Abstract:
A composition comprising as components a polypeptide IMPIα (including wild type) and/or a polypeptide IMPIα-fusion and at least one antibiotic compound, in particular an aminoglycoside antibiotic, and/or at least one bactericidal compound, wherein the polypeptides, the at least one antibiotic and the at least one bactericidal compound is present in the composition in concentrations which exhibit in combination a synergistic effect against resistant bacteria.

Description:
FIELD OF THE INVENTION 
       [0001]    This invention relates to combinations of molecules, nucleic acids, peptides and proteins inhibiting growth of resistant bacteria, and to the use of peptides or nuclear acids and their combinations with molecules and proteins inhibiting protease activity, growth of pathogens and formation of biofilms. More specifically, the invention relates to combinations of molecules, nucleic acids, peptides and proteins, and the use of nucleic acids, peptides and their combinations with molecules and proteins exhibiting activity against a spectrum of proteases of microbial or fungal origin, in particular against the metzincin family including thermolysin, anthrax neutral protease 599 (npr599), pseudolysin, and aureolysin, bacterial growth, especially in planktonic free and aggregate form, and the formation of bacterial biofilms. The invention relates further to pharmaceutical compositions comprising the molecules, nucleic acids, peptides or proteins, including compositions comprising additionally molecules of antibiotic activity. The invention also relates to methods of using the peptides or nucleic acids and their combinations with molecules and proteins to prevent and/or treat bacterial or fungal infections and their symptoms, including the reduction of toxic effects of secreted or membrane bound bacterial proteases such as aureolysin, bacillolysin, pseudolysin, vibriolysin, and anthrax npr599 by inhibiting their respective proteolytic activity, and to render biofilm protected or resistant bacteria susceptible for the effects of antibiotics. The inventions further relates to using the peptides or nucleic acids and their combinations with molecules and proteins at any stage of a bacterial infection, especially at early stages. 
       BACKGROUND OF THE INVENTION 
       [0002]    Current standard treatments for bacterial infection rely predominantly on antibiotics. Under certain conditions, however, the use of antibiotics provoques the emergence or selection of resistant bacterial strains. Even worse, some bacterial strains are capable of developing resistance against entire panels of antibiotics. Therefore several programs have been launched to develop new companion compounds targeting bacterial virulence. 
         [0003]    The mode of action of most antibiotics relies on the disruption of the bacterial growth cycle by preventing the synthesis or assembly of key components of bacterial processes such as cell wall synthesis, DNA replication and protein synthesis. Antibiotics are highly effective unless pathogens have become resistant against one or even multiple antibiotics. Today, multiresistant bacteria pose a major clinical problem and health threat (Health Care-Associated Infections, HAI). Infections due to antibiotic resistant microorganisms lead to significantly higher morbidity, longer hospitalization, increased mortality rates and increased health care costs. Especially the so called “ESKAPE” pathogens ( Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumonia, Acinetobacter baumannii, Pseudomonas aeruginosa , and  Enterobacter  species) represent a major harm to patients in hospitals. About 440,000 estimated HA infections among US adult inpatients annually result in additional healthcare cost of $9.8 billion dollar every year (Zimlichman et al. 2013). 
         [0004]    Many nosocomial infections are caused by  pseudomonas aeruginosa  which is responsible for 10% of all hospital acquired infections (Aloush et al 2006). Infections caused by this microorganism are often life threatening and difficult to treat due to its low susceptibility to antimicrobial agents and to the frequent emergence of antibiotic resistance during therapy. These strains are sensitive to just a few antibiotic agents like cephalosporins, carbenicillin, colistin, gentamycin, polymyxin, quinolones and streptomycin (Sivanmaliappan et al 2011). Their prominent drug resistance results from de novo emergence of resistance after exposure to antimicrobials, and patient-to-patient contamination with resistant  P. aeruginosa . Practically all known mechanisms of antimicrobial resistance can be observed, like: derepression of chromosomal AmpC cephalosporinase; production of plasmid or integrin mediated β lactamases from different molecular classes (carbenicillinases and extended spectrum β lactamases belonging to class A, class D oxacillinases and class B carbapenem hydrolysing enzymes); diminished outer membrane permeability (loss of OprD proteins); overexpression of active efflux systems with wide substrate profiles; synthesis of aminoglycoside modifying enzymes (phosphoryltransferases, acetyltransferases and adenylyltransferases); and structural alterations of topoisomerases II and IV determining quinolone resistance. Worryingly these mechanisms are often simultaneously developed and activated, thereby conferring multiresistant phenotypes, rendering this microbe less amenable to control in hospitals (Strateva et al 2009). According to data from the US Centers for Disease Control and Prevention and the National Nosocomial Infection Surveilance System,  P. aeruginosa  is the second most common cause of nosocomial pneumonia (17%), the third most common cause of urinary tract infections (7%), the fourth most common cause of surgical site infection (8%), the seventh most frequently isolated pathogen from the bloodstream (2%) and the fifth most common isolate (9%) overall from all sites (El Solh et al 2009). More importantly, it is the most common multidrug resistant Gram negative pathogen causing pneumonia in hospitalized patients. 
         [0005]    To support the therapy of bacterial infections, bacterial virulence factors have become targets for reducing the symptoms of bacterial infections. Being essential for maintaining bacterial pathogenicity, virulence factors promote i.a. resistance to environmental threats and to host defense mechanisms, growth capability, adherence to the host, tissue specificity, and access to nutrition resources. A variety of bacterial and often strain specific components are involved, many of them harmful to the host. The coordinated function of virulence factors determines the aggressiveness of the strain. In many cases virulence factors are secreted proteins or enzymes, sometimes exhibiting very specific functions. For example, one of the most toxic bacterial virulence factors is the so called Lambda-toxin (light chain) secreted by  Clostridium botulinum . The zinc-dependent protease is a thermolysin like protease (TLP) targeting synaptic vesicle fusion proteins and causing severe neurotoxic effects with a lethal dose as low eight nanograms per kilogram of body weight (Lebrun et al 2009). TLPs are present in many microorganism species, and many TLPs are regarded as key pathogenic factors involved in several severe bacterial infections. For example, Lambda-toxin from  Clostridium perfringens  degrades various human immune defense proteins. Vibriolysin from  Vibrio  spec. and Pseudolysin from  Pseudomonas aeruginosa  are potentially lethal blood-poisons in humans. Furthermore,  Bacillus anthracis  also disposes of potent metalloproteases. 
