title: Oral Phage Therapy of Acute Bacterial Diarrhea With Two Coliphage Preparations: A Randomized Trial in Children From Bangladesh.
abstract: BACKGROUND
  Antibiotic resistance is rising in important bacterial pathogens. Phage therapy (PT), the use of bacterial viruses infecting the pathogen in a species-specific way, is a potential alternative.
  
  
  METHODS
  T4-like coliphages or a commercial Russian coliphage product or placebo was orally given over 4 days to Bangladeshi children hospitalized with acute bacterial diarrhea. Safety of oral phage was assessed clinically and by functional tests; coliphage and Escherichia coli titers and enteropathogens were determined in stool and quantitative diarrhea parameters (stool output, stool frequency) were measured. Stool microbiota was studied by 16S rRNA gene sequencing; the genomes of four fecal Streptococcus isolates were sequenced.
  
  
  RESULTS
  No adverse events attributable to oral phage application were observed (primary safety outcome). Fecal coliphage was increased in treated over control children, but the titers did not show substantial intestinal phage replication (secondary microbiology outcome). 60% of the children suffered from a microbiologically proven E. coli diarrhea; the most frequent diagnosis was ETEC infections. Bacterial co-pathogens were also detected. Half of the patients contained phage-susceptible E. coli colonies in the stool. E. coli represented less than 5% of fecal bacteria. Stool ETEC titers showed only a short-lived peak and were otherwise close to the replication threshold determined for T4 phage in vitro. An interim analysis after the enrollment of 120 patients showed no amelioration in quantitative diarrhea parameter by PT over standard care (tertiary clinical outcome). Stool microbiota was characterized by an overgrowth with Streptococcus belonging to the Streptococcus gallolyticus and Streptococcus salivarius species groups, their abundance correlated with quantitative diarrhea outcome, but genome sequencing did not identify virulence genes.
  
  
  CONCLUSIONS
  Oral coliphages showed a safe gut transit in children, but failed to achieve intestinal amplification and to improve diarrhea outcome, possibly due to insufficient phage coverage and too low E. coli pathogen titers requiring higher oral phage doses. More knowledge is needed on in vivo phage-bacterium interaction and the role of E. coli in childhood diarrhea for successful PT.
  
  
  BACKGROUND
  The study was supported by a grant from Nestlé Nutrition and Nestlé Health Science. The trial was registered with Identifier NCT00937274 at ClinicalTrials.gov.
authors.affiliation: International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka 1212, Bangladesh.
authors.forename: Shafiqul Alam
authors.initials: SA
authors.lastname: Sarker
authors.affiliation: International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka 1212, Bangladesh.
authors.forename: Shamima
authors.initials: S
authors.lastname: Sultana
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Gloria
authors.initials: G
authors.lastname: Reuteler
authors.affiliation: Nestlé Institute of Health Science, EPFL Innovation Park, CH-1015 Lausanne, Switzerland.
authors.forename: Deborah
authors.initials: D
authors.lastname: Moine
authors.affiliation: Nestlé Institute of Health Science, EPFL Innovation Park, CH-1015 Lausanne, Switzerland.
authors.forename: Patrick
authors.initials: P
authors.lastname: Descombes
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Florence
authors.initials: F
authors.lastname: Charton
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Gilles
authors.initials: G
authors.lastname: Bourdin
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Shawna
authors.initials: S
authors.lastname: McCallin
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Catherine
authors.initials: C
authors.lastname: Ngom-Bru
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Tara
authors.initials: T
authors.lastname: Neville
authors.affiliation: International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka 1212, Bangladesh.
authors.forename: Mahmuda
authors.initials: M
authors.lastname: Akter
authors.affiliation: International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka 1212, Bangladesh.
authors.forename: Sayeeda
authors.initials: S
authors.lastname: Huq
authors.affiliation: International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka 1212, Bangladesh.
authors.forename: Firdausi
authors.initials: F
authors.lastname: Qadri
authors.affiliation: International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka 1212, Bangladesh.
authors.forename: Kaisar
authors.initials: K
authors.lastname: Talukdar
authors.affiliation: Nestlé Institute of Health Science, EPFL Innovation Park, CH-1015 Lausanne, Switzerland.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Kassam
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Michèle
authors.initials: M
authors.lastname: Delley
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Chloe
authors.initials: C
authors.lastname: Loiseau
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Ying
authors.initials: Y
authors.lastname: Deng
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Sahar
authors.initials: S
authors.lastname: El Aidy
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Bernard
authors.initials: B
authors.lastname: Berger
authors.affiliation: Nestlé Research Centre, Nestec Ltd., Vers-chez-les-Blanc, CH-1000 Lausanne 26, Switzerland.
authors.forename: Harald
authors.initials: H
authors.lastname: Brüssow
mesh_terms: D000284:Administration, Oral; D000293:Adolescent; D001459:Bangladesh; D002648:Child; D003090:Coliphages / Q000472:pathogenicity*; D003967:Diarrhea / Q000382:microbiology / Q000628:therapy*; D054308:Enteropathogenic Escherichia coli / Q000821:virology; D004927:Escherichia coli Infections / Q000382:microbiology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D000071059:Phage Therapy
keywords: Bacteriophages; Bangladesh; Bifidobacterium; Cfu, colony forming unit; Children; Diarrhea; EAEC, enteroaggregative E. coli; EPEC, enteropathogenic E. coli; ETEC, enterotoxigenic E. coli; Escherichia coli; M, ColiProteus phage cocktail from Microgen; ORS, oral rehydration solution; P, placebo; PT, phage therapy; RCT, randomized controlled trial; Streptococcus; T, T4 phage cocktail from NRC; pfu, plaque forming unit; qPCR, quantitative polymerase chain reaction