---
id: "edwards-2025-phage-therapy"
title: "Exploration of Providers’ Perceptions and Attitudes Toward Phage Therapy and Intentions for Future Adoption as an Alternative to Traditional Antibiotics in the US—A Cross-Sectional Study"
authors:
  - "Subi Gandhi"
  - "Dustin Edwards"
  - "Keith Emmert"
  - "Bonnie Large"
venue: "International Journal of Environmental Research and Public Health"
year: 2025
date: "2025-07-18"
doi: "10.3390/ijerph22071139"
url: "/research/publications/10-3390-ijerph22071139/"
pdf: "/research/publications/10-3390-ijerph22071139/dustin-edwards-10-3390-ijerph22071139.pdf"
pmc: "https://pmc.ncbi.nlm.nih.gov/articles/PMC12294182/"
openAccess: true
license: "cc-by"
citedBy: 2
citedBySource: "OpenAlex, read 2026-09-12"
---
# Exploration of Providers’ Perceptions and Attitudes Toward Phage Therapy and Intentions for Future Adoption as an Alternative to Traditional Antibiotics in the US—A Cross-Sectional Study

Survey of 196 US clinicians: 49 percent knew about phage therapy, 56 percent would consider using it.

## Abstract

Antibiotic resistance presents a global threat, making the swift development of alternative treatments essential. Phage therapy, which employs bacterial viruses that specifically target bacteria, shows promise. Although this method has been utilized for over a century, primarily in Eastern Europe, its use in the US remains limited. This study aimed to assess the awareness and willingness of US healthcare providers to adopt phage therapy in response to the growing issue of antibiotic resistance. A survey of 196 healthcare providers, primarily MDs and DOs, found that while 99% were aware of antimicrobial resistance, only 49% were knowledgeable about phage therapy as a treatment for resistant bacterial infections. Nonetheless, 56% were open to considering phage therapy, and this willingness was associated with prior knowledge, concerns about antibiotic resistance, previous training, and confidence in recommending it (p < 0.05). Our study of U.S. healthcare providers revealed key findings about their views on phage therapy as a potential alternative for treating bacterial infections. Credible information is essential to promoting phage therapy use among U.S. providers via educational initiatives, clinical guidance, and research dissemination to promote phage therapy use among U.S. providers. Evidence-based education and clinical guidance help providers make sound decisions on the appropriate and safe use of phage therapy.

## Full text

Machine-extracted from the PDF linked above. It carries the artifacts that come with reading a typeset two-column page: running heads, figure captions in the flow of the prose, and words broken across line ends. The abstract above is the registry's deposit and is the authoritative text.

Academic Editor: Guiying Li
Received: 4 June 2025
Revised: 5 July 2025
Accepted: 6 July 2025
Published: 18 July 2025
Citation: Gandhi, S.; Edwards, D.;
Emmert, K.; Large, B. Exploration of
Providers’ Perceptions and Attitudes
Toward Phage Therapy and
Intentions for Future Adoption as an
Alternative to Traditional Antibiotics
in the US—A Cross-Sectional Study.
Int. J. Environ. Res. Public Health 2025,
22, 1139. https://doi.org/10.3390/
ijerph22071139
Copyright: © 2025 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license
(https://creativecommons.org/
licenses/by/4.0/).
Article
Exploration of Providers’ Perceptions and Attitudes Toward
Phage Therapy and Intentions for Future Adoption as an
Alternative to Traditional Antibiotics in the US—A
Cross-Sectional Study
Subi Gandhi 1,*, Dustin Edwards 2 , Keith Emmert 3 and Bonnie Large 1
1 Department of Medical Lab Sciences, Public Health, and Nutrition Science, Tarleton State University,
1333 West Washington, Stephenville, TX 76402, USA
2 Department of Biological Sciences, Tarleton State University, 1333 West Washington,
Stephenville, TX 76402, USA; dcedwards@tarleton.edu
3 Department of Mathematics, Tarleton State University, 1333 West Washington, Stephenville, TX 76402, USA;
emmert@tarleton.edu
* Correspondence: gandhi@tarleton.edu
Abstract
Antibiotic resistance presents a global threat, making the swift development of alternative
treatments essential. Phage therapy, which employs bacterial viruses that specifically target
bacteria, shows promise. Although this method has been utilized for over a century, pri-
marily in Eastern Europe, its use in the US remains limited. This study aimed to assess the
awareness and willingness of US healthcare providers to adopt phage therapy in response
to the growing issue of antibiotic resistance. A survey of 196 healthcare providers, primarily
MDs and DOs, found that while 99% were aware of antimicrobial resistance, only 49%
were knowledgeable about phage therapy as a treatment for resistant bacterial infections.
Nonetheless, 56% were open to considering phage therapy, and this willingness was asso-
ciated with prior knowledge, concerns about antibiotic resistance, previous training, and
confidence in recommending it (p < 0.05). Our study of U.S. healthcare providers revealed
key findings about their views on phage therapy as a potential alternative for treating
bacterial infections. Credible information is essential to promoting phage therapy use
among U.S. providers via educational initiatives, clinical guidance, and research dissemina-
tion to promote phage therapy use among U.S. providers. Evidence-based education and
clinical guidance help providers make sound decisions on the appropriate and safe use of
phage therapy.
Keywords: phage therapy; antibiotic resistance; antimicrobial resistance; therapeutic
alternatives; physician attitudes
1. Introduction
Bacterial antibiotic resistance (ABR) poses a significant and growing global health
challenge [1–4]. This resistance occurs when bacteria develop the ability to withstand
antibiotics intended to eliminate them [5,6]. Since the advent of antibiotics in the 20th
century, they have become a vital cornerstone of modern medicine, saving millions of
lives from what were once fatal infections [4,7]. However, the overuse and misuse of
antibiotics, coupled with the natural capacity of bacteria to develop resistance through
genetic modifications, are critical drivers in the rise of antibiotic-resistant strains [4,8].
Int. J. Environ. Res. Public Health 2025, 22, 1139 https://doi.org/10.3390/ijerph22071139

