COMPOSITIONS TO PROMOTE THE HEALING OF SKIN ULCERS AND WOUNDS

Abstract

The present invention provides compositions comprising as an essential feature granulocyte-macrophage colony-stimulating factor (GM-CSF) together with fosfomycin for the treatment of wounds, ulcers, sores, burns and other injuries to the skin or mucous membranes of the body.

Claims

1. A pharmaceutical composition comprising a. granulocyte-macrophage colony-stimulating factor (GM-CSF) or a fragment or variant thereof, and b. fosfomycin in the form of an inorganic or organic salt thereof.

2. A method of accelerating the healing of a bacterially infected lesion comprising a wound, ulcer, sore or burn of the skin, mucosal membranes or connective tissue underlying the lesion, comprising: topically applying a pharmaceutical composition containing as active ingredients: i) granulocyte-macrophage colony-stimulating factor (GM-CSF) in the form of molgramostim or sargramostim, and ii) fosfomycin calcium to a subject that has said bacterially infected lesion, said composition being applied to the lesion as a dry powder.

3. The method according to claim 2 wherein the lesion is chronic.

4. The method according to claim 2 wherein the lesion is acute.

5. The method according to claim 2, wherein the lesion is associated with diabetes mellitus.

6. The method according to claim 2, wherein the lesion is associated with a decreased circulation of blood, a venous leg ulcer, a venous foot ulcer, an arterial leg ulcer, an arterial foot ulcer, or a decubitus ulcer.

7. The method according to claim 2, wherein the pharmaceutical composition contains GM-CSF at a concentration of 1 μg/g to 10 mg/g.

8. The method according to claim 2, wherein the pharmaceutical composition further comprises one or more additional antibiotic or antimicrobial agents.

9. The method according to claim 2, wherein the lesion is colonized by a bacterium, fungus, virus, or parasite.

10. The method according to claim 2, wherein the pharmaceutical composition comprises GM-CSF at a concentration of 5 μg/g to 500 μg/g.

11. The method according to claim 2, wherein the pharmaceutical composition comprises GM-CSF at a concentration of 10 μg/g to 200 μg/g.

Description

DETAILED DESCRIPTION OF THE INVENTION

[0040] The present invention provides compositions comprising granulocyte-macrophage-colony stimulating factor (GM-CSF) or a fragment or variant thereof, fosfomycin in the form of an inorganic or organic salt thereof, and in a further embodiment, an additional antibiotic or antimicrobial agent, and in a still further embodiment, an additional agent which has been found to promote wound healing. Such compositions are useful for the treatment of wounds, ulcers, sores and other types of injury to the skin and mucous membranes and are intended to be topically applied in various ways which be further described. The compositions and methods of the present invention are also in some embodiments useful in methods of treatment.

GM-CSF Preparations

[0041] For practical purposes, the GM-CSF preparations to be used in the present invention will not be purified native human GM-CSF, which could of course be used if it were available in sufficient quantity and problems of possible viral contamination were overcome, but human GM-CSF prepared in vitro by recombinant DNA technology. The preparation of human recombinant GM-CSF (hrGM-CSF) in mammalian cells has been described (Wong G G et al., 1985; Kaushansky K et al., 1986). Similar work has led to the production of hrGM-CSF with the non-proprietary name regramostim in Chinese hamster ovarian (CHO) cells (first reported by Moonen P et al., 1987). The expression of hrGM-CSF in Saccharomyces cerevisiae was reported by Cantrell M A et al. (1985), leading to the preparation known by the non-proprietary name sargramostim. Sargramostim differs from endogenous human GM-CSF in having a leucine residue instead of a praline residue at position 23 of the pro-peptide and is less glycosylated than either endogenous human GM-CSF or regramostim (Armitage J O, 1998). The expression of hrGM-CSF in Escherichia coli was reported by Burgess A W et al. (1987), leading to the preparation known by the non-proprietary name molgramostim, which is not glycosylated. All three hrGM-CSF preparations, regramostim, sargramostim and molgramostim can be used in the present invention, but only the last two are currently available.

[0042] A “functional homologue” of human GM-CSF is herein defined as a polypeptide having at least 50% sequence identity with the known and naturally occurring sequence and sequence variants of human GM-CSF and has one or more functions of the naturally occurring protein. These functions include the following: stimulating the growth and differentiation of hematopoietic precursor cells from various lineages, including granulocytes, macrophages and monocytes, enhancing functional activities of mature effector cells involved in antigen presentation and cell-mediated immunity, including neutrophils, monocytes, macrophages, and dendritic cells. The functions also include those of particular relevance to wound healing, such as facilitating wound contraction, causing local recruitment of inflammatory cells, improving the recruitment of neutrophils, inducing keratinocyte proliferation, activating mononuclear phagocytes, promoting the migration of epithelial cells, and further regulating cytokine production in the healing process. Regramostim, sargramostim and molgramostim may all be said to be functional homologues of naturally occurring human GM-CSF.

[0043] Evolutionary conservation between GM-CSF homologues of different closely related species, as assessed by amino-acid sequence alignment, can be used to pinpoint the degree of evolutionary pressure on individual amino-acid residues. Preferably, GM-CSF sequences are compared between species where GM-CSF function is conserved, for example, but not limited to mammals, including rodents, monkeys and apes. Residues under high selective pressure are more likely to represent essential amino acid residues that cannot easily be substituted than residues that change between species. It is evident from the above that a reasonable number of modifications or alterations of the human GM-CSF sequence can be made without interfering with the activity of the GM-CSF molecule according to the invention. Such GM-CSF molecules are herein referred to as functional homologues of human GM-CSF, and may be such variants and fragments of native human GM-CSF as described below.

[0044] As used herein, the expression “variant” refers to a polypeptide or protein which is homologous to the index protein, which is naturally occurring human GM-CSF in the present instance, but which differs from the index protein in that one or more amino-acid residues within the sequence of the index protein are substituted by other amino-acid residues. These substitutions may be regarded as “conservative” when an amino-acid residue is replaced by a different amino-acid residue with broadly similar properties, and “non-conservative” when an amino-acid residue is replaced by one of a different type. Broadly speaking, fewer non-conservative substitutions will be possible without altering the biological activity of the polypeptide.

