微生物学报

Sequence	Mechanism of action	Experimental evidence
Phage→Antibiotic	Phage-mediated lysis disrupts biofilm integrity, enhancing antibiotic penetration	(1) Effectively eradicates MRSA biofilms of varying robustness^[19]
(2) Complete eradication with ciprofloxacin addition 6-12 h post-phage^[68]
(3) 4.8 lg reduction in Pseudomonas aeruginosa biofilm; 2.3 lg reduction in Staphylococcus aureus biofilm^[57]
Antibiotic→Phage	Antibiotic pretreatment disrupts biofilm architecture, phages target matrix-embedded bacteria	(1) After 48 h treatment, bacterial density decreased by 2 lg^[69]
(2) Significantly improves survival in the Galleria mellonella infection model and is effective against strong, moderate, and weak biofilms^[19]
Simultaneous	Phage-mediated real-time EPS disruption, enhanced antibiotic penetration depth, and accelerated synergistic antibacterial kinetics	(1) Reduce biofilm viability by approximately 4-5 lg in long-term treatment^[58]
(2) 6.2 lg reduction in Pseudomonas aeruginosa biofilm burden; 5.7 lg reduction in Staphylococcus aureus biofilm burden^[70]

Sequence	Mechanism of action	Experimental evidence
Phage→Antibiotic	Phage-mediated lysis disrupts biofilm integrity, enhancing antibiotic penetration	(1) Effectively eradicates MRSA biofilms of varying robustness^[19]
(2) Complete eradication with ciprofloxacin addition 6-12 h post-phage^[68]
(3) 4.8 lg reduction in Pseudomonas aeruginosa biofilm; 2.3 lg reduction in Staphylococcus aureus biofilm^[57]
Antibiotic→Phage	Antibiotic pretreatment disrupts biofilm architecture, phages target matrix-embedded bacteria	(1) After 48 h treatment, bacterial density decreased by 2 lg^[69]
(2) Significantly improves survival in the Galleria mellonella infection model and is effective against strong, moderate, and weak biofilms^[19]
Simultaneous	Phage-mediated real-time EPS disruption, enhanced antibiotic penetration depth, and accelerated synergistic antibacterial kinetics	(1) Reduce biofilm viability by approximately 4-5 lg in long-term treatment^[58]
(2) 6.2 lg reduction in Pseudomonas aeruginosa biofilm burden; 5.7 lg reduction in Staphylococcus aureus biofilm burden^[70]

Administration route	Pathogenic bacteria	Indication	Pathogenic bacteria	Combined antibiotics	Antibiotic administrati-on routes	Result
Local Injection	Klebsiella pneumoniae	Wound infection, fracture-related infection	vB_KpnM_ M1	Meropenem, colistin, ceftazidime-avibactam	Intravenous injection	Significant clinical and imaging improvement^[61]
Aerosol inhalation	Pseudomonas aeruginosa	Pulmonary infection	vFB297	Amikacin, meropenem	Intravenous injection	Reduced sputum bacterial load, improved lung function^[75]
Pleural+ aerosol	Serratia marcescens	Infected pleural effusion	Spe5P4	Amikacin, meropenem	Intravenous injection	Resolution of chest pain and dyspnea, imaging recovery^[76]
Bladder irrigation	Klebsiella pneumoniae	Urinary tract infection	Kp152, Kp154, Kp155, Kp164, Kp6377, HD001	Trimethoprim-sulfamethoxazole	Oral	Complete pathogen clearance, no recurrence in 6 mo^[77]
Intravenous injection	Pseudomonas aeruginosa	Systemic infection	Pa53	Meropenem	Intravenous injection	No relapse in 2 a^[31]
	Mycobacterium chelonae	Infection in immunocompromised patient	Muddy	Omadacycline, bedaquiline, trimethoprim-sulfamethoxazole	Oral	Significant skin lesion improvement^[78]
Oral+bladder irrigation	Klebsiella pneumoniae	Urinary tract infection	Anti-Klebsiella pneumoniae phages	Meropenem	Intravenous injection	Symptom relief in 24 h negative urine culture for 14^[79]
Intraperitoneal injection	Pseudomonas aeruginosa	Severe infection requiring rapid control	JG005, JG024	Meropenem	Intraperiton-eal injection	Reduced alveolar-capillary permeability index (P=0.030 1) and 100% survival (96 h post-infection)^[80]

Administration route	Pathogenic bacteria	Indication	Pathogenic bacteria	Combined antibiotics	Antibiotic administrati-on routes	Result
Local Injection	Klebsiella pneumoniae	Wound infection, fracture-related infection	vB_KpnM_ M1	Meropenem, colistin, ceftazidime-avibactam	Intravenous injection	Significant clinical and imaging improvement^[61]
Aerosol inhalation	Pseudomonas aeruginosa	Pulmonary infection	vFB297	Amikacin, meropenem	Intravenous injection	Reduced sputum bacterial load, improved lung function^[75]
Pleural+ aerosol	Serratia marcescens	Infected pleural effusion	Spe5P4	Amikacin, meropenem	Intravenous injection	Resolution of chest pain and dyspnea, imaging recovery^[76]
Bladder irrigation	Klebsiella pneumoniae	Urinary tract infection	Kp152, Kp154, Kp155, Kp164, Kp6377, HD001	Trimethoprim-sulfamethoxazole	Oral	Complete pathogen clearance, no recurrence in 6 mo^[77]
Intravenous injection	Pseudomonas aeruginosa	Systemic infection	Pa53	Meropenem	Intravenous injection	No relapse in 2 a^[31]
	Mycobacterium chelonae	Infection in immunocompromised patient	Muddy	Omadacycline, bedaquiline, trimethoprim-sulfamethoxazole	Oral	Significant skin lesion improvement^[78]
Oral+bladder irrigation	Klebsiella pneumoniae	Urinary tract infection	Anti-Klebsiella pneumoniae phages	Meropenem	Intravenous injection	Symptom relief in 24 h negative urine culture for 14^[79]
Intraperitoneal injection	Pseudomonas aeruginosa	Severe infection requiring rapid control	JG005, JG024	Meropenem	Intraperiton-eal injection	Reduced alveolar-capillary permeability index (P=0.030 1) and 100% survival (96 h post-infection)^[80]

噬菌体与抗生素联合疗法在细菌性感染治疗中的研究进展

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任雪芳 ¹ , 卢瑞辞 ¹ , 有小娟 ¹ , 朱芮 ¹^,²^,^* , 李永伟 ¹^,²^,^*

微生物学报 | 综述 2025,65(11): 4780-4799

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微生物学报 | 综述 2025, 65(11): 4780-4799

噬菌体与抗生素联合疗法在细菌性感染治疗中的研究进展

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任雪芳¹, 卢瑞辞¹, 有小娟¹, 朱芮¹^,²^,^*, 李永伟¹^,²^,^*

作者信息

1 河南中医药大学第二临床医学院，河南中医药大学第二附属医院，河南郑州

2 河南省中医院检验中心，河南省防治耐药菌感染中医药重点实验室，郑州市病原微生物与细菌耐药监测重点实验室，河南郑州

Recent advances in phage-antibiotic combination therapy for bacterial infections

Xuefang REN¹, Ruici LU¹, Xiaojuan YOU¹, Rui ZHU¹^,²^,^*, Yongwei LI¹^,²^,^*

Affiliations

1 The Second Clinical Medical College of Henan University of Chinese Medicine, The Second Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, China