         [0006]    Pseudosysin, aureolysin, bacillolysin, pseudolysin, vibriolysin, and anthrax npr599 belong to the M4 or metzincin family of metalloproteinases for which mammals and many invertebrates lack specific inhibitors. These proteases are presumably at the origin of many pathological symptoms associated with severe infections such as septicemia, hemorrhagic tissue bleeding, necrosis and enhancement of vascular permeability (Chung et al. 2006). Severe diseases like gastric and peptic ulcers and gastric carcinoma originate at least partly from the effect of pathogen M4 metalloproteinases (Schmidtchen et al. 2003, Smith et al. 1994). 
         [0007]    Some virulence factors were recently recognized as putative targets for drug design and therapeutic intervention. While many newly discovered synthetic or natural small organic compounds exhibit anti virulence activity, antibodies neutralizing bacterial toxins are in the focus of current ant virulence strategies in industry. An example for this approach is the Humaneered® PEGylated, recombinant anti- Pseudomonas -PcrV antibody Fab′ fragment (KB001) that inhibits the function of the  Pseudomonas aeruginosa  type III secretion system (TTSS) (Milla et al. 2013). The PEGylation extends serum half-life and also protects against inactivation by proteases (mostly Pseudolysin) secreted by  Pseudomonas aeruginosa  at the target site. A clinical phase I/II trial for pneumonia prevention is currently ongoing. Another example is KBSA 301 from Kenta Biotech, a fully human IgG1 antibody highly specific for  S. aureus  exotoxin being active against MRSA and MSSA. 
         [0008]    Inhibitors of pseudolysin were also identified and published. It was assumed that pseudolysin inhibitors could interfere with biofilm formation and preservation. Thus, all published in vitro tests were carried out as biofilm interference tests of  pseudomonas  a. N-mercaptoacetyl-Phe-Tyr-amide (K(i)=41 nM) (Cathgart G. R. et al, 2011), phosphoramidon, a compound produced by the Bacterium  Streptomyces tanashiensis , and its derivative talopeptin, phosphonomadites, phenanthroline, and small molecules on a quinazolin basis (Khan et al 2009) all target pseudolysin, but also physiological M4 family related proteases of the host. Phosphoramidon, for example, is inhibiting the endogenous protein endothelin converting enzyme (ECE). These side effects are probably the main reason why none of these compounds was investigated further in clinical trials so far. 
         [0009]    Cathgart et al. (2011) observed that a number of pseudolysin inhibitors can reduce already formed  pseudomonas  a. biofilms, whearas planktonic pseudomona a. was not at all affected by said inhibitors. They further observed that biofilms could be completely dissolved when said inhibitors were combined with antibiotics like gentamycin or ciprofloxacin, and both, inhibitor and antibiotic, were applied at high doses. 
         [0010]    Popov et al. (Popov S. G. et al, 2005) published results of an experiment on the simultaneous application of an antibiotic compound (Ciprofloxacin, Bayer Healthcare AG) and metalloprotease inhibitors like phenanthroline and phosphoramidon in mice. They found that the two metalloproteinase inhibitors exerted an additional inhibition on the infectious strain, but only when applied with a delay of one or two days after the animal was challenged of with bacterial spores, and not immediately after the challenge. Immediate application of the inhibitor combination, however, resulted in just an insignificant difference in comparison to applying ciprofloxacin alone. Moreover the authors observed that applying pseudolysin inhibitors alone, i.e. without antibiotics in parallel, had no effect. These observations reflect the general expectation that the therapeutic effect of M4 protease inhibitors is limited to late infection stages when biofilms start forming and pseudolysin is shed. At these stages, a high dosis of both, inbitors and antibiotics, is expected to show strong inhibition of bacterial growth. 
         [0011]    A particular peptide inhibiting thermolysin-like enzymes is the insect metalloproteinase inhibitor IMPIα. It was originally discovered in and purified from the hemolymph of immunized  G. mellonella  larvae (Wedde et al. 1998). Its active moiety comprises 69 amino acids including intramolecular cystein bonds, and a molecular weight of 7667.7 Da. The molecule has a reported IC60 of 0.62, 0.86 and only 81.66 nM for thermolysin, bacillolysin and pseudolysin, respectively. IMPIα was tested against human metallo-matrix proteases MMP1, 2, 3, 7, 8, and -9, of which only MMP1 and MMP2 showed a negligible inhibition. From this comparison it was further deduced that an active site loop would be present in IMPIα between aa 33-aa40, including a cleavage site between aa37 (Asparagine) and aa38 (Isoleucin). Other known protein inhibitors of metalloproteinases do not inhibit proteinases of the M4 protease family. It was shown that IMPIα can be produced recombinantly in bacteria, especially in  E. coli . Eukaryotic cells such as CHO cells, transgenic plants and animals may also serve as sources for recombinant production. Alternatively, chemical synthesis of molecules and cell free recombinant production could also be means to produce IMPIα. 
         [0012]    Vilcinskas A (2011) discloses in a review “Anti-Infective therapeutics from the lepidopteran model host  Galleria mellonella ” Current Pharmaceutical Design 17(13), 1240-124 that the larvae of the greater wax moth  Galleria mellonella  prosper in use both as surrogate alternative model hosts for human pathogens and as a whole-animal-high-throughput-system for in vivo testing of antibiotics or mutant-libraries of pathogens. In addition, a broad spectrum of antimicrobial peptides and proteins has been identified in this insect during the past decade among which some appear to be specific for Lepidoptera. Its arsenal of immunity-related effector molecules encompasses peptides and proteins exhibiting potent activity against bacteria, fungi or both, whose potential as new anti-infective therapeutics is presently being explored. Of particular interest is the insect metalloproteinase inhibitor (IMPI) which has been discovered in  G. mellonella . The IMPI exhibits a specific and potent activity against thermolysin-like microbial metalloproteinases including a number of prominent virulence and/or pathogenic factors of human pathogens which are responsible for severe symptoms such as septicemia, hemorrhagic tissue bleeding, necrosis and enhancement of vascular permeability. The IMPI and antimicrobial peptides from  G. mellonella  may provide promising templates for the rational design of new drugs since evidence is available that the combination of antibiotics with inhibitors of pathogenassociated proteolytic enzymes yields synergistic therapeutic effects. The potential and limitations of insect-derived gene-encoded antimicrobial compounds as antiinfective therapeutics are discussed. 
