Abstract
Pseudomonas aeruginosa is an opportunistic human pathogen and one of the leading causes of nosocomial infections worldwide. The difficulty in treatment of pseudomonas infections arises from being multidrug resistant (MDR) and exhibits resistance to most antimicrobial agents due to the expression of different mechanisms overcoming their effects. Of these resistance mechanisms, the active efflux pumps in Pseudomonas aeruginosa that belong to the resistance nodulation division (RND) plays a very important role in extruding the antibiotics outside the bacterial cells providing a protective means against their antibacterial activity. Beside its role against the antimicrobial agents, these pumps can extrude biocides, detergents, and other metabolic inhibitors. It is clear that efflux pumps can be targets for new antimicrobial agents. Peptidomimetic compounds such as phenylalanine arginyl β-naphthylamide (PAβN) have been introduced as efflux pump inhibitors (EPIs); their mechanism of action is through competitive inhibition with antibiotics on the efflux pump resulting in increased intracellular concentration of antibiotic, hence, restoring its antibacterial activity. The advantage of EPIs is the difficulty to develop bacterial resistance against them, but the disadvantage is their toxic property hindering their clinical application. The structure activity relationship of these compounds showed other derivatives from PAβN that are higher in their activity with higher solubility in biological fluids and decreased toxicity level. This raises further questions on how can we compact Pseudomonas infections. Of particular importance, the recent resurgence in the use of older antibiotics such as polymyxins and probably applying stricter control measures in order to prevent their spread in clinical sittings.
Introduction
Pseudomonas aeruginosa is one of the most prevalent nosocomial pathogens associated with higher mortality rates and antibiotic costs. It can survive in different environments including soil, plants, and animals. It is also considered the most opportunistic human pathogen especially in immunocompromised patients and one of the top five pathogens of nosocomial diseases worldwide 1.
Pseudomonas infections are commonly reported in burns, urinary tract infections (UTI), and pulmonary diseases such as cystic fibrosis (CF). This diversity of pseudomonas infections is due to the development of various adaptive mechanisms such as the nutritional and metabolic pathways besides the regulation of gene expression. In addition, its ability to form biofilms provides greater protection against host immune defense systems and the susceptibility to various antimicrobial agents 2.
Pseudomonas aeruginosa is a multidrug resistant organism (MDR) and considered a phenomenon of bacterial resistance. This is demonstrated by different types of antibiotic resistance that are presented by this organism such as derepression of chromosomal AmpC cephalosporinase, production of plasmid or integron mediated β-lactamases from different molecular classes, lower outer membrane permeability (loss of OprD proteins), overexpression of active efflux systems, synthesis of aminoglycoside modifying enzymes (phosphoryl transferases, acetyl transferases, and adenyl transferases), and structural alterations of topoisomerases II and IV determining quinolone resistance. Taking into consideration that all these mechanisms are often present simultaneously thereby conferring multiresistant phenotypes 3456.
Quinolones (fluoroquinolones) and aminoglycosides are the major classes of antibiotics used in the treatment of infections caused by Pseudomonas aeruginosa. Fluoroquinolones act by inhibition of DNA replication and transcription via inhibition of DNA gyrase and topoisomerase IV. The mode of action of aminoglycosides depends on the inhibition of protein synthesis by binding to the 30s ribosomal subunit resulting in misreading of mRNA by inhibition of the transfer of peptidyl-tRNA across the ribosome 7. Even the use of antibiotic combinations between β-lactams antibiotics or β-lactams with β-lactamase inhibitors or different classes of aminoglycosides is useless in the management of pseudomonas infections 8. This has directed the attention to novel antimicrobial agents such as antibodies, phages, selective peptides, novel β-lactams, or other combinations of novel β-lactamase inhibitors with known penicillins or cephalosporins 8.
Role of efflux pumps in antibiotic resistance
Efflux pumps contribute to multidrug resistance as they expel different types of antibiotics and chemicals such as dyes, organic solvents, detergents, molecules needed for the cell–cell communication, biocides, and metabolic products. Hence understanding the mechanisms by which these pumps act and how to overcome its activity opens the door for restoring the antibiotic activity and constitute a promising target for novel antibacterial agents 910111213.
The bacterial multidrug efflux transporters can be divided into five classes: 1 small multidrug resistance (SMR), 2 major facilitator superfamily (MFS), 3 resistance nodulation cell division (RND), 4 multidrug and toxic compound extrusion (MATE), 5 ATP-binding cassette (ABC). Those five classes obtain energy required for the active transporting either from H+ protons (RND, SMR, and MFS), Na+ dependant (MATE), or by hydrolysis ATP (ABC) 1214.
