Overcoming bacteriophage insensitivity in Staphylococcus aureus using clindamycin and azithromycinat subinhibitory concentrations

Background Staphylococcus aureus is a pathogen of major concern in both acute infections and chronic conditions such as chronic rhinosinusitis (CRS). Bacteriophage (phage) therapy has recently regained interest for its potential to treat infections caused by antibiotic resistant strains including Methicillin Resistant Staphylococcus aureus (MRSA). However, bacteria can adapt and become resistant to phages. The aim of this study is to determine the potential for antibiotics to overcome phage resistance. Methods The susceptibility of S. aureus clinical isolates (CIs) to phages J‐Sa36, Sa83 and Sa87 alone or in combination with protein synthesis inhibitor (PSI) antibiotics clindamycin, azithromycin and erythromycin was assessed using plaque spot assays, minimum inhibitory concentration (MIC) assays, double layer spot assays and resazurin assays. The safety and efficacy of subinhibitory PSI antibiotics in combination with phage was tested in a Sprague Dawley rat model of sinusitis infected with a phage resistant S. aureus CI. Results All three antibiotics at subinhibitory concentrations showed synergy when combined with all 3 phages against S. aureus CIs in planktonic and biofilm form and could sensitize phage‐resistant S. aureus to promote phage infection. The combination of topical subinhibitory clindamycin or azithromycin and phage was safe and could eradicate S. aureus sinonasal biofilms in vivo. Conclusion Subinhibitory concentrations of PSI antibiotics could sensitize phage‐resistant S. aureus and MRSA strains to phages in vitro and in vivo. This data supports the potential use of phage‐PSI antibiotic combination therapies, in particular for difficult‐to‐treat infections with phage‐resistant S. aureus and MRSA strains. MSSA and MRSA biofilms have reduced sensitivity to antibiotics. Phage can lyse phage sensitive MSSA and MRSA strains but not phage insensitive strains. Subinhibitory protein synthesis inhibitor antibiotics can sensitize phage insensitive S. aureus strains to become sensitive to phage infection resulting in eradication of S. aureus infection in vitro and in vivo. Abbreviations: MSSA, methicillin‐susceptible Staphylococcus aureus; MRSA, methicillin‐resistant Staphylococcus aureus; MIC, minimum inhibitory concentration; Abx, antibiotic.