Int. J. Environ. Res. Public Health 2025, 22, 1139 2 of 21
In 2019 alone, it was estimated that nearly 5 million global deaths were associated with
ABR, while 1.27 million deaths were attributable to ABR [1]. The highest number of ABR-
associated deaths across all ages was observed in sub-Saharan Africa, while the lowest was
in Australasia, when predictive statistical modeling was employed to estimate the global
disease burden in different regions [1]. Among pathogens, the top six main contributors
globally were Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus
pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa [1].
Antimicrobial resistance (AMR) is a major public health issue in the United States [2].
Antimicrobials encompass a wide range of drugs used to treat infections caused by various
pathogens, including bacteria and fungi. Conversely, antibiotics are a specific type of drug
aimed at treating bacterial infections [9]. The Centers for Disease Control and Prevention
(CDC) has identified numerous drug-resistant bacteria as urgent, serious, and concerning
threats [5]. Nonetheless, the current pipelines for antibiotics are insufficient to combat
the escalating threat of AMR [10]. In 2013, around 2.6 million Americans were infected
annually by AMR pathogens, resulting in nearly 44,000 associated deaths [11]. Healthcare
Associated Infections (HAI) caused by one of the ESKAPEE pathogens (Enterococcus faecium,
Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa,
Enterobacter spp., and Escherichia coli) often harbor AMR [12]. The already critical situation
is worsened by the slow pace of new antibiotic development and dwindling interest in
this area [13]. Antibiotic usage for bacterial coinfections and secondary bacterial infections
has increased due to COVID-19 [14]. Therefore, AMR is expected to remain a major public
health challenge in the foreseeable future, highlighting the need for innovative and effective
strategies to tackle the issue [1,4,13].
Phage therapy has been explored as an alternative to conventional antibiotics [4,15,16].
Bacteriophages, commonly referred to as phages, are natural viruses that specifically target
bacteria and can serve as a medical treatment for bacterial infections [4,17,18]. Phages
possess several unique traits that distinguish them from antibiotics. They are noted for
their greater availability, variability, specificity, low inherent toxicity, effectiveness against
antibiotic-resistant bacteria, and minimal environmental impact [4,16]. These exceptional
traits render them effective alternatives to antibiotics for therapeutic use. However, phage
therapy faces several challenges, including the potential for bacteria to develop resistance to
phages, narrow host ranges that limit its applicability to diverse bacterial strains, difficulties
in optimizing dosing and delivery, the potential for immune responses such as anti-phage
antibody production, and complex regulatory frameworks [19–21].
Phages were first identified over a century ago by Felix d’Herrelle and Frederick Twort,
and since then, their potential as therapeutic agents has oscillated in popularity [16,22,23].
Currently, phage therapy is not considered the standard treatment in the U.S. or most other
nations, primarily due to the scarcity of centers, physicians, and researchers specializing
in this field [24,25]. However, recent advances in genetic engineering and phage biology,
alongside successful compassionate use cases addressing antibiotic-resistant infections,
have rekindled interest in phage therapy [24,26]. Furthermore, the National Institutes of
Health has allocated USD 2.5 million to 12 institutes globally to investigate phage therapy,
with several clinical trials now in progress to treat various infections [27].
In Eastern Europe, particularly in Georgia, Poland, and Russia, a strong historical
and scientific foundation exists for utilizing bacteriophages as a therapeutic agent, despite
their decline in popularity in the West [28]. Founded in 1923, the Eliava Institute of
Bacteriophages, Microbiology, and Virology in Tbilisi, Georgia, has served as a pivotal
center for phage research and production on a global scale [29]. Although there have been
challenges, including inconsistent production methods and quality control issues, ongoing
experience with phage therapy in Eastern Europe has led to significant scientific insights

Int. J. Environ. Res. Public Health 2025, 22, 1139 3 of 21
regarding its potential applications and limitations for treating various antibiotic-resistant
infections [30,31]. Given its growing acceptance, phage formulations are now readily
available at pharmacies in these countries. They are used to manage conditions such as
wound infections, septicemia, and even antibiotic-resistant hospital-acquired infections [19].
Although phage therapy offers a promising approach to combating antibiotic resis-
tance, its clinical uptake remains limited, particularly in the United States, primarily due
to knowledge and familiarity gaps among providers [29–31]. Several leading U.S. institu-
tions [20,26,32–36] are advancing clinical bacteriophage therapy, including the Center for
Innovative Phage Applications and Therapeutics (IPATH) at the University of California
San Diego; Tailored Antibacterials & Innovative Laboratories for Φ Research (TAILΦR)
at Baylor College of Medicine; the Center for Phage Technology (CPT) at Texas A&M
University; the Center for Phage Biology & Therapy at Yale University; the Phage Therapy
Program within Mayo Clinic’s Center for Individualized Medicine; the Pittsburgh Phage
Program (P3) at the University of Pittsburgh/UPMC; the Department of Defense Bacte-
riophage Therapeutics Program, based at the Naval Medical Research Center and Walter
Reed Army Institute of Research; and the Phage & CRISPR Immunology Group at Johns
Hopkins University School of Medicine. Many healthcare professionals remain unaware of
phage therapy or only possess a rudimentary understanding of its clinical applications and
effectiveness [37]. Despite having a long history, phage therapy has not been extensively in-
corporated into Western medical education or practice, leading to reluctance and underuse
in clinical environments [38,39].
Healthcare providers are strategically positioned to tackle the escalating threat of
antimicrobial resistance. Since physicians and other providers, such as physician assistants
and nurse practitioners, are the main prescribers of antimicrobials, they have a direct
impact on treatment decisions and patient care [40–42]. Their comprehension of antibiotic
resistance and new alternatives, such as phage therapy, is essential not only for informing
individual treatment decisions but also for influencing broader antimicrobial stewardship
practices. By enhancing their knowledge and involvement with phage therapy, healthcare
providers can promote its responsible integration, uphold evidence-based clinical advance-
ments, and contribute significantly to reducing dependence on conventional antibiotics.
The world currently faces a significant antibiotic shortage driven by insufficient re-
search and development, rising resistance, and an urgent need for equitable access to
solutions addressing this issue [3,4]. Additionally, healthcare providers’ understanding,
in conjunction with specific policies and regulations, plays a crucial role in the uptake of
scientific innovations in clinical practice. Our study aimed to evaluate healthcare providers’
awareness of phage therapy and their readiness to incorporate it into their practices, should
it become a viable treatment option in the near future in the United States. To accomplish
this, we conducted a nationwide cross-sectional survey targeting medical professionals
across all 50 states.
Several key research questions guided the study:
1. What is the present understanding and level of concern among healthcare providers
regarding antibiotic resistance?
2. If phage therapy were to become available in the United States, how receptive would
providers be to its adoption?
3. Does a provider’s likelihood of considering phage therapy correlate with specific
demographic characteristics, knowledge levels, or intention-related factors?

Int. J. Environ. Res. Public Health 2025, 22, 1139 4 of 21
2. Materials and Methods
2.1. Survey Design, Instrument, Inclusion Criteria, and Ethics
A cross-sectional survey was created to gather data from study participants (providers
practicing medicine in various US states). A twenty-item self-administered (see Appendix A)
survey was launched via Qualtrics (Qualtrics, Provo, UT) in summer 2021. The survey
was designed to be completed in under ten minutes and included a mix of multiple-choice
questions, Likert-type scales, and open-ended responses. The survey was divided into three
parts, as explained below:
1. Part I: Demographic questions included variables such as age, gender, race, ethnicity,
employment status, political affiliation, and marital status.
2. Part II: Profession-related questions inquired about the zip code of respondents’
current practice, the professional degree obtained (e.g., M.D., D.O.), the location of
practice, and the year of licensure attainment.
3. Part III: Questions evaluated knowledge of phage therapy and the respondents’
willingness to adopt phage therapy in the future.
2.2. Statistical Analysis
Data obtained from Qualtrics surveys were systematically consolidated utilizing
the R statistical software (version 4.1.2) to facilitate further in-depth analyses. In this
process, various descriptive statistics were calculated, including measures such as the mean,
median, frequencies, and percentages for the relevant variables of interest. Additionally,
the Chi-square Test of Independence was employed to investigate the relationships of
interest, applying an alpha significance level of 0.05 to determine statistical significance in
the findings.
2.3. Human Subjects Protection
This research received ethical approval from the Institutional Review Board (IRB) at the
university where it was conducted, confirming adherence to established ethical guidelines.
The research was deemed “exempt” by the IRB. Prior to participating in the Qualtrics
survey, all participants were thoroughly informed and provided with comprehensive
informed consent documents that outlined the purpose of the study, their role, and their
rights. Additionally, participants were given the option to opt out of the study at any point
during the survey, ensuring that their participation was completely voluntary. To protect
the confidentiality of the participants, all responses were recorded anonymously.
3. Results
In total, 225 healthcare providers took part in the survey. The majority held an M.D.
degree (71.6%), followed by D.O. degrees (25.8%). Additionally, licensed nurse practitioners
made up 1.3%, along with other provider types, also accounted for 1.3%. Table 1 illustrates
the demographic variables of the study participants.
Healthcare providers practicing in forty-six out of the fifty states participated in the
study. The top three states where the participants’ responses were higher compared to
other states were Florida (n = 22), California (n = 18), and Pennsylvania (n = 16). The four
non-represented states in the sample were Idaho, Montana, North Dakota, and Vermont.
When participants were assessed by zip codes, there were six with the highest number
of responses as follows: 33,065 (n = 3, Pompano Beach, FL), 60,101 (n = 3, Addison, IL),
17,603 (2, Lancaster, PA), 23,228 (n = 2, Richmond, VA), 55,905 (2, Rochester, MN) and
76,904 (n = 2, San Angelo, TX). Figure 1 below illustrates the diverse range of practice
facilities among healthcare providers across the US, while Figure 2 presents the distribution
of licensure attainment by decade.

