Review

An overview of the antimicrobial resistance mechanisms of bacteria

  • Received: 18 April 2018 Accepted: 13 June 2018 Published: 26 June 2018
  • Resistance to antimicrobial agents has become a major source of morbidity and mortality worldwide. When antibiotics were first introduced in the 1900’s, it was thought that we had won the war against microorganisms. It was soon discovered however, that the microorganisms were capable of developing resistance to any of the drugs that were used. Apparently most pathogenic microorganisms have the capability of developing resistance to at least some antimicrobial agents. The main mechanisms of resistance are: limiting uptake of a drug, modification of a drug target, inactivation of a drug, and active efflux of a drug. These mechanisms may be native to the microorganisms, or acquired from other microorganisms. Understanding more about these mechanisms should hopefully lead to better treatment options for infective diseases, and development of antimicrobial drugs that can withstand the microorganisms attempts to become resistant.

    Citation: Wanda C Reygaert. An overview of the antimicrobial resistance mechanisms of bacteria[J]. AIMS Microbiology, 2018, 4(3): 482-501. doi: 10.3934/microbiol.2018.3.482

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  • Resistance to antimicrobial agents has become a major source of morbidity and mortality worldwide. When antibiotics were first introduced in the 1900’s, it was thought that we had won the war against microorganisms. It was soon discovered however, that the microorganisms were capable of developing resistance to any of the drugs that were used. Apparently most pathogenic microorganisms have the capability of developing resistance to at least some antimicrobial agents. The main mechanisms of resistance are: limiting uptake of a drug, modification of a drug target, inactivation of a drug, and active efflux of a drug. These mechanisms may be native to the microorganisms, or acquired from other microorganisms. Understanding more about these mechanisms should hopefully lead to better treatment options for infective diseases, and development of antimicrobial drugs that can withstand the microorganisms attempts to become resistant.


    1. Introduction

    With the discovery of antibiotics, the healthcare community thought that the battle with infectious diseases was won. However, now that so many bacteria have become resistant to multiple antimicrobial agents, the war has seemingly escalated in favor of the bacteria. Infectious diseases are currently a significant cause of morbidity and mortality worldwide. An assessment of these diseases by the World Health Organization (WHO) found that lower respiratory infection, diarrheal diseases, HIV/AIDS, and malaria are in the top ten contributors to morbidity and mortality [1]. The advent of antimicrobial resistance has added significantly to the impact of infectious diseases, in number of infections, as well as added healthcare costs. Even though we have a very large number of antimicrobial agents from which to choose for potential infection therapy, there is documented antimicrobial resistance to all of these, and this resistance occurs shortly after a new drug is okayed for use. These concerns prompted the WHO to launch a Global Action Plan on antimicrobial resistance in 2015 [2].

    Antimicrobial agents can be divided into groups based on the mechanism of antimicrobial activity. The main groups are: agents that inhibit cell wall synthesis, depolarize the cell membrane, inhibit protein synthesis, inhibit nuclei acid synthesis, and inhibit metabolic pathways in bacteria. Table 1 gives examples of drugs from each of these groups. It would seem that with such a wide range of mechanisms we would have better control over the organisms. Unfortunately, improper stewardship of antimicrobial agents has helped lead to the tremendous resistance issue that we now face. Factors that have contributed to the growing resistance problem include: increased consumption of antimicrobial drugs, both by humans and animals; and improper prescribing of antimicrobial therapy. Overuse of many common antimicrobials agents by physicians may occur because the choice of drug is based on a combination of low cost and low toxicity [3]. There may also be improper prescribing of antimicrobials drugs, such as the initial prescription of a broad-spectrum drug that is unnecessary, or ultimately found to be ineffective for the organism(s) causing the infection [4]. The danger is that excessive use of antibiotics in humans leads to emergence of resistant organisms [5,6]. In addition, prior use of antimicrobial drugs puts a patient at risk for infection with a drug resistant organism, and those patients with the highest exposure to antimicrobials are most often those who are infected with resistant bacteria [3,7].

    For many years antibiotics have been used for treating or preventing disease in raising food animals. The animal feed often contains antibiotics in amounts that range from below therapeutic levels to full therapeutic levels, and the antibiotics used come from most of the antimicrobial classes used in humans. There is evidence to support the idea that feeding antibiotics to animals may result in development of antimicrobial resistant organisms, and that those resistant organisms may be transferred to the humans who consume those animals [8,9]. The antimicrobial resistance patterns seen in the animals reflects the types and amounts of antibiotics given to the animals. The transmission of antimicrobial resistance from the animals to humans may occur in various ways, with the direct oral route being the most common (includes eating meat plus ingestion of feces in contaminated food or water). Another common route is from direct contact with the animals by humans [9].

    Continued increases in antimicrobial resistance have led to fewer treatment options for patients, and an associated increase in morbidity and mortality. The result is that now we are facing more severe infections needing more extensive treatment, and longer courses of illness often requiring extended hospitalization. This has dramatically increased the healthcare costs associated with these infections. The CDC has reported that a conservative estimate is that over 2 million people in the U.S become ill each year with antimicrobial resistant infections, resulting in more than 23,000 deaths [10]. The costs attributed to these resistant infections ranges from nearly $7,000 to more than $29,000 per patient [11]. Studies on the healthcare costs for methicillin-resistant Staphylococcus aureus (MRSA) infections alone show that in the U.S. the costs are over $18,000 per case, in Germany the costs are nearly €9,000 per case, and in Switzerland there is an average added cost of over 100,000 Swiss francs per case [12,13,14]. Various methods of antimicrobial stewardship have been suggested to stem the increases in resistance. One method involves the use of diversity in antimicrobial use. This refers to various components such as not giving a single drug, but using two or more drugs, either alternatively or concurrently, preferably using drugs with different mechanisms of action [15,16].

    Table 1. Antimicrobial groups based on mechanism of action.
    Mechanism of Action Antimicrobial Groups
    Inhibit Cell Wall Synthesis β-Lactams
     Carbapenems
     Cephalosporins
     Monobactams
     Penicillins
    Glycopeptides
    Depolarize Cell Membrane Lipopeptides
    Inhibit Protein Synthesis Bind to 30S Ribosomal Subunit
     Aminoglycosides
     Tetracyclines
    Bind to 50S Ribosomal Subunit
     Chloramphenicol
     Lincosamides
     Macrolides
     Oxazolidinones
     Streptogramins
    Inhibit Nucleic Acid Synthesis Quinolones
     Fluoroquinolones
    Inhibit Metabolic Pathways Sulfonamides
    Trimethoprim
     | Show Table
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    2. Persistence versus resistance

    Before discussing the various aspects of antimicrobial resistance, it would be helpful to distinguish resistance from persistence. If a bacterium is resistant to a certain antimicrobial agent, then all of the daughter cells would also be resistant (unless additional mutations occurred in the meantime). Persistence, however, describes bacterial cells that are not susceptible to the drug, but do not possess resistance genes. The persistence is undoubtedly due to the fact that some cells in a bacterial population may be in stationary growth phase (dormant); and most antimicrobial agents have no effect on cells that are not actively growing and dividing. These persister cells occur at a rate of around 1% in a culture that is in stationary phase [17,18]. Figure 1 shows the difference between persistent and resistant bacterial cells.

    Figure 1. Resistance vs. persistence. When bacterial cells are exposed to an antimicrobial agent there are two possible scenarios. There may be cells present that are resistant to the antimicrobial agent (A). The non-resistant cells are killed, leaving only the resistant cells. When the resistant cells are regrown, all of the cells in the culture will be resistant. The other possibility is that there may be persister cells (dormant, not resistant) present (B). The non-persister cells are killed, leaving only the persister cells. When the persister cells are regrown, those cells not in a dormant state will still be susceptible to the antimicrobial agent.