         [0013]    Anja Clermont, et al discloses in Biochemical Journal August 2004, 382 (1) 315-322, in an article “Cloning and expression of an inhibitor of microbial metalloproteinases from insects contributing to innate immunity” that the first IMPI (inhibitor of metalloproteinases from insects) was identified in the greater wax moth,  Galleria mellonella . They report cloning and expression of a cDNA coding for this IMPI. The IMPI mRNA was identified among the induced transcripts from a subtractive and suppressive PCR analysis after bacterial challenge of  G. mellonella  larvae. Induced expression of the IMPI during a humoral immune response was confirmed by real-time PCR, which documented up to 500 times higher amounts of IMPI mRNA in immunized larvae in comparison with untreated ones. The IMPI sequence shares no similarity with those of tissue inhibitors of metalloproteinases or other natural inhibitors of metalloproteinases, and the recombinant IMPI specifically inhibits thermolysin-like metalloproteinases, but not matrix metalloproteinases. These results support the hypothesis that the IMPI represents a novel type of immune-related protein which is induced and processed during the  G. mellonella  humoral immune response to inactivate pathogenassociated thermolysin-like metalloproteinases. 
         [0014]    R. Caldwell et al. report in 2003 Wiley Periodicals, Inc. J Biomed Mater Res 67A: 1-10, 2003 about “Significant occurrences of arterial restenosis remain a complicating factor of endovascular stent implantation.” The incorporation of GM6001, a matrix metalloproteinase inhibitor (MMPI), into a poly(lactide-co-glycolide) (PLGA) absorbable coating for 316L stainless steel is proposed as a means to reduce the rate of smooth muscle cell proliferation and migration. Coatings were fabricated using a solvent evaporation technique, and the surfaces were characterized by noncontacting profilometry and scanning electron microscopy. Sufficient degradation of the PLGA determined by gel permeation chromatography occurred to release adequate amounts of the GM6001 from the coating within a 7-day period. A cumulative GM6001 release at day 42 was determined to be 77.8±1.4% of the actual GM6001 content within the coating. The coating containing the GM6001 reduced the rate of in vitro cell growth of human aortic smooth muscle cell (HASMC) by 30.7 and 37.4% compared to the metallic substrate only after 4 and 7 days, respectively. However, the MMP-2 activity normalized to cell number was not statistically different between the GM6001 releasing coating and the metal substrate. Using a scrape wound injury assay, the migration of HASMCs was shown to be decreased by 21.4% with GM6001 released from the PLGA coating compared to metallic substrate only. These results suggest that releasing a MMPI from an absorbable coating of a metallic substrate provides a reduction of HASMC proliferation and migration rates, while preserving the overall MMP activity in efforts to retain normal cellular regulation. 
         [0015]    A. Vilcinskas et al. disclose in Entomological Research 37 (Suppl. I) (2007) A79 “The greater wax moth  Galleria mellonella  as a mini-host model for human pathogens and as a reservoir of novel peptide antibiotics.” The IMPI represents a specific inhibitor of microbial metalloproteinases that are virulence factors of human pathogens. It strongly inhibits prominent thermolysin-like metalloproteinases such aureolysin, bacillolysin, pseudolysin and vibriolysin which have been identified as targets for the development of second generation antibiotics (Clermont et al. 2004). Since thermolysin-like microbial metalloproteinases play well established roles during pathogenesis and cause pathologic Symptoms such as increase of vascular permeability, hemorrhagic edema, and septic injury, the IMPI represents a promising template for the design of novel peptide antibiotics (Wedde et al. 2007). 
         [0016]    In summary, most known M4 protease inhibitors were found to exert activity against resistive bacteria only at later stages, whether alone or in combination with antibiotics. 
       SUMMARY OF THE INVENTION 
       [0017]    It is therefore an object of the present invention to provide compound combinations comprising IMPIα or IMPIα-fusion and at least one further bactericidal compound, or nucleic acids encoding for IMPIα or IMPIα-fusions, or their combinations with bactericidal compounds which are efficient in treating bacterial infections, especially infections involving bacteria partially or completely against at least one antibiotic, at any stage of the infection, and especially at early stages. Another aspect of the invention comprises the use of IMPIα or IMPIα-fusion, or nucleic acids encoding for IMPIα or IMPIα-fusions to express these peptides, and optionally at least one further bactericidal compound to treat a bacterial infection, especially infections involving partially or completely resistant bacteria, at any stage of the infection, and especially at an early stage. 
         [0018]    The object underlying the invention is accomplished by applying a composition of claim  1 . The claims depending on one or more independent claims are concerning specific embodiment of the invention. It is understood, that the term “comprising” can be replaced by “consisting of” without adding new matter. 
         [0019]    In one embodiment of the invention comprises the composition as components a polypeptide IMPIα (including wild type) and/or a polypeptide IMPIα-fusion and at least one antibiotic compound, in particular an aminoglycoside antibiotic, and/or at least one bactericidal compound, wherein the polypeptides, the at least one antibiotic and/or the at least one bactericidal compound is (are) present in the composition in concentrations which exhibit in combination a synergistic effect against resistant bacteria. 
         [0020]    The composition of the invention comprises in another embodiment nucleic acids encoding IMPIα or IMPIα-fusion effective against resistant bacteria, optionally in combination with at least one bactericidal and/or at least one antibiotic compound. 
         [0021]    In still another embodiment of the invention the polypeptide is selected from the group consisting of SEQ ID NOs: 10, 18, 20, 22, 24, 26, 28, 30, 32, 34, 36, 38, 40, 42, 44, 46, 48, 50, 52, 54, 56, 58, 60, 62, 64, 66, 68, 70, 72, 74, 76, 78, 80, 82, 84, and IMPIα-fusions, having the amino acid sequences of SEQ ID NOs: 6, 8, 12, 86, 88, 90, 92. 
         [0022]    Subject matter of the present invention is also a polypeptide suitable in a composition the invention, wherein the polypeptide is selected from the group consisting of SEQ ID NOs: 10, 18, 20, 22, 24, 26, 28, 30, 32, 34, 36, 38, 40, 42, 44, 46, 48, 50, 52, 54, 56, 58, 60, 62, 64, 66, 68, 70, 72, 74, 76, 78, 80, 82, 84, and IMPIα-fusions, having the amino acid sequences of SEQ ID NOs: 6, 8, 12, 86, 88, 90, 92. 
         [0023]    Subject matter of the present invention is also the use of a polypeptide having at least 70% homology, in particular 80%, 90% or 95% or 100% homology to the polypeptide of SEQ ID No 2 representing the wild-type of the protein insect metalloproteinase inhibitor IMPIα to treat bacterial infection by reducing the bacterial load of a patient as soon as the infection is suspected or diagnosed, or prophylactically before, during, or after surgery, especially to treat bacterial infection caused by bacteria which are at least partially or completely resistant to at least one antibiotic or bactericidal compound. 
         [0024]    In an embodiment of the invention the polypeptide is used in combination with a further bactericidal compound, especially at least one antibiotic and/or at least one bactericidal compound, wherein the at least one bactericidal or at least one antibiotic compound
       is administered in doses lower than inhibitory upon solitary application, or in higher doses up to maximally tolerable doses, and   is administered essentially simultaneously to IMPIα or separately in an individual dosing scheme, frequency, and treatment duration, especially with treatment breaks during which IMPIα application is continued.       
 