[0045] A person skilled in the art will know how to make and assess “conservative” amino-acid substitutions, by which one amino-acid residue is substituted by another having one or more shared chemical and/or physical characteristics. Conservative amino-acid substitutions are less likely to affect the functionality of the protein. Amino acids may be grouped according to their shared characteristics. A conservative amino-acid substitution is a substitution of one amino acid within a predetermined group of amino acids for another amino acid within the same group, within which the amino acids exhibit similar or substantially similar characteristics. Within the meaning of the term “conservative amino acid substitution” as applied herein, one amino acid may be substituted by another within groups of amino acids characterized by having [0046] i) polar side chains (Asp, Glu, Lys, Arg, His, Asn, Gin, Ser, Thr, Tyr and Cys) [0047] ii) non-polar side chains (Gly, Ala, Val, Leu, lie, Phe, Trp, Pro and Met) [0048] iii) aliphatic side chains (Gly, Ala Val, Leu and Ile) [0049] iv) cyclic side chains (Phe, Tyr, Trp, His and Pro) [0050] v) aromatic side chains (Phe, Tyr and Trp) [0051] vi) acidic side chains (Asp and Glu) [0052] vii) basic side chains (Lys, Arg and His) [0053] viii) amide side chains (Asn and Gin) [0054] ix) hydroxyl side chains (Ser and Thr) [0055] x) sulfur-containing side chains (Cys and Met) [0056] xi) amino acids being monoamino-dicarboxylic acids or monoamino-monocarboxylic-monoamidocarboxylic acids (Asp, Glu, Asn and Gin).

[0057] A functional homologue within the scope of the present invention is a polypeptide that exhibits at least 50% sequence identity with a naturally occurring form of human GM-CSF, such as at least 60% sequence identity, for example at least 70% sequence identity, such as at least 75% sequence identity, for example at least 80% sequence identity, such as at least 85% sequence identity, for example at least 90% sequence identity, such as at least 91% sequence identity, for example at least 91% sequence identity, such as at least 92% sequence identity, for example at least 93% sequence identity, such as at least 94% sequence identity, for example at least 95% sequence identity, such as at least 96% sequence identity, for example at least 97% sequence identity, such as at least 98% sequence identity, for example 99% sequence identity with a naturally occurring form of human GM-CSF.

[0058] Sequence identity can be calculated using a number of well-known algorithms and applying a number of different gap penalties. Any sequence alignment algorithm, such as but not limited to FASTA, BLAST, or GETSEQ, may be used for searching homologues and calculating sequence identity. Moreover, when appropriate, any commonly known substitution matrix, such as but not limited to PAM, BLOSSUM or PSSM matrices, may be applied with the search algorithm. For example, a PSSM (position specific scoring matrix) may be applied via the PSI-BLAST program. Moreover, sequence alignments may be performed using a range of penalties for gap-opening and extension. For example, the BLAST algorithm may be used with a gap-opening penalty in the range 5-12, and a gap-extension penalty in the range 1-2.

[0059] Accordingly, a variant or a fragment thereof according to the invention may comprise, within the same variant of the sequence or fragments thereof, or among different variants of the sequence or fragments thereof, at least one substitution, such as a plurality of substitutions introduced independently of one another.

[0060] It is clear from the above outline that the same variant or fragment thereof may comprise more than one conservative amino-acid substitution from more than one group of conservative amino acids as defined herein above.

[0061] Aside from the twenty standard amino acids and two special amino acids, selenocysteine and pyrrolysine, there are a vast number of “non-standard amino acids” which are not incorporated into protein in vivo. Examples of nonstandard amino acids include the sulfur-containing taurine and the neurotransmitters GABA and dopamine. Other examples are lanthionine, 2-aminoisobutyric acid, and dehydroalanine. Further non-standard amino are ornithine and citrulline.

[0062] Non-standard amino acids are usually formed through modifications to standard amino acids. For example, taurine can be formed by the decarboxylation of cysteine, while dopamine is synthesized from tyrosine and hydroxyproline is made by a posttranslational modification of praline (common in collagen). Examples of non-natural amino acids are those listed e.g. in 37 C.F.R. section 1.822 (b)(4), all of which are incorporated herein by reference.

[0063] Both standard and non-standard amino acid residues described herein can be in the “D” or “L” isomeric form.

[0064] It is contemplated that a functional equivalent according to the invention may comprise any amino acid including non-standard amino acids. In preferred embodiments, a functional equivalent comprises only standard amino acids.

[0065] The standard and/or non-standard amino acids may be linked by peptide bonds or by non-peptide bonds. The term peptide also embraces post-translational modifications introduced by chemical or enzyme-catalyzed reactions, as are known in the art. Such post-translational modifications can be introduced prior to partitioning, if desired. Amino acids as specified herein will preferentially be in the L-stereoisomeric form. Amino acid analogs can be employed instead of the 20 naturally occurring amino acids. Several such analogs are known, including fluorophenylalanine, norleucine, azetidine-2-carboxylic acid, S-aminoethyl cysteine, 4-methyl tryptophan and the like.

[0066] In one embodiment of the present invention, the GM-CSF variant comprises a conjugate capable of prolonging half-life of the active ingredient, such as for example albumin or a fatty acid.

[0067] Suitable variants will be at least 60% identical, preferably at least 70%, and accordingly, variants preferably have at least 75% sequence identity, for example at least 80% sequence identity, such as at least 85% sequence identity, for example at least 90% sequence identity, such as at least 91% sequence identity, for example at least 91% sequence identity, such as at least 92% sequence identity, for example at least 93% sequence identity, such as at least 94% sequence identity, for example at least 95% sequence identity, such as at least 96% sequence identity, for example at least 97% sequence identity, such as at least 98% sequence identity, for example 99% sequence identity with the predetermined sequence of a naturally occurring form of human GM-CSF.

[0068] Functional homologues may further comprise chemical modifications such as ubiquitination, labeling (e.g., with radionuclides, various enzymes, etc.), pegylation (derivatization with polyethylene glycol), or by insertion (or substitution by chemical synthesis) of amino acids such as ornithine, which do not normally occur in human proteins.

[0069] In addition to the peptidyl compounds described herein, sterically similar compounds may be formulated to mimic the key portions of the peptide structure and such compounds may also be used in the same manner as the polypeptides of the invention. This may be achieved by techniques of modelling and chemical designing known to those of skill in the art. For example, esterification and other alkylations may be employed to modify the amino terminus (N-terminus) of, e.g., a di-arginine peptide backbone, to mimic a tetrapeptide structure. It will be understood that all such sterically similar constructs fall within the scope of the present invention.

[0070] Peptides with N-terminal alkylations and C-terminal esterifications are also encompassed by the present invention. Functional equivalents also comprise glycosylated and covalent or aggregative conjugates formed with the same molecules, including dimers or unrelated chemical moieties. Such functional equivalents are prepared by linkage of functionalities to groups which are found in a fragment that includes any one or both of the N- and C-termini, by means known in the art.