    3. Origins of resistance

    Bacteria as a group or species are not necessarily uniformly susceptible or resistant to any particular antimicrobial agent. Levels of resistance may vary greatly within related bacterial groups. Susceptibility and resistance are usually measured as a function of minimum inhibitory concentration (MIC), the minimal concentration of drug that will inhibit growth of the bacteria. The susceptibility is actually a range of the average MICs for any given drug across the same bacterial species. If that average MIC for a species is in the resistant part of the range, the species is considered to have intrinsic resistance to that drug. Bacteria may also acquire resistance genes from other related organisms, and the level of resistance will vary depending on the species and the genes acquired [19,20].


    3.1. Natural resistance

    Natural resistance may be intrinsic (always expressed in the species), or induced (the genes are naturally occurring in the bacteria, but are only expressed to resistance levels after exposure to an antibiotic). Intrinsic resistance may be defined as a trait that is shared universally within a bacterial species, is independent of previous antibiotic exposure, and not related to horizontal gene transfer [20,21]. The most common bacterial mechanisms involved in intrinsic resistance are reduced permeability of the outer membrane (most specifically the lipopolysaccharide, LPS, in gram negative bacteria) and the natural activity of efflux pumps. Multidrug-efflux pumps are also a common mechanism of induced resistance [21,22]. Table 2 shows some examples of bacteria with intrinsic antimicrobial resistance.

    Table 2. Examples of bacteria with intrinsic resistance.
    Organism Intrinsic resistance
    Bacteroides (anaerobes) aminoglycosides, many β-lactams, quinolones
    All gram positives aztreonam
    Enterococci aminoglycosides, cephalosporins, lincosamides
    Listeria monocytogenes cephalosporins
    All gram negatives glycopeptides, lipopeptides
    Escherichia coli macrolides
    Klebsiella spp. ampicillin
    Serratia marcescens macrolides
    Pseudomonas aeruginosa sulfonamides, ampicillin, 1st and 2nd generation cephalosporins, chloramphenicol, tetracycline
    Stenotrophomonas maltophilia aminoglycosides, β-lactams, carbapenems, quinolones
    Acinetobacter spp. ampicillin, glycopeptides
     | Show Table
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    3.2. Acquired resistance

    Acquisition of genetic material that confers resistance is possible through all of the main routes by which bacteria acquire any genetic material: transformation, transposition, and conjugation (all termed horizontal gene transfer—HGT); plus, the bacteria may experience mutations to its own chromosomal DNA. The acquisition may be temporary or permanent. Plasmid-mediated transmission of resistance genes is the most common route for acquisition of outside genetic material; bacteriophage-borne transmission is fairly rare. Certain bacteria such as Acinetobacter spp. are naturally competent, and therefore capable of acquiring genetic material directly from the outside environment. Internally, insertion sequences and integrins may move genetic material around, and stressors (starvation, UV radiation, chemicals, etc.) on the bacteria are common causes of genetic mutations (substitutions, deletions etc.). Bacteria have an average mutation rate of 1 for every 106 to 109 cell divisions, and most of these mutations will be deleterious to the cell [19,23]. Mutations that aid in antimicrobial resistance usually only occur in a few types of genes; those encoding drug targets, those encoding drug transporters, those encoding regulators that control drug transporters, and those encoding antibiotic-modifying enzymes [20]. In addition, many mutations that confer antimicrobial resistance do so at a cost to the organism. For example, in the acquisition of resistance to methicillin in Staphylococcus aureus, the growth rate of the bacteria is significantly decreased [24].

    One huge conundrum of antimicrobial resistance is that the use of these drugs leads to increased resistance. Even the use of low or very low concentrations of antimicrobials (sub-inhibitory) can lead to selection of high-level resistance in successive bacterial generations, may select for bacteria that are hypermutatable strains (increase the mutation rate), may increase the ability to acquire resistance to other antimicrobial agents, and may promote the movement of mobile genetic elements [25].


    4. Mechanisms of resistance

    Antimicrobial resistance mechanisms fall into four main categories: (1) limiting uptake of a drug; (2) modifying a drug target; (3) inactivating a drug; (4) active drug efflux. Intrinsic resistance may make use of limiting uptake, drug inactivation, and drug efflux; acquired resistance mechanisms used may be drug target modification, drug inactivation, and drug efflux. Because of differences in structure, etc., there is variation in the types of mechanisms used by gram negative bacteria versus gram positive bacteria. Gram negative bacteria make use of all four main mechanisms, whereas gram positive bacteria less commonly use limiting the uptake of a drug (don't have an LPS outer membrane), and don't have the capacity for certain types of drug efflux mechanisms (refer to the drug efflux pumps later in this manuscript) [26,27]. Figure 2 illustrates the general antimicrobial resistance mechanisms.

    Figure 2. General antimicrobial resistance mechanisms.


    4.1. Limiting drug uptake

    As already mentioned, there is a natural difference in the ability of bacteria to limit the uptake of antimicrobial agents. The structure and functions of the LPS layer in gram negative bacteria provides a barrier to certain types of molecules. This gives those bacteria innate resistance to certain groups of large antimicrobial agents [28]. The mycobacteria have an outer membrane that has a high lipid content, and so hydrophobic drugs such as rifampicin and the fluoroquinolones have an easier access to the cell, but hydrophilic drugs have limited access [29,30].

    Bacteria that lack a cell wall, such as Mycoplasma and related species, are therefore intrinsically resistant to all drugs that target the cell wall including β-lactams and glycopeptides [31]. Gram positive bacteria do not possess an outer membrane, and restricting drug access is not as prevalent. In the enterococci, the fact that polar molecules have difficulty penetrating the cell wall gives intrinsic resistance to aminoglycosides. Another gram positive bacteria, Staphylococcus aureus, recently has developed resistance to vancomycin. Of the two mechanisms that S. aureus uses against vancomycin, a yet unexplained mechanism allows the bacteria to produce a thickened cell wall which makes it difficult for the drug to enter the cell, and provides an intermediate resistance to vancomycin. These strains are designated as VISA strains [30,32].

    In those bacteria with large outer membranes, substances often enter the cell through porin channels. The porin channels in gram negative bacteria generally allow access to hydrophilic molecules [28,33]. There are two main ways in which porin changes can limit drug uptake: a decrease in the number of porins present, and mutations that change the selectivity of the porin channel [29]. Members of the Enterobacteriaceae are known to become resistant due to reducing the number of porins (and sometime stopping production entirely of certain porins). As a group, these bacteria reduce porin number as a mechanism for resistance to carbapenems [34,35]. Mutations that cause changes within the porin channel have been seen in E. aerogenes which then become resistant to imipenem and certain cephalosporins, and in Neisseria gonorrhoeae which then become resistant to β-lactams and tetracycline [33,36].

    Another widely seen phenomenon in bacterial colonization is the formation of a biofilm by a bacterial community. These biofilms may contain a predominant organism (such as by Pseudomonas aeruginosa in the lung), or may consist of a wide variety of organisms, as seen in the biofilm community of normal flora in the gut. For pathogenic organisms, formation of a biofilm protects the bacteria from attack by the host immune system, plus provides protection from antimicrobial agents. The thick, sticky consistency of the biofilm matrix which contains polysaccharides, and proteins and DNA from the resident bacteria, makes it difficult for antimicrobial agents to reach the bacteria. Thus, to be effective, much higher concentrations of the drugs are necessary. In addition the bacterial cells in the biofilm tend to be sessile (slow metabolism rate, slow cell division), so antimicrobials that target growing, dividing bacterial cells have little effect. An important observation about biofilms is that it is likely that horizontal transfer of genes is facilitated by the proximity of the bacterial cells. That means that sharing of antimicrobial resistance genes is potentially easier for these bacterial communities [37,38,39].


    4.2. Modification of drug targets

    There are multiple components in the bacterial cell that may be targets of antimicrobial agents; and there are just as many targets that may be modified by the bacteria to enable resistance to those drugs. One mechanism of resistance to the β-lactam drugs used almost exclusively by gram positive bacteria is via alterations in the structure and/or number of PBPs (penicillin-binding proteins). PBPs are transpeptidases involved in the construction of peptidoglycan in the cell wall. A change in the number (increase in PBPs that have a decrease in drug binding ability, or decrease in PBPs with normal drug binding) of PBPs impacts the amount of drug that can bind to that target. A change in structure (e.g. PBP2a in S. aureus by acquisition of the mecA gene) may decrease the ability of the drug to bind, or totally inhibit drug binding [24,40].

