Heterogeneous efflux pump expression underpins phenotypic resistance to antimicrobial peptides

  1. Ka Kiu Lee
  2. Urszula Łapińska
  3. Giulia Tolle
  4. Maureen Micaletto
  5. Bing Zhang
  6. Wanida Phetsang
  7. Anthony D Verderosa
  8. Brandon M Invergo
  9. Joseph Westley
  10. Attila Bebes
  11. Raif Yuecel
  12. Paul A O’Neill
  13. Audrey Farbos
  14. Aaron R Jeffries
  15. Stineke van Houte
  16. Pierluigi Caboni
  17. Mark AT Blaskovich
  18. Benjamin E Housden
  19. Krasimira Tsaneva- Atanasova
  20. Stefano Pagliara

  • Curated by eLife

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    eLife Assessment

    This important study by Lee et al. investigates the heterogeneous response of non-growing bacteria to the antimicrobial peptide (AMP) tachyplesin. In this response, a subpopulation of bacteria limits the accumulation of a fluorescent analog of the AMP, avoiding lethal damage. The study provides compelling evidence of the reduced susceptibility to the antimicrobial peptide antibiotic tachyplesin in a subpopulation of cells characterized by reduced drug accumulation. The evidence on the underlying molecular mechanisms is solid.

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Abstract

Antimicrobial resistance threatens the viability of modern medical interventions. There is a dire need of developing novel approaches to counter resistance mechanisms employed by starved or slow-growing pathogens that are refractory to conventional antimicrobial therapies. Antimicrobial peptides have been advocated as potential therapeutic solutions due to low levels of genetic resistance observed in bacteria against these compounds. However, here we show that subpopulations of stationary phase Escherichia coli and Pseudomonas aeruginosa survive tachyplesin treatment without genetic mutations. These phenotypic variants display enhanced efflux activity to limit intracellular peptide accumulation. Differential regulation of genes involved in outer membrane vesicle section, membrane modification, and protease activity were also found between phenotypically resistant and susceptible cells. We discovered that formation of these phenotypic variants could be prevented by administering tachyplesin in combination with sertraline, a clinically used antidepressant, suggesting a novel approach for combatting antimicrobial-refractory stationary phase bacteria.

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  1. Version published to 10.7554/elife.99752.2 on eLife
  2. Version published to 10.7554/elife.99752 on eLife
  3. eLife

    eLife Assessment

    This important study by Lee et al. investigates the heterogeneous response of non-growing bacteria to the antimicrobial peptide (AMP) tachyplesin. In this response, a subpopulation of bacteria limits the accumulation of a fluorescent analog of the AMP, avoiding lethal damage. The study provides compelling evidence of the reduced susceptibility to the antimicrobial peptide antibiotic tachyplesin in a subpopulation of cells characterized by reduced drug accumulation. The evidence on the underlying molecular mechanisms is solid.

  4. eLife

    Reviewer #1 (Public review):

    Summary:

    This work contributes several important and interesting observations regarding the heterotolerance of non-growing Escherichia coli and Pseudomonas aeruginosa to the antimicrobial peptide tachyplesin. The primary mechanism of action of tachyplesin is thought to be disruption of the bacterial cell envelope, leading to leakage of cellular contents after a threshold level of accumulation. Although the MIC for tachyplesin in exponentially growing E. coli is just 1 ug/ml, the authors observe that a substantial fraction of a stationary phase population of bacteria survives much higher concentrations, up to 64 ug/ml. By using a fluorescently labelled analogue of tachyplesin, the authors show that the amount of per-cell intracellular accumulation of tachyplesin displays a bimodal distribution, and that the fraction of "low accumulators" correlates with the fraction of survivors. Using a microfluidic device, they show that low accumulators exclude propidium iodide, suggesting that their cell envelopes remain largely intact, while high accumulators of tachyplesin also stain with propidium iodide. They show that this phenomenon holds for several clinical isolates of E. coli with different genetic determinants of antibiotic resistance, and for a strain of Pseudomonas aeruginosa. However, the bimodal distribution does not occur in these organisms for several other antimicrobial peptides, or for tachyplesin in Klebsiella pneumoniae or Staphylococcus aureus, indicating some degree of specificity in the interaction between AMP and bacterial cell envelope. They next explore the dynamics of the fluorescent tachyplesin accumulation and show interestingly that a high degree of accumulation is initially seen in all cells, but that the "low accumulator" subpopulation manages to decrease the amount of intracellular fluorescence over time, while the "high accumulator"subpopulation continues to increase its intracellular fluorescence. Focusing on increased efflux as a hypothesised mechanism for the "low accumulator" phenotype, based on transcriptomic analysis of the two subpopulations, the authors screen putative efflux inhibitors to see if they can block the formation of the low accumulator subpopulation. They find that both the protonophore CCCP and the SSRI sertraline can block the formation of this subpopulation and that a combination of sertraline plus tachyplesin kills a greater fraction of the stationary phase cells than either agent alone, similar to the killing observed when growing cells are treated with tachyplesin.

    Strengths:

    This study provides new insight into the heterogeneous behaviours of non-growing bacteria when exposed to an antimicrobial peptide, and into the dynamics of their response. The single-cell analysis by FACS and microscopy is compelling. The results provide a much-needed single cell perspective on the phenomenon of tolerance to AMPs and a good starting point for further exploration.

    Weaknesses:

    The authors have substantially improved the clarity of the manuscript and have added additional experiments to probe further the location of the AMP relative to low and high accumulators, and the physiological states of these sub-populations. These experiments strengthen the assertion that low accumulators keep the AMP at the cell surface while high accumulators permit intracellular access to the AMP.

    However, many questions still remain about the physiological characterisation of the "low accumulator" cells. While the evidence presented does support an induced response that removes the AMP from the interior of the cell, no clear mechanism for this is favoured by the experiments presented.

    A double deletion of acrA and tolC (two out of the three components of the major constitutive RND efflux pump) reduces the appearance of the low accumulator phenotype, but interestingly, the single deletions have no effect, and a well-characterised inhibitor of RND efflux pumps also has no effect. The authors identify a two-component system, qseCB, that appears necessary for the appearance of low accumulators, but this system has pleiotropic effects on many cellular systems, with only tenuous connections to efflux. The selected pharmacological agents that could prevent the appearance of low accumulators do not offer clear insight into the mechanism by which low accumulators arise, because they have diverse modes of action.

    The transcriptomics data collected for low and high accumulator sub-populations are interesting, but in my opinion, the conclusions that can be drawn from these data remain overstated. It is not possible to make any claims about the total amount of "protein synthesis, energy production, and gene expression" on the basis of RNA-Seq data. The reads from each sample are normalised, so there is no information about the total amount of transcript. Many elements of total cellular activity are post-transcriptionally regulated, so it is impossible to assess from transcriptomics alone. Finally, the transcriptomic data are analysed in aggregated clusters of genes that are enriched for biological processes, for example: "Cluster 2 included processes involved in protein synthesis, energy production, and gene expression that were downregulated to a greater extent in low accumulators than high accumulators". However, this obscures the fact that these clusters include genes that are generally inhibitory of the process named, as well as genes that facilitate the process.

    The authors have added an experiment to attempt to assess overall metabolic activity in the low accumulator and high accumulator populations, which is a welcome addition. They apply the redox dye resazurin and observe lower resorufin (reduced form) fluorescence in the low accumulator population, which they take to indicate a lower respiration rate. This seems possible, however, an important caveat is that they have shown the low accumulator population to retain substantially lower amounts of multiple different fluorescent molecules (tachyplesin-NBD, propidium iodide, ethidium bromide) intracellularly compared to the high accumulator population. It seems possible that the low accumulator population is also capable of removing resazurin or resorufin from the intracellular space, regardless of metabolic rate. Indeed, it has previously been shown that efflux by RND efflux pumps influences resazurin reduction to resorufin in both P. aeruginosa and E. coli. By measuring only the retained redox dye using flow cytometry, the results may be confounded by the demonstrated ability of the low accumulator population to remove various fluorescent dyes. More work is needed to strongly support broad conclusions about the physiological states of the low and high accumulator populations.

    The phenomenon of the emergence of low accumulators, which are phenotypically tolerant to the antimicrobial peptide tachyplesin, is interesting and important even if there is still work to be done to understand the mechanism by which it occurs.

  5. eLife

    Reviewer #2 (Public review):

    Summary:

    This study reports on the existence of subpopulations of isogenic E. coli and P. aeruginosa cells that are tolerant to the antimicrobial peptide tachyplesin and are characterized by accumulation of low levels of a fluorescent tachyplesin-NBD conjugate. The authors then set out to address the molecular mechanisms, providing interesting insights even though the mechanism remains incompletely defined: The work demonstrates that increased efflux may cause this phenotype, putatively together with other changes in membrane lipid composition. The authors further demonstrate that pharmacological manipulation can prevent generation of tolerance. The authors are cautious in their interpretation and the claims made are largely justified by the data.

