Use Of Efflux Pump Inhibitors Research Articles

Advances in the Discovery of Efflux Pump Inhibitors as Novel Potentiators to Control Antimicrobial-Resistant Pathogens.

The excessive use of antibiotics has led to the emergence of multidrug-resistant (MDR) pathogens in clinical settings and food-producing animals, posing significant challenges to clinical management and food control. Over the past few decades, the discovery of antimicrobials has slowed down, leading to a lack of treatment options for clinical infectious diseases and foodborne illnesses. Given the increasing prevalence of antibiotic resistance and the limited availability of effective antibiotics, the discovery of novel antibiotic potentiators may prove useful for the treatment of bacterial infections. The application of antibiotics combined with antibiotic potentiators has demonstrated successful outcomes in bench-scale experiments and clinical settings. For instance, the use of efflux pump inhibitors (EPIs) in combination with antibiotics showed effective inhibition of MDR pathogens. Thus, this review aims to enable the possibility of using novel EPIs as potential adjuvants to effectively control MDR pathogens. Specifically, it provides a comprehensive summary of the advances in novel EPI discovery and the underlying mechanisms that restore antimicrobial activity. In addition, we also characterize plant-derived EPIs as novel potentiators. This review provides insights into current challenges and potential strategies for future advancements in fighting antibiotic resistance.

Phenotypic and genetic insights into efflux pump mechanism in Mycoplasma anserisalpingitidis.

Mycoplasma anserisalpingitidis is one of the most important waterfowl-pathogenic mycoplasmas. Due to inadequate antibiotic treatment, many strains with high minimal inhibitory concentration (MIC) values for multiple drugs have been isolated lately. Decreased antibiotic susceptibility in several Mycoplasma species are known to be associated with mutations in topoisomerase and ribosomal genes, but other strategies such as active efflux pump mechanisms were also described. The scope of this study was the phenotypic and genetic characterization of the active efflux mechanism in M. anserisalpingitidis. We measured the MIC values in the presence and absence of different efflux pump inhibitors (EPIs), such as carbonyl cyanide m-chlorophenylhydrazine (CCCP), orthovanadate (OV), and reserpine (RSP). Moreover, bioinformatic tools were utilized to detect putative regulatory sequences of membrane transport proteins coding genes, while comparative genome analysis was performed to reveal potential markers of antibiotic resistance. Out of the three examined EPIs, CCCP decreased the MICs at least two-fold below the original MICs (in 23 cases out of 36 strains). In the presence of OV or RSP, MIC value differences could be seen only if modified dilution series (10% decrease steps were used instead of two-fold dilutions) were applied (in 24/36 cases with OV and 9/36 with RSP). During comparative genome analysis, non-synonymous single nucleotide polymorphisms (nsSNPs) were identified in genes encoding ABC membrane transport proteins, which were displayed in higher percentages in M. anserisalpingitidis strains with increased MICs. In terms of other genes, a nsSNP was identified in DNA gyrase subunit A (gyrA) gene which can be related to decreased susceptibility to enrofloxacin. The present study is the first to highlight the importance of efflux pump mechanisms in M. anserisalpingitidis. Considering the observed effects of the EPI CCCP against this bacterium, it can be assumed, that the use of EPIs would increase the efficiency of targeted antibiotic therapy in the future control of this pathogen. However, further research is required to obtain a more comprehensive understanding of efflux pump mechanism in this bacterium.

Increasing antimicrobial susceptibility of MDR Salmonella with the efflux pump inhibitor 1-(1-Naphthylmethyl)-piperazine

