Efflux pumps play multiple roles in bacterial physiology, environmental adaptation, and antibiotic resistance. Early cystic fibrosis (CF) airway infections start with Staphylococcus aureus (SA), often later followed by Pseudomonas aeruginosa (PA) infections. In this study, we have evaluated the role of SA pumps NorA and Tet38 in survival and interaction with PA in CF patients. Data showed a ≥4-log10CFU/mL growth deficit of SA mutants ΔnorA and Δtet38 in an artificial sputum medium (ASM), suggesting NorA and Tet38 contributed to SA growth in CF sputum. In ASM, mucin activated norA but inhibited tet38, while extracellular DNA activated tet38 but inhibited norA, demonstrating complementary roles of mucin and DNA in affecting NorA and Tet38 expression. Furthermore, exposure of SA wild type to PA-excreted molecules affected pump expression; 3,4-dihydroxy-2-heptylquinoline PQS caused an increase in tet38 but a decrease in norA, 4-hydroxy-2-heptylquinoline HHQ caused a decrease in norA and tet38, and pyocyanin PYO caused a modest increase in norA, demonstrating differing additional roles of PA-secreted molecules influencing NorA and Tet38 expression. Evaluation of 48 randomly selected unique CF-associated SA showed that 18.8% were NorA-overexpressors and 10.4% were Tet38-overexpressors. NorA-overexpressors showed a fourfold increase in pyocyanin MIC and ≥16-fold in ciprofloxacin MIC. Furthermore, 89% of NorA-overexpressors carried an insertion of CAAT/ACAA/CTAT at the (-10) motif of the norA promoter, and 62.5% of these were co-isolated with PA.These data showed that SA survives PA killing in CF sputum conditions using sputum key components and PA-specific signal molecules to regulate NorA and Tet38 expression.
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