2 Inspection Center of Henan Province Hospital of TCM, Zhengzhou Key Laboratory of Pathogenic Microorganisms and Bacterial Drug Resistance Monitoring, Key Laboratory of Henan Province of Resistant Pathogen Infections Prevention and Therapy by Traditional Chinese Medicine, Zhengzhou, Henan, China

出版时间: 2025-11-04 doi: 10.13343/j.cnki.wsxb.20250317

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摘要

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抗生素耐药性的蔓延使细菌性感染成为全球公共卫生危机，传统抗生素治疗面临巨大挑战，亟需开发新型抗菌治疗策略。噬菌体是一类能够特异性裂解细菌的病毒，因其独特的杀菌机制以及对宿主菌的高度专一性，噬菌体疗法成为当前对抗耐药菌感染的重要替代疗法之一。然而，单一噬菌体疗法的应用受限于宿主范围窄、易产生噬菌体抗性细菌等问题。近年来，噬菌体-抗生素联合疗法备受关注，该疗法在增强杀菌效应、协同抑制双重抗性机制、扩大宿主范围、破坏生物膜以及治疗复杂感染等方面展现出独特优势，不仅突破了单一噬菌体疗法的局限性，也为多重耐药菌感染的治疗提供了新思路。本文将从噬菌体-抗生素联合疗法的协同作用机制、关键影响因素、现存挑战及优化策略等方面进行系统综述，为该领域的深入研究与临床转化提供理论依据和实践指导。

关键词

噬菌体疗法 / 噬菌体-抗生素联用 / 细菌性感染 / 抗生物膜

Abstract

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The spread of antibiotic resistance has made bacterial infections a global public health crisis, posing serious challenges to conventional antibiotic therapy and creating an urgent need to develop novel antibacterial strategies. As viruses are capable of specifically lysing bacteria, phages represent a promising alternative therapeutic strategy due to their unique killing mechanisms and high host specificity. Nevertheless, they face limitations in monotherapy due to their narrow host ranges and the emergence of phage-resistant bacteria. In recent years, phage-antibiotic combination therapy has garnered significant attention. It demonstrates unique advantages in enhancing bactericidal effects, synergistically inhibiting dual-resistance mechanisms, broadening the host range, disrupting biofilms, and treating complex infections. This therapy not only overcomes the limitations of single phage therapy but also paves new avenues for treating multidrug-resistant bacterial infections. This review systematically summarizes the synergistic mechanisms, key influencing factors, current challenges, and optimization strategies of phage-antibiotic combination therapy, aiming to provide a theoretical foundation and practical guidance for further research and clinical translation in this field.

Key words

phage therapy / phage-antibiotic combination / bacterial infection / antibiofilm

引用本文

任雪芳, 卢瑞辞, 有小娟, 朱芮, 李永伟. 噬菌体与抗生素联合疗法在细菌性感染治疗中的研究进展. 微生物学报, 2025 , 65 (11) : 4780 -4799 . DOI: 10.13343/j.cnki.wsxb.20250317

Xuefang REN, Ruici LU, Xiaojuan YOU, Rui ZHU, Yongwei LI. Recent advances in phage-antibiotic combination therapy for bacterial infections[J]. Acta Microbiologica Sinica, 2025 , 65 (11) : 4780 -4799 . DOI: 10.13343/j.cnki.wsxb.20250317

正文

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随着抗生素的广泛使用，抗微生物药物耐药性(antimicrobial resistance, AMR)已成为全球公共卫生领域的重大威胁^[1]。研究预测，2025-2050年AMR相关死亡人数将突破3 900万，造成巨大的经济负担和社会压力^[2]。临床监测数据显示，多重耐药(multidrug-resistant, MDR)菌的检出率持续攀升，其中，代表屎肠球菌(Enterococcus faecium, E)、金黄色葡萄球菌(Staphylococcus aureus, S)、肺炎克雷伯菌(Klebsiella pneumoniae, K)、鲍曼不动杆菌(Acinetobacter baumannii, A)、铜绿假单胞菌(Pseudomonas aeruginosa, P)和肠杆菌(Enterobacter, E)^[3]的“ESKAPE”病原体作为一类常见的MDR菌，已成为医院感染的重要致病因素。世界卫生组织(World Health Organization, WHO)将其归类为优先需要开发新型抗菌制剂治疗的病原体^[4]，并在2024年发布的《全球抗生素耐药性优先病原体清单》^[5]中将耐碳青霉烯类鲍曼不动杆菌(carbapenem-resistant Acinetobacter baumannii, CRAB)和耐碳青霉烯类肠杆菌科(carbapenem-resistant Enterobacteriaceae, CRE)列为关键优先级。中国作为AMR高负担国家，耐药形势尤为严峻^[6]。据中国细菌耐药监测网(China antimicrobial surveillance network, CHINET, https://www.chinets.com) 2024年的数据统计，耐碳青霉烯类革兰阴性杆菌检出比例仍持续处于较高水平，其中CRAB对亚胺培南和美罗培南的耐药率分别高达99.6%和99.7%^[7]。一项全国多中心队列研究(n=5 432)显示，CRAB感染患者的绝对风险差(27.2%)显著高于敏感株感染患者(15.4%, P<0.001)，其中血流感染(bloodstream infection, BSI)导致的额外死亡占比达27.6%^[8]。耐碳青霉烯类肺炎克雷伯菌(carbapenem-resistant Klebsiella pneumoniae,CRKP)感染的30 d病死率为34%，重症监护病房(intensive care unit, ICU)患者的死亡风险进一步加剧^[9]。上述数据凸显了“ESKAPE”病原体导致的高死亡率与治疗选择匮乏，已对全球医疗系统构成严峻威胁。因此开发新型抗菌策略以应对耐药性挑战成为当前领域的研究焦点。

噬菌体(bacteriophage, phage)被认为是地球上最古老且数量最多的生物体之一，它们作为细菌的自然天敌，与细菌共同进化了约40亿年^[1]。“噬菌体”一词最早可追溯到20世纪，由Felix d’Hérelle提出，其由蛋白质衣壳和内部的核酸(DNA或RNA) 2部分组成^[10]。按照生长周期的不同，噬菌体可分为裂解性噬菌体(lytic phage)和溶原性噬菌体(lysogenic phage)。裂解性噬菌体通过特异性结合并裂解宿主菌、释放子代噬菌体来实现自身增殖，其过程包括吸附、穿入、生物合成、成熟和释放5个基本阶段；相比之下，溶原性噬菌体能够稳定地整合进宿主的基因组，并随宿主DNA一同复制，仅在特定条件下才会激活裂解生命周期^[11]。随着AMR的不断加剧，加上新型抗生素研发周期长、难度大，噬菌体疗法(phage therapy, PT)作为抗生素的替代疗法重新受到广泛关注，具有高度特异性、易于分离、疗效显著、开发成本低以及安全性良好等优势^[12]。然而，单一PT受限于宿主范围狭窄、噬菌体抗性和免疫原性等问题，限制了其治疗效果^[1]。