[0071] The term “fragment thereof” may refer to any portion of the given amino-acid sequence. Fragments may comprise more than one portion from within the full-length protein, joined together. Suitable fragments may be deletion or addition mutants. The addition of at least one amino acid may be an addition of from preferably 2 to 250 amino acids, such as from 10 to 20 amino acids, for example from 20 to 30 amino acids, such as from 40 to 50 amino acids. Fragments may include small regions from the protein or combinations of these. The deletion and/or the addition may, independently of one another, be a deletion and/or an addition within a sequence and/or at the end of a sequence.

[0072] Deletion mutants suitably comprise at least 20 or 40 consecutive amino acid and more preferably at least 80 or 100 consecutive amino acids in length. Accordingly, such a fragment may be a shorter sequence taken from the sequence of human GM-CSF comprising at least 20 consecutive amino acids, for example at least 30 consecutive amino acids, such as at least 40 consecutive amino acids, for example at least 50 consecutive amino acids, such as at least 60 consecutive amino acids, for example at least 70 consecutive amino acids, such as at least 80 consecutive amino acids, for example at least 90 consecutive amino acids, such as at least 95 consecutive amino acids, such as at least 100 consecutive amino acids, such as at least 105 amino acids, for example at least 110 consecutive amino acids, such as at least 115 consecutive amino acids, for example at least 120 consecutive amino acids, wherein said deletion mutants preferably has at least 75% sequence identity, for example at least 80% sequence identity, such as at least 85% sequence identity, for example at least 90% sequence identity, such as at least 91% sequence identity, for example at least 91% sequence identity, such as at least 92% sequence identity, for example at least 93% sequence identity, such as at least 94% sequence identity, for example at least 95% sequence identity, such as at least 96% sequence identity, for example at least 97% sequence identity, such as at least 98% sequence identity, for example 99% sequence identity with a naturally occurring form of human GM-CSF.

[0073] It is preferred that functional homologues of GM-CSF comprise at most 500, more preferably at most 400, even more preferably at most 300, yet more preferably at most 200, such as at most 175, for example at most 160, such as at most 150 amino acids, for example at most 144 amino acids.

[0074] There are two known variants of human GM-CSF: a T1151 substitution in variant 1 and a I117T substitution in variant 2. Accordingly, in one embodiment of the invention, a functional homologue of GM-CSF comprises a sequence with high sequence identity to human GM-CSF NO: 1 or any of the splice variants.

[0075] Analogues of GM-CSF are, for example, described in U.S. Pat. Nos. 5,229,496, 5,393,870, and 5,391,485. Such analogues are also functional equivalents comprised within the present invention.

[0076] In one embodiment, GM-CSF is used according to the present invention in homo- or heteromeric form. Homo- and heteromeric forms of GM-CSF may comprise one or more GM-CSF monomers or functional homologous of GM-CSF as defined herein above. Homo- and heteromers include dimers, trimers, tetramers, pentamers, hexamers, heptamers, octamers, nonamers and decamers.

[0077] In one embodiment, a homodimer, trimer or tetramer of GM-CSF is used.

[0078] The amino-acid sequence of the precursor (including the signal peptide) form of GM-CSF of Homo sapiens (SEQ ID NO:1) is:

TABLE-US-00001 MWLQSLLLLG TVACSISAPA RSPSPSTQPW EHVNAIQEAR RLLNLSRDTA AEMNETVEVI SEMFDLQEPT CLQTRLELYK QGLRGSL TKL KGPLTMMASH YKQHCPPTPE TSCATQIITF ESFKENLKDF LLVIPFDCWE PVQE.

[0079] The amino-acid sequence of the corresponding mature protein (SEQ ID NO: 2) is:

TABLE-US-00002 APARSPSPST QPWEHVNAIQ EARRLLNLSR DTMEMNETV EVISEMFDLQ EPTCLQTRLE LYKQGLRGSL TKLKGPLTMM ASHYKQHCPP TPETSCATQI ITFESFKENL KDFLLVIPFD CWEPVQE

[0080] Functional homologues of a naturally occurring form of human GM-CSF according to the present invention may be commercially available, e.g. sargramostim (Leukine®; Immunex, Seattle, Wash., USA).

Recombinant Production of GM-CSF

[0081] GM-CSF or functional variants or homologues thereof can be produced in various ways, such as isolation from for example human or animal serum or from expression in cells, such as prokaryotic cells, yeast cells, insect cells, mammalian cells or in cell-free systems.

[0082] In one embodiment of the invention, GM-CSF is produced recombinantly by host cells. Thus, in one aspect of the present invention, GM-CSF is produced by host cells comprising a first nucleic acid sequence encoding the GM-CSF operably associated with a second nucleic acid sequence capable of directing expression in said host cells. The second nucleic acid sequence may thus comprise or even consist of a promoter that will direct the expression of protein of interest in said cells. A skilled person will be readily capable of identifying useful second nucleic acid sequence for use in a given host cell.

[0083] The process of producing a recombinant GM-CSF in general comprises the steps of [0084] providing a host cell [0085] preparing a gene expression construct comprising a first nucleic acid sequence encoding the GM-CSF operably linked to a second nucleic acid sequence capable of directing the expression of said protein of interest in the host cell [0086] transforming the host cell with the construct [0087] cultivating the host cell, thereby obtaining expression of the GM-CSF.

[0088] The recombinant GM-CSF thus produced may be isolated by any conventional method, such as any of the methods for protein isolation described herein below. The skilled person will be able to identify suitable protein isolation steps for purifying the GM-CSF.

[0089] In one embodiment of the invention, the recombinantly produced GM-CSF is excreted by the host cells. When the GM-CSF is excreted, the process of producing a recombinant protein of interest may comprise the steps of [0090] providing a host cell [0091] preparing a gene expression construct comprising a first nucleic acid sequence encoding the GM-CSF operably linked to a second nucleic acid sequence capable of directing the expression of said protein of interest in said host cell [0092] transforming said host cell with the construct [0093] cultivating the host cell, thereby obtaining expression of the GM-CSF and secretion of the GM-CSF into the culture medium [0094] thereby obtaining culture medium containing the GM-CSF.

[0095] The composition comprising GM-CSF and nucleic acids may thus in this embodiment of the invention be the culture medium or a composition prepared from the culture medium.

[0096] In another embodiment of the invention, said composition is an extract prepared from animals, parts thereof or cells or an isolated fraction of such an extract.

