Revolution in the fight against problematic skin

Staphylococcus aureus is a gram-positive bacterium that is part of the normal skin microbiome of humans and animals. It is characterized by the formation of biofilms, high resistance to the surrounding environment and rapid gene transfer using plasmids. Thanks to these factors, S. aureus easily acquires antibiotic resistance and becomes one of the most common causes of hospital-acquired infections. Therefore, the World Health Organization included it in the ESKAPE group, which includes the most dangerous pathogens against which it is most urgent to find new ways to treat them. Biofilms often grow in chronic wounds, on the surface of implants, endoprostheses and invasive medical devices

S. aureus causes a wide range of infections – from numerous skin infections, wound infections, pneumonia to sepsis. It is the cause of up to 80% of all detected nosocomial infections [2]. Skin infections caused by methicillin-resistant staphylococcus aureus tend to be the most problematic, which are the most common and new treatment options are therefore most in demand. In addition to infections from the hospital environment, it also causes community-spread infections, which mainly affect young and healthy individuals.

Phage therapy is proving to be one of the options for effectively fighting resistant strains. Phages can multiply at the site of infection without burdening the patient's organism and its microflora. In addition, it turns out that there are no side effects that commonly occur with antibiotic treatment. Unlike antibiotics, phages can destroy biofilms of bacteria because they can penetrate the biofilm mass that surrounds and protects them [4]. Phage therapy for methicillin-resistant Staphylococcus aureus (MRSA) appears to be a potential option for dealing with resistant infections, according to numerous studies from around the world - especially from the United States, China, Poland and other countries.

A 16-year-old boy who suffered from severe skin infections, multiple drug allergies, and multiple hereditary diseases was treated with a cocktail of phages that was applied in the form of a cream and solution to the affected areas. After 7 days, there was a significant improvement in the patient's health status, and after 6 months, a significant increase in the patient's quality of life [1].

After administration of phage cocktail AB-SA01 to diabetic mice with chronic wounds that were infected with MRSA, the majority of mice experienced complete wound healing. In all mice, the result of the treatment was better than the treatment with vancomycin, both in terms of the size of the wounds and the detected bacterial load. No side effects were observed in mice treated with the phage cocktail [3]. There are more similar works that publish the results of experimental phage therapy in mice. A similar study looked at phage therapy of ulcers infected with S. aureus, P. aeruginosa and A. baumanii in mice and pigs and diabetes. Phage treatment significantly reduced bacterial colony counts and improved ulcer healing in S. aureus and P aeruginosa infections. For A. baumanii, however, the treatment did not produce similarly successful results. Mice also responded better to treatment than pigs.

In another study, the effectiveness of the phage cocktail on non-healing wounds was tested in 20 selected patients between 16-20 years of age who were colonized by strains of S. aureus, E. Coli and P. aeruginosa. In total, the wound was treated with phage cocktail 3-5 times. After this application, the size of the wounds was significantly reduced and there was no sign of infection on the surface of the wounds after microbiological examination. In 7 patients, the wound completely healed after three weeks.

A similar study tested phage therapy for chronic wounds and skin ulcers in 48 patients, of whom twenty-one were healthy and 27 had diabetes. Those affected were infected with several types of bacteria at the same time, including S. aureus. Complete recovery occurred in 39 patients. The success rate was 90.5% for non-diabetics, 74.1% for diabetics. The leg ulcers were significantly reduced after treatment. Healing occurred within 90 days of the start of the study.

A subsequent study investigated the use of a phage cocktail of MR-5 and MR-10 phages coated with transferons (substances that enhance transport, regulate drug release and penetration) to treat skin abscesses on the thighs of mice caused by MRSA. Its effectiveness was then compared with a cocktail containing free phages without transferons. In both cases, there was a significant reduction in the bacterial load – in the transferron cocktail, the maximum load occurred on the 1st day of treatment, followed by a gradual decrease on the 6th day, when the tissue was completely sterile. For free phage cocktails, the maximum load was observed on day 3 of treatment, on day 9 the tissue was sterile. Without treatment, the infection resolved itself after 15-20 days [7].

Skin infections on the ears of rabbits colonized with a strain of S. aureus associated with biofilm formation were treated with bacteriophage every other day. The second control group was not treated at all, and the third group underwent removal of infected tissue in addition to phage treatment. While in the first two groups there was no significant reduction in the number of bacteria and acceleration of healing, in the third monitored group there was an improvement in all observed parameters [8].

