Running head: PHAGE THERAPY 1

Phage Therapy: Its the End of the World as we know it

Amber Jones Radcliffe

Western Washington University

PHAGE THERAPY 2

Phage Therapy: Its the End of the World as we know it

Intro

Several years ago now, my two young children of 6 and 8 contracted a virulent form of E.

coli O157: H7 and threw our entire family into a tailspin that left an indelible imprint on my life.

Ill never forget talking to the Nephrologist about the prognosis and treatment of the condition

causing my sons kidneys and other organs to shut down, while my sons small little body was

being pumped full of an unbelievable cocktail of drugs to treat his myriad of symptoms.

Because this bacterial infection is a gram negative strain, we cannot use antibiotics to try to

fight it. Gram negative bacteria when destroyed, release their toxins, causing a second wave of

illness that can actually be more harmful than the pathogen, itself. Our only hope at this point is

to make him as comfortable as possible and hope his body can fight it off on its own. I had just

taken a microbiology course only a few months before, so I asked the Doctor if phage therapy

would help.

How do you know about phage therapy?? the Doctor inquired incredulously. He knew

about it, even though it was still just an experimental approach that the US was reconsidering as

a means to fight the growing threat of intractable multi-drug resistant bacterial infections that

were becoming a worldwide epidemic. Unfortunately, phage therapy would have the same effect

as antibiotics in this case; it would lyse the bacterial cells and start a cascade effect that could be

deadly. I understood this at the time, but I was grasping at straws and would have gone to

Timbuktu for the remedy, if it would help. Luckily, after a month in the hospital with kidney

failure, dialysis, and pancreatitis, both of my children managed to fight it off and I was left with

an insatiable desire to find a better way to fight untreatable bacterial infections, other than time

and prayers.
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Bacteriophages, otherwise known as phages, are naturally occurring viruses that only

seek out and destroy one particular type of bacteria. Phage therapy has been around for

approximately 90 years, originally found in 1917. By the 1930s, US scientists were using

phages to treat a variety of bacterial infections. Not only did they effectively fight infections,

they did not harm host cells, or alter a persons beneficial bacteria (Potera, 2013). Lytic

bacteriophages are extremely specific obligatory intracellular parasitic viruses that inject their

own genetic material into a bacterial cell, high-jacking the bacterias own organelles to mass

produce an explosion of clone viruses, destroying the bacterial cell. Not only are phages finicky,

they can be selective even for a specific subspecies within a species (Wittebole, De Roock, Opal,

2014). That translates to effective infection fighting, but only if the right phage is chosen for the

right pathogen. Therefore mixtures are often employed to improve the likelihood of finding an

appropriate match. Furthermore, because phages self-propagate, only a very small dose is

required to be effective, making phage therapy potentially inexpensive to produce. (Abhilash, 1)

The exquisite specificity of phage therapy is both its strength and its weakness. Critics

point out that a drawback of phage therapy is the time that must be taken to appropriately

identify the pathogen in order to select the appropriate phages. Though I would argue that

identification is a necessary step regardless of treatment, new ways are being developed to speed

up this process. One such solution is the KeyPath MRSA/MSSA blood culture test. It determines

the strain of S. aureus in five hours, requires no specialized equipment to use, and is already

approved by the Food and Drug Administration (FDA) for use. (FDA, 2016)

While I acknowledge that antibiotics have served us well since the discovery of penicillin

and have saved countless lives throughout the years, bacteria are adept at developing resistance

at alarming rates. In fact, multi-drug resistant pathogens are now considered one of the great
PHAGE THERAPY 4

health care crises of modern day medicine and we are running out of new antibiotics. I believe

that the answer for this growing problem is phage therapy because it is effective, affordable and

is a springboard for innovation.

Process

This topic has been researched and studied so extensively, that thousands of clinical

studies have been conducted on the topic. Therefore this topic was best researched through more

comprehensive literature reviews and meta-analysis. I pulled from a variety of articles that

detailed the history and progression of bacteriophage therapy from past to present, but that also

discussed the criticisms and solutions posed by current research. I also included key direct

studies that cited pivotal information to some of my arguments. These included human and

animal studies, meta analysis, cohort studies and the like. I used CINHAL and Medline search

engines with the key word searches of bacteriophage, phage, multi-drug infection, sepsis, and

other MESH terms.

