Team:WHU-China/Implementation
Implementation
Since our project ‘The Negotiator’ aims at a novel prophylactic strategy for ventilator-associated pneumonia (VAP), the proposed end users are patients in need of ventilation. Both exogenous factors (outside environment, ventilator circuit and endotracheal tube) and endogenous factors (opportunistic pathogens hiding in human microbiota) could contribute to VAP, and invasive mechanical ventilation especially risky. During COVID-19 pandemic, the massive use of ventilators led to a dilemma situation. The mild symptoms of ventilator-associated pneumonia involve chill, fever and cough, while the severe symptoms might lead to death.
The invasive ventilators hurt the respiratory tract, on one hand further impairing the existing immune mechanisms, on the other hand providing pathogens with ample room for proliferation, with horrible results shown in the following CT scanning picture. Besides, VAP was commonly seen in patients with pre-existing chronic cardiopulmonary diseases, long-term use of antibiotics, hormones, anticancer drugs and immunodeficiency. Thus, a friendly and effective prophylactic therapy is demanded, and our ‘negotiators’ manifest these merits.
(Authorized by Yingling college, Junhao)
The envisioned usage of our ‘negotiator’ probiotics is described as follows:
(1) Evaluate the condition of patients to decide whether to use ventilators;
(2) Choose invasive mechanical ventilation or noninvasive mechanical ventilation;
(3) Oral or nasal delivery of negotiator probiotics before ventilation, with the amount
according to doctor’s prescriptions.
(4) Implement ventilation.
Initially, Tongji-China suggested to us a method of probiotic delivery similar to asthma inhaler in
our first meeting. After verifying the feasibility of this pattern by clinical experts, we propose
two more specific delivery methods:
(1) D.P.I., dry powder inhaler
The airflow generated during inhalation is used to send drug powders into the airway and lung
tissue, without the coordination of inhalation and manual control. The amount of drugs entering the
airway and lung tissue is more than that of aerosols, while the amount remaining in the oropharynx
is less than that of aerosols, thus enabling better efficacy and reduced side effects such as
oropharyngeal fungal infection.
(2) Nebulizer
Nebulizer inhalation is powered by compressed air or hyperbaric oxygen and is based on jet
interaction of gas to turn the liquid into mist, which is subsequently inhaled by patients through
face mask. Importantly, nebulizer inhalation can be used by critical patients or children who are
unable to actively breathe.
It’s believed through these two methods, our negotiator probiotics can enter the ‘battleground’-lower respiratory tract, and effectively deal with the tricky gram-negative bacteria and their increasing antimicrobial resistance. Furthermore, coupled with anti-inflammatory drugs (such as anti-IL-6 natural products), the strategy might avoid the potential side effects of over-activated chemotaxis. The feasibility of combinatorial usage will be discussed in the next section.
To develop a clinically potent therapy as well as a commercially feasible product, safety and
security should be the most important factors to consider. Through multiple rounds of discussions,
we recapitulated the biosafety concerns and our corresponding solutions.
Q: How to convince the customers the safety of orally delivered microorganisms?
A: The chassis we used, Escherichia coli Nissle 1917 (EcN), is a nonpathogenic E. coli strain and
one of the best examined probiotic strains. The safety, tolerability, and efficacy of consuming EcN
for curing chronic diseases have also been evaluated. Actually, we learned that the therapy of
orally delivered probiotics had been implemented during COVID-19 to improve dysfunctional gut
microbiota of patients, as Prof. Liu Tiangang introduced.
Q: How long will the probiotics stay in respiratory tract?
A: Recent interests towards microbiome in respiratory tract and their interactions with the host are
increasing, and it’s believed that the mucosa will renew the microbiota in lower respiratory tract
on a regular basis. Thus, our engineered EcN will not have a long-time stay. Additionally, we
discussed the use of suicide switches in the engineered probiotics with Tongji-China and UCAS-China,
to precisely control its staying time.
Q: How to guarantee the gene safety of the GMO products?
A: Two toxin-antitoxin (TA) systems will be constructed within our products, in case of gene
leakage. For instance, MazE and MazF: in our engineered probiotics, the existence of MazE renders
MazF ineffective, and the transfer of plasmids containing MazE will facilitate the suicide of
incomplete probiotics, to prevent the leakage of antibiotic resistance genes and important
modules.
Q: How to illustrate the side effects of ‘The Negotiator’ before clinical trials?
A: We wish to harness precise chemotaxis (both in timing and dosage) to achieve pathogen
eradication. Considering the timing, PQS, the indicator of exacerbated P. aeruginosa infection, is
used; considering the dosage, a TEV protease-guided machinery is created.
However, the actual results are still unpredictable due to the complexity of cytokine interactions. Thus, we want to illustrate our strategies in an organ-simulating chip before animal models and clinical trials. Additionally, the usage of combinatorial drugs can be evaluated by this method, considering some of current probiotic therapies in the market are combinatorial. If expected results are generated with little side effects, we will start our journey for commercialization.
Q: How to keep our products safe, controllable, effective and available, as Prof. Yang Daichang
introduced?
A: We have developed a business plan through collaborations with Tongji-China and UCAS-China, in
which we envision how to manufacture our products in Wuhan with safe and secure management.
