Heteroresistance Is Associated With in vitro Regrowth During Colistin Treatment in Carbapenem-Resistant Klebsiella pneumoniae
Open accessAbstract
Polymyxins including polymyxin B and colistin (polymyxin E) are considered the last resort for treating infections caused by carbapenem-resistant gram-negative bacteria. However, in vitro regrowth with the emergence of resistance during treatment is common. Polymyxin heteroresistance, particularly in Acinetobacter baumannii and Klebsiella pneumoniae, has been widely reported. This study was primarily performed to evaluate the prevalence of colistin heteroresistance in carbapenem-resistant K. pneumoniae (CR-KP) and the association between in vitro regrowth and heteroresistance. The mechanisms of colistin resistance and the ability of combination therapies to suppress resistance selection were further investigated. A population analysis profile (PAP) analysis showed that 69 (71.9%) of 96 CR-KP strains had colistin heteroresistance. Time-kill assays revealed that the colistin monotherapy could quickly eliminate the bacterial cells in strains without heteroresistance within the first 6 h. Conversely, it could initially reduce the number of cells in heteroresistant strains, but then regrowth occurred rapidly. Resistance screening at 12 and 24 h in the time-kill assays indicated that susceptible populations were killed, and regrowth was the exact result of the continued growth of resistant subpopulations. Colistin resistance in the regrowth subpopulations was mainly due to the overexpression of phoPQ and pmrD. Colistin combined with tetracyclines (tigecycline or minocycline) or aminoglycosides (amikacin or gentamicin) could effectively suppress the resistance selection and significantly elicit in vitro synergistic effects. These findings suggested that the combination therapy can be used to treat infections caused by CR-KP with colistin heteroresistance. Nevertheless, further in vivo studies considering drugs pharmacokinetics/pharmacodynamics are needed to confirm these findings.
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Time-kill assays can evaluate kinetics of heteroresistance and assess whether heteroresistant cells eventually adapt to drug pressure.
“By measuring the rate of cell death at various time points, this method can identify delayed growth or survival of heteroresistant subpopulations undetected by static MIC assays, and even evaluate the kinetics of heteroresistance and assess whether heteroresistant cells eventually adapt to drug pressure, which makes for wide clinical applicability [172,173,174].”
From Insight into the Mechanisms and Clinical Relevance of Antifungal Heteroresistance (2025) · cites this paper as [173]
The Time-Kill Assay methods describe sampling at multiple time points, and the Results (‘Relationship Between Heteroresistance and in vitro Regrowth’) report initial killing followed by regrowth in heteroresistant strains. The paper also tracks an increased frequency of resistant subpopulations under colistin exposure, but its Discussion attributes regrowth to continued growth of resistant subpopulations; it does not establish that heteroresistant cells eventually adapt to drug pressure. (LLM, conf=0.84)
Experimental — accuracy not yet measuredTime-kill assays can detect heteroresistance by identifying delayed growth or survival of heteroresistant subpopulations undetected by static MIC assays.
“By measuring the rate of cell death at various time points, this method can identify delayed growth or survival of heteroresistant subpopulations undetected by static MIC assays, and even evaluate the kinetics of heteroresistance and assess whether heteroresistant cells eventually adapt to drug pressure, which makes for wide clinical applicability [172,173,174].”
From Insight into the Mechanisms and Clinical Relevance of Antifungal Heteroresistance (2025) · cites this paper as [173]
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- Authors
- Wang, Y., Ma, X., Zhao, L., He, Y., Yu, W., Fu, S., Ni, W., & Gao, Z.
- Affiliations
- Peking University People's Hospital (CN)
- Corresponding author
- Ni, Wentao
- Gao, Zhancheng
- Venue
- Frontiers in Microbiology
- Publisher
- Frontiers Media SA
- Published
- 2022-04-07
- Volume
- 13
- Pages
- 868991-868991
- ISSN
- 1664-302X (ISSN-L)
- PMC
- PMC9022032
- OpenAlex
- W4225988440
- Cited by
- 27
- References
- 29
- Citations by year
- 2026: 3 · 2025: 13 · 2024: 6 · 2023: 5
- FWCI
- 1.97
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Microbiology (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- National Natural Science Foundation of China (81903672)
- China International Medical Foundation (Z-2018-35-2003)
- Topics
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Medicine › Antibiotic Resistance in Bacteria
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Bacterial Genetics and Biotechnology
- Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
- Keywords
- colistin heteroresistance, carbapenem-resistant Klebsiella pneumoniae, polymyxin resistance, PhoPQ, tigecycline, minocycline, amikacin, gentamicin, combination therapy, resistance selection, time-kill kinetics, population analysis profile
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