    Strengths:

    Going beyond the commonly used bulk techniques for studying susceptibility to AMPs , Lee et al. used of fluorescent antibiotic conjugates in combination with flow cytometry analysis to study variability in drug accumulation at the single cell level. This powerful approach enabled the authors to expose bimodal drug accumulation pattern that were condition dependent, but conserved across a variety of E. coli clinical isolates. Using cell sorting in combination with colony-forming unit assays as well as quantitative fluorescence microscopic analysis in a microfludics-setup the authors compellingly demonstrate that low accumulators (where fluorescence signal is mostly restricted to the membrane), can survive antibiotic treatment, whereas high accumulators (with high intracellular fluorescence) were killed.

    The relevance of efflux for the ´low accumulator´ phenotype and its survival is convincingly demonstrated by the following lines of evidence: i) A time-course experiment on tachyplesin-NBD pre-loaded cells revealed that all cells initially were high accumulators, before a subpopulation of cells subsequently managed to reduce signal intensity, demonstrating that the ´low accumulator´ phenotype is an induced response and not a pre-existing property. Ii) Double-mutants deficient in the delta acrA delta tolC double-KO, which showed reduced levels of low accumulators´. Interestingly, ´low accumulator´populations were nearly abrogated in bacteria deficient in the qse quorum sensing system, suggesting its centrality for the tachyplesin response. Even though this system may control acrA, the strength of the phenotype may suggest that it may control additional as-of-yet unidenitified factors relevant in the response to tachyplesin. Iii) treatment with efflux pump inhibitor sertraline and verapamil (even though some caution needs to be taken since it is not perfectly selective, see weakness) prevents generation of low accumulators. The observation that sertraline enhances tachyplesin-based killing is an important basis for developing combination therapies.

    The study convincingly illustrates how susceptibility to tachyplesin adaptively changes in a heterogeneous way dependent on the growth phases and nutrient availability. This is highly relevant also beyond the presented example of tachyplesin and similar subpopulation-based adaptive changes to the susceptibility towards antimicrobial peptides or other drugs may occur during infections in vivo and they would likely be missed by standardized in vitro susceptibility testing.

    Weaknesses:

    Some mechanistic questions regarding tachyplesin-accumulation and survival remain. One general shortcoming of the setup of the transcriptomics experiment is that the tachyplesin-NBD probe itself has antibiotic efficacy and induces phenotypes (and eventually cell death) in the ´high accumulator´ cells. As the authors state themselves, this makes it challenging to interpret whether any differences seen between the two groups are causative for the observed accumulation pattern of if they are a consequence of differential accumulation and downstream phenotypic effects.

    I have a few minor concerns regarding new data that was added during the revision:

    - The statement ´ Moreover, we found that the fluorescence of low accumulators decreased over time when bacteria were treated with 20 μg mL´ is, in my opinion, not supported by the data shown in Figure S4C. That figure shows that the abundance of ´low accumulator´ cells decreases over time. Following the rationale that protease K treatment may cleave surface-associated/extracellular tachyplesin-NDB, this should lead to a shift of ´low accumulator´population to the left, indicating reduced fluorescence intensity per cell. This is not so case, but the population just disappears. However, after 120 min of treatment more cells appear in the ´high accumulator´ state. This result is somewhat puzzling.

    - The authors used the metabolic dye resazurin to measure the metabolic activity of low vs. high accumulators. I am not entirely convinced that the lower fluorescence resorufin-fluorescence in tachyplesin-NBD accumulators really indicates lower metabolic activity, since a cell's fluorescence levels would also be affected by the cellular uptake and efflux. It appears plausible that the lower resorufin-fluorescence may result from reduced accumulation/increased efflux in the´low-tachyplesin NBD´ population.

    Comment on revisions: All my previous comments have been satisfactorily addressed by the authors.

  6. eLife

    Reviewer #3 (Public review):

    Summary:

    This important study shows that stationary phase bacteria survive antimicrobial peptide treatment by switching on efflux pumps, generating low accumulating subpopulations that evade killing-a finding with clear implications for the design of peptide based antibiotics and for researchers studying antimicrobial resistance. The evidence is solid and frequently convincing, as diverse single cell assays, genetics and chemical inhibition coherently link reduced intracellular peptide to survival, even though a few mechanistic details warrant further exploration.

    Strengths:

    The authors investigate how Escherichia coli (and, to a lesser extent, Pseudomonas aeruginosa) survive exposure to the antimicrobial peptide (AMP) tachyplesin. Because resistance to AMPs is thought to rely heavily on non genetic adaptations rather than on classical mutation based mechanisms, the study focuses on phenotypic heterogeneity and seeks to pinpoint the cellular processes that protect a subset of cells. Using fluorescently labelled tachyplesin, single cell imaging, flow cytometry, transcriptomics, targeted genetics, and chemical perturbations, the authors report that stationary phase cultures harbor two phenotypic states: high accumulating cells that die and low accumulating cells that survive. They further propose and show that inducible efflux activity is the primary driver of survival and show that either efflux inhibition (sertraline, verapamil) or nutrient supplementation prevents the emergence of low accumulators and boosts killing.
    The experiments unambiguously reveal that the cells respond to stress heterogeneously, with two distinct subpopulations - one with better survival than the other. This primary phenotype is convincingly shown across various E. coli strains, including clinical isolates. The authors probed the underlying mechanism from several angles, with important additional experiments in the revised version that strengthens the original conclusions in several ways. Newly added efflux assays with ethidium bromide, together with proteinase treatment experiments and ΔacrAΔtolC and ΔqseB/qseC mutant data, illustrate that the low accumulating subpopulation can actively export intracellular compounds. The authors took great care to temper their language to acknowledge other potential alternatives that could explain some of the data such as altered influx, vesicle release or proteolysis, metabolic activity of the cells, indirect effects of sertraline treatment, etc. Additional metabolic dye measurements confirm that low accumulators are less metabolically active, and a new data on nutrient supplementation shows that forcing growth increases peptide uptake and lethality. The authors clarify the crucial point of where antimicrobial peptides actually bind on the cell within the broader survival mechanism and present their conclusions, along with potential caveats, with commendable clarity.

    Weaknesses:

    Despite these advances, the contribution of efflux may require more direct evidence to further dissect whether efflux is necessary, sufficient, or contributory. The facts that the key low-efflux mutant still retains a small fraction of survivors and that the inhibitors used may cause other physiological changes leading to higher efflux are still unaccounted for. The lipidomic and vesicle findings, while intriguing, remain descriptive, and direct tests of their functional relevance would further solidify the mechanistic models.

    Conclusion:

    Even with these limitations, the study provides valuable insight into non genetic resistance mechanisms to AMPs and highlights inducible heterogeneity as a critical obstacle to peptide therapeutics. In a much broader context, this study also underscores the importance of efflux physiology even for those antimicrobials that seemingly would not have intracellular targets.

  7. eLife

    Author response:

    The following is the authors’ response to the original reviews

    Reviewer 1:

    (1) The initial high accumulation by all cells followed by the emergence of a sub-population that has reduced its intracellular levels of tachyplesin is a key observation and I agree with the authors' conclusion that this suggests an induced response to the AMP is important in facilitating the bimodal distribution. However, I think the conclusion that upregulated efflux is driving the reduction in signal in the "low accumulator" subpopulation is not fully supported. Steady-state amounts of intracellular fluorescent AMP are determined by the relative rates of influx and efflux and a decrease could be caused by decreasing influx (while efflux remained unchanged), increasing efflux (while influx remained unchanged), or both decreasing influx and increasing efflux. Given the transcriptomic data suggest possible changes in the expression of enzymes that could affect outer membrane permeability and outer membrane vesicle formation as well as efflux, it seems very possible that changes to both influx and efflux are important. The "efflux inhibitors" shown to block the formation of the low accumulator subpopulation have highly pleiotropic or incompletely characterised mechanisms of action so they also do not exclusively support a hypothesis of increased efflux.

    We agree with the reviewer that the emergence of low accumulators after 30 min in the presence of extracellular tachyplesin-NBD (Figure 4A) could be due to either decreased influx while efflux remained unchanged, increased efflux while influx remained unchanged, or both decreasing influx and increasing efflux. Increased proteolytic activity or increased secretion of OMVs could also play a role.

    We have now acknowledged that “Reduced intracellular accumulation of tachyplesin-NBD in the presence of extracellular tachyplesin-NBD could be due to decreased drug influx, increased drug efflux, increased proteolytic activity or increased secretion of OMVs.” (lines 313-315).

