Bacteriophage–Antibiotic Combination Therapy with Wound pH Monitoring in Resistant Purulent Surgical Infections: A Three-Case Series

Authors

DOI:

https://doi.org/10.66636/gmj.v1.i2.a117

Keywords:

bacteriophage therapy, antimicrobial resistance, surgical wound infection, biofilm, wound pH, Fournier gangrene, mediastinitis, Pseudomonas aeruginosa, Staphylococcus aureus, combination therapy

Abstract

Background Antimicrobial resistance and biofilm-associated persistence increasingly limit conventional antibiotic therapy in complex surgical wound infections. Adjunctive bacteriophage therapy and wound microenvironment monitoring represent emerging strategies whose real-world clinical evidence in severe surgical infections remains limited.

Methods We performed a retrospective descriptive three-case series in a tertiary surgical inpatient setting at the Eliava Phage Therapy Center (Tbilisi, Georgia) over the period 1 January 2024 to 1 January 2026. Adult patients with severe purulent surgical wound infections received an integrated regimen of staged surgical debridement, culture-directed systemic antibiotics, daily local application of a polyvalent bacteriophage preparation (Pyo phage, 10 mL/day), and adjunctive antiseptic wound care. Wound exudate pH was measured daily with calibrated indicator strips. Outcomes assessed included infection control, granulation, inflammatory markers, and dynamic changes in wound pH. Reporting follows the CARE 2017 guidelines.

Results Three patients (two men aged ≥60 years and one woman aged ≥64 years) presented with post-amputation necrotic wound infection, Fournier gangrene, and post-sternotomy mediastinitis, respectively. Cultured pathogens were Pseudomonas aeruginosa (Cases 1 and 3) and methicillin-sensitive Staphylococcus aureus (Case 2). Initial wound exudate pH ranged from 7.8 to 8.5 during active infection and declined to 6.5–7.0 during clinical recovery in all cases. Bacteriophage was administered for 18–23 days. All patients achieved infection control, healthy granulation, and no recurrence at follow-up; two underwent secondary reconstruction.

Conclusion In this case series, integrated bacteriophage–antibiotic therapy combined with surgical source control was associated with favourable clinical recovery in resistant purulent surgical infections. Wound exudate pH normalisation accompanied clinical improvement and may serve as a simple, low-cost adjunctive marker of treatment response. Prospective controlled studies are required to establish causality and standardise protocols.

Keywords bacteriophage therapy; antimicrobial resistance; surgical wound infection; biofilm; wound pH; Fournier gangrene; mediastinitis; Pseudomonas aeruginosa; Staphylococcus aureus; combination therapy

References

1. World Health Organization. Global antimicrobial resistance and use surveillance system (GLASS) report 2022. Geneva: World Health Organization; 2022. https://www.who.int/publications/i/item/9789240062702

2. Murray CJL, Ikuta KS, Sharara F, Swetschinski L, Robles Aguilar G, Gray A, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629–55. https://doi.org/10.1016/S0140-6736(21)02724-0

3. Yarahmadi A, Najafiyan H, Yousefi MH, Khosravi E, Shabani E, Afkhami H, et al. Beyond antibiotics: exploring multifaceted approaches to combat bacterial resistance in the modern era. Front Cell Infect Microbiol. 2025;15:1493915. https://doi.org/10.3389/fcimb.2025.1493915

4. Baquero F, Martínez JL, Lanza VF, Rodríguez-Beltrán J, Galán JC, San Millán A, et al. Evolutionary pathways and trajectories in antibiotic resistance. Clin Microbiol Rev. 2021;34(4):e00050-19. https://doi.org/10.1128/CMR.00050-19

5. Bjarnsholt T, Whiteley M, Rumbaugh KP, Stewart PS, Jensen PØ, Frimodt-Møller N. The importance of understanding the infectious microenvironment. Lancet Infect Dis. 2022;22(3):e88–92. https://doi.org/10.1016/S1473-3099(21)00122-5

6. Malone M, Bjarnsholt T, McBain AJ, James GA, Stoodley P, Leaper D, et al. The prevalence of biofilms in chronic wounds: a systematic review and meta-analysis of published data. J Wound Care. 2017;26(1):20–5. https://doi.org/10.12968/jowc.2017.26.1.20

7. Almatroudi A. Biofilm resilience: molecular mechanisms driving antibiotic resistance in clinical contexts. Biology (Basel). 2025;14(2):165. https://doi.org/10.3390/biology14020165