相较于单一PT，噬菌体-抗生素联合疗法可产生协同作用(phage-antibiotic synergy, PAS)，在增强杀菌效应、扩大抗菌谱、协同抑制双重抗性机制以及增强抗生物膜能力等方面展现出独特优势，在MDR菌感染的治疗中更具潜力^[13]。本文系统综述了PAS的作用机制、关键影响因素及其临床转化挑战，以期为噬菌体-抗生素联合疗法作为抗击AMR的潜在应用提供数据支持。

1 噬菌体-抗生素联合疗法的协同作用

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噬菌体-抗生素联合疗法的协同作用体现在：2种截然不同的杀菌机制联用比单独使用其中任一方式更有效，且两者通过多靶点作用可显著提升抗菌效果^[14]。《噬菌体治疗临床应用管理专家共识(2024版)》^[15]指出，联合疗法可通过靶向互补机制扩大抗菌谱，并推荐其在复杂感染中优先应用，以延缓耐药性发展并降低治疗失败风险。其核心机制可归纳为以下4个方面。

1.1 增强杀菌效应

噬菌体-抗生素联合疗法产生协同杀菌效应的核心在于：亚抑制浓度(sub-minimum inhibitory concentration, sub-MIC)抗生素可通过改变细菌形态与生理状态显著增强噬菌体的感染效率^[16]。该机制最早由Comeau等^[17]系统阐述，在体外实验中亚抑制浓度的β-内酰胺类和喹诺酮类抗生素能诱导细菌出现细胞壁缺陷或膜通透性改变，暴露出更多的噬菌体吸附位点，促进其感染和复制。这一过程可显著提高噬菌体的吸附效率、缩短其潜伏期，并增加子代噬菌体产量，最终实现协同增强的杀菌效果^[18] (图１)。后续研究在多种体内外模型中进一步证实了该协同作用。Loganathan等^[19]在体外实验中发现，磷霉素通过靶向抑制细胞壁合成，破坏细菌结构完整性，使噬菌体裂解效率提升约8倍(P<0.01)。Lu等^[20]通过耐甲氧西林金黄色葡萄球菌(methicillin- resistant Staphylococcus aureus, MRSA)的小鼠感染模型证实，噬菌体裂解酶LysP108与万古霉素联用时所需万古霉素浓度较单药组降低50%。Simon等^[21]通过体外实验证明，当噬菌体的感染复数(multiplicity of infection, MOI)为1或10时，噬菌体Sb-1与苯唑西林联用展现出明显优于单药的协同杀菌效果。此外，研究还揭示了针对溶原菌的一种特殊协同机制。溶原菌是指被溶原性噬菌体感染的细菌，其基因组中整合了前噬菌体(prophage)并维持潜伏状态。当前噬菌体受到外界刺激被激活时可脱离宿主基因组并进入裂解周期，导致溶原菌裂解死亡，这一过程被称为“溶原菌耗竭”^[22]。Al-Anany等^[23]在体外研究中发现，环丙沙星可通过诱导DNA损伤来激活细菌的SOS应答(SOS response)，使溶原菌对噬菌体和抗生素的敏感性同步增强，导致在噬菌体与环丙沙星联合治疗24 h内使活菌数减少8 lg CFU/mL，杀菌效果显著优于单环丙沙星组(P<0.001)。这些结果进一步证明了噬菌体-抗生素联合疗法在多种细菌性感染背景下的广泛适用性和优异杀菌表现。

1.2 扩大抗菌谱

噬菌体-抗生素联合疗法凭借两者的互补作用机制，通过抗生素改变宿主菌形态及增强噬菌体感染效率，从而覆盖更广泛的病原体种类及耐药表型，有效突破了单一PT的抗菌谱限制^[24]。Fatima等^[22]通过体外生物膜模型证明，多黏菌素B通过破坏细菌外膜脂多糖结构增强了噬菌体对生物膜内细菌的渗透和裂解能力，并显著扩大其抗菌谱。β-内酰胺类抗生素通过共价结合青霉素结合蛋白(penicillin-binding proteins, PBPs)的活性位点，阻断其介导的肽聚糖交联反应，导致细胞壁合成缺陷；同时激活细菌SOS应答，抑制分裂相关基因表达，促使细菌形成丝状体，从而扩大噬菌体吸附面积并增强细胞壁穿透效率^[24-25]。Bulssico等^[26]通过体外实验发现，头孢他啶和头孢氨苄正是通过这一机制增强了噬菌体的抗菌谱，增强了杀菌效果。Luo等^[27]进一步证实，噬菌体pb23与美罗培南联合可在体内外模型中有效抑制多株临床分离耐药菌，显著扩大抗菌谱。

噬菌体鸡尾酒(phage cocktails)由靶向不同细菌受体的噬菌体组成，可有效克服单一噬菌体宿主谱窄的局限性，与抗生素联用可更大程度扩展其抗菌谱^[13]。Kim等^[28]研发的噬菌体鸡尾酒KIM-C1与氨曲南联用，在体外实验中有效抑制96%的铜绿假单胞菌临床分离株，实现96%的生物膜清除率，在小鼠感染模型中该疗法对铜绿假单胞菌-金黄色葡萄球菌混合感染的治疗效果也显著优于单一疗法。Zhao等^[29]的体外实验证明，使用P7鸡尾酒结合临床剂量的黏菌素或替加环素，有效抑制(感染指数≤0.2)的菌株比例从单药治疗组的约3.4%-34.1%显著提升至72.7%-75.0%。以上数据明确验证了联合疗法在扩大抗菌谱方面的有效性。

1.3 噬菌体-抗生素协同抑制双重抗性机制

1.3.1 减少噬菌体抗性

细菌可通过多种机制进化出噬菌体抗性，包括表面受体突变或修饰以阻断噬菌体吸附、规律成簇的间隔短回文重复序列系统及相关蛋白(clustered regularly interspaced short palindromic repeats-associated, CRISPR-Cas)系统介导的特异性免疫反应、限制修饰系统(restriction-modification, R-M)降解外源DNA，以及流产感染系统(abortive infection, Abi)诱导宿主死亡以阻断噬菌体复制等，这些适应性机制虽增强了细菌的生存能力，却也导致单一PT治疗过程中噬菌体抗性的快速出现，削弱了裂解性噬菌体的抗感染治疗效果，严重限制了其在临床应用中的稳定性和持续疗效^[30]。相比之下，噬菌体与抗生素联用可对细菌施加双重选择压力，使其难以同步进化出双重抗性，从而显著降低抗性突变的发生频率^[29,31]。Wang等^[32]的体外研究显示，鲍曼不动杆菌AB48单用噬菌体HZY2308治疗24 h后抗性突变率达43.33% (13/30)，而联合亚抑制浓度的替加环素可完全抑制突变(P<0.000 1)，且联合疗法组的分级抑菌浓度(fractional inhibitory concentration, FIC)指数≤0.5证明协同作用显著，并维持抑菌效果超过13 h，显著逆转了单一噬菌体组13 h后抗菌活性下降的情况，有效阻断了抗性产生。值得注意的是，裂解性噬菌体具有优先裂解抗生素压力下诱导的高突变细菌的特性，有助于从源头阻断抗性突变体的积累^[26]。