Int. J. Environ. Res. Public Health 2025, 22, 1139 5 of 21
Table 1. Basic demographic characteristics of the study participants (n = 225).
Characteristics Mean Std Deviation
Age (Years)
Overall 54.29 9.99
Male 55.72 9.91
Female 51.38 9.68
Frequency (n) Percentage (%)
Gender
Male 148 65.8
Female 74 32.9
Others 3 1.3
Race
White 171 76.0
Black 6 2.7
Asian 36 16.0
Others 12 5.3
Ethnicity
Hispanic or Latino 4 1.8
Non-Hispanic or Latino 221 98.2
Employment Status
Employed full-time 206 91.6
Employed part-time 14 6.2
Retired and other 5 2.2
Political Affiliation
Conservative (very) 11 4.9
Conservative (moderate) 43 19.1
Conservative (light) 28 12.4
Neutral 50 22.2
Liberal (light) 23 10.2
Liberal (moderate) 34 15.1
Liberal (very) 10 4.4
Prefer not to answer 26 11.6
Marital Status
Married/Not married, but cohabiting 189 84.0
Married, but not cohabitating 4 1.8
Not married or cohabitating 29 12.9
Other 3 1.3
Professional Degree
Doctor of Medicine (MD) 161 71.6
Doctor of Osteopathic Medicine (DO) 58 25.8
Others (e.g., DPM, LNP) 6 2.7
When inquired about their familiarity with “phage therapy” as a treatment option for
resistant bacterial infections in either animals or humans, 49% (n = 110) of the providers
replied “yes.” In contrast, 32% (n = 72) answered “no,” while 19% (n = 43) expressed
uncertainty. Among those aware of phage therapy, 66 learned about it through conferences,
39 through their clinical practices, and 25 from professional schools. Additionally, providers
noted the following as “other” sources: news articles, casual readings, medical journals or
newsletters, internet resources, and medical news websites.

Int. J. Environ. Res. Public Health 2025, 22, 1139 6 of 21
Figure 1. Practice Setting Distribution Among U.S. Healthcare Providers Participating in the Survey.
Figure 2. Number of Medical Practitioners Licensed in the U.S. by Decade of Initial Licensure
(1975–2022).
Nearly all (99%) providers had previously been aware of antibiotic resistance in their
practices. The responses regarding the providers’ concerns about the current state of
antibiotic resistance in the U.S. and their perceptions of the importance of developing
alternative therapies for antibiotic resistance are illustrated in Figure 3a and 3b, respectively.
Figure 4 shows the distribution of providers based on their willingness to adopt phage
therapy in the future, by zip code. At the time of the survey, 125 physicians were willing to
adopt phage therapy, and 100 were undecided.

Int. J. Environ. Res. Public Health 2025, 22, 1139 7 of 21(a) (b)
Figure 3. (a). Physicians’ Concern about the Current State of Antibiotic Resistance in the United
States. (b). Physicians’ Perceptions of the Importance of Finding an Alternative Therapy for Antibiotic
Resistance in the United States.
Figure 4. Geographic Distribution of Healthcare Providers’ Willingness to Use Bacteriophage Ther-
apy in the U.S. (n = 225) [Note: Each dot corresponds to a survey respondent representing their
respective state].
Figure 5 illustrates the likelihood of integrating phage therapy into their practice,
influenced by their concern about the current state of antibiotic resistance, measured on
a Likert-type scale (1 = not concerned to 4 = extremely concerned). For those who are

Int. J. Environ. Res. Public Health 2025, 22, 1139 8 of 21
willing to adopt phage therapy, 55 (24.4%) are extremely concerned, 54 (24%) moderately
concerned, 16 (7.1%) slightly concerned, 0 (0%) are not concerned. The association between
critical variables and physicians’ future adoption of phage therapy is detailed in Table 2.
Figure 5. Provider Willingness to Adopt Phage Therapy and Perceived Concerns Regarding Antibiotic
Resistance (n = 225).
Table 2. The relationship between specific variables and physicians’ future willingness to adopt
phage therapy (n = 216).
Willing
N (%)
Unsure
N (%) χ2 p
Age (years) 0.286 0.59
<50 39 (18.1) 26 (12.0)
≥50 years 83 (38.4) 68 (31.5)
Gender 0.398 0.53
Male 84 (38.9) 60 (27.8)
Female 38 (17.6) 34 (15.7)
Race 0.681 0.71
White 92 (42.6) 73 (33.8)
Asian 20 (9.3) 16 (7.4)
Others 10 (4.6) 5 (2.3)
Employment Status 0.110 0.74
Employed full-time 113 (52.3) 85 (39.4)
Employed part-time, retired, other 9 (4.2) 9 (4.2)
Political Affiliation 4.73 0.19
Conservative 35 (16.2) 40 (18.5)
Neutral 32 (14.8) 18 (8.3)
Liberal 41 (19.0) 26 (12.0)
Prefer not to answer 14 (6.5) 10 (4.6)
Marital Status 1.035 0.31
Married/Not married, but cohabiting 99 (45.8) 82 (38.0)
Married, but not cohabitating/Not married or cohabitating 23 (10.6) 12 (5.6)
Year of Licensure Attainment 1.304 0.25
Before 1999 70 (32.4) 62 (28.7)
After 2000 52 (24.1) 32 (14.8)

