Table I Expert Consensus Quality and Safety Requirements for Sustainable Phage Therapy Products
表 I 可持续噬菌体疗法产品的质量与安全要求专家共识
From: Quality and Safety Requirements for Sustainable Phage Therapy Products
来自可持续噬菌体疗法产品的质量和安全要求
| A. Production environment A.生产环境 | |||
| When production activities include the processing of intermediate, bulk or finished phage products exposed to the environment, this must take place in an environment with specified air quality and cleanliness in order to minimize the risk of contamination. The effectiveness of these measures must be validated and monitored. Where intermediate, bulk or finished products are exposed to the environment during processing, without a subsequent microbial inactivation process, an air quality with particle counts and microbial colony counts equivalent to those of Grade A as defined in the current European Guide to Good Manufacturing Practice (GMP), Annex 1 and Directive 2003/94/EC is required with a background environment at least equivalent to GMP Grade D in terms of particles and microbial counts. The biosafety level (BSL) is determined by the host bacteria used in the production processes (e.g., BSL-2 for Pseudomonas aeruginosa). 如果生产活动包括处理暴露在环境中的中间产品、散装产品或噬菌体成品，则必须在空气质量和清洁度符合规定的环境中进行，以最大限度地降低污染风险。必须对这些措施的有效性进行验证和监测。如果中间产品、散装产品或成品在加工过程中暴露在环境中，而没有随后的微生物灭活过程，则要求空气质量的颗粒计数和微生物菌落计数相当于现行《欧洲药品生产质量管理规范指南》（GMP）附件 1 和第 2003/94/EC 号指令中规定的 A 级，背景环境的颗粒计数和微生物计数至少相当于 GMP D 级。生物安全级别 (BSL) 由生产过程中使用的宿主细菌决定（例如，铜绿假单胞菌为 BSL-2）。 | |||
| B. Production processes, equipment and materials B.生产流程、设备和材料 | |||
| All equipment and material must be designed and maintained to suit its intended purpose and must minimize any hazard to recipients and staff. All critical equipment and technical devices must be identified and validated, regularly inspected and preventively maintained in accordance with the manufacturers’ instructions. Where equipment or materials affect critical processing or storage parameters (e.g., temperature, pressure, particle counts, microbial contamination levels), they must be identified and must be the subject of appropriate monitoring, alerts, alarms and corrective action, as required, to detect malfunctions and defects and to ensure that the critical parameters are maintained within acceptable limits at all times. All equipment with a critical measuring function must be calibrated against a traceable standard if available. Maintenance, servicing, cleaning, disinfection and sanitation of all critical equipment must be performed regularly and recorded accordingly. 所有设备和材料的设计和维护都必须适合其预期用途，必须尽量减少对接受者和工作人员的任何危害。所有关键设备和技术装置都必须按照制造商的说明进行识别和验证、定期检查和预防性维护。如果设备或材料会影响关键的加工或储存参数（如温度、压力、颗粒计数、微生物污染水平），则必须对其进行识别，并根据需要对其进行适当的监控、警报、报警和纠正措施，以检测故障和缺陷，并确保关键参数始终保持在可接受的范围内。所有具有关键测量功能的设备都必须根据可追溯的标准（如有）进行校准。必须定期对所有关键设备进行维护、保养、清洁、消毒和卫生处理，并作相应记录。 | |||
| Production processes must be described in detail (equipment, materials, culture media, additives, culture conditions, purification steps,..) in standard operating procedures (SOPs) and must be validated (procedures published in relevant peer-reviewed journals could be considered ‘validated’). 生产过程必须在标准操作程序 (SOP) 中详细描述（设备、材料、培养基、添加剂、培养条件、纯化步骤等），并且必须经过验证（在相关同行评审期刊上发表的程序可视为 “经过验证”）。 | |||
