Development and Use of Personalized Bacteriophage-Based Therapeutic Cocktails To Treat a Patient with a Disseminated Resistant Acinetobacter baumannii Infection

Isolation and characterization a novel Acinetobacter bacteriophage with activity against several multidrug-resistant Gram-negative bacteria

Acinetobacter baumannii (A. baumannii) is a notorious nosocomial pathogen that is frequently associated with multidrug resistance around the world. Endolysin is a bacteriophage-produced hydrolytic enzyme. In this study, an urban waste water sample (1 L) was collected from Istanbul. A double-agar plating technique was used for host range analysis. The purified genomic DNA sequences were performed on the Miseq. De novo assembly of the crude sequences yielded a double-stranded DNA molecule with a length of 45,679 bp and a guanine-cytosine content of 37.6%. Genome annotation revealed that the vB_AbaM_YNAF genome comprises 85 open reading frames, 23 of which are functional and do not define any tRNA-rRNA genes. Electron microscopy examination and phylogenetic analysis of the genome revealed that vB_AbaM_YNAF represents a novel origin of an unclassified Obolenskvirus belonging to the class Caudoviricetes. vB_AbaM_YNAF infected one reference and three different multidrug-resistant (MDR) strains of each of A. baumannii and K. pneumoniae. However, it did not have any effect on a reference E. coli strain. Based on all of these findings, LysYAN could be a potential agent for treating MDR-Gram-negative bacteria. Further investigations on vB_AbaM_YNAF may be beneficial for designing an alternative weapon with probable wide host-range activity to fight MDR infections.

Recent advancements in bacterial anti-phage strategies and the underlying mechanisms altering susceptibility to antibiotics

The rapid spread of multidrug-resistant bacteria and the challenges in developing new antibiotics have brought renewed international attention to phage therapy. However, in bacteria-phage co-evolution, the rapid development of bacterial resistance to phage has limited its clinical application. This review consolidates the latest advancements in research on anti-phage mechanisms, encompassing strategies such as systems associated with reduced nicotinamide adenine dinucleotide (NAD+) to halt the propagation of the phage, symbiotic bacteria episymbiont-mediated modulation of gene expression in host bacteria to resist phage infection, and defence-related reverse transcriptase (DRT) encoded by bacteria to curb phage infections. We conduct an in-depth analysis of the underlying mechanisms by which bacteria undergo alterations in antibiotic susceptibility after developing phage resistance. We also discuss the remaining challenges and promising directions for phage-based therapy in the future.

Scalable purification of bacteriophages preparations

The use of bacteriophages to treat bacterial infections, known as phage therapy, has regained interest due to the rise of antibiotic-resistant bacteria. To make phage therapy more widely available, scalable purification methods that can adequately remove endotoxins, proteins and host cell DNA must be implemented. This is particularly important when considering intravenous (IV) administration, since the presence of these impurities is highly controlled by regulatory agencies. This work aimed at developing a purification workflow amenable to large-scale manufacturing, centred on the use anion-exchange chromatography (AEC). Lytic phage T4 and Escherichia coli K12 were used as the infection agent and host, respectively. Since endotoxins and phages are negatively charged, the use of an alkaline phosphatase (AP) prior to AEC was investigated to reduce their net negative charge and allow an efficient separation during chromatography. AP was used at 20 or 200 U/mL, and different AEC ligands and stationary phases were tested. H-bond chromatography (without enzymatic treatment) was exploited as well. Final phage titres up to 1.26 × 1011 PFU/mL (plaque forming units) and global recoveries up to 45.1 % were obtained. The highest removal of endotoxins (98.8 %) was obtained after treatment with 20 U/mL of AP, followed by AEC with a quaternary amine packed-bed column. Virtually all proteins and DNA were removed in all workflows. Some of the obtained phage preparations would be suitable for IV administration, regarding endotoxin content. These results demonstrate that an enzymatic treatment in combination with AEC is a promising and scalable alternative to current phage purification techniques.

Isolation and Characterization of a Novel Lytic Phage N22 and Its Effect on Drug-Resistant Klebsiella Pneumoniae

Background

Klebsiella pneumoniae (KP) infections present a significant clinical challenge and are frequently associated with elevated drug resistance. The use of phage therapy has resurged in response to escalating antibiotic resistance. This study aimed to address the multidrug resistance crisis in intensive care units by exploring the use of ceftazidime/avibactam (CAZ/AVI), a widely used clinical antimicrobial agent, in conjunction with phage therapy.

Materials and Methods

We screened a clinical strain of KP from ICU and successfully isolated phage N22 from hospital wastewater. We conducted an in-depth analysis of the physiological and biochemical properties of phage N22 and determined its optimal multiplicity of infection with the clinical KP strain. The inhibitory effects of phage N22 in combination with CAZ/AVI on biofilm formation were investigated. Comparative efficacies of these combinations were evaluated using a Galleria mellonella (G. mellonella) model.

Results

Phage N22 inhibited KP biofilm formation. The impact of varying phage N22 concentrations when used alongside CAZ/AVI was examined, and the combination of phage N22 and CAZ/AVI was more effective against KP than CAZ/AVI alone.

Conclusion

This study provides a preliminary investigation into the effects of combining CAZ/AVI with phage therapy, highlighting its potential significance in developing novel therapeutic strategies for bacterial infections resistant to CAZ/AVI. The findings underscore the importance of advancing highly effective phage agents as alternative treatment modalities for patients with infections refractory to conventional antibiotics.

Mystique, a broad host range Acinetobacter phage, reveals the impact of culturing conditions on phage isolation and infectivity

With the global rise of antimicrobial resistance, phage therapy is increasingly re-gaining traction as a strategy to treat bacterial infections. For phage therapy to be successful however, we first need to isolate appropriate candidate phages for both clinical and experimental research. Acinetobacter baumannii is an opportunistic pathogen known for its ability to rapidly evolve resistance to antibiotics, making it a prime target for phage therapy. Yet phage isolation may be hampered by A. baumannii's ability to rapidly switch between capsular states. Here, we report the discovery and structural characterisation of a novel lytic phage, Mystique. This phage was initially isolated against the wild-type AB5075: a commonly used clinical model strain. When screening Mystique on 103 highly diverse isolates of A. baumannii, we found that it has a broad host range, being able to infect 85.4% of all tested strains when tested on bacterial lawns - a host range that expanded to 91.3% when tested in liquid culture. This variation between solid and liquid culturing conditions on phage infectivity was also observed for several other phages in our collection that were assumed unable to infect AB5075, and some capsule negative mutants that seemed resistant to Mystique proved susceptible when assayed in liquid. This highlights how differences in culturing conditions can drastically impact phage infectivity, with important consequences for phage isolation and characterisation efforts. Finally, Mystique was found to be able to infect other species of Acinetobacter, making it a multi-species phage with broad applicability for further research.

Revisiting therapeutic options against resistant klebsiella pneumoniae infection: Phage therapy is key

Multi-drug resistant and carbapenem-resistant hypervirulent Klebsiella pneumoniae strains are spreading globally at an alarming rate, emerging as one of the most serious threats to global public health. The formidable challenges posed by the current arsenal of antimicrobials highlight the urgent need for novel strategies to combat K. pneumoniae infections. This review begins with a comprehensive analysis of the global dissemination of virulence factors and critical resistance profiles in K. pneumoniae, followed by an evaluation of the accessibility of novel therapeutic approaches for treating K. pneumoniae in clinical settings. Among these, phage therapy stands out for its considerable potential in addressing life-threatening K. pneumoniae infections. We critically examine the existing preclinical and clinical evidence supporting phage therapy, identifying key limitations that impede its broader clinical adoption. Additionally, we rigorously explore the role of genetic engineering in expanding the host range of K. pneumoniae phages, and discuss the future trajectory of this technology. In light of the 'Bad Bugs, No Drugs' era, we advocate leveraging artificial intelligence and deep learning to optimize and expand the application of phage therapy, representing a crucial advancement in the fight against the escalating threat of K. pneumoniae infections.