Int. J. Environ. Res. Public Health 2025, 22, 1139 9 of 21
Table 2. Cont.
Willing
N (%)
Unsure
N (%) χ2 p
Location of Practice 0.000 1.00
Rural zip codes 16 (7.4) 12 (5.6)
Non-rural zip codes 98 (45.4) 75 (34.7)
Providers’ Concerns about Antibiotic Resistance * 14.211 0.00 *
Slightly Concerned 15 (6.9) 16 (7.4)
Moderately Concerned 54 (25.0) 60 (27.8)
Extremely Concerned 53 (24.5) 18 (8.3)
Providers’ Knowledge of Phage Therapy 31.912 0.00 *
Yes 79 (36.6) 26 (12.0)
No 23 (10.6) 47 (21.8)
Not Sure 20 (9.3) 21 (9.7)
Event/Training Where Providers Learned About Phage Therapy 29.283 0.00 *
Professional School 21 (9.7) 4 (1.9)
Conference 44 (20.4) 17 (7.9)
Clinical Practice 23 (10.6) 14 (6.5)
Other 34 (15.7) 59 (27.3)
Patients Willing to Accept Phage Therapy If Endorsed By Physicians * 30.04 0.00 *
Very likely 21 (9.7) 2 (0.9)
Likely 63 (29.2) 30 (13.9)
Somewhat 38 (17.6) 62 (28.7)
* [Note: 11 physicians have already adopted phage therapy, 200 have not, and 14 are not sure.; Some categories
were omitted due to zero responses].
When the χ2 independence tests indicated a rejection of the null hypothesis, we
examined the adjusted Pearson residuals. These residuals, based on an alpha level of 0.05
and adjusted for the number of cells in each contingency table, helped identify significant
deviations from expected cell counts. Further details and illustrative examples can be found
in Appendix B (Figures A1–A4).
Physicians’ likelihood to employ phage therapy, in conjunction with their level of
worry ABR, reveals significant findings. Notably, instances where ABR concern is moderate
or extreme display statistical relevance. Extreme ABR concern shows the most substantial
deviations from expected counts. The highest positive deviation from the expected count is
observed when physicians exhibit a strong willingness to utilize phage therapy alongside
extreme ABR concern. Furthermore, moderate ABR concern paired with physician uncer-
tainty about using phage therapy yields the next highest positive deviation. These findings
are visually represented in Figure A1.
Statistical analysis revealed significant variations between physicians’ willingness to
use phage therapy and their level of awareness. Notably, a greater number of physicians
than expected were both willing to utilize phage therapy and possessed positive awareness
of it. Conversely, the number of physicians willing to use phage therapy despite negative
awareness was lower than anticipated. This relationship is illustrated in Figure A2.
Physicians with formal training in phage therapy, such as those that attended confer-
ences or professional schools, demonstrated a statistically higher willingness to use it. In
contrast, those who learned about phage therapy through means other than professional
education and clinical experience generally showed hesitation towards its application. This
is visually represented in Figure A3.
In physicians open to phage therapy, higher counts were observed than expected in
the “likely” or “very likely” categories for patients deemed receptive to such treatment.
Conversely, when physician uncertainty regarding phage therapy existed, a statistically
significant increase in physicians predicting their patients would be “somewhat likely” to
accept it was noted. These correlations are depicted in Figure A4.

Int. J. Environ. Res. Public Health 2025, 22, 1139 10 of 21
4. Discussion
The rise of antibiotic resistance in bacteria has become a global concern, and the impact
of these infections on morbidity and mortality is projected to grow in the foreseeable future
unless a promising alternative emerges. The renewed interest in phage therapy as an
alternative signifies a significant revival in treating drug-resistant infections [18,28,43,44].
It has gained considerable attention in recent years as a potential substitute for traditional
antibiotics. Despite this growing interest, the Food and Drug Administration (FDA) has
not yet approved phage therapy in the United States. This is primarily due to the need for
comprehensive clinical data to establish the treatment’s safety and efficacy. Nevertheless,
progress is being made in the field, as the first clinical trial investigating the intravenous
administration of phage therapy has received approval [43]. This trial represents a crucial
step forward in evaluating phage therapy’s therapeutic potential for patients with serious
bacterial infections, indicating that regulatory pathways may be opening for this innovative
treatment option.
Given the increasing international medical interest in phage therapy, it is a suitable
time to investigate the diverse aspects of phage therapy within the United States [43].
This timely and relevant investigation aligns with the international trend of heightened
attention toward this therapeutic approach. In addressing antimicrobial resistance in-
fections, the role of healthcare providers as primary facilitators of communication and
proponents of antimicrobial therapies is increasingly critical. Their comprehensive un-
derstanding of antimicrobial stewardship and capacity to effectively persuade patients
to embrace appropriate therapeutic interventions are pivotal, particularly at this crucial
juncture. This underscores the necessity for enhancing providers’ expertise in antimicrobial
knowledge and their confidence in guiding patients toward adopting these therapies to
treat ABR infections [38,39].
Although research on this topic has been carried out in other countries, no US-based
study has yet captured providers’ perspectives on adopting or future practices of phage ther-
apy. For instance, a recent survey of clinicians in the UK revealed that approximately 59%
had heard of phage therapy, and over 70% would consider using it in suitable cases. [18].
In Australia, 97% of infectious disease specialists expressed willingness to use phage ther-
apy if high-quality, regulated preparations were accessible. However, many pointed out
practical barriers, such as the need for timely access to phages (mentioned by 72% of re-
spondents) and logistical challenges in procurement [45]. Surveys in Poland have revealed
relatively modest baseline knowledge of phage therapy among healthcare providers—only
about one-third of physicians and dentists expressed a readiness to deepen their phage
knowledge—yet an overwhelming majority of respondents (84.4%) said they would un-
dergo phage treatment if needed, even if it meant paying out of pocket [46]. Similarly,
Korean infectious disease specialists showed limited awareness of phage therapy (only
a few felt well-informed), but most were still eager to participate in phage therapy clini-
cal trials, with concerns centered on safety, efficacy, and logistical challenges [47]. In the
United States, formal survey data are limited, but reports from clinical centers like UC San
Diego’s IPATH indicate a significant awareness gap—patients reportedly request phage
therapy more often than physicians provide it [48]. Overall, across different countries,
general awareness of phage therapy among providers remains variable and often limited,
but the attitude toward phage therapy is broadly positive; most physicians are open to
or enthusiastic about phage use for ABR infections. This study represents the first com-
prehensive national assessment of healthcare providers’ knowledge and attitudes toward
phage therapy in the United States. By examining provider perspectives on this emerging
treatment, we offer critical insights into the potential of phage therapy as an alternative
strategy for combating ABR infections.

Int. J. Environ. Res. Public Health 2025, 22, 1139 11 of 21
Our survey of U.S. healthcare providers revealed meaningful insights into their per-
ceptions of phage therapy as an emerging alternative for treating bacterial infections.
Participants represented diverse professional backgrounds, with a majority holding M.D.
degrees and working in private practice. Most respondents acknowledged the growing
challenge of antibiotic resistance and reported some familiarity with phage therapy, often
through professional conferences or clinical experiences. Encouragingly, a notable propor-
tion expressed interest in incorporating phage therapy into their future practice. However,
many providers remained uncertain, likely due to limited exposure, concerns about clinical
efficacy, ethical concerns, and the lack of standardized regulatory guidance [18,49]. Impor-
tantly, nearly one-third of providers had not previously encountered phage therapy as a
treatment option, pointing to significant gaps in awareness and training.
These findings are consistent with previous studies that have identified a lack of
knowledge about bacteriophage therapy among healthcare providers as a key barrier to
its wider acceptance and use [31,50,51]. Our data corroborates this, with only about half
of the respondents reporting prior knowledge of phage therapy. When comparing global
perspectives, our findings indicate a lower level of readiness among U.S. providers to adopt
phage therapy than their international counterparts. For example, approximately 70% of
clinicians in Canada and the UK have reported their willingness to use phage therapy in
appropriate cases [18,52]. At the same time, an Australian survey found that 97% would
consider its use, provided it met established safety and purity standards [45]. Notably,
higher acceptance rates in these studies may reflect greater exposure or institutional fa-
miliarity with phage therapy, particularly in the UK, where respondents had prior clinical
experience with it, potentially inflating perceived acceptance [18].
The current understanding of phage therapy within the U.S. healthcare system is
varied, yet amid growing concerns about antibiotic resistance, there is a noticeable shift in
provider attitudes. Many healthcare professionals are increasingly receptive to alternatives,
viewing phage therapy as a potential complement, or even a replacement, in specific clinical
scenarios. This rising awareness is likely influenced by exposure to professional devel-
opment opportunities and firsthand clinical experiences. However, significant hesitancy
remains, largely due to limited access to robust clinical data, unclear regulatory pathways,
and uncertainty about practical implementation.
To reduce ambiguity and support the appropriate adoption of phage therapy, it is
essential that American healthcare providers have access to reliable, evidence-based in-
formation. Educational initiatives, both online and in-person, along with clear clinical
guidelines and hands-on training, are critical. Enhancing provider education, expanding
the dissemination of research, and integrating phage therapy into ongoing medical educa-
tion will not only improve individual patient outcomes but also contribute meaningfully to
the broader public health effort to combat antibiotic resistance. Transitioning phage therapy
from an experimental concept to a viable clinical tool hinges on making such resources
widely accessible and actionable.
Our study presents findings that may inform future research and practice, while
acknowledging several key limitations. While our sample size is considerable, it may
not fully capture the diversity of healthcare providers throughout the US. The number of
physicians involved in each state was limited, which likely restricted the representation
of the average opinions and beliefs of healthcare providers both within individual states
and across all states. Furthermore, our research relies on self-reported data, which are
vulnerable to biases related to recall and social desirability [53]. Another limitation is that,
although we identified a correlation between previous awareness of phage therapy and
future willingness to adopt it, we cannot definitively establish causality due to the study’s
cross-sectional design.