| SOPs must detail the specifications for all critical materials and reagents. In particular, specifications for culture media, additives (e.g., solutions) and packaging materials must be defined. Critical reagents and materials must meet documented requirements and specifications and when applicable the requirements of Council Directive 93/42/EEC of 14 June 1993 concerning medical devices and Directive 98/79/EC of the European Parliament and of the Council of 27 October 1998 on in vitro diagnostic medical devices. If possible, animal component free culture media and additives should be used (the Note for Guidance on Minimizing the Risk of Transmitting Animal Spongiform Encephalopathy Agents via Human and Veterinary Medicinal Products (EMEA/410/01) in its current version is to be applied). If animal–product free media are not used, Transmitting Animal Spongiform Encephalopathy (TSE)-free certification should be obtained for all components containing products of animal origin. 标准操作程序必须详细说明所有关键材料和试剂的规格。特别是，必须规定培养基、添加剂（如溶液）和包装材料的规格。关键试剂和材料必须符合文件规定的要求和规格，并在适用时符合 1993 年 6 月 14 日关于医疗器械的理事会指令 93/42/EEC 和 1998 年 10 月 27 日欧洲议会和理事会关于体外诊断医疗器械的指令 98/79/EC 的要求。在可能的情况下，应使用不含动物成分的培养基和添加剂（应采用最新版的《关于将通过人 类和兽药产品传播动物海绵状脑病病原体的风险降至最低的指导说明》（EMEA/410/01））。如果不使用不含动物产品的培养基，则所有含有动物产品的成分都应获得不含传播动物海绵状 脑病（TSE）的认证。 | |||
| Analytical methods can be validated according to: a) EMEA/CHMP/EWP/192217/2009 “Guideline on bioanalytical method validation” or b) CPMP/ICH /381/95 “ICH Topic Q 2 (R1) Validation of Analytical Procedures: Text and Methodology”. 可根据以下标准对分析方法进行验证：a) EMEA/CHMP/EWP/192217/2009 “生物分析方法验证指南 “或 b) CPMP/ICH /381/95 “ICH Topic Q 2 (R1) Validation of Analytical Procedures：文本和方法”。 | |||
| Bacteria and phage bank systems need to be set up. These bank systems typically consist of Master seed lots and Working seed lots. The generation and characterization of the banks should be performed in accordance with principles of CPMP/ICH guideline Q5D. The banked phages and bacteria should be characterized for relevant phenotypic and genotypic markers so that the identity, viability (activity for phages), and purity of organisms used for the production are ensured. Biological Resource Centers [10] could function as repositories for bacteriophage Master Seeds and host bacteria. 需要建立细菌和噬菌体库系统。这些菌种库系统通常由主菌种批次和工作菌种批次组成。细菌和噬菌体库的生成和特征描述应按照 CPMP/ICH 准则 Q5D 的原则进行。应根据相关的表型和基因型标记对噬菌体和细菌库进行鉴定，以确保用于生产的生物体的特性、活力（噬菌体的活性）和纯度。生物资源中心[ 10] 可充当噬菌体母种和宿主细菌的储存库。 | |||
| C. Quality Assurance and Quality Control (QA/QC) specifications C.质量保证和质量控制（QA/QC）规范 | |||
| Products/characteristics 产品/特性 | Control test 控制测试 | Limits of acceptance 接受的限度 | Recommended test procedures 建议的测试程序 |
| C.1. Host bacteria used in production (stock suspensions) C.1.生产中使用的宿主细菌（悬浮种群） | |||
| The bacterial hosts used in the production process – with the exception of selection, adaptation and efficiency of plating (EOP) and host range determination – should be as safe (or least pathogenic) as feasible. 生产过程中使用的细菌宿主–除了选择、适应性和培养效率（EOP）以及宿主范围的确定–应尽可能安全（或致病性最小）。 | |||
| Origin 起源 | Document pedigree/history/pathogenicity level 记录血统/历史/致病程度 | Known origin 已知来源 | Screening of scientific literature, lab books, consignment letters,.. 筛选科学文献、实验室书籍、委托书等。 |
| Identification 身份验证 | Identification at the species and strain levels 物种和菌株级别的鉴定 | Matching species and strain identification 匹配物种和菌株鉴定 | • State of the art clinical microbiology techniques – 最先进的临床微生物学技术 |