[0097] In an embodiment of the invention, the GM-CSF is recombinantly produced in vitro in host cells and isolated from cell lysate, cell extract or from tissue culture supernatant. In a more preferred embodiment, the GM-CSF is produced by host cells that are modified in such a way that they express the relevant GM-CSF. In an even more preferred embodiment of the invention, said host cells are transformed to produce and excrete the relevant GM-CSF.

[0098] Pharmaceutical compositions according to the present invention may comprise GM-CSF or functional variants or homologues thereof at a concentration of 1 μg/mL to 10 mg/mL, more preferably 5 μg/mL to 500 μg/mL, and even more preferably 10 μg/mL to 200 μg/mL.

Fosfomycin Preparations

[0099] The fosfomycin preparations that fall within the scope of the present invention are compounds and salts of compounds that comprise the structure (−)(IR, 2 S)-1,2-epoxypropylphosphonic acid, systematic name [(2R,3S)-3-methyloxiran-2-yl]phosphonic acid, formula weight 138.1 Da. Although the free acid form of this structure is used as a basis for calculating the effective amounts and concentrations of fosfomycin, the free acid is unstable and the antibiotic is presented for clinical use as an inorganic or organic salt. Non-limiting examples of inorganic counter-ions of fosfomycin salts within the scope of the present invention are sodium, calcium, potassium, lithium, ammonium, magnesium. Non-limiting examples of organic counter-ions of fosfomycin salts within the scope of the present invention are trometamol (also known as tromethamine or tris, systematic name 2-amino-2-hydroxymethyl-propane-1,3-diol), phenylethylamine, and a large number of other biocompatible organic amines. The principal forms of fosfomycin in current use that come within the scope of this invention are: [0100] i) Fosfomycin disodium, formula weight 182.0 Da, pH of 5% solution 9.0-10.5. This salt is highly soluble in water, irritant to the stomach, and is principally used for intravenous injection. [0101] ii) Fosfomycin calcium monohydrate, formula weight 194.1 Da, pH of 0.4% solution 8.1-9.6. This salt is sparingly soluble in water but is less irritating to the stomach and is used for oral treatment. Its bioavailability may be as low as 12% (Bergan T, 1990). [0102] iii) Fosfomycin trometamol, formula weight 259.2 Da, pH of 5% solution 3.5-5.5. This salt is highly soluble in water, is well tolerated when given orally and is used especially as a single-dose oral treatment for lower urinary tract infection, showing a bioavailability of about 40%.

[0103] Common to these preparations is that they are stable for at least 3 years as dry powders at 25° C., but show a pH-dependent instability in aqueous solution, at 25° C. losing 10% of fosfomycin activity within 10 h at pH 3, 2 months at pH 6.5 and 2 years at pH 9.75. Reduced stability at low pH must be taken into in account when formulating aqueous compositions for topical application with a suitable shelf life.

Combination with Other Antimicrobial Agents

[0104] A composition of the present invention may also contain one or more additional antimicrobial agents to potentiate its bactericidal action on important pathogens such as Staphylococcus aureus or Pseudomonas aeruginosa, prevent the overgrowth of any strains that develop resistance on prolonged treatment, or broaden the antimicrobial spectrum to include non-bacterial pathogens, including but not limited to fungi. Non-limiting examples of antimicrobial agents that may be included in the composition are: fusidic acid or sodium fusidate, penicillins, cephalosporins, aminoglycosides, macrolides, vancomycin, lincomycin, clindamycin, fluoroquinolones, mupirocin, bacitracin, polymyxin B, gramicidins, metronidazole, clotrimazole, ketoconazole and nystatin. Particularly suitable for inclusion are agents which show a synergic bactericidal action with fosfomycin, non-limiting examples of which are: penicillin, ampicillin, carbenicillin, methicillin, oxacillin, mezlocillin, piperacillin, aztreonam, imipenem, cephalexin, cephalothin, cefamandole, cefoxitin, cefmetazole, cefotaxime, cefazolin, cefoperazone, cefsulodine, ceftadizime, cefepime, streptomycin, gentamicin, kanamycin, netilmicin, tobramycin, amikacin, erythromycin, midecamycin, vancomycin, lincomycin, clindamaycin, teicoplanin, daptomycin, ciprofloxacin, ofloxazine, levofloxazin, pefloxacin, sparfloxacin. Certain antibiotics are incompatible with fosfomycin in aqueous solution, such as ampicillin, methampicillin, cephaloridine, cephalothin, streptomycin, gentamicin, kanamycin, a feature that may make them unsuitable for aqueous compositions within the scope of this invention.

[0105] In one embodiment, the additional antibiotic or antibacterial agent is selected from the list of arbekacin, aztreonam, cefoxitin, cefoperazone, cephalexin, clindamycin, flucloxacillin, meropenem, metronidazole, mezlocillin, or vancomycin. The selection of clindamycin or meropenem or metronidazole is particularly intended for the treatment of wounds suspected or known through appropriate bacterial culture to be infected with anaerobic bacteria including Bacteroides species.

[0106] In another embodiment, the additional antibiotic is at least a combination of aztreonam and arbekacin. This is particularly intended for the treatment of wounds suspected or known through appropriate bacterial culture to be infected with Pseudomonas aeruginosa.

[0107] As all the above compounds are known to the skilled person, it will not present an undue burden to the skilled person to choose from the list of compounds which compound(s) to combine with the GM-CSF and fosfomycin treatment on the basis of test data on the identity of the infective organisms that are to be treated.

Further Ingredients of the Pharmaceutical Composition

[0108] Vitamin A and anti-oxidant agents may further have a stimulating effect on the tissue during the process of healing. In one embodiment of the present invention, the composition as defined herein further comprises vitamin A and/or an anti-oxidant agent, non-limiting examples of which are: vitamin E (in the form of alpha-tocopherol), ubiquinone, idebenone, carotenoids such as lycopene, ascorbic acid or ascorbates, and nicotinamide.