Int. J. Environ. Res. Public Health 2025, 22, 1139 12 of 21
Social and cultural factors, such as political ideology, significantly influence health
decisions [54,55]. An example of this concept is readily illustrated by the vaccine uptake
rates at the population level [54,55]. A study on vaccine confidence among primary care
physicians during the COVID-19 pandemic suggested that conservative physicians might
be less likely to present information about the benefits of vaccination, especially in areas
where vaccine hesitancy and conservative views are prevalent [56]. The same study also
noted a broader issue related to vaccine hesitancy among physicians: limited training on
vaccines and vaccinology in medical school, which may lead to less well-formed opinions on
vaccines. This shortfall in training, combined with the misinformation-laden environment
surrounding COVID-19 and vaccines, suggests that some physicians may rely more on
news and misinformation than on scientific evidence. Literature has demonstrated that
medical conservatism among physicians can limit medical advancements [57,58]. In our
study, we were unable to demonstrate the association between political affiliation and the
intentionality of adopting phage therapy. However, this finding contributes to the ongoing
discourse on the complex relationship between political beliefs, healthcare decision-making,
and the acceptance of new treatment modalities, such as phage therapy, and should be
supported by future robust studies.
The future understanding of phage therapy acceptance in the US involves several
crucial elements, including public perception, access to education, and media portrayal.
A prior study in the UK revealed limited awareness and inadequate understanding of
phage therapy [18]. However, a related framing experiment demonstrated that even slight
exposure to information on antibiotic resistance and alternative treatments can significantly
enhance public acceptance of phage therapy. Participants also expressed a keen interest in
the need for increased public education on the subject [18]. The SEA-PHAGES program,
supported by the Howard Hughes Medical Institute, plays a vital role in advancing the
acceptance of phage therapy in the US by improving educational access [49–54]. By in-
volving over 5500 undergraduate students each year in phage discovery and genomics,
the program nurtures a deeper understanding and interest in phage therapy among to-
morrow’s scientists and healthcare providers. This hands-on experience equips students
with knowledge about the potential of phage therapy, preparing them to be informed
advocates in their future roles. Such extensive educational efforts build a knowledge base
that can enhance the acceptance and implementation of phage therapy into the broader
community. Additionally, raising public awareness and understanding of phage therapy
could benefit from media coverage and the sharing of success stories. For example, scien-
tists featured on popular platforms like CNN help clarify phage therapy and showcase its
potential as a promising alternative to conventional antibiotics, particularly in addressing
antibiotic-resistant infections [55]. Future surveys could assess the current public aware-
ness of phage therapy in the US, focusing on the impact of media coverage, common
misconceptions, and knowledge gaps to inform effective communication strategies. Fur-
thermore, exploring how educational programs impact students’ attitudes towards phage
therapy would yield insights into the influence of education on the perspectives of future
healthcare professionals.
5. Conclusions
Our research shows a positive outlook among healthcare providers toward phage
therapy despite its limited use. The gap between interest and application highlights the
need for educational initiatives to increase awareness and understanding of phage therapy
as a viable alternative for treating bacterial infections. Addressing potential barriers to
widespread use should be a priority for the healthcare community. Future research should
focus on comprehensively understanding these barriers. Further studies are also required

Int. J. Environ. Res. Public Health 2025, 22, 1139 13 of 21
to confirm the correlation between years of licensure attainment and the willingness to
adopt phage therapy. As antibiotic resistance worsens globally, it is critical to explore
and accept alternative treatments. The study evaluated providers’ knowledge of phage
therapy, their exposure to relevant information during professional development, and their
willingness to adopt this treatment in the future. We aimed to determine how demographic
and professional characteristics shape these perceptions. The data gathered provide insights
into healthcare providers’ understanding of phage therapy and implications for policy and
practice decisions in US primary care settings.
Author Contributions: Conceptualization, S.G. and D.E.; methodology, S.G., D.E. and K.E.; software,
K.E.; validation, S.G., D.E. and K.E.; formal analysis, S.G. and K.E.; investigation, S.G., D.E., B.L. and
K.E.; data curation, S.G. and K.E.; writing—original draft preparation, S.G. and B.L.; writing—review
and editing, S.G., B.L., D.E. and K.E.; visualization, S.G. and K.E.; supervision, S.G. and D.E.; project
administration, D.E. and S.G.; funding acquisition, D.E. and S.G. All authors have read and agreed to
the published version of the manuscript.
Funding: This research was sponsored by the President’s Excellence in Research Grant, funded in
2022 by the Division of Research, Innovation, and Economic Development at Tarleton State University.
Institutional Review Board Statement: This study was deemed exempt by the Institutional Review
Board at the university where the study was conducted.
Informed Consent Statement: All participants provided informed consent electronically before
participating in the survey/study.
Data Availability Statement: The original data presented in the study are openly available in
“Bacteriophage Therapy Perceptions and Attitudes Towards Therapy”, Mendeley Data, V1, doi:
10.17632/3gyrjdgk4y.1.
Acknowledgments: The authors would like to thank Misty Smith for their valuable input during the
preparation of this manuscript. Their contributions to the literature review and efforts in strength-
ening the overall quality of the paper were greatly appreciated. During the preparation of this
manuscript, the authors used Google Gemini and Grammarly to enhance the quality of visuals
and/or writing. The authors have reviewed and edited the output and take full responsibility for the
content of this publication.
Conflicts of Interest: The authors declare no conflicts of interest.
Appendix A. Questionnaire
I. Demographics
1. What is your age in years?
_____________(years)
2. What is your gender identity
# Male
# Female
# Transgender man
# Transgender women
# Gender non-conforming
# Intersex
# Other
# Prefer not to answer
3. Race
# White/Caucasian

Int. J. Environ. Res. Public Health 2025, 22, 1139 14 of 21
# Black or African American
# Middle Eastern or North African
# Native American, American Indian, or Alaskan Native
# Asian
# Native Hawaiian or Pacific Islander
# Two or more races
# Other/Unknown
# Prefer not to answer
4. Ethnicity
# Hispanic or Latino
# Non-Hispanic or Latino
5. What is your employment status?
# Employed full-time
# Employed part-time
# Retried
6. What is your political affiliation?
# Very conservative
# Moderately conservative
# Lightly conservative
# Neutral
# Lightly liberal
# Moderately liberal
# Very liberal
# Prefer not to answer
7. What is your marital status?
# Married
# Marries, but not cohabitating
# Not married, but cohabiting
# Not married or cohabitating
II. Profession-related questions
8. What is your zip code of practice?
__________________________________
9. What is your professional degree?
# Doctor of Medicine (MD)
# Doctor of Osteopathic Medicine (DO)
# Podiatrist (DPM)
# Licensed Nurse Practitioner (LNP)
# Other_________________
10. What is your primary location of practice? Select those that apply.
# Hospital
# Private practice/clinic
# Urgent care clinic
# Hospice
# Ambulatory surgical center
# Group practice

