Synergistic Effects of Phage/Antibiotics to Combat Infection

This report delves into the synergistic effect of phage/antibiotics to combat infection. It covers the notion of synergistic effect, impact, and ways to promote it. The report also includes a literature review on the topic, including the mechanism of action and the effectiveness of the combination therapy. The aim of the report is to understand the synergistic effect of phage/antibiotics to combat infection.

Pharmacotherapy Bacteriophage
therapeutics

Table of Contents
TITLE..............................................................................................................................................1
CHAPTER 1: INTRODUCTION (1500)........................................................................................1
Aim.........................................................................................................................................1
Objective.................................................................................................................................2
RATIONALE FOR THE RESEARCH...........................................................................................2
CHAPTER 2: LITERATURE REVIEW (3500).............................................................................2
Notion of synergistic effect of phage/antibiotics to combat infection...................................2
Impact of synergistic effect of phage/antibiotics to combat infection...................................5
Ways and strategies that promote synergistic effect of phage/antibiotics to combat infection8
CHAPTER 3: RESEARCH METHODOLOGY (2500)................................................................10
CHAPTER 4: RESULT AND DISCUSSION (1500)..................................................................15
CHAPTER 5: CONCLUSION AND RECOMMENDATION (1000)..........................................18
Conclusion............................................................................................................................18
Recommendation..................................................................................................................19
REFERENCES..............................................................................................................................22

