Indications for use
Treatment and prevention of purulent-inflammatory and enteral diseases caused by Pseudomonas aeruginosa, as well as dysbiosis. Indications for use: diseases of the ear, throat, nose, respiratory tract and lungs - inflammation of the sinuses, middle ear, sore throat, pharyngitis, laryngitis, tracheitis, bronchitis, pneumonia, pleurisy, surgical infections - wound suppuration, burns, abscess, phlegmon, boils , carbuncles, hidradenitis, panaritium, paraproctitis, mastitis, bursitis, osteomyelitis, urogenital infections - urethritis, cystitis, pyelonephritis, colpitis, endometritis, salpingoophoritis. Enteral infections - gastroenterocolitis, cholecystitis, dysbacteriosis. Generalized septic diseases, purulent-inflammatory diseases of newborns - omphalitis, pyoderma, conjunctivitis, gastroenterocolitis, sepsis, etc. Other diseases caused by Pseudomonas aeruginosa. For prophylactic purposes, the drug is used for the treatment of postoperative and newly infected wounds, as well as for the prevention of nosocomial infections for epidemic indications. An important condition for effective phage therapy is the preliminary determination of the phage sensitivity of the pathogen.
Directions for use and doses
Treatment of purulent-inflammatory diseases with localized lesions should be carried out simultaneously both locally and through the mouth for 7-20 days (according to clinical indications). Depending on the nature of the source of infection, the bacteriophage is used: Locally in the form of irrigation, lotions and tamponing with liquid phage in an amount of up to 200 ml, depending on the size of the affected area. For abscesses, the bacteriophage is injected into the cavity of the lesion after removing the pus using a puncture. The amount of the administered drug should be slightly less than the volume of removed pus. In case of osteomyelitis, after appropriate surgical treatment, 10-20 ml of bacteriophage is poured into the wound. Introducing up to 100 ml of bacteriophage into cavities - pleural, articular and other limited cavities, after which capillary drainage is left, through which the bacteriophage is reintroduced over several days. For cystitis, pyelonephritis, urethritis, the drug is taken orally. If the cavity of the bladder or renal pelvis is drained, the bacteriophage is injected through the cystostomy or nephrostomy 1-2 times a day, 20-50 ml into the bladder and 5-7 ml into the renal pelvis. For purulent-inflammatory gynecological diseases, the drug is administered into the cavity of the vagina and uterus in a dose of 5-10 ml once daily. For purulent-inflammatory diseases of the ear, throat, nose, the drug is administered in a dose of 2-10 ml 1-3 times a day. The bacteriophage is used for rinsing, washing, instilling, introducing moistened turundas (leaving them for 1 hour). For intestinal forms of the disease, diseases of internal organs, and dysbiosis, the bacteriophage is used orally and in an enema. The bacteriophage is given orally 3 times a day on an empty stomach 1 hour before meals. In the form of enemas, they are prescribed once a day instead of once orally. The use of bacteriophages does not exclude the use of other antibacterial drugs. If chemical antiseptics were used to treat wounds before using the bacteriophage, the wound should be thoroughly washed with a sterile sodium chloride solution. Use of bacteriophage v in children (up to 6 months). For sepsis and enterocolitis in newborns, including premature babies, the bacteriophage is used in the form of high enemas (through a gas tube or catheter) 2-3 times a day (see table). In the absence of vomiting and regurgitation, it is possible to use the drug by mouth. In this case, it is mixed with breast milk. A combination of rectal (in enemas) and oral (by mouth) use of the drug is possible. The course of treatment is 5-15 days. In case of recurrent course of the disease, repeated courses of treatment are possible. In order to prevent sepsis and enterocolitis during intrauterine infection or the risk of nosocomial infection in newborns, the bacteriophage is used in the form of enemas 2 times a day for 5-7 days. In the treatment of omphalitis, pyoderma, and infected wounds, the drug is used in the form of applications, twice a day, a gauze cloth is moistened with a bacteriophage, and it is applied to the umbilical wound or to the affected area of the skin.
