1. Š 2022. The American Society for Microbiology | Privacy Policy, Terms of Use and State Disclosures
Patterson, with Strathdee, 1 month after phage
therapy beganâit was his first trip outside.
Source: Courtesy of Steffanie Strathdee.
Bacteriophages.
Source: https://commons.wikimedia.org/
wiki/File:Bacteriophages_at_work.jpg
Felix d'Herelle
Source: https://commons.wikime
dia.org/wiki/File:F%C3%A9lix_
d%27H%C3%A9relle.jpg
Phage Therapy: Past, Present and
Future
Aug. 31, 2022 SHARE THIS !
Antimicrobial resistance (AMR) has made it so that, for a growing number of bacterial
pathogens, the success rate of antibiotics is iffy, at best. More than 1.2 million people died
as a direct result of AMR bacterial infections in 2019. If nothing changes, by 2050, 10
million people are expected to die from drug-resistant diseases every year. The message is
clear: find alternative therapies or face a reality in which once-treatable infections cause
once-preventable deaths.
Enter: Bacteriophage therapy.
Bacteriophages, or phages, are viruses that
specifically target bacteria. Phage therapy involves
using phages to treat bacterial infections. Phages
are everywhere. From the soil to our guts, there are
thousands of different types. In contrast to many
antibiotics, which obliterate harmful bacteria,
while simultaneously decimating the microbiota
(thus triggering a new set of problems), each phage
has evolved to more narrowly target bacterial
strains or species. This specificity makes phage
therapy an attractive alternative for managing
infections, especially those caused by multi-drug resistant (MDR) bacteria.
Yet, phage therapy has largely existed on the fringes of medicine, particularly in Western
countries like the U.S., where it is occasionally approved for compassionate use (i.e., used
on an emergency basis when no other approved therapies are available). Why? And what
needs to happen to make phage therapy mainstream? The answers are entrenched in a
tangle of historical skepticism, regulatory and manufacturing hurdles and physiological
aspects of phages themselves.
The Rise and Fall of Phage Therapy in the West
Phage therapy is nothing newâits origins date back over 100 years. The French-Canadian
microbiologist, Felix dâHerelle, is credited with discovering and naming bacteriophages
(though there is debate as to whether dâHerelle or the British microbiologist, Frederick
Twort, was the official discoverer of phage). In any case, dâHerelleâs use of phages to combat
bacterial infections jumpstarted international effortsâlargely centered in the former Soviet
Unionâto test the efficacy of phage therapy for treating everything from typhoid fever to
cholera.
Early studies were promising, though experiments were
often improperly designed by todayâs standards (i.e., lacked
placebos or control groups, among other issues). The results
were also published in non-English journals, making them
largely inaccessible to Western scientists. Nevertheless,
phage therapy did have a stint in the U.S. Throughout the
1940s, several U.S. pharmaceutical companies produced
phage preparations to treat various infections, including
those of the upper respiratory tract and abscesses.
Phage Therapy Falls to the Wayside of Western Medicine
However, phage therapy eventually fell out of favor in the
West for several reasons. For one, scientists were skeptical
about how well it worked. Improper phage storage or
purification likely played a role. For instance, early
commercial preparations included âpreservatives,â such as phenol, which denatured and
inactivated phages. Scientists also didnât understand that phages were highly specific for
the bacteria they targetedâphage preparations were often used to treat bacterial infections
that were not susceptible to the therapeutic phage(s).
Societal factors were also important. After World War II, phage therapy research and use
continued in eastern European countries, where it persists to this day. Indeed, phage
therapy is still a routine medical practice in Georgia, Poland and Russia. However, the war
prompted scientists in western Europe and the U.S. to avoid phage therapy, given its close
ties to the former Soviet Union. The discovery of penicillin was the final nail in phage
therapyâs coffinâthe advent of antibiotics revolutionized how bacterial infections were
treated and became the gold standard in much of the world.
A Phage Therapy Renaissance
Over the past decade, however, phage therapy has experienced a renaissance in the U.S.,
spurred, in part, by the growing threat of AMR. Dr. Steffanie Strathdee, Associate Dean of
Global Health Sciences and Co-Founder and Co-Director of the Center for Innovative Phage
Applications and Therapeutics (IPATHâthe first dedicated phage therapy center in North
America) at University of California, San Diego (UCSD), has been at the forefront of the
phage therapy movement.