         [0027]    In a further embodiment of the invention the polypeptide is used for treating bacterial infections which are at least partially caused by bacteria resistant to one or more bactericidal and/or antibiotic compounds. 
         [0028]    In yet another embodiment of the invention the polynucleotide coding for the polypeptide of the composition is used to transfect cells of the patient and express said polypeptide in these cells. 
         [0029]    In still another embodiment of the invention the polypeptide of the composition can be used for coating or sterilizing devices, especially implants. It can be advantageously be used in combination with other bactericidal compounds. 
         [0030]    Subject matter of the present invention is also a pharmaceutical composition containing the polypeptide of the composition the invention suitable for injection, inhalation or topical application. 
         [0031]    In one embodiment of the pharmaceutical composition it can comprise further at least one bactericidal and/or at least one antibiotic compound. 
         [0032]    Subject matter of the invention is also the composition of the invention for use in the treatment of an infection of a patient caused by bacteria resistant against one or more antibiotic and/or bactericidal compound, in particular for use in the early treatment of an infection caused by bacteria resistant against one or more antibiotic and/or bactericidal compound. 
         [0033]    As used herein, the following terms have the following meanings unless expressly stated to the contrary. 
         [0034]    The term “device” comprises device used in a clinical setting and especially devices being in contact with patients, and in particular devices being temporarily or permanently in contact with body fluids like blood, serum, lymph, etc., which will be transferred back into the body, or implants designated to be positioned inside a patient&#39;s body. Devices comprise stents, cathetres, intraveneous cannulae, pace makers, artificial joints and bones, biodegradable and permanent medication deposits, patches and debridements, and dental fills and crowns. 
         [0035]    The term “patient” comprises humans infected by bacteria or prone to bacterial infection, regardless of their gender, age, genomic profile, ethnic or anamnesis. 
         [0036]    It also includes all animals infected by bacteria, escpecially domestic animals, such as farm animals including birds and fish, and companion animals like dogs and cats. 
         [0037]    The term “wtIMPIα” refers to a protein with an amino acid sequence as in SEQ ID NO:2 and consists of the N-terminal fragment of the full length IMPI molecule which is endogenously cleaved from the larger precursor molecule IMPI. 
         [0038]    The term “mtIMPIα” or “Mutein IMPIα” comprises all recombinant or synthetic proteins with an amino acid sequence which is at least 70%, especially 80% 90%, 95% homologous, but not identical to SEQ ID NO: 2 (wtIMPIα) and which inhibits at least one protease of the M4 protease family with an IC 50 &lt;1000 nM, especially IC 50 &lt;100 nM, including those solely mutated in the amino acid stretch 35 to 39, such as those listed in amino acid sequence SEQ ID NO: 18, 20, 22, 24, 26, 28, 30, 32, 34, 36, 38, 40, 42, 44, 46, 48, 50, 52, 54, 56, 58, 60, 62, 64, 66, 68, 70, 72, 74, 76, 78, 80, 82, 84. 
         [0039]    The term “M4 protease” refers to the definition given in the MEROPS online database of peptidases (http://merops.sanger.ac.uk/cgi-bin/famsum?family=M4). 
         [0040]    The term “biologically active” as used herein refers to wtIMPIα or mtIMPIα demonstrating inhibition of thermolysin or another member of the M4 protease family with an IC 50 &lt;1000 nM especially IC 50 &lt;100 nM or about 10 nM. 
         [0041]    The term “IMPIα” shall include biologically active mtIMPIα and wtIMPIα, which may be chemically modified. 
         [0042]    The term “IMPIα-fusion” shall include biologically active IMPIα being part of a larger peptide or protein 
         [0043]    The term “resistant bacteria” refers to some subpopulations of bacterial species, which are able to survive after exposure to one or more antibiotics or bactericidial compounds. Bacteria resistant to multiple antibiotics or bactericidial compounds are considered multidrug resistant (MDR). 
         [0044]    The term “early stage” of an infection means at diagnosis of an infection, before diagnosis when only unspecific symptoms of infections are manifest, or even prophylactic, i.e. when a risk of infection is assumed, and no symptoms are manifest. At early stages of an infection bacteria are still in low concentrations at exponential or log growth phases and have not yet formed biofilms to a large extent. A treatment applied at early stage of infections is called an early tetreatment. 
         [0045]    The term “antibiotic compound” means an agent that either kills or inhibits the growth of a microorganism. 
         [0046]    In particular the antibiotic compound is an aminoglycoside antibiotic, e. g. 
         [0000]    
       
