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Bacteriophage Therapy against biofilm infections

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Bacteriophage Therapy against biofilm infections

Postby inmacdonald » Sat 29 Sep 2012 3:39

Nature Medicine Sept 2012

Bacteriophage Therapy for Biofilm Infections

Link:
http://www.nature.com/nm/journal/v18/n9 ... 2-1318.pdf

{summary for Bagge: "Breaking bad biofilms" see pictures in the article}

Best,
a
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Re: Bacteriophage Therapy against biofilm infections

Postby Lorima » Sun 30 Sep 2012 1:39

Removed my earlier post for now, as it had more than one topic interwoven. I'll rework it and post the phage thoughts here, and the rest in a new, or appropriate old, thread.

The two topics were (1) thoughts about phage as an anti-bacterial, which would be a long time coming, even if it does, and
(2) thoughts about what could be done right now, with regard to prevention, and to treatment for people with late, disseminated Bb infection.

It really doesn''t pay to edit while hanging out watching a movie with my mother-in-law. Although I got an interesting first draft out of it.
Best wishes,
Lorima

Oops, Dr. M has already replied. So, here's the original post again, in all its multi-topic glory. Sorry about that.

Original post:

Thanks for the ref, it's really interesting. Enough that I'm fantasizing about changing the focus of my science to participate in it. I'm based in Boston, where some of the work is ongoing. But I'm pretty old to enter a new field.

Spanky has asked me what I think of the "Small Four" (= the small RTC's on more ceph + doxy treatment for people who have been failed by previous antibiotic treatment). What I think is that in "neglected late Lyme" (late diagnosis, insufficient or no treatment), many, if not most, get significantly better within a year or so of starting antibiotics. Three months? don't even bother. Relapse will occur. Orals are okay for those who aren't about to die, but the dose has to reach sufficiently above the MIC (= minimum inhibitory concentration) to ensure having enough in the brain to kill the bugs, when they're metabolically active enough to be killed. It's hard to get these levels in the CSF (=brain), which is why IV is often used.

But they may have to stay on Abx for years. With IV, this is inconvenient, expensive, and prone to causing infections simply because of the mechanics of the IV. Since it's not a sure or quick fix for neglected late Lyme, I think the ambulatory who are not in great pain might prefer high dose orals. My family has been doing this for years, some pulsed and one constantly, and no one has had ANY side-effects from the treatment. Knock on wood. Everybody goes to the Lyme doctor every two months; this Lyme doctor is not greedy. it's a whole lot cheaper than treating "fibromyalgia" or "CSF" symptoms, and nobody's on disability.

This is a real win, compared to how things were going under the IDSA's protocol. (Which prevented diagnosis entirely, because no one passed the two-tier test, or the clinical "requirements" they cooked up.) They each have several specific bands on IgM that change over time (=current infection), and they had "mystery" neurological illnesses, not to mention the migrating tendon and ligament problems, that were becoming disabling. That's enough evidence for me.

But this strategy leaves a lot of people dependent on on-going or often-repeated antibiotic therapy. And due to the antimicrobial stewardship campaigns, it's going to be hard for those patients to get their antibiotics, without access to a doctor who's willing to risk losing his license for "negligence" in the treatment of Lyme. (Where "negligence" = failure to restrict testing and therapy to match the guidelines, not failure to treat the patient adequately.)

I agree with antimicrobial stewardship in principle; the problem is how it's being applied. It seems like there are two positions in medicine: "on" and "off". It used to be that antibiotics flowed freely, sometimes when they shouldn't. Now they're often not prescribed, even when they should be. Can't we get a little more discernment here, even in the mainstream? These people are said to be smart. A little complexity shouldn't throw them for a loop.