A single application of phage had the same therapeutic effect on the treatment of chronic diabetic wounds as the drug (an antibiotic from the oxazolidinone group), which is used to treat diabetic ulcers. When both treatments were combined, the resulting treatment was much faster and more successful (in terms of histopathological analysis, detected bacterial load and wound size) [9].

The first paper in France that described successful phage therapy with S.aureus dates from 1921. Research was carried out by Bruynoghe and Maisin in Belgium in the same year. It was found that the injection of staphylococcal phages near the ulcers (furuncles and carbuncles) resulted in improvement of the condition in 6 patients within 48 hours. There was a decrease in swelling, a decrease in pain and a reduction in fever [14].

Gougerot and Peyre also dealt with phage therapy for recurrent farunculosis and impetigo. Phages were injected with a syringe into the affected area, in the case of impetigo the crusts were first removed from the wounds and then the wounds were smeared with phage. A dressing saturated in phage solution was then applied to the wound. Pustules increased during the first day, but after 48 hours the lesions dried and disappeared [14].

Already during the Winter War of the USSR against Finland in 1939-1940, a phage preparation was used to treat infections of various types of wounds. Soldiers treated with a phage cocktail effective against Streptococcus and Staphylococcus bacteria developed at the Eliav Institute in Tbilisi, present-day Georgia. Thanks to phage therapy, up to 89% of wounded soldiers survived, compared to 58% of those who did not receive phage therapy. It also reduced the incidence of gangrene in soldiers by 30% [10].

In Poland, Sklopek et al. between 1981 and 1986, they applied phage therapy to 550 patients who suffered from purulent skin infections (purulent ulcers, subcutaneous inflammations, furunculosis, inflammation of the lymphatic channels...). Over 92.4% of patients (508) responded positively to the treatment, in 38 patients there was a temporary improvement and in 4 patients the treatment was not effective. A total of 518 patients were affected by antibiotic-resistant infections [15]. In another Polish study involving 1307 patients affected by multidrug-resistant infections, phage therapy of purulent burns was described in 49 patients. Phages were administered both topically and orally. 42 patients were successfully treated. The average duration of treatment was 32 days [21].

Over-the-counter phage products are available in Georgia and Russia. Pyophage is a cocktail of phages against several different types of bacteria, including S. aureus. It is used to treat purulent skin or wound infections [14].

In the book by the authors Chanishvilio and Sharp, the chapter Phage therapy in dermatology describes the successful phage therapy of a wide range of skin infections - abscesses, furuncles and various dermatitis. Over 6,000 patients were enrolled in the study, and 70-100% of patients recovered within 4-8 days of starting treatment. The phages were injected every other day with the dose gradually increasing. Already after 2 injections, it brought significant pain relief, the resulting scarring of the healed wound was significantly smaller. Another successful Georgia study from 1970 looked at the treatment of staphylococcal ulcers, carbuncles, furuncles and hidradenitis where antibiotics had failed. 94.4% of patients were successfully treated, 4.3% experienced significant improvement, and 1.3% of patients did not respond to treatment [14].

Nowadays, a clinical trial is only conducted when all known treatment procedures have been exhausted. One such study was conducted on 6 diabetic patients whose ulcers were infected with MRSA and the infection was not sensitive to any antibiotic treatment. The ulcers were treated with phage Sb-1 and there was complete eradication of MRSA from the wounds in all patients in the study. After 7 weeks, the ulcers were completely healed [11].

Cislo et al. conducted a study focused on phage therapy of purulent skin infections caused by various pathogens (E.coli, S. aureus. K. pneumoniae, P. aeruginosa...) in 31 patients. During the 2-16 weeks of treatment, the overall condition improved, local inflammation was suppressed, ulcers healed faster, and control bacteriological tests were negative. In 16 patients there was complete healing, in 7 significant improvement, in 2 only temporary and in 1 it was insufficient. Adverse effects occurred in 6 cases [19].