The efflux pump transporter in Pseudomonas aeruginosa belongs to the (RND) family. It is composed of three parts, the transporter, the linker, and the outer membrane pore that ensures that the extruded compound does not remain in the periplasm, hence, avoiding its return to the cytosol 15. There are 12 types of RND efflux systems including for example MexAB-OprM, MexCD-OprJ, MexEF-OprN, MexXY-OprM, MexPQ-OpmE, MexMN-OprM, and MexVW-OprM that differ in their substrates as shown in Table 1. Of these different types of efflux pumps, MexAB-OprM is the one constitutionally expressed in Pseudomonas aeruginosa accounting for the intrinsic resistance to flouroquinolones and pathogenicity of this organism 1316171819. Fig. 1 MexAB-OprM consists of three subunits, MexA and OprM acting by substrate recognizing energy transfer and connecting the MexB and OprM, and the antibiotic discharge duct protein 20. As a result, antibiotics are entrapped by MexB and transferred to OprM and finally extruded by MexA 212223. Higher resistance profiles of Pseudomonas aeruginosa to quinolones can result from mutations in the genes encoding for efflux pump MexAB-oprM that regulate the resistance for quinolones, β-lactams, and β-lactamase inhibitors 24. Beside its well-defined activity against the known antimicrobial agents, MexAB-OprM pump confers resistance to the other non-antibiotic compounds such as tea tree oil and its monoterpene components α-terpineol and the related alcohols 25.
Published online:
13 May 2011Fig. 1. Schematic illustration of the main efflux pump MexAB-OprM in Pesudomonas aeuroginosa as examples for the Resistance-Nodulation-Division (RND) family showing that it is energy dependant on hydrogen protons.
![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/zljm20/2011/zljm20.v006.i01/ljm.v6i0.5870/20170328/images/medium/zljm_a_11815815_f0001_ob.jpg"})
Fig. 1. Schematic illustration of the main efflux pump MexAB-OprM in Pesudomonas aeuroginosa as examples for the Resistance-Nodulation-Division (RND) family showing that it is energy dependant on hydrogen protons.
Table 1. Substrates and the general regulators of major efflux pumps in Pseudomonas aeruginosa
In spite of being important to provide resistance to many antibiotics, MexAB-OprM pump cannot confer resistance to the human antimicrobial polypeptides cathelicidins, α and β-defensins by testing the action of these antimicrobial agents versus the wild-type pseudomonas strains and strains mutant in the genes encoding for the pump expression 26. On the other hand, it was shown that MexXY-OprM has a role in the resistance to aminoglycoside antibiotics that was approved by the deletion of the genes responsible for this efflux pump expression resulting in the increased sensitivity of the mutant strains to aminoglycosides than the wild-type strains 27.
Role of efflux pumps to antibiotic resistance in biofilms
It is well known that biofilms can play an important role in resistance to antibiotics due to the extracellular polysaccharide matrix, higher bacterial cell density, and lower bacterial growth that provide a good protective means for the bacterial cells against antimicrobial agents 28. In addition, a novel efflux pump has been identified as important to increase the bacterial antibiotic resistance in biofilms rather than the planktonic cells where the deletion of the genes encoding for this pump render the cells in biofilms more sensitive to antibiotics, such as tobramycin, indicating that this efflux pump is essential to pseudomonas antibiotic resistance in biofilms rather than the planktonic state 29.
Genetic organization of Pseudomonas aeruginosa RND efflux operons
The genetic organization of RND efflux pump operons comprises of three steps. First, the genes regulating the RND transporter and membrane fusion protein are always present. Second, the genes encoding the operon regulators and the outer membrane channel proteins are not always present taking into account that some operons do not have regulatory genes or outer membrane regulatory gene linked to the efflux operon. Third, some additional regulatory genes can be present beside the regulatory genes for the efflux transporter and membrane fusion protein such as in case of mexGHI-opmD that contains mexG, which encodes a membrane protein required for pump function 30.
Regulation of expression of Pseudomonas aeruginosa RND efflux pumps
Efflux systems other than MexAB-OprM are tightly regulated that recently was verified by transcriptional profiling using Affymetrix Gene Chips. This expression differs from one system to the other, where the expression of MexGHI-OprM is dependent on the cell density indicating that its regulator is the quorum signaling 26, while in the case of MexXY its expression is inducible and enhanced by the presence of certain antibiotics 31. The CzrAB-OpmN divalent cation RND pump is regulated via two compartment regulatory systems in the presence of divalent cations and some isolates that resist antibiotic treatment show susceptibility to the same antibiotic when propagated in the laboratory suggesting inducible components of resistance 13. Other efflux systems are overexpressed as a result of mutations in their encoding genes for regulatory proteins due to the exposure antimicrobial agents either in vivo or in vitro taking into consideration that these mutations are persistent, which is indicated by the expression that remains long even after removal of the selective pressure 32. For MexAB-OprM, which is always expressed in low but detectable amounts, Hao et al. 33 have shown that MexR, which is a MarR family protein, can negatively regulate multidrug efflux systems in Pseudomonas aeruginosa. The mechanism of MexR-regulated antibiotic resistance is due to the formation of intermonomer disulfide bonds in MexR dimer that leads to its dissociation from promoter DNA, derepression of the mexAB-oprM drug efflux operon, and increased antibiotic resistance of Pseudomonas aeruginosa. It was also shown that macrolide antibiotics can downregulate the gene expression of MexAB-OprM, where azithromycin lowers the expression of this efflux pump by 70% resulting in the increased sensitivity of Pseudomonas aeuroginosa to different antibiotics such as chloramphenicol and tetracycline. Besides the previously known regulators, there are other unidentified regulators since many efflux systems are expressed in the absence of their regulatory factors 3435. Eisaku et al. 36 have shown that the OprM subunit of efflux pump MexAB-OprM can be replaced by the OprN subunit in MexEF-OprN without affecting its activity but the reverse is not.