TITLE
“Investigation into the synergistic effects of phage/antibiotics to combat infection”
CHAPTER 1: INTRODUCTION (1500)
The phage-antibiotic synergy is referring as process where sub lethal concentration of some
selected antibiotic can sustain to produce the host bacteria stimulation in virulent phase (Silva
and et. al., 2021). The enhancing notion of sub lethal concentration of antibiotic drug for
example name cefotaxime provide the outcome that is observed under increase T4 plaque size
and T4 associated concentration. Technically, synergistic effect is well determining for number
of cases which must be acute or chronic depend on severity (Lin and et. al., 2018). Numerically,
ΣFIC ≤ 0.5 at phage concentration that is associated between 103 and 106 with the unit of
PFU/mL. At the complied level of 1012 PFU of phage’s/mL, the effect was highly additive (≥1
ΣFIC ≤ 2), with this, higher concentration of phage has ability to kill the bacteria without any
antibiotic addition. Non antibiotic alternative treatment are used to show the combat which help
to enhance the infection which is usually causes by multidrug resistant bacteria which steadily
required (Maharjan and et. al., 2022). In some recent years, bacteriophages have remembered to
make the potential replace or complement the role of antibiotic as show the bacterial viruses that
have ability to make the inactivate pathogen. In this, for studying of synergistic effect of phage
antibiotic combination is usually based on some example which contained organism named
Citrobacter amalonaticus and Escherichia coli. These two organism is useful to create
understanding regarding the synergistic effect of phase/anitibiotic to combat the infection. In
reference with Citrobacter amalonaticus isolate of phage antibiotic combination. The Citrobacter
amalonaticus isolate the study which is put together with phage of MRM57 (Narulita and et. al.,
2020). In this, eight different antibiotics with various mechanism of action which is used in
combination with phage to impact the combination treatment on the less inhibitory concentration
or also depend on dilution of organism to understand the resistivity of drug. The research work
usually covers the topic that is well related with synergistic effect of phage/antibiotic as an
effective aspect for combat of infection (Raza, Matuła, Karoń, and Paczesny, 2021).
Antibiotic synergy is defined as response when two or more than two antibiotics are
administered simultaneously with the purpose to treat bacterial infections. Synergistic
mechanism is defined as a process where two or more than two materials produce larger effect in
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comparison to single compound. The antibiotics work collaboratively which enhance the potency
of the drug. The efficacy of the drug also get increased then the single administered drug.
Synergistic effects of drugs are found most effective in order to combat bacterial infections as it
broaden antibacterial spectrum. Administration of combination of drugs ensures that at least one
single active drug will kill or prevent the infecting organism (Zhang and et. al., 2019). For
example, penicillin G is a antibacterial drug and it is combination of gentamicin and
streptomycin. This combination is found effective to deal with 17 and 16 of bacterial strains.
Finding of various peptide antibiotic has leaded in a novel area of research for antibacterial
agents. Ribosomally synthesised natural peptides are discovered as novel therapeutic approach
to treat the bacterial infection due to their antimicrobial potency. Naturally found antimicrobial
peptides are principle elements of the natural host shielding molecules of a very wide range of
plants, species and animals. It has been analysed that naturally found peptides shows broaden
antimicrobial activities (Yang and et. al., 2020). Antibiotic synergy is defined as response when
two or more than two antibiotics are administered simultaneously with the purpose to treat
bacterial infections. Synergistic mechanism is defined as a process where two or more than two
materials produce larger effect in comparison to single compound. The antibiotics work
collaboratively which enhance the potency of the drug. The efficacy of the drug also get
increased then the single administered drug. Synergistic effects of drugs are found most effective
in order to combat bacterial infections as it broaden antibacterial spectrum. Administration of
combination of drugs ensures that at least one single active drug will kill or prevent the infecting
organism. For example, penicillin G is a antibacterial drug and it is combination of gentamicin
and streptomycin shows broad spectrum of antibacterial activity. Studies revealed the
effectiveness of group of natural peptides at the site of action which is cytoplasmic membrane.
This includes mechanism of binding monomers to cytoplasmic membrane in order to form ion
channels pores. There are some multi-drug resistant organism, has been spreading widely and
founded life-threatening for human beings (Gounani and et. al., 2019). Combination therapy of
antibacterial agents helps to treat the bacterial infections effectively. Many research has been
conducted to study the synergy in vivo and in vitro to collect the data about the therapeutic
effects of combination of drugs. Some combinations may result in enhance mutational
intensities. Synergistic drugs have also some negative effects as it increases risk of toxicity and
adverse effect. Research shows that synergistic validity is more effective to prevent antimicrobial
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resistance. Two synergistic drugs are found as effective than single administered drug.
Synergism enhance the efficiency and efficacy of the drug. Multi-drug resistance to treat
bacterial infections is leading across the world (Sharahi and et. al., 2019). Administration of
combination of drugs is considered as an effective novel approach to treat the bacterial diseases.
Synergistic antibacterial activity of group of natural antimicrobial peptides are inactive against
multi-resistant staphylococcal epidermis in vivo and in vitro. Erythromycin, ampicillin and
penicillin are studies as show synergistic effect in combination. The antibacterial activity get
increased with the administration of combination of drugs. Tetracycline drugs shows synergistic
effects with I1WL5W and additive activity with L11W, I4WL5W AND L12W. Since past 10
years, increasing number of multi-resistant bacterial species have enhanced due to
administration of antibiotics across the world. With the help of different mechanism the
development of novel antibiotics has been discovered (Wei, Yu, and Chen, 2019). Synergistic
drugs are recovered after failure of single administered drug. Some bacteria are found drug
resistant and most of the single drug components are not able to kill the infecting bacteria. In
such cases, synergistic drugs are given as increases the potency and efficiency of the drug against
the bacterial infection. Combination of chemicals and active components shows novel approach
to improve and enhance antibacterial activity. Combination therapy or synergistic drugs are
helpful to reduce the dose of the administered drug. It is also helpful to minimize adverse effects
of the drugs. It is a novel approach made to overcome with problems such as adverse effects and
toxicity. Sometimes, combination of drugs are used to overcome the side effects of individual
component present in the drug. Low intensity and high toxicity hinders the development of
antimicrobial agents. Administration of synergistic drugs helps to overcome both of these (Yu
and et. al., 2019).
Aim
To understand the synergistic effect of phage/antibiotics to combat infection.
Objective
 To analyse the notion of synergistic effect of phage/antibiotics to combat infection.
 To evaluate impact of synergistic effect of phage/antibiotics to combat infection.
 To examine the ways and strategies that promote synergistic effect of phage/antibiotics to
combat infection.
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RATIONALE FOR THE RESEARCH
The rationale for the research well show the effectiveness while involving with research work. In
addition, while conducting the research it helps to provide personal as well professional
development. Therefore, the study also generates the knowledge and various skills that is
appropriate as per term of topic. The topic which is chosen for the report is usually focus on the
broad term where investigation is used to done that is about impact of synergistic effect of
antibiotic in combat with infection. The study is broad and provide knowledge that is related
with topic. The personal development means they create sense of knowledge on personal level
which help in future to provide recommendation of antibiotic to relative and friend to combat
with infection. On other hand, professional develop is carried as per the knowledge which is
useful for the future implication when they are related with future placement and courses.
CHAPTER 2: LITERATURE REVIEW (3500)
Notion of synergistic effect of phage/antibiotics to combat infection
With the view point of Prasanth Manohar and colleagues, Antibiotics has been prescribed
to combat infection by resisting the growth or reproduction process of infectious agents within
the body. Specific antibiotics are being prescribed by doctors according to the bacteria or virus
invaded in the body. These drugs eliminate the infectious agents and helps to develop immunity
which assist body to fight against the invaded infectious agents along with natural immunity of
human body, which contains T cells and memory cells. Natural immunity of a human body is too
strong that it can even recognise the infectious agent, if attack further (Pires and et. al., 2022).
The concurrent overuse and over prescription of antibiotics are the main causes of development
of antibiotic resistance in bacteria. Thousands of deaths have been detected every year due to
lack of antibiotic-resistant infections. Shortage of proper and effective treatment options, phage
therapy has re-emerged as a better treatment to treat multidrug resistant infection with
remarkable clinical outcomes. For example; Citrobacter spp. is a gram negative bacteria belong
to Enterobacteriaceae family. These species are commonly found in water, food, soil and the
intestinal tract. They may cause infection in urinary tract, respiratory tract, and bloodstream in
humans. Antibiotics used to treat Citrobacter infections are glycylcycline, aminoglycosides,
beta-lactams, cephalosporins, and polymyxin-B. Beta-lactams is the essential antibiotic class
which target bacterial cell wall. Meropenem, carbenicillin, cefotaxime are highly effective.
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The serious antibiotic crisis has led the researchers to study for the effective of combination of
antibiotics. Even after implementing various approaches to fight against multidrug resistance,
bacteria did not stop to evolve and persist. Phage therapy is a potential option to antimicrobial
chemotherapy, but the use of phages alone without any antibiotics can leads to the development
of phage-resistant bacteria (Chen and et. al., 2022). It has become important to search for an
alternative to stop bacteria from evolving and developing resistance to antibiotics. So antibiotics
and phages have been combined to generate synergistic effect. Phase-antibiotic synergy has
revealed some promising result in eliminating bacteria. Some antibiotics are capable to stimulate
the production of phages through a bacterial host and frame larger plaques along with antibiotics.
And certain antibiotics may have a sublethal concentration which may promote the release of
progeny phages from bacterial cells. Phage-antibiotic synergy (PAS) is so effective that it can
reduce the usage of amount of antibiotic and reduce the emergence of antibiotic resistance in
bacteria. This synergistic combination postulated to be more effective in controlling bacteria.
The research indicates that the combination of antibiotics and phages are more suitable to treat
Gram-positive bacteria including MRSA (methicillin-resistant Staphylococcus aureus) as well as
Enterococcus strains. There is different mechanism of action that can be helpful in explaining the
phenomenon of PAS. 1)cell elongation; 2)size of plaque enhanced by antibiotics, accelerated
plaque amplification and increased burst size; 3)Antibiotic-resistant mutant occurrence decrease
and decrease of phage occur; 4)presence of phage results in increasing antibiotic susceptibility;
5)Antibiotic MIC seems to get reduce due to addition of phages to the antibiotic; 6)Phage
enzyme leads to decompose the bacterial cell wall which facilitate the diffusion of antibiotic and
increase cell penetration (Letrado and et. al., 2018). Comeau and colleagues described that the
process of cell filamentation has been observed during PAS. Quinolones and beta-lactams caused
both PAS and filamentation whereas tetracycline and gentamicin caused neither PAS nor
filamentation. Some researchers said that some antibiotics are capable to promote lysis of cell
given that filamentation induces disturbances in the layer of peptidoglycan and which may
induce phage lysis genes encoded enzymes. This phenomenon can lead to rapid lysis and
enhanced the rate of phage production.
From another mechanism it has been demonstrated that sublethal concentration of
tetracycline, linezolid, and ketolide antibiotics can increase plaque size by three times while
quinolones and beta-lactams antibiotics cannot produce this effect (Tagliaferri, Jansen, and Horz,
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2019). An in vitro study indicated that phage combination that cause infection to S. aureus and
antibiotics (tetracycline, clarithromycin, ciprofloxacin, linezolid, cefotaxime) enhance the
production of progeny phage. Combined therapies of antibiotics and phages were investigated in
vitro to fight against drug-resistant uropathogens. The production of phage MFP through a
uropathogenic E. coli strain can be increased distinctly by low dose of Cefotaxime. It has been
observed that similar effect is effective for beta-lactam, T4-like phages, mitomycin C and
quinolone antibiotics. Lowering antibiotic MIC values give synergistic effects of antibiotics with
E. coli phage cocktail and similar with amikacin when median MIC reduced from 8 to 2 μg/ml
and for fosfomycin, it was reduced from 32 to 8 μg/ml.
PAS have been studied in animal models to evaluate the effect of phages in falling down the
inflammatory reaction, to identify actual synergistic effect of antibiotics and phages. Studies
revealed the data about liposome-encapsulated phages, that they can be effective in diminishing
inflammatory responses. For instance, Kaur and colleagues suggested that levels of TNF-alpha
cytokines, Interleukin-1beta and PCT are surgically implanted in mice by K-wire into intra-
medullary canal, with a specific phage and linezolid antibiotic with lower concentration as in
comparison with K-wire (Luo and et. al., 2022). As a result, intracellular bacterial counts will be
decreased and bring down to a certain level and increasing effect of oxidative killing through
phagocytes. In this situation, the bactericidal activity and phagocytic functions were seeming to
be increased since bacteria are killed and digested by macrophages in vivo. The use and effect of
phages alone as well their combination with antibiotics has also been studied in patients suffer
with suppurative bacterial infection in Poland. To research for the topic of interests, professionals
first administered phages orally or locally and obtained more effective results than the condition
when combined treatment were given along with phages nad antibiotics. Statistically significant
results were observed. From these results, possibility of existence of antagonistic effect between
phages and antibiotics has been considered. An another experiment was conducted by Zilistenau
and colleagues, to check the efficacy of combination of phage-antibiotic and solitary effect of
phage therapy. About 87 patients of chronic UTI has been selected. When phages were
administered orally at 20 ml dose for 5 days and antibiotics were given for 10 days. It has been
observed that almost 92.8% of positive cases shown efficient results while when combination of
antibiotic-phages were given, only 64.4% of patients shown good results. This treatment also
shown the results of existing antagonistic effect between antibiotics and phages.
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Apart from bacterial infection, studies and experiments of combination of antibiotics and
phages has been conducted in case of orthopaedic infections in humans. A trauma-related left
tibial infection patient who has developed the resistance from K. pneumoniae and A. baumanni
has administered the combination of phages K. pneumoniae and A. baumanni through injection
for consecutively 5 days and then after giving break of 1 week, colistin iv and meropenem
administered simultaneously for 6 days observed to give a good clinical outcome with fast
healing of tissues and eradicate positive culture. Such clinical data, it can be evaluated that the
combination of antibiotics and phage M1 caused clinical improvements (Li and et. al., 2021).
Nowadays, phages are used alone by professionals to improve the effectiveness of therapy; by
giving as a supplement for existing antimicrobials or against antibiotic-resistant bacteria. In
humans, cases of recurrent bacterial infections have been treated by applying phages and
antibiotics which shown promising treatment outcomes. Good clinical results have been obtained
in respiratory, orthopaedic, and urinary tract cases from 2018 to 2022 with the application of
combined treatments.
It is important to investigate phage-antibiotic interactions in vitro to intercept antagonism and to
ensure synergistic effect to understand the results of treatments effectively. It should be
considered to understand that phage-antibiotic interaction can depend on dose and type of each
agent as well the time of administration. More research and studies are still going-on to increase
understanding about the combined-action of antibiotics and phages in vivo and in vitro. This may
help in achieving a milestone in near future.
Impact of synergistic effect of phage/antibiotics to combat infection
According to the viewpoint of Deijing, (2019) it is well analysed that the synergistic effect is
required for the various cases where drug is administered in combined form to sum the effect for
better therapeutic effect. Moreover, antibiotic synergy is referring as one of the three process
which is possible when two or more antibiotic are used respectively to the treat the condition or
used to fight against the infection. In the synergistic response, the applied antibiotic is usually
work together to sum the effect which is applicable to reduce the situation which is chronic or
life threatening (Vazquez-Muñoz and et. al., 2019). The applied antibiotic is generally work
together in order to show the effect more potent than if each antibiotic which is were applied. In
this, they are taking into comparison with additive effect, where the potency of an antibiotic
combination which is roughly equal to combined potencies of each antibiotic singly and they
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showing antagonistic effect. Moreover, the potency of combination is less than the combined
potencies of showing each antibiotic (Rezzoagli and et. al., 2020).
According to author of Yan, (2013) the discussion is based on the Gram negative and Gram
positive bacteria which act as the main cause of infection among the mammals. In addition, they
are also showing emergence of their antimicrobial resistance is an enhancing issue in human
medicine. The diabolical fraction or structure which is associated with polycatonic peptide
represent the conserved theme that is based on antimicrobial defence. Therefore, it is essential to
provide new structural class of highly active antimicrobial agents and they are showing the
potential act as resource for development novel anti-infective agents (Namivandi-Zangeneh and
et. al., 2018). Studies is well indicated that they are polycationic peptide that have number of
variable that show antibacterial, antifungal and antiprotozoal activity in vitro chemotherapy. For
instance, compound may be very valuable as adjuvants for antimicrobial chemotherapy. Studies
used to elaborate that to exert their antimicrobial and antiendotoxic activity where peptide must
initiate bind to lipopolysaccharide of outer membrane for gram negative bacteria. The LPGs
usually trigger acute phase response to infection and compound or molecule which is generally
involved in the recognition process that has been extensively studied to show their response for
infection. Context with comparison that is little to known concern towards the bioactive
component which is gram positive bacteria and mechanism through which the target cell is well
activated by such elements (Shahzad and et. al., 2018). Therefore, peptidoglycan is referring as
the major component of the gram positive cell wall and does not contain LPS. Additionally, it is
also analysing to trigger various defensive mechanism as response which is against bacterial
infections. For example, current study confirmed that positive activity of each peptide against
Gram negative or Gram positive bacteria. In addition, the combination effect is well studied that
shows synergy between ranalexin and hydrophobic antibiotic such as polymyxin E, doxycycline
and clarithromycin. Therefore, the magainin II which is well refer as the synergistic with Beta
lactam. In other hand, the mechanism and configuration show the positive interaction which is
appears in the term of complex (Ipe, Kumar, Love, and Hamlet, 2020).
According to the vision of Ekta and Purva, (2022), the synergistic effect is defined with the
help of antibiotic synergy in order to treat infection. In this, treatment of staphylococcal infection
is difficult due to the resistance with the persisted form that pose an added threat of recalcitrant
infection. Therefore, antibiotic combination which is widely studied as an alternative strategy
8