         
               
               
               
             
           
               
                   
                   
               
               
                   
                 Generic 
                 Brand Name 
               
               
                   
                   
               
             
             
               
                   
                 Amikacin 
                 Amikin 
               
               
                   
                 Gentamicin 
                 Garamycin, G-Mycin, Jenamicin 
               
               
                   
                 Kanamycin 
                 Kantrex 
               
               
                   
                 Neomycin 
                 Mycifradin, Myciguent 
               
               
                   
                 Netilmicin 
                 Netromycin 
               
               
                   
                 Paromomycin 
                   
               
               
                   
                 Streptomycin 
                 Nebcin 
               
               
                   
                 Tobramycin 
               
               
                   
                   
               
             
          
         
       
     
         [0047]    The term “bactericidial compounds” means a substance that kills bacteria. Bactericides are e.g. disinfectants, antiseptics, or antibiotics. 
         [0048]    The term “synergistic” means that the interaction of multiple elements in a system producing an effect different from or greater than the sum of their individual effects. 
     
    
     
       BRIEF DESCRIPTION OFT THE FIGURES 
         [0049]      FIG. 1 : Comparison of growth curves of  P. aeruginosa  cultures (DSM No. 50071) in the presence (long dashed line) and absence (short dashed line) of the M4-metalloprotease inhibitor IMPIα (45 μM; NB-Medium No. 5) in presence of (a) 1.000, (b) 500, (c) 250 and (d) 125 ng/ml Gentamycin. 
           [0050]      FIG. 2 : Growth curves of  P. aeruginosa  cultures (DSM No. 50071) in presence of different Gentamycin concentrations (8,000; 4,000; 2,000; 1,000; 500; 250; 125; 62.5 ng/ml; NB-Medium) (a) without and (b) in presence of M4-metalloprotease inhibitor IMPIα (45 μM; NB-Medium No. 5) 
           [0051]      FIG. 3 : Growth curves of  P. aeruginosa  cultures (DSM No. 50071) in presence of 45 (black, diamond symbols) and 20 (dark grey, triangles) μM IMPIα and absence (light grey, horizontal bars) of IMPIα (NB-Medium No. 5), in presence of different gentamycin concentrations (8000; 4000; 2000; 1000; 500; 250; 125; 62.5 ng/ml) (a) after 12 h (b) after 24 h (c) after 36 h and (d) after 48 h. 
           [0052]      FIG. 4 : The formation of freely suspended biofilm in flocs is a successful strategy used by  Pseudomonas aeruginosa  to overcome stressful environmental conditions (e.g. addition of Gentamicin Gm to buffer; Panel A (62.5 ng/ml) and B (125 ng/ml)). When incubated with Insect Metalloprotease Inhibitor (IMPIα), biofilm formation is prohibited (Panel C and D at 62.5 and 125 ng/ml Gm doses, respectively). 
           [0053]      FIG. 5 : Comparison of growth curves of  P. aeruginosa  clultures (VB7623, Cllinical isolate from tracheal secrete) in presence (long dashed line) and absence (short dashed line) of the M4-metalloprotease inhibitor IMPIα (25 μM; NB-Medium No. 5) in presence of (a) 1,000 (b) 500, and (c) 250 ng/ml Gentamycin 
           [0054]      FIG. 6 : At low concentrations of gentamycin (dashed lines) the growth rate of  P. aeruginosa  clultures VB7623 seem to enhance growth after 26 h in NB-medium, a growth which could be part of general stress response. 
           [0055]      FIG. 7 : At very low concentrations gentamycin has no effect on the growth rate of  P. aeruginosa  clultures VB7623. Furthermore no stress response can be observed. 
           [0056]      FIG. 8 : Growth curves of  Pseudomonas aeruginosa  cultures (Clinical Isolate VB7623 from tracheal secrete, assessed as 4MRGN strain [EUCAST]) in presence (dark grey, triangles) and absence (light grey, horizontal bars) of the M4-metalloprotease inhibitor IMPIα (25 μM, NB-Medium No. 5) in presence of different gentamycin concentrations (8000; 4000; 2000; 1000; 500, 250, 125, 62.5 ng/ml) (a) after 12 h (b) after 24 h (c) after 36 h and (d) after 48 h. 
           [0057]      FIG. 9 : Comparison of the development of pyoveridine (dark grey background in circular light grey structure, i.e. the plate wells) during growth of  P. aeruginosa  (Clinical Isolate VB7623 from tracheal secrete, assessed as 4MRGN strain [EUCAST]) in presence (lower rectangle) and absence (upper rectangle) of the M4-metalloprotease inhibitor IMPIα (73 μM; NB-Medium No. 5), and different Gentamycin concentrations (32; 8; 4; 2; 1; 0.5; 0.25; 0.125 μg/ml) in a 96-well plate after 48 h. Pyoveridine is not expressed in the concurrent presence of IMPI and Gentamycin, not even at gentamycin concentrations as low as 0.125 μg/ 
           [0058]      FIG. 10 : Comparison of growth curves of  P. aeruginosa P. aeruginosa  cultures (VB7623, Clinical isolate from tracheal secrete) in the presence (long dashed line) and absence (short dashed line) of the M4-metalloprotease inhibitor IMPIα (73 μM; NB-Medium No. 5) in presence of 125 ng/ml gentamycin. 
           [0059]      FIG. 11 : Comparison of growth curves of  P. aeruginosa  cultures (VB7623, Clinical isolate from tracheal secrete) in presence (dark thick line) and absence (short dashed line) of the M4-metalloprotease inhibitor IMPIα (73 μM; NB-Medium No. 5) in presence of different gentamycin-concentrations (500; 250; 125 ng/ml GM), positive control in grey. 
           [0060]      FIG. 12 : Comparison of growth curves of  P. aeruginosa  cultures (clinical isolate VB7623 from tracheal secrete, assessed as 4MRGN strain [EUCAST]) in the presence (dark grey) and absence (light grey) of the M4-metalloprotease inhibitor IMPI (73 μM; NB-Medium No. 5). in the presence of different Gentamycin concentrations (32; 8; 4; 2; 1 μg/ml; 500; 250; 125; 62.5 ng/ml) after (a) 12 h, (b) 24 h, (c) 36 h, (d) 48 h. 
           [0061]      FIG. 13 : Antibiogram of the  Pseudomonas aeruginosa  strain VB7623 which was isolated from the tracheal secrete of a patient. The strain was assessed as multiresistant Gram-negative strain (4MRGN [EUCAST]). 
           [0062]      FIG. 14 : Comparison of growth curves of  P. aeruginosa  cultures (VB7623, clinical isolate from tracheal secrete) in the presence (black line) and absence (grey line) of the M4-metalloprotease inhibitor IMPIα without the use of gentamicin or any other antibiotics. IMPIα concentration is (a) 25 μM; NB-Medium No. 5 and (b) 60 μM; NB-Medium No. 5. 
           [0063]      FIG. 15 : Comparison of the development of planctonic biofilm and pyoveridine (grey colour in the wells) during growth of  P. aeruginosa  (clinical isolate VB7623 from tracheal secrete, assessed as 4MRGN strain [EUCAST]) in the presence (black outlined rectangle) and absence (double outlined rectangle) of the M4-metalloprotease inhibitor IMPI (60 μM; NB-Medium No. 5) in a 96-well plate after 48 h. Pyoveridine (grey colour) is secreted less in presence of IMPIα, in which case also no plantonic biofilm can be observed. 