The efflux pump inhibitors as new therapeutic agents
The continuous increase in the development of multidrug resistance by many pathogens has resulted in difficulties fighting many infectious diseases. In view of the fact that the majority of those multidrug resistant pathogens expresses and overproduces efflux pumps that are responsible for the expelling and extruding of the antibiotics from inside the cells, the new direction for other chemotherapeutics is the use of efflux pump inhibitors (EPIs) 37. Using the (EPIs) together with antibiotics can reduce the invasiveness of Pseudomonas aeruginosa besides its role in lowering the antibiotic minimal inhibitory concentration 18. For example, the sensitivity to ciprofloxacin by Pseudomonas aeruginosa is largely increased upon using this inhibitor proving that efflux pumps play a role in the resistance of this organism to this antibiotic 38. Thus the inhibition of the efflux pumps is promising in order to 1 increase the intracellular drug concentration, 2 restore the drug activity against the resistant strains, and 3 minimizes further development of resistant strains. However, this requires the understanding of the structural and physiological mechanisms of the responsible efflux pumps 2939.
The inhibition of efflux pumps can be achieved by different mechanisms as shown in (Fig. 2): 1 interference with the regulatory steps needed for the expression of the efflux pump, 2 chemical changes in the antibiotic structure hence hindering its attachment as the specific substrate, 3 disruption of the assembly of the efflux pump-components, 4 inhibition of the substrate (antibiotic) binding by either competitive or non-competitive binding using other compounds, 5 blocking the outer most pores responsible for the efflux of antibiotic compound, 6 interference with the energy required for the pump activity 3740.
Published online:
13 May 2011Fig. 2. Schematic illustration showing the general mechanisms of efflux pump inhibition and the targets that can be affected using efflux pump MexAB-OprM efflux pump as an example.
![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/zljm20/2011/zljm20.v006.i01/ljm.v6i0.5870/20170328/images/medium/zljm_a_11815815_f0002_ob.jpg"})
Fig. 2. Schematic illustration showing the general mechanisms of efflux pump inhibition and the targets that can be affected using efflux pump MexAB-OprM efflux pump as an example.
Many compounds were tested for their efflux pump inhibition ability including some analogues for antibiotic substrates and other chemical compounds, but few are used that take into consideration the structure-activity relationship and the spectrum of the activity 39. The general methodology used for testing the efficacy of these efflux inhibitors is simply performed by comparing the intracellular concentration of the added antibiotic to the bacterial cell culture before and after the addition of the (EPIs) such as phenylalanine arginyl β-naphthylamide (PAβN). If the compound under testing showed higher intracellular concentration of the antibiotic, it is considered a good efflux inhibitor and vice versa 4142.
Peptidomimetic compounds (PAβN) as efflux inhibitors against pseudomonas infections
The most widely used compounds as (EPIs) for pseudomonas overexpressing MexAB pump are the group of peptidomimetic molecules with phenylalanine arginyl β-naphthylamide (PAβN) as a leading compound (MC-207,110) (Fig. 3a) and other many derivatives being studied using the structure activity relationship. The mechanism of action of these inhibitors is through competitive inhibition mechanism, where the efflux pumps recognize them as a substrate instead of the target antibiotics (quinolones mainly ciprofloxacin and levofloxacin) and as long as the pumps expel these inhibitors outside the cells, the antibiotic remains intracellular and increasing in concentration. Taking into consideration that PAβN has a differential behavior, meaning that it can compete with certain antibiotics and not the other depending on the nature of the efflux pump and the large substrate-binding site 434445.
Published online:
13 May 2011Fig. 3. Efflux pump inhibitors (EPIs) acting against Pseudomonas aeruginosa (a) phenylalanine arginyl β-naphthylamide, PAβN (MC-207,110) and its derivative (MC-04,124) and (b) pyridopyrimidine derivative.
![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/zljm20/2011/zljm20.v006.i01/ljm.v6i0.5870/20170328/images/medium/zljm_a_11815815_f0003_ob.jpg"})
Fig. 3. Efflux pump inhibitors (EPIs) acting against Pseudomonas aeruginosa (a) phenylalanine arginyl β-naphthylamide, PAβN (MC-207,110) and its derivative (MC-04,124) and (b) pyridopyrimidine derivative.