The relationship of the microbiome, associated metabolites and the gut barrier with pancreatic cancer

Pancreatic cancers have high mortality and rising incidence rates which may be related to unhealthy western-type dietary and lifestyle patterns as well as increasing body weights and obesity rates. Recent data also suggest a role for the gut microbiome in the development of pancreatic cancer. Here, we review the experimental and observational evidence for the roles of the oral, gut and intratumoural microbiomes, impaired gut barrier function and exposure to inflammatory compounds as well as metabolic dysfunction as contributors to pancreatic disease with a focus on pancreatic ductal adenocarcinoma (PDAC) initiation and progression. We also highlight some emerging gut microbiome editing techniques currently being investigated in the context of pancreatic disease. Notably, while the gut microbiome is significantly altered in PDAC and its precursor diseases, its utility as a diagnostic and prognostic tool is hindered by a lack of reproducibility and the potential for reverse causality in case-control cohorts. Future research should emphasise longitudinal and mechanistic studies as well as integrating lifestyle exposure and multi-omics data to unravel complex host-microbiome interactions. This will allow for deeper aetiologic and mechanistic insights that can inform treatments and guide public health recommendations.

Bypassing Evolution of Bacterial Resistance to Phages: The Example of Hyper-Aggressive Phage 0524phi7-1

The ideal bacteriophages (phages) for the treatment of bacterial disease (phage therapy) would bypass bacterial evolution to phage resistance. However, this feature (called a hyper-aggression feature) has never been observed to our knowledge. Here, we microbiologically characterize, fractionate, genomically classify, and perform electron microscopy of the newly isolated Bacillus thuringiensis phage 0524phi7-1, which we find to have this hyper-aggression feature. Even visible bacterial colonies are cleared. Phage 0524phi7-1 also has three other features classified under hyper-aggression (four-feature-hyper-aggressive phage). (1) Phage 0524phi7-1 forms plaques that, although sometimes beginning as semi-turbid, eventually clear. (2) Clear plaques continue to enlarge for days. No phage-resistant bacteria are detected in cleared zones. (3) Plaques sometimes have smaller satellite plaques, even in gels so concentrated that the implied satellite-generating phage motion is not bacterial host generated. In addition, electron microscopy reveals that phage 0524phi7-1 (1) is a myophage with an isometric, 91 nm-head (diameter) and 210 nm-long contractile tail, and (2) undergoes extensive aggregation, which inhibits typical studies of phage physiology. The genome is linear double-stranded DNA, which, by sequencing, is 157.103 Kb long: family, Herelleviridae; genus, tsarbombavirus. The data suggest the hypothesis that phage 0524phi7-1 undergoes both swimming and hibernation. Techniques are implied for isolating better phages for phage therapy.

The Microbiome and Metabolic Dysfunction-Associated Steatotic Liver Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a condition wherein excessive fat accumulates in the liver, leading to inflammation and potential liver damage. In this narrative review, we evaluate the tissue microbiota, how they arise and their constituent microbes, and the role of the intestinal and hepatic microbiota in MASLD. The history of bacteriophages (phages) and their occurrence in the microbiota, their part in the potential causation of MASLD, and conversely, "phage therapy" for antibiotic resistance, obesity, and MASLD, are all described. The microbiota metabolism of bile acids and dietary tryptophan and histidine is defined, together with the impacts of their individual metabolites on MASLD pathogenesis. Both periodontitis and intestinal microbiota dysbiosis may cause MASLD, and how individual microorganisms and their metabolites are involved in these processes is discussed. Novel treatment opportunities for MASLD involving the microbiota exist and include fecal microbiota transplantation, probiotics, prebiotics, synbiotics, tryptophan dietary supplements, intermittent fasting, and phages or their holins and endolysins. Although FDA is yet to approve phage therapy in clinical use, there are multiple FDA-approved clinical trials, and this may represent a new horizon for the future treatment of MASLD.

The Application of DNA Viruses to Biotechnology

The delivery of biomolecules to target cells has been a longstanding challenge in biotechnology. DNA viruses naturally evolved the ability to deliver genetic material to cells and modulate cellular processes. As such, they inherently possess requisite characteristics that have led to their extensive study, engineering, and development as biotechnological tools. Here, we overview the application of DNA viruses to biotechnology, with specific implications in basic research, health, biomanufacturing, and agriculture. For each application, we review how an increasing understanding of virology and technological methods to genetically manipulate DNA viruses has enabled advances in these fields. Additionally, we highlight the remaining challenges to unlocking the full biotechnological potential of DNA viral technologies. Finally, we discuss the importance of balancing continued technological progress with ethical and biosafety considerations.

Exploring the intricacies of antimicrobial resistance: Understanding mechanisms, overcoming challenges, and pioneering innovative solutions

Antimicrobial resistance (AMR) poses a growing global threat. This review examines AMR from diverse angles, tracing the story of antibiotic resistance from its origins to today's crisis. It explores the rise of AMR, from its historical roots to the urgent need to counter this escalating menace. The review explores antibiotic classes, mechanisms, resistance profiles, and genetics. It details bacterial resistance mechanisms with illustrative examples. Multidrug-resistant bacteria spotlight AMR's resilience. Modern AMR control offers hope through precision medicine, stewardship, combination therapy, surveillance, and international cooperation. Converging traditional and innovative treatments presents an exciting frontier as novel compounds seek to enhance antibiotic efficacy. This review calls for global unity and proactive engagement to address AMR collectively, emphasizing the quest for innovative solutions and responsible antibiotic use. It underscores the interconnectedness of science, responsibility, and action in combatting AMR. Humanity faces a choice between antibiotic efficacy and obsolescence. The call is clear: unite, innovate, and prevail against AMR.

Recent insights on phage therapy against multidrug-resistant Acinetobacter baumannii

Acinetobacter baumannii is a prevalent clinical pathogen commonly found to be multidrug-resistant (MDR), causing serious to life-threatening infections, particularly hospital-acquired infections with limited therapeutic options. The MDR phenotype developed against this critical pathogen is increasingly developed globally, reaching a pan-drug-resistant phenotype conferring non-susceptibility to all antimicrobials used in its treatment according to the standard guidelines. Therefore, it is critical to develop innovative treatment approaches, such as phage therapy, considering the rise in drug-resistant A. baumannii infections. In this review, we highlight and discuss the up-to-date antimicrobial resistance of A. baumannii, the use of phages, their limitations, and future perspectives in treating A. baumannii infections. In addition, the combination of phages with antimicrobials, preclinical and clinical studies including pharmacokinetics and pharmacodynamics properties have been discussed.

Phage-antibiotic combinations against Klebsiella pneumoniae: impact of methodological approaches on effect evaluation

Background

The combined use of bacteriophages and antibiotics represents a promising strategy for combating multidrug-resistant bacterial pathogens. However, the lack of uniformity in methods for assessing combination effects and experimental protocols has resulted in inconsistent findings across studies. This study aimed to evaluate the effects of interactions between phages and antibiotics on Klebsiella pneumoniae strains using various statistical approaches to formalize combination effects.

Methods

Effects were assessed for four antibiotics from distinct classes (gentamicin, levofloxacin, meropenem, chloramphenicol), three phages from different genera (Dlv622, Seu621, FRZ284), and a depolymerase (Dep622) on three K. pneumoniae strains of the KL23 capsule type. Antibiotics were used at Cmax concentrations, and phages at sublethal levels. A modified t-test, Bliss independence model, two-way ANOVA, and checkerboard assay were employed to evaluate the results.