PhagoBioDerm has been used to treat radiation burns infected with MRSA. PhageBiDerm is a cocktail of lytic phages with different hosts in a polymer mixture. Wound suppuration, which lasted for more than a month despite aggressive antibiotic treatment, successfully stopped 2-7 days after the first treatment [12]. Markoishvili and his colleagues also used PhagoBioDerm to treat infected venous stasis skin ulcers. The preparation was administered both alone and in combination with other treatment strategies. 70% of 100 patients had complete ulcer healing [14].

In addition to the phages themselves, endolysins are also used - lytic proteins that help the phages get out of the host cell. These are highly specific to the host and do not affect the human organism and the surrounding microflora. The Micreos company introduced the Gladskin brand, whose main active ingredient is mainly phage endolysins. One such product is Staphefekt SA.100, which has been found to significantly reduce the bacterial load and cure skin infections caused by S. aureus when applied topically to the affected area [13].

References:

[1] Plumet, L., Ahmad-Mansour, N., Dunyach-Remy, C., Kissa, K., Sotto, A., Lavigne, J. P., Costechareyre, D., & Molle, V. (2022). Bacteriophage Therapy for Staphylococcus Aureus Infections: A Review of Animal Models, Treatments, and Clinical Trials. Frontiers in cellular and infection microbiology, 12, 907314. https://doi.org/10.3389/fcimb.2022.907314

[2] Plumet, L., Ahmad-Mansour, N., Dunyach-Remy, C., Kissa, K., Sotto, A., Lavigne, J. P., Costechareyre, D., & Molle, V. (2022). Bacteriophage Therapy for Staphylococcus Aureus Infections: A Review of Animal Models, Treatments, and Clinical Trials. Frontiers in cellular and infection microbiology, 12, 907314. https://doi.org/10.3389/fcimb.2022.907314

[3] Kifelew, L. G., Warner, M. S., Morales, S., Vaughan, L., Woodman, R., Fitridge, R., Mitchell, J. G., & Speck, P. (2020). Efficacy of phage cocktail AB-SA01 therapy in diabetic mouse wound infections caused by multidrug-resistant Staphylococcus aureus. BMC microbiology, 20(1), 204. https://doi.org/10.1186/s12866-020-01891-8

[4] Gupta P, Singh HS, Shukla VK, Nath G, Bhartiya SK. Bacteriophage Therapy of Chronic Nonhealing Wound: Clinical Study. The International Journal of Lower Extremity Wounds. 2019;18(2):171-175. doi:10.1177/1534734619835115

[6] Atshan, S.S.; Hamat, R.A.; Aljaberi, M.A.; Chen, J.-S.; Huang, S.-W.; Lin, C.-Y.; Mullins, B.J.; Kicic, A. Phage Therapy as an Alternative Treatment Modality for Resistant Staphylococcus aureusInfections. Antibiotics2023, 12, 286. https://doi.org/10.3390/antibiotics12020286

[7] Chhibber S, Shukla A, Kaur S. Transfersomal Phage Cocktail Is an Effective Treatment against Methicillin-Resistant Staphylococcus aureus-Mediated Skin and Soft Tissue Infections. Antimicrob Agents Chemother. 2017 Sep 22;61(10):e02146-16. doi: 10.1128/AAC.02146-16. PMID: 28739792; PMCID: PMC5610514.

[8] Seth AK, Geringer MR, Nguyen KT, Agnew SP, Dumanian Z, Galiano RD, Leung KP, Mustoe TA, Hong SJ. Bacteriophage therapy for Staphylococcus aureus biofilm-infected wounds: a new approach to chronic wound care. Plast Reconstr Surg. 2013 Feb;131(2):225-234. doi: 10.1097/PRS.0b013e31827e47cd. PMID: 23357984.

[9] Chhibber S, Kaur T, Sandeep Kaur. Co-therapy using lytic bacteriophage: effective treatment in eliminating methicillin resistant Staphylococcus aureus (MRSA) from diabetic foot infections. PLoS One. 2013;8(2):e56022. doi: 10.1371/journal.pone.0056022. Epub 2013 Feb 13. PMID: 23418497; PMCID: PMC3572146.

[10] Chang RYK, Morales S, Okamoto Y, Chan HK. Topical application of bacteriophages for treatment of wound infections. Transl Res. 2020 Červen;220:153-166. DOI: 10.1016/j.trsl.2020.03.010. EPUB 2020 19. března. PMID: 32268129; PMCID: PMC7293950.