Nosocomial infection is one of the most common problems faced by every hospital. In 2010, 35 hospitals in Wuhan investigated 23,441 patients and found the incidence rate and infection rate were 3.37% and 3.54% respectively [4]. Currently, to cope with nosocomial infections, the mainstream therapy is using antibiotics. However, among infections, antimicrobial resistant bacteria were common. According to The Centers for Disease Control and Prevention (CDC), the rate of multi-drug resistant bacteria infections in medical intensive care units (ICU) in the United States is 41.7%; about 23,000 people die each year because of multi-drug resistant bacteria infections, resulting in more than $3.5 billion in socioeconomic losses [2]. Additionally, Carbapenem-resistant Enterobacteriaceae (CRE), Acinetobacter baumannii (CRAB) and Pseudomonas aeruginosa (CRPA) have been identified by the World Health Organization as key R&D requirements [9]. Due to existing limitations, novel therapies need to be developed.
It’s our wish to develop a prophylactic biotic drug for nosocomial infections of gram-negative bacteria, thus a novel pipeline is demanded. In the early stage of pipeline development, our products will be manufactured by qualified OEM companies around Wuhan. As freshmen in entrepreneurship, we lack management experience in industrial pipelines development, so it is necessary to find a suitable contract manufacturer for mass production to both reduce costs and improve efficiency. These merits enhance the competitiveness of our products and enable the research team to focus more on upgrading our products. We envision preliminary pipelines as follows: The manufacturing plan will be formulated based on monthly sales plan and order status. Each pipeline is standardized and recorded to realize the traceability of product quality. QC department will monitor the manufacturing process, including checking our strains, end products and important processes, to ensure the biosafety and product quality. Meanwhile, we will strictly implement the inventory management system to guarantee that the product inventory can meet the reasonable market demand and improve the inventory turnover rate. Importantly, our marketing will make full use of the cooperations between Wuhan University and affiliated hospitals (Renmin Hosipital and Zhongnan Hospital) or research institutes to provide point-to-point supply.
Public confidence towards genetic engineering in China is limited, and the technology used in the manufacturing of this product may be questioned, while orally delivered microorganisms may also create a psychological burden on customers. For the phenomenon that the public has a psychological resistance to genetic engineering, we should strengthen the work of popularizing transgenic technology in the process of market promotion, so that the public can understand all aspects of genetically modified technology in principle, thus reducing the public's fear of genetically modified organisms. Meanwhile, we need to comprehensively control the biosafety, and explain in the product description as follows: the technology used in the manufacturing process to control the biosafety within the allowable range; the biological characteristics of the probiotic chassis used, so as to reduce the psychological burden of the public on orally delivering engineered microorganisms.
The main competitors of our products are antibiotics and synthetic drugs. However, China is a big country in the manufacturing and delivery of antibacterial drugs. The annual production of antibacterial raw materials is about 210,000 tons, and the export is about 30,000 tons. According to the "survey report on the current situation of public safe drug use" issued by the State Food and Drug Administration on September 1, 2012 [8], about 25% of China's households have antibacterial drugs on hand, and 23.9% of people use antibacterial drugs after catching a cold. Among the top 100 drugs sold in China's medical institutions, 29 belong to antibacterial drugs, and the annual sales of the third generation cephalosporins alone exceed 1 billion yuan. It can be seen that antibacterial drugs occupy a large market share, so the first problem to be solved is to occupy a certain market.
Although antibiotics occupy a large proportion of the market at present, their shortcomings are also increasingly exposed. After each kind of antibiotic enters the clinic, it is accompanied by the drug-resistant bacteria. Currently, the abuse of antibiotics has led to the emergence of a large amount of “super bacteria”, which has greatly threatened human health. In this context, the market will certainly seek antibiotic-alternative drugs. In principle, the product can target at specific bacteria, and show a good effect on exterminating drug-resistant bacteria, such as our negotiator probiotics.
Aimed at P. aeruginosa, the application scope is relatively narrow. In order to expand the application scope of our products, we should continue to carry out the research and development of our products, and further optimize our products from the aspects of principle, technology and production, so as to improve the therapeutic effect and function spectrum of our products. At the same time, we should promote the clinical trials and accelerate the transformation of products from adjuvant drugs to prescription drugs. Also, we can also seek help from leading biological companies.
As we all know that biopharmaceutical startups spend a lot of money in the early stages of development. The cycles of research, development and production are relatively long, thus, how to endeavour the early stage becomes one of the most important issues we need to consider. In order to meet this great challenge, we have formulated a strategy of phased development. In the early stages of development, in addition to our R&D activities, we will apply for technical services and patent licensing to fund our R&D activities and corporate operations.
As our product is a brand-new drug, there are few comparable products and treatment methods, and customers will have greater concerns when choosing our product. Therefore, compared with other antibacterial drugs, our product marketing will be more difficult. Based on this, we will continue to improve our experimental scheme to ensure that our experiment is repeatable and traceable, and enhance the inhibitory effect of the product against Gram-negative bacteria in practice. At the same time, we will increase publicity efforts, achieve excellence in STEM education, and actively cooperate with prominent research teams to expand the influence of ‘The Negotiator’.
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[8]
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