Salmonella is a widespread foodborne pathogen that can exhibit multidrug resistance (MDR; resistance to ≥3 antimicrobial classes). Therefore, the development of new preventative measures against MDR Salmonella is highly important. Bacterial antibiotic resistance is commonly mediated by efflux pumps. In this study, two compounds that block efflux pump activity, 1-(1-Naphthylmethyl)-Piperazine (NMP) and Phenylalanine-arginine β-naphthylamide (PaβN), were tested with the antibiotic tetracycline to determine if a synergistic reduction in resistance could be achieved in tetracycline-resistant Salmonella. The efflux pump inhibitors (EPIs) reduced Salmonella resistance to tetracycline by 16 to 32-fold in several tetracycline resistant isolates. For example, the tetracycline minimum inhibitory concentration (MIC) for MDR Salmonella enterica serovar I 4,[5],12:i:- USDA15WA-1 (SX 238) was 256 μg/mL. However, in the presence of NMP (250 μg/mL), the MIC dropped to 8 μg/mL which is below the Clinical Laboratory Standards Institute (CLSI) breakpoint for tetracycline resistance in Salmonella (≥16 μg/mL). Confocal and transmission electron microscopy revealed NMP-mediated damage to Salmonella membranes at a higher concentration (1000 μg/mL), implying that the EPI disrupts membrane morphology which can lead to cell death; however, this effect was dependent on NMP concentration, as NMP blocked efflux activity with less of a membrane-disrupting effect at a lower concentration (250 μg/mL). These findings suggest that the use of EPIs can reduce the MIC of tetracycline and restore the effectiveness of the antibiotic against tetracycline-resistant Salmonella.

Effects of four efflux pump inhibitors on the activities of clarithromycin against Mycobacterium abscessus

Objective: To detect the effects of four efflux pump inhibitors on the minimum inhibitory concentration of clarithromycin (CLA) against Mycobacterium abscessus (M. abscessus) in vitro, and to explore the role of efflux pump in CLA resistance of M. abscessus. Methods: Four frequently-used efflux pump inhibitors (Carbonyl Cyanide 3-chlorophenylhydrazone, CCCP, N, N'-dicyclohexylcarbodiimide, DCC, Verapamil, VP, Reserpine, RSP) were evaluated in this study. The minimum inhibitory concentration (MIC) values of clarithromycin against M. abscessus reference strain and 60 clinical strains with or without efflux pump inhibitors were detected by Alamar Blue method. Sequence analysis of erm(41) and rrl genes known to be associated with CLA resistance in M. abscessus was performed to analyze the correlation between the effect of efflux pump inhibitors on MIC and mutation of resistance-related genes. Results: CCCP, DCC, VP and RSP could reduce the MIC of M. abscessus to CLA, and the effect of RSP was weaker than the other three efflux pump inhibitors. Among the sixty M. abscessus clinical strains, ten strains were resistant to clarithromycin, seven of which had rrl gene mutation. The CLA resistance rate of smooth phenotype isolates was higher than that of rough phenotype isolates. At 3 day of clarithromycin incubation, the MICs of resistant strains were all reduced by efflux pump inhibitors. Compared with the strains with rrl gene mutation, efflux pump inhibitors had a greater effect on the strains without rrl gene mutation. At 14 day of clarithromycin incubation, 83% of M. abscessus subsp. abscessus, were induced to be resistant, and all of them were T28 sequence type of erm(41). With the occurrence of induced drug resistance, the effect of efflux pump inhibitor on CLA MIC decreased. Efflux pump inhibitors had no statistically significant diffence in the effect of effcux pump inhibitors on CLA MIC levels in different phenotypes of isolates. Conclusions: Efflux pump is involved in the resistance process of M. abscessus to CLA. Efflux pump inhibitors reduce the drug resistance to clarithromycin against M. abscessus in different degrees. The use of efflux pump inhibitors may provide a new way to alleviate the drug resistance of M. abscessus.

A Microbe-Derived Efflux Pump Inhibitor of the Resistance-Nodulation-Cell Division Protein Restores Antibiotic Susceptibility in Escherichia coli and Pseudomonas aeruginosa

The use of efflux pump inhibitors (EPIs) as potentiators along with the traditional antibiotics assists in the warfare against antibiotic-resistant superbugs. Efflux pumps of the resistance-nodulation-cell division (RND) family play crucial roles in multidrug resistance in Escherichia coli and Pseudomonas aeruginosa. Despite several efforts, clinically useful inhibitors are not available at present. This study describes ethyl 4-bromopyrrole-2-carboxylate (RP1) isolation, an inhibitor of RND transporters from the library of 4000 microbial exudates. RP1 acts synergistically with antibiotics by reducing their minimum inhibitory concentration in strains overexpressing archetype RND transporters (AcrAB-TolC and MexAB-OprM). It also improves the accumulation of Hoechst 33342 and inhibits its efflux (a hallmark of EPI functionality). The antibiotic-RP1 combinations prolong the postantibiotic effects and reduce the mutation prevention concentration of antibiotics. Additionally, from Biolayer Interferometry spectra, it appears that RP1 is bound to AcrB. RP1 displays low mammalian cytotoxicity, no Ca2+ channel inhibitory effects, and reduces the intracellular invasion of E.coli and P.aeruginosa in macrophages. Furthermore, the RP1-levofloxacin combination is nontoxic, well-tolerated, and notably effective in a murine lung infection model. In sum, RP1 is a potent EPI and worthy of further consideration as a potentiator to improve the effectiveness of existing antibiotics.

