They have been used for almost a 100 years in Russia with great efficiency. Our inability to use phage therapy here is due to terrible incentives created by intellectual “property” laws and regulations that assume standardized treatmentments.
A post on this from a day or so ago, my usual take on phage, from the standpoint of someone who works in healthcare epidemiology and has always been fond of phage therapy:
1) Even with resistance on the rise, we still have antibiotics that work. Phage therapy is a "someday we're going to need this...we think" type treatment.
2) There's no such thing as a "broad spectrum" phage. They're organism specific, and that means not only would you need to keep a phage library on hand, but you'd have to do a lot of diagnostic tests. That's going to be both expensive and tricky.
3) Phages are living things. Not only is that a weird regulatory framework to be in for a drug, but it also means that you need to be able to keep phage alive. In contrast, antibiotics are inert.
4) Phage therapy is also relatively new in the West, which means there's just less of a R&D infrastructure behind it.
There have been people working on commercializing phage therapy since I was in undergrad (I'm now a tenure-track professor). The problem is it's hard, and antibiotics are so much better as a treatment that there's kind of a ceiling on the excitement that they can generate.
We have antibiotics that work for most infections. For people with antibiotic-resistant infections (especially hospital-borne ones) they are already not an option. A childhood acquaintance of mine with CF recently died of an antibiotic-resistant infection in her newly-transplanted lungs. Lack of awareness and research into phage therapy was fatal in her case, as it meant they started the process late and it took longer than it needed to.
Said process is: take samples of the infectious agent, culture them, and send the cultured bacteria to "phage banks" so they can test their existing phages against it. There's a lead time both because of the initial setup required per-patient, and because of the scarcity of comprehensive phage banks and the lack of good coordination between them.
And yes, highly resistant infections are a problem - and one I work on - but from a "market forces" perspective they're still relatively rare. Even for most highly resistant infections we still have some antibiotics that work - not well, and not without side effects, etc.
In this particular case, they found a phage for the particular infection, but at too late of a stage - most of the development I've heard of has been less about basic research and more about building institutional processes for quickly finding existing predators of a given bacterium. (Which, I agree, is a lot more expensive and risky than an antibiotic if you can find one that works.)
I'm very sorry for your loss.
Re 2) I don't think that would be a problem considering together with 1 there will simply be a need to develop a quick but reliable method to test for which collection of phages work, probably even develop cocktails of phages for a more broad application. Reducing the amount of antibiotics used would also help reduce the risk of the broad spectrum antibiotic failing because of resistant bacteria.
3) Phages are living things depending on who you ask. Phages are rather simple and will to my knowledge remain viable for a good and long time. Antibiotics may be inert but also have an expiration date, you can't just use an 60yo antibiotic and hope that works. At some point the contents of the antibiotic will have broken down and oxidized.
4)Fair but apparently people have been using it in the Eastern Block for a while with some success. There are some shoulders to stand on and continue R&D.
2) "There will simply be a need to develop a quick but reliable method to test..." is a really big ask. We don't have quick but reliable tests for some common human pathogens. You can't simply posit that a great test will work. You're right about antibiotic stewardship, which is something I work on, but that's orthogonal to how good phage are as a clinical treatment.
3) While yes, in some particularly strict senses they're not alive, the actual point of that is there's currently no phage preparation technique that is not extremely lab intensive at the site of treatment.
4) Agreed - and the Russians and Georgians have some really cool work, but even there, it's for what are, clinically, extremely difficult edge cases, rather than the kinds of things antibiotics are routinely used for.
4) USSR jumped onto antibiotics as soon as they were available, and hasn't really looked back.
Successfully regulating antibiotics is a worldwide effort. I'm not confident we'll ever be more than moderately successful at that.
Proper antibiotics circulation is a policy problem; phage therapy is scientific, technological and policy problem.
5) phages are viruses and our bodies are very efficient at not letting them in, so you can't just pop a pill, you need them injected into the bloodstream
6) you need a lot of phages (and/or a steady supply of them) because they don't replicate in our bodies (they don't infect us), but our immune system is very good at clearing them out so their blood concentration drops really fast
7) because phages are viruses and we need them injected into bloodstream in copious amounts, our own immune response to them may become a problem. Potentially-fatal-cytokine-storm kind of a problem.
Viruses are more like a delicate molecule than like a living thing, because they don't have a metabolism. Kept in the proper conditions they last indefinitely.
"more like" in this context. "Are viruses alive" is the most popular thread in bio-ontology, locked by the moderator after 12,493 pages of heated debate.
But there's a few major concerns:
1. Most preparations are bespoke. The FDA has made some headway with this because of fecal transplants, but it's still a problem.
2. Phages evolve. That's one of the benefits of them. Generally speaking, self-adaptive medications are not something we have a good regulatory context for.
3. They need culturing, isolation, identification, etc. and those are "wet lab" things.
bacteriocidal antibiotics tend to be cytotoxic with aminoglycosides causing hearing loss, fluoroquinolones causing heart problems tendon problems psychiatric problems and even more. Cdiff colitis is a deadly risk and also toxic epidermal necrolysis. These effects are noted to be happening more often than previously thought in clinical trials, in some cases because they can develop overtime rather than immediately.
No they're not. Virus particles are totally inert on their own. They incorporate themselves into and modify other living systems. But that's no different from drugs.
And while there's no rule that prevents that, I don't know of a single drug - or even the suggestion of a drug - that's capable of integrating with a bacterial host genome, producing the needed compounds, and then exporting them out of the cell.
It's not impossible, no, but it's not a thing presently happening.
How is that any different from probiotics or yeast? Those are also "living" but my understanding is that they are dormant and inactive until reactivated.
(Lots of good points raised in your comment, though.)
- Viruses aren't particularly stable. They're fussy little things - it's easy to deactivate them.
- How you get phage preparations is to find them where the bacteria you want to target are growing, then culture them, filter out the bacterial endotoxins (because that'll kill someone), and then use that purified preparation. That needs a lab, and one that's reasonably good at what it does, vs. a random pharmacist at Walmart.
https://archive.org/details/BBCHorizonS1997e13TheVirusThatCu...