Understanding evolution to tackle antibiotic resistance in Pseudomonas aeruginosa

Abstract

Antibiotic resistance (AR) constitutes a major public health concern, which has been aggravated in recent decades due to the emergence and spread of multidrug-resistant microorganisms, especially Gram-negative bacteria. Among them, Pseudomonas aeruginosa stands out; it is an opportunistic pathogen, widely distributed in nature, that frequently infects hospitalized patients and presents low susceptibility to many antimicrobials, as well as an overwhelming capacity to develop AR via mutation, mainly during chronic infections. Hence, novel treatment strategies are needed to deal with the infections caused by this bacterium. Collateral sensitivity, whereby acquiring resistance to one drug increases susceptibility to a second drug, is an evolutionary trade-off that may be exploited for treating bacterial infections by the combination or sequential use of drugs' pairs. This application is only possible if those collateral sensitivity phenotypes are conserved within different genetic contexts, environments and situations; robust collateral sensitivity events were searched for during this thesis. We determined that tobramycin, tigecycline and ceftazidime resistance acquisition in P. aeruginosa is associated with a robust fosfomycin collateral sensitivity and ascertained the mechanism responsible for this event. Further, we observed that ciprofloxacin exposure selects distinct mutations in different genetic backgrounds of P. aeruginosa, all of them leading to a robust tobramycin and aztreonam collateral sensitivity, and we proposed tobramycin-ciprofloxacin and ciprofloxacin-aztreonam combinations as promising therapies against infections caused by this bacterium. We also determined that media composition and nutrients’ availability constrain the pathways towards tobramycin, ceftazidime and ceftazidime-avibactam resistance in P. aeruginosa, but fosfomycin collateral sensitivity associated with ceftazidime resistance robustly emerges when P. aeruginosa evolves in different media mimicking those that can be encountered during infection. The compensation of fitness costs associated with the acquisition of AR in the absence of selective pressure could cause a decline of AR, which may also be used for designing therapeutic strategies considering those specific antibiotics whose resistance is robustly unstable in absence of selection. In this thesis, we observed that compensatory evolution of fitness costs associated with ceftazidime resistance in P. aeruginosa leads to a ceftazidime resistance decline in distinct genetic backgrounds, both in antibiotic-free and in sublethal tobramycin environments. The alternation of ceftazidime with drug restriction periods or the switch back to ceftazidime after a ceftazidime-tobramycin alternation may be feasible therapeutic approaches against P. aeruginosa infections. For its part, AR may be transiently induced by some conditions encountered by bacteria during infection, compromising the antibiotic treatments. In this thesis we identified dequalinium chloride, procaine and atropine, which can be present in P. aeruginosa site infections, as inducers of the expression of MexCD-OprJ efflux pump encoding genes, hence transiently increasing ciprofloxacin resistance of this bacterium. Finally, by further studying efflux pumps regulation and considering their ancestral function, we determined that the identification of compounds which are both substrates and inducers of efflux pumps of P. aeruginosa constitutes an effective strategy for finding molecules that reduce the virulence potential of this pathogen. Overall, the results of this thesis allow us to propose novel treatment strategies against P. aeruginosa infections, based on the identification of novel drugs and on the rational use of the antibiotics that we already have, as well as to better understand AR evolution