Efflux Pump Mediated Antimicrobial Resistance by Staphylococci in Health-Related Environments: Challenges and the Quest for Inhibition.

The increasing emergence of antimicrobial resistance in staphylococcal bacteria is a major health threat worldwide due to significant morbidity and mortality resulting from their associated hospital- or community-acquired infections. Dramatic decrease in the discovery of new antibiotics from the pharmaceutical industry coupled with increased use of sanitisers and disinfectants due to the ongoing COVID-19 pandemic can further aggravate the problem of antimicrobial resistance. Staphylococci utilise multiple mechanisms to circumvent the effects of antimicrobials. One of these resistance mechanisms is the export of antimicrobial agents through the activity of membrane-embedded multidrug efflux pump proteins. The use of efflux pump inhibitors in combination with currently approved antimicrobials is a promising strategy to potentiate their clinical efficacy against resistant strains of staphylococci, and simultaneously reduce the selection of resistant mutants. This review presents an overview of the current knowledge of staphylococcal efflux pumps, discusses their clinical impact, and summarises compounds found in the last decade from plant and synthetic origin that have the potential to be used as adjuvants to antibiotic therapy against multidrug resistant staphylococci. Critically, future high-resolution structures of staphylococcal efflux pumps could aid in design and development of safer, more target-specific and highly potent efflux pump inhibitors to progress into clinical use.

Plant Phyto-constituents as Antibiotic Adjuvants: A Systematic Review and Bibliometric Analysis

The advent of antibiotics in the 19th century has significantly reduced the morbidity and mortality of infectious diseases. However, irrational use of antibiotics in humans as well as in animals has driven the 21st century to the rapid emergence of MultiDrug Resistance Bacteria (MRB). Moreover, the dissemination of COVID-19 pandemic has paved the way for MRB, typically due to increased use of antibiotics to avoid secondary infections.
 The fast pace progression of bacterial resistance for the antibiotics and their combinations is making the management of MRB infections tough and increasing the cost of the treatment as well. However, use of Efflux Pump Inhibitors (EPI) as adjuvant for antibiotics has shown a ray of hope by retaining the susceptibility of the antibiotics and thereby reducing the burden of immediate requirement of new antibiotics for MRB. Accordingly, the present paper is aimed to scrutinize the predominant literature depicting the plant Phyto-constituents as an EPI and adjuvant for antibiotics in the management of MRB infections.
 The systematic review of the present paper indicates that the plant phyto-constituents belonging to the class of alkaloids, terpenoids, flavonoids can effectively be used as EPIs for antibiotics such as Ciprofloxacin, Norfloxacin, Tetracyclines and Chloramphenicol. Bibliometric analysis indicates that the Journal of Antimicrobial Chemotherapy, Antimicrobial Agents and Chemotherapy and BMC Complementary & Alternative Medicine have published impactful articles on EPI potential of plant phyto-constituents. Further, authors Kuete V, Dzotam JK, Falcao-silva VD, Gibbons S, Kuiate JR, Mbaveng AT, Tankeo SB and Voukeng IK are the major contributors and productive authors.