Results

Among 48 combinations, 33 effects were statistically significant, including 26 cases of synergy and 7 of antagonism. All statistical methods showed consistency in identifying effects; however, the t-test and Bliss method detected a greater number of effects. The strongest synergy was observed with levofloxacin in combination with Seu621 or Dep622 across all bacterial strains. Checkerboard assays confirmed synergy in selected cases but indicated that combined effects could vary with antimicrobial concentrations.

Conclusion

The choice of analytical method substantially impacts the detection of phage-antibiotic effects. The t-test and Bliss method, due to their simplicity and sensitivity, may be optimal for clinical application, while two-way ANOVA for confirming strong interactions. These results emphasize the need to consider interaction characteristics when designing therapeutic strategies.

Bacteriophage therapy for multidrug-resistant infections: current technologies and therapeutic approaches

Bacteriophage (phage) therapy has emerged as a promising solution to combat the growing crisis of multidrug-resistant (MDR) infections. There are several international centers actively engaged in implementation of phage therapy, and recent case series have reported encouraging success rates in patients receiving personalized, compassionate phage therapy for difficult-to-treat infections. Nonetheless, substantial hurdles remain in the way of more widespread adoption and more consistent success. This Review offers a comprehensive overview of current phage therapy technologies and therapeutic approaches. We first delineate the common steps in phage therapy development, from phage bank establishment to clinical administration, and examine the spectrum of therapeutic approaches, from personalized to fixed phage cocktails. Using the framework of a conventional drug development pipeline, we then identify critical knowledge gaps in areas such as cocktail design, formulation, pharmacology, and clinical trial design. We conclude that, while phage therapy holds promise, a structured drug development pipeline and sustained government support are crucial for widespread adoption of phage therapy for MDR infections.

Novel antibacterial agents and emerging therapies in the fight against multidrug-resistant Acinetobacter baumannii

Acinetobacter baumannii, a multidrug-resistant pathogen, poses a critical challenge in healthcare settings due to its adaptability and limited treatment options. The global rise in antimicrobial resistance (AMR) has underscored the urgent need for novel therapeutic strategies to combat infections caused by extensively drug-resistant (EDR) and pan-drug-resistant (PDR) A. baumannii. Traditional antibiotic discovery methods, such as whole-cell screening, have fallen short, consistently identifying drugs prone to resistance. This review explores the discovery of new anti-bacterial agents targeting A. baumannii, focusing on emerging therapeutic approaches, including nanoparticle-based therapies, antimicrobial peptides, and antibiotic combination therapies. Nanoparticle-based approaches, leveraging enhanced penetration and multi-mechanistic action, show promise in overcoming resistance, though challenges such as toxicity and biocompatibility persist. Additionally, combination therapies, such as polymyxins with carbapenems, have demonstrated efficacy in clinical settings. This review also highlights the limitations of current therapies, the mechanisms of bacterial resistance, and the role of alternative strategies like bacteriophage therapy. Emphasis is placed on the need for further research into overcoming cross-resistance and enhancing therapeutic efficacy against A. baumannii. The review concludes by discussing the importance of advancing research into novel agents, optimizing dosage strategies, and addressing the challenges posed by toxicity to ensure the effective treatment of A. baumannii infections in both hospital and community settings.

Isolation and characterization of Acinetobacter phage vAbaIN10 active against carbapenem-resistant Acinetobacter baumannii (CRAB) isolates from healthcare-associated infections in Dakar, Senegal

BACKGROUND

Carbapenem-resistant Acinetobacter baumannii (CRAB) is a critical antimicrobial resistance threat and a WHO-prioritized pathogen. With intrinsic resistance to multiple antibiotics and the emergence of pan-resistant isolates, CRAB infections are challenging to treat, often relying on polymyxins, tigecycline, aminoglycosides, or combinations, though co-resistance is rising globally. Phage therapy is considered as a potential treatment for multidrug-resistant A. baumannii. This study focused on isolating and characterizing phages active against CRAB strains from healthcare-associated infections in Dakar, Senegal.

METHODS

A lytic phage, Acinetobacter vAbaIN10, was isolated from wastewater collected at the Aristide Le Dantec Hospital in Dakar, Senegal. Isolation, host range, efficiency of plating, temperature and pH stability, lysis kinetics, one-step growth test, sequencing, and genomic analysis were performed.

RESULTS

Phage vAbaIN10 belongs to the class Caudoviricetes and the genus Friunavirus. Its genome is 40,279 bp in size. Phage vAbaIN10 is stable across a wide pH range (3-9) and temperature range (25°C-60°C). The phage's lytic activity was evaluated at different multiplicities of infection (MOI): MOI 10, 1, and 10⁻¹. All MOIs significantly reduced the growth of host bacteria. The one-step growth curve showed that vAbaIN10 had a latency period of 25 min and a burst size of approximately 4.78 × 10³ phages per infected bacterial cell. No tRNA, mtRNA, clustered regularly interspaced short palindromic repeat, virulence factors, or antibiotic resistance genes were found in the genome.

CONCLUSIONS

The biological and genomic characteristics of vAbaIN10 meet the requirements for its potential use in phage therapy.

Phage treatment of multidrug-resistant bacterial infections in humans, animals, and plants: The current status and future prospects

Phages, including the viruses that lyse bacterial pathogens, offer unique therapeutic advantages, including their capacity to lyse antibiotic-resistant bacteria and disrupt biofilms without harming the host microbiota. The lack of new effective antibiotics and the growing limitations of existing antibiotics have refocused attention on phage therapy as an option in complex clinical cases such as burn wounds, cystic fibrosis, and pneumonia. This review describes clinical cases and preclinical studies in which phage therapy has been effective in both human and veterinary medicine, and in an agricultural context. In addition, critical challenges, such as the narrow host range of bacteriophages, the possibility of bacterial resistance, and regulatory constraints on the widespread use of phage therapy, are addressed. Future directions include optimizing phage therapy through strategies ranging from phage cocktails to broadening phage host range through genetic modification, and using phages as vaccines or biocontrol agents. In the future, if phage can be efficiently delivered, maintained in a stable state, and phage-antibiotic synergy can be achieved, phage therapy will offer much needed treatment options. However, the successful implementation of phage therapy within the current standards of practice will also require the considerable development of regulatory infrastructure and greater public acceptance. In closing, this review highlights the promise of phage therapy as a critical backup or substitute for antibiotics. It proposes a new role as a significant adjunct to, or even replacement for, antibiotics in treating multidrug-resistant bacterial infections.

R-pyocins as targeted antimicrobials against Pseudomonas aeruginosa

R-pyocins, bacteriocin-like proteins produced by Pseudomonas aeruginosa, present a promising alternative to phage therapy and/or adjunct to currently used antimicrobials in treating bacterial infections due to their targeted specificity, lack of replication, and stability. This review explores the structural, mechanistic, and therapeutic aspects of R-pyocins, including their potential for chronic infection management, and discusses recent advances in delivery methods, paving the way for novel antimicrobial applications in clinical settings.