Strathdeeâs foray into phage therapy stems from personal experience. In 2015, her
husband, Dr. Tom Patterson, a professor of psychiatry at UCSD School of Medicine,
contracted a deadly infection, caused by MDR Acinetobacter baumannii, while on vacation
in Egypt. No antibiotics could control his infection. âThe doctors basically said, âthere's
nothing else that we can do'âŚAnd you could see him wasting away in front of us,â Strathdee
recalled.
With time running out, she scoured the internet to find somethingâanythingâthat could
save Patterson. An article about phage therapy piqued her interest and she broached the
idea with Pattersonâs doctors, who, with approval from the U.S. Food and Drug
Administration (FDA), agreed to give it a try.
The team relied on researchers from the
Center for Phage Technology at Texas A&M
University, as well as scientists from the U.S.
Navy, to find phages that could kill Pattersonâs
A. baumannii isolate. The phage huntâwhich
included combing through pre-existing phage
libraries (i.e., collections of phages previously
isolated from diverse sources) and isolating
new phages from sewage, barnyard waste and
even the bilges of Navy shipsâwas successful.
After receiving an intravenous phage cocktail,
Patterson began to improve almost
immediately. He made a full recovery and, 9
months after entering the hospital, went
home. Four years later, Patterson and
Strathdee published a book, The Perfect
Predator, documenting the story.
Patterson's high-profile case brought phage therapy research into the spotlight. Over the
past few years, there have been a growing number of case studies in the U.S. and western
European countries highlighting the efficacy of phage therapy for treating diverse MDR
infections, from lung infections in cystic fibrosis patients to urinary tract infections.
Challenges of Developing Phage Therapuetics
Nevertheless, while phage therapy is no longer on the back burner of medicine in the U.S.,
itâs not at the forefront either. âOne of the biggest reasons why phage therapy is not
mainstream in the West right now is because the clinical trials haven't been done to show
that it's efficacious,â Strathdee explained. She noted that clinical trials form the backbone of
therapeutic development in the U.S.âanecdotal evidence and/or case studies are not
enough.
Finding the Right Phages Can Take Time
There are 2 types of phages: lytic and temperate. Strictly lytic phages infect their host cell
and cause it to burst, thus killing the bacterium. Temperate, or lysogenic, phages donât kill
their bacterial prey outrightâthey integrate their genome (which may harbor AMR or toxin
genes) into the host cell. The phage may eventually lyse the cell, but this does little to
immediately thwart bacterial infection, and may contribute to the spread of AMR and other
virulence genes. As such, it is critical to ensure strictly lytic phages are used for phage
therapies.
Lytic phages replicate within bacteria and lyse the host cell immediately after assembly. In a
lysogenic cycle, phages integrate their genome into that of the host cell.
Source: https://journals.asm.org/doi/10.1128/JCM.00229-19
With that in mind, the process for identifying phages to treat an infection can be lengthy. It
often involves testing phages from existing libraries to find those that kill a patientâs
bacterial isolate. âItâs like [having] a million keys and youâre trying to sort through a million
locks to figure out which key matches the lock,â Strathdee said. One study reported a range
of 28 to 386 days between the time of request for phage therapy and actual administration
to the patient.
However, there are products being developed with a broader target range. For example,
Locus Biosciences, a company that develops engineered phage biotherapeutics,
manufactures phage cocktail drug products for each of 4 different pathogens (Escherichia
coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Staphyloccocus aureaus) that
target >95% of clinical strains. This approach does not require culturing a patientâs isolate
and screening a library for the right phages, and thus may streamline the process.
Manufacturing and Administrating Phage Therapeutics Isn't Straightforward
Unlike antibiotics, where concentrations of the drug decrease within the body over time,
phages multiply. This means that the dose of a phage cocktail that a patient is administered
is not necessarily the dose they receive. How this self-replicating feature of phage therapies
influences treatment efficacy, and potential for adverse effects, is still unknown. â[We need]
pharmacokinetic and pharmacodynamic studies to try to figure out, âokay, [if] you deliver
this amount of phage, but through this particular route, what happens to the phage?ââ
Strathdee said.