8. Tong SYC, Davis JS, Eichenberger E, Holland TL, Fowler VG Jr. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev. 2015;28(3):603–61. https://doi.org/10.1128/CMR.00134-14

9. Percival SL, McCarty S, Hunt JA, Woods EJ. The effects of pH on wound healing, biofilms, and antimicrobial efficacy. Wound Repair Regen. 2014;22(2):174–86. https://doi.org/10.1111/wrr.12125

10. Gethin G. The significance of surface pH in chronic wounds. Wounds UK. 2007;3(3):52–6.

11. Pinto AM, Cerqueira MA, Bañobre-Lópes M, Pastrana LM, Sillankorva S. Bacteriophages for chronic wound treatment: from traditional to novel delivery systems. Viruses. 2020;12(2):235. https://doi.org/10.3390/v12020235

12. Gordillo Altamirano FL, Barr JJ. Phage therapy in the postantibiotic era. Clin Microbiol Rev. 2019;32(2):e00066-18. https://doi.org/10.1128/CMR.00066-18

13. Golkar Z, Bagasra O, Pace DG. Bacteriophage therapy: a potential solution for the antibiotic resistance crisis. J Infect Dev Ctries. 2014;8(2):129–36. https://doi.org/10.3855/jidc.3573

14. Alaoui Mdarhri H, Benmessaoud R, Yacoubi H, Seffar L, Guennouni Assimi H, Hamam M, et al. Alternative therapeutic approaches to conventional antibiotics: advantages, limitations and potential application in medicine. Antibiotics (Basel). 2022;11(12):1826. https://doi.org/10.3390/antibiotics11121826

15. Abedon ST, Kuhl SJ, Blasdel BG, Kutter EM. Phage treatment of human infections. Bacteriophage. 2011;1(2):66–85. https://doi.org/10.4161/bact.1.2.15845

16. Knezevic P, Obreht D, Curcin S, Petrusic M, Aleksic V, Kostanjsek R, et al. Phages of Pseudomonas aeruginosa: response to environmental factors and in vitro ability to inhibit bacterial growth and biofilm formation. J Appl Microbiol. 2011;111(1):245–54. https://doi.org/10.1111/j.1365-2672.2011.05043.x

17. Jończyk-Matysiak E, Łodej N, Kula D, Owczarek B, Orwat F, Międzybrodzki R, et al. Factors determining phage stability/activity: challenges in practical phage application. Expert Rev Anti Infect Ther. 2019;17(8):583–606. https://doi.org/10.1080/14787210.2019.1646126

18. Wang R., Yeh Y-J, An Y-N., Virly, Engineering pH-sensitive erodible chitosan hydrogel composite containing bacteriophage: An interplay between hydrogel and bacteriophage against Staphylococcus aureus. International Journal of Biological Macromolecules, 2023. https://doi.org/10.1016/j.ijbiomac.2023.127371

19. Riley DS, Barber MS, Kienle GS, Aronson JK, von Schoen-Angerer T, Tugwell P, et al. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol. 2017;89:218–35. https://doi.org/10.1016/j.jclinepi.2017.04.026

20. Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Fournier’s gangrene: a clinical review. Arch Ital Urol Androl. 2016;88(3):157–64. https://doi.org/10.4081/aiua.2016.3.157

21. Abu-Omar Y, Kocher GJ, Bosco P, Barbero C, Waller D, Gudbjartsson T, et al. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg. 2017;51(1):10–29. https://doi.org/10.1093/ejcts/ezw326

Cover of the Georgian Medical Journal (GMJ), Volume 1, Issue 2 (2026), titled “Health Systems Performance and Quality of Care: Measurement, Improvement, and Outcomes,” with a blue world map background representing global health connectivity. Includes the themes “Quality, Safety, Results” and the publisher Public Health Institute of Georgia.

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05/07/2026

How to Cite

Mishidze, I., Chanishvili, N., Gelashvili, S., & Arabidze, G. (2026). Bacteriophage–Antibiotic Combination Therapy with Wound pH Monitoring in Resistant Purulent Surgical Infections: A Three-Case Series: . Georgian Medical Journal, 1(2), 1–14. https://doi.org/10.66636/gmj.v1.i2.a117

Issue

Vol. 1 No. 2 (2026): Health Systems Performance and Quality of Care

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Case Reports

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Copyright (c) 2026 Irakli Mishidze, Nina Chanishvili, Salome Gelashvili, Gela Arabidze

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