EFFECT OF EFFLUX PUMP INHIBITORS ON ANTIMICROBIAL ACTIVITY OF FLORFENICOL AGAINST RESISTANT STRAINS OF PORCINE ACTINOBACILLUS PLEUROPNEUMONIAE AND PASTEURELLA MULTOCIDA

The aim of this study is to investigate whether combinational use of efflux pump inhibitors (EPIs) could improve florfenicol (FF) antimicrobial activity. Five EPIs including Carbonyl Cyanide Chlorophenylhydrazone (CCCP), omeprazole, Phenylalanine-arginine [Formula: see text]-naphthylamide (PA[Formula: see text]N), reserpine and verapamil were individually combined with FF and the minimum inhibitory concentration (MIC) against porcine Actinobacillus pleuropneumoniae and Pasteurella multocida were evaluated by the broth microdilution assay. The results indicated that CCCP demonstrated substantial improvement on the antimicrobial activity (FF MIC reduction [Formula: see text] folds) while PAßN showed minimal effect at high concentrations (80–120[Formula: see text][Formula: see text]g/mL). The MICs of FF were further examined with CCCP at 5[Formula: see text][Formula: see text]g/mL against resistant A. pleuropneumoniae and at 2[Formula: see text][Formula: see text]g/mL against resistant P. multocida. With this combination, a total of 75% (6/8) of A. pleuropneumoniae and 100% (8/8) of P. multocida resistant isolates showed significantly reduced ([Formula: see text] folds) FF MICs. In addition, 100% of the 16 resistant bacterial strains carried the floR gene that regulates the phenicol-specific efflux pump (FloR pump). The time kill experiments were used to verify the effect of CCCP demonstrating a bactericidal effect in resistant A. pleuropneumoniae and synergistic effect in resistant P. multocida. In contrast, the FF MICs were not significantly affected in the FF susceptible strains of these two bacteria. These findings suggested that despite small sample sizes, consistent beneficial effects of CCCP were evident such that the combinational use of selective EPI with FF might be an alternative antibacterial strategy against FF resistant A. pleuropneumoniae and P. multocida. The anti-efflux mechanism was indicated, but more researches to further decipher the mechanisms of CCCP’s effects are warranted.

Isoniazid and verapamil modulatory activity and efflux pump gene expression in Mycobacterium tuberculosis

INTRODUCTION: Resistance to first-line anti-tuberculosis drugs is a major concern in the treatment of the disease. New strategies, such as the use of efflux pump inhibitors (EPIs), are being investigated to improve the outcome of the treatment. Verapamil (VP), one such inhibitor, was shown to inhibit several efflux pump (EP) Mycobacterium tuberculosis proteins and demonstrate synergic activity with anti-TB drugs.OBJECTIVE: To evaluate the combinatory effect of isoniazid (INH) and VP in M. tuberculosis.METHODS: Minimal inhibitory concentrations and combinatory effects of INH+VP were determined using respectively resazurin microtitre assay plate (REMA) and resazurin drugs combination microtitre assay (REDCA). From the results, we selected three bacilli with different susceptibility profiles and assessed their expression of 10 EP genes through quantitative reverse transcription polymerase chain reaction after exposure to INH, VP and INH + VP for 48 h.RESULTS: A significant reduction of INH MIC was observed in INH-susceptible isolates upon combination with VP. In brief, gene expression assays revealed expression patterns that could be correlated with each resistance profile, presence or absence of gene mutations and combinatory effect with VP.CONCLUSION: Combining VP with INH showed important results in drug-susceptible strains, and clinical trials on combined VP + anti-TB drugs should be discussed.

Development of an accumulation assay and evaluation of the effects of efflux pump inhibitors on the retention of chlorhexidine digluconate in Pseudomonas aeruginosa and Staphylococcus aureus

BackgroundChlorhexidine digluconate (CHG) is used as a disinfectant. The emergence of pathogens resistant to the biocide raises health concern. Information on specific efflux mechanisms utilised by bacteria to confer reduced susceptibility to the biocide, may be used to develop ways of preventing the efflux of the biocide from nosocomial pathogens resulting in higher disinfection activity. The aim of the study was to evaluate the role of ATP-binding cassette transporters on the transport of CHG in bacteria.MethodsClinical strains of Pseudomonas aeruginosa, Staphylococcus aureus and their respective laboratory strains ATCC 27853 and ATCC 9144 were used for susceptibility tests. The minimum inhibitory concentration (MIC) of CHG with or without an efflux pump inhibitor [reserpine or carbonyl cyanide m-chlorophenylhydrazone (CCCP)] was determined using the broth microdilution method. A spectrophotometric method to quantify the amount of chlorhexidine in a sample was developed, validated and used to quantify CHG within P. aeruginosa and S. aureus cells.ResultsIn the presence of reserpine, the MIC of CHG against the clinical strains of P. aeruginosa and S. aureus decreased from 6.3 to 3.2 µg/ml but showed no change against both ATCC isolates. The MIC of CHG in the presence of CCCP for both strains of P. aeruginosa remained unchanged but showed a reduction for both isolates of S. aureus. The suitability of the spectrophotometric method developed for quantifying the amount of CHG accumulated in microbial cells was validated and used successfully to quantify CHG accumulated within bacterial cells.ConclusionThe spectrophotometric determination of CHG within microbial cells may be used to quantify CHG in microbial cells. Only the clinical strain of P. aeruginosa showed significant efflux of CHG suggesting the participation of efflux transporters in the pumping out of CHG from this isolate. The use of efflux pump inhibitors together with the biocide may be explored to preventing the efflux of the biocide from P. aeruginosa resulting in order to increase disinfection activity.