Pharmacokinetic and pharmacodynamic studies are needed to inform
the development and administration of effective phage therapeutics.
Source: https://journals.asm.org/doi/10.1128/MMBR.00012-19
Similarly, researchers must confirm âthat [the phages] perform in the matrix theyâre
expected to perform [in],â said Dr. Nick Conley, Vice President of Technology at Locus
Biosciences. For example, if phages are used to treat a urinary tract infection (UTI), they
need to be active in urine.
There are also important considerations from a manufacturing standpoint. For instance, to
create phage preparations, the phages are amplified in bacterial hostsâthey infect the
bacteria, the bacteria lyse and release more phages to create a high-titer phage soup.
However, upon lysis, âall of the guts of the bacteria get spilled out,â Conley explained. This
includes toxins and DNA, among other cell components, which must be removed before the
phage could be, for example, injected into someoneâs bloodstream.
Potential for Bacterial Phage Resistance
Patients generally receive mixtures (cocktails) of phages that target bacteria in different
ways. The chances of the bacteria evolving resistance to multiple phages is lower than for a
single phageâlower, but not impossible. Patients receiving phage therapy must be
continuously monitored to ensure the phages are still effective against their infection. If
not, researchers must find a new set of phages that can combat the pathogen.
Still, the development of resistance is not always a bad thing. In some cases, the
modifications to the bacteria that promote phage resistance increase their susceptibility to
antibiotics, and thus work synergistically with the antibiotics to promote their efficacy.
The Future of Phage Therapy
Despite the challenges, the outlook for phage therapy is promising. Strathdee emphasized
that the FDA is âon boardâ with phage therapy and, according to Conley, âhas been very
thoughtful and reasonableâ in its approach to regulating phage therapeutics. The U.S.
National Institutes of Health (NIH) recently awarded $2.5 million to 12 institutes around the
world to study phage therapy. Clinical trials are also underway, including a multi-center
Phase 1b/2 trial assessing the microbiological activity of a single dose of phage therapy in
cystic fibrosis patients chronically colonized with P. aeruginosa. Additionally, in July 2022,
Locus kicked off a phase 2/3 trial evaluating the safety, tolerability, pharmacokinetics and
efficacy of a phage drug product for treating acute uncomplicated UTI caused by MDR E.
coli.
Scientists are also studying whether they can optimize phage lifestyle to create more
effective therapies. Locus, for instance, is developing phage therapeutics that use CRISPR-
Cas3 technology. The phages deliver CRISPR-Cas3 to their bacterial host, which irreparably
shreds the bacterial DNA. Compared to normal phages, this allows for more robust killing.
Conley highlighted that the ability modify phages, including with many other non-Cas
payloads, bolsters their potential as a key tool for fighting AMR moving forward.
For Strathdee, the future of phage therapy rests in the hands of the next generation of
scientists. There is a burgeoning community of young researchers âwho are really excited
about the prospect of phage therapy.â It is this zeal, coupled with collaboration, increased
funding and advancements in clinical trials, that will be key for bringing phage therapy out
of the shadows. âWhere thereâs a will, thereâs a way.â
Explore Antimicrobial Resistance Resources
SHARE THIS !
CLINICIAN CLINICAL INFECTIONS & VACCINES ANTIMICROBIAL AGENTS & RESISTANCE
RESEARCHER GLOBAL HEALTH ARTICLE PHAGE
AU T H O R : M A D E L I N E B A R R O N , P H . D.
Genomic
Incaration
Lysogenic
Cycle
Lytic
Cycle
SpontancousInduction
Rinsunthesis
Assemb
Madeline Barron, Ph.D. is the Science Communications Specialist at ASM. She obtained
her Ph.D. from the University of Michigan in the Department of Microbiology and
Immunology.
Register for ASM
Conference on Next-
Generation
Sequencing
REGISTER NOW !
Discover ASM
membership
JOIN OR RENEW !
Get published in an
ASM journal
SUBMIT NOW !
Donate
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Microbiology
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Washington, DC 20036
202-737-3600
service@asmusa.org
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Home / Articles / Phage Therapy: Past, Present and Future
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#
![Š 2022. The American Society for Microbiology | Privacy Policy, Terms of Use and State Disclosures
Patterson, with Strathdee, 1 month after phage
therapy beganâit was his first trip outside.