Dose

[0109] By “effective amount” of the pharmaceutical compositions of the present invention is meant a dose, which, when administered to a subject in need thereof, achieves a concentration which has a beneficial biological effect, i.e. by treatment, prevention or alleviation of irritation or lesion such as wounds, ulcers and other lesions of the skin, mucosal membranes or connective tissue of the body. Such an effective amount may be determined by a patient's attending physician or veterinarian and is readily ascertained by one of ordinary skill in the art. Factors which influence what a therapeutically effective amount will be include the following: [0110] i) The specific activity of the therapeutic agent being used, [0111] ii) The type of lesion (mechanical or thermal, full or partial thickness, etc.) [0112] iii) The size of the lesion [0113] iv) The depth of the lesion (if full thickness) [0114] v) The presence of infection and the type of infection [0115] vi) The time elapsed since the infliction of the injury infliction [0116] vii) The existence of other disease states [0117] viii) The age, physical condition, and nutritional status of the patient

[0118] Other medication that the patient may be receiving will affect the determination of the therapeutically effective amount of the therapeutic agent to administer.

[0119] Whereas the effective amounts and dosages of the ingredients of the a pharmaceutical composition are determined in relation to body weight or body surface area for systemic treatments, for topical application of a composition to wounds and ulcers, the effective amounts and dosages are more appropriately expressed in terms of the area of wound or ulcer to be treated, e.g. expressed in square centimeters, provided that the systemic absorption of the active ingredients does not lead to an adversely high dosage for the patient.

[0120] The effective amount of GM-CSF or a functional variant or homologue thereof, for topical application to a wound or ulcer may be from 1 microgram (μg) to 100 μg per square centimeter per day, such as in the range of 2 μg to 80 μg per square centimeter per day, and especially in the range of 5 μg to 50 μg per square centimeter per day. The effective amount is expressed in terms of the amount to be given of a fully functional homologue of human GM-CSF such as molgramostim and is adjusted according to functional activity of the homologue used.

[0121] In practical terms, a pharmaceutical composition of the present invention comprises GM-CSF or a fragment or variant thereof at a concentration in the range of 1 μg/mL (or μg/g) to 10 mg/mL (or mg/g), such as in the range of 5 μg/mL (or μg/g) to 500 μg/mL (or μg/g), or such as in the range of 10 μg/mL (or μg/g) to 200 μg/mL (or μg/g).

[0122] The effective amount of a suitable salt of fosfomycin for topical application to a wound or ulcer may be from 10 mg to 1000 μg per square centimeter per day, such as in the range of 20 μg to 800 μg per square centimeter per day, and especially in the range of 50 μg to 500 μg per square centimeter per day. The effective amount is expressed in terms of the content of fosfomycin free acid in the preparation used.

[0123] In practical terms, a pharmaceutical composition of the present invention comprises a fosfomycin salt at a concentration in the range of 100 μg/mL (or μg/g) to 30 mg/mL (or mg/mL), such as in the range of 250 μg/mL (or μg/g) to 10 mg/mL (or mg/g) in terms of fosfomycin free acid.

[0124] The effective amount of an additional antimicrobial agent for topical application is known in the art and may be added to the pharmaceutical compositions of the present invention in an amount that is adjusted so that when an effective amount of GM-CSF and fosfomycin is given, an effective amount of the additional antimicrobial agent is also given. In practice, this means that fusidic acid, for example, will be added to the composition in a similar amount to that of fosfomycin, while tobramycin, for example, will be added in an amount that is between 1% and 10% of the amount of fosfomycin.

[0125] The effective daily dose is preferably administered once a day, but may be administered in divided doses twice a day, three times a day, four times a day, five times a day or six times a day.

[0126] Duration of dosing will typically range from 1 day to about 4 months, such as in the range of 1 day to 2 days, 2 days to 3 days, 3 days to 4 days, 4 days to 5 days, 5 days to 6 days, or in the range of 1 week to 2 weeks, 2 weeks to 3 weeks, 3 weeks to 4 weeks, or in the range of 1 month to 2 months, 2 months to 3 months, 3 months to 4 months, as long as the lesion remains unhealed.

[0127] The transformation of a resting macrophage into a fully immunocompetent dendritic cell after in vitro incubation of macrophages with GM-CSF takes approximately 10 days. In one embodiment, a duration of a dose has the length allowing for said a transformation, thus the duration can be in the range of 7 days to 14 days, such as 8 days to 12 days, for example 8 days, or 9 days, or 10 days, or 11 days, or 12 days.

[0128] A dose regime may alternate between periods of administration of the pharmaceutical composition according to the present invention and periods with no administration (a pause in treatment). A period with a pause of treatment in such a dose regime may last for 5 days to 10 days, for example 5 days, or 6 days, or 7 days, or 8 days, or 9 days, or for example 10 days or more, for example 1 to 4 months.

[0129] Examples of dosage regimes may include a cycle of 10 days of treatment with the pharmaceutical composition according to the present invention and 7 days' pause of treatment. The pause of treatment may be prolonged to 2 or 3 weeks or more, up to 6 weeks, if alternative treatment with a preparation that does not contain antibiotic is substituted. This is to prevent the generation of antibiotic-resistant organisms in the individual wound.

[0130] The conversion of resting macrophages into dendritic cells may be boosted by repeating a dosage regime. Thus dosage regimes can be repeated one, two, three, four, five or more times in order to obtain an effective treatment.

[0131] In one embodiment, a dosage regime is repeated, such as once, two times, three times or more times, for example repeated for the rest of the lifespan of a subject in need.

[0132] In another embodiment, patients are treated with a dosage regime of 10 days treatment with pharmaceutical composition according to the present invention, followed by a pause of 7-20 days in said treatment and subsequently repeating the dosage regime 2-3 or more times.

Formulations

[0133] The pharmaceutical composition of the present invention may be in the form of a powder, dusting powder spray, paste, ointment, lotion, gel, cream, salve, emulsion, suspension, solution, spray, sponge, strip, plaster, pad, dressing, or formulated in an ostomy plate. The active ingredients of the composition may be suspended as a micronized powder in non-aqueous media or dissolved in aqueous media.

[0134] A dusting powder is a preferred formulation, as the active ingredients of the composition are compatible with each other and show long-term stability at room temperature in the dry powder form. The formulation may contain powder additives such as starch stearate, cellulose, lactose, zinc oxide, silicon dioxide, magnesium carbonate, talc or clay.

[0135] An ointment comprising hydrocarbon gels without an aqueous component is also a preferred formulation, as the fosfomycin in micronized form is not subject to degradation by hydrolysis in the presence of water at sub-alkaline pH levels, and will have a suitably long shelf life. The ointment may be made into a paste by the addition of powders such as starch, zinc oxide, talc or titanium dioxide.

[0136] Example 2 gives the composition of an ointment to provide an effective dose of GM-CSF and fosfomycin in a single daily application.

[0137] Example 3 gives the composition of an ointment to provide an effective dose of GM-CSF and fosfomycin together with clindamycin in a single daily application to provide a strong action against anaerobic bacteria and also against methicillin-resistant Staphylococcus aureus (MRSA).