溶原性噬菌体与抗生素联用时也显示出减少噬菌体抗性发生的潜力：SOS诱导类抗生素(喹诺酮类、磺胺类)可激活细菌的SOS应答，促使前噬菌体从宿主基因组中切除并进入裂解周期，从而减少溶原化(lysogenization)现象；而非SOS诱导类抗生素(氨基糖苷类)则通过干扰噬菌体生命周期抑制其从溶原化向裂解状态的转变，进而间接降低噬菌体抗性的发生风险^[33]。然而，由于溶原性噬菌体生命周期的复杂性，其在协同抗菌机制中的作用尚未被充分研究，其可能存在区别于裂解性噬菌体的独特抗性阻断策略，亟待深入探索。

1.3.2 抑制细菌抗生素耐药性演化并恢复抗生素敏感性

噬菌体-抗生素联合疗法可通过多重机制有效延缓乃至逆转抗生素耐药性的演化进程。首先，噬菌体特异性裂解携带耐药基因的细菌，限制耐药基因在微生物群体中的水平转移与扩散，从而减少对抗生素的选择压力并抑制耐药基因的积累^[34]。Koncz等^[35]基于全球鲍曼不动杆菌基因组数据设计出覆盖85%以上流行耐药株的噬菌体鸡尾酒，使接合质粒的传播效率降低70%，并在大蜡螟(Galleria mellonella)模型中与对照组相比，噬菌体-抗生素联合疗法使bla_OXA-23等耐药基因在肠道环境中的定植密度下降55%。其次，联合疗法已被证实可显著降低细菌对抗生素的最低抑制浓度(minimum inhibitory concentration, MIC)^[36]。Ghatbale等^[37]通过体外培养模型观察到，噬菌体与万古霉素联用可使耐药肠球菌的MIC值恢复至敏感水平(1-2 µg/mL)，而与氨苄西林联用时则显著增强其对天然耐药菌的抑菌活性。更为关键的是，当细菌在进化中获得噬菌体抗性时常需付出代谢或者结构上的适应性代价，即所谓的“进化权衡”，不仅表现为生物膜形成能力与毒力因子表达下降，荚膜、O-抗原、菌毛、外膜蛋白和外排泵等结构的表达降低或者丢失，还伴随着对多种抗生素敏感性的提高^[38-39]。Wang等^[32]通过体外实验证实，抗性菌株AB48-R因表面受体丢失或突变，使其噬菌体吸附效率从54%显著降至25%，同时该菌株的抗生素敏感性也发生改变，如对阿米卡星和妥布霉素从耐药转为敏感，对头孢吡肟和庆大霉素从耐药转为中介。这些策略通过“进化权衡”与剂量优化为控制抗生素耐药性发展提供了新思路。

联合疗法通过多重机制协同逆转细菌固有耐药性：在代谢层面，Qin等^[40]通过体外实验阐明单用噬菌体H5虽可诱导细菌通过wcaJ突变减少荚膜合成，导致对头孢他啶的交叉敏感性，但联合疗法则通过反向选择并诱导多个galU突变形成双向代谢调控网络，有效抑制了单药治疗时的代谢优势通路；在结构靶向层面，Chan等^[41]通过体外实验揭示了噬菌体OMKO1通过结合外排泵OprM受体直接抑制外排泵功能，使铜绿假单胞菌对头孢他啶、环丙沙星的MIC值显著降低。Zhao等^[29]的体外实验进一步指出，噬菌体通过破坏革兰氏阴性菌的外膜完整性能够恢复CRKP对β-内酰胺类药物的敏感性。然而，这种耐药性逆转依赖于噬菌体的持续存在，一旦噬菌体被移除，细菌菌株可能迅速恢复原有耐药表型。这一特性在Orozco-Ochoa等^[42]的体外模型中得到证实，采用低剂量噬菌体Indie (10⁸ PFU/mL)与头孢他啶(1.6 μg/mL)联合治疗可维持长达17 h的持续抑菌效果，抑菌率超过85%，避免了单用噬菌体时仅4 h即出现的耐药逃逸现象。因此，联合疗法的有效转化和长期协同抗菌效果需策略性持续给药^[29,37]。综上所述，噬菌体-抗生素联合疗法通过削减耐药基因储备、降低抗生素MIC并迫使细菌在进化中付出高昂代价以逆转抗生素敏感性等方式，为MDR菌感染提供了切实可行的新型治疗策略。

1.4 增强抗生物膜能力

生物膜是由细菌及其分泌的胞外聚合物(extracellular polymeric substances, EPS)形成的结构化群落，其中EPS主要包括多糖、蛋白质、胞外DNA (extracellular DNA, eDNA)和脂质等成分^[43-44]。生物膜是植入导管及囊性纤维化等慢性复杂感染久治不愈的关键原因，也是耐药性持续进化的重要场所^[45]。噬菌体-抗生素联合疗法可通过以下3个方面协同破坏生物膜，显著提升杀菌和感染清除能力。(1) 噬菌体可通过分泌EPS解聚酶或释放内源性酶有效破坏生物膜的物理屏障，增强抗生素在膜内的渗透能力，实现高效杀菌^[46-48]。Hu等^[49]通过体外生物膜实验指出，噬菌体通过激活宿主菌分泌降解EPS酶和蛋白酶促进细菌荚膜的降解，破坏细菌生物膜结构。值得注意的是，物理屏障的破坏虽减弱了生物膜的稳定性，但细菌可借助群体感应(quorum sensing, QS)系统快速启动修复机制，调控EPS合成以重建生物膜结构；而联合疗法通过同步抑制QS系统阻断这一修复过程^[17]。Rastegar等^[50]利用体外生物膜实验证实，当噬菌体与β-内酰胺类抗生素联用时对鲍曼不动杆菌生物膜的抑制率与清除率提升50%以上(P<0.01)。(2) 噬菌体可通过裂解酶破坏细菌细胞壁或膜结构，从而裂解细菌并释放子代噬菌体；抗生素则靶向活跃菌的合成代谢途径，与噬菌体形成协同抗生物膜作用^[46,51]。Shi等^[52]的体外生物膜研究发现，噬菌体Phage_Pae01编码多种溶菌相关蛋白破坏细菌的细胞壁结构，而庆大霉素则可减少耐药突变体的增殖，当两者联合处理24 h后生物膜内细菌数量与对照组相比显著减少，且生物膜结构被完全破坏。(3) 生物膜内的休眠菌因代谢停滞而对抗生素高度耐受，噬菌体可激活其休眠状态以恢复其对抗生素敏感性^[53]。Maffei等^[54]采用体外生物膜实验提出，噬菌体Paride通过裂解释放细胞壁碎片，激活休眠菌壁合成通路，将其与美罗培南联用时杀菌率超过99%。Xiao等^[55]在体外实验中表明，人工噬菌体Ir@Co₃O₄(S)通过纳米催化降解EPS，并激活休眠菌的氧化应激促使其代谢活化，从而显著抑制目标菌株的生物膜形成，抑制率达70% (图2)。

生物膜的形成是一个动态的过程，在临床环境中尤其是在慢性感染和长期植入医疗器械的患者中，常见到由2种或多种病原体形成的混合生物膜感染^[56]，通常其结构更加复杂，较单物种生物膜更难以清除和治疗。Akturk等^[57]研究发现，在人造真皮伤口感染模型中噬菌体与庆大霉素联用可协同抑制铜绿假单胞菌-金黄色葡萄球菌混合生物膜生长，显著降低细菌载量并抑制耐药性发展。上述研究表明，噬菌体-抗生素联合疗法在生物膜感染的控制中具有显著优势，展现出良好的临床应用潜力。