Efficacy

We have all heard that there is a growing problem in medicine. People are developing

new, resistant strains of infection and pharmaceutical companies are losing the battle, with a

variety of increasingly ineffective antibiotics available to fight the newest super infections. Why?

If drug companies make money from new drugs, it seems that this would be a golden

opportunity, ripe for the picking. One of the problems facing drug companies today is that new

antibiotics are increasingly difficult to find, develop and test. Pharmaceutical companies are on

the hook for millions of dollars to develop, research, test and trial new antibiotics, which requires

a large investment of time (De Vos, Rose, Jennes, Pirnay, 2012). Because bacteria divide rapidly

in optimal conditions, they also mutate rapidly, which can therefore develop resistance to
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antibiotics in as little as days. (Pray, para 1) Therefore, a pharmaceutical company can

theoretically begin the process of developing a new antibiotic that is already obsolete before it is

ready to market. In a free market system, the problems are just too costly to justify investment

for drug companies.

Antibiotics have also been grossly misused over the years. In addition to human misuse,

agriculture is a major source of over-application for boosting production and therefore produces

widespread resistance, accelerating the problem (Potera, 2013). Meanwhile, people are dying at

alarming rates, requiring new and improved ways to combat the problem (Wittebole et al., 2014)

When a patient is treated with antibiotics, their entire microbial ecosystem is destroyed.

The bacterial imbalance caused by treatment with antibiotics can lead to serious secondary

infections, often extending hospitalization time, expense and mortality. This doesnt occur with

phage therapy (Abhilash, Vidya, Jagadevi, 2008). Studies show that phage therapy doesnt just

have little impact on the microbiota, but careful surveys of the microbiome of healthy adult

volunteers confirmed the preservation of their pre-existing gut flora after phage therapy. In

addition, after treatment with a 9-phage cocktail, there was no secondary overgrowth infection to

contend with (Wittebole et al., 2014).

Allergies are another common problem with antibiotics, which is not only inconvenient,

but can be life threatening and reduce the variety of treatment options for infection. This is not a

problem with phage therapy; no one has been found to have allergies to phages (Abhilash et al.,

2008). An allergy to phages would be like having an allergy to water; not only are they prevalent

in the body, but there is no way to avoid them. In fact, phages are more abundant than bacteria,

literally ubiquitous to our everyday natural environment (Svoboda, 2009). To put the sheer
PHAGE THERAPY 6

magnitude of phages into perspective, we are literally composed of more phages than anything

else, living or otherwise. Not only are phages everywhere and reside in the trillions in everyone,

but scientists are beginning to understand the necessity of the microbes to our immunity and are

increasingly viewed as a type of non-host immune system (Barr, Rita, Mike, Whiteson, Erb,

Pogliano, Stotland, et al., 2013).

Another way that phages particularly outperform antibiotics, is their remarkable ability to

penetrate biofilms, a polysaccharide matrix that encapsulate and protect gram negative bacteria.

Most antibiotics are ineffective against biofilms, but if they are uniquely capable of penetrating

the biofilm barrier, they are ineffective against the intracellular environment. (De Vos et al.,

2012) In addition, biofilms can protect bacteria from industrial cleansers such as bleach,

allowing for subsequent infestation (Potera, 2013). This is not an issue for phages, which are

equipped with targeted enzymes that treat biofilms like an appetizer for the main course.

Consequently, phages have unlimited access inside the bacterial cell, which scientists are already

exploiting by combining phages with antibiotics, to maximize effectiveness and, hopefully

minimize antibiotic resistance (Wright, para 3). Another novel use of phage therapy is through

its remarkable specificity: they can be used to diagnose infection. After all, they will only attack

and lyse one variety of bacteria, which can be tracked (Potera, 2013).

Within the US, foodborne illness is a widespread problem that causes 9.4 million cases of

food poisoning annually, hospitalizes approximately 56,000 and results in over 1,350 deaths,

according to the Centers for Disease Control and Prevention. Listeria monocytogenes is one such

food borne microbe that is extremely problematic for the food industry and causes listeriosis,

which has a fatility rate of approximately 20%.