Biofilm formation ability of Salmonella enterica serovar Typhimurium acrAB mutants

Recent studies offer contradictory findings about the role of multidrug efflux pumps in bacterial biofilm development. Thus, the aim of this study was to investigate the involvement of the AcrAB efflux pump in biofilm formation by investigating the ability of AcrB and AcrAB null mutants of Salmonella enterica serovar Typhimurium to produce biofilms. Three models were used to compare the ability of S. Typhimurium wild-type and its mutants to form biofilms: formation of biofilm on polystyrene surfaces; production of biofilm (mat model) on the air/liquid interface; and expression of curli and cellulose on Congo red-supplemented agar plates. All three investigated genotypes formed biofilms with similar characteristics. However, upon exposure to chloramphenicol, formation of biofilms on solid surfaces as well as the production of curli were either reduced or were delayed more significantly in both mutants, whilst there was no visible effect on pellicle formation. It can be concluded that when no selective pressure is applied, S. Typhimurium is able to produce biofilms even when the AcrAB efflux pumps are inactivated, implying that the use of efflux pump inhibitors to prevent biofilm formation is not a general solution and that combined treatments might be more efficient. Other factors that affect the ability to produce biofilms depending on efflux pump activity are yet to be identified.

Overexpression of Efflux Pump in Multiresistant Pseudomonas aeruginosa: How You Will Discover and Treat It?