Int. J. Environ. Res. Public Health 2025, 22, 1139 15 of 21
# Skilled nursing home
# Nursing home
# Home health
# Other (please explain) ________________________
11. In which year did you achieve a license or licensure to practice medicine (Example—
1970, 1985)?
______________
III. Antibiotic Resistance and Phage-related Questions
12. Have you heard of the term “antibiotic resistance” before this survey?
# Yes
# No
13. How concerned are you about the current state of antibiotic resistance and its public
health burden in the US?
# Not concerned
# Slightly concerned
# Moderately concerned
# Extremely concerned
14. How important do you feel about finding an alternative therapy option for treating
antibiotic-resistant bacteria (ARB) in the US?
# Very Important
# Important
# Moderately Important
# Slightly Important
# Not Important
15. Have you heard of “bacteriophage therapy” or “phage therapy” as an alternative
method to treat resistant bacterial infections in animals and/or humans?
# Yes
# No
# Not sure
16. Where did you learn about “bacteriophage therapy” or “phage therapy”?
# Professional school
# Conference
# Clinical Practice
# Other (please explain) ________________________
17. Will your patients accept “bacteriophage therapy” or “phage therapy” if you recom-
mend them as an alternative therapy to treat their resistant bacterial conditions?
# Very likely
# Likely
# Somewhat
# Not at all
18. I am willing to treat patients with “bacteriophage therapy” or “phage therapy” instead
of traditional antibiotics when necessary, in the future.
# Yes
# No
# Not sure

Int. J. Environ. Res. Public Health 2025, 22, 1139 16 of 21
19. I am willing to learn more about “bacteriophage therapy” or “phage therapy” in the
near future for consideration as an alternative therapy in my practice.
# Very likely
# Likely
# Somewhat
# Not at all
20. I am already using “bacteriophage therapy” or “phage therapy” in my clinical practice.
# Yes
# No
# Not sure
Thank you for your participation in this survey!
Appendix B
Appendix B.1
For those χ2 tests for independence that are rejected at the α = 0.05 level, we used
the adjusted Pearson residuals to examine each cell in the table for statistically significant
contributions to the rejection of the null hypothesis. The adjusted Pearson residuals were
calculated using
rij = Oij − Eij
√
Eij(1 − mi / N)(1 − nj / N)
where Oij and Eij represent the observed and expected counts in row i and column j,
respectively, mi and nj represent the number of row and column totals, respectively, and
N represents the overall total. Since rij follows a standard normal distribution, we can
calculate critical values, CV, based upon an adjusted level α = 0.05 / (number o f cells).
If rij > CV or rij < −CV, then that cell is significantly different from the expected count
under the null hypothesis of independence. Specifically, if rij > 0, it indicates that there are
more observed values than expected. Conversely, if rij < 0, then there are fewer observed
than expected. In Figures A1–A4, cells that are bluer indicate a positive rij, while cells that
are redder indicate a negative rij.
The analysis first examined physicians’ concerns regarding antibiotic-resistant bacteria
in relation to their willingness to utilize phage therapy. The critical value for significance
was set at ±2.39, based on a Bonferroni-adjusted alpha level of α = 0.05/6. As shown
in Figure A1, four cells demonstrated significant deviations from expected frequencies.
Statistically significant contributions were identified when the standardized residual rij
exceeded 2.39. This pattern was evident among physicians who reported a willingness
to try phage therapy and expressed high concern about antibiotic resistance, as well as
those who were uncertain about trying phage therapy but exhibited moderate concern.
Conversely, rij values below −2.39 indicated statistically significant underrepresentation
among physicians who were moderately concerned about antibiotic resistance yet willing
to try phage therapy, and those who were extremely concerned but uncertain about using
phage therapy.
The analysis next considered physicians’ awareness of phage therapy in relation
to their willingness to use it. The critical value for significance was set at ±2.39, based
on a Bonferroni-adjusted alpha level of α = 0.05/6. As shown in Figure A2, four cells
demonstrated statistically significant deviations from expected values. The pattern of
results was similar to that observed in Figure A1, although the adjusted Pearson residuals
were more pronounced.

Int. J. Environ. Res. Public Health 2025, 22, 1139 17 of 21
Figure A1. Adjusted Pearson residuals for physicians’ willingness to use phage therapy by level of
concern about ABR [Critical value ± 2.39 (Bonferroni-adjusted α = 0.05/6)].
Figure A2. Adjusted Pearson residuals for physicians’ willingness to use phage therapy by level of
awareness [Critical value ± 2.39 (Bonferroni-adjusted α = 0.05/6)].
Next, we examined the association between physicians’ willingness to use phage
therapy and the type and setting of their prior training on the topic. A critical value of

Int. J. Environ. Res. Public Health 2025, 22, 1139 18 of 21
±2.5 was applied, based on a Bonferroni-adjusted alpha of α = 0.05/8. As illustrated in
Figure A3, six cells showed statistically significant deviations from expected frequencies.
Physicians trained through conferences or professional schools and willing to adopt phage
therapy contributed positively to the model, while those uncertain about its use showed
significant negative contributions from the same training sources. The most pronounced
effects were observed among those who received training through alternative venues,
where uncertainty was associated with significant positive contributions and willingness
with significant negative contributions.
Finally, we examined the relationship between physicians’ willingness to use phage
therapy and their perceptions of patients’ willingness to accept such treatment. Results are
presented in Figure A4. All cells showed statistically significant contributions, indicating
rejection of the null hypothesis. Positive contributions were observed when physicians were
willing to use phage therapy and believed their patients were likely or very likely to accept
it. In contrast, a significant negative contribution occurred when physicians were willing
but perceived their patients as only somewhat likely to accept treatment. Among physicians
who were uncertain about using phage therapy, the pattern of contributions swapped.
Figure A3. Adjusted Pearson residuals for physicians’ training location in relation to their knowledge
and willingness to use phage therapy [Critical value ± 2.5 (Bonferroni-adjusted α = 0.05/8)].