Source: Courtesy of Steffanie Strathdee.
Bacteriophages.
Source: https://commons.wikimedia.org/
wiki/File:Bacteriophages_at_work.jpg
Felix d'Herelle
Source: https://commons.wikime
dia.org/wiki/File:F%C3%A9lix_
d%27H%C3%A9relle.jpg
Phage Therapy: Past, Present and
Future
Aug. 31, 2022 SHARE THIS !
Antimicrobial resistance (AMR) has made it so that, for a growing number of bacterial
pathogens, the success rate of antibiotics is iffy, at best. More than 1.2 million people died
as a direct result of AMR bacterial infections in 2019. If nothing changes, by 2050, 10
million people are expected to die from drug-resistant diseases every year. The message is
clear: find alternative therapies or face a reality in which once-treatable infections cause
once-preventable deaths.
Enter: Bacteriophage therapy.
Bacteriophages, or phages, are viruses that
specifically target bacteria. Phage therapy involves
using phages to treat bacterial infections. Phages
are everywhere. From the soil to our guts, there are
thousands of different types. In contrast to many
antibiotics, which obliterate harmful bacteria,
while simultaneously decimating the microbiota
(thus triggering a new set of problems), each phage
has evolved to more narrowly target bacterial
strains or species. This specificity makes phage
therapy an attractive alternative for managing
infections, especially those caused by multi-drug resistant (MDR) bacteria.
Yet, phage therapy has largely existed on the fringes of medicine, particularly in Western
countries like the U.S., where it is occasionally approved for compassionate use (i.e., used
on an emergency basis when no other approved therapies are available). Why? And what
needs to happen to make phage therapy mainstream? The answers are entrenched in a
tangle of historical skepticism, regulatory and manufacturing hurdles and physiological
aspects of phages themselves.
The Rise and Fall of Phage Therapy in the West
Phage therapy is nothing newâits origins date back over 100 years. The French-Canadian
microbiologist, Felix dâHerelle, is credited with discovering and naming bacteriophages
(though there is debate as to whether dâHerelle or the British microbiologist, Frederick
Twort, was the official discoverer of phage). In any case, dâHerelleâs use of phages to combat
bacterial infections jumpstarted international effortsâlargely centered in the former Soviet
Unionâto test the efficacy of phage therapy for treating everything from typhoid fever to
cholera.
Early studies were promising, though experiments were
often improperly designed by todayâs standards (i.e., lacked
placebos or control groups, among other issues). The results
were also published in non-English journals, making them
largely inaccessible to Western scientists. Nevertheless,
phage therapy did have a stint in the U.S. Throughout the
1940s, several U.S. pharmaceutical companies produced
phage preparations to treat various infections, including
those of the upper respiratory tract and abscesses.
Phage Therapy Falls to the Wayside of Western Medicine
However, phage therapy eventually fell out of favor in the
West for several reasons. For one, scientists were skeptical
about how well it worked. Improper phage storage or
purification likely played a role. For instance, early
commercial preparations included âpreservatives,â such as phenol, which denatured and
inactivated phages. Scientists also didnât understand that phages were highly specific for
the bacteria they targetedâphage preparations were often used to treat bacterial infections
that were not susceptible to the therapeutic phage(s).
Societal factors were also important. After World War II, phage therapy research and use
continued in eastern European countries, where it persists to this day. Indeed, phage
therapy is still a routine medical practice in Georgia, Poland and Russia. However, the war
prompted scientists in western Europe and the U.S. to avoid phage therapy, given its close
ties to the former Soviet Union. The discovery of penicillin was the final nail in phage
therapyâs coffinâthe advent of antibiotics revolutionized how bacterial infections were
treated and became the gold standard in much of the world.
A Phage Therapy Renaissance
Over the past decade, however, phage therapy has experienced a renaissance in the U.S.,
spurred, in part, by the growing threat of AMR. Dr. Steffanie Strathdee, Associate Dean of
Global Health Sciences and Co-Founder and Co-Director of the Center for Innovative Phage
Applications and Therapeutics (IPATHâthe first dedicated phage therapy center in North
America) at University of California, San Diego (UCSD), has been at the forefront of the
phage therapy movement.