[0138] Example 4 gives the composition of an ointment to provide an effective dose of GM-CSF and fosfomycin together with arbekacin and aztreonam in a single daily application to provide a strong action against Pseudomonas aeruginosa.

[0139] Aqueous media such as gels, creams, lotions, solutions and suspensions can also be used, but will require that the pH be adjusted to a value between pH 7 and pH 10, preferably to at least pH 8, to ensure a reasonable stability of the fosfomycin component and thus a suitable shelf life for the formulation. The pH of the aqueous medium can be adjusted by means of low concentrations of suitable biocompatible buffering ingredients, non-limiting examples being tromethamine, sodium carbonate and bicarbonate, as well as sodium dihydrogen phosphate and disodium hydrogen phosphate. Tonicity adjusting agents, such as for example sodium chloride, potassium chloride, or calcium chloride, may also be added.

[0140] The compositions according to the present invention may be formulated for improved penetration and efficacy of the active ingredients in their passage over the transmucosal barrier or epidermis. Improved passage over the transmucosal barrier may be obtained by a formulation which is capable of adhering to the mucosa, epidermis, or wound surface. This is an intrinsic characteristic of the ointment formulation proposed, but special agents which improve penetration may be added, non-limiting examples of which are propylene glycol, polyethylene glycol, dimethylsulfoxide, 1-decyl dimethylsulfoxide, N-methylpyrrolidone, diethyl toluamide, isopropyl myristate, isopropyl palmitate and esters of oleic acid.

[0141] Formulations according to the present invention may comprise pharmaceutically acceptable carriers and excipients including microspheres, liposomes, micelles, microcapsules, nanoparticles or the like. The GM-CSF component may, for example, be formulated in a liposome with an outer fatty layer with a core of water phase in which the GM-CSF component is dissolved. The lipid layer of such formulations overcomes the penetration barrier of the epidermis or mucous membrane.

[0142] Conventional liposomes are typically composed of phospholipids (neutral or negatively charged) and/or cholesterol. The liposomes are vesicular structures based on lipid bilayers surrounding aqueous compartments. They can vary in their physicochemical properties such as size, lipid composition, surface charge and number and fluidity of the phospholipids bilayers. The most frequently used lipid for liposome formation are: 1,2-dilauroyl-sn-glycero-3-phosphocholine (DLPC), 1,2-dimyristoyl-sn-glycero-3-phosphocholine (DMPC), 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC), 1,2-di stearoyl-sn-glycero-3-phosphocholine (DSPC), 1,2-dioleoyl-sn-glycero-3-phosphocholine (DOPC), 1,2-dimyristoyl-sn-glycero-3-phosphoethanolamine (DMPE), 1,2-dipalmitoyl-sn-glycero-3-phosphoethanolamine (DPPE), 1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOPE), 1,2-dimyristoyl-sn-glycero-3-phosphate (monosodium salt) (DMPA), 1,2-dipalmitoyl-sn-glycero-3-phosphate (monosodium salt) (DPPA), 1,2-dioleoyl-sn-glycero-3-phosphate (monosodium salt) (DOPA), 1,2-dimyristoyl-sn-glycero-3-[phospho-rac-(1-glycerol)] (sodium salt) (DMPG), 1,2-dipalmitoyl-sn-glycero-3-[phospho-rac-(1-glycerol)] (sodium salt) (DPPG), 1,2-dioleoyl-sn-glycero-3-[phospho-rac-(1-glycerol)] (sodium salt) (DOPG), 1,2-dimyristoyl-sn-glycero-3-[phospho-1-serine] (sodium salt) (DMPS), 1,2-dipalmitoyl-sn-glycero-3-[phospho-1-serine) (sodium salt) (DPPS), 1,2-dioleoyl-sn-glycero-3-[phospho-1-serine] (sodium salt) (DOPS), 1,2-dioleoyl-sn-glycero-3-phosphoethanolamine-n-(glutaryl) (sodium salt) and 1,1′,2,2′tetramyristoyl cardiolipin (ammonium salt). Formulations composed of DPPC in combination with other lipids or modifiers of liposomes are preferred, e.g. in combination with cholesterol and/or phosphatidylcholine.

[0143] A useful way of producing liposomes is to attach hydrophilic polymer polyethylene glycol (PEG) covalently to the outer surface of the liposome. Some of the preferred lipids are: 1,2-dipalmitoyl-sn-glycero-3-phosphoethanolamine-n-[methoxy (polyethyleneglycol)-2000] (ammonium salt), 1,2-dipalmitoyl-sn-glycero-3-phosphoethanolamine-n[methoxy(polyethyleneglycol)-5000] (ammonium salt), 1,2-dioleoyl-3-trimethylammonium-propane (chloride salt) (DOTAP).

[0144] Possible lipids applicable for liposomes are supplied by e.g. Avanti, Polar Lipids, Inc., Alabaster, Ala., USA. Additionally, the liposome suspension may include lipid-protective agents which protect lipids against free-radical and lipid-peroxidative damage on storage. Lipophilic free-radical quenchers, such as alpha-tocopherol and water-soluble iron-specific chelators, such as ferrioxamine, are preferred.

[0145] Several methods are available for preparing liposomes, as described in, e.g., Szoka F et al. (1980), U.S. Pat. Nos. 4,235,871, 4,501,728 and 4,837,028, all of which are incorporated herein by reference. Another method produces multi-lamellar vesicles of heterogeneous sizes. In this method, the vesicle-forming lipids are dissolved in a suitable organic solvent or solvent system and dried under vacuum or an inert gas to form a thin lipid film. If desired, the film may be re-dissolved in a suitable solvent, such as tertiary butanol, and then lyophilized to form a more homogeneous lipid mixture which is in a more easily hydrated powder-like form. This film is covered with an aqueous solution of the targeted drug and the targeting component and allowed to hydrate, typically over a 15-60 minute period with agitation. The size distribution of the resulting multi-lamellar vesicles can be shifted toward smaller sizes by hydrating the lipids under more vigorous agitation conditions or by adding solubilizing detergents such as deoxycholate.

[0146] To ensure adequate shelf-life of the components of the dermatological formulation, especially that of fosfomycin, which is unstable in aqueous media at physiological pH, while at the same time providing a formulation that is acceptable to the patient in terms of irritation at the site of application, an embodiment of the invention comprises the provision of the active components in a kit as separate parts to be mixed shortly before use. The kit may further comprise a medium into which the components can be mixed prior to the topical application to the wound. The medium may contain, in addition to other ingredients, buffering agents such as those mentioned above to ensure that the pH of the formulation is appropriate for dermatological use once all the ingredients have been mixed.