| • Highly discriminating (molecular/genomic) typing techniques (e.g., MLST, AFLP, PFGE, Rep-PCR,..) – 高分辨（分子/基因组）分型技术（如 MLST、AFLP、PFGE、Rep-PCR……） | |||
| Most often it will not be possible to find or quickly generate a suitable host bacterium that is free of prophages or phage-like elements, but one should nevertheless strive to use non-lysogenic strains, containing as few phages or other phage-like elements of genetic exchange [11, 12] as possible 在大多数情况下，不可能找到或快速生成不含噬菌体或类似噬菌体元素的合适宿主细菌，但还是应该努力使用非异源菌株，尽可能减少噬菌体或其他类似噬菌体元素的基因交换[ 11, 12]。 | • Induction of phages – 噬菌体的诱导 | As few spontaneously produced (or by induction) temperate phages, complete prophage sequences or phage-like elements as possiblea 尽可能减少自发产生（或通过诱导产生）的温带噬菌体、完整的噬菌体序列或类似噬菌体的元素 a | • In vitro induction methods (Mitomycine C [13] or UV induction) – 体外诱导法（丝裂霉素 C [ 13] 或紫外线诱导法） |
| • Host genome screening for phage or phage-like elements – 宿主基因组筛选噬菌体或类似噬菌体的元素 | • State of the art DNA sequencing and analysis (bioinformatics) procedures – 最先进的 DNA 测序和分析（生物信息学）程序 | ||
| Avoid mutator strains as host bacteria 避免将变异菌株作为宿主菌 | Screen for mutator strains in case of doubt 如有疑问，筛查变异菌株 | No mutator strain 无突变株 | State of the art tests (e.g., fosfomycin and rifampicin Disk Diffusion Tests) [14] 最先进的试验（如磷霉素和利福平盘扩散试验）[ 14] 。 |
| Validated preservation/storage (cryopreservation, freeze-drying,..) 经过验证的保存/贮存（低温保存、冷冻干燥……） | Monitor storage conditions (e.g., temperature) 监控储存条件（如温度） | Variable, depending on the preservation method 因保存方法而异 | Variable (e.g., temperature probes, temperature indicator labels,..) 变量（如温度探针、温度指示标签等） |
| C.2. Bacteriophages (Master Seed lots) C.2.噬菌体（原种批次） | |||
| Origin 起源 | Document bacteriophage pedigree/history (e.g., isolation source) 记录噬菌体的血统/历史（如分离来源） | • Known origin – 已知来源 | Screening of scientific literature, lab books, consignment letters,… 筛选科学文献、实验室书籍、托运信件、… |
| • Natural or naturally evolved bacteriophages – 天然或自然进化的噬菌体 | |||
| Identification 身份验证 | • Identification at the family (subfamily), genus and species and strain level – 科（亚科）、属、种和菌株一级的鉴定 | Matching identification, morphology and biology 匹配识别、形态和生物学 | • State of the art DNA or RNA sequencing and analysis procedures – 最先进的 DNA 或 RNA 测序和分析程序 |
| • Morphology and biology – 形态学和生物学 | • Highly discriminating genotyping techniques (e.g., AFLP, fRFLP [15])b – 高分辨基因分型技术（如 AFLP、fRFLP [ 15]) b | ||
| • State of the art classification according to the International Committee on Taxonomy of Viruses (ICTV) – 根据国际病毒分类委员会（ICTV）进行的最新分类 | |||
| • State of the art electron microscopy (optional)c – 最先进的电子显微镜（可选） c | |||
| • One step growth curve [16] – 一步式增长曲线 [ 16］ | |||
| Not containing potentially damaging genetic determinants (e.g., conferring toxicity, virulence, lysogeny or antibiotic resistance) 不含潜在的破坏性基因决定因子（例如，赋予毒性、毒力、溶解性或抗生素抗性的基因决定因子）。 | Genome analysis for known potentially damaging genetic determinants 对已知的潜在破坏性基因决定因素进行基因组分析 | Absence of potentially damaging genetic determinantsd 不存在可能造成损害的遗传决定因素 d | • State of the art DNA or RNA sequencing and genome analysis (bioinformatics) procedures – 最先进的 DNA 或 RNA 测序和基因组分析（生物信息学）程序 |
| Non-transducing (optional) [17] 非转换（可选） [ 17] | Screen for ‘general transduction’ 筛选 “一般转导 | Does not pack random host DNA in a portion of progeny phage particlese 不会在后代噬菌体颗粒的一部分中随机添加宿主 DNA e | Transduction assay [18] 转导试验 [ 18］ |