           [0064]      FIG. 16 : Excitation and emission scan of the fluorophores (a) pyochelin and (b) pyoveridin. Both molecules are essential for virulence and are expressed upon quorum sensing. A difference spectrum was taken by centrifuging the cultivation medium and measuring the supernatant against medium. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0065]    The inventors discovered that applying IMPIα, having for example the amino acid sequences of SEQ ID NOs: 10, 18, 20, 22, 24, 26, 28, 30, 32, 34, 36, 38, 40, 42, 44, 46, 48, 50, 52, 54, 56, 58, 60, 62, 64, 66, 68, 70, 72, 74, 76, 78, 80, 82, 84, and IMPIα-fusions, having for example the amino acid sequences of SEQ ID NOs: 6, 8, 12, 86, 88, 90, 92, reduce and stop growth of resistant bacteria at any stage of the infection, especially when applied in combination with at least one further bactericidal compound, surprisingly when the composition of the invention was applied at early stages of the infection. This observation is surprising because IMPIα interfere with M4 protease activity, for example with thermolysin, pseudolysin, aureolysin, vibriolysin, bacillolysin and npr599, which are shed only at high bacterial concentrations, e.g. during or after biofilm formation as is the case for  pseudomonas aeruginosa . Therefore one has to expect that M4 protease inhibitors only interfere with bacteria after biofilm growth, as several publications on non resistant bacteria suggest. 
         [0066]    The inventors discovered, however, that IMPIα and IMPIα fusions or its combination with bactericidal compounds delays, stops or even reverses growth of resistant bacteria in a solution containing just non adherent bacteria. In this experiment, care was taken by visual inspection that biofilm formation and hence protease shedding had not yet started. More precisely it was observed that a delay of bacterial growth starts much earlier during the so called “late log” (late logarithmic) phase, when bacterial growth kinetics still follows a logarithmic function of time. 
         [0067]    The inventors also discovered that IMPIα and IMPIα fusions or its combination with at least one bactericidal compound effectively prohibits biofilm formation, even for resistant bacterial strains. 
         [0068]    Furthermore the inventors discovered that combining IMPIα or IMPIα-fusions and antibiotics always inhibits growth of resistant bacteria synergistically, regardless of the antibiotics concentration and the stage of the infections. Even at sub inhibitory antibiotic doses IMPIα or IMPIα-fusions interfere with bacterial growth. 
         [0069]    The inventors observed, for example, that the synthesis of the  P. aeruginosa  siderophore pyoverdine, known to be involved in the synthesis of virulence factors, is inhibited synergistically by IMPIα and the antibiotic gentamycin. 
         [0070]    Thus, subject matter of the invention are compositions containing IMPIα or IMPIα-fusions and at least one further bactericidal compound, and the use of any IMPIα against partially or completely resistant or even multiresistant strains of bacteria, such as multiresistant  Staphylococcus aureus  (MRSA) alone or in combination with antibiotics or other bactericidal compounds to treat patients or protect devices, especially implants. This use of IMPIα or IMPIα-fusions is particularly advantageous since it is bactericidal even without applying antibiotics in parallel, or even with very low doses of antibiotics. IMPIα or IMPIα-fusions may be used to affect bacteria being planktonic, isolated sessile or forming biofilms, at any stage of an infection including early stages. Thus, bacteria resistant against antibiotics will still be affected by IMPIα. Moreover, IMPIα can act synergistically with antibiotics in areas of the patient&#39;s body where antibiotics concentrations are low due to, e.g., rapid dilution or low drug influx related to low diffusion rate or mechanisms inducing active outflow of the drug. So by use of IMPIα and IMPIα fusions and combinations with bactericidal compounds according to the invention these areas cannot become areas where, due to sub inhibitory concentrations of the antibiotic, bacteria could respond to the challenge by developing resistance. 
         [0071]    Further contemplated is the use of IMPIα or IMPIα-fusions with the IMPIα element exhibiting additional modifications, such as chemical modifications in the side chain or at the N and/or C terminal for improving biological or chemical properties such as bioavailability, stability, and effectivity. The modification may also provide for a detectable label, for example a chemiluminescent structural element, one or more radioactive isotopes in one or more side chains of an amino acid in the polypeptide, an enzyme which is able to generate a colour reaction and the like. A cystein, for example, may be added for linking a water soluble polymer such as polyethylene glycol, or other amino acids like lysine, cysteine, histidine, arginine, asparaginic acid, glutamic acid, serine, threonine, or tyrosin could also be used for coupling polymers to the peptide. Another example is the insertion of tripeptide sequences NXT or NXS or fragments thereof with X designating any amino acid except P, which may be recognized by a cellular enzyme adding glycosylation elements. Suitable, clinically acceptable, water soluble polymers include polyethylenglycol (PEG) and polysialic acid (PSA). 
         [0072]    IMPIα-fusions according to the invention comprise IMPIα and at least one polypeptide having a physiological function, in particular IMPI13, an antibody or antibody fragment, scaffolds such as lipocalin, ankyrin, fibronectin, transferrin, tetranectin, adnectin, albumin, uteroglobin, or protein A, functional peptides such as transferrin, peptides useful for diagnostic applications, such as green fluorescent protein (GFP), or peptide tags enabling immobilization on technical surfaces, such as hexahistidine, or glutathione-S-transferase (GST). 
         [0073]    There are three super families (cytosolic, mitochondrial, and MAPEG) of GSTs: while classes from the cytosolic super family of GSTs possess more than 40% sequence homology, those from other classes may have less than 25%. Cytosolic GSTs are divided into 13 classes based upon their structure: alpha, beta, delta, epsilon, zeta, theta, mu, nu, pi, sigma, tau, phi, and omega. Mitochondrial GSTs are in class kappa. The MAPEG super family of microsomal GSTs consists of subgroups designated I-IV, between which amino acid sequences share less than 20% identity. Human cytosolic GSTs belong to the alpha, zeta, theta, mu, pi, sigma, and omega classes, while six isozymes belonging to classes I, II, and IV of the MAPEG super family are known to exist: 
         [0000]    
       