2 噬菌体-抗生素联合疗法的影响因素与优化策略

收起

虽然噬菌体-抗生素联合疗法已被证实在多方面展现出良好的协同作用，但在临床制定联合疗法方案时仍需综合考虑多个关键因素^[58]，如噬菌体与抗生素的选择、给药顺序、剂量配比以及给药方式等，这些因素均可影响抗感染治疗的协同作用及最终疗效。因此，为最大限度提高对MDR菌感染的治疗效果，需通过系统的体内外实验和临床研究评估，并对噬菌体-抗生素联合疗法进行持续优化和调整。

2.1 噬菌体与抗生素的选择

2.1.1 噬菌体-抗生素对细菌的双重匹配

噬菌体-抗生素联合疗法的有效性依赖于两大关键因素：一是噬菌体对靶细菌的匹配性，二是靶细菌对所选抗生素的敏感性。噬菌体的宿主特异性是其发挥裂解作用的核心基础，主要依赖其受体结合蛋白(receptor-binding proteins, RBPs)识别并结合细菌表面的特定受体，如脂多糖、荚膜、外膜蛋白、鞭毛或菌毛等，从而介导感染过程的启动^[59]。这种特异性结合决定了噬菌体的宿主范围和裂解能力^[10]。抗生素的选择同样至关重要，首先应通过药敏实验确定目标菌株的MIC，并参考美国临床和实验室标准协会(Clinical and Laboratory Standards Institute, CLSI)或欧盟药敏试验标准委员会(European Committee on Antimicrobial Susceptibility Testing, EUCAST)发布的标准对其敏感性进行判读^[60]。在此基础上，还需综合评估所选抗生素的组织穿透力、潜在耐药风险及与噬菌体的宿主范围的匹配程度，并通过体外协同实验加以验证，从而优化联合疗法方案，为其后续应用提供可靠支撑^[28]。

2.1.2 噬菌体-抗生素的相互作用

噬菌体-抗生素联合疗法中的抗菌效果高度依赖于两者之间的分子作用模式。根据其相互作用关系，可将两者的相互作用系统地归类为3种类型，其机制与临床意义如下。(1) 协同作用(synergistic)：指噬菌体与抗生素联用后产生的抑菌效果显著优于单药治疗，可通过增强抗菌效应、扩大抗菌谱及延缓耐药性等方式实现^[16-17]。(2) 拮抗作用(antagonistic)：指噬菌体与抗生素联用后其杀菌效果显著弱于两者各自单独使用时的效果。某些抗生素可能通过抑制噬菌体的复制过程而削弱联合疗法的效果^[61]。蛋白质合成抑制剂可通过干扰细菌的核糖体功能，阻断噬菌体复制周期，从而降低噬菌体的裂解效率^[62]。此外，群体感应抑制剂通过下调细菌T4菌毛表达显著降低噬菌体的吸附率，进而影响其裂解能力^[63]。研究指出某些抗生素在亚抑制浓度下与噬菌体联用时噬菌体裂解能力下降，导致体内外实验中细菌存活率升高^[28]。因此，在设计联合疗法方案时需规避此类拮抗组合。(3) 独立作用(independent)：指噬菌体与抗生素联用后各自独立发挥抗菌效应，彼此之间未表现出明显的协同增效或拮抗抑制，抗菌效果相当于两者单独使用时作用的相加。尽管缺乏协同增效，但该策略仍可能通过双重机制提升治疗效果、降低耐药风险^[61]。Duan等^[64]的体外实验表明，噬菌体Spe5P4与亚胺培南联用可使生物膜内细菌负荷显著降低90%，并抑制外排泵基因(mexB)与生物膜相关基因(pelA)的表达。噬菌体与抗生素的相互作用呈现动态可变性，其协同、拮抗或独立作用可随细菌耐药性发展、治疗方案调整及微环境变化相互制约与转换。

2.1.3 抗生素类别

不同类别的抗生素在组织穿透力、杀菌机制以及耐药选择压力方面存在显著差异，从而影响噬菌体-抗生素联合疗法的整体疗效。研究表明，美罗培南、环丙沙星和黏菌素等抗生素单药疗效有限，但与噬菌体联用可实现4 lg CFU/mL减少^[65]。此外，β-内酰胺抗生素和氟喹诺酮类抗生素在亚抑制浓度时会导致细胞分裂紊乱，如伸长、肿胀或细胞丝状化^[26,65]。细菌的形态变化可改变噬菌体的吸附效率，缩短潜伏期，加速裂解过程^[17,66]。氨基糖苷类抗生素，包括庆大霉素、阿朴霉素和卡那霉素，已证实可在噬菌体生命周期的早期阶段——噬菌体基因组复制前阻断其生命周期，对多种双链DNA噬菌体的特定家族显示出广泛的抑制作用^[67]。大环内酯类抗生素通过抑制细菌蛋白质合成发挥抗菌作用，与噬菌体联用时能够降低其自身的MIC，从而提高联合疗法的临床应用效果^[68]。因此，抗生素的类别通过影响细菌形态、噬菌体生命周期及其自身药代动力学特性，共同决定了噬菌体-抗生素联合疗法的最终效应^[42]。

2.2 给药顺序

噬菌体-抗生素联合疗法中给药顺序是影响疗效的重要因素，应根据病原菌的生物学特性、感染的阶段以及预期的治疗目标进行合理设计。(1) 噬菌体先于抗生素，该策略可通过噬菌体优先裂解细菌、破坏生物膜结构，并有助于唤醒休眠菌，从而增强抗生素的渗透性和杀菌效率，也可减少抗生素对噬菌体活性的干扰，尤其适用于生物膜相关感染。如表1所示，该策略在多数体外研究中表现出最佳效果，但是其效果可能受噬菌体复制周期和细菌密度影响较大，应充分评估噬菌体的感染效率、给药剂量和时机^[71]。(2) 抗生素先于噬菌体，可在急性感染早期迅速降低细菌负荷，减少毒素释放和炎症损伤。此外，借由某些抗生素(如β-内酰胺、氟喹诺酮)诱导的细胞形态改变，增加噬菌体的吸附位点和复制效率^[16-18]。然而需注意可能因抗生素快速降低细菌密度而限制噬菌体增殖与扩散，影响治疗效果。(3) 两者同时给药，则操作简便、起效快，可在感染早期通过2种独立的杀菌机制快速降低细菌负荷，并对细菌施加同步多重选择压力，从而在一定程度上延缓单一耐药或噬菌体抗性的出现，也可借助协同作用降低各自剂量，减少毒副反应^[58,19]。然而，该策略存在一定拮抗风险，需依赖高剂量或多次给药以克服抗生素对噬菌体活性的潜在干扰。