Bacteriophages in the complex treatment of acute bacterial rhinosinusitis
Acute bacterial rhinosinusitis (ABRS) is a fairly common disease with a constant upward trend. For example, in the United States in recent years, approximately 25 million visits to medical care per year have been recorded for ABRS [17, 18]. In Russia, this problem is further complicated by the fact that from year to year more and more patients require hospital treatment, and the proportion of patients hospitalized for diseases of the paranasal sinuses increases annually by 1.5–2%. Thus, in the structure of otorhinolaryngological hospitals, patients with sinus pathology make up from 15 to 36%. Maxillary sinusitis and ethmoiditis are more common [1, 5, 9, 12]. The classification of ABRS is based on the duration and recurrence of symptoms. The most successful, in our opinion, is the classification proposed by a special commission of the American Academy of Otolaryngology Head and Neck Surgery (Table 1) [14]. According to the severity of the course, the following are distinguished: • mild course: nasal congestion, mucous or mucopurulent discharge from the nose and/or into the oropharynx, increased body temperature up to 37.5˚C, headache, weakness, hyposmia; on an x-ray of the paranasal sinuses - the thickness of the mucous membrane is less than 6 mm; • moderate: nasal congestion, purulent discharge from the nose and/or into the oropharynx, body temperature above 37.5˚C, pain and tenderness on palpation in the projection of the sinus, headache, hyposmia, malaise, there may be radiating pain in the teeth and ears; on an x-ray of the paranasal sinuses - thickening of the mucous membrane of more than 6 mm, complete darkening or fluid level in one or two sinuses; • severe: nasal congestion, often profuse purulent discharge from the nose and/or into the oropharynx (but may be completely absent), body temperature above 38˚C, severe pain on palpation in the projection of the sinus, headache, anosmia, severe weakness; on the x-ray of the paranasal sinuses - complete darkening or fluid level in more than two sinuses; blood test: leukocytosis, shift of the formula to the left, increased ESR, orbital, intracranial complications or suspicions of them. A serious complication is cavernous sinus thrombosis, the mortality rate of which reaches 30% and does not depend on the adequacy of antibacterial therapy [14]. Most often, acute rhinosinusitis develops against the background of ARVI. It is believed that during viral infections the paranasal sinuses are involved in the inflammatory process to one degree or another. But the formation of OBRS occurs only in 1 or 2% of cases. However, 1–2% is a fairly large incidence rate. One of the reasons for the increase in the number of patients with acute bacterial purulent rhinosinusitis is recognized to be changes in the nature of the immune response of the mucous membranes of the nose and pharynx. In particular, sinusitis is considered a manifestation of an infectious syndrome caused by immune deficiency both at the local and systemic levels [2, 5, 9]. According to A.S. Lopatin, ABRS is almost always caused by stagnation of secretions and impaired ventilation in the paranasal sinuses. And if mucociliary transport is disrupted, prolonged contact of pathogenic bacteria with mucosal cells makes it possible to form bacterial inflammation.
As a rule, the most significant role in the development of bacterial infections of the upper respiratory tract is played by Streptococcus pneumoniae, Haemophilus influenzae, as well as Streptococcus pyogenes, Moraxella catarrhalis, Staphylococcus aureus, Pseudomonas aeruginosa, Proteus spp, Escherichia coli and a number of other pathogenic and opportunistic strains of bacteria [ 1, 2, 5, 6, 14]. The main medications in the treatment of ABRS are antibacterial drugs, the use of which is aimed at eradicating pathogens. It is believed that the optimal use of antibiotics to which microorganisms are most sensitive (Table 2).
The criterion for the rationality of prescribed antibiotic therapy is the assessment of the patient’s condition 72 hours (3rd day) after the start of treatment. Positive dynamics of the patient's condition suggests continuation of initial antibiotic therapy. If there is no positive clinical dynamics, the antibiotic should be changed after 72 hours. In the treatment of sinusitis, in most cases, priority remains with antibacterial monotherapy. Prescribing two or more antibiotics is justified in cases of severe sinusitis or the presence of complications [5]. The duration of treatment depends on the drug chosen and the severity of the sinusitis. The course of treatment can range from 7 to 14 days. It is important to completely stop the inflammatory process in the paranasal sinuses, therefore, with the goal of complete eradication of the pathogen, you should focus on a treatment period of 7–10 days. Considering the significant role of swelling of the nasal mucosa and obstruction of the anastomosis of the natural openings of the paranasal sinuses in the pathogenesis of ARS, great importance is attached to vasoconstrictor drugs: xylometazoline, oxymetazoline, phenylephrine, etc. Topical glucocorticosteroids have relatively recently entered the arsenal of drugs for the treatment of acute rhinosinusitis. The purpose of the prescription is to reduce the secretion of glands of the mucous membrane, reduce tissue edema and, as a result, improve nasal breathing (mometasone furoate nasal spray 100 mcg 2 times / day) [5, 6].