         
               
               
             
           
               
                   
               
               
                 GST Class 
                   Homo sapiens  GST Class Members 
               
               
                   
               
             
             
               
                 Alpha 
                 GSTA1, GSTA2, GSTA3, GSTA4, GSTA5 
               
               
                 Kappa 
                 GSTK1 
               
               
                 Mu 
                 GSTM1, GSTM1L (RNAi), GSTM2, GSTM3, GSTM4,  
               
               
                   
                 GSTM5 
               
               
                 Omega 
                 GSTO1, GSTO2 
               
               
                 Pi 
                 GSTP1 
               
               
                 Theta 
                 GSTT1, GSTT2, GSTT4 
               
               
                 Zeta 
                 GSTZ1 (aka GSTZ1 MAAI-Maleylacetoacetate isomerase) 
               
               
                 Microsomal 
                 MGST1, MGST2, MGST3 
               
               
                   
               
             
          
         
       
     
         [0074]    An IMPIα fusion may also comprise a linker of 1-100 amino acids between IMPIα and the polypeptide. 
         [0075]    Another subject matter of the invention are nucleic acids, especially single stranded RNA, coding for IMPIα or IMPIα-fusion, which are administered into a patient and taken up by cells into their cytoplasm, where the cellular protein expression machinery expresses the IMPIα or IMPIα-fusion from the nucleic template. Preferred are nucleic acids coding for an IMPIα-fusion, wherein the fused element comprises a signal peptide inducing secretion of the assembled and posttranslationally modified IMPIα-fusion protein. Once secreted, the IMPIα-fusion protein acts in a manner similar to an IMPIα or IMPIα-fusion protein directly applied to the patient. 
         [0076]    Nucleic acids according to the invention may be modified to resist degradation and improve delivery. Useful modifications include LNA (Locked nucleic acids) or PNA (peptide nucleic acids), and phosphodiester or phosphorothioate modified backbones. Specific formulations for nucleic acid administration in a pharmaceutical composition include liposomes. 
         [0077]    The use of the polypeptide or fusion polypeptide comprising IMPIα according to the invention includes treating patients, such as humans or animals infected by microorganisms capable of secreting bacterial toxins of the M4 or Metzincin family of metalloproteinases, in particular thermolysine, aureolysin, bacillolysin, pseudolysin, vibriolysin, Msp peptidase, Mpl Peptidase, or anthrax npr599. 
         [0078]    In another aspect of the invention, the simultaneous use of antibiotics or other bactericidal compounds, and IMPIα or IMPIα-fusions is provided at any time of infection, including early stages. Simultaneous application may comprise dosing schemes with a delay between application of antibiotics and M4 protease inhibitors, a different application frequency or different and individually evolving dosings. These drug application schemes may prove beneficial for the patient or facilitate the application. 
         [0079]    Bactericidal compounds amenable for use according to the invention include all antibiotics, such as listed in http://en.wikipedia.org/wiki/List_of_antibiotics, for example. They further include antibodies like the anti- Pseudomonas -PcrV antibody Fab′ fragment (KB001, Kalos Therapeutics, Inc.), and a fully human IgG1 antibody highly specific for  S. aureus  Exotoxin (KBSA 301, Kenta Biotech Ltd.) 
         [0080]    Subject matter of the invention are also the use of IMPIα or IMPIα fusions or a nucleic acid comprising a section coding for IMPIα or IMPIα-fusions in a suitable pharmaceutical composition and the use thereof to treat bacterial infections, especially in combination with antibiotics in a single pharmaceutical composition so that they are always applied simultaneously to the patient. 
         [0081]    Another embodiment of the invention comprises the use of antibiotics or other bactericidal compounds in one pharmaceutical composition and of IMPIα or IMPIα-fusions or a nucleic acid comprising a section coding for IMPI or IMPIα or IMPIα-fusions in a separate one. The separate entities can be advantageous for treating patients since the doses relative to each other can be varied independently over time, as well as the individual frequency of administration. A delayed application of the two compositions may be beneficial to prohibit side effects to occur or to limit their strength. Separate entities exhibit the further advantage that different formulations can be chosen, which may even be required for particular molecule combinations. 
         [0082]    Subject matter of the invention are also particular dosing schemes, such as combining maximum doses for both, IMPIα and bactericidal compounds. Another dosing scheme may include reduction of the applied dose of the bactericidal compound for some time, even down to sub inhibitory doses, where the combination of IMPIα and the bactericidal compound is still active. The benefit of such temporary dose regimen would be to encounter development of resistance against the compounds. 