PHAGE THERAPY 7

ListShield by Intralytix is the first phage product approved as a food additive by the

FDA and specifically targets L. monocytogenes in prepared deli meats and poultry. L.

monocytogenes is a microbe that contaminates both dairy products and raw produce. It grows

even when refrigerated and causes serious problems for the food industry because it is so

difficult to eliminate. According to the manufacturer, their product eliminates 95% of all L.

monocytogene microbes (Potera, 2013).

Another product called EcoShield, is used as a spray on red meat before it is ground

into hamburger in order to kill Escherichia coli O157:H7, which causes 62,000 foodborne

illnesses in the US every year. Because E coli O157:H7 is so potent, only a very small amount

can infect a very large batch of hamburger. Thanks to biofilms, E coli O157:H7 can live on raw

produce, and hard surfaces even with the use of industrial cleansers. The manufacturer of

EcoShield claims an efficacy of 95% in only 5 minutes and the USDAs tests found that the

product removed 100 percent of E coli within a day. Both commercial products are, odorless,

tasteless, invisible, and noncorrosive. Now, there are more products being developed for

agriculture, veterinary medicine, wound healing and oral care (Potera, 2013).

Affordability

The affordability of phage therapy is an inherent strength of this antimicrobial. They can

be found anywhere bacteria are found, because they are attracted to their prey. Because bacteria

are nimble and can adapt quickly to external attacks through adapted resistance, phage are

equally as agile and evolve right alongside bacteria. Therefore, in order to find a phage for a new

pathogenic form of bacteria, a person has to look no further than the sample taken, where the

complimentary phages are attracted like bees to honey. Propagating phages takes around two

weeks from start to finish, unlike the process to develop a drug which takes years. Due to the
PHAGE THERAPY 8

relative economy of phages, they would be an excellent solution for developing nations

(Abhilash et al., 2008).

In addition to the culture and propagation process, the majoriy of the true cost of

introducing phage therapy to the US is the FDA approval process. The FDA must regulate phage

therapy if it is to be used on humans for medical use. Though the FDA has approved products for

agriculture and food production, it is considered an organic food additive and is not being used as

a drug (Casto, Hurwitz, Kou, Mansour, Mayzel, Policke, & Woolf, 2016). In fact, as long as a

product is used directly to treat human disease, the FDA requires that each individual phage be

approved separately. In addition to trialing each unique phage for approval, if any of the phages

mutate during testing, regardless of harm, the trial would be thrown out. The very characteristic

that makes phages so effectivethat expert ability to shape-shiftmakes it difficult for them to

pass muster with the U.S. regulatory authorities (Svoboda, 2009).

Phage Therapy must be vetted for medical use, the same way any new drug would. In

order to be approved, an Investigational New Drug application must be completed for each type

of phage. For traditional drugs, the FDA wants each component of a drug combination to be

proven safe and effective both individually and in combination. For phage cocktails, that means

the activity, potency, and stability of each phage must be demonstrated, said a spokesperson

from the FDA, Rita Chappelle. Considering that there are potentially hundreds, if not thousands

of each bacteriophage that may be used for treatment, the logistics and costs become staggering

(Potera, 2013).

Another way that phage therapy is cost effective, is as a potential source of revenue for

the pharmaceutical industry. Because lysogenic phages transfer their own DNA into a cell, there

are all kinds of potential for introducing susceptibility back into bacteria. Phages can have
PHAGE THERAPY 9

modified DNA incorporated into their genome, which is transferred directly to their target

bacteria. For example, in the case of MRSA which is methicillin resistant, phage can be used to

transfer sensitivity back into staphylococcus. Researchers have already demonstrated that this

can be done. Additionally, phage can be used to carry an antibiotic on its surface, which brings

the drug precisely where its needed (Viertel, Mareike, Ritter, Hans-Peter, 2014). This would be a

tremendous advantage for pharmaceutical companies, making existing antibiotics effective once

more and reducing external pressure to develop new antibiotics (Wittebole et al., 2014)