Strathdeeâs foray into phage therapy stems from personal experience. In 2015, her
husband, Dr. Tom Patterson, a professor of psychiatry at UCSD School of Medicine,
contracted a deadly infection, caused by MDR Acinetobacter baumannii, while on vacation
in Egypt. No antibiotics could control his infection. âThe doctors basically said, âthere's
nothing else that we can do'âŚAnd you could see him wasting away in front of us,â Strathdee
recalled.
With time running out, she scoured the internet to find somethingâanythingâthat could
save Patterson. An article about phage therapy piqued her interest and she broached the
idea with Pattersonâs doctors, who, with approval from the U.S. Food and Drug
Administration (FDA), agreed to give it a try.
The team relied on researchers from the
Center for Phage Technology at Texas A&M
University, as well as scientists from the U.S.
Navy, to find phages that could kill Pattersonâs
A. baumannii isolate. The phage huntâwhich
included combing through pre-existing phage
libraries (i.e., collections of phages previously
isolated from diverse sources) and isolating
new phages from sewage, barnyard waste and
even the bilges of Navy shipsâwas successful.
After receiving an intravenous phage cocktail,
Patterson began to improve almost
immediately. He made a full recovery and, 9
months after entering the hospital, went
home. Four years later, Patterson and
Strathdee published a book, The Perfect
Predator, documenting the story.
Patterson's high-profile case brought phage therapy research into the spotlight. Over the
past few years, there have been a growing number of case studies in the U.S. and western
European countries highlighting the efficacy of phage therapy for treating diverse MDR
infections, from lung infections in cystic fibrosis patients to urinary tract infections.
Challenges of Developing Phage Therapuetics
Nevertheless, while phage therapy is no longer on the back burner of medicine in the U.S.,
itâs not at the forefront either. âOne of the biggest reasons why phage therapy is not
mainstream in the West right now is because the clinical trials haven't been done to show
that it's efficacious,â Strathdee explained. She noted that clinical trials form the backbone of
therapeutic development in the U.S.âanecdotal evidence and/or case studies are not
enough.
Finding the Right Phages Can Take Time
There are 2 types of phages: lytic and temperate. Strictly lytic phages infect their host cell
and cause it to burst, thus killing the bacterium. Temperate, or lysogenic, phages donât kill
their bacterial prey outrightâthey integrate their genome (which may harbor AMR or toxin
genes) into the host cell. The phage may eventually lyse the cell, but this does little to
immediately thwart bacterial infection, and may contribute to the spread of AMR and other
virulence genes. As such, it is critical to ensure strictly lytic phages are used for phage
therapies.
Lytic phages replicate within bacteria and lyse the host cell immediately after assembly. In a
lysogenic cycle, phages integrate their genome into that of the host cell.
Source: https://journals.asm.org/doi/10.1128/JCM.00229-19
With that in mind, the process for identifying phages to treat an infection can be lengthy. It
often involves testing phages from existing libraries to find those that kill a patientâs
bacterial isolate. âItâs like [having] a million keys and youâre trying to sort through a million
locks to figure out which key matches the lock,â Strathdee said. One study reported a range
of 28 to 386 days between the time of request for phage therapy and actual administration
to the patient.
However, there are products being developed with a broader target range. For example,
Locus Biosciences, a company that develops engineered phage biotherapeutics,
manufactures phage cocktail drug products for each of 4 different pathogens (Escherichia
coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Staphyloccocus aureaus) that
target >95% of clinical strains. This approach does not require culturing a patientâs isolate
and screening a library for the right phages, and thus may streamline the process.
Manufacturing and Administrating Phage Therapeutics Isn't Straightforward
Unlike antibiotics, where concentrations of the drug decrease within the body over time,
phages multiply. This means that the dose of a phage cocktail that a patient is administered
is not necessarily the dose they receive. How this self-replicating feature of phage therapies
influences treatment efficacy, and potential for adverse effects, is still unknown. â[We need]
pharmacokinetic and pharmacodynamic studies to try to figure out, âokay, [if] you deliver
this amount of phage, but through this particular route, what happens to the phage?ââ
Strathdee said.
Pharmacokinetic and pharmacodynamic studies are needed to inform
the development and administration of effective phage therapeutics.