2.3 剂量调整

在噬菌体-抗生素联合疗法中，抗生素浓度和噬菌体滴度是影响疗效的关键因素。合理的剂量配比有助于增强协同杀菌效应。需要注意的是，抗生素剂量过高可能会抑制细菌代谢，降低噬菌体的复制效率；反之，剂量不足则可能导致杀菌不彻底，增加耐药风险^[19]。一方面，低浓度或亚抑制浓度的抗生素可减缓细菌生长而不完全抑制其代谢，为噬菌体吸附和裂解提供有利条件，同时减少潜在的拮抗作用^[17,72-73]。Wang等^[32]通过体外实验发现，噬菌体HZY2308与替加环素在低MOI (0.01)和亚抑制浓度(1/32 MIC)可显著增强抑菌效果，24 h的协同作用优于单一治疗组(P<0.05)。此外，经噬菌体预处理后可将抗生素所需剂量降至临床可行范围^[68]。另一方面，高滴度的噬菌体可有效穿透生物膜等复杂屏障，实现高效且彻底的杀菌作用^[41]。Manohar等^[74]通过体外研究证实，单用高浓度头孢他啶(32 µg/mL)对铜绿假单胞菌生物膜无效，但与高滴度噬菌体联用后则可实现生物膜的完全清除。同时，噬菌体鸡尾酒在与抗生素的协同抗菌效应存在明显的剂量依赖性，其强效抑菌作用需达到较高滴度才能充分展现，当噬菌体滴度低于10⁵ PFU/mL时两者联用不显示协同作用，而当超过该滴度时则可有效清除生物膜并维持长效抑菌^[41]。

综上所述，噬菌体与抗生素剂量的优化并非简单累加，而应根据具体菌株、噬菌体和抗生素的特性通过系统试验确定最佳的协同配比，以期在保证疗效的同时最大限度地减少药物用量和潜在的副作用。

2.4 给药方式

在联合疗法中给药方式的选择是实现精准治疗的关键环节。临床上已采用多种成熟的噬菌体给药途径(表2)，包括静脉注射^[31]、局部注射或冲洗^[61]、雾化吸入^[74]、口服和局部用药^[79]等。在实验研究的动物感染模型中常用腹腔注射^[80]、鼻腔滴注^[81]等给药途径，也探索了直肠给药等新型给药途径，旨在拓展噬菌体在特殊感染场景下的应用。抗生素的给药通常采用静脉注射或口服等方式。给药方式的选择应根据感染类型、病灶解剖位置、病原体特性以及患者的免疫状态等多种因素综合决策，结合不同给药方式的药理优势，实现个体化、靶向化的协同治疗效果^[82] (图3)。

2.5 免疫问题

噬菌体作为外源性物质进入人体后会迅速触发宿主的免疫防御系统，这已成为其临床应用的主要障碍之一。宿主的固有免疫系统首先作出响应：吞噬细胞(巨噬细胞、树突状细胞)能直接吞噬噬菌体并清除；中性粒细胞通过Fcγ受体识别噬菌体-抗体复合物，进而触发脱颗粒反应，释放活性氧(reactive oxygen species, ROS)及中性粒细胞胞外诱捕网(neutrophil extracellular traps, NETs)，进一步加速噬菌体降解；补体系统的激活具有双重性：一方面，细菌感染过程中暴露的病原抗原可激活膜攻击复合物(membrane attack complex, MAC)，协同杀灭病原菌；另一方面，补体蛋白C3b沉积在噬菌体表面会直接阻断其吸附宿主菌，导致噬菌体失活；此外，噬菌体DNA被Toll样受体9识别后能刺激免疫细胞释放白细胞介素(interleukin, IL)-12、IL-8等炎性因子；部分噬菌体还可通过TLR3/TRIF通路诱导I型干扰素产生，进一步抑制吞噬功能^[83-84]。上述免疫反应使得静脉注射的噬菌体在人体内半衰期极短(通常仅2-6 h)，难以在深部组织或慢性感染灶维持有效浓度^[85]。

适应性免疫系统对PT提出了更为严峻的挑战。反复的噬菌体给药极易诱导机体产生高滴度的特异性中和抗体。临床观察发现约25%的患者(5/20)因产生噬菌体中和抗体而导致疗效显著降低^[86]。免疫记忆的形成则进一步加剧这一问题：肺移植患者在初次接触噬菌体后，21 d内即可检测到特异性抗体和循环滤泡辅助性T细胞，再次给药时可发生快速、强烈的免疫清除反应^[87]。值得注意的是，即使未接受过PT的健康人群体内也可能存在针对特定噬菌体(如T4噬菌体衣壳蛋白)的天然抗体，这些抗体的交叉反应进一步限制了PT的临床应用^[88]。此外，噬菌体制剂中可能残留的内毒素或裂解释放的细菌碎片可引发发热、肝损伤等炎症反应，在免疫低下患者中甚至可能诱发脓毒症风险^[83]。

为应对这些挑战，聚乙二醇(polyethylene glycol, PEG)修饰作为一种有效策略被广泛应用。PEG化通过在噬菌体表面形成亲水屏障显著减少免疫识别和清除，延长其在血液循环中的半衰期，从而支持更长的给药间隔，为克服免疫清除障碍提供了重要途径^[89]。此外，通过优化给药途径，如局部给药或分次渐增给药^[90]、联合免疫抑制剂使用^[79]或应用载体包裹技术(如脂质体或纳米颗粒包裹^[91-93])均可有效降低噬菌体诱导的免疫反应，延缓特异性中和抗体的产生；而轮换噬菌体或使用噬菌体鸡尾酒疗法则可避免重复给药导致的免疫记忆迅速清除问题^[90]。同时，利用基因工程手段对噬菌体表面抗原进行改造、去除或掩盖免疫原性较高的表位也被视为未来重要的发展方向之一^[94]。这些多样化的策略为进一步提高PT的安全性和临床应用前景提供了重要支撑^[95]。

2.6 新型递送系统

新型噬菌体及抗生素递送系统的研发旨在解决传统PT中存在的多重障碍，包括噬菌体被机体免疫系统快速清除、反复给药后诱导免疫记忆导致疗效下降、在骨组织等部位难以达到有效治疗浓度、生物膜结构对噬菌体渗透形成物理屏障以及噬菌体对环境条件敏感、活性易丧失等问题^[96-98]。通过构建脂质体、水凝胶、纳米颗粒或细胞递送平台可有效延长噬菌体在体内的循环时间，增强其穿透屏障和靶向递送能力，同时提高稳定性并实现与抗生素的协同控释，从而显著提升噬菌体-抗生素联合疗法在复杂感染中的应用潜力^[92,99]。Li等^[96]设计了一种由脂质体与噬菌体组成的纳米复合系统，用于靶向杀灭金黄色葡萄球菌，在上皮细胞共培养模型中显著提高了噬菌体对细胞相关感染的杀菌效率，增强了其在黏附感染环境中的治疗效果。Sawant等^[99]开发了一种可吸入噬菌体脂质体递送系统，用于治疗铜绿假单胞菌肺部感染，体外研究表明该系统可显著提高噬菌体在雾化过程中的稳定性，并减少其被肺上皮细胞摄取，从而增强对胞外细菌的杀菌效果。Chadha等^[91]利用脂质体包载噬菌体，在小鼠肺部感染模型中显著提高了噬菌体递送效率，减少了免疫清除。Chen等^[100]研发了一种同时负载噬菌体鸡尾酒与万古霉素的水凝胶共递送系统，体外实验显示该系统能有效穿透并清除MRSA生物膜，细菌负荷减少高达99.72%。Chen等^[98]构建了一种由海藻酸钠微球和水凝胶组成的复合递送系统，同时负载噬菌体与美罗培南，用于治疗铜绿假单胞菌骨折相关感染，通过兔骨髓炎模型发现显著增强了局部抗菌效果并延长了药物释放时间，为深部骨组织感染治疗提供了新策略。Zhao等^[97]基于RBPs组装出2种特异性纳米递送系统，通过将抗生素负载于RBPs偶联的纳米颗粒中实现了感染部位的精准药物富集；体内外实验证实，该系统能将万古霉素和美罗培南对肺部CRKP及MRSA的抗菌效率显著提升3-5倍。Wdowiak等^[92]设计并制备了由绿茶提取物包裹的银纳米颗粒(G-TeaNPs)与噬菌体联合组成的递送系统，体外实验显示该系统在低剂量下即可显著抑制耐药金黄色葡萄球菌和沙门氏菌感染，同时兼具良好的生物相容性与环境友好性。此外，Xiao等^[55]研制的人工噬菌体Ir@Co₃O₄(S)通过纳米催化尖刺靶向降解EPS，协同抗生素穿透生物膜，体外生物膜实验表明该系统使目标菌株的生物膜形成能力降低70%。