Innovations

Phages offer a tremendous wealth of options for bioengineers, who are finding novel

ways to modify phages for our benefit. In addition to the modified phages described previously,

bioengineers have also created non-lytic bacteriophages for gram negative infections (Viertel et

al., 2014 ). As described by the doctor in the introduction, gram negative bacteria such as E. coli

release endotoxins when lysed. However, this problem can be overcome with the engineering of

non-lytic phages, that destroy bacteria without releasing endotoxins. Preliminary studies for non-

lytic phages are promising; resulting in decreased inflammatory reactions compared to

antibiotics (Viertel et al., 2014). M13R is an example of an engineered non-lytic phage,

developed by a group of bioengineers, with a system of programmed death controlled by two

modules: a stable toxin and an unstable antidote that neutralised the toxin effect (Hagens, Blsi,

2003). In addition to drastically reduced endotoxin release upon cell death, they have the added

benefit of not propagating within the cell, eliminating any concern of widespread release of

genetically modified viruses (Viertel et al., 2014).

Phages are being used for a variety of applications. They are being produced as biocides

for surfaces that are difficult to sanitize, such as soft surfaces like curtains, uniforms or chairs.
PHAGE THERAPY 10

Such a product could also be used to prevent infection on medical devices, catheters and even

sutures. The University of Pittsburgh has been developing a phage nasal spray that has the

potential to prevent TB transmission (Potera, 2013). Even cancer treatment is being pursued,

with promising results, after inadvertently discovering antitumor activity following phage

inoculation. A preliminary study showed that tumor-specific phages caused neutrophils to

phagocitize a tumor without any other external interventions (Eriksson, Tsagozis, Lundberg,

Parsa, Mangsbo, Persson, Harris, Pisa, 2009).

Dendritic cells, which are a component of the innate immune defense against invaders

and tumors, are synergistically enhanced by phages. Clinical studies demonstrate that the

presence of phages not only prevent further tumor growth, but facilitate enhanced dendritic

tumor destruction. Phages also increase the anti-tumor activity of leukocytes, which are the

mainstay of immunity, and are being studied with further clinical research (Elzbieta, Rossowska,

Weber-Dabrowska, Zabocka, Grski, 2008). Other innovations for cancer treatment include bio-

engineered phages, that display and present anticancer peptides that find, detect, and facilitate

cellular uptake of targeted drugs to fight the tumors, and not the surrounding tissues (Jin, Jin,

Hong, 2014). Cancer is one of the biggest health problems of modern day, so its heartening to

think that phages might be part of the solution.

Another way that phages are being developed, is by isolating lysins and holins, which are

the active agents that phages employ to destroy bacterial cells. In contrast to bacteriophages that

target a specific bacterial cell, lysins and holins are non-discriminate annihilators of a variety of

bacteria, allowing for general application (Potera, 2013). Lysins may also be a useful backdoor

method for FDA approval. Its simpler to have one or two isolated enzymes approved, which
PHAGE THERAPY 11

would get the foot in the door for approval, generating more acceptance overall for phages

(Casto et al., 2016).

Lysins are only effective against gram positive bacterial infections such as staph,

(because the enzyme cant get through the gram negative cell membrane) but they have the

unique advantage that bacteria cannot become resistant to them (Viertel et al., 2014). Scientists

are developing powerful, engineered lysins that are projected to be effective against MRSA and

Streptococcus pneumonia which has implications for treatment in areas where these infections

are rampant such as hospitals, daycare centers, long term care facilities and also military

barracks.

Synthesis

Not only are bacteriophages an omnipresent, natural presence in our bodies, they keep

our flora in check. As scientists learn more about the natural microbiota of the body and its

critically essential role to the immune system, bacteriophages become even more significant,

because they sit at the top of the microbial food chain, managing every aspect of our bodys

flora.

Therefore, its strange to consider that one of the criticisms of phage therapy is their

effect on the immune system, specifically on antibodies or changes in leukocyte levels. Phages

do affect the immune system, activating the immune system to produce antibodies against them,

which limits the total number of phages that can circulate. However, the flip side of that coin, is

that phages also enhance the activities of the immune system. Based on the evidence, its clear

that phages are an important factor in controlling and destroying tumors, by influencing the

activities of the innate immune system. In addition, many of the best minds in scientific research
PHAGE THERAPY 12

are finding that the microbiota, which solidly includes phages, is not just beneficial to the

immune system, but is a central component of the immune system, itself. This radical new way

of seeing the microbial community in our bodies, may take time to gain traction in the medical

community, but clinical studies are bearing it out. Phages are not just omnipresent, but have co-

evolved to optimize their hosts immunity, which in turn ensures their own survival. They are a

symbiotic bridge between bacteria and the immune system that modify, suppress and activate in

a continuous dance that is simultaneously self-serving and advantageous to us.