Back to phage, as far as treatment for late neuroLyme patients (which seems to me to be the majority of the actual patients (as opposed to the diagnosed patients),
1) It might be hard to get the phage into biofilms-they're small, but not as small as antibiotic molecules. Unless they can eat through the mucous-like layer that protects them. If this is really what's going on, rather than (or in addition to) small colonies in the tendons, ligaments, etc. (Not up to speed on this yet; been focusing on the brain.
2) It would be hard to get the phage into the CNS. I can't quite see getting it approved to be injected into the CNS any time soon - but I don't work on humans, only on cultured mammalian cells, and in the past, on mice. wonder how hard it is to work on the mouse CNS? I'll have to ask around.
3) "Herx" might be a problem - that could be checked out in mice. And if there's really autoimmunity to bacterial debris, that could be a problem. But I don't think there's rock-solid evidence about that yet.

I think the answer for Lyme (and co-infections) is improved prevention (routine tick-avoidance apparel and habits), and the banning of (1) the two-tier test, (2) short low-dose doxy treatment, and (3) denial of many of the common symptoms. That's all social, not technical - it could be started tomorrow. Think about bike helmets and car safety seats for infants - people will protect their children if they know how.

For me, it's mostly about getting rid of the guidelines, dismantling the Lyme establishment, which controls most of the research money, and then starting the clinical science all over again where it stopped sometime in the 1980's, with competent clinicians and scientists in charge this time. I think Willie Burgdorfer said something similar.

But phage sounds pretty good for a relatively superficial bug like strep. Maybe initially with antibiotics after the phage treatment, to guard against rheumatic fever, PANDAS (PANS), etc. Follow the treated patients for strep antibody production, and see if lysing the bugs early is enough to prevent production of antibodies that cause autoimmune or inflammatory problems.
Fun to think about.

Best regards, Lorima
Last edited by Lorima on Sun 30 Sep 2012 5:08, edited 4 times in total.
"I have to understand the world, you see."
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Re: Bacteriophage Therapy against biofilm infections

Postby inmacdonald » Sun 30 Sep 2012 2:31

Dear Lorima,

I enjoyed reading your post. You know of course that voices of opposition will probably
strike this thread like thunderbolts, but that's why Franklin used lightning rods.

I have always been a disbeliever in the use of specific frequencies of ultrasound
and in the use of electric fields to combat bacterial infections of any type.
But...
After viewing the Dr William Costerton video,( link posted elsewhere on LNE)
I have changed my views. If Costerton's explanation of the use of specific Ultrasound
frequencies and the use of Direct electrical current under controled conditions
is a pathway to an adjuvant therapy modality for destroying biofilms, I believe
that these therapies will some day be perfected.
Costerton even offered for consideration the idea that Root canal problems in Dentistry
might also someday be amenable to similar adjuvant modes of therapy.
More work needs to be done. But Costerton and his collaborators have visualized
nanowires which form electrical connections between members of a biofilm community
an which facilitate communication between individual members of biofilm communities.

I attach links to some image which demonstrate the architecture of borrelia burgdorferi
biofilm communities - namely specialized bacteria differing in structure and more
specialized in function from the planktonic microbes which initiated the community
( ie. fromation of granular, cystic, and cell wall deficient spheroplast derivatives
of planktonic spiral forms) all wrapped in an Exracelluar matrix derived from
the bodies ( and carrcasses) of the biofilm community population.

99% of all microbes on planet earth have the ability to exist in biofilm communities.

Links:
http://dl.dropbox.com/u/47501788/CytoVi ... %20ECM.tif

http://dl.dropbox.com/u/47501788/CytoVi ... 20blue.tif

https://dl.dropbox.com/u/47501788/CytoV ... 0forms.tif

https://dl.dropbox.com/u/47501788/CytoV ... 0green.tif

Best,
alan
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Re: Bacteriophage Therapy against biofilm infections

Postby Lorima » Sun 30 Sep 2012 5:02

Well, I'm clearly much less an original thinker than you are; I'm more of an incrementalist. I've avoided taking any position on alternative therapies, because I have no idea which ones might work, and I doubt it will be known in my lifetime, seeing as how I'm no spring chicken.

