The “antibiotic pipeline” had a tremendous growth in the late 20
th century and since the beginning of 21
st century, the pipeline is experiencing a long lag phase owing to the evolution of antimicrobial resistance leaving drugs like tigecycline, carbapenems and colistin as last resort drugs to treat infections caused by MDR pathogens [
48]. Resistance to these drugs have also evolved and hence search for an alternative or adjunct therapy is the need of hour. Desperate need to tackle this situation has reminded the researchers of a century-old bacteriophage therapy. Felix d’ Herelle, who identified and termed bacteriophages, was the first to use phage to clinically treat bacterial dysentery in 1919 [
49]. Another trial phage therapy was carried out by him on the people of Punjab, India to treat cholera and found a 90% reduction in mortality [
50]. Nevertheless, owing to various controversies and rapid progress in the development of antibiotics pushed phage therapy behind. However, rising antibiotic resistance has re-kindled the interests towards bacteriophages. Bacteriophages have been reported against different pathogenic strains of Pseudomonas aeruginosa, Clostridium difficile, Vibrio parahemolyticus, Staphylococcus aureus, Acinetobacter baumannii, E. coli and Klebsiella pneumoniae, individually or in combination with antibiotics, thus favoring reuse of antibiotics [
48]. In this study, we have isolated phages targeting MDR E. coli clinical isolate (U1007) that is resistant to multiple antibiotics belonging to 7 different classes (
Table S2), including carbapenems and is ESBL positive (
Figure S11B) and hence falls under the critical priority pathogen list as designated by WHO [
51]. Attempts to identify phages against another colistin resistant E. coli U3790 was unsuccessful owing to the presence of the capsule as reported earlier and also due to the intact prophages within its genome [
42]. Prophages in bacterial genome can evolve mechanisms like blocking phage genome injection, blocking phage binding and preventing the interaction of phage receptor on the bacterial membrane to evade superinfection by other related phages, though the exact mechanism is still not known [
52]. Nevertheless, bacteriophages targeting MDR E. coli U1007 were isolated from The Ganges River (designated as U1G), Cooum River (CR) and Hospital Waste water(M) (
Figure S1). We recently reported a phage KpG, belonging to Podoviridae, specific to MDR K. pneumoniae from Ganges, which was able to curtail the host’s planktonic and biofilm mode of growth [
53]. There are other numerous reports available on rich diversity of bacteriophages against various pathogens being isolated from The Ganges [
54,
55]. This is attributed to the origin of Ganges The Himalayan permafrost, which has trapped bacteriophages from a long period and is released gradually while melting and hence it forms a seed source of bacteriophage [
56]. Both Cooum River and Hospital wastewater are likely to harbor a lot of MDR bacteria. Depending upon the origin hospital waste water is likely to harbor MDR microbes from 0.58 to 40 % [
57] As the prevalence of drug resistant microbes are likely to be higher in hospital wastewater, the propensity to harbor phages that target drug resistant microbes are also high. TEM imaging revealed that U1G belongs to the Podoviridae family, containing an icosahedral head of mean diameter 71.68 nm and a short non-contractile tail. Whereas CR phage possessed a shorter head of 31.64 nm and a moderate tail of 24.37 nm and is likely to belong to Myoviridae. On the other hand M phage had a head of 54 nm and a long tail of 104 nm (
Figure 1) hence it probably belongs to Siphoviridae. Thus in this study we had successfully isolated phages belonging to three different families yet targeting the same host. A recent study has shown that nettle manure harbored phages belonging to Siphoviridae and Podoviridae targeting the same plant pathogen Pseudomonas syringae pv. tomato [
58]. However, genome analysis of U1G by PHASTER revealed the presence of RNA polymerase and hence U1G is deemed under Schitoviridae. Reports show that by 2020 there were only 115 members that were classified under this newly proposed family Schitoviridae [
43]. Interestingly we also observed during whole genome BLAST analysis (
Table S4) that a prophage in Enterococcus faecium strain ME3 chromosome displayed 95.94 % identity (with 91% coverage and e-value of 0) with U1G phage genome but the presence and probable expression of antirepressor protein in U1G (
Figure 2) might favor its lytic life cycle. Presence of a highly homologous prophage genome in Enterococci imply that U1G might possibly use Enterococcus faecium as a host, we tried to infect a reference strain of Enterococcus faecium with U1G using spot test, our attempts to infect was unsuccessful probably because genome harbored prophage prevents super infection by a similar phage. One step growth data showed that U1G possessed a burst size of 124 PFU/cell and a latent period of 25 min. M phage also exhibited a shorter latent period of 20 min but its burst size was 150 PFU/cell Whereas CR phage had a short burst size of 114 PFU/cell (