In Vitro Interactions Between Bacteriophages and Antibacterial Agents of Various Classes Against Multidrug-Resistant Metallo-β-Lactamase-Producing Pseudomonas aeruginosa Clinical Isolates

Background: Combination therapy with antibiotics and phages has been suggested to increase the antibacterial activity of both antibiotics and phages. We tested the in vitro activity of five antibiotics belonging to different classes in combination with lytic bacteriophages against multidrug-resistant metallo-β-lactamase (MBL)-producing Pseudomonas aeruginosa isolates. Material/Methods: A total of 10 non-repetitive well-characterized MBL-producing P. aeruginosa isolates (5 NDM, 5 VIM) co-resistant to aminoglycosides and quinolones were used. Phage-antibiotic interactions were assessed using an ISO-20776-based broth microdilution checkerboard assay in 96-well microtitration plates. Two-fold dilutions of colistin (8-0.125 mg/L), ciprofloxacin, meropenem, aztreonam, and amikacin (256-4 mg/L) were combined with ten-fold dilutions of five different phages (5 × 109-5 × 100 PFU/mL) belonging to Pakpunavirus, Phikzvirus, Pbunavirus, and Phikmvvirus genus. Plates were incubated at 35 ± 2 °C for 24 h, and the minimum inhibitory concentration of antibiotics (MICA) and phages (MICP) were determined as the lowest drug and phage concentration, resulting in <10% growth based on photometric reading at 550 nm. Interactions were assessed based on the fractional inhibitory concentration index (FICi) of three independent replicates and clinical relevance based on the reversal of phenotypic resistance. The statistical significance of each drug alone and in combination with phages was assessed using GraphPad Prism 8.0. Results: Synergistic and additive interactions were found for 60-80% of isolates for all drugs. FICis were statistically significantly lower than 0.5 for colistin (p = 0.005), ciprofloxacin (p = 0.02), meropenem (p = 0.003), and amikacin (p = 0.002). Interactions were found at clinically achievable concentrations for colistin, meropenem, and amikacin, and a reversal of phenotypic resistance was observed for most strains (63-64%) for amikacin and meropenem. Antagonism was found for few isolates with all antibiotics tested. Phage vB_PaerM_AttikonH10 and vB_PaerP_AttikonH4 belonging to Phikzvirus and Phikmvvirus genus, respectively, showed either synergistic (FICi ≤ 0.35) or additive effects with most antibiotics tested. Conclusions: Synergy was observed for most drugs and phages with amikacin, showing strong synergy and reversal of phenotypic resistance against most isolates. Taking into account the wide utility of jumbo phages obtained, the findings of vB_PaerM_AttikonH10 in combination with different classes of antibiotics can enhance the activity of currently ineffective antibiotics against MBL-producing P. aeruginosa isolates.

Emerging antimicrobial therapies for Gram-negative infections in human clinical use

The growing problem of multi-drug resistance (MDR) is prevalent in Gram-negative infections, and the significant decline in antibiotic development poses a critical threat to global public health. Many emerging non-antibiotic therapies have been proposed, including phage therapy, anti-virulence agents, antimicrobial peptides, plasmapheresis, and immunotherapy options. To identify the therapies most likely to be the next immediate step in treatment for MDR Gram-negative infections, this review highlights emerging therapeutics that have either been successfully used for compassionate care or are currently undergoing clinical trials.

Re-Emergence of Bacteriophages and Their Products as Antibacterial Agents: An Overview

Microbes possess diverse genetic and metabolic traits that help them withstand adverse conditions. Microbial pathogens cause significant economic losses and around 7.7 million human deaths annually. While antibiotics have historically been a lifesaving treatment, their effectiveness is declining due to antibiotic-resistant strains, prompting the exploration of bacterial predation as an alternative. Bacteriophages (BPhs) have reemerged as antibacterial agents, offering advantages over antibiotics, such as (i) high specificity, (ii) self-replication, and (iii) strong killing capacity. This review explores BPh- and enzyme-based antibacterial strategies for infectious disease treatment, discussing phage-antibiotic synergy, the risks of BPh resistance, and the role of quorum sensing in BPh therapy.

In vitro resensitization of multidrug-resistant clinical isolates of Enterococcus faecium and E. faecalis through phage-antibiotic synergy

Bacteriophages are an increasingly attractive option for the treatment of antibiotic-resistant infections, but their efficacy is difficult to discern due to the confounding effects of antibiotics. Phages are generally delivered in conjunction with antibiotics, and thus, when patients improve, it is unclear whether the phages, antibiotics, or both are responsible. This question is particularly relevant for enterococcus infections, as limited data suggest phages might restore antibiotic efficacy against resistant strains. Enterococci can develop high-level resistance to vancomycin, a primary treatment. We assessed clinical and laboratory isolates of Enterococcus faecium and Enterococcus faecalis to determine whether we could observe synergistic interactions between phages and antibiotics. We identified synergy between multiple phages and antibiotics including linezolid, ampicillin, and vancomycin. Notably, antibiotic susceptibility did not predict synergistic interactions with phages. Vancomycin-resistant isolates (n = 6) were eradicated by the vancomycin-phage combination as effectively as vancomycin-susceptible isolates (n = 2). Transcriptome analysis revealed significant gene expression changes under antibiotic-phage conditions, especially for linezolid and vancomycin, with upregulated genes involved in nucleotide and protein biosynthesis and downregulated stress response and prophage-related genes. While our results do not conclusively determine the mechanism of the observed synergistic interactions between antibiotics and phages, they do confirm and build upon previous research that observed these synergistic interactions. Our work highlights how using phages can restore the effectiveness of vancomycin against resistant isolates. This finding provides a promising, although unexpected, strategy for moving forward with phage treatments for vancomycin-resistant Enterococcus infections.

Early Detection, Diagnosis, Prevention, and Treatment of Infection to Avoid Sepsis and Septic Shock in Severely Burned Patients: A Narrative Review

The early detection, diagnosis, anticipation, and therapy of infections to prevent sepsis and septic shock remain significant challenges in cases of grave burns. This narrative review explores various tools for early infection detection, including emerging biomarkers, the American Burn Association's clinical criteria, and traditional blood parameters. A comparative study of the American Burn Association, Mann-Salinas, and Sepsis-3 criteria highlights the superior early detection capabilities of the Sepsis-3 criteria. However, the authors recommend that sepsis should be prospectively evaluated, identified, and classified by the intensive care group, rather than by relying solely on retrospective items, though the latter may still be necessary in certain cases. Advances in biomarker identification, including polymerase chain reaction (PCR) and gene expression (mRNA) profiling, offer diagnostic advantages over current methods, enabling early detection within 4 to 6 h of intensive care unit admission. Mass spectrometry also shows promise for the rapid determination of bacteria, yeast, and fungi based on bacteria protein profiles. Source control remains crucial, and the use of antibacterial topical agents has significantly improved the survival rates of severely burned patients. However, antibiotic selection must be made judiciously to avoid resistance. Despite these advancements, significant progress is still needed to improve the rapid identification, actual presence, prevention, and therapy of infections to reduce the incidence of sepsis and septic shock in this patient subgroup.

Multi-strain phage induced clearance of bacterial infections

Bacteriophage (or 'phage' - viruses that infect and kill bacteria) are increasingly considered as a therapeutic alternative to treat antibiotic-resistant bacterial infections. However, bacteria can evolve resistance to phage, presenting a significant challenge to the near- and long-term success of phage therapeutics. Application of mixtures of multiple phages (i.e., 'cocktails') has been proposed to limit the emergence of phage-resistant bacterial mutants that could lead to therapeutic failure. Here, we combine theory and computational models of in vivo phage therapy to study the efficacy of a phage cocktail, composed of two complementary phages motivated by the example of Pseudomonas aeruginosa facing two phages that exploit different surface receptors, LUZ19v and PAK_P1. As confirmed in a Luria-Delbrück fluctuation test, this motivating example serves as a model for instances where bacteria are extremely unlikely to develop simultaneous resistance mutations against both phages. We then quantify therapeutic outcomes given single- or double-phage treatment models, as a function of phage traits and host immune strength. Building upon prior work showing monophage therapy efficacy in immunocompetent hosts, here we show that phage cocktails comprised of phage targeting independent bacterial receptors can improve treatment outcome in immunocompromised hosts and reduce the chance that pathogens simultaneously evolve resistance against phage combinations. The finding of phage cocktail efficacy is qualitatively robust to differences in virus-bacteria interactions and host immune dynamics. Altogether, the combined use of theory and computational analysis highlights the influence of viral life history traits and receptor complementarity when designing and deploying phage cocktails in immunocompetent and immunocompromised hosts.

Geographic variation in abundance and diversity of Acinetobacter baumannii Vieuvirus bacteriophages

Introduction

Prophages play a crucial role in the genomic diversity of Acinetobacter baumannii, contributing to its pathogenicity and adaptation.