| In vitro efficacy 体外疗效 | Determination of host range on a panel of target species (reference) strains 确定目标物种（参考）菌株的宿主范围 | Broad host range (if possible) 广泛的主机范围（如果可能） | • Titration of bacteriophages against target bacteria according to the soft-agar overlay method [19] – 根据软琼脂覆盖法滴定噬菌体对目标细菌的抗药性[ 19］ |
| Variable threshold according to species (e.g., 根据物种的不同，阈值也不同（例如：”……”）、 | |||
| >75% for Staphylococcus aureus) 金黄色葡萄球菌 >75%) | • Spot test [16] – 现场测试 [ 16］ | ||
| Stability of lysis (optional)f 裂解的稳定性（可选） f | Stable lysis in broth culture for 24–48 h 在肉汤培养中稳定裂解 24-48 小时 | Appelmans method [20] 阿佩尔曼斯法[ 20］ | |
| Efficiency of plating (EOP) under conditions similar to eventual clinical application (optional) 在与最终临床应用类似的条件下的电镀效率（EOP）（可选） | Threshold EOP value 阈值 EOP 值 | EOP determination [19] 确定 EOP [ 19] | |
| Determination of frequency of emergence of phage-resistant bacteria 确定抗噬菌体细菌出现的频率 | Low frequency of emergence of resistance 出现抗药性的频率低 | Method described by Adams [19] 亚当斯描述的方法[ 19］ | |
| Improvement / adaptation / ‘training’ (if warranted) 改进/调整/”培训”（如有必要） | Optimization of host range 优化主机范围 | Broadened and stable host range 扩大并稳定寄主范围 | • Titration of bacteriophages against target bacteria according to the soft-agar overlay method [16] – 根据软琼脂覆盖法滴定噬菌体对目标细菌的抗药性[ 16] 。 |
| • Spot test [16] – 现场测试 [ 16］ | |||
| Validated preservation/storage (cryopreservation, freeze-drying,..) 经过验证的保存/贮存（低温保存、冷冻干燥……） | Monitor storage conditions (e.g., temperature) 监控储存条件（如温度） | Variable, depending on the preservation method 因保存方法而异 | Variable (e.g., temperature probes, temperature indicator labels,..) 变量（如温度探针、温度指示标签等） |
| C.3. Bacteriophages (Working Seed lots/Active Substances) C.3.噬菌体（工作种子批次/活性物质） | |||
| Quantitative determination of active substance (bacteriophages) 活性物质（噬菌体）的定量测定 | Bacteriophage titration 噬菌体滴定 | Variable. Typically log(8) – log(10) plaque forming units (pfu)/ml 变量。通常为 log(8) – log(10) 斑块形成单位 (pfu)/ml | Soft-agar overlay method [19] 软琼脂覆盖法[ 19］ |
| Identification of active substance 活性物质的鉴定 | Genomic fingerprinting 基因组指纹识别 | Matching genomic fingerprint (max. deviation depends on method) 匹配基因组指纹（最大偏差取决于方法） | State of the art genotyping techniques (e.g., AFLP, fRFLP [15]) 最先进的基因分型技术（如 AFLP、fRFLP [ 15]) |
| Microbial contamination 微生物污染 | Sterility (when there is no sense of urgency)g 不育症（当没有紧迫感时） g | Sterile (absence of micro-organisms) 无菌（无微生物） | Membrane filtration method based on the European Pharmacopoeia (EP) 基于《欧洲药典》（EP）的膜过滤法 |
| Absence of pathogens (when there is a sense of urgency) 无病原体（当有紧迫感时） | Aseptic (absence of pathogens) 无菌（无病原体） | State of the art clinical microbiology methods 最先进的临床微生物学方法 | |
| Toxicity 毒性 | Bacterial endotoxin or lipopolysaccharides (LPS) quantification [21] 细菌内毒素或脂多糖（LPS）定量[ 21] 。 | Depends on posology and method and route of administration. The maximum level for intravenous applications for pharmaceutical and biological products is set to 5 endotoxin units per kg of body weight per hour (EP). 取决于体位、给药方法和途径。药物和生物制品静脉注射的最高浓度为每公斤体重每小时 5 个内毒素单位（EP）。 | Limulus Amebocyte Lysate (LAL) assay according to the EP (e.g., kinetic-QCL method) 根据 EP（如动力学-QCL 法）进行的鹅卵石卵母细胞裂解液（LAL）检测 |
| Bacterial DNA contaminationh 细菌 DNA 污染 h | Screen for (potentially damaging) host bacterial DNA 筛选（可能造成破坏的）宿主细菌 DNA | Absence of potentially damaging genetic determinants that are known to be present in the host bacterium 不含宿主细菌中已知的具有潜在破坏性的基因决定因子 | Methods for the quantification of bacterial DNA in general (e.g., PicoGreen) or for the quantification of known DNA sequences (e.g., qPCR) 细菌 DNA 的一般定量方法（如 PicoGreen）或已知 DNA 序列的定量方法（如 qPCR）i |