Indications

[0147] The present invention provides pharmaceutical compositions for use in the treatment of wounds, ulcers, sores, burns or other lesions of the skin, mucosal membranes or connective tissue of the body, which may be acute or chronic. Such lesions may be caused by a broad spectrum of events and/or may be associated with other diseases. The lesions to be treated include those associated with incision, laceration, abrasion, blister, hematoma, puncture, penetration, gunshot, electricity, irradiation, chemical, trauma, crush, bite, burn, frost, surgery, primary cancer or metastasis, benign tumor, acne, infections such as bacterial infection (which may be combined with fungal or viral of parasitic infection), lesions associated with decreased circulation of blood, such as leg ulcers and foot ulcers associated with venous insufficiency or arterial insufficiency, decubitus ulcers, pressure sores or bedsores, and lesions associated with diabetes mellitus.

[0148] Chronic wounds, now generally called “non-healing wounds”, or lesions, wounds or ulcers arise when a wound fails to follow an appropriate timely healing process to achieve the normal sustained and stable anatomic and functional integrity of the healed tissue. Generally speaking, a skin lesion which has failed to make substantial progress towards healing within a period of three months, or which has become stable in a partially healed state for more than three months, could be categorized as a chronic or “non-healing” wound. This general definition is not universally applicable, as the age and fitness of the patient, as well as other factors such as diseases or disorders suffered by the patient (for example, circulatory disorders), can significantly lengthen the normal healing process. In such circumstances a skin lesion which is unhealed after six months can be categorized as a “non-healing” wound.

[0149] A “non-healing” wound or chronic skin lesion is ulcerous when it involves focal loss of epidermis and at least part of the dermis. Chronic ulcerous skin lesions are usually accompanied by other symptoms apart from the failure of the normal healing process. Typical accompanying signs and symptoms include one or more of the following: pain, exudation, bad smell, excoriation, wound spreading, tissue necrosis, irritation and hyperkeratosis. Such symptoms can be extremely debilitating and embarrassing for patients, and can seriously harm the patient's quality of life. In severe cases, they can necessitate the amputation of limbs or even cause death.

[0150] Malignant or pre-malignant chronic ulcerous skin lesions may arise in connection with a primary cancer of the skin, or with a metastasis to the skin from a local tumor or from a tumor at a distant site. They may be draining or non-draining. They may, for example, take the form of a cavity, an open area on the surface of the skin, skin nodules, or a nodular growth extending from the surface of the skin.

[0151] The pharmaceutical compositions of the present invention are useful for treatment of all the above-mentioned non-healing wounds or chronic ulcerous skin lesions, and thus reduce or prevent one or more symptoms accompanying such lesions.

EMBODIMENTS

[0152] 1. A pharmaceutical composition comprising [0153] a. granulocyte-macrophage colony-stimulating factor (GM-CSF) or a fragment or variant thereof, and [0154] b. osfomycin in the form of an inorganic or organic salt thereof [0155] 2. The pharmaceutical composition according to embodiment 1 comprising one or more additional antibiotic or antimicrobial agents. [0156] 3. The composition according to embodiment 2, wherein the one or more additional antibiotic or antimicrobial agent is selected from the list of fusidic acid, penicillins, cephalosporins, aminoglycosides, macrolides, vancomycin, lincomycin, clindamycin, fluoroquinolones, mupirocin, bacitracin, polymyxin B, gramicidins, metronidazole, clotrimazole, ketoconazole and nystatin. [0157] 4. The composition according to embodiment 2 or 3, wherein the one or more additional antibiotic or antimicrobial agent is selected from the list of penicillin, ampicillin, carbenicillin, methicillin, oxacillin, flucloxacillin, mezlocillin, piperacillin, aztreonam, imipenem, cephalexin, cephalothin, cefamandole, cefoxitin, cefmetazole, cefotaxime, cefazolin, cefoperazone, cefsulodine, ceftadizime, cefepime, streptomycin, gentamicin, kanamycin, netilmicin, tobramycin, amikacin, erythromycin, midecamycin, vancomycin, lincomycin, clindamaycin, teicoplanin, daptomycin, ciprofloxacin, ofloxazine, levofloxazin, pefloxacin, sparfloxacin, ceftriaxone, arbekacin, or vancomycin. [0158] 5. The composition according to any one of the preceding embodiments, wherein the wound or lesion is infected with staphylococcus such as Staphylococcus aureus or pseudomonas such as Pseudomonas aeruginosa. [0159] 6. The composition according to any one of the preceding embodiments, wherein the composition is not in an aqueous solution, and wherein the additional antibiotic or microbial agent is any one of ampicillin, methampicillin, cephaloridine, cephalothin, streptomycin, gentamicin, or kanamycin. [0160] 7. The composition of any one of the preceding embodiments, wherein the composition further comprises one or more of the following: vitamin A, an antioxidant agent, such as one or more of the following: vitamin E (in the form of alphatocopherol), ubiquinone, idebenone, carotenoids in example lycopene, ascorbic acid or ascorbates, or nicotinamide. [0161] 8. The pharmaceutical composition according to any one of the previous embodiments, wherein the composition is for the treatment, alleviation or accelerating the healing of a lesion such as a wound, ulcer, sore or burn of any one of the skin, mucosal membranes or connective tissue underlying the lesion. [0162] 9. The pharmaceutical composition according to anyone of the previous embodiments, wherein the lesion is chronic. [0163] 10. The pharmaceutical composition according to any one of embodiments 1-11, wherein the lesion is acute. [0164] 11. The pharmaceutical composition according to any one of the previous embodiments, wherein the lesion is associated with colonization or infection by a bacterium, fungus, virus, or parasite. [0165] 12. The composition according to any one of the previous embodiments, wherein the lesion is infected with bacteria from any one of the genera Staphylococcus, Streptococcus, Neisseria, Escherichia, Proteus, Serratia, Salmonella, Shigella, Pseudomonas, Haemophilus, and Vibrio, Proteus spp., Klebsiella and Enterobacter spp., Peptostreptococcus (including Peptoniphilus, Finegoldia and Anaerococcus) and Fusobacterium. [0166] 13. The composition according to any one of the previous embodiments, wherein the active components are provided in a kit as separate parts to be mixed shortly before use. [0167] 14. The kit according to embodiment 13, wherein the kit further comprises a medium into which the components can be mixed prior to the topical application to the wound. [0168] 15. The pharmaceutical composition according to any one of the previous embodiments, wherein the lesion is associated with diabetes mellitus. [0169] 16. The pharmaceutical composition according to any one of the previous embodiments, wherein the lesion is associated with decreased circulation of blood, such as venous leg ulcers, venous foot ulcers, arterial leg ulcers, arterial foot ulcers, and decubitus ulcers. [0170] 17. The pharmaceutical composition according to any one of the previous embodiments formulated for topical application as a powder, paste, ointment, lotion, gel, cream, salve, emulsion, suspension, solution, spray, sponge, strip, plaster, pad, dressing, or formulated in an ostomy plate. [0171] 18. The composition according to any one of the previous embodiments, wherein GM-CSF and fosfomycin is for topical administration, and the additional antimicrobial drug is for non-topical administration. [0172] 19. The pharmaceutical composition according to any one of embodiments 1 to 14 wherein the GM-CSF is in a liposomal or micelle or microcapsule or nanoparticle formulation. [0173] 20. The pharmaceutical composition according to any one of the preceding embodiments wherein the GM-CSF variant is at least 70% identical to SEQ ID NO:1 or 2. [0174] 21. The pharmaceutical composition according to any one of the preceding embodiments wherein the GM-CSF fragment comprises at least 50 contiguous amino acid residues of any one of SEQ ID NO:1 or 2. [0175] 22. The pharmaceutical composition according to embodiment 21, wherein the fragment is at least 70% identical to SEQ ID NO:1 or 2 in the range of overlap. [0176] 23. The pharmaceutical composition according to any one of the preceding embodiments, comprising GM-CSF or a fragment or variant thereof at a concentration of 1 μg/mL to 10 mg/mL. [0177] 24. The pharmaceutical composition according to any one of the preceding embodiments, comprising GM-CSF or a fragment or variant thereof at a concentration of 5 μg/mL to 500 μg/mL. [0178] 25. The pharmaceutical composition according to any one of the preceding embodiments, comprising GM-CSF or a fragment or variant thereof at a concentration of 10 μg/mL to 200 μg/mL. [0179] 26. The pharmaceutical composition according to any one of the preceding embodiments, comprising a fosfomycin salt at a concentration of 100 μg/mL to 10 mg/mL in terms of fosfomycin free acid. [0180] 27. The pharmaceutical composition according to any one of the preceding embodiments, comprising a fosfomycin salt at a concentration pf 250 μg/mL to 1 mg/mL in terms of fosfomycin free acid. [0181] 28. The pharmaceutical composition according to embodiments 17 and 18, wherein the fosfomycin salt is fosfomycin disodium or fosfomycin calcium or fosfomycin trometamol, also known as fosfomycin tromethamine. [0182] 29. The pharmaceutical composition according to any one of the preceding embodiments, further comprising one or more additional antibiotic or antimicrobial agents. [0183] 30. The pharmaceutical composition according to any one of the preceding embodiments further comprising vitamin A and/or an anti-oxidant agent. [0184] 31. The pharmaceutical composition according to any one of the preceding embodiments, wherein the GM-CSF variant comprises a conjugate capable of prolonging the half-life of the GM-CSF. [0185] 32. The pharmaceutical composition according to the preceding embodiment, wherein the conjugate capable of prolonging half-life of the GM-CSF variant is albumin or a fatty acid. [0186] 33. The pharmaceutical compositions according to any one of the preceeding claims are also useful I in methods of treatment.