    The glycopeptides (e.g. vancomycin) also work by inhibiting cell wall synthesis, and lipopeptides (e.g. daptomycin) work by depolarizing the cell membrane. Gram negative bacteria (thick LPS layer) have intrinsic resistance to these drugs [41]. Resistance to vancomycin has become a major issue in the enterococci (VRE—vancomycin-resistant enterococci) and in Staphylococcus aureus (MRSA). Resistance is mediated through acquisition of van genes which results in changes in the structure of peptidoglycan precursors that cause a decrease in the binding ability of vancomycin [21,40]. Daptomycin requires the presence of calcium for binding. Mutations in genes (e.g. mprF) change the charge of the cell membrane surface to positive, inhibiting the binding of calcium, and therefore, daptomycin [42,43,44].

    Resistance to drugs that target the ribosomal subunits may occur via ribosomal mutation (aminoglycosides, oxazolidinones), ribosomal subunit methylation (aminoglycosides, macrolides—gram positive bacteria, oxazolidinones, streptogramins) most commonly involving erm genes, or ribosomal protection (tetracyclines). These mechanisms interfere with the ability of the drug to bind to the ribosome. The level of drug interference varies greatly among these mechanisms [45,46,47].

    For drugs that target nucleic acid synthesis (fluoroquinolones), resistance is via modifications in DNA gyrase (gram negative bacteria—e.g. gyrA) or topoisomerase IV (gram positive bacteria—e.g. grlA). These mutations cause changes in the structure of gyrase and topoisomerase which decrease or eliminate the ability of the drug to bind to these components [48,49].

    For the drugs that inhibit metabolic pathways, resistance is via mutations in enzymes (DHPS—dihydropteroate synthase, DHFR—dihydrofolate reductase) involved in the folate biosynthesis pathway and/or overproduction of resistant DHPS and DHFR enzymes (sulfonamides—DHPS, trimethoprim—DHFR). The sulfonamides and trimethoprim bind to their respective enzymes due to their being structural analogs of the natural substrates (sulfonamides—p-amino-benzoic acid, trimethoprim—dihydrofolate). The action of these drugs is through competitive inhibition by binding in the active site of the enzymes. Mutations in these enzymes are most often located in or near the active site, and resulting structural changes in the enzyme interfere with drug binding while still allowing the natural substrate to bind [50,51].


    4.3. Drug inactivation

    There are two main ways in which bacteria inactivate drugs; by actual degradation of the drug, or by transfer of a chemical group to the drug. The β-lactamases are a very large group of drug hydrolyzing enzymes. Another drug that can be inactivated by hydrolyzation is tetracycline, via the tetX gene [45,52].

    Drug inactivation by transfer of a chemical group to the drug most commonly uses transfer of acetyl, phosphoryl, and adenyl groups. There are a large number of transferases that have been identified. Acetylation is the most diversely used mechanism, and is known to be used against the aminoglycosides, chloramphenicol, the streptogramins, and the fluoroquinolones. Phosphorylation and adenylation are known to be used primarily against the aminoglycosides [52,53,54,55].


    4.4. β-lactamases

    The most widely used group of antimicrobial agents are the β-lactam drugs. The members of this drug group all share a specific core structure which consists of a four-sided β-lactam ring. Resistance to the β-lactam drugs occurs through three general mechanisms: (1) preventing the interaction between the target PBP and the drug, usually by modifying the ability of the drug to bind to the PBP (this is mediated by alterations to existing PBPs or acquisition of other PBPs; (2) the presence of efflux pumps that can extrude β-lactam drugs; (3) hydrolysis of the drug by β-lactamase enzymes [56,57].

    The β-lactamases (originally called penicillinases and cephalosporinases) inactivate β-lactam drugs by hydrolyzing a specific site in the β-lactam ring structure, causing the ring to open. The open-ring drugs are not able to bind to their target PBP proteins. The known β-lactamases are wide-spread, and the group contains enzymes that are able to inactivate any of the current β-lactam drugs. The production of β-lactamases is the most common resistance mechanism used by gram negative bacteria against β-lactam drugs, and the most important resistance mechanism against penicillin and cephalosporin drugs [45,58].

    The β-lactamase enzymes are classified based on their molecular structure and/or functional characteristics. Structurally they are placed into four main categories (A, B, C, or D). There are three functional groupings based on the substrate specificity: the cephalosporinases, the serine β-lactamases, and the metallo (zinc-dependent) β-lactamases. These enzymes may also be commonly known by their enzyme family; for example: the TEM (named after the first patient) family, the SHV (sulphydryl variable) family, and the CTX (preferentially hydrolyze cefotaxime) family. Gram negative bacteria may produce β-lactamases from all four structural groups. The β-lactamases found in gram positive bacteria are mainly from group A, with some from group B [59,60,61,62].

    These enzymes may be innately found on the bacterial chromosome or may be acquired via a plasmid. Many members of the Enterobacteriaceae family of gram negative bacteria possess chromosomal β-lactamase genes. Other gram negative bacteria that possess these include Aeromonas spp., Acinetobacter spp., and Pseudomonas spp. Plasmid-carried β-lactamase genes are most commonly found in the Enterobacteriaceae, but may also be found in some species of gram positive bacteria such as Staphylococcus aureus, Enterococcus faecalis, and Enterococcus faecium [26,59].

    The first β-lactamase to be characterized was from E. coli and is chromosomally encoded by the ampC gene (so named for ampicillin resistance). This gene is constitutively expressed at a low level, but mutations may result in overexpression of the gene. The AmpC β-lactamases are most effective against the penicillins and some first generation cephalosporins. There are also many plasmid-borne β-lactamases which carry a variety of bla genes (β-lactamase genes). If these β-lactamases confer resistance to later generation cephalosporins, they were designated as ESBLs, and include members of the TEM, SHV, CTX-M, and OXA enzyme families. The largest group is the CTX-Ms, which are most commonly found in E. coli, especially UTI isolates. The ESBL producers may also be resistant to multiple drug classes, but are generally sensitive to β-lactamase inhibitors. The β-lactamase inhibitors are structurally similar to β-lactamases, have weak antimicrobial ability alone, but work synergistically in combination with a β-lactam drug. Commonly used β-lactamase inhibitor/drug pairings include amoxicillin/clavulanic acid, ampicillin/sulbactam, and piperacillin/tazobactam [56,59,60,63,64,65,66].

    Recently there has been an emergence of β-lactamases that are active against the carbapenems (carbapenemases), and are found primarily in the Enterobacteriaceae. There are two types of carbapenemases; the Klebsiella pneumoniae carbapenemases (KPCs), and those designated as Carbapenem-Resistant Enterobacteriaceae (CRE) enzymes. The KPCs belong to the serine Class A (functional group 2f) β-lactamases, are resistant to all β-lactam drugs, but may still be affected by β-lactamase inhibitors. In bacteria that are CRE strains the carbapenemases are all metallo-β-lactamases (MBLs) in Class B, functional group 3a, and are capable of hydrolyzing all β-lactam drugs, but are not inactivated by β-lactamase inhibitors. The most widely distributed CREs are the IMP-1 (for imipenem resistance) and VIM-1 (Verona integron encoded MBL) types. A new MBL has recently been identified, mainly in strains of E. coli. It has been designated as NDM-1 (New Delhi MBL). Infections caused by CRE strains have been associated with in-hospital mortality of up to 71% [56,57,58,67,68].