The Emergence and spread of multiresistant strains of Pseudomonas aeruginosa is increasing problem, because it is associated with high morbidity and mortality. P. aeruginosa has intrinsic resistance to a wide variety of antibiotics, including most β-lactams, chloramphenicol, tetracyclines and fluoroquinolones through its impermeable outer membrane. Recently, P. aeruginosa strains, which has acquired resistance to antipseudomonal antibiotics such as ciprofloxacin, ceftazidime, imipenem, and piperacillin, has been frequently reported [1]. In addition to impermeability of membrane, efflux, target alteration, enzyme inactivation, salvage pathway, and target protein protection are known mechanisms of antibiotic resistance. Among these mechanisms, active efflux of drug through efflux pump system is thought to be associated with acquired resistance in P. aeruginosa. There are various efflux pump systems in bacteria. The resistance-nodular-cell division (RND) family type of secondary multidrug transporters, which use the transmembrane electrochemical gradient of protons or sodium ions to drive the extrusion of drugs from the cell, has been found in P. aeruginosa [2]. Especially, 4 out of 12 RND efflux pump system is thought to play a role in the exportation of antimicrobial agents in P. aeruginosa [3]. MexAB-OprM is expressed constitutively and related to fluoroquinolones, β-lactams, tetracycline, macrolides, novobiocin, chloramphenicol, trimethoprim, sulfonamides, meropenem resistance, but not imipenem. MexXY-OprM is also constitutively expressed and known to cause resistant to aminoglycosides, ciprofloxacin, levofloxacin, cefepime, but not ceftazidime. Unlike MexAB-OprM and MexXY-OprM, MexCD-OprJ and MexEF-OprN are induced by their substrates. MexCD-OprJ is not detectable in wild type cell and it cause resistant to tetracycline, macrolides, chloramphenicol, novobiocin, trimethorpim and some β-lactams. MexEF-OprN is quiescent in wild type cell and related to fluoroquinolones, chloramphenicol, trimethorpim and imipenem resistance [4]. JDumas, et al. [5] reported that gene expression changes of efflux pump in P. aeruginosa cause resistant to antimicrobial agents. Using quantitative realtime-PCR, they observed several fold increasing of efflux pump genes, mexA, mexB and oprM, in antibiotic-resistant clinical strains. Shigemura, et al. [6] also reported that overexpression of mexC leads to levofloxacin resistance, and increased expression of mexB or mexC is related to complicated urinary tract infection (UTI) in P. aeruginosa strains clinically isolated from UTI patients. Other than in P. aeruginosa, association of efflux pump gene overexpression and antimicrobial resistance is also reported in other microorganisms [7,8]. Adabi, et al. [9] demonstrated that efflux pump activity is related to ciprofloxacin resistance in P. aeruginosa strains clinically isolated from burned patients, using efflux pump inhibitor (EPI), carbonyl cyanide-m-chlorophenylhydrazone (CCCP). Compared to the absensce of EPI, they detected ciprofloxacin susceptibility is increased in the presence of EPI. However, they only checked the presence of efflux pump genes by PCR, which cannot assess expression level of efflux pump. Although detection method using EPI for efflux pump overexpression was used in some previous researches [10], it is indirect and non-quantitative method. Instead, recent researches use quantitative real-time PCR to discover overexpression of efflux pump [5,6,7]. Adabi, et al. [9] also showed susceptibility to a variety of antibiotics, beside ciprofloxacin, increase in presence of EPI, and suggested use of EPI in combination with antibiotics. Multiresistant P. aeruginosa infection is associated with higher mortality rate and difficult to treat. A point that most of multiresistant strains show overexpressed efflux pump, it is reasonable treatment strategy to use EPI together with antibiotics [11]. However, toxic property of EPI in clinical application is not to be known clearly. Furthermore, safety and effectiveness of combination therapy are key point to disclose through further studies. Spread of multiresistant P. aeruginosa is very serious problem in terms of immunocompromised patients and hospital infection control system. To control multiresistant P. aeruginosa, which has overexpressed efflux pump, choice of detection method and treatment strategy is very important thing. Further studies should consider not only expression level of efflux pump via quantitative real-time PCR, but also effectiveness and safety of EPI and antibiotic combination therapy in various multiresistant P. aeruginosa strains.

Low contamination of Campylobacter spp. on chicken carcasses in Minas Gerais state, Brazil: Molecular characterization and antimicrobial resistance

Here, we evaluated Campylobacter contamination on chicken carcasses and phenotypic and genotypic profiles of antimicrobial resistance of the isolated strains. A total of 95 of samples were collected from 19 slaughterhouses from Minas Gerais - Brazil, and analyzed by MPN-PCR method. Campylobacter was found in 16.8% of samples with microbial load ranging from 60 to 184 MPN/carcass. All isolates were resistant to at least 5 (31.2%) of the antimicrobials screened using the disk diffusion method. Thr-86-Ile gyrA mutation, blaOxA-61 and tet(O) genes were found in 95%, 100% and 40% resistant isolates to ciprofloxacin, ampicillin and tetracycline, respectively. Almost all isolates (90%) showed the three genes required to synthesize the CmeABC efflux system. The use of efflux pump inhibitor (PAβN) resulted in a significant reduction in the MICs of antimicrobials (2–128 fold), indicating the importance of efflux systems in conferring antimicrobial resistance. Campylobacter were detected at low concentrations in Brazilian chicken carcasses. However, high-levels of antimicrobial resistance were observed and associated with several mechanisms. This study provides a baseline survey on contamination of Campylobacter in Brazilian chicken carcasses and its antimicrobial resistance, giving support for actions directed at reducing this pathogen in the food chain.

Energy metabolism and drug efflux in Mycobacterium tuberculosis.