| Acidity or basicity of aqueous solution 水溶液的酸碱性 | pH measurement pH 值测量 | Variable (typically 6,5–7,5) 可变（通常为 6,5-7,5） | pH test (EP method) pH 值测试（EP 法） |
| Purity 纯净 | Clarity of phage solution 噬菌体溶液的透明度 | Absence of visible particles 无可见颗粒 | EP method, CPMP-ICH guideline EP 方法，CPMP-ICH 指南 |
| Validated preservation/storage (cooling, cryopreservation, freeze-drying,..) 经过验证的保存/贮藏（冷却、低温保存、冻干……） | Monitor/record/demonstrate storage conditions (temperature,..) 监控/记录/演示存储条件（温度等） | Variable (e.g., 2–8°C) 可变（例如，2-8°C） | Variable (e.g., temperature probes, temperature indicator labels,..) 变量（如温度探针、温度指示标签等） |
| C.4. Finished products C.4.成品 | |||
| Bulk products may be diluted (typically to log(5)–log(7) pfu/ml), combined or added to a carrier (hydrogel, ointment, cream, bandage,..) prior to clinical use. Dilution solutions, carriers and packaging materials must meet documented requirements and specifications and when applicable the requirements of Council Directive 93/42/EEC of 14 June 1993 concerning medical devices. Carriers must be chosen that allow the required phage activity during the intended application period (stability). 批量产品在临床使用前可稀释（通常稀释至 log(5)-log(7) pfu/ml）、合并或添加到载体（水凝胶、软膏、霜剂、绷带等）中。稀释溶液、载体和包装材料必须符合文件要求和规格，并在适用时符合 1993 年 6 月 14 日关于医疗器械的理事会指令 93/42/EEC 的要求。选择的载体必须能够在预期的应用期间（稳定性）保持所需的噬菌体活性。 | |||
| The following information must be provided either on the label or in accompanying documentation: (a) description (definition) and, if relevant, dimensions of the bacteriophage product; (b) date of production of the bacteriophage product (c) storage recommendations; (d) instructions for opening the container, package, and any required manipulation/reconstitution; (e) expiration dates (incl. after opening/manipulation); (f) instructions for reporting serious adverse reactions and/or events; (g) presence of potentially harmful residues (e.g., antibiotics, ethylene oxide); (h) contraindications; (e) how to dispose of unused (expired) bacteriophage products. 标签上或随附文件中必须提供以下信息：(a) 说明（定义）和噬菌体产品的尺寸（如相关）；(b) 噬菌体产品的生产日期；(c) 储存建议；(d) 打开容器、包装和任何必要的操作/更换的说明；(e) 到期日（包括打开/操作后）；(f) 报告严重不良反应和/或事件的说明；(g) 是否存在潜在的有害残留物（如抗生素、环氧乙烷）；(h) 禁忌症；(e) 如何处置未使用（过期）的噬菌体产品、(e) 如何处置未使用（过期）的噬菌体产品。 | |||
| Validated storage (cold storage,..) 验证存储（冷藏等） | Monitor/record/demonstrate storage conditions (temperature,..) 监控/记录/演示存储条件（温度等） | Variable (e.g., 2–8°C) 可变（例如，2-8°C） | Variable (e.g., temperature probes, temperature indicator labels,..) 变量（如温度探针、温度指示标签等） |
| D. Shelf life of phage stock suspensions, working solutions and finished products (at recommended storage conditions) D.噬菌体悬浮液、工作溶液和成品的保质期（建议的储存条件下） | |||
| Stability 稳定性 | • Periodic quantitative determination of the active substances (bacteriophages) or breakdown products – 活性物质（噬菌体）或分解产物的定期定量测定 | The shelf life is the time period during which the product remains sterile and the activity and pH remain within specified limit thresholds 保质期是指产品保持无菌状态、活性和 pH 值保持在规定限值范围内的时间段。 | • Soft-agar overlay method [15] – 软琼脂覆盖法 [ 15] |
| • Periodic determination of sterility – 定期测定无菌状态 | • CPMP-ICH guideline, Q5C, Q1A – CPMP-ICH 准则、Q5C、Q1A | ||
| • Periodic pH measurements – 定期测量 pH 值 | • Membrane filtration method (EP method) – 膜过滤法（EP 法） | ||