    There is a lot of emphasis on the development of more effective β-lactamase inhibitor drug combinations, especially in an effort to combat the CRE strains. One newer β-lactamase/drug combination is ceftolozane/tazobactam, which is mainly used against P. aeruginosa, and shows promise against gram negative ESBL producing strains. There are also newer β-lactamase inhibitors which do not have a structure similar to the β-lactam drugs. The first one of these to be approved for use is avibactam, and it has been approved for use with ceftazidime against gram negative bacteria. In addition, avibactam is being tested for use with aztreonam against CREs. Another β-lactamase inhibitor which in non β-lactam structured is vaborbactam. It was approved for use with meropenem in 2017 against gram negative bacteria causing complicated urinary tract infections (cUTIs). Unfortunately, so far none of the newer combination drugs is designed to combat the CREs directly. The metallo-β-lactamases are proving difficult to defeat as these enzymes comprise 3 groups that vary greatly in structure and mechanisms [69,70,71].


    4.5. Drug efflux

    Bacteria possess chromosomally encoded genes for efflux pumps. Some are expressed constitutively, and others are induced or overexpressed (high-level resistance is usually via a mutation that modifies the transport channel) under certain environmental stimuli or when a suitable substrate is present. The efflux pumps function primarily to rid the bacterial cell of toxic substances, and many of these pumps will transport a large variety of compounds (multi-drug [MDR] efflux pumps). The resistance capability of many of these pumps is influenced by what carbon source is available [28,72].

    Most bacteria possess many different types of efflux pumps. There are five main families of efflux pumps in bacteria classified based on structure and energy source: the ATP-binding cassette (ABC) family, the multidrug and toxic compound extrusion (MATE) family, the small multidrug resistance (SMR) family, the major facilitator superfamily (MFS), and the resistance-nodulation-cell division (RND) family. Most of these efflux pump families are single-component pumps which transport substrates across the cytoplasmic membrane. The RND family are multi-component pumps (found almost exclusively in gram negative bacteria) that function in association with a periplasmic membrane fusion protein (MFP) and an outer membrane protein (OMP-porin) to efflux substrate across the entire cell envelope [28,29,73,74]. There are instances where other efflux family members act with other cellular components as multicomponent pumps in gram negative bacteria. One member of the ABC family, MacB, works as a tripartite pump (MacAB-TolC) to extrude macrolide drugs. A member of the MFS, EmrB, works as a tripartite pump (EmrAB-TolC) to extrude nalidixic acid in E. coli [75,76]. Figure 3 shows the basic structure of the various efflux pump families.

    Efflux pumps found in gram positive bacteria may confer intrinsic resistance because of being encoded on the chromosome. These pumps include members of the MATE and MFS families and efflux fluoroquinolones. There are also gram positive efflux pumps known to be carried on plasmids. Currently, the characterized pumps in gram positive bacteria are from the MFS family [77,78,79,80]. Efflux pumps found in gram negative bacteria are widely distributed and may come from all five of the families, with the most clinically significant pumps belonging to the RND family [28,79].

    Figure 3. General structure of main efflux pump families.


    4.6. ABC transporter family

    The ABC efflux family contains both uptake and efflux transport systems. The members of this family are unique in that they use energy derived from ATP hydrolysis. These pumps transport amino acids, drugs, ions, polysaccharides, proteins, and sugars. Bacterial ABC transporters usually are made up of six transmembrane segments (TMS) consisting of α-helices, function in the membrane in pairs, either as homodimers or heterodimers, and work in conjunction with cytoplasmic ATPases. These pumps have fairly specific substrates, and there are very few found in clinically significant bacteria. One notable ABC pump is found in Vibrio cholerae (VcaM), and is capable of transporting fluoroquinolones and tetracycline [29,81,82].


    4.7. MATE transporter family

    The MATE efflux family use a Na+ gradient as the energy source, and efflux cationic dyes, and most efflux fluoroquinolone drugs. Some MATE pumps have also been shown to efflux some aminoglycosides. Other substrates for these pumps may have unrelated chemical structures. These pumps are made up of twelve TMS. Very few of these have been characterized in bacteria, and most are found in gram negative organisms. The first to be characterized was the NorM pump from chromosomal DNA in Vibrio parahaemolyticus. Other clinically significant bacteria that have NorM pumps include Neisseria gonorrhoeae and Neisseria meningitidis [73,83,84].


    4.8. SMR transporter family

    The SMR efflux family are energized by the proton-motive force (H+), are hydrophobic, and efflux mainly lipophilic cations, so may have a very narrow substrate range. The genes for these pumps have been found in chromosomal DNA and on plasmids and transposable elements. These pumps are made up of four TMS and function as asymmetrical homotetramers. Drug efflux has only been seen in a few of these pumps, and these most commonly confer resistance to β-lactams and some aminoglycosides. Examples of SMR pumps are seen in Staphylococcus epidermidis (the SMR pump which transports ampicillin, erythromycin and tetracycline) and Escherichia coli (the EmeR pump which transports vancomycin, erythromycin, and tetracycline) [28,29,85,86].


    4.9. MFS transporter family

    The MFS efflux family catalyze transport via solute/cation (H+ or Na+) symport or solute/H+ antiport. They are involved in the transport of anions, drugs (e.g. macrolides and tetracycline), metabolites (e.g. bile salts), and sugars. The MFS pumps have the greatest substrate diversity as a group, yet individually tend to be substrate specific. Examples of this substrate specificity include Acinetobacter baumannii having separate MFS pumps for erythromycin (SmvA) and chloramphenicol (CraA and CmlA), and Escherichia coli having separate MFS pumps for macrolides (MefB), fluoroquinolones (QepA), and trimethoprim (Fsr). There are rare examples of MFS pumps with a slightly broader substrate specificity, such as in the NorA pump in Staphylococcus aureus which transports fluoroquinolones and chloramphenicol (these antimicrobials are the most commonly transported by MFS pumps), or the S. aureus LmrS pump which transports linezolid, erythromycin, chloramphenicol, and trimethoprim. These pumps are made up of twelve or fourteen TMS, and over 1,000 have been sequenced in bacteria. Most MFS pumps have been found on bacterial chromosomes, and nearly 50% of the efflux pumps in E. coli are MFS pumps [28,29,45,87].


    4.10. RND transporter family

    The RND efflux family members catalyze substrate efflux via a substrate/H+ antiport mechanism, and are found in numerous gram negative bacteria. They are involved in the efflux of antibiotics (all are multi-drug transporters), detergents, dyes, heavy metals, solvents, and many other substrates. Some of these pumps may be drug or drug class specific (Tet pump—tetracycline; Mef pump—macrolides). Many other RND pumps are capable of transporting a wide range of drugs, such as the MexAB-OprM pump in Pseudomonas aeruginosa that confers intrinsic resistance to β-lactams, chloramphenicol, tetracycline, trimethoprim, sulfamethoxazole, and some fluoroquinolones. These pumps are complex multi-component pumps generally made up of twelve TMS and contain two large periplasmic loops between TMS 1 and 2, and TMS 7 and 8. In order to function, these pumps will connect to an OMP and that connection is stabilized by MFPs. Interestingly, these pumps share a high degree of homology among the RND members. The genes for the RND pumps are generally organized as an operon. In many, the gene organization is as follows: the gene for the regulator (which may be transcribed in the opposite direction to the other genes) is adjacent to the MFP gene, which is adjacent to the main pump gene, and then the OMP gene. Probably the most widely studied RND pump is the AcrAB-TolC pump in Escherichia coli, which confers resistance to penicillins, chloramphenicol, macrolides, fluoroquinolones, and tetracycline. The AcrB pump protein contains two binding pockets which allow the binding of substrates of varying size and chemical properties [28,29,52,73,74,79,82,88].

    Table 3 shows a summary of the antimicrobial resistance mechanisms that are used against the various drugs.