The inherent drug susceptibility of microorganisms is determined by multiple factors, including growth state, the rate of drug diffusion into and out of the cell, and the intrinsic vulnerability of drug targets with regard to the corresponding antimicrobial agent. Mycobacterium tuberculosis, the causative agent of tuberculosis (TB), remains a significant source of global morbidity and mortality, further exacerbated by its ability to readily evolve drug resistance. It is well accepted that drug resistance in M. tuberculosis is driven by the acquisition of chromosomal mutations in genes encoding drug targets/promoter regions; however, a comprehensive description of the molecular mechanisms that fuel drug resistance in the clinical setting is currently lacking. In this context, there is a growing body of evidence suggesting that active extrusion of drugs from the cell is critical for drug tolerance. M. tuberculosis encodes representatives of a diverse range of multidrug transporters, many of which are dependent on the proton motive force (PMF) or the availability of ATP. This suggests that energy metabolism and ATP production through the PMF, which is established by the electron transport chain (ETC), are critical in determining the drug susceptibility of M. tuberculosis. In this review, we detail advances in the study of the mycobacterial ETC and highlight drugs that target various components of the ETC. We provide an overview of some of the efflux pumps present in M. tuberculosis and their association, if any, with drug transport and concomitant effects on drug resistance. The implications of inhibiting drug extrusion, through the use of efflux pump inhibitors, are also discussed.

The Efflux Inhibitor Phenylalanine-Arginine Beta-Naphthylamide (PAβN) Permeabilizes the Outer Membrane of Gram-Negative Bacteria

Active efflux of antimicrobial agents is a primary mechanism by which bacterial pathogens can become multidrug resistant. The combined use of efflux pump inhibitors (EPIs) with pump substrates is under exploration to overcome efflux-mediated multidrug resistance. Phenylalanine-arginine β-naphthylamide (PAβN) is a well-studied EPI that is routinely combined with fluoroquinolone antibiotics, but few studies have assessed its utility in combination with β-lactam antibiotics. The initial goal of this study was to assess the efficacy of β-lactams in combination with PAβN against the opportunistic pathogen, Pseudomonas aeruginosa. PAβN reduced the minimal inhibitory concentrations (MICs) of several β-lactam antibiotics against P. aeruginosa; however, the susceptibility changes were not due entirely to efflux inhibition. Upon PAβN treatment, intracellular levels of the chromosomally-encoded AmpC β-lactamase that inactivates β-lactam antibiotics were significantly reduced and AmpC levels in supernatants correspondingly increased, potentially due to permeabilization of the outer membrane. PAβN treatment caused a significant increase in uptake of 8-anilino-1-naphthylenesulfonic acid, a fluorescent hydrophobic probe, and sensitized P. aeruginosa to bulky antibiotics (e.g. vancomycin) that are normally incapable of crossing the outer membrane, as well as to detergent-like bile salts. Supplementation of growth media with magnesium to stabilize the outer membrane increased MICs in the presence of PAβN and restored resistance to vancomycin. Thus, PAβN permeabilizes bacterial membranes in a concentration-dependent manner at levels below those typically used in combination studies, and this additional mode of action should be considered when using PAβN as a control for efflux studies.

The protein synthesis inhibitors mycalamides A and E have limited susceptibility toward the drug efflux network

The mycalamides belong to a family of protein synthesis inhibitors noted for antifungal, antitumour, antiviral, immunosuppressive, and nematocidal activities. Here we report a systematic analysis of the role of drug efflux pumps in mycalamide resistance and the first isolation of mycalamide E. In human cell lines, neither P-glycoprotein overexpression nor the use of efflux pump inhibitors significantly modulated mycalamide A toxicity in the systems tested. In Saccharomyces cerevisiae, it appears that mycalamide A is subject to efflux by the principle mediator of xenobiotic efflux, Pdr5p along with the major facilitator superfamily pump Tpo1p. Mycalamide E showed a similar efflux profile. These results suggest that future drugs based on the mycalamides are likely to be valuable in situations where efflux pump-based resistance leads to failure of other chemotherapeutic approaches, although efflux may be a mediator of resistance in antifungal applications.