It was also shown that PAβN can restore the activity of other unrelated antibiotics such as chloramphenicol and macrolides; hence, it can be considered a broad spectrum efflux pump inhibitor 4346. Other derivatives were designed from PAβN such as MC-04,124 (Fig. 3a), which is more stable in biological fluids, shows less toxicity levels and more activity against Pseudomonas aeruginosa overexpressing efflux pumps 47.
Structure-activity relationship of peptidomimetic compounds
The structural activity relationship of these compounds revealed that the modification of these compounds by the addition of various hydrophilic chains had yielded a pyridopyrimidine compound (Fig. 3b) with improved solubility (e.g. morpholine derivative) that showed higher activity through the potentiation of flouroquinolones and β-lactam antibiotics in addition to inhibition of the β-lactam efflux 174849.
The PAβN-derived (EPIs) still remain the most studied and developed family against Pseudomonas aeruginosa, though more studies concerning the structure activity relationship, pharmacokinetics, and stability in biological fluids are required. The main advantage of using the PAβN-derived (EPIs) is the difficulty to develop resistance to them, where any pump mutation leading to inhibitor resistance will lead to resistance to the antibiotic substrate. The disadvantage of those compounds is their low affinity to the target that necessitates the use of higher doses and for a longer time in addition to only substrates that share the inhibitor binding site will be affected 40.
The main drawbacks associated with these EPI compounds is their toxic properties hindering their clinical applications; however, they are used in order to evaluate the different efflux mechanisms expressed by different pathogenic bacteria besides the measurement of the affinity of efflux pumps to them in relation to the antibiotics 4650. It has been demonstrated that PAβN is more potent as an efflux inhibitor against MexAB-OprM pump of Pseudomonas aeruginosa when compared to quinoline derivatives (another class of EPIs) that could be attributed to the difference in the screening protocols for the antibiotic used as a substrate (levofloxacin versus chloramphenicol) for the two EPI classes (peptidomimetics or quinoline derivatives) 41.
The Mpex Company has already developed a compound that is a combination of an antibiotic and EPI for the systemic treatment of serious hospital acquired infections caused by multidrug resistant pathogens such as Pseudomonas aeruginosa 37.
Is there a role for older antimicrobials and infection control measures?
The discovery of polymyxins goes back to 1947 as products being synthesized from Bacillus polymyxa 51. There use has declined in the late 1970–1980s because of their neuro- and nephrotoxicity and emergence of newer less toxic antimicrobials 52. However, as many multidrug-resistant bacteria including pseudomonas are still only susceptible to polymyxins (polymyxin B and colistin [polymyxin E]), this has leading clinicians reconsidering their application for the management of multidrug-resistant gram-negative bacterial infections in clinical practice. In a number of recent studies, it has been demonstrated that polymyxins remain active against most gram-negative bacteria in vitro, and that intravenous or inhaled polymyxins have been found to be effective and considerably less toxic than reported in older studies 5253. For instance, the global resistance rate against polymyxin B in different centers in Europe, Asia, and America were 1.3% for P. aeruginosa and 2.1% for A. baumannii isolates 54. Colistin is available commercially as colistin sulfate (i.e. colistin) and sodium colistin methanesulfonate (CMS), which is administered parenterally. The CMS is an inactive prodrug of colistin and, after parenteral administration, colistin is formed in vivo 5556.
On the other hand, as cross-contamination appears to be a common route for the spread of infection by MDR resistant pseudomonas spp. among patients, there is a need to underscore the importance of stricter control measures with recommended infection control practices to limit the spread of MDR pseudomonas clones inside the hospital environment 5758.
Conclusions
Pseudomonas aeruginosa is responsible for a high percentage of nosocomial infections. The difficulty in its treatment by antibiotics arises from its capability of nearly expressing all mechanisms of antibiotic resistance; hence, it is considered a multidrug-resistant (MDR) organism 15.
Many compounds have been identified as (EPIs) when used as adjuvants or in combination with the effective antibiotics 37. It is also important to take into account both the pharmacokinetics and pharmacodynamics when choosing the efflux inhibitors to be adapted with those combined antibiotics 59. In addition, more assay techniques are required in order to design and quantify the (EPIs) and measuring their kinetic parameters in relation to the efflux pump components. These parameters are essential for choosing between the general EPI that can inhibit the action of one transporter that expels various antibiotics in one bacterial species or a specific EPI that inhibits the pumping of one antibiotic family in various bacteria 39.