综上所述，联合疗法在各类策略的实施中均需应对以下挑战：(1) 不同组合的相互作用(协同/拮抗/独立)具有高度不确定性，需通过实验验证；(2) 噬菌体与抗生素在药代动力学特性、组织分布及免疫清除途径上可能存在差异，可能导致有效作用时间的错位，影响治疗效果；(3)双重抗菌压力虽可延缓单一耐药的产生，但也可能诱导双重耐受菌株的出现，噬菌体裂解与抗生素杀菌效应叠加可能导致细菌内毒素和代谢产物的大量释放，从而加剧炎症反应。因而，在设计联合疗法方案时应综合考虑药物作用机制、剂量配比、感染类型及宿主状态，以实现疗效最大化并降低不良反应风险。

3 噬菌体-抗生素联合疗法的应用展望

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在多重耐药性日益严重的背景下，PT被视为最具潜力的抗生素替代抗菌策略之一^[101]。尽管PT已有近百年的临床应用历史，但其现代医学推广仍需在严谨的监管框架下循序渐进^[102]。目前，格鲁吉亚和俄罗斯已将噬菌体制剂纳入国家药典^[103]；欧盟则依据《2001/83/EC指令》将其归类为“人用医药产品”进行监管；美国食品药品监督管理局(Food and Drug Administration, FDA)将噬菌体定义为生物制品，要求研发过程需遵循严格的药品生产质量管理规范(good manufacturing practice of medical products, GMP)。截至目前，FDA尚未批准任何商业化噬菌体制剂，相关临床试验主要通过试验性新药(investigational new drug, IND)途径开展，以全面评估其安全性与有效性，并保障受试者权益^[104-105]。鉴于噬菌体-抗生素联合疗法的显著优势，其广泛推广仍需从多个层面协同推进。

3.1 政策监管的完善

国内噬菌体的标准化生产和监管尚处于起步阶段，亟需建立契合噬菌体生物学特性的专门监管路径，并制定统一的行业技术标准。建议简化紧急使用审批程序，使噬菌体能够更及时地应用于临床急需情况；同时完善知识产权保护与成果转化配套政策，鼓励企业和科研机构持续投入创新研发；建立长期药品安全监测体系，保障患者用药安全。通过财政补贴、税收优惠和科研基金引导加大基础研究投入，推动个性化噬菌体疗法从实验室迈向临床。

3.2 技术研发的深化

在基础研究方面，借助多组学技术和生物信息学分析深入构建宿主菌-噬菌体-抗生素互作的分子调控网络，并建立动态预测模型以此优化联合疗法策略。面对联合疗法研究缺乏标准化评价体系的挑战，需构建体内外多层级评价体系，如体外利用微流控技术等构建动态生物膜系统，模拟临床环境；体内则完善慢性感染动物模型，如慢性伤口感染、骨髓炎等模型，同时利用大蜡螟模型和小鼠模型可分别作为初筛和深入研究的有效工具。基因编辑技术的应用将增强噬菌体的裂解能力并改善其生物膜穿透性，如CRISPR-Cas系统、工程化噬菌体等技术。此外，噬菌体的筛选需优先覆盖WHO列为优先名单的前十大耐药菌种，确保其具有特异性裂解活性、非溶原性率>99%、无耐药基因或毒力因子，并在生产过程中严格遵循GMP规范，严格控制内毒素水平。在此基础上，构建广谱、高效的噬菌体资源库，开发基于表型与基因组匹配的快速筛选技术平台。与此同时，开发更多新型递送系统至关重要，旨在实现噬菌体协同释放、精准靶向及药代优化，从而延长药效并降低免疫清除风险。

3.3 临床应用的推进

在临床转化层面，亟需建立统一的疗效与安全性评价体系，系统比较不同噬菌体-抗生素联合疗法方案的给药时机、剂量及疗程。加强多中心临床研究合作，积累实践案例，并结合适应性实验设计持续优化方案。完善噬菌体资源库、优化质量控制标准、推动国际监管协调与数据互认等，加速联合疗法的临床转化。

本文系统综述了噬菌体-抗生素联合疗法在治疗细菌性感染中的潜在应用，探讨了其协同作用机制、治疗复杂感染的能力、影响治疗效果的因素以及临床应用中的挑战。未来需通过多学科协同推进机制研究、技术创新与临床验证推动噬菌体-抗生素联合疗法从实验室走向临床常规化应用，为应对全球日益严峻的抗菌药物耐药危机提供新思路和切实可行的解决方案。

作者贡献声明

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任雪芳：初稿撰写、研究构思、数据采集及论文修改；卢瑞辞：研究设计和编辑写作；有小娟：获取基金和审查；朱芮：框架设计、审阅、获取基金及论文修改；李永伟：监督指导和获取基金。

作者利益冲突公开声明

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作者声明不存在任何可能会影响本文所报告工作的已知经济利益或个人关系。

基金

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河南省科技攻关项目(242102310148)
河南省自然科学基金(242300420437)
河南省高等学校重点科研项目(24A310007)
河南省高等学校重点科研项目(25A320042)
吴阶平医学基金会科研专项基金(320.6750.2024-03-27)

参考文献

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2025年第65卷第11期

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文章信息

doi: 10.13343/j.cnki.wsxb.20250317

接收时间：2025-04-16
首发时间：2025-11-10
出版时间：2025-11-04

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文章信息

作者

出版历史

收稿日期：2025-04-16
录用日期：2025-07-09

基金

Henan Provincial Science and Technology Research Project(242102310148)

河南省科技攻关项目(242102310148)

Natural Science Foundation of Henan Province(242300420437)

河南省自然科学基金(242300420437)

Key Scientific Research Project of Henan Higher Education Institutions(24A310007)

河南省高等学校重点科研项目(24A310007)

Key Scientific Research Project of Henan Higher Education Institutions(25A320042)

河南省高等学校重点科研项目(25A320042)

Wu Jieping Medical Foundation Research Special Fund(320.6750.2024-03-27)

吴阶平医学基金会科研专项基金(320.6750.2024-03-27)