The reason I'm okay with years-long courses of antibiotics is that it has the best rationale, reasoning from biological plausibility - even though "cure" from a long-term infections with Bb (seven years before diagnosis in one case, 17 in another, and the third maybe 15 years or so) seems unlikely. We seem to have gotten some remission though. I'm just doing what makes sense to me, and judging the results empirically. Weintraub said it: Cure Unknown.

I'll read the refs you sent and think them over, probably next week as I'm on vacation with family now. I did see two unusual and noteworthy things today: a black swan, and a classic ACA case. The swan was at the zoo, and the ACA case is here in southeastern Pennsylvania, in the USA. Where there is said to be no ACA. Is there anything in the dogma about this disease I can believe? Probably not. I get burned every time.

I'll take some pictures of the ACA, if my relative doesn't mind. I wonder what kind of biopsy is needed to culture, or view. I understand that ACA is about the only source that can be biopsied for spirochetes in late Bb infections (I think Carina posted info about that). Although one of us has a lot of petechiae that appeared after several years of infection; I thought about getting a dermatologist I know to PCR them, and a pathologist to dark-field scope them, but now the patient is on antibiotics, so... there probably wouldn't be spiral forms in them...? I'm realizing I shouldn't make any assumptions based on simplistic logic. That's how we all got into this mess. I should look up more about petechiae too. Hmm, maybe I really am going to do some lab research on Lyme.

Well, maybe this should be a PM, but I'll try it this way. Nice to have some new thoughts to chew on while I do the family things. Tomorrow we're up early to go birding at Cape May, NJ. Huge numbers of warblers seen there yesterday.

Best, L
"I have to understand the world, you see."
Richard Feynman
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Re: Bacteriophage Therapy against biofilm infections

Postby RitaA » Sun 30 Sep 2012 6:22

Lorima wrote: I did see two unusual and noteworthy things today: a black swan, and a classic ACA case. The swan was at the zoo, and the ACA case is here in southeastern Pennsylvania, in the USA. Where there is said to be no ACA. Is there anything in the dogma about this disease I can believe? Probably not. I get burned every time.

I'll take some pictures of the ACA, if my relative doesn't mind. I wonder what kind of biopsy is needed to culture, or view.


Lorima,

Sorry for butting in, however I recently posted the following information on CanLyme for a woman in Canada who suspects she has ACA. I have a feeling that Dr. MacDonald and Carina will both have valuable information to add once they have a chance to read your post.

http://emedicine.medscape.com/article/1051695-overview

Acrodermatitis chronica atrophicans (ACA) is the third or late stage of European Lyme borreliosis.[1, 2] This unusual progressive fibrosing skin process is caused by an ongoing active infection with Borrelia afzelii. First delineated in 1883,[3] it was described in 1902 as a tissue paper–like cutaneous atrophy.[4]

ACA is evident on the extremities, particularly on the extensor surfaces. It begins with an inflammatory stage characterized by bluish red discoloration and cutaneous swelling and concludes several months or years later with an atrophic phase. Sclerotic skin plaques may also develop. Physicians should use serologic and histologic examination to confirm this diagnosis.

The choice of treatment for ACA depends on the coexistence of other signs or symptoms of Lyme borreliosis. Appropriate consultations (ie, a neurologist, ophthalmologist, rheumatologist, or cardiologist) should be sought if extracutaneous signs and symptoms are present. ACA patients without concurrent extracutaneous disease do not require hospitalization.


http://emedicine.medscape.com/article/1051695-workup

Genetic profiles of strains of B burgdorferi sensu lato derived from patients with acrodermatitis chronica atrophicans (ACA) often show the highly conserved MLa1 pattern characteristic of B afzelii; however, they may demonstrate the large restriction fragment patterns typical of B garinii.