Int. J. Environ. Res. Public Health 2025, 22, 1139 19 of 21
Figure A4. Adjusted Pearson residuals for physicians’ willingness to use phage therapy and their per-
ceptions of patients’ willingness to accept it [Critical value ± 2.39 (Bonferroni-adjusted α = 0.05/6)].
References
1. Murray, C.J.L.; Ikuta, K.S.; Sharara, F.; Swetschinski, L.; Aguilar, G.R.; Gray, A.; Han, C.; Bisignano, C.; Rao, P.; Wool, E.; et al.
Global Burden of Bacterial Antimicrobial Resistance in 2019: A Systematic Analysis. Lancet 2022, 399, 629–655. [CrossRef]
[PubMed]
2. CDC. What Exactly Is Antibiotic Resistance? Available online: https://www.cdc.gov/antimicrobial-resistance/about/?CDC_
AAref_Val=https://www.cdc.gov/drugresistance/about.html (accessed on 2 December 2023).
3. Antimicrobial Resistance. Available online: https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
(accessed on 2 December 2023).
4. Salam, M.A.; Al-Amin, M.Y.; Salam, M.T.; Pawar, J.S.; Akhter, N.; Rabaan, A.A.; Alqumber, M.A.A. Antimicrobial Resistance: A
Growing Serious Threat for Global Public Health. Healthcare 2023, 11, 1946. [CrossRef] [PubMed]
5. Antibiotic Resistance Threats in the United States, 2019; Centers for Disease Control and Prevention: Atlanta, GA, USA, 2019.
6. Martens, E.; Demain, A.L. The Antibiotic Resistance Crisis, with a Focus on the United States. J. Antibiot. 2017, 70, 520–526.
[CrossRef] [PubMed]
7. Ventola, C.L. The Antibiotic Resistance Crisis: Part 1: Causes and Threats. P T Peer-Rev. J. Formul. Manag. 2015, 40, 277–283.
8. Prestinaci, F.; Pezzotti, P.; Pantosti, A. Antimicrobial Resistance: A Global Multifaceted Phenomenon. Pathog. Glob. Health 2015,
109, 309–318. [CrossRef] [PubMed]
9. CDC. Antimicrobial Resistance. Available online: https://www.cdc.gov/drugresistance/index.html (accessed on 4 July 2025).
10. Available online: https://www.gao.gov/assets/820/819518.pdf (accessed on 4 July 2025).
11. CDC. Others Antibiotic Resistance Threats in the United States; US Department of Health and Human Services: Washington, DC,
USA, 2019.
12. Kline, A.; Cobián Güemes, A.G.; Yore, J.; Ghose, C.; Van Tyne, D.; Whiteson, K.; Pride, D.T. Current Clinical Laboratory Challenges
to Widespread Adoption of Phage Therapy in the United States. Antibiotics 2025, 14, 553. [CrossRef] [PubMed]
13. World Health Organization. Lack of New Antibiotics Threatens Global Efforts to Contain Drug-Resistant Infections. New Release
Geneva, 17 January 2020.
14. Markovskaya, Y.; Gavioli, E.M.; Cusumano, J.A.; Glatt, A.E. Coronavirus Disease 2019 (COVID-19): Secondary Bacterial Infections
and the Impact on Antimicrobial Resistance during the COVID-19 Pandemic. Antimicrob. Steward. Healthc. Epidemiol. 2022,
2, e114. [CrossRef] [PubMed]

Int. J. Environ. Res. Public Health 2025, 22, 1139 20 of 21
15. Abedon, S.T.; García, P.; Mullany, P.; Aminov, R. Editorial: Phage Therapy: Past, Present and Future. Front. Microbiol. 2017, 8, 981.
[CrossRef] [PubMed]
16. Hatfull, G.F.; Dedrick, R.M.; Schooley, R.T. Phage Therapy for Antibiotic-Resistant Bacterial Infections. Annu. Rev. Med. 2022,
73, 197–211. [CrossRef] [PubMed]
17. Fabijan, A.P.; Iredell, J.; Danis-Wlodarczyk, K.; Kebriaei, R.; Abedon, S.T. Translating Phage Therapy into the Clinic: Recent
Accomplishments but Continuing Challenges. PLoS Biol. 2023, 21, e3002119. [CrossRef]
18. Simpson, E.A.; Stacey, H.J.; Langley, R.J.; Jones, J.D. Phage Therapy: Awareness and Demand among Clinicians in the United
Kingdom. PLoS ONE 2023, 18, e0294190. [CrossRef] [PubMed]
19. Altamirano, F.L.G.; Barr, J.J. Phage Therapy in the Postantibiotic Era. Clin. Microbiol. Rev. 2019, 32, e00066-18. [CrossRef]
[PubMed]
20. Suh, G.A.; Lodise, T.P.; Tamma, P.D.; Knisely, J.M.; Alexander, J.; Aslam, S.; Barton, K.D.; Bizzell, E.; Totten, K.M.C.; Campbell,
J.L.; et al. Considerations for the Use of Phage Therapy in Clinical Practice. Antimicrob. Agents Chemother. 2022, 66, e0207121.
[CrossRef] [PubMed]
21. Strathdee, S.A.; Hatfull, G.F.; Mutalik, V.K.; Schooley, R.T. Phage Therapy: From Biological Mechanisms to Future Directions. Cell
2023, 186, 17–31. [CrossRef] [PubMed]
22. d’Hérelle, F. Sur un microbe invisible antagoniste des bacilles dysentériques. Comptes Rendus Hebd. Séances Acad. Sci. 1917,
165, 373–375.
23. Twort, F.W. Further Investigations on the Nature of Ultra-Microscopic Viruses and Their Cultivation. J. Hyg. 1936, 36, 204–235.
[CrossRef] [PubMed]
24. McCallin, S.; Sacher, J.C.; Zheng, J.; Chan, B.K. Current State of Compassionate Phage Therapy. Viruses 2019, 11, 343. [CrossRef]
[PubMed]
25. Abedon, S.T.; Danis-Wlodarczyk, K.M.; Alves, D.R. Phage Therapy in the 21st Century: Is There Modern, Clinical Evidence of
Phage-Mediated Efficacy? Pharmaceuticals 2021, 14, 1157. [CrossRef] [PubMed]
26. Schooley, R.T.; Biswas, B.; Gill, J.J.; Hernandez-Morales, A.; Lancaster, J.; Lessor, L.; Barr, J.J.; Reed, S.L.; Rohwer, F.; Benler, S.;
et al. Development and Use of Personalized Bacteriophage-Based Therapeutic Cocktails to Treat a Patient with a Disseminated
Resistant Acinetobacter Baumannii Infection. Antimicrob. Agents Chemother. 2017, 61, e00954-17. [CrossRef] [PubMed]
27. Rimon, A.; Gelman, D.; Yerushalmy, O.; Coppenhagen-Glazer, S.; Katvan, E.; Nir-Paz, R.; Hazan, R. Phage Therapy in Israel, Past,
Present, and Future. Phage 2022, 3, 85–94. [CrossRef] [PubMed]
28. Chanishvili, N. Chapter 1—Phage Therapy-History from Twort and d’Herelle Through Soviet Experience to Current Approaches.
In Advances in Virus Research; Łobocka, M., Szybalski, W., Eds.; Academic Press: New York, NY, USA, 2012; Volume 83, pp. 3–40.
29. Kutateladze, M.; Adamia, R. Bacteriophages as Potential New Therapeutics to Replace or Supplement Antibiotics. Trends
Biotechnol. 2010, 28, 591–595. [CrossRef] [PubMed]
30. Weber-D ˛abrowska, B.; Mulczyk, M.; Górski, A. Bacteriophage Therapy of Bacterial Infections: An Update of Our Institute’s
Experience. In Inflammation; Springer: Dordrecht, The Netherlands, 2001; pp. 201–209.
31. Mi˛edzybrodzki, R.; Borysowski, J.; Weber-D ˛abrowska, B.; Fortuna, W.; Letkiewicz, S.; Szufnarowski, K.; Pawełczyk, Z.; Rogó ˙z, P.;
Kłak, M.; Wojtasik, E.; et al. Clinical Aspects of Phage Therapy. Adv. Virus Res. 2012, 83, 73–121. [CrossRef] [PubMed]
32. Terwilliger, A.L.; Liu, C.G.; Green, S.I.; Clark, J.R.; Salazar, K.C.; Hernandez Santos, H.; Heckmann, E.R.; Trautner, B.W.; Ramig,
R.F.; Maresso, A.W. Tailored Antibacterials and Innovative Laboratories for Phage (Φ) Research: Personalized Infectious Disease
Medicine for the Most Vulnerable at-Risk Patients. Phage 2020, 1, 66–74. [CrossRef] [PubMed]
33. Le, T.; Nang, S.C.; Zhao, J.; Yu, H.H.; Li, J.; Gill, J.J.; Liu, M.; Aslam, S. Therapeutic Potential of Intravenous Phage as Standalone
Therapy for Recurrent Drug-Resistant Urinary Tract Infections. Antimicrob. Agents Chemother. 2023, 67, e0003723. [CrossRef]
[PubMed]
34. Kortright, K.E.; Chan, B.K.; Koff, J.L.; Turner, P.E. Phage Therapy: A Renewed Approach to Combat Antibiotic-Resistant Bacteria.
Cell Host Microbe 2019, 25, 219–232. [CrossRef] [PubMed]
35. Nagel, T.; Musila, L.; Muthoni, M.; Nikolich, M.; Nakavuma, J.L.; Clokie, M.R. Phage Banks as Potential Tools to Rapidly and
Cost-Effectively Manage Antimicrobial Resistance in the Developing World. Curr. Opin. Virol. 2022, 53, 101208. [CrossRef]
[PubMed]
36. Dedrick, R.M.; Guerrero-Bustamante, C.A.; Garlena, R.A.; Russell, D.A.; Ford, K.; Harris, K.; Gilmour, K.C.; Soothill, J.; Jacobs-Sera,
D.; Schooley, R.T.; et al. Engineered Bacteriophages for Treatment of a Patient with a Disseminated Drug-Resistant Mycobacterium
Abscessus. Nat. Med. 2019, 25, 730–733. [CrossRef] [PubMed]
37. Viertel, T.M.; Ritter, K.; Horz, H.-P. Viruses versus Bacteria-Novel Approaches to Phage Therapy as a Tool against Multidrug-
Resistant Pathogens. J. Antimicrob. Chemother. 2014, 69, 2326–2336. [CrossRef] [PubMed]
38. Morris, A.M. Antimicrobial Stewardship Programs: Appropriate Measures and Metrics to Study Their Impact. Curr. Treat. Options
Infect. Dis. 2014, 6, 101–112. [CrossRef] [PubMed]