    Table 3. Antimicrobial resistance mechanisms.
    Drug Drug Uptake Limitation Drug Target Modification Drug Inactivation Efflux Pumps
    β-Lactams Decreased numbers of porins, no outer cell wall Gram pos—alterations in PBPs Gram pos, gram neg—β-lactamases RND
    Carbapenems Changed selectivity of porin
    Cephalosporins Changed selectivity of porin
    Monobactams
    Penicillins
    Glycopeptides Thickened cell wall, no outer cell wall Modified peptidoglycan
    Lipopeptides Modified net cell surface charge
    Aminoglycosides Cell wall polarity Ribosomal mutation, methylation Aminoglycoside modifying enzymes, acetylation, phosphorylation, adenylation RND
    Tetracyclines Decreased numbers of porins Ribosomal protection Antibiotic modification, oxidation MFS, RND
    Chloramphenicol Ribosomal methylation Acetylation of drug MFS, RND
    Lincosamides Gram pos—ribosomal methylation ABC, RND
    Macrolides Ribosomal mutation, methylation ABC, MFS, RND
    Oxazolidinones Ribosomal methylation RND
    Streptogramins ABC
    Fluoroquinolones Gram neg—DNA gyrase modification Acetylation of drug MATE, MFS, RND
    Gram pos—topoisomerase IV
    Sulfonamides DHPS reduced binding, overproduction of resistant DHPS RND
    Trimethoprim DHFR reduced binding, overproduction of DHFR RND
    ABC—ATP binding cassette family, DHFR—dihydrofolate reductase, DHPS—dihydropteroate synthase, MATE—multidrug and toxic compound extrusion family, MFS—major facilitator superfamily, PBP—penicillin-binding protein, RND—resistance-nodulation-cell division family.
     | Show Table
    DownLoad: CSV

    4.11. Impact of antimicrobial resistance for individual bacteria

    It is vitally important that we have a clear picture of how many of these resistance mechanisms individual bacteria may have in their arsenals. An excellent and important example of this is MRSA. The increase in costs for MRSA infections was mentioned previously [12,13,14]. These increased costs are affected by excess length of hospital stay, increases in number of tests needed, and increased medical and rehabilitation services provided. We also need to think about the impact on morbidity and mortality caused by MRSA, including significant increases in disease complications. The methicillin susceptible Staphylococcus aureus (MSSA) and MRSA strains possess the same large number of virulence factors including surface molecules that promote colonization, and secreted molecules that allow invasion of and damage to host cells. These virulence factors assist the bacteria in causing multiple types of infections. Since MRSA is well known for infections of skin and related tissues, it is easier to spread the infection from person-to-person, especially in hospital settings. It has been estimated that the mortality rate for MRSA infections is 2-3 times higher than that for MSSA strains. In addition, MRSA strains are frequently multidrug resistant, which limits the impact of available antimicrobial therapy [24,61]. Table 4 is a summary of the types of resistance mechanisms that S. aureus has in place [61]. There are of course, many pathogens that have similarly diverse arsenals (e.g. Escherichia coli and Klebsiella pneumoniae) and are becoming resistant to most of the antimicrobial agents available.

    Table 4. Antimicrobial resistance mechanisms in Staphylococcus aureus.
    Resistance Mechanism Antimicrobial Agents
    Limiting Drug Uptake Glycopeptides
    Modification of Drug Target β-lactams
    Glycopeptides
    Lipopeptides
    Aminoglycosides
    Tetracyclines
    Macrolides
    Lincosamides
    Oxazolidinones
    Streptogramins
    Fluoroquinolones
    Metabolic Pathway Inhibitors
    Inactivation of Drug β-lactams
    Chloramphenicol
    Active Drug Efflux Tetracyclines
    Fluoroquinolones
     | Show Table
    DownLoad: CSV

    5. Conclusions

    The reality is that bacterial are very versatile and adaptive. In order to survive they need to be capable of dealing with toxic substances. Free living bacteria need to be able to survive toxic attacks and waste products from other organisms. It should come as no surprise that the bacteria that infect humans are able to defend themselves against antimicrobial agents. With the alarming increase in antimicrobial resistance, it is imperative that we find ways to combat these pathogens. Unfortunately, there is no easy (or cheap, probably) answer to this dilemma. Perhaps we need to rethink how we design new antimicrobial agents; or maybe start looking to natural substances for clues on what could be used in this fight.

    The mechanisms described here are as varied as are the bacteria themselves. These bacterial weapons pretty much cover all of the antimicrobial agents that we have, and there are probably more resistance mechanisms out there that we have not yet characterized. The outlook for fighting microorganisms might seem to be a little bleak. In 2010 the Infectious Diseases Society of America (ISDA) requested that by 2020 there would be FDA approval of 10 novel antibiotics. As of 2016, 8 new drugs had been approved, but only one of these is a novel antibiotic. The median time in the approval pipeline for these drugs was 6.2 years, and the cost per dose of these drugs ranges from nearly $2,000 to nearly $4,200 [89]. So we will need to work hard, and work quickly to find remedies for this pressing problem.


    Conflict of interest

    The author declares that there are no conflicts of interest in this paper.