Methods

In this study, we induced and sequenced seven prophages from five isolates of A. baumannii. These were analyzed with 967 prophages identified from various isolates worldwide, plus 21 genomes of other phages infecting A. baumannii previously reported in NCBI. To have an overview of the populations of the prophages infecting A. baumannii.

Results

Our analysis revealed 13 major prophage clusters within the analyzed A. baumannii isolates. Notably, prophages belonging to the Vieuvirus genus were the most prevalent. Specifically, Vieuvirus-related phages were frequently identified in isolates from Thailand, Mexico, China, and South Korea, which show the geographic prevalence of A. baumannii prophages.

Discussion

This study highlights the importance of considering geographic factors to fully understand prophage diversity and their significant role in the evolutionary dynamics of A. baumannii.

Whole-genome evaluation and prophages characterization associated with genome of carbapenem-resistant Acinetobacter baumannii UOL-KIMZ-24-2

Carbapenem-resistant Acinetobacter baumannii (CRAB) is an emerging threat to healthcare settings in many countries, principally in South Asia. The current study was aimed to identify, evaluate whole-genome and characterize the prophages in genome of CRAB strain, recovered from patients of Lahore General Hospital, Lahore. More than 200 samples were collected and identified by morphological and biochemical tests. These strains were also subjected to a comprehensive antimicrobial susceptibility evaluation using Kirby-Bauer method and further confirmed as CRAB strains by exploring blaOXA-51. In addition, the whole-genome evaluation of a Acinetobacter baumannii UOL-KIMZ-24-2 was carried out using various Bioinformatics tools. A total of 150 strains of A. baumannii were recovered and identified in the current study. Among them, 49% strains were found resistant to carbapenem. The blaOXA-51 was found prevalent in the genome of A. baumannii recovered from medical ICU (38%). In addition, the UOL-KIMZ-24-2 genome analysis based on multilocus sequence typing (MLST) highlighted that UOL-KIMZ-24-2 belonged to ST2 (Pasteur scheme) sequence type. A total of 29 antimicrobial resistance (AMR) genes were present, importantly, blaOXA-66, blaOXA-23 and blaOXA-25. The mobile genetic elements (MGEs) were identified as transposases and belonged to four classes e.g. IS15d1, ISAba24, ISEc29, and ISEc35. A total of 14 virulence factors encoded by 58 different genes were detected in UOL-KIMZ-24-2. In addition, the phage sequences were identified in genome of UOL-KIMZ-24-2, divided into 3 regions. In conclusion, UOL-KIMZ-24-2 contained a mixture of AMR genes, MGEs. prophages sequences and virulence genes.

Dysbiosis-NK Cell Crosstalk in Pancreatic Cancer: Toward a Unified Biomarker Signature for Improved Clinical Outcomes

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer with poor prognosis, primarily due to its immunosuppressive tumor microenvironment (TME), which contributes to treatment resistance. Recent research shows that the microbiome, including microbial communities in the oral cavity, gut, bile duct, and intratumoral environments, plays a key role in PDAC development, with microbial imbalances (dysbiosis) promoting inflammation, cancer progression, therapy resistance, and treatment side effects. Microbial metabolites can also affect immune cells, especially natural killer (NK) cells, which are vital for tumor surveillance, therapy response and treatment-related side effects. Dysbiosis can affect NK cell function, leading to resistance and side effects. We propose that a combined biomarker approach, integrating microbiome composition and NK cell profiles, can help predict treatment resistance and side effects, enabling more personalized therapies. This review examines how dysbiosis contributes to NK cell dysfunction in PDAC and discusses strategies (e.g., antibiotics, probiotics, vaccines) to modulate the microbiome and enhance NK cell function. Targeting dysbiosis could modulate NK cell activity, improve the effectiveness of PDAC treatments, and reduce side effects. However, further research is needed to develop unified NK cell-microbiome interaction-based biomarkers for more precise and effective patient outcomes.

Bacteriophages: A Challenge for Antimicrobial Therapy

Phage therapy, which involves the use of bacteriophages (phages) to combat bacterial infections, is emerging as a promising approach to address the escalating threat posed by multidrug-resistant (MDR) bacteria. This brief review examines the historical background and recent advancements in phage research, focusing on their genomics, interactions with host bacteria, and progress in medical and biotechnological applications. Additionally, we expose key aspects of the mechanisms of action, and therapeutic uses of phage considerations in treating MDR bacterial infections are discussed, particularly in the context of infections related to virus-bacteria interactions.

Treatment Approaches for Carbapenem-Resistant Acinetobacter baumannii Infections

Carbapenem-resistant Acinetobacter baumannii has been associated with over three hundred thousand annual deaths globally. It is resistant to most available antibiotics and associated with high morbidity and mortality. No global consensus currently exists for treatment strategies that balance safety and efficacy because of heterogeneity of treatment regimens in current clinical practice and scarcity of large-scale controlled studies arising from difficulties in establishing robust clinical outcomes. This review outlines the epidemiology and resistance mechanisms of carbapenem-resistant A. baumannii, then summarizes available clinical data on each approved agent with activity against this pathogen. Emerging treatment options such as cefiderocol and sulbactam-durlobactam show promise, but their success hinges on comprehensive clinical validation and access in regions most impacted by this pathogen. New therapeutic modalities that are in various stages of clinical development are also discussed.

Chloramphenicol and gentamicin reduce the evolution of resistance to phage ΦX174 by suppressing a subset of E. coli LPS mutants

Bacteriophages infect gram-negative bacteria by attaching to molecules present on the bacterial surface, often lipopolysaccharides (LPS). Modification of LPS can lead to resistance to phage infection. In addition, LPS modifications can impact antibiotic susceptibility, allowing for phage-antibiotic synergism. The evolutionary mechanism(s) behind such synergistic interactions remain largely unclear. Here, we show that the presence of antibiotics can affect the evolution of resistance to phage infection, using phage ΦX174 and Escherichia coli C. We use a collection of 34 E. coli C LPS strains, each of which is resistant to ΦX174, and has either a "rough" or "deep rough" LPS phenotype. Growth of the bacterial strains with the deep rough phenotype is inhibited at low concentrations of chloramphenicol and, to a much lesser degree, gentamicin. Treating E. coli C wild type with ΦX174 and chloramphenicol eliminates the emergence of mutants with the deep rough phenotype, and thereby slows the evolution of resistance to phage infection. At slightly lower chloramphenicol concentrations, phage resistance rates are similar to those observed at high concentrations; yet, we show that the diversity of possible mutants is much larger than at higher chloramphenicol concentrations. These data suggest that specific antibiotic concentrations can lead to synergistic phage-antibiotic interactions that disappear at higher antibiotic concentrations. Overall, we show that the change in survival of various ΦX174-resistant E. coli C mutants in the presence of antibiotics can explain the observed phage-antibiotic synergism.

Use of adjuvants to improve antibiotic efficacy and reduce the burden of antimicrobial resistance

INTRODUCTION

The increase in antibiotic resistance, together with the absence of novel antibiotics, makes mandatory the introduction of novel strategies to optimize the use of existing antibiotics. Among these strategies, the use of molecules that increase their activity looks promising.

AREAS COVERED

Different categories of adjuvants have been reviewed. Anti-resistance adjuvants increase the activity of antibiotics by inhibiting antibiotic resistance determinants. Anti-virulence approaches focus on the infection process itself; reducing virulence in combination with an antibiotic can improve therapeutic efficacy. Combination of phages with antibiotics can also be useful, since they present different mechanisms of action and targets. Finally, combining antibiotics with adjuvants in the same molecule may serve to improve antibiotics' efficacy and to overcome potential problems of differential pharmacokinetics/pharmacodynamics.