    However, the emergence of low accumulators after 60 min in the absence of extracellular tachyplesin-NBD in our efflux assays (Figure 4C) cannot be due to decreased influx while efflux remained unchanged because of the absence of extracellular tachyplesin-NBD. We acknowledge that in our original manuscript we did not explicitly state that the efflux assays reported in Figure 4C-D were performed in the absence of tachyplesin-NBD in the extracellular environment. We have now clarified this point in our manuscript, we have added illustrations in Figure 4A, 4C-D and we have also carried out efflux assays using ethidium bromide (EtBr) to further support our conclusions about the primary role played by efflux in reducing tachyplesin accumulation in low accumulators. We have added the following paragraphs to our revised manuscript:

    “Next, we performed efflux assays using ethidium bromide (EtBr) by adapting a previously described protocol [62]. Briefly, we preloaded stationary phase E. coli with EtBr by incubating cells at a concentration of 254 µM EtBr in M9 medium for 90 min. Cells were then pelleted and resuspended in M9 to remove extracellular EtBr. Single-cell EtBr fluorescence was measured at regular time points in the absence of extracellular EtBr using flow cytometry. This analysis revealed a progressive homogeneous decrease of EtBr fluorescence due to efflux from all cells within the stationary phase E. coli population (Figure S13A). In contrast, when we performed efflux assays by preloading cells with tachyplesin-NBD (46 μg mL-1 or 18.2 μM), followed by pelleting and resuspension in M9 to remove extracellular tachyplesin-NBD, we observed a heterogeneous decrease in tachyplesin-NBD fluorescence in the absence of extracellular tachyplesin-NBD: a subpopulation retained high tachyplesin-NBD fluorescence, i.e. high accumulators; whereas another subpopulation displayed decreased tachyplesin-NBD fluorescence, 60 min after the removal of extracellular tachyplesin-NBD (Figure 4B). Since these assays were performed in the absence of extracellular tachyplesin-NBD, decreased tachyplesin-NBD fluorescence could not be ascribed to decreased drug influx or increased secretion of OMVs in low accumulators, but could be due to either enhanced efflux or proteolytic activity in low accumulators.

    Next, we repeated efflux assays using EtBr in the presence of 46 μg mL-1 (or 20.3 µM) extracellular tachyplesin-1. We observed a heterogeneous decrease of EtBr fluorescence with a subpopulation retaining high EtBr fluorescence (i.e. high tachyplesin accumulators) and another population displaying reduced EtBr fluorescence (i.e. low tachyplesin accumulators, Figure S14B) when extracellular tachyplesin-1 was present. Moreover, we repeated tachyplesin-NBD efflux assays in the presence of M9 containing 50 μg mL-1 (244 μM) carbonyl cyanide m-chlorophenyl hydrazone (CCCP), an ionophore that disrupts the proton motive force (PMF) and is commonly employed to abolish efflux and found that all cells retained tachyplesin-NBD fluorescence (Figure S15B). However, it is important to note that CCCP does not only abolish efflux but also other respiration-associated and energy-driven processes [63].

    Taken together, our data demonstrate that in the absence of extracellular tachyplesin, stationary phase E. coli homogeneously efflux EtBr, whereas only low accumulators are capable of performing efflux of intracellular tachyplesin after initial tachyplesin accumulation. In the presence of extracellular tachyplesin, only low accumulators can perform efflux of both intracellular tachyplesin and intracellular EtBr. However, it is also conceivable that besides enhanced efflux, low accumulators employ proteolytic activity, OMV secretion, and variations to their bacterial membrane to hinder further uptake and intracellular accumulation of tachyplesin in the presence of extracellular tachyplesin.”

    These amendments can be found on lines 316-350 and in the new Figure S13 and Figure 4. We have also carried out more tachyplesin-NBD accumulation assays using single and double gene-deletion mutants lacking efflux components, please see Response 3 to reviewer 2 and the data reported in Figure 4B.

    (2) A conclusion of the transcriptomic analysis is that the lower accumulating subpopulation was exhibiting "a less translationally and metabolically active state" based on less upregulation of a cluster of genes including those involved in transcription and translation. This conclusion seems to borrow from well-described relationships referred to as bacterial growth laws in which the expression of genes involved in ribosome production and translation is directly related to the bacterial growth (and metabolic) rate. However, the assumptions that allow the formulation of the bacterial growth laws (balanced, steady state, exponential growth) do not hold in growth arrest. A non-growing cell could express no genes at all or could express ribosomal genes at a very low level, or efflux pumps at a high level. The distribution of transcripts among the functional classes of genes does not reveal anything about metabolic rates within the context of growth arrest - it only allows insight into metabolic rates when the constraint of exponential growth can be assumed. Efflux pumps can be highly metabolically costly; for example, Tn-Seq experiments have repeatedly shown that mutants for efflux pump gene transcriptional repressors have strong fitness disadvantages in energy-limited conditions. There are no data presented here to disprove a hypothesis that the low accumulators have high metabolic rates but allocate all of their metabolic resources to fortifying their outer membranes and upregulating efflux. This could be an important distinction for understanding the vulnerabilities of this subpopulation. Metabolic rates can be more directly estimated for single cells using respiratory dyes or pulsed metabolic labelling, for example, and these data could allow deeper insight into the metabolic rates of the two subpopulations. My main recommendation for additional experiments to strengthen the conclusions of the paper would be to attempt to directly measure metabolic or translational activity in the high- and low-accumulating populations. I do not think that the transcriptomic data are sufficient to draw conclusions about this but it would be interesting to directly measure activity. Otherwise, it might be reasonable to simply soften the language describing the two populations as having different activity levels. They do seem to have different transcriptional profiles, and this is already an interesting observation.

    We agree with the reviewer that it might be misleading to draw conclusions on bacterial metabolic states solely based on transcriptomic data. We have therefore removed the statement “low accumulators displayed a less translationally and metabolically active state”. We have instead stated the following: “Our transcriptomics analysis showed that low tachyplesin accumulators downregulated protein synthesis, energy production, and gene expression processes compared to high accumulators”. Moreover, we have employed the membrane-permeable redox-sensitive dye C12-resazurin, which is reduced to the fluorescent C12-resorufin in metabolically active cells, to obtain a more direct estimate of the metabolic state of low and high accumulators of tachyplesin. We have added the following paragraph reporting our new data:

    “Our transcriptomics analysis also showed that low tachyplesin accumulators downregulated protein synthesis, energy production, and gene expression compared to high accumulators. To gain further insight on the metabolic state of low tachyplesin accumulators, we employed the membrane-permeable redox-sensitive dye, resazurin, which is reduced to the highly fluorescent resorufin in metabolically active cells. We first treated stationary phase E. coli with 46 μg mL-1 (18.2 μM) tachyplesin-NBD for 60 min, then washed the cells, and then incubated them in 1 μM resazurin for 15 min and measured single-cell fluorescence of resorufin and tachyplesin-NBD simultaneously via flow cytometry. We found that low tachyplesin-NBD accumulators also displayed low fluorescence of resorufin, whereas high tachyplesin-NBD accumulators also displayed high fluorescence of resorufin (Figure S16), suggesting lower metabolic activity in low tachyplesin-NBD accumulators.”

    These amendments can be found on lines 398-408 and in Figure S16.

    (3) The observation that adding nutrients to the stationary phase cultures pushes most of the cells to the "high accumulator" state is presented as support of the hypothesis that the high accumulator state is a higher metabolism/higher translational activity state. However, it is important to note that adding nutrients will cause most or all of the cells in the population to start to grow, thus re-entering the familiar regime in which bacterial growth laws apply. This is evident in the slightly larger cell sizes seen in the nutrient-amended condition. In contrast to stationary phase cells, growing cells largely do not exhibit the bimodal distribution, and they are much more sensitive to tachyplesin, as demonstrated clearly in the supplement. Growing cells are not necessarily the same as the high-accumulating subpopulation of non-growing cells.

    Following the reviewer’s suggestion, we are no longer using the nutrient supplementation data to support the hypothesis that high accumulators possess higher metabolism or translational activity.

    The nutrient supplementation data is now only used to investigate whether tachyplesin-NBD accumulation and efficacy can be increased, and not to show that high tachyplesin-NBD accumulators are more metabolically or translationally active.

    Furthermore, our previous statement “Our data suggests that such slower-growing subpopulations might display lower antibiotic accumulation and thus enhanced survival to antibiotic treatment.” has now been removed from the discussion.