Figure S5). The exponential growth of phage and its lytic efficiency is majorly dependent on latent period and burst size. Larger burst size usually results from a long latent period and vice versa. However, a phage with shorter latent period and relatively good burst size possesses an enhanced capability to lyse host cells faster [
59]. Thus among the 3 phages employed M phage has both a short latent period and a relatively high burst size (
Figure S5). Experimental evidences and predictive modeling indicate that host cell densities and phage latent periods are inversely related and phages could be evolving towards a latent period optimum which tends to maximize the population of phages that grows in the presence of a specific quality and quantity of host cells [
59]. Host specificity assay revealed that all three phages U1G, CR and M were highly specific to its host U1007 and U1G displayed a faint lysis zone against U3790 whereas CR and M phage displayed faint lysis against U2354 strain (
Figure S6). No clearance or appearance of plaques were seen for clinical isolates, including the reference strain MG1655. As U1G exhibited a faint zone against another colistin resistant strain U3790, this led to a hypothesis that the phage U1G might be specific to colistin resistant E. coli and does not affect colistin sensitive strains of E. coli which includes both pathogens or commensals. As colistin resistance confers chemical alteration to LPS [
60], it is likely that altered LPS could serve as a receptor for phage entry, which was also predicted by ML algorithm (
Table 2). Previous report showed that a panel of colistin resistant K. pneumoniae were more susceptible to lytic phage, isolated from sewage water, than to their respective colistin susceptible strains [
61]. The isolated phages were observed to be negatively charged and since colistin resistant strains possess reduced cell surface negative charge, electrostatic interaction might have favored the enhanced susceptibility of colistin resistant strains to the phages[
61]. In the current study, we employed a machine learning-based approaches for host receptor prediction, specifically based on the RBP sequence. To the best of our knowledge, this is the first reported study on host receptor prediction utilizing this ML-based approach. Most studies primarily focus on predicting the hosts of bacteriophages rather than the receptors [
36,
62]; The advantage of using machine learning tools to predict host cell surface receptors is that it will reduce significant time and labor as conventional phage adsorption studies to identify host receptor will involve laborious screens with large mutant libraries and for clinical isolates such mutant libraries needs to be created first which is cumbersome [
63]. Machine learning tools will considerably reduce the labor by pinning down on a handful of putative receptors for which knock outs (even in clinical isolates) can potentially be developed and screened. Random forest algorithm using all sequence features and features based on ANOVA approach identified LPS O antigen as the host receptor employed by the phage tail protein for entry into the host. As LPS O antigen knock outs are difficult to generate in an isogenic background, we attempted to physiologically validate other receptor(s) that are predicted by the other feature selection approach. Random forest algorithm (upon L2 regularization) identified OmpC as one of the host cell surface receptors for U1G phage. As OmpC expression is modulated by medium osmolality [
44,
45], to validate the role of OmpC as a host cell surface receptor, U1G phage was exposed to cells grown under conditions that either upregulate OmpC (high osmolality) or downregulate OmpC (low osmolality) and equal ratio of phages to bacterial cells were maintained for both treatments and the results showed that phage titers were indeed high when OmpC is upregulated (
Figure 4) this validates the prediction by RF algorithm (
Table 2) that OmpC is the host cell surface receptor for the U1G phage. Future studies will attempt to create knock outs of predicted receptors (LPS O antigen, LamB, FhuA, OmpC, OmpF, TonB) in isogenic (U1007) background and reaffirm predictions of host cell surface receptors made by ML algorithms for all the three phages. The current ML algorithm takes into account only the nucleotide and protein sequence features of RBPs. However, further enhancements can be made by incorporating structural features once the relevant data becomes available[
64]. Relative to CR and M phages, U1G phage was more thermostable and it retained 50 % viability at 65°C (Fig S7). Conversely M and CR phage displayed greater viability in alkaline pH relative to U1G phage (Fig S8). Interestingly, pH is also known to affect the expression of OmpC [
65]. A previous report has shown that acidic pH stimulates OmpC whereas alkaline pH stimulates OmpF [
64] as OmpC is the receptor employed by U1G, reduced phage titers at alkaline pH for U1G might as well be attributed to reduced expression of OmpC at alkaline pH.