EXPERT OPINION

The successful combination of inhibitors of β-lactamases with β-lactams has shown that adjuvants can improve the efficacy of current antibiotics. In this sense, novel anti-resistance adjuvants able to inhibit efflux pumps are still needed, as well as anti-virulence compounds that improve the efficacy of antibiotics by interfering with the infection process. Although adjuvants may present different pharmacodynamics/pharmacokinetics than antibiotics, conjugates containing both compounds can solve this problem. Finally, already approved drugs can be a promising source of antibiotic adjuvants.

How to: assess patient suitability for unlicensed phage therapy in the United Kingdom

BACKGROUND

Bacteriophage (phage) therapy is a promising alternative antimicrobial approach that has the potential to transform the way we treat bacterial infections. The antibiotic resistance crisis is driving renewed interest in phage therapy. There are currently no licensed phage therapy medicinal products and phage therapy is used in small but growing patient numbers on an unlicensed basis.

OBJECTIVES

This article provides guidelines on the assessment of patient suitability for unlicensed phage therapy for clinicians in the United Kingdom.

SOURCES

This article builds on Health Improvement Scotland's recommendation for the consideration of phage therapy in difficult-to-treat infections and the experience of the author group, who have collectively assessed the suitability of 30 patients for phage therapy.

CONTENT

In the United Kingdom, unlicenced medicines, including phages, may be considered to meet special clinical needs. The use of unlicenced medicines is governed by national legislation and local National Health Service trust policies. Phages can be used in any National Health Service trust and decisions about suitability should be made through existing local clinical management pathways. This article sets out guidelines to support local clinical teams in the assessment of patient suitability for phage therapy. Clinical and microbiological considerations are presented, including allergy and pregnancy.

IMPLICATIONS

The assessment of patient suitability for phage therapy is within the scope of local clinical teams. Local assessment through existing clinical management pathways will develop confidence and competence in phage therapy among clinical teams nationally and ensure timely patient care.

Synthesis of Headful Packaging Phages Through Yeast Transformation-Associated Recombination

De novo synthesis of phage genomes enables flexible genome modification and simplification. This study explores the synthetic genome assembly of Pseudomonas phage vB_PaeS_SCUT-S4 (S4), a 42,932 bp headful packaging phage, which encapsidates a terminally redundant, double-stranded DNA genome exceeding unit length. We demonstrate that using the yeast TAR approach, the S4 genome can be assembled and rebooted from a unit-length genome plus a minimal 60 bp terminal redundant sequence. Furthermore, we show that S4 can be synthesized from arbitrary starting nucleotides and modified with a red fluorescent protein as a reporter. Additionally, we successfully designed and assembled synthetic S4 phages with reduced genomes, knocking out up to 10 of the 24 hypothetical genes simultaneously, with a combined length of 2883 bp, representing 6.7% of the unit-length genome. This work highlights the potential for engineering simplified, customizable headful packaging phage genomes, providing a foundation for future studies of these phages for potential clinical applications.

Phage therapy for extensively drug resistant Acinetobacter baumannii infection: case report and in vivo evaluation of the distribution of phage and the impact on gut microbiome

Numerous studies have documented successful instances of bacteriophage therapy in treating infections caused by extensively drug-resistant Acinetobacter baumannii (XDRAB). However, the safety profile of phage therapy and its effects on the human gut microbiota remain areas of concern. In this study, we collected blood, sputum, and fecal samples from an elderly female patient during two phases of inhaled bacteriophage therapy targeting extensively drug-resistant Acinetobacter baumannii (XDRAB). We investigated the in vivo distribution of bacteriophages and their impact on the gut microbiome. Bacteriophage DNA was detected in blood samples exclusively during the first 4 days of the second phase of phage therapy, with Ct values ranging from 32.6 to 35.3. In sputum samples, the Ct values of phages demonstrated a decreasing trend from 45 to 14.7 during the first phase of phage therapy, subsequently stabilizing between 28.5 and 26.8 in the second phase. In fecal samples, a significant reduction in the Ct value of phages was observed following both phases of bacteriophage treatment, with values decreasing from 35.5 to 22.5 and from 32.6 to 22.7, respectively. The composition of the gut microbiota was analyzed using Illumina-based 16S rRNA sequencing from fecal samples. Sequencing analysis revealed significant alterations in the microbiota composition at both the phylum and genus levels during phage therapy. These findings suggest that inhaled phages are detectable in human blood and tend to accumulate in the intestines. Furthermore, notable changes in the gut microbiota were observed throughout the duration of the phage treatment.

Carbapenem-resistant Acinetobacter baumannii raises global alarm for new antibiotic regimens

Carbapenem-resistant Acinetobacter baumannii (CRAB) is a top-priority pathogen causing a nosocomial infection that increases morbidity and mortality. Treatment options for CRAB are relatively limited by pharmacokinetic restrictions, such as substantial toxicity. Therefore, we must better understand this pathogen to develop new treatments and control strategies. The review aims to provide an overview of the current understanding of acquired, adaptive, and intrinsic Carbapenem-resistant pathways in A. baumannii, as well as its consequences on healthcare systems, particularly critical care units. The review also provides insights into how CRAB infections are currently managed worldwide and why novel therapeutic regimens are needed. The peculiarity of A. baumannii and its often reported virulence factors have been discussed further. In conclusion, the purpose of this review is to emphasize the current knowledge on CRAB, as it causes major worry in the field of nosocomial infections as well as overall public health.

Evaluation of effectiveness of bacteriophage purification methods

The use of bacteriophages for therapy has increased over the last decade. While there is need for clear regulatory pathways for bacteriophage approval for mainstream use in clinical practice, practitioners and patients have been able to access bacteriophage therapy under compassionate grounds and through magistral preparations. However, there is currently no standard for purifying these bacteriophages to ensure safety, and good manufacturing practice certification may not be achieved in these emergency uses. In this study, we employed an Interleukin Receptor Associated Kinase (IRAK) 3 knockout monocyte-based assay to evaluate the endotoxin removal efficacy of three common bacteriophage purification methods: Triton X-100 exposure, CsCl density gradient ultracentrifugation, and Pierce™ High-Capacity Endotoxin Removal Resin spin columns. In our experiments we tested these purification methods on three different bacteriophage morphotypes: siphovirus, podovirus and myovirus. We showed that the lowest endotoxin levels and immune responses were achieved when purifying bacteriophages with Triton-X treatment. The results from purifying with CsCl density gradient ultracentrifugation were comparable, and these were both significantly better than purification with Pierce™ High-Capacity Endotoxin Removal Resin spin columns. We also showed that Triton X-100 purification resulted in the lowest loss of bacteriophage titres. Finally, of the bacteriophages tested here, it did not appear that virus morphology affected efficacy of endotoxin removal.

Translational research priorities for bacteriophage therapeutics

The growing threat of antimicrobial resistant (AMR) bacterial pathogens coupled with the relative dearth of promising novel antibiotics requires the discovery and development additional medical interventions. Over the past decade bacteriophages have emerged one of the most promising new tools to combat AMR pathogens. Anecdotal clinical experiences under so-called 'compassionate use' regulatory pathways as well as a limited number of clinical trials have provided ample evidence of safety and early evidence of efficacy. For phages to reach their full potential it is critical that rigorous clinical trials be conducted that define their optimal use and that enable regulatory authorities to support the commercialization required to afford global access. The clinical development of phage therapeutics requires the design and execution of clinical trials that take full advantage of lessons learned from a century of antibiotic development and that use clinical investigation as a platform in which aspects of phage biology that are critical to therapeutics are more clearly elucidated. Translational research that elucidates phage biology in the context of clinical trials will promote highly relevant hypothesis-driven work in basic science laboratories and will greatly accelerate the development of the field of phage therapeutics.