| • pH test (EP method) – pH 值测试（EP 法） | |||
| E. Surveillance E.监视 | |||
| The clinical use of phage therapy products must be surveyed and reported, including possible adverse events and reactions associated with the use of phage therapy products. A centralized (publicly available) reporting system is warranted. 必须对噬菌体治疗产品的临床使用情况进行调查和报告，包括与使用噬菌体治疗产品相关的可能的不良事件和反应。有必要建立一个集中（公开）报告系统。 | |||
- aToday it may be impossible to successfully cure some host strains that are indispensable for the production of some therapeutically interesting phages. In addition, in some cases it might be necessary to use phages that were isolated from the patient’s bacteria and that are not able to replicate in known host strains devoid of prophages. However, since that sort of phage preparations are only designed to be used in that given patient, any remaining traces of DNA from that host bacterium would be orders of magnitude less than the amount already present in the patient from whom that bacterium was isolated for this purpose
a 如今，我们可能无法成功治愈某些宿主菌株，而宿主菌株是生产某些具有治疗意义的噬菌体所不可或缺的。此外，在某些情况下，可能有必要使用从患者细菌中分离出来的噬菌体，这些噬菌体无法在没有噬菌体的已知宿主菌株中复制。然而，由于这种噬菌体制剂只设计用于特定患者，因此从宿主细菌中残留的任何 DNA 微量都会比为此目的从患者体内分离细菌时已经存在的数量少得多。 - bThis genetic fingerprint can be used to timely identify bacteriophages and confirm their presence in Working Seed lots and in finished products, without having to re-perform full genome sequencing. It is however expected that fast, low-cost and accurate full genome sequencing and analysis (of bacteriophages) will replace routine microbial genotyping techniques in the near future
b 这种基因指纹图谱可用于及时识别噬菌体，并确认它们是否存在于工作种子批次和成品中，而无需重新进行全基因组测序。不过，预计在不久的将来，快速、低成本、准确的全基因组测序和分析（噬菌体）将取代常规的微生物基因分型技术。 - cIn some cases (e.g., novel bacteriophages with no homology in databases), electron microscopy could provide important information and could thus be warranted
c 在某些情况下（例如，数据库中没有同源物的新型噬菌体），电子显微镜可以提供重要信息，因此有必要这样做 - dIn general, it is recommended to only use lytic phages (and no temperate phages) in phage therapy. Lytic phages are more potent killers of host bacteria, making them more effective in therapy than temperate phages. Following lysogenic induction, temperate phages may transfer fragments of host bacterial DNA into non-targeted bacteria (possibly belonging to other species). This phenomenon is called transduction or phage-mediated horizontal gene transfer (HGT). If these DNA fragments contain toxin-encoding or antibiotic resistance-mediating genes, temperate phages could thus produce new pathogenic strains. However, in the future, the dogma that the use, in treatment, of temperate phages is impossible or undesirable because of the danger of HGT might be abandoned in certain circumstances (science- and risk-based decision, taking into consideration the patients’ needs). In certain bacterial species, the number of strictly virulent phages is small and it might not be possible to isolate adequate new virulent phages in due time. Phage mediated HGT is abundant and virtually ubiquitous in bacterial populations and the additional and immediate danger to the patient related to the use of temperate phages in the course of phage therapy (days) is bound to be limited. Moreover, if a temperate phage acts as a lytic phage in relation to a particular pathogen, the probability of HGT might not be higher than for inherent genetic virulent phages [22]. In the future, temperate phages might specifically be used in therapy, e.g., to introduce, by lysogenization, genes conferring sensitivity to antimicrobials [23] or to inhibit virulence traits [24]. Finally, antibiotic stress was also shown to induce genetic transformability in human pathogens [25]