EXAMPLES

[0187] The following non-limiting examples further illustrate the present invention.

Example 1: Sequences

[0188]

TABLE-US-00003 SEQ ID NO: 1 - Human GM-CSF precursor >sp|P04141|CSF2_HUMAN Granulocyte-macrophage colony-stimulating factor OS = Homo sapiens MWLQSLLLLGTVACSISAPARSPSPSTQPWEHVNAIQEARRLLNLSRDTM EMNETVEVISEMFDLQEPTCLQTRLELYKQGLRGSLTKLKGPLTMMASHY KQHCPPTPETSCATOI ITFESFKEN LKDFLL VI PFDCWEPVQE SEQ ID NO: 2 - mature human GM-CSF >sp|P04141|18-144 APARSPSPSTQPWEHVNAIQEARRLLNLSRDTMEMNETVEVISEMFDLQE PTCLQTRLELYKQGLRGSLTKLKGPLTMMASHYKQHCPPTPETSCATQII TFESFKENLKDFLLVIPFDCWEPVQE

Example 2: Ointment for Treating Wounds, Ulcers, Sores or Burns of the Skin

[0189]

TABLE-US-00004 Molgramostim 0.5 mg 0.05%  micronized Fosfomycin trometamol 5 mg 0.5% micronized Chlorbutanol, anhydrous 5 mg 0.5% Mineral oil 50 mg .sup. 5% White Petrolatum to 1 g to 100%

[0190] This composition may be especially suitable for leg ulcers due to venous insufficiency, which do not show clinical signs of gross bacterial infection.

Example 3: Ointment for Treating Wounds, Ulcers, Sores or Burns of the Skin, which Contains a Further Antibiotic in Addition to Fosfomycin

[0191]

TABLE-US-00005 Molgramostim 0.5 mg 0.05%  micronized Fosfomycin trometamol 5 mg 0.5% micronized Clindamycin phosphate 10 mg 1.0% micronized Chlorbutanol, anhydrous 5 mg 0.5% Mineral oil 50 mg .sup. 5% White Petrolatum to 1 g to 100%

[0192] This composition may be especially suitable for treating wounds and ulcers in which infection with anaerobic bacteria is suspected or verified by anaerobic bacterial culture. It may also be suitable for wounds infected with methicillin-resistant Staphylococcus aureus (MRSA) verified by culture to be sensitive to clindamycin.

Example 4: Ointment for Treating Wounds, Ulcers, Sores or Burns of the Skin, which Contains a Further Two Antibiotics in Addition to Fosfomycin

[0193]

TABLE-US-00006 Molgramostim 0.5 mg 0.05%  micronized Fosfomycin trometamol 5 mg 0.5% micronized Arbekacin sulfate 2 mg 0.2% micronized Aztreonam 5 mg 0.5% micronized Chlorbutanol, anhydrous 5 mg 0.5% Mineral oil 50 mg .sup. 5% White Petrolatum to 1 g to 100%

[0194] This composition may be especially suitable for treating wounds and ulcers in which infection with Pseudomonas aeruginosa is suspected or verified by bacterial culture.

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