Sxt1, Isolated from a Therapeutic Phage Cocktail, Is a Broader Host Range Relative of the Phage T3

Using Escherichia coli BW25113 as a host, we isolated a novel lytic phage from the commercial poly-specific therapeutic phage cocktail Sextaphage® (Microgen, Russia). We provide genetic and phenotypic characterization of the phage and describe its host range on the ECOR collection of reference E. coli strains. The phage, hereafter named Sxt1, is a close relative of classical coliphage T3 and belongs to the Teetrevirus genus, yet its internal virion proteins, forming an ejectosome, differ from those of T3. In addition, the Sxt1 lateral tail fiber (LTF) protein clusters with those of the phages from the Berlinvirus genus. A comparison of T7, T3, and Sxt1 LTFs reveals the presence of insertions leading to the elongation of Sxt1 tail fibers, which, together with the difference in the HRDRs (host range-determining regions), might explain the expanded host specificity for the Sxt1.

Successful phage-antibiotic therapy of P. aeruginosa implant-associated infection in a Siamese cat

Antibiotic-resistant pathogens are a growing global issue, leading to untreatable infectious diseases in both humans and animals. Personalized bacteriophage (phage) therapy, the use of specific anti-bacterial viruses, is currently a leading approach to combat antibiotic-resistant infections. The implementation of phage therapy has primarily been focused on humans, almost neglecting the impact of such infections on the health and welfare of companion animals. Pets also have the potential to spread resistant infections to their owners or the veterinary staff through zoonotic transmission. Here, we showcase personalized phage-antibiotic treatment of a cat with a multidrug-resistant Pseudomonas aeruginosa implant-associated infection post-arthrodesis surgery. The treatment encompassed a tailored combination of an anti-P. aeruginosa phage and ceftazidime, precisely matched to the pathogen. The phage was topically applied to the surgical wound while the antibiotic was administered intramuscularly. After two treatment courses spanning 7 and 3 weeks, the surgical wound, which had previously remained open for five months, fully closed. To the best of our knowledge, this is the first case of personalized phage therapy application in felines, which provides further evidence of the effectiveness of this approach. The successful outcome paves the way for personalized phage-antibiotic treatments against persistent infections therapy in veterinary practice.

Phage therapy: A targeted approach to overcoming antibiotic resistance

The rise of antibiotic-resistant bacterial infections has become a significant global health threat, necessitating the need for alternative therapeutic strategies. The use of bacteriophages-viruses that particularly infect and lyse bacteria-in phage therapy has resurfaced as a potentially effective substitute for conventional antibiotics. This narrative review aims to explore the mechanisms, applications, challenges, and prospects of phage therapy in combating antibiotic-resistant infections. A thorough analysis of the literature was carried out by exploring online databases, such as Google Scholar, PubMed, Scopus, and Web of Science. The search focused on peer-reviewed articles, clinical trials, and authoritative reports published in the last 10 years. The review synthesized findings from studies on phage mechanisms, therapeutic applications, regulatory challenges, and advances in phage engineering. Phage therapy demonstrates several advantages over antibiotics, including high specificity for target bacteria, the ability to penetrate biofilms, and a lower propensity for resistance development. However, significant challenges remain, such as regulatory and production hurdles, the potential for phage resistance, and interactions with the host immune system. Advances in genetic engineering have enhanced the therapeutic potential of phages, and personalized phage therapy is emerging as a viable approach for tailored treatments. Phage therapy holds significant promise as an alternative to antibiotics, particularly in the fight against antibiotic-resistant bacteria. While challenges persist, ongoing research, technological advancements, and collaborative efforts are crucial for integrating phage therapy into mainstream clinical practice, potentially revolutionizing the treatment of bacterial infections and addressing the global antibiotic resistance crisis.

Capsular polysaccharide structure of Acinetobacter baumannii K58 from clinical isolate MRSN31468

Capsular polysaccharides (CPS) of Acinetobacter baumannii is a virulence factor with diverse structures. CPS are produced by the CPS biosynthesis gene cluster in their K locus (KL). However, CPS variations may occur due to insertion of additional genes from external sources, e.g., prophages. Recently, the CPS structure from a clinical isolate, BAL062 which includes KL58 locus, was found to have a pseudaminic acid isomer (8ePse5NAc7NAc) as a result of prophage inserted epaA/epaB genes. Here, we report a CPS structure produced by A. baumannii strain MRSN31468 which also belongs to a KL58 type. The K58 CPS structure was determined by 1D and 2D NMR analysis of the oligosaccharides derived from the CPS by a phage depolymerase, and supported by the sugar composition analysis. The K58 CPS structure has the following tetra saccharide repeating unit. The K58 CPS differs from the CPS from BAL062 only by replacing 8-epimerized β-8ePse5NAc7NAc with β-Pse5NAc7NAc.

Potentially effective antimicrobial treatment for pneumonia caused by isolates of carbapenem-resistant and extensively drug-resistant Acinetobacter baumannii complex species: what can we expect in the future?

INTRODUCTION

Acinetobacter baumannii complex (Abc) is currently a significant cause of difficult-to-treat pneumonia. Due to the high prevalence rates of carbapenem- and extensively drug-resistant (CR, XDR) phenotypes, limited antibiotic options are available for the effective treatment of pneumonia caused by CR/XDR-Abc.

AREAS COVERED

In vitro susceptibility data, relevant pharmacokinetic profiles (especially the penetration ratios from plasma into epithelial-lining fluid), and pharmacodynamic indices of key antibiotics against CR/XDR-Abc are reviewed.

EXPERT OPINION

Doubling the routine intravenous maintenance dosages of conventional tigecycline (100 mg every 12 h) and minocycline (200 mg every 12 h) might be recommended for the effective treatment of pneumonia caused by CR/XDR-Abc. Nebulized polymyxin E, novel parenteral rifabutin BV100, and new polymyxin derivatives (SPR206, MRX-8, and QPX9003) could be considered supplementary combination options with other antibiotic classes. Regarding other novel antibiotics, the potency of sulbactam-durlobactam (1 g/1 g infused over 3 h every 6 h intravenously) combined with imipenem-cilastatin, and the β-lactamase inhibitor xeruborbactam, is promising. Continuous infusion of full-dose cefiderocol is likely an effective treatment regimen for CR/XDR-Abc pneumonia. Zosurabalpin exhibits potent anti-CR/XDR-Abc activity in vitro, but its practical use in clinical therapy remains to be evaluated. The clinical application of antimicrobial peptides and bacteriophages requires validation.

Isolation, characterization, and potential application of Acinetobacter baumannii phages against extensively drug-resistant strains

One of the significant issues in treating bacterial infections is the increasing prevalence of extensively drug-resistant (XDR) strains of Acinetobacter baumannii. In the face of limited or no viable treatment options for extensively drug-resistant (XDR) bacteria, there is a renewed interest in utilizing bacteriophages as a treatment option. Three Acinetobacter phages (vB_AbaS_Ftm, vB_AbaS_Eva, and vB_AbaS_Gln) were identified from hospital sewage and analyzed for their morphology, host ranges, and their genome sequences were determined and annotated. These phages and vB_AbaS_SA1 were combined to form a phage cocktail. The antibacterial effects of this cocktail and its combinations with selected antimicrobial agents were evaluated against the XDR A. baumannii strains. The phages exhibited siphovirus morphology. Out of a total of 30 XDR A. baumannii isolates, 33% were sensitive to vB_AbaS_Ftm, 30% to vB_AbaS_Gln, and 16.66% to vB_AbaS_Eva. When these phages were combined with antibiotics, they demonstrated a synergistic effect. The genome sizes of vB_AbaS_Ftm, vB_AbaS_Eva, and vB_AbaS_Gln were 48487, 50174, and 50043 base pairs (bp), respectively, and showed high similarity. Phage cocktail, when combined with antibiotics, showed synergistic effects on extensively drug-resistant (XDR) strains of A. baumannii. However, the need for further study to fully understand the mechanisms of action and potential limitations of using these phages is highlighted.