In vitro time kill study with Phage combinations, individually and in combination with colistin showed that phage combination along with colistin showed better ability in restricting regrowth relative to treatment with monophages (
Figure 5). Usually one would expect a drastic reduction when using phage combinations, as all three phages belonged to different families as evident from the morphology (Fig 1). But phylogenetic analysis based on genome similarity showed that U1G is distinct from CR and M which are quite closely related to each other (
Figure 3). Earlier studies have shown that co-infection by different phages on the same host might result in smaller burst size and infection exclusion [
66] which might account for the relatively lower titers observed in triple phage combinations.LPS O antigen is predicted as one of the targets for the phages by ML tools (
Table 2), alteration of O antigen is a common phenomenon so bacteria gaining resistance to U1G is possible which necessitates the use of phage cocktails. It is likely that the bacteria during its attempt to develop phage resistance might partially lose resistance to colistin and hence the combination can achieve enhanced killing than when individually treated. Zebrafish model has been used to study the efficiency of bacteriophages in curtailing infections caused by P. aeruginosa, K. pneumoniae, E. coli and E. faecalis[
53,
67,
68,
69]. Nevertheless, the majority of studies have compared the effect of antibiotics and phage therapy and very few reports have studied the combination of antibiotic and phage therapy. In our earlier study, we found that the combination of Streptomycin and KpG (Podoviridae phage specific to K. pneumoniae) curtailed the infection by 98% relative to untreated control, whereas KpG alone caused 77% reduction and only streptomycin resulted in 63% reduction in colony counts [
53]. In the present study, a drastic improvement in phage titers of upto 2.2 log CFU was observed when bi-phage (U+M) combination was used along with colistin relative to bi-phage treatment alone in fish infection study (Fig 6). A similar trend was not observed when all three phages were used in combination with colistin, which resulted in modest 0.5 log CFU difference between phage cocktails with and without colistin (
Figure 6).Enhanced phage activity in the presence of subinhibitory concentrations of antibiotic termed as phage antibiotic synergy (PAS) as reported by Comeau et al., 2007 [
70] was observed by many others as reviewed by North et al.,2019 [
71] and is attributed to enhanced burst size or collateral sensitivity to antibiotics due to phage resistance [
72]. Future studies of one step growth curve with sub MIC levels of colistin can unravel whether enhanced burst size triggered by the antibiotic is responsible for PAS observed in the present study. Phage antibiotic combination treatments can reduce rate of resistance evolution to either phage or antibiotic or for both [
73]. In the present study, U1G+CR+M & U1G+M along with colistin caused a significant 3.0 and 3.5 log decline respectively (
Figure 6), which reaffirms the potential of phage cocktail to restrict bacterial bioburden in vivo and can be potentially evaluated for its efficacy in mammalian models.