    (4) It might also be worth adding some additional context around the potential to employ efflux inhibitors as therapeutics. It is very clear that obtaining sufficient antimicrobial drug accumulation within Gram-negative bacteria is a substantial barrier to effective treatments, and large concerted efforts to find and develop therapeutic efflux pump inhibitors have been undertaken repeatedly over the last 25 years. Sufficiently selective inhibitors of bacterial efflux pumps with appropriate drug-like properties have been challenging to find and none have entered clinical trials. Multiple psychoactive drugs have been shown to impact efflux in bacteria but usually using concentrations in the 10-100 uM range (as here). Meanwhile, the Ki values for their human targets are usually in the sub- to low-nanomolar range. The authors rightly note that the concentration of sertraline they have used is higher than that achieved in patients, but this is by many orders of magnitude, and it might be worth expanding a bit on the substantial challenge of finding efflux inhibitors that would be specific and non-toxic enough to be used therapeutically. Many advances in structural biology, molecular dynamics, and medicinal chemistry may make the quest for therapeutic efflux inhibitors more fruitful than it has been in the past but it is likely to remain a substantial challenge.

    We agree with this comment and we have now added the following statement:

    “This limitation underscores the broader challenge of identifying EPIs that are both effective and minimally toxic within clinically achievable concentrations, while also meeting key therapeutic criteria such as broad-spectrum efficacy against diverse efflux pumps, high specificity for bacterial targets, and non-inducers of AMR [117]. However, advances in biochemical, computational, and structural methodologies hold the potential to guide rational drug design, making the search for effective EPIs more promising [118]. Therefore, more investigation should be carried out to further optimise the use of sertraline or other EPIs in combination with tachyplesin and other AMPs.”

    This amendment can be found on lines 535-542.

    (5) My second recommendation is that the transcriptomic data should be made available in full and in a format that is easier for other researchers to explore. The raw data should also be uploaded to a sequence repository, such as the NCBI Geo database or the EMBL ENA. The most useful format for sharing transcriptomic data is a table (such as an excel spreadsheet) of transcripts per million counts for each gene for each sample. This allows other researchers to do their own analyses and compare expression levels to observations from other datasets. When only fold change data are supplied, data cannot be compared to other datasets at all, because they are relative to levels in an untreated control which are not known. The cluster analysis is one way of gaining insight into biological function revealed by transcriptional profile, but it can hide interesting additional complexities. For example, rpoS is named as one of the transcription-associated genes that are higher in the high accumulator subpopulation and evidence of generally increased activity. But RpoS is the stress sigma factor that drives much lower levels of expression generally than the housekeeping sigma factor RpoD, even though it recognises many of the same promoters (and some additional stress-specific promoters). Therefore, increased RpoS occupancy of RNAP would be expected to result in overall lower levels of transcription. However, it is also true that the transcript level for the rpoS gene is a particularly poor indicator of expression - rpoS is largely post-transcriptionally regulated. More generally, annotations are always evolving and key functional insights related to each gene might change in the future, so the results are a more durable resource if they are presented in a less analysed form as well as showing the analysis steps. It can also be important to know which genes were robustly expressed but did not change, versus genes that were not detected.

    Sequencing data associated with this study have now been uploaded and linked under NCBI BioProject accession number PRJNA1096674 (https://www.ncbi.nlm.nih.gov/bioproject/PRJNA1096674).

    We have added this link to the methods under subheading “Accession Numbers” on lines 858-860. Additionally, transcripts per million counts for each gene for each sample have been added to the Figure 3 - Source Data file as requested by the reviewer.

    (6) In the introduction, the susceptibility of AMP efficacy to resistance mechanisms is discussed:

    "However, compared to small molecule antimicrobials, AMP resistance genes typically confer smaller increases in resistance, with polymyxin-B being a notable exception 7, 8. Moreover, mobile resistance genes against AMPs are relatively rare, and horizontal acquisition of AMP resistance is hindered by phylogenetic barriers owing to functional incompatibility with the new host bacteria9, again with plasmid-transmitted polymyxin resistance being a notable exception."

    It seems worth pointing out that polymixins are the only AMPs that can reasonably be compared with small molecule antibiotics in terms of resistance acquisition since they are the only AMPs that have been widely used as drugs and therefore had similar chances to select for resistance among diverse global microbial populations.

    We have now clarified that we are referring to laboratory evolutionary analyses of resistance towards small molecule antibiotics and AMPs (Spohn et al., 2019) and that polymyxins are the only AMPs that have been used in antibiotic treatment to date.

    We have added the following statement to address this point:

    “Bacteria have developed genetic resistance to AMPs, including proteolysis by proteases, modifications in membrane charge and fluidity to reduce affinity, and extrusion by AMP transporters. However, compared to small molecule antimicrobials, AMP resistance genes typically confer smaller increases in resistance in experimental evolution analyses, with polymyxin-B and CAP18 being notable exceptions [8]. Moreover, mobile resistance genes against AMPs are relatively rare and horizontal acquisition of AMP resistance is hindered by phylogenetic barriers owing to functional incompatibility with the new host bacteria [9]. Plasmid-transmitted polymyxin resistance constitutes a notable exception [10], possibly because polymyxins are the only AMPs that have been in clinical use to date [9].”

    This amendment can be found on lines 57-65.

    (7) In the description of Figure 4, " tachyplesin monotherapy" is mentioned. It is not really appropriate to describe the treatment of a planktonic culture of bacteria in a test tube as a therapy since there is no host that is benefitting.

    We have now replaced “tachyplesin monotherapy” with “tachyplesin treatment”.

    (8) In the discussion, it is stated that " tachyplesin accumulates intracellularly only in bacteria that do not survive tachyplesin exposure" but this is clearly not true. All bacteria accumulate tachyplesin intracellularly initially, but if the bacteria are non-growing during the exposure, some of them are able to reduce their intracellular levels. The fraction of survivors is roughly correlated with the fraction of bacteria that do not maintain high intracellular levels of tachyplesin and that do not stain with propidium iodide, but for any given cell it seems that there is no clear point at which a high intracellular level of tachyplesin means that it will definitely not survive.

    We have now clarified this statement as follows: “We show that after an initial homogeneous tachyplesin accumulation within a stationary phase E. coli population, tachyplesin is retained intracellularly by bacteria that do not survive tachyplesin exposure, whereas tachyplesin is retained only in the membrane of bacteria that survive tachyplesin exposure.”

    This amendment can be found on lines 443-446.

    (9) Also in the discussion: " Our data suggests that such slower-growing subpopulations might display lower antibiotic accumulation and thus enchanced [sic] survival to antibiotic treatment." This does not really relate to the results here because the bimodal distributions were primarily studied in the absence of growth. In the LB/exponential growth situations where the population was growing but a very small subpopulation of low accumulators was observed, no measurements were made to indicate subpopulation growth rates.

    We have now removed this statement from the manuscript.

    (10) In discussion, L-Ara4N appears to be referred to as both positively charged and negatively charged; this should be clarified.

    We have now clarified that L-Ara4N is positively charged.

    This amendment can be found on line 496.

    (11) Discussion of TF analysis seems to overstate what is supported by the evidence. The correlation of up- and downregulated genes with previously described TF regulons (probably measured in very different conditions) does not really demonstrate TF activity. This could be measured directly with additional experiments but in the absence of those experiments claims about detecting TF activity should probably be avoided. The attempts to directly demonstrate the importance of those transcription factors to the observed accumulation activity were not successful.

    We have now removed from the discussion the previous paragraph related to the TF analysis. We have also modified the results section reported the TF analysis as follows: “Next, we sought to infer transcription factor (TF) activities via differential expression of their known regulatory targets [61]. A total of 126 TFs were inferred to exhibit differential activity between low and high accumulators (Data Set S4). Among the top ten TFs displaying higher inferred activity in low accumulators compared to high accumulators, four regulate transport systems, i.e. Nac, EvgA, Cra, and NtrC (Figure S12). However, further experiments should be carried out to directly measure the activity of these TFs.”

    Finally, we have also moved the TFs’ data from Figure 3 to Figure S12 in the Supplementary information.

    These amendments can be found on lines 288-293.

    (12) When discussing the possibility of nutrient supplementation versus efflux inhibition as a potential therapeutic strategy, it could be noted that nutrient supplementation cannot be done in many infection contexts. The host immune system and host/bacterial cell density control nutrient access.

    We have now added the following statement: “Moreover, nutrient supplementation as a therapeutic strategy may not be viable in many infection contexts, as host density and the immune system often regulate access to nutrients [3]”.

    These amendments can be found on lines 553-555.

    Reviewer 2:

    (1) Some questions regarding the mechanism remain. One shortcoming of the setup of the transcriptomics experiment is that the tachyplesin-NBD probe itself has antibiotic efficacy and induces phenotypes (and eventually cell death) in the ´high accumulator´cells. This makes it challenging to interpret whether any differences seen between the two groups are causative for the observed accumulation pattern or if they are a consequence of differential accumulation and downstream phenotypic effects.