In this review it was demonstrated that efflux pumps are very important to provide resistance to antimicrobial agents especially in Pseudomonas aeruginosa, hence they can be targets for new promising antimicrobial compounds. The benefits of these (EPIs) will be the ability to reuse the traditional antibiotics that became no longer effective due to the development of bacterial resistance through the efflux pumps; hence, this will save a lot of cost and effort that is required to develop new antimicrobial agents, which will face the same problem of developing microbial resistance in the case that these pumps are not inhibited. Many studies showed that the use of peptidomimetic molecules as phenylalanine arginyl β-naphthylamide (PAβN) or other derivatives of PAβN by structural modifications results in a significant decrease of Pseudomonas aeruginosa resistant to antibiotics – mainly flouroquinolones. In the future more derivatives are needed using the structure activity relationship in order to minimize the disadvantages of the present compounds associated with higher toxic properties and less biological stability. Also more advanced techniques for assaying the (EPIs) and determination of the exact efflux system for each antibiotic are required in order to design appropriate inhibitors for antibiotics.
Conflict of interest and funding
The authors have not received any funding or benefits from industry or elsewhere to conduct this study.
| Efflux pump | Substrates | Regulators and function | Reference |
|---|---|---|---|
| MexAB-OprM | β-lactam, β-lactam inhibitors, SDS, fluoroquinolones, tetracycline, novobiocin, chloramphenicol, macrolides, trimethoprim, triclosan, ethidium bromide, aromatic hydrocarbons, thiolactomycin, cerulenin, acylated homoserine lactones. | MexR (repressor) | (54, 58) |
| MexCD-OprJ | β-lactam, fluoroquinolones, tetracycline, chloramphenicol, novobiocin, macrolides, trimethoprim, triclosan, ethidium bromide, SDS, aromatic hydrocarbons, crystal violet, acriflavin. | NfxB (repressor) | (54) |
| MexEF-OprN | Fluoroquinolones, chloramphenicol, trimethoprim, triclosan, aromatic hydrocarbons, pseudomonas quinolone signal (precursors)? | MexS (repressor) MexT (activator) | (21, 54) |
| MexGHI-OprD | Vanadium, acylated homoserine lactones? | LasR? RhlR? (unknown) | (19) |
| MexXY | Tetracycline, erythromycin, aminoglycosides, fluoroquinolones | MexZ (repressor) | (14) |
References
- Farhat U, Salman A, Jawad A. Antimicrobial susceptibility and ESBL prevalence in Pseudomonas aeruginosa isolated from burn patients in the North West of Pakistan. Burns. 2009; 35: 1020–5. [Crossref], [Web of Science ®], [Google Scholar]
- Jeff GL, Mathias K, Candice S, Chelsa J, Gabriel M, Alyssa S, et al.. Flagellum-mediated biofilm defense mechanisms of Pseudomonas aeruginosa against host-derived lactoferrin. Infect Immun. 2009; 77: 4559–66. [Crossref], [Web of Science ®], [Google Scholar]
- McGowan JE Jr. Resistance in non-fermenting gram-negative bacteria: multidrug resistance to the maximum. Am J Infect Control. 2006; 34: 29–37. [Crossref], [Web of Science ®], [Google Scholar]
- Hancock RE, Speert DP. Antibiotic resistance in Pseudomonas aeruginosa: mechanisms and impact on treatment. Drug Resist Updat. 2000; 3: 247–55. [Crossref], [Web of Science ®], [Google Scholar]
- Falagas ME, Bliziotis IA. Pandrug-resistant gram negative bacteria: the dawn of the post-antibiotic era?. Int J Antimicrob Agents. 2007; 29: 630–6. [Crossref], [Web of Science ®], [Google Scholar]
- Gooderham WJ, Hancock REW. Regulation of virulence and antibiotic resistance by two-component regulatory systems in Pseudomonas aeruginosa. FEMS Microbiol Rev. 2009; 33: 279–94. [Crossref], [Web of Science ®], [Google Scholar]
- Neda G, Scott A, Andrew P, Nader P. Detection of point mutations associated with antibiotic resistance in Pseudomonas aeruginosa. Int J Antimicrob Agents. 2009; 34: 414–8. [Crossref], [Web of Science ®], [Google Scholar]
- Page MG, Heim J. Prospects for the next anti Pseudomonas drug. Curr Opin in Pharmacol. 2009; 9: 558–65. [Crossref], [Web of Science ®], [Google Scholar]