[11] FISH, R., E. KUTTER, G. WHEAT, B. BLASDEL, M. KUKATELADZE a S. KUHL. Bacteriophage treatment of intransigent diabetic toe ulcers: a case series. Journal of Wound Care [online]. 2016, 13 July 2016 [cit. 2023-03-16]. Dostupné z: https://www.magonlinelibrary.com/doi/abs/10.12968/jowc.2016.25.Sup7.S27

[12] D. Jikia, N. Chkhaidze, E. Imedashvili, I. Mgaloblishvili, G. Tsitlanadze, R. Katsarava, J. Glenn Morris, Jr, Alexander Sulakvelidze, The use of a novel biodegradable preparation capable of the sustained release of bacteriophages in the complex treatment of multidrug‐resistant Staphylococcus aureus‐infected local radiation injuries caused by exposure to Sr90, Clinical and Experimental Dermatology, Volume 30, Issue 1, 1 January 2005, Pages 23–26,, https://doi.org/10.1111/j.1365-2230.2004.01600.x

[13] TOTTÉ, J.E.E, M.B. VAN DOORN a S.G.M.A. PASMANS. Successful Treatment of Chronic Staphylococcus aureus-Related Dermatoses with the Topical Endolysin Staphefekt SA.100: A Report of 3 Cases. Karger [online]. 2017, 22 May 2017, (2), 7 [cit. 2023-03-16]. Dostupné z: https://www.karger.com/Article/FullText/473872

[14] Abedon, Sarah J. Kuhl, Bob G. Blasdel & Elizabeth Martin Kutter(2011) Phage therapy of human infections, Taylor and Francis online, 1:2, 66-85, DOI: 10.4161/bact.1.2.15845

[15] Slopek S, Weber-Dabrowska B, Dabrowski M, Kucharewicz-Krukowska, Results of bacteriophage treatment of suppurative bacterial infections in the years 1981-1986 Arch Immunol Ther Exp (Warsz). Dostupné online: https://pubmed.ncbi.nlm.nih.gov/3455647/,  1987;35(5):569-83. PMID: 3455647.

[16] Capparelli, R., Parlato, M., Borriello, G., Salvatore, P., & Iannelli, D. (2007). Experimental phage therapy against Staphylococcus aureus in mice. Antimicrobial agents and chemotherapy, 51(8), 2765–2773. https://doi.org/10.1128/AAC.01513-06

[17] Chhibber, S., Kaur, T., & Sandeep Kaur (2013). Co-therapy using lytic bacteriophage: effective treatment in eliminating methicillin resistant Staphylococcus aureus (MRSA) from diabetic foot infections. PloS one, 8(2), e56022. https://doi.org/10.1371/journal.pone.0056022

[18] Patel DR, Bhartiya SK, Kumar R, Shukla VK, Nath G. Use of Customized Bacteriophages in the Treatment of Chronic Nonhealing Wounds: A Prospective Study. The International Journal of Lower Extremity Wounds. 2021;20(1):37-46. doi:10.1177/1534734619881076

[19] Cisło M, Dabrowski M, Weber-Dabrowska B, Woytoń A ,Bacteriophage treatment of suppurative skin infections, Archivum Immunologiae et Therapiae Experimentalis. 1987 ;https://pubmed.ncbi.nlm.nih.gov/3447533/ 35(2):175-183. PMID: 3447533.

[20] MENDES, Jao J., Clara LEANDRO, Sofia CORTE-REAL, Raquel BARBOSA, Patricia CAVACO-SILVA, José MELO-CRISTINO, Andrzej GÓRSKI a Miguel GARCIA. Wound healing potential of topical bacteriophage therapy on diabetic cutaneous wounds. Wound Repair and Regeneration: The International Journal of Tissue Repair and Regeneration [Wiley Online Library]. 2013, 11 June 2013, 21(4), 8 [cit. 2023-03-16]. Dostupné z: https://onlinelibrary.wiley.com/doi/full/10.1111/wrr.12056?saml_referrer=

[21] Duplessis CA, Biswas B. A Review of Topical Phage Therapy for Chronically Infected Wounds and Preparations for a Randomized Adaptive Clinical Trial Evaluating Topical Phage Therapy in Chronically Infected Diabetic Foot Ulcers. Antibiotics. 2020; 9(7):377. https://doi.org/10.3390/antibiotics9070377