    We agree with the reviewer and we have now acknowledged that “tachyplesin-NBD has antibiotic efficacy (see Figure 2) and has an impact on the E. coli transcriptome (Figure 3). Therefore, we cannot conclude whether the transcriptomic differences reported between low and high accumulators of tachyplesin-NBD are causative for the distinct accumulation patterns or if they are a consequence of differential accumulation and downstream phenotypic effects.”

    These amendments can be found on lines 283-287.

    (2) It would be relevant to test and report the MIC of sertraline for the strain tested, particularly since in Figure 4G an initial reduction in CFUs is observed for sertraline treatment, which suggests the existence of biological effects in addition to efflux inhibition.

    We have now measured the MIC of sertraline against E. coli BW25113 finding the MIC value to be 128 μg mL-1 (418 µM). This value is more than four times higher compared to the sertraline concentration employed in our study, i.e. 30 μg mL-1 (98 μM).

    These amendments can be found on lines 389-391 and data has been added to Figure 4 – Source Data.

    (3) The role of efflux systems is further supported by the finding that efflux pump inhibitors sensitize E. coli to tachyplesin and prevent the occurrence of the tolerant ´low accumulator´ subpopulations. In principle, this is a great way of validating the role of efflux pumps, but the limited selectivity of these inhibitors (CCCP is an uncoupling agent, and for sertraline direct antimicrobial effects on E. coli have been reported by Bohnert et al.) leaves some ambiguity as to whether the synergistic effect is truly mediated via efflux pump inhibition. To strengthen the mechanistic angle of the work analysis of tachyplesin-NBD accumulation in mutants of the identified efflux components would be interesting.

    We have now performed tachyplesin-NBD accumulation assays using 28 single and 4 double E. coli BW25113 gene-deletion mutants of efflux components and transcription factors regulating efflux. While for the majority of the mutants we recorded bimodal distributions of tachyplesin-NBD accumulation similar to the distribution recorded for the E. coli BW25113 parental strain (Figure 4B and Figure S13), we found unimodal distributions of tachyplesin-NBD accumulation constituted only of high accumulators for both DqseB and DqseBDqseC mutants as well as reduced numbers of low accumulators for the DacrADtolC mutant (Figure 4B). Considering that the AcrAB-TolC tripartite RND efflux system is known to confer genetic resistance against AMPs like protamine and polymyxin-B [29,30] and that the quorum sensing regulators qseBC might control the expression of acrA [64] , these data further corroborate the hypothesis that low accumulators can efflux tachyplesin and survive treatment with this AMP.

    These amendments can be found on lines 351-361, in the new Figure 4B and in the new Figure S14.

    Moreover, we have also carried out further efflux assays with both ethidium bromide and tachyplesin-NBD to further demonstrate the role of efflux in reduced accumulation of tachyplesin as well as acknowledging that other mechanisms (i.e reduced influx, increased protease activity or increased secretion of OMVs) could play an important role, please see Response 1 to Reviewer 1.

    (4) The authors imply that protease could contribute to the low accumulator mechanism. Proteases could certainly cleave and thus inactivate AMPs/tachyplesin, but would this effect really lead to a reduction in fluorescence levels since the fluorophore itself would not be affected by proteolytic cleavage?

    We agree with the reviewer that nitrobenzoxadiazole (NBD) might not be cleaved by proteases that inactivate tachyplesin and other AMPs. Therefore, inactivation of tachyplesin by proteases might not affect cellular fluorescence levels unless efflux of NBD is possible following the cleavage of tachyplesin-NBD. We have therefore removed the statement “Conversely, should efflux or proteolytic activities by proteases underpin the functioning of low accumulators, we should observe high initial tachyplesin-NBD fluorescence in the intracellular space of low accumulators followed by a decrease in fluorescence due to efflux or proteolytic degradation.” We have now stated the following: “Low accumulators displayed an upregulation of peptidases and proteases compared to high accumulators, suggesting a potential mechanism for degrading tachyplesin (Table S1 and Data Set S3).”

    These amendments can be found on lines 280-282.

    (5) To facilitate comparison with other literature (e.g. papers on sertraline) it would be helpful to state compound concentrations also as molar concentrations.

    We have now added the molar concentrations alongside all instances where concentrations are stated in μg mL-1.

    (6) The authors tested a series of efflux pump inhibitors and found that CCCP and sertraline prevented the generation of the low accumulator subpopulation, whereas other inhibitors did not. An overview and discussion of the known molecular targets and mode of action of the different selected inhibitors could reveal additional insights into the molecular mechanism underlying the synergy with tachyplesin.

    We have now added molecular targets and mode of action of the different inhibitors where known. “Moreover, we repeated tachyplesin-NBD efflux assays in the presence of M9 containing 50 μg mL-1 (244 μM) carbonyl cyanide m-chlorophenyl hydrazone (CCCP), an ionophore that disrupts the proton motive force (PMF) and is commonly employed to abolish efflux and found that all cells retained tachyplesin-NBD fluorescence (Figure S15B). However, it is important to note that CCCP does not only abolish efflux but also other respiration-associated and energy-driven processes [63].” And “Interestingly, M9 containing 30 µg mL-1 (98 μM) sertraline (Figure 4D and S15C), an antidepressant which inhibits efflux activity of RND pumps, potentially through direct binding to efflux pumps [65] and decreasing the PMF [66], or 50 µg mL-1 (110 μM) verapamil (Figure S15D), a calcium channel blocker that inhibits MATE transporters [67] by a generally accepted mechanism of PMF generation interference [68,69], was able to prevent the emergence of low accumulators. Furthermore, tachyplesin-NBD cotreatment with sertraline simultaneously increased tachyplesin-NBD accumulation and PI fluorescence levels in individual cells (Figure 4E and F, p-value < 0.0001 and 0.05, respectively). The use of berberine, a natural isoquinoline alkaloid that inhibits MFS transporters [70] and RND pumps [71], potentially by inhibiting conformational changes required for efflux activity [70], and baicalein, a natural flavonoid compound that inhibits ABC [72] and MFS [73,74] transporters, potentially through PMF dissipation [75], prevented the formation of a bimodal distribution of tachyplesin accumulation, however displayed reduction in fluorescence of the whole population (Figure S15E and F). Phenylalanine-arginine beta-naphthylamide (PAbN), a synthetic peptidomimetic compound that inhibits RND pumps [76] through competitive inhibition [77], reserpine, an indole alkaloid that inhibits ABC and MFS transporters, and RND pumps [78], by altering the generation of the PMF [69], and 1-(1-naphthylmethyl)piperazine (NMP), a synthetic piperazine derivative that inhibits RND pumps [79], through non-competitive inhibition [80], did not prevent the emergence of low accumulators (Figure S15G-I).”

    These amendments can be found on lines 337-342 and 367-385.

    (7) Page 8. The term ´medium accumulators´ for a 1:1 mix of low and high accumulators is misleading.

    We have now replaced the term “medium accumulators” with “a 1:1 (v/v) mixture of low and high accumulators”.

    These amendments to the description can be found on lines 238-239.

    (8) Figure 3. It may be more appropriate to rephrase the title of the figure to ´biological processes associated with low tachyplesin accumulation´ (rather than ´facilitate accumulation´). The same applies to the section title on page 8.

    We have amended the title of Figure 3 as requested by the reviewer.

    (9) The fact that the low accumulation phenotype depends on the growth media and conditions and can be prevented by nutrients is highly relevant. I would encourage the authors to consider showing the corresponding data in the main manuscript rather than in the SI.

    We have created a new Figure 5, displaying the impact of the nutritional environment and bacterial growth phase on both tachyplesin-NBD accumulation and efficacy.

    (10) In the discussion the authors state´ Heterogeneous expression of efflux pumps within isogenic bacterial populations has been reported 29,32,33,67-69. However, recent reports have suggested that efflux is not the primary mechanism of antimicrobial resistance within stationary-phase bacteria 31,70.´. In light of the authors´ findings that the response to tachyplesin is induced by exposure and is not pre-selected, could they speculate on why this specific response can be induced in stationary, but not exponential cells? Could there be a combination of pre-existing traits and induced responses at play? Could e.g. the reduced growth rate/metabolism in these cells render these cells less susceptible to the intracellular effects of tachyplesin and slow down the antibiotic efficacy, giving the cells enough time to mount additional protective responses that then lead to the low accumulation phenotype?

