruif, Felix d'Herelle, and phage |journal=J Hist Med Allied Sci |volume=46 |issue=3 |pages=315–32 |year=1991 |pmid=1918921|doi=10.1093/jhmas/46.3.315] cite web |url=http://www.time.com/time/magazine/article/0,9171,847952,00.html |title=Phage Findings - TIME |accessdate=2007-12-13 |format= |work=] cite web |url=http://www.sparknotes.com/lit/arrowsmith/section11.rhtml |title=SparkNotes: Arrowsmith: Chapters 31–33 |accessdate=2007-12-13 |format= |work=]
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