Inhibition of AdeB, AceI, and AmvA Efflux Pumps Restores Chlorhexidine and Benzalkonium Susceptibility in ATCC 19606.

The management of infections caused by is hindered by its intrinsic tolerance to a wide variety of biocides. The aim of the study was to analyze the role of different efflux pumps (EPs) in tolerance to chlorhexidine (CHX) and benzalkonium (BZK) and identify non-toxic compounds, which can restore susceptibility to CHX and BZK in . ATCC 19606 strain was tolerant to both CHX and BZK with MIC and MBC value of 32 mg/L. CHX subMIC concentrations increased the expression of and (RND superfamily), (PACE family) and (MFS superfamily) EP genes. The values of CHX MIC and MBC decreased by eightfold in Δ and twofold in Δ or Δ mutants, respectively, while not affected in Δ mutant; EPs double and triple deletion mutants showed an additive effect on CHX MIC. CHX susceptibility was restored in double and triple deletion mutants with inactivation of gene. BZK MIC was decreased by fourfold in Δ mutant, and twofold in Δ and Δ mutants, respectively; EPs double and triple deletion mutants showed an additive effect on BZK MIC. BZK susceptibility was recovered in Δ Δ Δ and Δ Δ Δ triple mutants. The structural comparison of AdeB and AdeJ protomers showed a more negatively charged entrance binding site and F-loop in AdeB, which may favor the transport of CHX. The carbonyl cyanide m-chlorophenylhydrazine protonophore (CCCP) EP inhibitor reduced dose-dependently CHX MIC in ATCC 19606 and in Δ, Δ, or Δ mutants, but not in Δ mutant. Either piperine (PIP) or resveratrol (RV) at non-toxic concentrations inhibited CHX MIC in ATCC 19606 parental strain and EPs gene deletion mutants, and CHX-induced EP gene expression. Also, RV inhibited BZK MIC and EP genes expression in ATCC 19606 parental strain and EPs mutants. These results demonstrate that tolerance to CHX and BZK in is mediated by the activation of AdeB, AceI and AmvA EPs, AdeB playing a major role. Importantly, inhibition of EP genes expression by RV restores CHX and BZK susceptibility in