Where does all of this fit into modern medicine? Currently, medical facilities are engaged

in an all out war against infection, employing every tool at their disposal to prevent and fight

infection. Hospitals are fighting infection on two fronts; both community-acquired infection and

also Hospital Acquired Infection, otherwise known as HAIs. HAIs require improved infection

control with every interaction between medical professionals and the patient to not only prevent

cross-contamination, but also prevent unnecessary antibiotic resistant super-infections. One of

the ways hospitals employ to combat the problem are antimicrobial cleansers and soaps, which

are used for hand washing, hard surface cleansing and equipment decontamination. At first

glance, such products may appear to be in conflict with phage therapy, but as the growing

mountain of evidence illustrates; such cleansers may be complimented by the addition of phages,

which could be chosen to fight specific bacterial strains that are resistant, enhancing efficacy.

In contrast to combining antibiotics with phages, there are plenty of circumstances where

they should be used alone. Examples include people with antibiotic allergies, those with

secondary super-infections, such as C. difficile, and multi-drug resistant organisms that require a

specific, brand new variety of phage for the job. Each example is a perfect illustration that

antibiotics are not just failing to work, but are also causing harm. Not so with phages, which
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have almost no downsides, except their inability to be tied down. In short, the very attributes that

make phages so inexpensive, nimble and versatile, are the very same characteristics that make

them hard to embrace by the only entity that stands between phage therapy and the US

pharmaceutical market: the FDA. Its precisely because the FDA cannot categorize, patent and

control bacteriophages, that keep them from the American public.

Though it appears to be an insurmountable problem to approve phages with our current

system, given time, the FDA will have to be re-tooled to accept this dramatically different form

of treatment. Perhaps the only way to do this is to wait until the public is desperate for an

alternative. Public outcry and irrefutable evidence that phage therapy not only works, but is not a

threat to safety will be the impetus required for such a large reformation. The scientific

community will play a key role in persuading the powers that be, but the FDA is just a

government entity and cannot stand in the way of medical breakthroughs that may be the only

thing that can protect people.

The inherent unpredictability of viruses cannot be the sticking point preventing forward

momentum with a therapy that can be such a benefit to society. Because phages can mutate and

swap genetic DNA sequences with bacteria, critics are understandably suspicious of anything so

capricious. In particular, it is concerning to authors such as Wittebole et al. that phages could

theoretically transfer pathogenicity to bacteria, increasing virulence. While I can understand the

insecurity that unknown variables present, I remain skeptical that a virus would create problems

like that for itself. By focusing on the uncertain nature of phages, detractors are overlooking

lifes most fundamental imperative: preservation of self. After all, the virus is the predator and

must parasitize their complementary bacteria or die. It would not only be counterproductive for

the virus to ensure its own demise, but counter-evolutionary.

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Conclusion

Worst case scenarios aside, phage therapy and all of its potential for novel applications

continues to be studied and tested, proving more effective and affordable than previously

expected. Not only does phage therapy have exciting benefits in the fight against life threatening

infection, but the potential for innovation is undeniable and must be pursued. I believe phage

therapy will overcome the uncertainty and concerns common with anything new. In particular,

FDA approval is a formidable obstacle, but I believe that like the phage, our first priority is the

preservation of the human race. Therefore, Im confident that the growing threat, combined with

the substantial evidence in favor of phages, will bring about the necessary changes needed to the

government, in order to accept this prospective treatment. Given more time, phage therapy will

ironically be the old solution needed for the new future of infection control. And not a moment

too soon when lives are at stake.

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Bacteriophage Adhering to Mucus Provide a Nonhost-Derived Immunity. Proceedings of the
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Casto, A., Hurwitz, A., Kou, K., Mansour, G., Mayzel, A., Policke, R., . . . & Woolf, A. (2016).
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