with the main aim to treat the condition or to take the combat with the help of synergy that
greater the efficient of drug when they are sum together with same purpose (Wu, Tang, and
Uskokovic, 2018).
Therefore, clinical interest in the synergism dates back to the early of 1950 where healthcare
practitioner noted that patient with the infection for example enterococcal endocarditis are
usually experience high relapse rate when they are treated alone with Penicillin G and
elaborative discussion also configure that lower relapse rate when Penicillin G is combined with
streptomycin to combat with infection. In addition, research community has conducted several of
studies which is about investigation of synergy that is related with drug or medication in order to
treat infection which require additional therapeutic effect to minimise the chronic state of patient
(Chi, and Holo, 2018). The example is well above discussed, in this, the impact of synergy is
well analysed in all the cases where appropriate drug combination such as Penicillin G with
streptomycin show high rate of therapeutic to deal with the infection of enterococal endocarditis.
As per the current time, combination therapy is well recognised as providing the broad spectrum
of antibiotic coverage, effectively combat with poly-microbial infection, reducing selection of
antibiotic resistant strain, minimising the dose toxicity where applicable and in some of cases
they provide synergistic activity (Contreras, Munita, and Arias, 2019).
According to the Zhou, (2022), it is analysed from overall study that antibiotic synergy is
desirable sense for healthcare setting for several. At patient level, the boosted antimicrobial
potency provided by synergy allow the body which is more rapid clear infection that show the
result in shorter courses of antibiotic therapy. Therefore, the shorter courses of therapy which is
showing effect of dose related toxicity. At the higher synergistic effect which is useful for
combating resistant that is based on bacterial strain through enhanced potency and for stalling the
spread of bacterial resistance through the total eradication for the infection. It also shows aspect
of prevention for evolutionary selection of resisted cell and strains (Patrulea, Borchard, and
Jordan, 2020).
Ways and strategies that promote synergistic effect of phage/antibiotics to combat infection
Synergistic effect is referred to as one of the three possible outcomes that occur when more
than two antibiotics are administered simultaneously for the treatment of an infection. The
synergistic effect of antibiotics is also referred to as the antibiotic synergy where the combination
of antibiotics is considered desirable in a clinical sense for various reasons. This condition boosts
9