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    1045. Samta Manori, Avinash Gangal, Aakanksha Jain Kaushik, Vishwajeet Bachhar, Vibha Joshi, Manisha Duseja, Ramesh Chandra, Ravi Kumar Shukla, Radical-mediated photocatalytic dye degradation and antimicrobial properties of La2NiMnO6 nanoparticles, 2025, 1144-0546, 10.1039/D4NJ04437A
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    1047. Sara García-Vela, Aurore Cournoyer, Zain Sánchez-Reinoso, Laurent Bazinet, Antimicrobial Peptides from Porcine Blood Cruor Hydrolysates as a Promising Source of Antifungal Activity, 2024, 14, 2304-8158, 8, 10.3390/foods14010008
    1048. Deepali Desai, Rabindra Nath Misra, Nageswari R Gandham, Nikunja Kumar Das, Sahjid Mukhida, Shahzad Mirza, First Report of Virulence Factors in Carbapenem-resistant Klebsiella pneumoniae from Maharashtra, India, 2024, 19, 0974-3901, 729, 10.4103/jdmimsu.jdmimsu_374_24
    1049. O. M. Aladejana, A. O. Ogunlade, O. A. Thonda, G. Obi, Plasmid Profile and Curing of Multiple Antibiotic Resistant Escherichia coli Isolated from Straw Colored Fruit Bats (Eidolon helvum ), 2024, 2756-4045, 5038, 10.48198/NJPAS/24.A10
    1050. Vaida Damulienė, Vilma Kaškonienė, Paulius Kaškonas, Rūta Mickienė, Audrius Maruška, Improved Antibacterial Properties of Fermented and Enzymatically Hydrolyzed Bee Pollen and Its Combined Effect with Antibiotics, 2024, 18, 1424-8247, 15, 10.3390/ph18010015
    1051. Linh Doan, Nam N. Lam, Khoa Tran, Khanh G. Huynh, Fruit derived silver nanoparticles synthesis for beginners – a review, 2025, 11, 2055-0324, 20, 10.1080/20550324.2024.2442270
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    1053. Vimarishi Koul, Akshi Sharma, Diksha Kumari, Vishwani Jamwal, Tashi Palmo, Kuljit Singh, Breaking the resistance: integrative approaches with novel therapeutics against Klebsiella pneumoniae, 2025, 207, 0302-8933, 10.1007/s00203-024-04205-y
    1054. Daohong Zhang, Deepak Kukkar, Poornima Bhatt, Ki-Hyun Kim, Kamalpreet Kaur, Jianlong Wang, Novel nanomaterials-based combating strategies against drug-resistant bacteria, 2024, 09277765, 114478, 10.1016/j.colsurfb.2024.114478
    1055. Eman Abdelsalam, Amal Mosad Ibrahim, Ahmed A. El-Rashedy, Mohamed S. Abdel-Aziz, Omnia Kutkat, Faten K. Abd EL-Hady, Combating COVID-19 and its co-infection by Aspergillus tamarii SP73-EGY using in vitro and in silico Studies, 2025, 15, 2045-2322, 10.1038/s41598-024-77854-0
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    1057. S. Amrutha, Paramita Das, Anjali Nayak, Supratip Laha, Sharmina Begum, Sakshi Bhardwaj, Synthesis and anti-microbial evaluation with in silico studies of novel 2-aminothiazole benzohydrazide derivatives, 2025, 11, 2314-7253, 10.1186/s43094-024-00759-2
    1058. Thiago Hideo Endo, Mariana Homem de Mello Santos, Sara Scandorieiro, Bruna Carolina Gonçalves, Eliana Carolina Vespero, Márcia Regina Eches Perugini, Wander Rogério Pavanelli, Gerson Nakazato, Renata Katsuko Takayama Kobayashi, Selective Serotonin Reuptake Inhibitors: Antimicrobial Activity Against ESKAPEE Bacteria and Mechanisms of Action, 2025, 14, 2079-6382, 51, 10.3390/antibiotics14010051
    1059. Urvashi Kesarwani, Ashutosh Kumar Dubey, Antibacterial efficacy of bone mimicking-hydroxyapatite nanoplates with varying morphology, 2025, 13877003, 113918, 10.1016/j.inoche.2025.113918
    1060. Hamed Tahmasebi, Neda Arjmand, Marzieh Monemi, Ali Babaeizad, Farnaz Alibabaei, Negar Alibabaei, Aisa Bahar, Valentyn Oksenych, Majid Eslami, From Cure to Crisis: Understanding the Evolution of Antibiotic-Resistant Bacteria in Human Microbiota, 2025, 15, 2218-273X, 93, 10.3390/biom15010093
    1061. Monica-Cornelia Sardaru, Irina Rosca, Simona Morariu, Elena-Laura Ursu, Alexandru Rotaru, Synergistic Antibacterial Action of Norfloxacin-Encapsulated G4 Hydrogels: The Role of Boronic Acid and Cyclodextrin, 2025, 11, 2310-2861, 35, 10.3390/gels11010035
    1062. Paula Cortés, Ekaterina Pokrant, Karina Yévenes, Aldo Maddaleno, Andrés Flores, María Belén Vargas, Lina Trincado, Matías Maturana, Lisette Lapierre, Javiera Cornejo, Antimicrobial Residues in Poultry Litter: Assessing the Association of Antimicrobial Persistence with Resistant Escherichia coli Strains, 2025, 14, 2079-6382, 89, 10.3390/antibiotics14010089
    1063. Akash Mishra, Anupam Jyoti, Krishna Aayush, Juhi Saxena, Kanika Sharma, Harnessing Nanoparticles to Overcome Antimicrobial Resistance: Promises and Challenges, 2025, 31, 13816128, 292, 10.2174/0113816128326718240809091654
    1064. Sharifa Ezat WP, M Norhidayah, Muhammad Nur Amir AR, Factors associated with multidrug-resistant organism (MDRO) mortality: an analysis from the national surveillance of multidrug-resistant organism, 2018-2022, 2025, 25, 1471-2334, 10.1186/s12879-024-10338-8
    1065. Seomin Kang, Jeong-Eun Han, Young-Sik Choi, In-Chul Jeong, Jin-Woo Bae, Isolation and characterization of a novel lytic phage K14-2 infecting diverse species of the genus Klebsiella and Raoultella, 2025, 15, 1664-302X, 10.3389/fmicb.2024.1491516
    1066. Emira D’Amico, Gitana Maria Aceto, Morena Petrini, Chiara Cinquini, Simonetta D’Ercole, Giovanna Iezzi, Tania Vanessa Pierfelice, How Will Nanomedicine Revolutionize Future Dentistry and Periodontal Therapy?, 2025, 26, 1422-0067, 592, 10.3390/ijms26020592
    1067. Claire Julie Akwongo, Luca Borrelli, Kurt Houf, Alessandro Fioretti, Maria Francesca Peruzy, Nicoletta Murru, Antimicrobial resistance in wild game mammals: a glimpse into the contamination of wild habitats in a systematic review and meta-analysis, 2025, 21, 1746-6148, 10.1186/s12917-024-04462-5
    1068. Arunima Singh, Yogesh Kumar Vishwakarma, Neelmani Bhardwaj, R. S. Singh, 2024, Chapter 15, 978-981-97-8738-8, 293, 10.1007/978-981-97-8739-5_15
    1069. Caglar Ersanli, Ioannis Skoufos, Konstantina Fotou, Athina Tzora, Yves Bayon, Despoina Mari, Eleftheria Sarafi, Konstantina Nikolaou, Dimitrios I. Zeugolis, Release Profile and Antibacterial Activity of Thymus sibthorpii Essential Oil-Incorporated, Optimally Stabilized Type I Collagen Hydrogels, 2025, 12, 2306-5354, 89, 10.3390/bioengineering12010089
    1070. Medarametla Venkatesh, Chappidi Hazarathaiah Yadav, Mavallur Varalakshmi, Substituted-1,3,4-oxadiazole Indole Derivatives: Design, Synthesis, Characterization, and Evaluation of the Antimicrobial and Anti-Inflammatory Activities, 2024, 60, 1070-4280, 2276, 10.1134/S1070428024110162
    1071. Esteban Zavaleta-Monestel, Carolina Rojas-Chinchilla, Jeimy Campos-Hernández, Ernesto Martínez-Vargas, Utility of Artificial Intelligence in Antibiotic Development: Accelerating Discovery in the Age of Resistance, 2025, 2168-8184, 10.7759/cureus.78296
    1072. Renata Morales-Márquez, Lucía Delgadillo-Ruiz, Alfredo Esparza-Orozco, Eladio Delgadillo-Ruiz, Rómulo Bañuelos-Valenzuela, Benjamín Valladares-Carranza, María Isabel Chávez-Ruvalcaba, Francisca Chávez-Ruvalcaba, Héctor Emmanuel Valtierra-Marín, Norma Angélica Gaytán-Saldaña, Marisa Mercado-Reyes, Luz Adriana Arias-Hernández, Evaluation of Larrea tridentata Extracts and Their Antimicrobial Effects on Strains of Clinical Interest, 2025, 26, 1422-0067, 1032, 10.3390/ijms26031032