- Vidal-Aroca F, Meng A, Minz T, Page MG, Dreier J. Use of resazurin to detect mefloquine as an efflux-pump inhibitor in Pseudomonas aeruginosa and Escherichia coli. J Microbiol Methods. 2009; 79: 232–7. [Crossref], [Web of Science ®], [Google Scholar]
- Dreier J. Active drug efflux in bacteria. In: Bonomo RA, Tolmasky M. Enzyme-mediated resistance to antibiotics. WashingtonDC: ASM Press. 2007. p. 235–64. [Crossref], [Google Scholar]
- Livermore DM. Multiple mechanisms of antimicrobial resistance in Pseudomonas aeruginosa: our worst nightmare?. Clin Infect Dis. 2002; 34: 634–40. [Crossref], [Web of Science ®], [Google Scholar]
- Piddock LJ. Clinically relevant chromosomally encoded multidrug resistance efflux pumps in bacteria. Clin Microbio Rev. 2006; 19: 382–402. [Crossref], [Web of Science ®], [Google Scholar]
- Schweizer HP. Efflux as a mechanism of resistance to antimicrobials in Pseudomonas aeuroginosa and related bacteria: unanswered questions. Genet Mol Res. 2003; 2: 48–62. [Google Scholar]
- Misra R, Bavro VN. Assembly and transport mechanism of tripartite drug efflux systems. Biochimica et Biophysica Acta. 2009; 1794: 817–25. [Crossref], [Web of Science ®], [Google Scholar]
- Tanya S, Daniel Y. Pseudomonas aeruginosa – a phenomenon of bacterial resistance. J Med Microbiol. 2009; 58: 1133–48. [Crossref], [Web of Science ®], [Google Scholar]
- George GZ, Daryl JH, Kristen S, James AK. Role of efflux mechanisms on fluoroquinolone resistance in Streptococcus pneumoniae and Pseudomonas aeruginosa. Int J Antimicrob Agents. 2004; 24: 529–35. [Crossref], [Web of Science ®], [Google Scholar]
- Yoshida K, Nakayama K, Yokomizo Y, Ohtsuka M, Takemura M, Hoshino K, et al.. MexAB-OprM specific efflux pump inhibitors in Pseudomonas aeruginosa, Part 6: exploration of aromatic substituents. Bioorg Med Chem. 2006; 14: 8506–18. [Crossref], [Web of Science ®], [Google Scholar]
- Hirakata Y, Kondoc A, Hoshino K, Yano H, Arai K, Hirotani A, et al.. Efflux pump inhibitors reduce the invasiveness of Pseudomonas aeruginosa. Int J Antimicrob Agents. 2009; 34: 343–6. [Crossref], [Web of Science ®], [Google Scholar]
- Mima T, Sekiya H, Mizushima T, Kuroda T, Tsuchiya T. Gene cloning and properties of the RND-type multidrug efflux pumps MexPQ-OpmE and MexMN-OprM from Pseudomonas aeruginosa. Microbiol Immunol. 2005; 49: 999–1002. [Crossref], [Web of Science ®], [Google Scholar]
- Poole K. Multidrug efflux pumps and antimicrobial resistance in Pseudomonas aeruginosa and related organisms. J Mol Microbiol Biotechnol. 2001; 3: 255–63. [Web of Science ®], [Google Scholar]
- Murakami S, Nakashima R, Yamashita E, Matsumoto T, Yamaguchi A. Crystal structures of a multidrug transporter reveal a functionally rotating mechanism. Nature. 2006; 443: 173–9. [Crossref], [Web of Science ®], [Google Scholar]
- Higgins MK, Bokma E, Koronakis E, Hughes C, Koronakis V. Structure of the periplasmic component of a bacterial drug efflux pump. Proc Natl Acad Sci. 2004; 101: 9994–9. [Crossref], [Web of Science ®], [Google Scholar]
- Eda S, Maseda H, Nakae T. An elegant means of self-protection in gram-negative bacteria by recognizing and extruding xenobiotics from the periplasmic space. J Biol Chem. 2003; 278: 2085–8. [Crossref], [Web of Science ®], [Google Scholar]
- Jalal S, Ciofu O, Høiby N, Gotoh N, Wretlind B. Molecular mechanisms of fluoroquinolone resistance in Pseudomonas aeruginosa isolates from cystic fibrosis patients. Antimicrob Agents Chemother. 2000; 44: 710–12. [Crossref], [Web of Science ®], [Google Scholar]
- Papadopoulos CJ, Christine FC, Barbara JC, Riley TV. Role of the MexAB-OprM efflux pump of Pseudomonas aeruginosa in tolerance to tea tree (Melaleuca alternifolia) oil and its monoterpene components terpinen-4-ol, 1,8-cineole, and α-terpineol. Appl Environmen Microbiol. 2008; 74: 1932–5. [Crossref], [Web of Science ®], [Google Scholar]
- Rieg S, Huth A, Kalbacher H, Kern WV. Resistance against antimicrobial peptides is independent of Escherichia coli AcrAB, Pseudomonas aeruginosa MexAB and Staphylococcus aureus NorA efflux pumps. Int J Antimicrob Agents. 2009; 33: 174–6. [Crossref], [Web of Science ®], [Google Scholar]