    We have now acknowledged that it is conceivable that other pre-existing traits of low accumulators also contribute to reduced tachyplesin accumulation. For example, reduced protein synthesis, energy production and gene expression in low accumulators could slow down tachyplesin efficacy, giving low accumulators more time to mount efflux as an additional protective response.

    “As our accumulation assay did not require the prior selection for phenotypic variants, we have demonstrated that low accumulators emerge subsequent to the initial high accumulation of tachyplesin-NBD, suggesting enhanced efflux as an induced response. However, it is conceivable that other pre-existing traits of low accumulators also contribute to reduced tachyplesin accumulation. For example, reduced protein synthesis, energy production, and gene expression in low accumulators could slow down tachyplesin efficacy, giving low accumulators more time to mount efflux as an additional protective response.”

    This amendment can be found on lines 482-489.

    (11) In the abstract: Is it true that low accumulators ´sequester´ the drug in their membrane? In my understanding ´sequestering´ would imply that low accumulators would bind higher levels of tachyplesin-NBD in their membrane compared to high accumulators (and thereby preventing it from entering the cells). According to Figure 1 J, K, it rather seems that the fluorescent signal around the membrane is also stronger in high accumulators.

    We have now removed the sentence “low accumulators sequester the drug in their membrane” from the abstract. We have instead stated: “These phenotypic variants display enhanced efflux activity to limit intracellular peptide accumulation.”

    These amendments can be found on lines 34-35.

    Reviewer 3:

    (1) The authors' claims about high efflux being the main mechanism of survival are unconvincing, given the current data. There can be several alternative hypotheses that could explain their results, such as lower binding of the AMP, lower rate of internalization, metabolic inactivity, etc. It is unclear how efflux can be important for survival against a peptide that the authors claim binds externally to the cell. The addition of efflux assays would be beneficial for clear interpretations. Given the current data, the authors' claims about efflux being the major mechanism in this resistance are unconvincing (in my humble opinion). Some direct evidence is necessary to confirm the involvement of efflux. The data with CCCP in Figure 4C can only indicate accumulation, not efflux. The authors are encouraged to perform direct efflux assays using known methods (e.g., PMIDs 20606071, 30981730, etc.). Figure 4A: The data does not support the broad claims about efflux. First, if the peptide is accumulated on the outside of the outer membrane, how will efflux help in survival? The dynamics shown in 4A may be due to lower binding, lower entry, or lower efflux. These mechanisms are not dissected here. Second, the heterogeneity can be preexisting or a result of the response to this stress. Either way, whether active efflux or dynamic transcriptomic changes are responsible for these patterns is not clear. Direct efflux assays are crucial to conclude that efflux is a major factor here.

    This important comment is similar in scope to the first comment of reviewer 1 and it is partly due to the fact that we had not clearly explained our efflux assays reported in Figure 4 in the original manuscript. We kindly refer this reviewer to our extensive response 1 to reviewer 1 and corresponding amendments on lines 316-350 and in the new Figure S13 and Figure 4 (reported in the response 1 to reviewer 1 above), where we have now fully addressed this reviewer’s and reviewer 1 concerns, as well as performing new experiments following their important suggestions and the methods described in PMIDs 20606071 suggested by this reviewer.

    (2) The fluorescent imaging experiments can be conducted in the presence of externally added proteases, such as proteinase K, which has multiple cleavage sites on tachyplesin. This would ensure that all the external peptides (both free and bound) are removed. If the signal is still present, it can be concluded that the peptide is present internally. If the peptide is primarily external, the authors need to explain how efflux could help with externally bound peptides. Figure 1J-K: How are the authors sure about the location of the intensity? The peptide can be inside or outside and still give the same signal. To prove that the peptide is inside or outside, a proteolytic cleavage experiment is necessary (proteinase K, Arg-C proteinase, clostripain, etc.).

    We thank the reviewer for this important suggestion.

    We have now performed experiments where stationary phase E. coli was incubated in 46 μg mL-1 (18.2 μM) tachyplesin-NBD in M9 for 60 min. Next, cells were pelleted and washed to remove extracellular tachyplesin-NBD and then incubated in either M9 or 20 μg mL-1 (0.7 μΜ) proteinase K in M9 for 120 min. We found that the fluorescence of low accumulators decreased over time in the presence of proteinase K; in contrast, the fluorescence of high accumulators did not decrease over time in the presence of proteinase K. These data therefore suggest that tachyplesin-NBD is present only on the cell membrane of low accumulators and both on the membrane and intracellularly in high accumulators.

    Moreover, confocal microscopy using tachyplesin-NBD along with the membrane dye FM™ 4-64FX further confirmed that tachyplesin-NBD is present only on the cell membrane of low accumulators and both on the membrane and intracellularly in high accumulators.

    These amendments can be found on lines 173-179, lines 188-192 and in the new Figures S4 and S6.

    (3) Further genetic experiments are necessary to test whether efflux genes are involved at all. The genetic data presented by the authors in Figure S11 is crucial and should be further extended. The problem with fitting this data to the current hypothesis is as follows: If specific efflux pumps are involved in the resistance mechanism, then single deletions would cause some changes to the resistance phenotype, and the data in Figure S11 would look different. If there is redundancy (as is the case in many efflux phenotypes), the authors may consider performing double deletions on the major RND regulators (for example, evgA and marA). Additionally, the deletion of pump components such as TolC (one of the few OM components) and adaptors (such as acrA/D) might also provide insights. If the peptide is present in the periplasm, then deletions involving outer components would become important.

    This important comment is similar in scope to the third comment of reviewer 2. We have now performed tachyplesin-NBD accumulation assays using 28 single and 4 double E. coli BW25113 gene-deletion mutants of efflux components and transcription factors regulating efflux. While for the majority of the mutants we recorded bimodal distributions of tachyplesin-NBD accumulation similar to the distribution recorded for the E. coli BW25113 parental strain (Figure 4B and Figure S13), we found unimodal distributions of tachyplesin-NBD accumulation constituted only of high accumulators for both DqseB and DqseBDqseC mutants as well as reduced numbers of low accumulators for the DacrADtolC mutant.

    These amendments can be found on lines 351-361, in the new Figure 4B and in the new Figure S14, please also see our response to comment 3 of reviewer 2.

    (4) Line numbers would have been really helpful. Please mention the size of the peptide (length and spatial) for readers.

    We have now added line numbers to the revised manuscript. The length and molecular weight of tachyplesin-1 have now been added on lines 75.

    (5) Figure S4 is unclear. How were the low accumulators collected? What prompted the low-temperature experiment? The conclusion that it accumulates at the outer membrane is unjustified. Where is the data for high accumulators?

    We have now corrected the results section to state that tachyplesin-NBD accumulates on the cell membranes, rather than at the outer membrane of E. coli cells.

    These amendments can be found on lines 178 and 190.

    We would like to clarify that in Figure S4 we compare the distribution of tachyplesin-NBD single-cell fluorescence at low temperature versus 37 °C across the whole stationary phase E. coli population, we did not collect low accumulators only.

    The low-temperature experiment was prompted by a previous publication paper (Zhou Y et al. 2015: doi: 10.1021/ac504880r. Epub 2015 Mar 24. PMID: 25753586) that showed non-specific adherence of antimicrobials to the bacterial surface occurs at low temperatures and that passive and active transport of antimicrobials across the membrane is significantly diminished. Additionally, there are previous reports that suggest low temperatures inhibit post-binding peptide-lipid interactions, but not the primary binding step (PMID: 16569868; PMCID: PMC1426969; PMID: 3891625; PMCID: PMC262080).

    Therefore, the low-temperature experiment was performed to quantify the fluorescence of cells due to non-specific binding. This quantification allowed us to deduce that fluorescence levels of high accumulators are above the measured non-specific binding fluorescence (measured in the low-temperature experiment for the whole stationary phase E. coli population) is the result of intracellular tachyplesin-NBD accumulation. In contrast, the comparable fluorescence levels between all the cells in the low-temperature experiment and the low accumulator subpopulation at 37 °C suggest that tachyplesin-NBD is predominantly accumulated on the cell membranes of low accumulators instead of intracellularly.

    Please also see our response to comment 2 above for further evidence supporting that tachyplesin-NBD accumulates only on the cell membranes of low accumulators and both on the cell membranes and intracellularly in low accumulators.

    (6) Figure S5: Describe the microfluidic setup briefly. Why did the distribution pattern change (compared to Figure 1A)? Now, there are more high accumulators. Does the peptide get equally distributed between daughter cells?

    We have now added a brief description of the microfluidic setup on lines 182-184.