    1073. Yingpeng Li, Gongshi Lin, Theerakamol Pengsakul, Qingpi Yan, Lixing Huang, Antibiotic Resistance in Vibrio parahaemolyticus: Mechanisms, Dissemination, and Global Public Health Challenges—A Comprehensive Review, 2025, 17, 1753-5123, 10.1111/raq.13010
    1074. Aiswarya M. Rajesh, Shraddha Subhash Pawar, Kruthi Doriya, Rambabu Dandela, Combating antibiotic resistance: mechanisms, challenges, and innovative approaches in antibacterial drug development, 2025, 10.37349/eds.2025.100887
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    1077. Artemijs Sceglovs, Ingus Skadins, Marco Chitto, Juta Kroica, Kristine Salma-Ancane, Failure or future? Exploring alternative antibacterials: a comparative analysis of antibiotics and naturally derived biopolymers, 2025, 16, 1664-302X, 10.3389/fmicb.2025.1526250
    1078. Bowon Jung, Eun Jin Heo, Dieu Linh Nguyen, Ui Joung Youn, Ki Hyun Kim, Boram Son, Seulah Lee, Antimicrobial Steroids from Poisonous Mushroom Gymnopilus orientispectabilis and Their Molecular Docking Studies, 2025, 12, 2297-8739, 23, 10.3390/separations12020023
    1079. Neha Yadav, Santosh K. Misra, Nitroaromatic Compounds Dictate Electrochemical Properties of Escherichia coli by Manipulating the Cellular Membrane, 2025, 1543-8384, 10.1021/acs.molpharmaceut.4c01537
    1080. Sabine Berteina-Raboin, Comprehensive Overview of Antibacterial Drugs and Natural Antibacterial Compounds Found in Food Plants, 2025, 14, 2079-6382, 185, 10.3390/antibiotics14020185
    1081. Frank V. Pellegrini, Emily A. Caflisch, Nicole A. Aulik, Verification of the Efficacy of the GTLS Antibiotic Cocktail on Frozen Bovine Semen, 2025, 00220302, 10.3168/jds.2024-25535
    1082. Lee Xianhao Song, Mechanisms of antimicrobial resistance, 2024, 123, 2791-0210, 734, 10.54097/a5hezm47
    1083. Subash Chandra Nayak, P. Bhagya Latha, Bharath Kandanattu, Unni Pympallil, Ankit Kumar, Harish Kumar Banga, The Oral Microbiome and Systemic Health: Bridging the Gap Between Dentistry and Medicine, 2025, 2168-8184, 10.7759/cureus.78918
    1084. Thandizo Kapatsa, Adriano Lubanga, Akim Bwanali, Gracian Harawa, Steward Mudenda, Pascal Chipewa, Mapeesho Kamayani, Tumaini Makole, Abdisalam Ali, Abdullahi Mohamed, Kim Tae Youn, Lorie Kim, Won Daniel, Matthew Kim, Tarek Chehab, Thomas Nyirenda, Behavioral and Socio-Economic Determinants of Antimicrobial Resistance in Sub-Saharan Africa: A Systematic Review, 2025, Volume 18, 1178-6973, 855, 10.2147/IDR.S503730
    1085. Grinsun Sharma, Shishir Paudel, Anisha Chalise, Biswash Sapkota, Nirmal Raj Marasine, Taklo Simeneh Yazie, Knowledge, Attitude, and Practice on Antibiotic Use and Resistance Among Undergraduates, Pokhara Metropolitan, Nepal, 2025, 2025, 2314-6133, 10.1155/bmri/9928264
    1086. Priyanka Chambial, Neelam Thakur, Prudhvi Lal Bhukya, Anbazhagan Subbaiyan, Umesh Kumar, Frontiers in superbug management: innovating approaches to combat antimicrobial resistance, 2025, 207, 0302-8933, 10.1007/s00203-025-04262-x
    1087. Roderich D. Süssmuth, Marcel Kulike‐Koczula, Peng Gao, Simone Kosol, Fighting Antimicrobial Resistance: Innovative Drugs in Antibacterial Research, 2025, 1433-7851, 10.1002/anie.202414325
    1088. Roderich D. Süssmuth, Marcel Kulike‐Koczula, Peng Gao, Simone Kosol, Innovative Wirkstoffe aus der antibakteriellen Forschung im Kampf gegen mikrobielle Resistenzen, 2025, 0044-8249, 10.1002/ange.202414325
    1089. Susan Jyakhwo, Andrei Dmitrenko, Vladimir V. Vinogradov, Computer-Aided Discovery of Synergistic Drug–Nanoparticle Combinations for Enhanced Antimicrobial Activity, 2025, 1944-8244, 10.1021/acsami.4c21133
    1090. Richard Kolade Omole, Nkem Torimiro, Oluwole Isaac Adeyemi, Muthupandian Saravanan, Elizabeth Oladoyin Agboluaje, May P. Xiong, Reama Chinedu George, Enhanced Antibacterial Efficacy of Lysinibacillus fusiformis-Mediated Bimetallic Silver-gold Nanocomposites Against Multidrug-resistant Chronic Wound Bacterial Pathogens, 2025, 29501946, 100275, 10.1016/j.microb.2025.100275
    1091. Diana Tangdan Ampulembang, Irda Handayani, Nursin Abdul Kadir, Bacterial Identification and Antibiotic Sensitivity Tests of COVID-19 Patients at ICU Wahidin Sudirohusodo Hospital, 2025, 31, 2477-4685, 155, 10.24293/ijcpml.v31i2.2275
    1092. Ramses Gallegos-Monterrosa, Jimena I. Cid-Uribe, Gustavo Delgado-Prudencio, Deyanira Pérez-Morales, María M. Banda, Alexis Téllez-Galván, Edson N. Carcamo-Noriega, Ulises Garza-Ramos, Richard N. Zare, Lourival D. Possani, Víctor H. Bustamante, Blue benzoquinone from scorpion venom shows bactericidal activity against drug-resistant strains of the priority pathogen Acinetobacter baumannii, 2025, 0021-8820, 10.1038/s41429-025-00809-8
    1093. Xuewei Zou, Bai Xie, Therapeutic Mechanisms of Phenothiazine Drugs: A Mini-Review of Advances in Cancer Treatment and Antibiotic Resistance, 2025, 24, 1726-6890, 10.5812/ijpr-157923
    1094. Sarah Raquel de Annunzio, Bruna de Lima Moraes, Marcelo Assis, Paula Aboud Barbugli, Vinícius Henrique Ferreira Pereira de Oliveira, Elson Longo, Carlos Eduardo Vergani, Antimicrobial activity and biocompatibility of alpha-silver tungstate nanoparticles, 2025, 11, 24058440, e42648, 10.1016/j.heliyon.2025.e42648
    1095. Habiba lawal, Shamsaldeen Ibrahim Saeed, Mohammed Sani Gaddafi, Nor Fadhilah Kamaruzzaman, Guilherme Dilarri, Green Nanotechnology: Naturally Sourced Nanoparticles as Antibiofilm and Antivirulence Agents Against Infectious Diseases, 2025, 2025, 1687-918X, 10.1155/ijm/8746754
    1096. Manisha Aswal, Nirpendra Singh, Neelja Singhal, Manish Kumar, An integrated proteo-transcriptomics approach reveals novel drug targets against multidrug resistant Escherichia coli, 2025, 16, 1664-302X, 10.3389/fmicb.2025.1531739
    1097. Michela Galgano, Francesco Pellegrini, Elisabetta Catalano, Loredana Capozzi, Laura Del Sambro, Alessio Sposato, Maria Stella Lucente, Violetta Iris Vasinioti, Cristiana Catella, Amienwanlen Eugene Odigie, Maria Tempesta, Annamaria Pratelli, Paolo Capozza, Acquired Bacterial Resistance to Antibiotics and Resistance Genes: From Past to Future, 2025, 14, 2079-6382, 222, 10.3390/antibiotics14030222
    1098. Sadman Sakib, Nesha May O. Andoy, Jessica Y. C. Yang, Anna Galang, Ruby May A. Sullan, Shan Zou, Antimicrobial and anti-inflammatory effects of polyethyleneimine-modified polydopamine nanoparticles on a burn-injured skin model, 2025, 2047-4830, 10.1039/D4BM01530D
    1099. Ina Gajic, Nina Tomic, Bojana Lukovic, Milos Jovicevic, Dusan Kekic, Milos Petrovic, Marko Jankovic, Anika Trudic, Dragana Mitic Culafic, Marina Milenkovic, Natasa Opavski, A Comprehensive Overview of Antibacterial Agents for Combating Multidrug-Resistant Bacteria: The Current Landscape, Development, Future Opportunities, and Challenges, 2025, 14, 2079-6382, 221, 10.3390/antibiotics14030221
    1100. Arijit Sengupta, Joshua Stoltenberg, Mary R. Coveyou, Maria C. Perakis, Alexander Kuiken, The role of solketal as a building block for the synthesis of nonhemolytic acrylate-based cationic binary copolymers with antibacterial activity against Bacillus subtilis and Micrococcus luteus., 2025, 211, 13815148, 106211, 10.1016/j.reactfunctpolym.2025.106211