antimicrobial potency at patient level which ultimately results in short courses of antibiotic
therapy. Synergistic effects are also used to combat resistant bacterial strains by increased
potencies and obstructing the spread of bacterial resistance (Grygorcewicz and et. al., 2021). This
is done by total eradication of infection in the body. Antimicrobial resistance is a serious threat to
human race, because of which, the most effective strategy used to fight resistance is through
combination therapy. The use of bacteriophages, in recent years have proven to potentially
replace the role of normal antibiotics. This is because bacterial viruses have the ability to
inactivate or slow the functioning of pathogens. The development of new antimicrobial agents is
crucial to combat infections caused by multidrug-resistant (MDR) bacteria. The combination of
phage-antibiotic synergy is known to promote the process of phage replication and reduce the
growth and development of bacterial resistance. The antimicrobial efficacy and the therapeutic
performance of phage-antibiotic synergy is known to positively impact the bacterial inhibitory
effects to extreme levels. The rise of antibiotic resistance is the reason why phage therapy has
been increasingly studied and researched upon (Gonzalez‐Moreno and et. al., 2021).
The antimicrobial action produced from the combination of bacteriophages and antibiotics
should be promoted and the information about this study should be distributed so that all patients
can shift from administration of conventional antibiotic medications. The main focus for the
promotion of antibacterial activity should be evidence based (Chang, Nang, Chan and Li, 2022).
The use of antimicrobial phage therapy is essential to be evidence based because of its
application on human body. The application of proper research methods in wide range of fields
such as biology, chemistry, toxicology and pharmacology is crucial during the development of
new medicines. Without the application of clinical research, there is no evidence to prove the
efficacy of new treatments over the old ones. Therefore, research overview is one way through
which healthcare workers navigate towards finding the most effective therapy for care for
patients. Application of appropriate research methods towards identification of efficacy of
bacteriophage-antibiotic therapy information which is reliable and authentic. Along with
implementation of research methods, for the promotion of synergistic effect of combination
therapy, it is crucial to build credibility of information. The emphasis will be laid more on the
principles of the therapy rather than invalid and inappropriate information. Along with
knowledge build-up, the appropriate research about this therapy will ensure the understanding of
10