Unfortunately, due to the uncontrolled use of drugs, especially antibacterial ones, there is a constant evolution of bacterial cells that acquire new properties and become more resistant. Over the past decade, the resistance of these bacteria to macrolides and penicillins, traditionally widely used in otolaryngology, has increased significantly. In addition, in recent years there has been a sharp increase in the number of bacteria producing extended-spectrum β-lactamases, which is associated with the widespread use of first, second and third generation cephalosporins in inpatient and outpatient practice [10].
Antibiotic resistance is a fairly serious problem in the treatment of sinusitis. According to the literature, a particularly large percentage is observed in Western European countries, which complicates the treatment tactics of sinusitis [5]. The spread of antibiotic resistance among pathogens of diseases of the ENT organs, along with toxic, immunosuppressive and allergic reactions to the administration of antibiotics, is the leading reason for the decrease in the effectiveness of antibacterial therapy. However, in recent years, a large number of strains of microorganisms have appeared that are not sensitive to antibiotics widely used in practice [9]. Thus, methicillin resistance is observed in 30–40% of Staphylococcus aureus. There has been a tendency towards increasing resistance to penicillins, macrolides, as well as aminopenicillins and first and second generation cephalosporin antibiotics [5, 9].
In addition to the resistance of microorganisms to drugs, we also have to deal with another pressing problem - the body’s allergic reaction to an antibiotic. The above data draws our attention to the need to search for new antibacterial drugs that can be used to treat patients with rhinosinusitis. As an alternative, highly effective bacteriophage preparations can be used, attention to which has justifiably increased recently [3, 4, 11]. Bacteriophages, or phages (from ancient Greek φᾰγω - “I devour”) are viruses that selectively infect bacterial cells. Most often, bacteriophages multiply inside bacteria and cause their lysis. The discoverer of bacteriophages was the Canadian scientist, bacteriologist Felix D'Herelle (25.4.1873, Montreal - 22.2.1949, Paris), but in 1929 Alexander Fleming, observing the antagonism of Penicillium notatum and staphylococcus in a mixed culture, discovered penicillin and suggested the possibility of its use for medicinal purposes, and phage therapy was forgotten for some time. However, now that the effects of antibiotic use have changed the properties of many bacteria, scientists have again turned their attention to this group of drugs. Publications documenting phage therapy belong to the group of Stephan Slopek from the Institute of Immunology and Experimental Medicine of the Polish Academy of Sciences (Wroclaw). This group published a series of detailed articles in Archivum Immunologiae et Therapie Experimentalis (cf. Slopek et al., 1983, 1985, 1987), describing the results of phage treatment from 1981 to 1986 in 550 patients [8]. Bacteriophage preparations have been successfully used in Russia for more than 60 years (1936 - the beginning of the use of bacteriophages in the USSR).
What is the mechanism of action of bacteriophages? The process of interaction between a virulent bacteriophage and a cell consists of several stages: adsorption of the bacteriophage on the cell, penetration into the cell, biosynthesis of phage components and their assembly, and release of bacteriophages from the cell. The duration of this process can range from several minutes to several hours. Then cell lysis occurs and new mature bacteriophages are released. A very important property of bacteriophages is their specificity. Based on specificity, there are polyvalent bacteriophages that lyse cultures of one family or genus of bacteria, monovalent (monophages) - lysing cultures of only one type of bacteria, and also characterized by the highest specificity - typical bacteriophages, capable of causing lysis of only certain types (variants) of a bacterial culture within a species bacteria [7, 12, 13].