- Jeannot K, Elsen S, Köhler T, Attree I, van Delden C, Plésiat P. Resistance and virulence of Pseudomonas aeruginosa clinical strains overproducing the MexCD-OprJ efflux pump. Antimicrob Agents Chemoth. 2008; 52: 2455–62. [Crossref], [Web of Science ®], [Google Scholar]
- Mah TF, O'Toole GA. Mechanisms of biofilm resistance to antimicrobial agents. Trends Microbiol. 2001; 9: 34–9. [Crossref], [Web of Science ®], [Google Scholar]
- Zhang L, Mah TF. Involvement of a novel efflux system in biofilm-specific resistance to antibiotics. J Bacteriol. 2008; 190: 4447–52. [Crossref], [Web of Science ®], [Google Scholar]
- Aendekerk S, Ghysels B, Cornelis P, Baysse C. Characterization of a new efflux pump, MexGHI-OpmD, from Pseudomonas aeruginosa that confers resistance to vanadium. Microbiology. 2002; 148: 2371–81. [Crossref], [Web of Science ®], [Google Scholar]
- Masuda N, Sakagawa E, Ohya S, Gotoh N, Tsujimoto H, Nishino T. Substrate specificities of MexAB-OprM, MexCD-OprJ, and MexXY-OprM efflux pumps in Pseudomonas aeruginosa. Antimicrob Agents Chemoth. 2000; 44: 3322–7. [Crossref], [Web of Science ®], [Google Scholar]
- Chuanchuen R, Narasaki CT, Schweizer HP. The MexJK efflux pump of Pseudomonas aeruginosa requires OprM for antibiotic efflux but not for efflux of Triclosan. J Bacteriol. 2002; 184: 5036–44. [Crossref], [Web of Science ®], [Google Scholar]
- Hao C, Jie H, Peng RC, Lefu L, Zigang L, Leslie MH, et al.. The Pseudomonas aeruginosa multidrug efflux regulator MexR uses an oxidation-sensing mechanism. PNAS. 2008; 105: 13586–91. [Crossref], [Web of Science ®], [Google Scholar]
- Sugimura M, Maseda H, Hanaki H, Nakae T. Macrolide antibiotic-mediated down regulation of MexAB-OprM efflux pump expression in Pseudomonas aeruginosa. Antimicrob Agents Chemother. 2008; 52: 4141–4. [Crossref], [Web of Science ®], [Google Scholar]
- Adewoye L, Sutherland A, Srikumar R, Poole K. The MexR repressor of the mexAB-oprM multidrug efflux operon in Pseudomonas aeruginosa: characterization of mutations compromising activity. J Bacteriol. 2002; 184: 4308–12. [Crossref], [Web of Science ®], [Google Scholar]
- Eisaku Y, Shima E, Sayaka K. Functional interaction sites of OprM with MexAB in the Pseudomonas aeruginosa multidrug efflux pump. FEMS Microbiology Letters. 2009; 299: 200–4. [Crossref], [Web of Science ®], [Google Scholar]
- Pagès J-M, Amaral L. Mechanisms of drug efflux and strategies to combat them: challenging the efflux pump of gram-negative bacteria. Biochimica et Biophysica Acta. 2009; 1794: 826–33. [Crossref], [Web of Science ®], [Google Scholar]
- Tohidpour A, Peerayeh SN, Mehrabadi JF, Yazdi HR. Determination of the efflux pump mediated resistance prevalence in Pseudomonas aeruginosa, using an efflux pump inhibitor. Curr Microbiol. 2009; 59: 352–5. [Crossref], [Web of Science ®], [Google Scholar]
- Mahamoud A, Chevalier J, Alibert-Franco S, Kern WV, Pagès JM. Antibiotic efflux pumps in gram-negative bacteria: the inhibitor response strategy. J Antimicrob Chemoth. 2007; 59: 1223–9. [Crossref], [Web of Science ®], [Google Scholar]
- Poole K, Lomovskaya O. Can efflux inhibitors really counter resistance?. Infect Disease. 2006; 3: 145–52. [Google Scholar]
- Mahamoud A, Chevalier J, Davin-Regli A. Quinolone derivatives as promising inhibitors of antibiotic efflux pump in multidrug resistant Enterobacter aerogenes. Curr Drug Targets. 2006; 7: 843–7. [Crossref], [Web of Science ®], [Google Scholar]
- Ghisalberti D, Mahamoud A, Baitiche M. Chloroquinolines block antibiotic efflux pump in resistant Enterobacter aerogenes isolates. Int J Antimicrob Agents. 2006; 27: 565–9. [Crossref], [Web of Science ®], [Google Scholar]
- Lomovskaya O, Warren MS, Lee A, Galazzo J, Fronko R, Lee M, et al.. Identification and characterization of inhibitors of multidrug resistance efflux pumps in Pseudomonas aeruginosa: novel agents for combination therapy. Antimicrob Agents Chemother. 2001; 45: 105–16. [Crossref], [Web of Science ®], [Google Scholar]
- Renau TE, Léger R, Yen R, She MW, Flamme EM, Sangalang J, et al.. Peptidomimetics of efflux pump inhibitors potentiate the activity of levofloxacin in Pseudomonas aeruginosa. Bioorg Med Chem Lett. 2002; 12: 763–6. [Crossref], [Web of Science ®], [Google Scholar]