    1101. Hassan Mivehchi, Aisan Eskandari-Yaghbastlo, Parnian Pour Bahrami, Anis Elhami, Farbod Faghihinia, Seyedeh Tabasom Nejati, Kimia Sadat Kazemi, Mohsen Nabi Afjadi, Exploring the role of oral bacteria in oral cancer: a narrative review, 2025, 16, 2730-6011, 10.1007/s12672-025-01998-2
    1102. Timothy Kench, Nasima Sultana Chowdhury, Khondaker Miraz Rahman, Ramon Vilar, Discovery of Phototoxic Metal Complexes with Antibacterial Properties via a Combinatorial Approach, 2025, 0020-1669, 10.1021/acs.inorgchem.4c05414
    1103. Cicera Laura Roque Paulo, Priscilla Ramos Freitas Alexandre, Ana Carolina Ferreira Araujo, Ray Silva Almeida, Emílio Sousa Albuquerque, Cícera Datiane de Morais Oliveira-Tintino, Igor J. S. Nascimento, João Xavier Araújo-Júnior, Edeildo Ferreira da Silva-Junior, Thiago Mendonça de Aquino, Francisco Jaime Bezerra Mendonça-Junior, José Bezerra de Araújo-Neto, Maria Karollyna do Nascimento Silva Leandro, Irwin Rose Alencar de Menezes, Henrique Douglas Melo Coutinho, Janaina Esmeraldo Rocha, Evaluation of the Efflux Pump Inhibition Activity of Thiadiazine-Derived Compounds Against the Staphylococcus aureus 1199B Strain, 2025, 18, 1424-8247, 323, 10.3390/ph18030323
    1104. Joana F. Couceiro, Rodrigo Costa, Tina Keller-Costa, 2025, Chapter 15, 978-3-031-76691-6, 215, 10.1007/978-3-031-76692-3_15
    1105. Melissa Santibañez, Alejandra M. Rincon-Ponte, Gabriela Sastre Perez, Antimicrobial Stewardship Principles for Critically Ill Patients, 2025, 36, 1559-7768, 5, 10.4037/aacnacc2025715
    1106. Anshika Gupta, Akriti Verma, Kalpana Katiyar, Phytochemical-based drug designing against efflux-pump of ESKAPE pathogen to combat multidrug-resistant: an in silico study , 2025, 0739-1102, 1, 10.1080/07391102.2025.2472401
    1107. Juste Ouindgueta Bonkoungou Isidore, Edith Malatala Nikiema Marguerite, Garba Zakaria, Bako Evariste, Belem Souleymane, Soma Djifahamaï, Bintou Josiane Diarra Fatimata, Sibiri Zoma Barthélémy, Gampene Modeste, Siourimè Somda Namwin, Sore Souleymane, Barro Nicolas, Detection of blaCTX-M, blaTEM, and blaSHV genes in ESBL-producing enterobacterales from poultry farms in the peri-urban area of Ouagadougou, Burkina Faso, 2025, 17, 2141-2308, 14, 10.5897/JMA2024.0472
    1108. Mohammad A. Obeid, Hanin Alyamani, Abdelrahman Alenaizat, Tutku Tunç, Alaa A. Aljabali, Manal M. Alsaadi, Nanomaterial-Based Drug Delivery Systems in Overcoming Bacterial Resistance: Current Review, 2025, 08824010, 107455, 10.1016/j.micpath.2025.107455
    1109. Francisco Bernardo Dácio Araújo, Jaqueline Barbosa de Almeida, Elias Kahllyl da Silva Moraes, Ilidio Antônio Barbosa Formoso Junior, Diniz Soares Cantuária, Resistência bacteriana ao uso de antibiótico: mecanismos, desafios e estratégias de enfrentamento , 2025, 16, 2178-9010, e4709, 10.7769/gesec.v16i3.4709
    1110. Miriam Reverter, Sarahi Vega-Heredia, Philip J. Warburton, 2025, Chapter 2, 978-981-97-7319-0, 17, 10.1007/978-981-97-7320-6_2
    1111. Mahya Yasemi, Amir Jalali, Mohammad Asadzadeh, Majid Komijani, Organophosphate pesticides and their potential in the change of microbial population and frequency of antibiotic resistance genes in aquatic environments, 2025, 376, 00456535, 144296, 10.1016/j.chemosphere.2025.144296
    1112. Dinara T. Nurpeisova, Anastassiya A. Mashentseva, Fatima Abuova, Saida H. Aleskhanova, Murat Barsbay, Highly Efficient CuO/Cu@PC Composite Membranes for the Photocatalytic Degradation and Sorption of Roxithromycin from Aqueous Solutions, 2025, 2590048X, 100677, 10.1016/j.rinma.2025.100677
    1113. Jacob Moran, Kevin B. Wood, From Fluctuations and Disorder to Scaling and Control: The Emergence of Resistance in Microbial Communities, 2025, 16, 1947-5454, 297, 10.1146/annurev-conmatphys-042924-110923
    1114. Jakub Jagielski, Karolina Dydak, Kaja Jaskot, Dmytro Soloviov, Maciej Kozak, Grzegorz Nowaczyk, Antibacterial lipid liquid crystalline nanoparticles – synthesis and optimization by central composite design, 2025, 53, 2169-1401, 69, 10.1080/21691401.2025.2472928
    1115. Kathirvel Brindhadevi, Arivalagan Pugazhendhi, Enhancing biohydrogen production through microbial fermentation with the addition of nanometal ions, 2025, 215, 13640321, 115552, 10.1016/j.rser.2025.115552
    1116. Shoshana C. Williams, Madeline B. Chosy, Carolyn K. Jons, Changxin Dong, Alexander N. Prossnitz, Xinyu Liu, Hector Lopez Hernandez, Lynette Cegelski, Eric A. Appel, Polyacrylamide-Based Antimicrobial Copolymers to Replace or Rescue Antibiotics, 2025, 2374-7943, 10.1021/acscentsci.4c01973
    1117. Subramanian Sundaramoorthy, 2025, 9781119791645, 295, 10.1002/9781119792192.ch11
    1118. Natalie Naidoo, Oliver T. Zishiri, Presence, Pathogenicity, Antibiotic Resistance, and Virulence Factors of Escherichia coli: A Review, 2025, 4, 2674-1334, 16, 10.3390/bacteria4010016
    1119. Debolina Chatterjee, Karthikeyan Sivashanmugam, Unraveling the Complex Antimicrobial Resistance Gene Network of Pseudomonas aeruginosa using Systems Biology ApproachUnraveling the Complex Antimicrobial Resistance Gene Network of Pseudomonas aeruginosa using Systems Biology Approach, 2025, 19, 09737510, 106, 10.22207/JPAM.19.1.01
    1120. Ritisha Dey, Domonique Olivia Valle, Abhijit Chakraborty, Kimberly A. Mayer, Jagadeesh Kumar Uppala, Anish Chakraborty, Shama Mirza, Troy Skwor, Steven Forst, Madhusudan Dey, Quorum sensing regulators and non-ribosomal peptide synthetases govern antibacterial secretions in Xenorhabdus szentirmaii, 2025, 16, 1664-302X, 10.3389/fmicb.2025.1560663
    1121. Ze Liang, Zijian Liang, Hang‐Wei Hu, Kate Howell, Zhongxiang Fang, Pangzhen Zhang, Food substances alter gut resistome: Mechanisms, health impacts, and food components, 2025, 24, 1541-4337, 10.1111/1541-4337.70143
    1122. Raphaël Charron, Pierre Lemée, Antoine Huguet, Ornella Minlong, Marine Boulanger, Paméla Houée, Christophe Soumet, Romain Briandet, Arnaud Bridier, Strain-dependent emergence of aminoglycoside resistance in Escherichia coli biofilms, 2025, 9, 25902075, 100273, 10.1016/j.bioflm.2025.100273
    1123. Rajpal Tyagi, Anuj Maurya, 2025, Chapter 13, 978-3-031-80624-7, 291, 10.1007/978-3-031-80625-4_13
    1124. Biel Garcias, Mar Batalla, Anna Vidal, Inma Durán, Laila Darwich, Trends in Antimicrobial Resistance of Canine Otitis Pathogens in the Iberian Peninsula (2010–2021), 2025, 14, 2079-6382, 328, 10.3390/antibiotics14040328
    1125. Ebenezer Aborah, Matthew Ayitah, Kwesi Felix Boafo, Anely Ortiz-Alegria, Manjusha Lekshmi, Chandrashekar K. Dhanush, Sanath Kumar, Manuel F. Varela, Multidrug resistance and major facilitator superfamily antimicrobial efflux pumps of the ESKAPEE pathogen Staphylococcus aureus, 2025, 10.37349/eds.2025.100897
    1126. Afrah Siddique, Muhammad Hubab, Abdul Rashid P. Rasheela, Raniya Samad, Mohammad Al-Ghouti, Sami Sayadi, Nabil Zouari, Microplastics and their role in the emergence of antibiotic resistance in bacteria as a threat for the environment, 2025, 25901826, 10.1016/j.enceco.2025.03.006
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