Mechanisms of Antibiotic Resistance in Salmonella: Efflux Pumps, Genetics, Quorum Sensing and Biofilm Formation

Multidrug resistance (MDR) to antibiotics presents a serious therapeutic problem in the treatment of bacterial infections. The importance of this mechanism of resistance in clinical settings is reflected in the increasing number of reports of multidrug resistant isolates. In Salmonella enterica, the most common etiological agent of food borne salmonellosis worldwide, MDR is becoming a major concern. In Salmonella the main mechanisms of antibiotic resistance are mutations in target genes (such as DNA gyrase and topoisomerase IV) and the over-expression of efflux pumps. However, other mechanisms such as changes in the cell envelope; down regulation of membrane porins; increased lipopolysaccharide (LPS) component of the outer cell membrane; quorum sensing and biofilm formation can also contribute to the resistance seen in this microorganism. To overcome this problem new therapeutic approaches are urgently needed. In the case of efflux-mediated multidrug resistant isolates, one of the treatment options could be the use of efflux pump inhibitors (EPIs) in combination with the antibiotics to which the bacteria is resistant. By blocking the efflux pumps resistance is partly or wholly reversed, allowing antibiotics showing no activity against the MDR strains to be used to treat these infections. Compounds that show potential as an EPI are therefore of interest, as well as new strategies to target the efflux systems. Quorum sensing (QS) and biofilm formation are systems also known to be involved in antibiotic resistance. Consequently, compounds that can disrupt or inhibit these bacterial “communication systems” will be of use in the treatment of these infections.

The third-generation P-glycoprotein inhibitor tariquidar may overcome bacterial multidrug resistance by increasing intracellular drug concentration

The use of efflux pump inhibitors may be a powerful strategy to overcome transporter-mediated bacterial multidrug resistance. In the present study, we set out to investigate the potency of tariquidar, a third-generation P-glycoprotein inhibitor in clinical development, for overcoming bacterial resistance towards ciprofloxacin. Staphylococcus aureus 29213 (SA29213) and S. aureus 1199B (SA1199B), which overexpresses the multidrug transporter NorA, as well as Pseudomonas aeruginosa 27853 and Stenotrophomonas maltophilia BAA-85, which expresses SmeDEF, were exposed to ciprofloxacin in the presence and absence of tariquidar or, for comparative reasons, elacridar. Activity of both P-glycoprotein inhibitors was evaluated by determination of MICs and time-kill curves, and by quantification of uptake of ciprofloxacin into bacterial cells. Activity of tariquidar and elacridar was comparable for S. aureus strains, and both dose-dependently increased susceptibility towards ciprofloxacin. Highest effects were observed for SA1199B, where the addition of tariquidar resulted in a 10-fold reduction of the ciprofloxacin MIC, while no effect was observed for P. aeruginosa. For S. maltophilia, elacridar but not tariquidar improved susceptibility. Uptake of [14C]ciprofloxacin and modification of susceptibility showed significant correlations (r=0.89, P<0.0001). Tariquidar had no intrinsic activity against any strain tested. We conclude that tariquidar has potent inhibitory effect against certain bacterial efflux pumps in vitro. Their high activity at clinically achievable concentrations might yield this class of drugs promising for future applications in infectious diseases.

Inhibitors of Multidrug Resistant Efflux Systems in Bacteria

Resistance of bacteria to many classes of antibiotics is an increasing problem worldwide. Multidrug resistance efflux pumps are recognized as an important component of resistance in both Gram-positive and Gram-negative bacteria. Some bacterial efflux pumps may be selective for one substrate, such as tetracycline, or transport antibiotics of different classes, conferring a multiple drug resistance (MDR) phenotype. Efflux pump inhibitors (EPIs) are promising therapeutic agents, as they should restore the activity of standard antibiotics. The efflux pump inhibitor-antibiotic combination is expected to increase the intracellular concentration of antibiotics that are expelled by efflux pumps, decrease the intrinsic bacterial resistance to antibiotics, reverse the acquired resistance associated with efflux pumps overexpression, and reduce the frequency of the emergence of resistant mutant strains. In recent years, different classes of EPIs have been described and tested, including analogues of antibiotic substrates and new molecules. This review focuses on the families of MDR efflux pumps, and on the current progress for the clinical use of EPIs. The present article is a good review of the recent patents related to efflux pump inhibitors.

Use of Efflux Pump Inhibitors (EPIs) to overcome bacterial Multi-Drug Resistance (MDR): plants as a source of chemodiversity and their adaptive response toward bacterial stress

Use of Efflux Pump Inhibitors (EPIs) to overcome bacterial Multi-Drug Resistance (MDR): plants as a source of chemodiversity and their adaptive response toward bacterial stress