         [0083]    IMPIα or IMPIα-fusions may be combined with ingredients to form a pharmaceutical composition. The pharmaceutical composition may include water and salts at physiological concentrations, solubilizing or dispersing agents, or anti-oxidant, or particles forming micelles, such as liposomes. This pharmaceutical composition may be filled in a glass or plastic vials, or in a syringe. The pharmaceutical composition may also contain additives supporting drying or freeze-drying of the pharmaceutical composition, for example cyclodextrins or saccharides, in particular disaccharides. 
         [0084]    IMPIα or IMPIα-fusions or nucleic acids encoding for IMPIα or IMPIα-fusions and combinations with bactericidal compounds may be administered parenterally, orally, or topically using suitable pharmaceutical compositions, or attached to a patch or wound debridement from where the medication elutes into a wound of the patient. 
         [0085]    IMPIα or IMPIα-fusions or nucleic acids encoding for IMPIα or IMPIα-fusions and combinations with bactericidal compounds may be administered in biodegradable containers suitable for implantation into patients, or a reservoir attached or included in a device may contain IMPIα or IMPIα-fusions actively or passively deployed so that the device is situated in an area with known high load of target bacteria. 
       Examples 
       [0086]    1. Measurements of Extracellular DNA in Microtitre Tray Cultures 
         [0087]    A method for tracking eDNA (extracellular DNA) was derived and compiled partly from similar procedures and conditions found in the literature and modified by the inventors. 
         [0088]    The reference strain  P. aeruginosa  (DSM No. 50071; MIC 8 mg/liter), partially resistant to Gentamycin, was studied in parallel with a clinical isolate of  P. aeruginosa  PAO1 (DSM No. 19880) to evaluate eDNA accumulation over time in the presence and absence of IMPI. First the strains were cultured in NB medium (Nutrient Broth No. 4) overnight at 37° C. and grown to stationary phase. From these bacteria, 5 μl were used to inoculate 96-well black flat bottom plates (Greiner) containing NB medium (200 μl). The NB medium contained either double concentrated NB medium (2×; 100 μl) diluted with 100 μl TBS-buffer (Negative Control) or medium diluted with IMPI, which was previously solved in TBS (100 μl; Positive Control). The final concentration of IMPI per well was 35 μM for experiments with  P. aeruginosa  DSM 50071 and DSM 19880 respectively. To stain extracellular DNA and membrane-compromised (dead) bacteria in aggregates of  P. aeruginosa,  1 μL of 1 mm stock solution of BOBO-3 stain (Life Technologies) was added to 5 mL cultures at the start of growth experiments (incubation in the dark). BOBO-3 is a membrane-impermeable fluorescent dye (λ ex 570, λ em 602) that binds to DNA and therefore specifically stains extracellular DNA which Images were taken over 48 h by a high-definition area scan (99×99 points) on a well of a 96-well microplate using a synergy H4 plate reader (Biotek). 
         [0089]    2. MIC Determination and OD-Measurement 
         [0090]    Gentamycin MIC (minimal inhibitory concentration) values were determined using a standard two fold microtiter broth dilution protocol with Nutrient Broth as medium. Midexponential phase cultures of  P. aeruginosa  reference strain DSM No.: 50071 and two antibiotic-resistant clinical isolates ( P. aeruginosa  VB7623 and VB7444), which were isolated from the tracheal secrete of a patient, were tested. Antimicrobial susceptibility testing of the clinical isolates was performed by the University Clinic Tubingen. Typically gentamicin concentrations between 8 μg/ml and 0.0625 μg/ml were chosen to estimated bacterial growth and determine the MIC values. Further, the OD (optical density) at 600 nm in the presence and absence of the insect metalloprotease inhibitor IMPI was investigated. For assessing influences of IMPI on bacterial growth final concentrations of IMPI between 20 and 75 μM were used. Bacterial growth was monitored at 37° C. over 48 h. All MIC values were done as triplicates. 
         [0091]    The subsequent table lists the sequences printed in the ensuing sequence protocol. The leading number denotes the SEQ ID NO for the nucleotide sequence, the subsequent even number missing number would denote the SEQ ID NO of the respective peptide sequence. 
         [0000]    1 IMPIalpha (wild type or wtIMPIalpha)
 
3 IMPIbeta (wild type or wt IMPIbeta)
 
       5 GST/IMPIalpha 
     7 GST/IMPIbeta 
     9: IMPIalpha Pos37 NnG Pos38 InL Pos39 RnA 
     11: GST/IMPIalpha Pos37 NnG Pos38 InL Pos39 RnA 
     13: IMPIalpha Pos52 RnK 
     15: GST/IMPIalpha Pos52 RnK 
     17: IMPI Pos35 InL 
     19: IMPI Pos35 InM 
     21: IMPI Pos35 InF 
     23: IMPI Pos35 InC 
     25: IMPI Pos35 InN 
     27: IMPI Pos35 InQ 
     29: IMPI Pos35 InH 
     31: IMPI Pos35 InK 
     33: IMPI Pos35 InR 
     35: IMPI Pos36 InV 
     37: IMPI Pos36 InM 
     39: IMPI Pos36 InF 
     41: IMPI Pos36 InW 
     43: IMPI Pos36 InY 
     45: IMPI Pos36 InS 
     47: IMPI Pos36 InT 
     49: IMPI Pos36 InN 
     51: IMPI Pos36 InQ 
     53: IMPI Pos36 InH 
     55: IMPI Pos36 InR 
     57: IMPI Pos36 InK 
     59: IMPI Pos39 InV 
     61: IMPI Pos39 InK 
     63: IMPI Pos35 InW 
     65: IMPI Pos35 InY 
     67: IMPI Pos39 RnA 
     69: IMPI Pos35 InC 
     71: IMPI Pos35 InK 
     73: IMPI Pos35 InR 
     75: IMPI Pos35 InL 
     77: IMPI Pos35 InM 
     79: IMPI Pos35 InF 
     81: IMPI Pos35 InQ 
     83: IMPI Pos35 InH 
     85: GST/IMPI Pos35 InN 
     87: GST/IMPI Pos36 InS 
     89: GST/IMPI Pos39 InK 
     91: GST/IMPI Pos35 InC 
       [0092]    93: IMPI signal peptide,
 
95: IMPI like ( Solenopsis , Peptide only, no nucleotide sequence provided)
 
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