Colistin Resistance Mechanism and Management Strategies of Colistin-Resistant Acinetobacter baumannii Infections

The emergence of antibiotic-resistant Acinetobacter baumannii (A. baumannii) is a pressing threat in clinical settings. Colistin is currently a widely used treatment for multidrug-resistant A. baumannii, serving as the last line of defense. However, reports of colistin-resistant strains of A. baumannii have emerged, underscoring the urgent need to develop alternative medications to combat these serious pathogens. To resist colistin, A. baumannii has developed several mechanisms. These include the loss of outer membrane lipopolysaccharides (LPSs) due to mutation of LPS biosynthetic genes, modification of lipid A (a constituent of LPSs) structure through the addition of phosphoethanolamine (PEtN) moieties to the lipid A component by overexpression of chromosomal pmrCAB operon genes and eptA gene, or acquisition of plasmid-encoded mcr genes through horizontal gene transfer. Other resistance mechanisms involve alterations of outer membrane permeability through porins, the expulsion of colistin by efflux pumps, and heteroresistance. In response to the rising threat of colistin-resistant A. baumannii, researchers have developed various treatment strategies, including antibiotic combination therapy, adjuvants to potentiate antibiotic activity, repurposing existing drugs, antimicrobial peptides, nanotechnology, photodynamic therapy, CRISPR/Cas, and phage therapy. While many of these strategies have shown promise in vitro and in vivo, further clinical trials are necessary to ensure their efficacy and widen their clinical applications. Ongoing research is essential for identifying the most effective therapeutic strategies to manage colistin-resistant A. baumannii. This review explores the genetic mechanisms underlying colistin resistance and assesses potential treatment options for this challenging pathogen.

A blueprint for broadly effective bacteriophage-antibiotic cocktails against bacterial infections

Bacteriophage (phage) therapy is a promising therapeutic modality for multidrug-resistant bacterial infections, but its application is mainly limited to personalized therapy due to the narrow host range of individual phages. While phage cocktails targeting all possible bacterial receptors could theoretically confer broad coverage, the extensive diversity of bacteria and the complexity of phage-phage interactions render this approach challenging. Here, using screening protocols for identifying "complementarity groups" of phages using non-redundant receptors, we generate effective, broad-range phage cocktails that prevent the emergence of bacterial resistance. We also discover characteristic interactions between phage complementarity groups and particular antibiotic classes, facilitating the prediction of phage-antibiotic as well as phage-phage interactions. Using this strategy, we create three phage-antibiotic cocktails, each demonstrating efficacy against ≥96% of 153 Pseudomonas aeruginosa clinical isolates, including biofilm cultures, and demonstrate comparable efficacy in an in vivo wound infection model. We similarly develop effective Staphylococcus aureus phage-antibiotic cocktails and demonstrate their utility of combined cocktails against polymicrobial (mixed P. aeruginosa/S. aureus) cultures, highlighting the broad applicability of this approach. These studies establish a blueprint for the development of effective, broad-spectrum phage-antibiotic cocktails, paving the way for off-the-shelf phage-based therapeutics to combat multidrug-resistant bacterial infections.

Mathematical comparison of protocols for adapting a bacteriophage to a new host

Interest in phage therapy-the use of bacterial viruses to treat infections-has increased recently because of the rise of infections with antibiotic-resistant bacteria and the failure to develop new antibiotics to treat those infections. Phages have shown therapeutic promise in recent work, and successful treatment minimally requires giving the patient a phage that will grow on their infecting bacterium. Although nature offers a bountiful and diverse supply of phages, there have been a surprising number of patient infections that could not be treated with phages because no suitable phage was found to kill the patient's bacterium. Here, we develop computational models to analyze an alternative approach to obtaining phages with new host ranges-directed evolution via laboratory propagation of phages to select mutants that can grow on a new host. The models separately explore alternative directed evolution protocols for phage variants that overcome three types of bacterial blocks to phage growth: a block in adsorption, temperate phage immunity to superinfection, and abortive infection. Protocols assume serial transfer to amplify pre-existing, small-effect mutants that are initially rare. Best protocols are sensitive to the nature of the block, and the models provide several insights for enhancing success specific to each case. A common result is that low dilution rates between transfers are beneficial in reducing the mutant growth rate needed to ascend. Selection to overcome an adsorption block is insensitive to many protocol variations but benefits from long selection times between transfers. A temperate phage selected to grow on its lysogens can evolve in any of three phenotypes, but a common protocol favors the desired changes in all three. Abortive infection appears to be the least amenable to evolving phage growth because it is prone to select phages that avoid infection.

Therapeutic and Diagnostic Potential of a Novel K1 Capsule Dependent Phage, JSSK01, and Its Depolymerase in Multidrug-Resistant Escherichia coli Infections

Bacteriophages are viruses that have the potential to combat bacterial infections caused by antimicrobial-resistant bacterial strains. In this study, we investigated a novel lytic bacteriophage, vB_EcoS_JSSK01, isolated from sewage in Hualien, Taiwan, which effectively combats multidrug-resistant (MDR) Escherichia coli of the K1 capsular type. K1 E. coli is a major cause of severe extraintestinal infections, such as neonatal meningitis and urinary tract infections. Phage JSSK01 was found to have a genome size of 44,509 base pairs, producing approximately 123 particles per infected cell in 35 min, and was highly stable across a range of temperatures and pH. JSSK01 infected 59.3% of the MDR strains tested, and its depolymerase (ORF40) specifically degraded the K1 capsule in these bacteria. In a zebrafish model, JSSK01 treatment after infection significantly improved survival, with survival in the treated group reaching 100%, while that in the untreated group dropped to 10% after three days. The functional activity of depolymerase was validated using zone inhibition and agglutination tests. These results indicate that JSSK01 and its substrate-specific depolymerase have promising therapeutic and diagnostic applications against K1-encapsulated MDR E. coli infections.

Designing a simple and efficient phage biocontainment system using the amber suppressor initiator tRNA

Multidrug-resistant infections are becoming increasingly prevalent worldwide. One of the fastest-emerging alternative and adjuvant therapies being proposed is phage therapy. Naturally isolated phages are used in the vast majority of phage therapy treatments today. Engineered phages are being developed to enhance the effectiveness of phage therapy, but concerns over their potential escape remain a salient issue. To address this problem, we designed a biocontained phage system based on conditional replication using amber stop codon suppression. This system can be easily installed on any natural phage with a known genome sequence. To test the system, we individually mutated the start codons of three essential capsid genes in phage φX174 to the amber stop codon (UAG). These phages were able to efficiently infect host cells expressing the amber initiator tRNA, which suppresses the amber stop codon and initiates translation at TAG stop codons. The amber phage mutants were also able to successfully infect host cells and reduce their population on solid agar and liquid culture but could not produce infectious particles in the absence of the amber initiator tRNA or complementing capsid gene. We did not detect any growth-inhibiting effects on E. coli strains known to lack a receptor for φX174 and we showed that engineered phages have a limited propensity for reversion. The approach outlined here may be useful to control engineered phage replication in both the lab and clinic.

Phage susceptibility testing methods or 'phagograms': where do we stand and where should we go?

Phage therapy is a highly promising approach to address the challenge that is presented by the global burden of antimicrobial resistance. Given the natural specificity of phages, phage susceptibility testing (PST) is a prerequisite for successful personalized therapy, allowing the selection of active phages from large and diverse collections. However, the issue of an easy-to-use and standardized technique remains. In this review, we describe the principles, advantages and drawbacks of two routinely used PST techniques: plaque and growth kinetic assays. These are labour-intensive and time-consuming methods that require automation of one or more steps, including preparation of test panels, incubation, reading and analysis of results. In addition to automation, there is an urgent need to establish a reference method to enable efficient of PST techniques selection of therapeutic phages. We discuss knowledge gaps and parameters that need to be investigated to work towards this goal.