    The difference in the abundance of low and high accumulators between the microfluidics and flow cytometry measurements is likely due to differences in cell density, i.e. a few cells per channel vs millions of cells in a tube. A second major difference is that tachyplesin-NBD is continuously supplied in the microfluidic device for the entire duration of the experiment, therefore, the extracellular concentration of tachyplesin-NBD does not decrease over time. In contrast, tachyplesin-NBD is added to the tube only at the beginning of the experiment, therefore, the extracellular concentration of tachyplesin-NBD likely decreases in time as it is accumulated by the bacteria. The relative abundance of low and high accumulators changes with the extracellular concentration of tachyplesin-NBD as shown in Figure 1A.

    We have added a sentence to acknowledge this discrepancy on lines 186-187.

    No instances of cell division were observed in stationary phase E. coli in the absence of nutrients in all microfluidics assays. Therefore, we cannot comment on the distribution of tachyplesin-NBD across daughter cells.

    (7) How did the authors conclude this: "tachyplesin accumulation on the bacterial membrane may not be sufficient for bacterial eradication"? It is completely unclear to this reviewer.

    We presented this hypothesis at the end of the section “Tachyplesin accumulates primarily in the membranes of low accumulators” as a link to the following section “Tachyplesin accumulation on the bacterial membranes is insufficient for bacterial eradication” where we test this hypothesis. For clarity, we have now moved this sentence to the beginning of the section “Tachyplesin accumulation on the bacterial membranes is insufficient for bacterial eradication”.

    (8) What is meant by membrane accumulation? Outside, inside, periplasm? Where? Figure 2H conclusions are unjustified. Bacterial killing with many antibiotics is associated with membrane damage, which is an aftereffect of direct antibiotic action. How can the authors state that "low accumulators primarily accumulate tachyplesin-NBD on the bacterial membrane, maintaining an intact membrane, strongly contributing to the survival of the bacterial population"? This reviewer could not find justifications for the claims about the location of the accumulation or cells actively maintaining an intact membrane. Also, PI staining reports damage both membranes.

    Based on the experiments that we have carried out after this reviewer’s suggestions, please see response 2 above, it is likely that tachyplesin-NBD is present only on the bacterial surface, i.e. in or on the outer membrane of low accumulators, considering that their fluorescence decreases during treatment with proteinase K. However, to take a more conservative approach we have now written on the cell membranes throughout the manuscript, i.e. either the outer or the inner membrane.

    We have also rephrased the statement reported by the reviewer as follows:

    “Taken together with PI staining data indicating membrane damage caused by high tachyplesin accumulation, these data demonstrate that low accumulators, which primarily accumulate tachyplesin-NBD on the bacterial membranes, maintain membrane integrity and strongly contribute to the survival of the bacterial population in response to tachyplesin treatment.”

    These amendments can be found on lines 228-232.

    (9) Figure 3: The findings about cluster 2 and cluster 4 genes do not correlate logically. If the cells are in a metabolically low active state, how are the cells getting enough energy for active efflux and membrane transport? This scenario is possible, but the authors must confirm the metabolic activity by measuring respiration rates. Also, metabolically less-active cells may import a lower number of peptides to begin with. That also may contribute to cell survival. Additionally, lowered metabolism is a known strategy of antibiotic survival that is distinctly different from efflux-mediated survival.

    Following this reviewer’s comment and comment 2 of reviewer 1, we have now carried out further experiments to estimate the metabolic activity of low and high accumulators. Please see our response to comment 2 of reviewer 1 above.

    (10) Figure S10: How did the authors test their hypothesis that cardiolipin is involved in the binding of the peptide to the membrane? The transcriptome data does not confirm it. Genetic experiments are necessary to confirm this claim.

    We would like to clarify that we have not set out to test the hypothesis that cardiolipin is involved in the binding of tachyplesin-NBD. We have only stated that cardiolipin could bind tachyplesin due to its negative charge. We have now cited two previous studies that suggest that tachyplesin has an increased affinity for lipids mixtures containing either cardiolipin (Edwards et al. ACS Inf Dis 2017) or PG lipids (Matsuzaki et al. BBA 1991), i.e. the main constituents of cardiolipins.

    These amendments can be found on lines 264-267.

    (11) Figure 4B-F: There are several controls missing. For Sertraline treatment, the authors must test that the metabolic profile, transcriptomic changes, or import of the peptide are not responsible for enhanced survival. CCCP will not only abolish efflux but also many other respiration-associated or all other energy-driven processes.

    Figure 4D presents data acquired in efflux assays in the absence of extracellular tachyplesin-NBD. Therefore, altered tachyplesin-NBD import cannot contribute to the lack of formation of the low accumulator subpopulation.

    We have now acknowledged that it is conceivable that increased tachyplesin efficacy is due to metabolic and transcriptomic changes induced by sertraline.

    These amendments can be found on lines 396-397.

    We have also acknowledged that CCCP does not only abolish efflux but also other respiration-associated and energy-driven processes.

    These amendments can be found on lines 341-342.

  8. Version published to 10.1101/2024.04.22.590445v4 on bioRxiv
  9. Version published to 10.1101/2024.04.22.590445v3 on bioRxiv
  10. Version published to 10.7554/elife.99752.1 on eLife
  11. eLife

    eLife assessment

    This important study by Lee et al. investigates the heterogeneous response of non-growing bacteria to the antimicrobial peptide (AMP) tachyplesin. In this response, a subpopulation of bacteria limits the accumulation of a fluorescent analog of the AMP, avoiding lethal damage. The study provides compelling data showing the differential accumulation of AMP in subpopulations and its correlation with antimicrobial efficacy. However, the evidence for increased efflux as the main survival mechanism remains incomplete.

  12. eLife

    Reviewer #1 (Public Review):

    Summary:

    This work contributes several important and interesting observations regarding the heterotolerance of non-growing Escherichia coli and Pseudomonas aeruginosa to the antimicrobial peptide tachyplesin. The primary mechanism of action of tachyplesin is thought to be disruption of the bacterial cell envelope, leading to leakage of cellular contents after a threshold level of accumulation. Although the MIC for tachyplesin in exponentially growing E. coli is just 1 ug/ml, the authors observe that a substantial fraction of a stationary phase population of bacteria survive much higher concentrations, up to 64 ug/ml. By using a fluorescently-labelled analogue of tachyplesin, the authors show that the amount of per-cell intracellular accumulation of tachyplesin displays a bimodal distribution and that the fraction of "low accumulators" correlates with the fraction of survivors.

    Using a microfluidic device, they show that low accumulators exclude propidium iodide, suggesting that their cell envelopes remain largely intact, while high accumulators of tachyplesin also stain with propidium iodide. They show that this phenomenon holds for several clinical isolates of E. coli with different genetic determinants of antibiotic resistance, and for a strain of Pseudomonas aeruginosa. However, the bimodal distribution does not occur in these organisms for several other antimicrobial peptides, or for tachyplesin in Klebsiella pneumoniae or Staphylococcus aureus, indicating some degree of specificity in the interaction between AMP and bacterial cell envelope. They next explore the dynamics of the fluorescent tachyplesin accumulation and show interestingly that a high degree of accumulation is initially seen in all cells, but that the "low accumulator" subpopulation manages to decrease the amount of intracellular fluorescence over time, while the "high accumulator" subpopulation continues to increase its intracellular fluorescence. Focusing on increased efflux as a hypothesised mechanism for the "low accumulator" phenotype, based on transcriptomic analysis of the two subpopulations, the authors screen putative efflux inhibitors to see if they can block the formation of the low accumulator subpopulation. They find that both the protonophore CCCP and the SSRI sertraline can block the formation of this subpopulation and that a combination of sertraline plus tachyplesin kills a greater fraction of the stationary phase cells than either agent alone, similar to the killing observed when growing cells are treated with tachyplesin.

    Strengths:

    This study provides new insight into the heterogeneous behaviours of non-growing bacteria when exposed to an antimicrobial peptide, and into the dynamics of their response. The single-cell analysis by FACS and microscopy is compelling. The results provide a much-needed single-cell perspective on the phenomenon of tolerance to AMPs and a good starting point for further exploration.

    Weaknesses:

    My main concerns surround the conclusions drawn about the physiological underpinnings of these behaviours, based in part on transcriptomic analysis and also on the observation of the dynamics. I think deeper consideration of the relative contributions of influx and efflux to the observed accumulation dynamics, and the slow/non-growing context of the observations would be helpful. In particular, these issues seem important:

    (1) The initial high accumulation by all cells followed by the emergence of a sub-population that has reduced its intracellular levels of tachyplesin is a key observation and I agree with the authors' conclusion that this suggests an induced response to the AMP is important in facilitating the bimodal distribution. However, I think the conclusion that upregulated efflux is driving the reduction in signal in the "low accumulator" subpopulation is not fully supported. Steady-state amounts of intracellular fluorescent AMP are determined by the relative rates of influx and efflux and a decrease could be caused by decreasing influx (while efflux remained unchanged), increasing efflux (while influx remained unchanged), or both decreasing influx and increasing efflux. Given the transcriptomic data suggest possible changes in the expression of enzymes that could affect outer membrane permeability and outer membrane vesicle formation as well as efflux, it seems very possible that changes to both influx and efflux are important. The "efflux inhibitors" shown to block the formation of the low accumulator subpopulation have highly pleiotropic or incompletely characterised mechanisms of action so they also do not exclusively support a hypothesis of increased efflux.