- Renau TE, Léger R, Filonova L, Flamme EM, Wang M, Yen R, et al.. Conformationally-restricted analogues of efflux pump inhibitors that potentiate the activity of levofloxacin in Pseudomonas aeruginosa. Bioorg Med Chem Lett. 2003; 13: 2755–8. [Crossref], [Web of Science ®], [Google Scholar]
- Lomovskaya O, Bostian KA. Practical applications and feasibility of efflux pump inhibitors in the clinic – a vision for applied use. Biochem Pharmacol. 2006; 71: 910–18. [Crossref], [Web of Science ®], [Google Scholar]
- Watkins WJ, Landaverry Y, Léger R, Litman R, Renau TE, Williams N, et al.. The relationship between physicochemical properties, in vitro activity and pharmacokinetic profiles of analogues of diamine-containing efflux pump inhibitors. Bioorg Med Chem Lett. 2003; 13: 4241–4. [Crossref], [Web of Science ®], [Google Scholar]
- Yoshida K, Nakayama K, Kuru N, Kobayashi S, Ohtsuka M, Takemura M, et al.. MexAB-OprM specific efflux pump inhibitors in Pseudomonas aeruginosa, Part 5: carbon-substituted analogues at the C-2 position. Bioorg Med Chem. 2006; 14: 1993–2004. [Crossref], [Web of Science ®], [Google Scholar]
- Yoshida KI, Nakayama K, Ohtsuka M, Kuru N, Yokomizo Y, Sakamoto A, et al.. MexAB-OprM specific efflux pump inhibitors in Pseudomonas aeruginosa. Part 7: highly soluble and in vivo active quaternary ammonium analogue D13-9001, a potential preclinical candidate. Bioorg Med Chem. 2007; 15: 7087–97. [Crossref], [Web of Science ®], [Google Scholar]
- Kriengkauykiat J, Porter E, Lomovskaya O. Use of an efflux pump inhibitor to determine the prevalence of efflux pump-mediated fluoroquinolone resistance and multidrug resistance in Pseudomonas aeruginosa. Antimicrob Agents Chemother. 2005; 49: 565–70. [Crossref], [Web of Science ®], [Google Scholar]
- Benedict RG, Langlykke AF. Antibiotic activity of bacillus polymyxa. J Bacteriol. 1947; 54: 24–25. [Web of Science ®], [Google Scholar]
- Falagas ME, Kasiakou SK. Colistin: the revival of polymyxins for the management of multidrug-resistant gram-negative bacterial infections. Clin Infect Dis. 2005; 40: 1333–41. [Crossref], [Web of Science ®], [Google Scholar]
- Li JK, Nation RL, Turnidge JD, Milne RW, Coulthard K, Rayner CR, et al.. Colistin: the re-emerging antibiotic for multidrug-resistant Gram-negative bacterial infections. Lancet Infect Dis. 2006; 6: 589–601. [Crossref], [Web of Science ®], [Google Scholar]
- Gales AC, Jones RN, Sader HS. Global assessment of the antimicrobial activity of polymyxin B against 54 731 clinical isolates of gram-negative bacilli: report from the SENTRY antimicrobial surveillance programme (2001–2004). Clin Microbiol Infect. 2006; 12: 315–21. [Crossref], [Web of Science ®], [Google Scholar]
- Li J, Coulthard K, Milne R, Nation RL, Conway S, Peckham D, et al.. Steady-state pharmacokinetics of intravenous colistin methanesulphonate in patients with cystic fibrosis. J Antimicrob Chemother. 2003; 52: 987–92. [Crossref], [Web of Science ®], [Google Scholar]
- Plachouras D, Karvanen M, Friberg LE, Papadomichelakis E, Antoniadou A, Tsangaris I, et al.. Population pharmacokinetic analysis of colistin methanesulfonate and colistin after intravenous administration in critically ill patients with gram-negative bacterial infections. Antimicrob Agents Chemother. 2009; 53: 3430–6. [Crossref], [Web of Science ®], [Google Scholar]
- Widmer AF, Wenzel RP, Trilla A, Bale MJ, Jones RN, Doebbeling BN. Outbreak of Pseudomonas aeruginosa infections in a surgical intensive care unit: probable transmission via hands of a health care worker. Clin Infect Dis. 1993; 16: 372–6. [Crossref], [Web of Science ®], [Google Scholar]
- Moolenaar RL, Crutcher JM, San Joaquin VH, Sewell LV, Hutwagner LC, Carson LA, et al.. A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission?. Infect Control Hosp Epidemiol. 2000; 21: 80–5. [Crossref], [Web of Science ®], [Google Scholar]
- Lomovskaya O, Zgurskaya HI, Totrov M, Watkins WJ. Waltzing transporters and ‘the dance macabre’ between humans and bacteria. Nat Rev. Drug Discov. 2007; 6: 56–65. [Crossref], [Google Scholar]