drug-drug interactions. The drug-drug interactions in this therapy have known showcase, the
prevention of formation of biofilms by phages.
Drug-drug interactions help in the identification of inhibition or induction of metabolism of
the drug along with pharmacodynamic action of the drug on human body. It is crucial to evaluate
drug-drug interactions to analyse the action of a drug or combination drugs (Javed, Parvaiz and
Manzoor, 2019). The importance of medication management in drug interactions potentiate the
clinical effects along with chances of overdose of drug. Understanding the drug interactions can
help in altering the pharmacological effect of another drug, thereby, contributing to synergistic
effect of the drug. The implementation of synergistic effect of phage-microbial therapy can alter
the pharmacodynamic and pharmacokinetic interactions which leads to increased effect of the
drug when given in combination with the bacteriophage. There is a possibility that this
alternation might result in the emergence of an entirely new effect of the drug. A systematic
research method involves the usage of exposure of two or more chemicals or antibiotics for
achieving a greater effect as the sum of the chemicals. The bacteriophages rupture the cell walls
of the bacterial cells during their lytic cycles. Bacteriophages cause antibiotic resistance as the
bacterial cells have become resistant to antibiotics, in general. The presence of bacteriophages is
considered effective against various species of bacteria cells such as MDR, XDR and PDR. The
mechanisms developed by bacteria to resist the action of antibiotics is inhibited by phages and
their efficacy (Ramesh and et. al., 2021).
Monitoring and reporting of adverse drug reactions helps healthcare workers cater
information about the safety and efficacy of pharmaceutical products. The development of
management plans is ensured with appropriate risk factors. The measurement of ADR incidence
helps in preventing the healthcare workers to avoid prescription of the drugs to the patients as
this will lead to lower incidences of occurrence of adverse drug reactions. Disclosing the quality
and frequency of these adverse drug reactions enables the workers to identify the intensity at
which risk factors can influence the monitoring of adverse drug workers. There are many
incidents which have proven the there is need for monitoring the safe use of drugs.
Pharmacovigilance based studies aids in better understanding about the efficiency of phage-
antibiotic resistance and appropriate planning can help in reducing the adverse effects of drugs in
patients as these methods facilitate in collecting information about the antibiotic during its pre-
marketing phase through the conduction of a clinical trial (Oyejobi and et. al., 2022). The study
11

about ADRs helps in the identification of quantity and quality of risks associated with the use of
phage-antibiotics. The synergistic phage antibiotic combination has proved to hail itself as one
possible therapeutic measure to increase the efficacy of antibiotics. These antibiotics when
combined with phages produce a toxic effect for bacteria by lowering their MIC for drug
resistant strains.
CHAPTER 3: RESEARCH METHODOLOGY (2500)
Research methodology is referring as the way which help to explain about researcher that
they have proximal intend where they carry out research in justified way. The research
methodology configures the tool and technique which is used in order to collect the data and
information for the research work or project. It is generally a logical plan that is systematic in
order to address issue of topic that is undertaken within the project. In this, impact is analysing
which occur due to synergistic effect of antibiotic to combat the infection. In addition, the
synergy of medication such as antibiotic are used in major ratio in order to treat issue which is
arise by infection (Akmalovna, and Olimovna, 2020).
Research method: In context with research work, it is well determining that secondary
method is used in order to collect data and information. Moreover, the use of secondary method
is appropriate in order to research wide range of data that is appropriate for research topic.
Additionally, topic is to determine the impact or effect of synergistic antibiotic to deal with the
issue of infection. The topic is wide and require update as per new research so it is difficult to
conduct primary research (Djafar, Yunus, Pomalato, and Rasid, 2021). If primary research is
conducted on such topic, difficulties are arising which may render reality of data and information
because it requires long time to process and analyse synergistic effect. Moreover, secondary
research is suitable and appropriate as per the topic to investigate a wide range of data and
information with the help of article, books and website that provide data which is about synergy
of antibiotic in order reach such therapeutic level that show bacteriostatic or bactericidal, the
therapeutic mechanism is usually depend on sum of antibiotic that is used for infection treatment.
Therefore, study allow the reader to gather knowledge because the major of data is well collected
from secondary sources. The reason that allow researcher to choose secondary method for
information extraction is simple and allow investigation that can be taken on broad level. The
research method has significant role where it provides researcher reliability and validity to
collect the data and information that develops a sense of knowledge related with topic. The topic
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is about synergy of medication especially antibiotic for treatment of infection. therefore, various
antibiotic is studied in order to show the addition on effect in term of therapeutic that reaches as
such action potential that dual the mechanism of drug for the treatment for illness of disease
which is associated with infection (Virus, fungi and so on). For example, endococcal infection is
well treated with synergistic antibiotic that is predominantly name with reference to combination
where Penicillin G with Streptomycin for the such above infection treatment. Such data is well
elucidated from the use of secondary research which provide knowledge in term topic
(SCHIOPU, 2022).
In addition, research method has chosen for the project or in this research work is secondary
method. In addition, the secondary method is usually allowing the researcher to drive
investigation on the broader level and make proportional that support data and information with
proper evidence based information. It is also elaborated with the study where review of article
and journals are used to take place for selection and collection of data that is related with
justified topic. With this all, research method helps to provide the way which show that
researcher follow secondary method for data collection and extraction (Giakoni, López, Segado,
Manzanares, and Mínguez, 2022).
Search strategy: The search strategy is well focus on the aspect which is taken in order to extract
the data and information that is adequate for the research topic. In addition, it is also analysing
the search strategy have wide range of resource that used to collect data and information. The
importance to use search strategy for research work is to provide wide range of information that
is used to interpret and collect data for research work as based on topic. In this research work, the
major search strategy which is used for the data extraction and elucidation are PubMed, Science
Direct, Springer Link, Medicine Plus and many more. They act as resource where article, book
and journals are show presence and with help of review as well as evaluation process data and
information is selected for the research work. The topic is broad and various antibiotic are
discussed with therapeutic effect that is associated with synergistic effect. From above, PubMed
is work as suitable search platform that used frequently for data extraction for research work.
PubMed is act as resource where article is readily present that show their relevance as per
fundamental concept which may be available in qualitative and quantitative and carries the
research with evidence based information. In addition, the study helps to foster the knowledge
13