    (2) A conclusion of the transcriptomic analysis is that the lower accumulating subpopulation was exhibiting "a less translationally and metabolically active state" based on less upregulation of a cluster of genes including those involved in transcription and translation. This conclusion seems to borrow from well-described relationships referred to as bacterial growth laws in which the expression of genes involved in ribosome production and translation is directly related to the bacterial growth (and metabolic) rate. However, the assumptions that allow the formulation of the bacterial growth laws (balanced, steady state, exponential growth) do not hold in growth arrest. A non-growing cell could express no genes at all or could express ribosomal genes at a very low level, or efflux pumps at a high level. The distribution of transcripts among the functional classes of genes does not reveal anything about metabolic rates within the context of growth arrest - it only allows insight into metabolic rates when the constraint of exponential growth can be assumed. Efflux pumps can be highly metabolically costly; for example, Tn-Seq experiments have repeatedly shown that mutants for efflux pump gene transcriptional repressors have strong fitness disadvantages in energy-limited conditions. There are no data presented here to disprove a hypothesis that the low accumulators have high metabolic rates but allocate all of their metabolic resources to fortifying their outer membranes and upregulating efflux. This could be an important distinction for understanding the vulnerabilities of this subpopulation. Metabolic rates can be more directly estimated for single cells using respiratory dyes or pulsed metabolic labelling, for example, and these data could allow deeper insight into the metabolic rates of the two subpopulations.

    The observation that adding nutrients to the stationary phase cultures pushes most of the cells to the "high accumulator" state is presented as support of the hypothesis that the high accumulator state is a higher metabolism/higher translational activity state. However, it is important to note that adding nutrients will cause most or all of the cells in the population to start to grow, thus re-entering the familiar regime in which bacterial growth laws apply. This is evident in the slightly larger cell sizes seen in the nutrient-amended condition. In contrast to stationary phase cells, growing cells largely do not exhibit the bimodal distribution, and they are much more sensitive to tachyplesin, as demonstrated clearly in the supplement. Growing cells are not necessarily the same as the high-accumulating subpopulation of non-growing cells.

    It might also be worth adding some additional context around the potential to employ efflux inhibitors as therapeutics. It is very clear that obtaining sufficient antimicrobial drug accumulation within Gram-negative bacteria is a substantial barrier to effective treatments, and large concerted efforts to find and develop therapeutic efflux pump inhibitors have been undertaken repeatedly over the last 25 years. Sufficiently selective inhibitors of bacterial efflux pumps with appropriate drug-like properties have been challenging to find and none have entered clinical trials. Multiple psychoactive drugs have been shown to impact efflux in bacteria but usually using concentrations in the 10-100 uM range (as here). Meanwhile, the Ki values for their human targets are usually in the sub- to low-nanomolar range. The authors rightly note that the concentration of sertraline they have used is higher than that achieved in patients, but this is by many orders of magnitude, and it might be worth expanding a bit on the substantial challenge of finding efflux inhibitors that would be specific and non-toxic enough to be used therapeutically. Many advances in structural biology, molecular dynamics, and medicinal chemistry may make the quest for therapeutic efflux inhibitors more fruitful than it has been in the past but it is likely to remain a substantial challenge.

  13. eLife

    Reviewer #2 (Public Review):

    Summary:

    This study reports on the existence of subpopulations of isogenic E. coli and P. aeruginosa cells that are tolerant to the antimicrobial peptide tachyplesin and are characterized by the accumulation of low levels of a fluorescent tachyplesin-NBD conjugate. The authors then set out to address the molecular mechanisms, providing interesting insights even though the mechanism remains incompletely defined: The work suggests that amongst others changes in membrane lipid composition and increased drug efflux may cause this phenotype and it demonstrates that pharmacological manipulation can prevent generation of tolerance. The authors are cautious in their interpretation and the claims made are largely justified by the data.

    Strengths:

    Going beyond the commonly used bulk techniques for studying susceptibility to AMPs , Lee et al. used fluorescent antibiotic conjugates in combination with flow cytometry analysis to study variability in drug accumulation at the single-cell level. This powerful approach enabled the authors to expose bimodal drug accumulation patterns that were condition-dependent, but conserved across a variety of E. coli clinical isolates. Using cell sorting in combination with colony-forming unit assays as well as quantitative fluorescence microscopic analysis in a microfluidics setup the authors compellingly demonstrate that low accumulators (where the fluorescence signal is mostly restricted to the membrane), can survive antibiotic treatment, whereas high accumulators (with high intracellular fluorescence) were killed. Comparative transcriptomics analysis of sorted ´low accumulator´ and ´high accumulator´ subpopulations suggest that changes in the lipid composition, increased efflux, and other mechanisms may contribute to tachyplesin-tolerance in this subpopulation. Lipidomics analysis of bulk untreated vs. tachyplesin-NBD treated cells confirmed changes in the lipid composition in accordance with the transcriptomics data. Intriguingly, a time-course experiment on tachyplesin-NBD accumulation revealed that all cells initially were high accumulators, before a subpopulation of cells subsequently managed to reduce the signal intensity (most likely through efflux), demonstrating that the ´low accumulator´ phenotype is an induced response and not a pre-existing property.

    Finally, the demonstration that treatment with efflux pump inhibitors (although some caution needs to be taken regarding the selectivity of these inhibitors, see comment on weaknesses below) prevents the generation of low accumulators and enhances tachyplesin-based killing is an important basis for developing combination therapies.

    The study convincingly illustrates how susceptibility to tachoplesin adaptively changes in a heterogeneous way dependent on the growth phases/ environments and availability of nutrients. This is highly relevant also beyond the presented example of tachyplesin and similar subpopulation-based adaptive changes to the susceptibility towards antimicrobial peptides or other drugs that may occur during infections in vivo and they would likely be missed out by standardized in vitro susceptibility testing.

    Weaknesses:

    Some questions regarding the mechanism remain. One shortcoming of the setup of the transcriptomics experiment is that the tachyplesin-NBD probe itself has antibiotic efficacy and induces phenotypes (and eventually cell death) in the ´high accumulator´cells. This makes it challenging to interpret whether any differences seen between the two groups are causative for the observed accumulation pattern or if they are a consequence of differential accumulation and downstream phenotypic effects. The role of efflux systems is further supported by the finding that efflux pump inhibitors sensitize E. coli to tachyplesin and prevent the occurrence of the tolerant ´low accumulator´ subpopulations. In principle, this is a great way of validating the role of efflux pumps, but the limited selectivity of these inhibitors (CCCP is an uncoupling agent, and for sertraline direct antimicrobial effects on E. coli have been reported by Bohnert et al.) leaves some ambiguity as to whether the synergistic effect is truly mediated via efflux pump inhibition. It would be relevant to test and report the MIC of sertraline for the strain tested, particularly since in Figure 4G an initial reduction in CFUs is observed for sertraline treatment, which suggests the existence of biological effects in addition to efflux inhibition.

  14. eLife

    Reviewer #3 (Public Review):

    Summary:

    The study tests the phenotypic response of bacteria (mainly E. coli) to antimicrobial peptides (AMPs) such as tachyplesin. The resistance mechanisms to AMPs differ from those to classical antibiotics in that AMP resistance involves more non-genetic mechanisms, which are largely unknown but are important to understand. This work aims to elucidate the mechanism of such phenotypic resistance.

    Strengths:

    The experiments unambiguously reveal that the cells respond to stress heterogeneously, with two distinct subpopulations - one with better survival than the other. This primary phenotype is convincingly shown across various E. coli strains, including clinical isolates.

    Weaknesses:

    The authors' claims about high efflux being the main mechanism of survival are unconvincing, given the current data. There can be several alternative hypotheses that could explain their results, such as lower binding of the AMP, lower rate of internalization, metabolic inactivity, etc. It is unclear how efflux can be important for survival against a peptide that the authors claim binds externally to the cell. The addition of efflux assays would be beneficial for clear interpretations. Further genetic experiments are necessary to test whether efflux genes are involved at all.

  15. Version published to 10.1101/2024.04.22.590445v2 on bioRxiv
  16. Version published to 10.1101/2024.04.22.590445v1 on bioRxiv