The diagnosis of ACA should be based on the following:

• Careful evaluation of the history, including epidemiologic data and symptoms of early and late infection

• A detailed physical examination

• Specific serologic tests results and the histopathologic picture of skin biopsy specimens

A negative history of exposure to ticks should not exclude the diagnosis. B afzelii can be identified in skin lesions by means of polymerase chain reaction (PCR) testing, but both cultures and direct spirochetal stains are usually negative.


http://emedicine.medscape.com/article/1 ... rkup#a0756

Because ACA is often confused with vascular conditions, serologic proof of the diagnosis and histologic verification are considered obligatory.[13] PCR testing for Borrelia -specific DNA (rather than culture of the spirochete) is sometimes a necessary adjunctive measure. Borrelia has been only rarely isolated from the blood culture in these patients. For example, in one study, the organism was isolated from blood in only 3 (1.5%) of 200 ACA patients.[14]


http://emedicine.medscape.com/article/1 ... w2aab6b5b4

Histologic findings

The most important histologic findings in ACA are the presence of telangiectasias and the presence of cellular infiltrates of lymphocytes with admixed plasma cells in the absence of any other explanation for the plasma cells (eg, syphilis or myeloma). Although these changes are not diagnostic, they are highly suggestive (see the images below).

[Some visuals for pathologists and possibly other medical professionals]

In its atrophic stage, ACA demonstrates striking epidermal atrophy, a normal zone just below the epidermis, dilated blood vessels, and a lymphocytic–plasma cell infiltrate within the upper dermis. Plasma cell–rich infiltrates within a sclerotic dermis should suggest the possibility of ACA. Neural lymphocytic infiltration may be evident. Leukocytoclastic vasculitis or vessel occlusion may be seen in some cases. The subcutis is involved in a large percentage of patients.

Warthin-Starry stains may show spirochetes in some cutaneous biopsy specimens, though this often is not the case. Immunohistochemical studies show few B cells despite a substantial number of plasma cells.


I hope you're having the best possible visit with family members.

Rita A
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Re: Bacteriophage Therapy against biofilm infections

Postby panda » Sun 30 Sep 2012 11:21

@ Lorima

Concerning to investigate the ACA I would try to get an immunohistochemical examination with confirmation via PCR – after some weeks having completed abx. In my opinion the best method would be the “focus floating microscopy” (FFM), developed by Zelger, Eisendle et al. (Innsbruck, Austria):

Focus floating microscopy: "gold standard" for cutaneous borreliosis?
Eisendle K, Grabner T, Zelger B.
Am J Clin Pathol. 2007 Feb;127(2):213-22.
http://ajcp.ascpjournals.org/content/127/2/213.long

http://www.ncbi.nlm.nih.gov/pubmed?term=%22focus%20floating%20microscopy%22


Since also in Brazil* (dermato-)pathologists were able to learn this method you could try to introduce it in the US. Prof. Zelger wrote to me that “FFM is a sophistic refined technique of Immunohistochemistry (primarily) on paraffin material. Basically any (dermato-)pathologic laboratory should be able to do that.”


* Presence of Borrelia burgdorferi "Sensu Lato" in patients with morphea from the Amazonic region in Brazil.
Santos M, Ribeiro-Rodrigues R, Talhari C, Ferreira LC, Zelger B, Talhari S.
Int J Dermatol. 2011 Nov;50(11):1373-8. doi: 10.1111/j.1365-4632.2011.05081.x.
http://www.ncbi.nlm.nih.gov/pubmed/22004491

Borrelia Burgdorferi "sensu lato" in Brazil: Occurrence confirmed by immunohistochemistry and focus floating microscopy.
Talhari S, de Souza Santos MN, Talhari C, de Lima Ferreira LC, Silva RM Jr, Zelger B, Massone C, Ribeiro-Rodrigues R.
Acta Trop. 2010 Sep;115(3):200-4. Epub 2010 Mar 6.
http://www.ncbi.nlm.nih.gov/pubmed/20211144