Int. J. Environ. Res. Public Health 2025, 22, 1139 21 of 21
39. Cunha, C.B.; Cunha, B.A. Infectious Diseases and Antimicrobial Stewardship in Critical Care Medicine; CRC Press: Boca Raton, FL,
USA, 2020; ISBN 9781351583381.
40. Charani, E.; Castro-Sanchez, E.; Sevdalis, N.; Kyratsis, Y.; Drumright, L.; Shah, N.; Holmes, A. Understanding the Determinants
of Antimicrobial Prescribing within Hospitals: The Role of “Prescribing Etiquette”. Clin. Infect. Dis. 2013, 57, 188–196. [CrossRef]
[PubMed]
41. Sanchez, G.V.; Fleming-Dutra, K.E.; Roberts, R.M.; Hicks, L.A. Core Elements of Outpatient Antibiotic Stewardship. MMWR.
Recomm. Rep. 2016, 65, 1–12. [CrossRef] [PubMed]
42. Pulcini, C.; Gyssens, I.C. How to Educate Prescribers in Antimicrobial Stewardship Practices. Virulence 2013, 4, 192–202. [CrossRef]
[PubMed]
43. Voelker, R. FDA Approves Bacteriophage Trial. J. Am. Med. Assoc. 2019, 321, 638. [CrossRef] [PubMed]
44. Office of the Commissioner Bacteriophage. Are Viruses That Target and Kill Specific Bacterial Spec. Available online: https://
www.fda.gov/science-research/fda-science-forum/impact-various-routes-administered-phages-host-microbial-community (ac-
cessed on 21 November 2023).
45. Plymoth, M.; Lynch, S.A.; Khatami, A.; Sinclair, H.A.; Sacher, J.C.; Zheng, J.; Lin, R.C.Y.; Iredell, J.R. Attitudes to Phage Therapy
among Australian Infectious Diseases Physicians. bioRxiv 2023. [CrossRef]
46. ˙Zaczek, M.; Zieli ´nski, M.W.; Górski, A.; Weber-D ˛abrowska, B.; Mi˛edzybrodzki, R. Perception of Phage Therapy and Research
across Selected Professional and Social Groups in Poland. Front. Public. Health 2025, 13, 1490737. [CrossRef] [PubMed]
47. Bhattacharya, S. Response to Phage Therapy in Korea: A Prescribers’ Survey of Attitudes amongst Korean Infectious Diseases
Specialists towards Phage Therapy. Infect. Chemother. 2024, 56, 278–279. [CrossRef] [PubMed]
48. Aslam, S.; Lampley, E.; Wooten, D.; Karris, M.; Benson, C.; Strathdee, S.; Schooley, R.T. Lessons Learned from the First 10
Consecutive Cases of Intravenous Bacteriophage Therapy to Treat Multidrug-Resistant Bacterial Infections at a Single Center in
the United States. Open Forum Infect. Dis. 2020, 7, ofaa389. [CrossRef] [PubMed]
49. Sahoo, K.; Meshram, S. The Evolution of Phage Therapy: A Comprehensive Review of Current Applications and Future
Innovations. Cureus 2024, 16, e70414. [CrossRef] [PubMed]
50. Abedon, S.T.; Kuhl, S.J.; Blasdel, B.G.; Kutter, E.M. Phage Treatment of Human Infections. Bacteriophage 2011, 1, 66–85. [CrossRef]
[PubMed]
51. Pirnay, J.-P.; Blasdel, B.G.; Bretaudeau, L.; Buckling, A.; Chanishvili, N.; Clark, J.R.; Corte-Real, S.; Debarbieux, L.; Dublanchet, A.;
De Vos, D.; et al. Quality and Safety Requirements for Sustainable Phage Therapy Products. Pharm. Res. 2015, 32, 2173–2179.
[CrossRef] [PubMed]
52. German, G.J.; Kus, J.V.; Schwartz, K.L.; Webster, D.; Yamamura, D.L. Experience and Interest in Bacteriophage Therapy in Canada:
An AMMI Canada Survey. 2022 Annual Conference Conférence Annuelle. Off. J. Assoc. Med. Microbiol. Infect. Dis. Can. 2022,
7, 1–131. [CrossRef]
53. Althubaiti, A. Information Bias in Health Research: Definition, Pitfalls, and Adjustment Methods. J. Multidiscip. Healthc. 2016,
9, 211–217. [CrossRef] [PubMed]
54. Robinson, R.; Nguyen, E.; Wright, M.; Holmes, J.; Oliphant, C.; Cleveland, K.; Nies, M.A. Factors Contributing to Vaccine
Hesitancy and Reduced Vaccine Confidence in Rural Underserved Populations. Humanit. Soc. Sci. Commun. 2022, 9, 416.
[CrossRef] [PubMed]
55. Kawakami, A.; Gandhi, S.; Lehman, D.; Jacobs, K.J. Redefining the Vulnerable Population in Public Health Research: Incorporating
Ideological Determinants of Anti-Vaccination Attitudes. In Social Factors, Health Care Inequities and Vaccination; Kronenfeld, J.J.,
Ed.; Emerald Publishing Limited: Somerville, MA, USA, 2023; Volume 40, pp. 65–79.
56. Callaghan, T.; Washburn, D.; Goidel, K.; Nuzhath, T.; Spiegelman, A.; Scobee, J.; Moghtaderi, A.; Motta, M. Imperfect Messengers?
An Analysis of Vaccine Confidence among Primary Care Physicians. Vaccine 2022, 40, 2588–2603. [CrossRef] [PubMed]
57. Martensen, R.L. The Effect of Medical Conservatism on the Acceptance of Important Medical Discoveries. J. Am. Med. Assoc.
1996, 276, 1933. [CrossRef]
58. Mandrola, J.; Cifu, A.; Prasad, V.; Foy, A. The Case for Being a Medical Conservative. Am. J. Med. 2019, 132, 900–901. [CrossRef]
[PubMed]
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.