d 一般来说，建议在噬菌体疗法中只使用溶菌噬菌体（而不使用温性噬菌体）。溶解性噬菌体对宿主细菌的杀伤力更大，因此在治疗中比温性噬菌体更有效。溶菌诱导后，温和噬菌体可能会将宿主细菌的 DNA 片段转移到非目标细菌（可能属于其他物种）中。这种现象被称为转导或噬菌体介导的水平基因转移（HGT）。如果这些 DNA 片段含有毒素编码基因或抗生素抗性介导基因，温带噬菌体就可能因此产生新的致病菌株。不过，在未来的某些情况下，由于 HGT 的危险性而不可能或不应该使用温带噬菌体进行治疗的教条可能会被放弃（以科学和风险为基础的决定，同时考虑到病人的需求）。在某些细菌物种中，严格意义上的毒性噬菌体数量很少，可能无法及时分离出足够的新毒性噬菌体。噬菌体介导的 HGT 在细菌种群中大量存在，几乎无处不在，因此在噬菌体疗法过程中使用温带噬菌体（天数）对患者造成的额外和直接危险必然有限。此外，如果温带噬菌体在特定病原体中充当溶菌噬菌体，那么发生 HGT 的概率可能并不比固有基因毒性噬菌体高[ 22]。未来，温带噬菌体可能会被专门用于治疗，例如，通过溶菌作用引入对抗菌素敏感的基因[23]或抑制毒力特征[24]。最后，抗生素压力也被证明可以诱导人类病原体的基因转化能力[25]。 - eToday, it is not feasible to exclude the possibility of low levels of generalized transduction by therapeutic phages into any of the infecting and commensal bacteria present in or on the patient. The use in phage therapy of phages that mediate some random general transduction might be considered in certain circumstances (science- and risk-based decision, taking into consideration the patients’ needs)
e 如今，排除治疗用噬菌体对患者体内或身上的任何感染菌和共生菌进行低水平一般性转导的可能性是不可行的。在某些情况下，可以考虑在噬菌体疗法中使用介导某些随机普遍转导的噬菌体（以科学和风险为基础的决定，同时考虑到患者的需求）。 - fIn some cases, phages that produce stable lysis will not be found in a timely fashion. Phages that induce relatively fast in vitro bacterial resistance might then be considered
f 在某些情况下，无法及时找到能产生稳定裂解的噬菌体。这时，可以考虑使用能诱导相对较快的体外细菌抗药性的噬菌体 - gIn some cases, sterility may not be required (e.g., ‘non-sterile for topical application’)
g 在某些情况下，可能不要求无菌（例如，”非无菌局部应用”）。 - hWorking Seed lots can be contaminated with low levels of DNA derived from the host bacteria used in production. Potentially damaging genetic determinants (e.g., conferring toxicity, virulence or antibiotic resistance) might then be transferred (through transformation) to bacteria present in or on the patient, which could potentially make them (more) pathogenic. While this would be expected to occur at a level well below exchanges already going on within the patient’s body involving their own pathogenic bacteria and phages already resident it makes sense to select hosts that are as devoid of pathogenicity factors as reasonably possible for growing therapeutic phage and treating the phage with DNase in the course of their purification to destroy such contaminants. If no non-pathogenic bacterial strain is available for growing the phage, constructing a ‘defanged’ host strain, with all pathogenicity determinants deleted, could be envisaged as the best main step in avoiding this issue. Note that the use of non-pathogenic host bacterial strains also reduces the potential hazard to the personnel involved in the production of therapeutic phages
h 工作种子批次可能受到来自生产所用宿主细菌的低水平 DNA 污染。具有潜在破坏性的基因决定因素（例如，赋予毒性、毒性或抗生素抗性）可能会（通过转化）转移到患者体内或身上的细菌，从而可能使它们（更具）致病性。虽然预计这种情况发生的程度会远远低于病人体内已经发生的涉及其自身致病细菌和噬菌体的交流，但选择尽可能没有致病因子的宿主来培养治疗噬菌体，并在纯化过程中用 DNase 处理噬菌体以消灭这些污染物，是有道理的。如果没有用于培养噬菌体的非致病性细菌菌株，可以设想构建一个 “去势 “宿主菌株，删除所有致病性决定因素，这是避免这一问题的最佳主要步骤。需要注意的是，使用非致病性宿主菌株还能减少对参与生产治疗用噬菌体的人员的潜在危害。 - iA threshold level should be determined. Note that some DNA quantification methods might also pick up phage DNA
i 应确定一个阈值水平。请注意，某些 DNA 定量方法可能也会检测到噬菌体 DNA