with topic because broad level of resource is available where data is collected and appropriate
study is used to taken that support topic for data and information (Te Ava, and Page, 2020).
In other hand, Springer Link and other resource is also undertaking that is appropriate for
data collection and selection which may generate relevance for study and also foster condition
that provide wide range of knowledge that is based on topic. For example, the example of
Pencilling G with streptomycin is elucidated from PubMed from the study of article and other
related example that show the combination between ranalexin and polymyxin E, doxycycline and
clarithromycin. Similarly, maginin II was demonstrated to be synergistic with ceftriaxone,
amoxicillin clavulanate, ceftazidime, meropenem, piperacillin and Beta lactam antibiotic. Along
with this, some information is also collected that is showing synergistic effect has been well
demonstrated for double and triple antibiotic combination including an aminoglycoside, anti-
psedomonal beta lactam, colistin, a fluoroquinolone, a macrolide or rifampin which is well used
against the multidrug resistant pseudomonas spp (Steuer, 2022).
Database used: The database is referring as the form of storage where material and resource are
available in the form of article, books and Journals from where data is collected and selected for
research work. Database is act as work space where millions of article are stored. In addition, for
research work data is well used by researcher to configure research work appropriately with
information which is evident for topic. In this research work, the major database is well used for
the collection and selection or selection of data are PubMed, EMBASE, Cochrane library and
UpToDate. They are essential in order to provide wide range of data and information that is well
suitable for the topic which is undertaken for the research work. the research question is
answered significantly with proper research. Therefore, the study has been taken in order to
provide the wide range of data and information which is well selected for the research work with
help of database that provide article to choose the information which evidence based for research
question that is investigated under research work (Fedotov, and Polushkina, 2021).
Web of science and Scopus is act as interdisciplinary research database and have shown the
broad scope. For biomedical research, medicine and healthcare there are number of outstanding
academic database which is well used in order to provide outstanding database that provide true
in the daily research.
PubMed: PubMed is referring as the number that one source to turn to. It is also hosted at
National institutes of Health (NIH) and provide bibliographic information that include the
14

abstract and link or connected to the full text publisher website that is more than 28 million
article. In this, 28 million article, abstract and other related article.
EMBASE: In this, Excerpta Medica Database is proprietary research database that is include in
its corpus PubMed. It is also being accessed by provider that is rectify with database provider
such as Ovid. In this database, approx. 38 million of article are covered with abstract and full text
preview with the subscription that is related with the subscription to EMBASE and individual
publisher. In addition, they are also exported in the format with RIS (Brazil, Brazil, and Brazil,
2020).
Cochrane Library: The Cochrane Library is also best known for their systematic review.
Therefore, the data and information is well collected form such source because they updated the
information as soon they get. As per research question or topic, the study has wide fraction
where new antibiotic is introduced with synergistic effect that create relevance within research
work. In this, the coverage that is counted within the research work is well demonstrated and
show that about thousands of high qualities reviews. In addition, abstract is used to fill that show
the inclusion of abstract as well as related with article with adequate reference that create
evidence based data for the selected data and information.
Research choice: In addition to research work, it is well analysed that study is usually follow the
context where appropriate selection of research choice is undertaken. In research work,
qualitative method or mono-method is used for collection and selection of data for research
work. Therefore, study allow to make qualitative research as choice where major of data is well
provide the aspect in which concept, model and theoretical framework are well used which may
provide information which is adequate. In context with the research work, it is well analysed that
qualitative choice is common among research process where proper study is taken and as
according to strategies the new set of data is prepared which is confirmed with proper review of
article and journals. The article are journals are chosen on qualitative based and review according
to the research question. The choice is also considered within research work because with help of
qualitative data the proper study is used to taken that allow researcher to make the proper
preparation for data collection and create range of studies that support information while using
proper evidence based practice (Mustaqim, Amin, and Sibuea, 2022).
Research tool and technique: The tool and technique which is used within the research work
especially for secondary method is challenging when research question is undertaken. In
15

addition, major tool which is used for secondary research method are government publication,
public records, historical and statistical document, and appropriate journals that is related with
study of the research work. Therefore, it is also analysed that the database and search strategy
show the available resource which is predominantly used to configure information for the
research work that is important and create relevance within research work. In addition, the
government publication is showing their presence on NCBI that have collective article related
with topic. In this historical data and information is collected through website that acquire
secondary data where researcher perform some evaluation and review and prepared data for their
research work with proper evidence. NCBI is evidence based source that implied with database
to provide broad fraction of data and information for the research to make appropriate research
work. The tool and technique within research work is appropriate in order to show the context
that provide proper aspect for reliability and validation that have broad range which suggest the
part that carry the research in appropriate way. It is well configuring that the study provides brief
outlook and show the derivation towards tool such publication based on government and all are
focused within research and provide range of data that is evidence based (Kamble, 2022).
Ethical consideration: The ethical consideration is also act as the main factor which is
undertaken within the research in order to make appropriate research while following the proper
ethical base which is putted by research committee to maintain the ethics. In addition, it is well
analysed that the study has various scope which allow to get the proper understanding toward the
topic and also mentioned important point that used undertaken within research process.
Therefore, ethical committee have scope that they are decided to manage the function of research
or process of conducting that create conflict or issue with the research work. ethical
consideration is showing the research are set of principle that help to guide the research design
and practice. In this, the major of principle which is showing the include voluntary participation,
informed consent, confidentiality, in addition, they show potential for harm and more. These all
aspect are usually creating scenario while conducting the research in order to follow such key
point of ethical consideration and develop knowledge which is well suitable for the research
work. Due to breach in the ethical consideration, secondary research is usually follow some
concept that help to develop sense of knowledge for research where people anonymity must be
drive that have aspect to create effective term and appropriate research work (AbuKhamis, and
Abdelhadi, 2022).
16