Bacteriophage preparations are used to treat purulent-septic and enteral diseases caused by opportunistic bacteria of the genera Escherichiae, Proteus, Pseudomonas, Enterobacter, Staphylococcus, Streptococcus, Klebsiellae. It is these bacteria that are the causative agent of severe sinusitis against the background of immunodeficiency states, as mentioned earlier. Bacteriophages have a number of advantages: specificity of action, absence of inhibition of normal microflora and allergic reactions, stimulation of specific and nonspecific immunity factors [3, 4, 7, 12, 16]. The use of specific bacteriophages makes it possible to optimally carry out targeted lysis of pathogenic flora for the purpose of an antimicrobial effect, as well as to restore normal microbiocenosis. Bacteriophages do not have a toxic effect and do not suppress normal microflora. They indirectly have a stimulating immunological effect, affecting cellular and humoral immunity [19]. Various preparations of bacteriophages, used in accordance with the type of pathogen, are highly effective in the treatment of peritonsillar abscesses, inflammation of the sinuses, purulent-septic diseases of patients in intensive care units, surgical infections, pyelonephritis, cholecystitis, gastroenterocolitis, intestinal dysbiosis, inflammatory diseases and sepsis of newborns [3, 7, 11]. The absence of adverse pathological reactions to the use of bacteriophage preparations allows their effective use in newborns and children in the first year of life [Voroshilova N.N. et al., 2000]. Therapeutic and prophylactic bacteriophages are manufactured in compliance with all aseptic requirements and are preparations based on natural components contained in water and soil, so they can be prescribed to children and adults. According to their composition, bacteriophages are divided into monopreparations containing virulent phages of bacteria of the same genus or species - staphylococcal, streptococcal (including enterococcal), proteus, pseudomonas aeruginosis (pseudomonas aeruginosa), Klebsiella pneumoniae, coli, dysenteric polyvalent, typhoid, salmonella (gr. . ABCDE), and combined phages, which contain several monopreparations. The combined ones include: coli-proteus, Klebsiella polyvalent, polyvalent pyobacteriophages (purified, complex and Sextaphage®) - containing bacteriophages staphylococcal, streptococcal, proteaceous, Pseudomonas aeruginosa (pseudomonas aeruginosa), Klebsiella, coli, as well as Intesti-bacteriophage containing bacteriophages against Shigella , Salmonella, Staphylococcus, Enterococcus, Proteus, Pseudomonas aeruginosa and Enteropathogenic Escherichia coli.
One of the combined drugs is Sextafag® (polyvalent liquid pyobacteriophage), produced in Russia by the Federal State Unitary Enterprise NPO Microgen of the Russian Ministry of Health [11]. NPO Microgen is one of the top three Russian pharmaceutical companies and is the largest national manufacturer of immunobiological preparations: vaccines, serums, specific immunoglobulins, culture media, allergens, probiotics. A unique area of scientific and production activity of NPO Microgen is the production of bacteriophages - safe antibacterial drugs, an effective alternative to antibiotics. Sextaphage® is a mixture of sterile filters of phagolysates of staphylococci, streptococci, enterococci, Escherichia coli, Proteus, Pseudomonas aeruginosis and Klebsiella pneumoniae. Release form: in bottles and ampoules. Pyobacteriophage Sextaphage® is approved for use in newborns from 0 months, as well as in pregnant women, which indicates the safety of the drug.
Pyobacteriophage polyvalent (Sextaphage®) has the ability to specifically lyse microorganisms corresponding to the phage. The drug has proven itself well in purulent-inflammatory diseases of the upper and lower respiratory tract, including in the treatment of ABRS. The drug is taken orally. It can be used in conjunction with antibacterial agents according to the traditional regimen of antibacterial therapy, which were discussed above. Sextaphage® is usually prescribed on an empty stomach in liquid form, 20 ml 2–3 times a day. The drug is used in monotherapy, combination therapy with antibiotics is also possible. The duration of the course is, as a rule, no more than 7–10 days.
The drug is approved for use in newborns from 0 months. Thus, therapy for ABRS, especially caused by pathogens of nosocomial strains, against the background of immunodeficiency states, is justified with bacteriophage preparations and is a promising direction. Can be considered as an alternative to antibiotic therapy and as an adjuvant treatment with classical antibacterial therapy. The emergence of new bacteriophage preparations serves as a promise for studying the antibacterial properties of these drugs against the main causative agents of inflammatory diseases of the ENT organs, as well as studying the effect of bacteriophage preparations on the immune status of patients.
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