ACA – US:
Acrodermatitis chronica atrophicans. ACA is the cutaneous manifestation of late-stage Lyme borreliosis in Europe. Very few cases of ACA have been reported in the United States, most likely explained by the near-exclusive causation of ACA by B. afzelii—a borrelial genospecies that is not present in North America.
(...)
The differential diagnoses of ACA include deep vein thrombosis, superficial thrombophlebitis, arterial occlusive vascular disease, acrocyanosis, livedo reticularis, lymph-edema, pernio (chilblains), erysipelas, bursitis/arthritis, and morphea.

from:
J Clin Aesthet Dermatol. 2012 Aug;5(8):18-28.
Borrelia burgdorferi Infections in the United States.
Heymann WR, Ellis DL.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3424593/


Acrodermatitis chronica atrophicans: a case report and review of the literature.
Smetanick MT, Zellis SL, Ermolovich T.
Cutis. 2010 May;85(5):247-52. Review.
http://www.ncbi.nlm.nih.gov/pubmed/20540415
Abstract
Acrodermatitis chronica atrophicans (ACA) is a rare tertiary manifestation of Lyme borreliosis, manifesting as inflammatory and atrophic lesions on acral skin. Although ACA rarely has been reported in the United States, it may be seen in approximately 10% of European cases of Lyme borreliosis, most commonly associated with the genospecies Borrelia afzelii. We report a presumptive case of ACA involving an American woman from Pennsylvania with convincing clinical, histopathologic, and serologic findings. We also provide an overview of the history, epidemiology, pathogenesis, clinical and histopathologic presentation, and treatment of ACA.


Best wishes to you and your relatives,
Panda


Edited to add:
FFM in the US?

Focus-floating microscopy for detecting borrelia species in tissue sections: back to basics.
White KP, Barry CI, Patterson JW. [Department of Pathology, University of Virginia Health System, Charlottesville, VA, USA]
Arch Dermatol. 2008 May;144(5):662-3.
Newer and more sophisticated diagnostic techniques are continually being developed, making traditional microscopic evaluation of tissue sections appear rather old fashioned. Even the era of immunohistochemistry, in situ hybridization, and computer-assisted image analysis is being supplanted, for example, by the rise of molecular diagnostics using tissue microarrays or in vivo methods such as confocal scanning laser microscopy.1 It is generally recognized that polymerase chain reaction (PCR) techniques can detect evidence of infection or neoplasia even where none is evident by microscopic methods.2 - 3 Therefore, it is encouraging to those of us who are life-long microscopists to learn of a new technique that is largely founded on classic histopathologic skills. Such a technique is focus-floating microscopy. In this issue of the Archives, Eisendle et al4 demonstrate the successful use of this method in identifying Borrelia species in tissue sections from patients with lichen sclerosus.

http://archderm.jamanetwork.com/article.aspx?articleid=419652
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Re: Bacteriophage Therapy against biofilm infections

Postby inmacdonald » Sun 30 Sep 2012 14:51

Thank you Lorima, Rita, and Panda
for your excellent and richly referenced discussions.

Correspondence with colleagues is essential to stimulate
thinking about new avenues of pathogenesis for Lyme Boreliosis.
Best,
alan
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Re: Bacteriophage Therapy against biofilm infections

Postby inmacdonald » Mon 1 Oct 2012 2:56

Supplementary Informatiion: Transhemispheric transmission of the borrelia agents of Acrodermatitis Chronica Atrophicans: Opportunities for Infectious disease Sleuthing in year 2012....

The issue of Acrodermatitis Chronica Atrophicans cases in the USA:

My bias has been to suspect the idea that any ACA cases diagnosed in USA residents
might have been acquired by patients who vacationed in Europe,and then
subsequently returned to the USA, passed through the decade or two decade or three
decade latent period ( tardive stage) and subsequently presented with gross
and microscopic evidence of Acrodermatitis Chronica Atophicans.