CHAPTER 4: RESULT AND DISCUSSION (1500)
To find out the results of therapeutic approach it is important to go through the results
obtained from clinical data. From source; doi: 10.1128/AAC.45.3.649-659.2001 The efficiency
of phage treatment was recorded about 92% (clinical improvements) and 84% (bacteriological
clearance). In order to get and evaluate the results; clinicians and scientists supposed to apply
different approaches to find out the most effective and beneficial way to administer the drugs in
patients. Phages have been administered through different routes of administration (Gelman and
et. al., 2021). When applied subcutaneously or through surgical drains in patients who have
developed resistance from antibiotics to combat infections. It has been shown that about 92% of
patients have shown the signs of eliminating the infection from their body. Many major human
phage studies were performed in different countries to analyse for safety, efficacy and check the
quality of phages prepared through genetic engineering or any other method. In a study
approximately 131 cancer patients having infections due to post-surgical wound participated in
the study. Patients were divided into groups; one group has given phages while the rest were
allowed to run only on antibiotics. In 82% of the cases, phage treatment was successful while in
61% cases antibiotic treatment was observed to be successful. Patients suffering from
Staphylococcus, Pseudomonas, and proteus infections were taken into consideration to analyse
for immunogenicity of therapeutic phages in 57 patients. It has been analysed that the phages'
immunogenicity did not seems to interfere with therapy. In a publication record from Poland,
phages were found to be effective in treating skin infection caused by Klebsiella, Pseudomonas,
E. coli, etc. treating cerebrospinal meningitis in new born, recurrent sub-hepatic and sub-phrenic
abscesses, and many other chronic bacterial diseases. Phages were observed to be effective in
treating lung infection, specifically; staphylococcal lung infection (Górski and et. al., 2019).
From the viewpoint of Merril et. al., a potential problem may generate due to clearance of
phages from the patient as it may decrease down the number of phages and bring them to an
insufficient level which will not be enough to fight against the infecting bacteria. To overcome
this issue, authors preferred to adopt for a natural selection strategy in order to select the phages
which have an ability to remain within the circulation system of mice. This mechanism is likely
to explain mechanism of phase-host bacterial cell interaction (Nikolich and Filippov, 2020).
Many such problems have been addressed and strategies were adopted to control the issues and
modification were made to improvise the existing procedures to improve the efficacy of the
17

therapy. From research results; clinicians and scientists were able to know several characteristics
associated with bacteriophages that are responsible to make them potentially attractive
therapeutic entities. Some of the characteristics includes; high specificity, potentially effective in
lysing pathogenic bacteria, rapidly modifiable, safe (Uyttebroek and et. al., 2022). In a positive
viewpoint, it well recognised that phage therapy has been treated with appropriate dosing, by
administering phage-antibiotic or phage through appropriate and most potential route of
administration, antibiotic compatibility, and duration. Many researchers think, phage transition
cannot be done due to the belief of considering chemical antibiotics as more superior to combat
resistance problem as well due to lack of financial resources or necessary capabilities. It has been
analysed that if continues use of phages leads to develop resistant in bacterial population then
biogeography studies recommend that it would be impossible to develop a new infectious phages
that would have supposed to combat the bacterial infection. Flores and colleagues concluded in
their studies that phages are capable to infect many different strains of host from different
origins. Many illustrations have shown that a single bacteriophage can remain infective to
bacteria and can serve as a host for several bacteriophages which are even derived from multiple
distant geographical locations. From a historic perspective, phage therapy has failed once
already. It is important to deal with the procedure carefully in second try. Conventional
antibiotics become difficult to discover so current ecological and evolutionary understanding
related to phage biology is supposed to provide good and efficient results with continues
availability.
Increasing reports of limited discoveries of antibiotics and development of antimicrobial
resistance have ignited the urge of innovation in researchers and results to revitalize the studies
of bacteriophage in the Western world. Therapy based on bacteriophage or combination of
phage-antibiotic mainly demands to go through lytic phase of phages in order to kill respective
bacterial hosts (Hatfull, Dedrick and Schooley, 2022). Demand and need for phage therapy is
highly increasing as it has capability to provide life-saving therapeutic results and leads to
success multiple clinical trials. However, regulations and policy related to clinical use is one of
the biggest challenge faced by evolving phage procedure. This report discussed the MDR (Multi-
drug resistance) gram-negative pathogens which considers the highest critical priority. The report
also focuses on present situation of-the-art in phage therapy targeting critical multi drug
resistance pathogens. There are many negative and positive effect of phage therapy on human
18

body and also different countries have adopted different approaches to introduce the phage
therapy into clinical practice and implement different policies. In future many researchers and
clinical professionals aims to advance the phage therapy in combination with antibiotics or alone
phages. There are many ignorable challenges that lie ahead in the direction of shifting world
from complete reliance on antibiotics.
From the source of: https://www.frontiersin.org/articles/10.3389/fcimb.2018.00376/full;
Phage therapy is definitely an attractive solution to fight against increasing antibiotic resistance.
Many studies and researches have revealed the in vivo and in vitro potential of therapeutic
phages and numerous clinical trials have conducted over the last few years. With many
challenges and doubts in clinical practices, further data is being collected to present strong
regulatory cases in favour of phage therapy. Continuos progression toward relevant schemes on
the basis of knowledge of phage application guide related work and processes towards a
reasonable implementation structure (Dąbrowska and Abedon, 2019). It is a fact that one size
does not fit to all so it is important to make a collaborative effort and design models of phages
that should prove to be effective enough in providing better health outcomes. The factor of
utmost importance is to always consider to maintain high standards of quality, safety and
efficacy despite the frustration of legislative parameters. Clinicians and scientists should
continue to discuss with appropriate regulatory bodies and take steps to move forward to make
improvements in this area as soon as possible without any delay. Phage therapy is undoubtedly
effective but there still are many things that remain to be discovered and gain knowledge about.
In context to phage therapy, clinical and non-clinical trials are still remaining
unsuccessful in determining pharmacokinetics and pharmacodynamics (PK/PD), all possible
clinical applications and effect as combination therapy with antibiotics. Discussion regarding
current challenges in phage therapy cover: quality and safety requirements, stability of phage
preparation, phage screening methods, efficiency of phages against biofilms, evolution of
bacteria to develop resistance against phages. Synergism between phages and antibiotics does not
possible for all phage-antibiotic combinations. While preparing combinations, if high dose of
antibiotics has been used there is a possibility of antagonistic effect may arise. Even in some
cases, if no antimicrobial activity is seen in combined preparation; it may significantly prevent
the development of phage-and antibiotic- resistant bacteria. In order to bring improvements in
phage therapy approach, clinicians and researchers try to bring modifications in phage genomes
19

