While the majority of the antibiotics such as beta-lactams rely on the pore-forming porins to pass through the OM for intracellular processes, the low permeability of the bacterial OM has been identified as a challenging barrier for antibiotic sensitivity. In order to overcome these obstacles, there is a need for research to shift focus on antimicrobials with OM-targeting properties. Although the clinical use of OM-targeting colistin has been revisited, the unwelcome trends of colistin resistance among the Gram-negative bacteria followed soon after this, demanding global attention. Since the discovery of mobilised colistin resistance (
mcr) genes, which cause lipid A modification
[5], a wide variety of colistin resistance related to horizontal gene transfer has been described
[6]. The effects of
mcr expression on the global physical properties of bacterial membranes were previously discussed elsewhere
[7]. Resistance to colistin can also arise through mutations in the chromosomal genes that alter the membrane properties. The modifications of the PmrA/PmrB and PhoP/PhoQ two-component systems and the inactivation of the
mgrB gene (a regulator of the PhoP/PhoQ system) are known to be majorly involved in colistin resistance via LPS modification
[8]. Among these,
mgrB mutations seem to be common and increasingly reported in
Klebsiella pneumoniae as compared to other Enterobacterales
[9][10][11][12]. In
K. pneumoniae, mgrB mutations which involve substitution, disruption, or inactivation have been identified as playing a prominent role in mediating colistin resistance
[8].
2. Action of Colistin on Bacterial OM
The antibacterial activity of colistin targets the OM; as such, it is of a narrow spectrum and is potent mostly against Gram-negative bacteria, but not Gram-positive bacteria. It is active against most of the Enterobacterales including
Klebsiella spp.,
E. coli, Salmonella spp.,
Enterobacter spp.,
Citrobacter spp., and
Shigella spp., but
Proteus spp. and
Serratia spp. are intrinsically resistant to colistin. Categorised as cationic antimicrobial peptides (CAMPs), the colistin compound is positively charged and thus binds to the negatively charged phosphate groups of lipid A on the LPS via electrostatic interaction. The lipid A is an important building block of LPS which plays a critical role in maintaining bacterial permeability. Colistin acts competitively by displacing the divalent cations of calcium (Ca
2+) and magnesium (Mg
2+)—ions that otherwise help in stabilising the LPS molecules
[13]. This leads to a series of processes of the loss of membrane integrity, the loss of the osmotic integrity of the cell membrane, the leakage of cell contents, and, subsequently, cell death
[14]. Although LPS has been identified as the initial target of colistin activity, the exact mode of action of colistin remains unclear. Furthermore, colistin also exerts anti-endotoxin activity of lipid A through binding and neutralising the LPS molecules
[13]. Mularski et al. (2016) examined the effect of coslitin on the OM of wild-type
K. pneumoniae using cryo-electron microscopy (cryo-EM). Cryo-EM presented the clear visibility of the cytoplasmic membrane, peptidoglycan, OM, and fimbriae of the bacterial cell. The wide-type cells showed significant membrane damages after 2 h of exposure to colistin, including OM rupture, peptidoglycan discontinuity, and membrane blebs
[15]. It has been demonstrated that the membrane damage by polymyxin molecules occurs in a concentration-dependent manner. At high polymyxin concentrations, the antibiotic molecules will form aggregates at the bacterial surface, leading to large physical defects
[7]. Due to the non-specific nature of polymyxin interactions with membranes, polymyxins are avidly bound to the brush-border membrane of the kidney cells, leading to its undesired nephrotoxicity. Thus, attempts have been made to add antioxidants to the peptide molecules with the aim of suppressing polymyxin-induced membrane damage
[16].
Overview of Colistin Resistance in K. pneumoniae
Before diving into the profound mechanism of
mgrB gene mutations leading to colistin resistance in
K. pneumoniae, an overview of other molecular resistance mechanisms identified will be discussed here and summarised in
Table 1. Kim et al. (2014) reported that the PmrA/PmrB and PhoP/PhoQ two-component systems are upregulated in
K. pneumoniae upon exposure to colistin. The upregulation of
pmrA/pmrB can be caused by mutations in
pmrA or
pmrB, followed by the upregulation of
pmrC and the
arnBCADTEF operon, which subsequently results in the synthesis of L-Ara4N (4-amino-4-deoxy-
L-arabinose) and PEtn (phosphoethanolamine) to lipid A
[17]. The crosstalk between another two-component system, QseB/QseC, with PmrA/PmrB in
Escherichia coli has been elucidated; however, the role of QseB/QseC in conferring colistin resistance in
K. pneumoniae is not well characterised
[18]. Nevertheless, recent studies showed that alterations in QseC contributed to polymyxins resistance
[19][20]. Gene transformation experiments also proved that mutations in
yciM and
lpxM produced cells with decreased colistin susceptibility
[19][21]. The role of
yciM and
lpxM in contributing to colistin resistance still needs to be mechanistically elucidated. It has been suggested that both mutations are associated with LPS production and lipid A modification because
yciM is responsible for LPS biosynthesis regulation in
E. coli [22], while
lpxM encodes for lipid A acyltransferase
[21]. Additionally, the CrrA/CrrB two-component system’s crosstalk with the PmrA/PmrB regulatory pathway has also been proposed to be mediated by the connector protein CrrC
[23]. Mutations in
crrB leading to CrrC expression have been found to result in reduced colistin susceptibility
[19][23]. Apart from LPS and lipid A-associated resistance mechanisms, efflux pumps in
K. pneumoniae, including AcrAB and KpnEF, can also be responsible for reducing colistin sensitivity. The
acrB knockouts and
kpnEF mutants have been demonstrated to display restored sensitivity towards a wide range of antibiotics, including polymyxin
[24][25].