There have been many dermatologists who have looked for ACA cases
which were vectored by ticks resident in the USA. Aside from one Abstract
issued by my friend, the late Dr Paul Lavoie of SanFrancisco, California in the 1980's
there have been absolutely no proven ACA cases acquired in the USA.

I recently corresponded with the authors of the ACA case from a resident of the
State of Pennsylvania. A past history of travel to Europe was elicited, but the trip was
in the distant past. I raised the possibility of a European tick bite clinically occult with
'subsequent slow progression to ACA.
The travel connection possibility remains open. It is interesting to note an epidemiology study
of LB cases in the residents of the Netherlands. A substantial percentage of the Netherlands
patient group were classified, upon detailed study by the reporting physicians, as having acquired
their LB as a result of travel to European countries outside of the Netherlands.
And then there is the nagging question of BBsl ( afzelii>>garinii) as the species which cause ACA
in Europe. One case and only one case of Bbss was found in a large series, and this strain might
be a Bbss strain not endemic in the USA. DNA hybridization or species specific PCR must be done to answer
these questions.
Finally there is the intellectually attractive possibility that as a result of avian transoceanic migrations,
or by transatlantic commerce in Horses and other large animals, that ticks carrying Bbsl (Afzelii or garinii)
might have established sites of endemicity in the continental USA.
All fascinating possibilities.
The work of Dr Theobold Smith in the 1890's resulted in the discovery of ticks carryng Texan piroplasmas
fo Cattle pens inthe Chicago Illinois slaughterhouse yards.The texas ticks dropped off the Texas cattle and
infected cattle which had been reared in the Northern states. Transcontinental Cattle drives ( a la "Rawhide")
were the explanation for the transport of Texan Piroplasmosis to the stockyards of Chicago.
Fascinating stuff indeed
Best,
A
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Re: Bacteriophage Therapy against biofilm infections

Postby Lorima » Wed 3 Oct 2012 0:56

Thanks to you all for information about ACA. The elderly Pennsylvania lady sounds very relevent. I thought about arranging for those researchers to study the rash, but my elderly Pennsylvania lady doesn't want to pursue it. Or rather, it would have to be a family project, and the rest of the family feels it's not worthwhile. I'm a more distant member of the family, so I'm leaving it up to them.

It sounds as if a variety of researchers have looked into whether there is ACA in the US, and have not found it. So I'm filing my observation into the "uncertain" part of my brain, which is where I keep a lot of intriguing but inconclusive stuff. ;) . The black swan observation still stands, however.

Thanks again for your quick and thorough responses - it's great not to be so alone in all this.

Best wishes,
Lorima
"I have to understand the world, you see."
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Re: Bacteriophage Therapy against biofilm infections

Postby inmacdonald » Wed 3 Oct 2012 3:11

Dear Rita, Lorima, and Panda,

From time to time i hear from Correspondents in Mexico who wonder about the emergence of
Borrelia garinii in Mexico. the molecular proof has not yet appeared, but I thin that we all
recall the case study of the German thoroughbred horse who died from lyme borreliosis, as verified
by autopsy.
Thoroughbred horses are routinely transported from Europe to Mexico. It is theorectially poossible
that I. ricinus carrying b. garinii or B. afzelii could be the vehicle for the transoceanic spread
of European Borrelia strains to the Northern hemisphere ( or to the southern hemisphere too_)
Then there is always the possiblity of Trans-oceanic spread of European borrelia strains via
avian migratioon.

The Sentinel signs would be the emergence of Borrelia lymphocytoma, and ACA cases
vectored by local ticks in patients who had never vacationed in Europe.

Food for thought, and the opportunity to again admire the detective work of the legendary
pathologist Dr Theobold Smith in the 1890's in Texas.

Best,
a
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