(Hyman, 2019). Many advancements have been implemented in synthetic biology field by
applying different techniques to engineer phage genomes. To increase the phage antimicrobial
activity; phages were specialised to deliver specific cargo. For example; Lactonase and
dispersing B enzymes were genetically designed into phage T7 to enhancer the phage activity
against biofilms.
Most of the efforts in engineering approach limit their focus on temperate phages and
lytic phages. Overall it has been estimated that engineering approaches are potential to bring
improvements in antimicrobial activity of phages and can potentially create innovative strategies
to combat bacterial infections. In addition to this, engineered phages are less complicated to get
patent in comparison to natural phages. That is why they may have more chances to gain
commercial interest as well. It is obvious that infectious disease has no boundaries, to access
phage therapy globally; an action plan is required. So it is important to maintain an active
collaboration among different nations to defeat regulatory and logistic challenges. As well active
coordination between scientists and clinicians is required to fulfil the knowledge gap and fasten
up the advancement in the field (Morrisette and et. al., 2020).
CHAPTER 5: CONCLUSION AND RECOMMENDATION (1000)
Conclusion
From the analysis of the above research method, it can be concluded that the synergistic
effect produced by the action of combination of different antibiotics and a bacteriophage leads to
inactivity of bacterial cells causing infection in humans. Bacteriophages are considered natural
antibiotics and a good alternative treatment for the tackling the onset of disease. Phages have the
ability to multiple in number and work against antibiotic resistant bacteria. Even though, the
information about phage therapy is not brand-new but there is not enough evidence based
research done for the same. The use of phage therapy is not limited to the treatment of bacterial
infections; it is also used in food industry to prevent the action of bacteria causing food
poisoning. Phages are also added to processed foods where they act as bactericidal agents. Well
researched successful cases, awareness about the advantages and high success rate of phage
therapies can lead to the process becoming more familiar with healthcare workers and patients.
The occurrence of antibiotic resistance is considered a global concern therefore; the use of
bacteriophages is considered a consolidating approach for the inactivation of bacteria which is
20

resistant to normal antibiotics. The synergy between the sub lethal concentration of antibiotics
pronounced by the release of bacteriophages. A major setback in the medicine industry is the
emergence of antibiotic resistance, affecting the overall health of the individuals all around the
globe. Increase in the number of antibiotic resistant groups is considered a potential approach for
treatment.
Phage therapy is an alternative to antibiotic therapy, involving the use of lytic phages for
bactericidal action of bacterium. Bacteriophages particularly infect bacterial cells and not human
cells as eukaryotic cells lack the presence of particular receptors required by bacteriophages to
bind to. Antibiotic resistance has proven to lead to high hospital costs and delayed stays at the
healthcare centre along with increased mortality rates. Therefore, there is an urgent need to
introduce an alternative method for combating infection caused by bacteria. There is various
evidence based studies that have shown the effect of phage therapy in reducing bacterial density,
particularly in drug resistant bacteria. Additionally, phage therapy is known to restrict the
development of virulence factors of bacteria. There are greater advantages o bacteriophages such
as the ability to replicate oneself and exceptionally lesser side effects. Therefore, they can also be
used for patients who are allergic to antibiotics. Research also shows that phages have the
potential to restore the antibacterial activity exhibited by bacteria resistant to antibiotics. A
single bacteriophage will combat a single bacterial cell. Therefore, there are only a few units of
phages required per treatment for targeting bacterial densities. Phage therapy is administered
through the subcutaneous route or surgical drains. The effectiveness of antimicrobial agents and
increasing in bacterial killings results because of the combined effect of peptides and antibiotics.
Recommendation
According to the evaluation of above research methodologies and discussion, it will be
recommended to implement the use of synergistic phage-antibiotic combination in different
aspects of medical sciences for the treatment of patients for combating infection. The increased
intensity of bacterial resistance highly depends on the class of antibiotic which is paired with the
bacteriophage to achieve the level of synergism required. The combined effect of synergism
produced helps in suppressing the re-emergence of infectious resistant cells that have the ability
to produce infections. The bacteriophage therapy is a promising approach for combating the
bacteria which are resistant to multidrug antibiotics. Bacteriophages being natural enemies of
bacteria are sound everywhere such as soil, water thereby, keeping the population of bacterial
21

growth in check. This property of bacteriophages is exploited by scientists by development of
phage-antibiotic synergistic effect to combat the occurrence of infections caused by antibiotic
resistant bacteria. Phage therapy enables the binding of the phage to the bacteria cells which is
followed by injecting of viral DNA or RNA inside the bacterial cell causing infection. The viral
genome of the phage multiplies inside the bacteria leading to lysis of the bacteria. However,
apart from the ability of phage-antibiotic combination therapy, there are several disadvantages to
these solutions. The main problems which the implementation of phage therapy is that antibiotics
have the potential to attack more than one species of bacterium.
There is a high chance of bacteriophage destroying the all the species of bacteria present
in the body, some of which are involved in the digestion of food, production of nutrients and
maintaining the balance of body. This is the main reason why there are various side effects of
administering phage therapy. Therefore, in order combat these situations, it is crucial to facilitate
ongoing research on the development of alternative methods for the treatment of bacterial
infections. Additionally, persistent phage therapy can act as a triggering factor for the bacterial
species to become even stronger resulting in phage resistance. Another disadvantage for phage
therapy includes the issue of using the exact species of phages for combating the effect of a
bacterial infections. To prevent the possibility of bacterial cells becoming resistant to phages,
mutually exclusive methods should be discovered and implemented upon for the treatment. The
ongoing research for use of phages in animals and humans needs more evidence regarding the
safety and efficacy of this particular therapy method. There are various species of phages for
countering the number of species of bacteria. Evidence based research suggests that there are
unique phages that attack a unique bacterium, making the action of phage therapy species
specific. The treatment of infection that do not react to regular antibiotics is possible through
phage therapy. The development and discovery of antibiotics is losing its effectiveness due to the
ability of bacteria to grow resistant to the actions of antibiotics. The goal of researchers
essentially is to pit “predators Vs predators” to facilitate the investigation of innovative methods
for combating drug-resistant bacteria and viruses.
22

23

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