Source: https://journals.asm.org/doi/10.1128/MMBR.00012-19
Similarly, researchers must confirm âthat [the phages] perform in the matrix theyâre
expected to perform [in],â said Dr. Nick Conley, Vice President of Technology at Locus
Biosciences. For example, if phages are used to treat a urinary tract infection (UTI), they
need to be active in urine.
There are also important considerations from a manufacturing standpoint. For instance, to
create phage preparations, the phages are amplified in bacterial hostsâthey infect the
bacteria, the bacteria lyse and release more phages to create a high-titer phage soup.
However, upon lysis, âall of the guts of the bacteria get spilled out,â Conley explained. This
includes toxins and DNA, among other cell components, which must be removed before the
phage could be, for example, injected into someoneâs bloodstream.
Potential for Bacterial Phage Resistance
Patients generally receive mixtures (cocktails) of phages that target bacteria in different
ways. The chances of the bacteria evolving resistance to multiple phages is lower than for a
single phageâlower, but not impossible. Patients receiving phage therapy must be
continuously monitored to ensure the phages are still effective against their infection. If
not, researchers must find a new set of phages that can combat the pathogen.
Still, the development of resistance is not always a bad thing. In some cases, the
modifications to the bacteria that promote phage resistance increase their susceptibility to
antibiotics, and thus work synergistically with the antibiotics to promote their efficacy.
The Future of Phage Therapy
Despite the challenges, the outlook for phage therapy is promising. Strathdee emphasized
that the FDA is âon boardâ with phage therapy and, according to Conley, âhas been very
thoughtful and reasonableâ in its approach to regulating phage therapeutics. The U.S.
National Institutes of Health (NIH) recently awarded $2.5 million to 12 institutes around the
world to study phage therapy. Clinical trials are also underway, including a multi-center
Phase 1b/2 trial assessing the microbiological activity of a single dose of phage therapy in
cystic fibrosis patients chronically colonized with P. aeruginosa. Additionally, in July 2022,
Locus kicked off a phase 2/3 trial evaluating the safety, tolerability, pharmacokinetics and
efficacy of a phage drug product for treating acute uncomplicated UTI caused by MDR E.
coli.
Scientists are also studying whether they can optimize phage lifestyle to create more
effective therapies. Locus, for instance, is developing phage therapeutics that use CRISPR-
Cas3 technology. The phages deliver CRISPR-Cas3 to their bacterial host, which irreparably
shreds the bacterial DNA. Compared to normal phages, this allows for more robust killing.
Conley highlighted that the ability modify phages, including with many other non-Cas
payloads, bolsters their potential as a key tool for fighting AMR moving forward.
For Strathdee, the future of phage therapy rests in the hands of the next generation of
scientists. There is a burgeoning community of young researchers âwho are really excited
about the prospect of phage therapy.â It is this zeal, coupled with collaboration, increased
funding and advancements in clinical trials, that will be key for bringing phage therapy out
of the shadows. âWhere thereâs a will, thereâs a way.â
Explore Antimicrobial Resistance Resources
SHARE THIS !
CLINICIAN CLINICAL INFECTIONS & VACCINES ANTIMICROBIAL AGENTS & RESISTANCE
RESEARCHER GLOBAL HEALTH ARTICLE PHAGE
AU T H O R : M A D E L I N E B A R R O N , P H . D.
Genomic
Incaration
Lysogenic
Cycle
Lytic
Cycle
SpontancousInduction
Rinsunthesis
Assemb
Madeline Barron, Ph.D. is the Science Communications Specialist at ASM. She obtained
her Ph.D. from the University of Michigan in the Department of Microbiology and
Immunology.
Register for ASM
Conference on Next-
Generation
Sequencing
REGISTER NOW !
Discover ASM
membership
JOIN OR RENEW !
Get published in an
ASM journal
SUBMIT NOW !
Donate
American Society for
Microbiology
1752 N St. NW
Washington, DC 20036
202-737-3600
service@asmusa.org
! " # $ % &
Connect With ASM
Academy Directory
ASM Connect
Customer Service
ASM Staff
Listservs
My ASM Account
Membership Directory
Support ASM
Volunteer
Donate to ASM
Corporate Council
Advertise With ASM
Stay Up to Date
Newsroom
Agar Art
Careers at ASM
Diversity & Inclusion
Ethics
History of Microbiology
Home / Articles / Phage Therapy: Past, Present and Future
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