Before the discovery of the plasmid-mediated colistin resistance gene,
mcr-1, which was reported in 2015
[5], chromosomal mutations were the only known mechanisms for acquired colistin resistance. The
mcr-1 gene encodes for the PEtn transferase, which adds the PEtn residue to the lipid A moiety. The gene was initially discovered from the isolates from food animal farms, and it has since been identified to be circulating among the Enterobacterales.
K. pneumoniae was one of the initial species that carried
mcr-1 [5]. Since then, nine other
mcr genes (
mcr-2 to
mcr-10) have been discovered and disseminated worldwide
[26]. So far,
mcr-1, mcr-3, mcr-7, mcr8, and
mcr-10 have been reported in
K. pneumoniae [27][28][29]. A cell morphology study showed that cells overexpressing
mcr-1 presented varying marked increases in the thickness and density of the cell envelopes as compared with cells carrying empty plasmid
[30][31]. The increased expression of
mcr-1 was also concomitantly observed with a reduced cell growth rate and viability. This observation has been suggested to be related to the cell fitness and survival
[31].
In an induction experiment using recombinant
E. coli, it was observed that higher expression levels of
mcr-9 genes were induced by sub-inhibitory concentrations of colistin, and this inducible expression was shown to be related to the QseC-QseB two-component system
[20]. While both of the
mgrB and
mcr-1 genes confer colistin resistance through LPS modifications, Zhu et al. (2021) demonstrated that the coexistence of the
mcr-1 gene and chromosomal mutations posed a fitness cost of the
K. pneumoniae mutant. The study reported that
mcr-1-negative strains harboured mutations in
phoQ and
mgrB more frequently, while
crrA and
pmrB mutations occurred more frequently in the
mcr-1-positive strains
[32]. A cloning study demonstrated that the
mcr-1 gene has no impact on colistin resistance when it coexists with the inactivated
mgrB gene in clinical
K. pneumoniae [33]. The finding of this experiment suggests no synergistic effect of both genes, except for the leading role played by
mgrB inactivation in conferring colistin resistance.
The biological cost of colistin resistance is associated with bacterial growth rates, virulence, and transmissibility, which consequentially influence the evolution of antibiotic resistance. The insertional inactivated
mgrB mutants were found to be stable even without the presence of antibiotic selection, and did not cause any significant fitness cost to the bacterial host experimentally
[9]. A further epidemiological observation using the murine gut colonisation model corroborated that the reduced biological cost of
mgrB mutants is an important mechanism for enhanced survival outside the host and host-to-host transmission in
K. pneumoniae [34]. The consequences of
mgrB mutation were further underscored by an experiment using a waxworm infection model to demonstrate that inactivated MgrB contributed to the heightened hypervirulence of
K. pneumoniae [35].
Table 1. Overview of colistin resistance in K. pneumoniae.
3. MgrB as a PhoP/PhoQ Regulator
Olaitan et al. (2014) observed that mutations in
mgrB contribute more in colistin resistance among the
K. pneumoniae compared to the mutations involved in other two-component systems, such as
pmrA/pmrB and
phoP/phoQ [8]. In order to ascertain the importance of these two-component systems in
mgrB-mediated lipid A modifications, the lipid A moieties synthesised by
mgrB-phoQ and
mgrB-phoQ-pmrAB mutants as well as the mutants complemented with
phoPQ were compared. It was found that the previous mutants (
mgrB-phoQ and
mgrB-phoQ-pmrAB) resembled that of the wild-type, while the mutants complemented with
phoPQ resembled the lipid A produced by the
mgrB mutant. This further confirmed that the inactivation of the
mgrB gene giving rise to colistin resistance can be PhoPQ- but not PmrAB-dependent
[35]. MgrB is a small, 47-amino acid regulatory transmembrane protein which negatively regulates the PhoP/PhoQ system in Gram-negative bacteria
[36]. A pioneering study by Poirel et al. (2015) demonstrated that a premature stop codon in the sequence of
mgrB, leading to truncated MgrB with only 29 amino acids, is a key target for colistin resistance in
K. pneumoniae [11]. However, it is understudied how such a small protein exerts a great impact on the PhoP/PhoQ pathway. Previous work has suggested that MgrB acts by directly inhibiting PhoQ histidine kinase activity, thereby modulating a negative feedback loop
[36][37]. Studies have suggested that MgrB may interact with other proteins aside from PhoQ for stress responses. In acidic conditions, the inactivation of MgrB resulted in the increased accumulation of RpoS, the stress regulator, through the regulation of IraM expression
[34][38]. In the absence of functional MgrB, PhoQ over-activation and the accumulation of RposS were found to be significant contributors during the environmental survival of
K. pneumoniae [34].
In
E. coli, a recent work suggested that the MgrB transmembrane and periplasmic regions are necessary membrane anchors establishing the physical interaction with PhoQ but are not sufficient to inhibit PhoQ. Further investigation also pinpointed a number of functionally important residues spread across the protein that are important for PhoQ’s inhibitory function. The study also tested the expression levels of MgrB orthologs from
K. pneumoniae and other related enterobacterial species in
E. coli. As expected, MgrB from
K. pneumoniae, Serratia spp., and
Salmonella Typhimurium showed comparable reporter activities to that of
E. coli MgrB, indicating that the MgrB orthologs are generally highly conserved
[39]. Interestingly, although MgrB orthologs are found several Enterobacterales, further studies are clearly needed to decipher how mutations in
mgrB have emerged as a predominant mechanism for acquired colistin resistance, as compared to other species, especially
E. coli.