作者信息

1 河南中医药大学第二临床医学院，河南中医药大学第二附属医院，河南郑州

2 河南省中医院检验中心，河南省防治耐药菌感染中医药重点实验室，郑州市病原微生物与细菌耐药监测重点实验室，河南郑州

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2种不同金属材料的力学参数

科 Family	属数 Number of genus	种数 Number of species	占总种数比例 Percentage of total species (%)	属 Genus	种数 Number of species	占总种数比例 Percentage of total species (%)
鹅膏菌科Amanitaceae	2	11	5.26	鹅膏菌属 Amanita	10	4.78
小菇科 Mycenaceae	2	12	5.74	丝盖伞属 Inocybe	5	2.39
多孔菌科 Polyporaceae	8	14	6.70	蜡蘑属 Laccaria	5	2.39
红菇科 Russulaceae	3	23	11.00	小皮伞属 Marasmius	6	2.87
				小菇属 Mycena	11	5.26
				光柄菇属 Pluteus	5	2.39
				红菇属 Russula	17	8.13
				栓菌属 Trametes	5	2.39

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Sequence	Mechanism of action	Experimental evidence
Phage→Antibiotic	Phage-mediated lysis disrupts biofilm integrity, enhancing antibiotic penetration	(1) Effectively eradicates MRSA biofilms of varying robustness^[19]
(2) Complete eradication with ciprofloxacin addition 6-12 h post-phage^[68]
(3) 4.8 lg reduction in Pseudomonas aeruginosa biofilm; 2.3 lg reduction in Staphylococcus aureus biofilm^[57]
Antibiotic→Phage	Antibiotic pretreatment disrupts biofilm architecture, phages target matrix-embedded bacteria	(1) After 48 h treatment, bacterial density decreased by 2 lg^[69]
(2) Significantly improves survival in the Galleria mellonella infection model and is effective against strong, moderate, and weak biofilms^[19]
Simultaneous	Phage-mediated real-time EPS disruption, enhanced antibiotic penetration depth, and accelerated synergistic antibacterial kinetics	(1) Reduce biofilm viability by approximately 4-5 lg in long-term treatment^[58]
(2) 6.2 lg reduction in Pseudomonas aeruginosa biofilm burden; 5.7 lg reduction in Staphylococcus aureus biofilm burden^[70]

Sequence

Mechanism of action

Experimental evidence

Phage→Antibiotic

Phage-mediated lysis disrupts biofilm integrity, enhancing antibiotic penetration

(1) Effectively eradicates MRSA biofilms of varying robustness^[19]

(2) Complete eradication with ciprofloxacin addition 6-12 h post-phage^[68]

(3) 4.8 lg reduction in Pseudomonas aeruginosa biofilm; 2.3 lg reduction in Staphylococcus aureus biofilm^[57]

Antibiotic→Phage

Antibiotic pretreatment disrupts biofilm architecture, phages target matrix-embedded bacteria

(1) After 48 h treatment, bacterial density decreased by 2 lg^[69]

(2) Significantly improves survival in the Galleria mellonella infection model and is effective against strong, moderate, and weak biofilms^[19]

Simultaneous

Phage-mediated real-time EPS disruption, enhanced antibiotic penetration depth, and accelerated synergistic antibacterial kinetics

(1) Reduce biofilm viability by approximately 4-5 lg in long-term treatment^[58]

(2) 6.2 lg reduction in Pseudomonas aeruginosa biofilm burden; 5.7 lg reduction in Staphylococcus aureus biofilm burden^[70]

Administration route	Pathogenic bacteria	Indication	Pathogenic bacteria	Combined antibiotics	Antibiotic administrati-on routes	Result
Local Injection	Klebsiella pneumoniae	Wound infection, fracture-related infection	vB_KpnM_ M1	Meropenem, colistin, ceftazidime-avibactam	Intravenous injection	Significant clinical and imaging improvement^[61]
Aerosol inhalation	Pseudomonas aeruginosa	Pulmonary infection	vFB297	Amikacin, meropenem	Intravenous injection	Reduced sputum bacterial load, improved lung function^[75]
Pleural+ aerosol	Serratia marcescens	Infected pleural effusion	Spe5P4	Amikacin, meropenem	Intravenous injection	Resolution of chest pain and dyspnea, imaging recovery^[76]
Bladder irrigation	Klebsiella pneumoniae	Urinary tract infection	Kp152, Kp154, Kp155, Kp164, Kp6377, HD001	Trimethoprim-sulfamethoxazole	Oral	Complete pathogen clearance, no recurrence in 6 mo^[77]
Intravenous injection	Pseudomonas aeruginosa	Systemic infection	Pa53	Meropenem	Intravenous injection	No relapse in 2 a^[31]
	Mycobacterium chelonae	Infection in immunocompromised patient	Muddy	Omadacycline, bedaquiline, trimethoprim-sulfamethoxazole	Oral	Significant skin lesion improvement^[78]
Oral+bladder irrigation	Klebsiella pneumoniae	Urinary tract infection	Anti-Klebsiella pneumoniae phages	Meropenem	Intravenous injection	Symptom relief in 24 h negative urine culture for 14^[79]
Intraperitoneal injection	Pseudomonas aeruginosa	Severe infection requiring rapid control	JG005, JG024	Meropenem	Intraperiton-eal injection	Reduced alveolar-capillary permeability index (P=0.030 1) and 100% survival (96 h post-infection)^[80]

Administration route

Pathogenic bacteria

Indication

Pathogenic bacteria

Combined antibiotics

Antibiotic administrati-on routes

Result

Local

Injection

Klebsiella pneumoniae

Wound infection, fracture-related infection

vB_KpnM_

Meropenem, colistin, ceftazidime-avibactam

Intravenous injection

Significant clinical and imaging improvement^[61]

Aerosol inhalation

Pseudomonas aeruginosa

Pulmonary infection

vFB297

Amikacin, meropenem

Intravenous injection

Reduced sputum bacterial load, improved lung function^[75]

Pleural+ aerosol

Serratia marcescens

Infected pleural effusion

Spe5P4

Amikacin, meropenem

Intravenous injection

Resolution of chest pain and dyspnea, imaging recovery^[76]

Bladder irrigation

Klebsiella pneumoniae

Urinary tract infection

Kp152, Kp154, Kp155, Kp164, Kp6377, HD001

Trimethoprim-sulfamethoxazole

Oral

Complete pathogen clearance, no recurrence in 6 mo^[77]

Intravenous injection

Pseudomonas aeruginosa

Systemic infection

Pa53

Meropenem

Intravenous injection

No relapse in 2 a^[31]

Mycobacterium chelonae

Infection in immunocompromised patient

Muddy

Omadacycline, bedaquiline, trimethoprim-sulfamethoxazole

Oral

Significant skin lesion improvement^[78]

Oral+bladder irrigation

Klebsiella pneumoniae

Urinary tract infection

Anti-Klebsiella pneumoniae phages

Meropenem

Intravenous injection

Symptom relief in 24 h negative urine culture for 14^[79]

Intraperitoneal injection

Pseudomonas aeruginosa

Severe infection requiring rapid control

JG005, JG024

Meropenem

Intraperiton-eal injection

Reduced alveolar-capillary permeability index (P=0.030 1) and 100% survival (96 h post-infection)^[80]