Pseudomonas aeruginosa ist ein gramnegatives Bakterium, welches insbesondere bei abgeschwächter Immunabwehr schwere Infektionen auslösen kann. Es besitzt eine hohe intrinsische Resistenz gegenüber Antibiotika, so dass nur eine begrenzte Anzahl von Antimikrobiotika wie beispielsweise Aminoglykoside für die Behandlung zur Verfügung steht. Unter Antibiotikatherapie wird zudem eine schnelle Resistenzentwicklung beobachtet, daher ist die Weiterentwicklung und Optimierung der Therapieoptionen von großer Bedeutung. Die vorliegende Arbeit untersucht den Einfluss von Colistin auf die Aminoglykosidresistenz bei Pseudomonas aeruginosa. 25 Bakterienstämme, die zu Beginn gegenüber Amikacin, Tobramycin und Gentamicin resistent waren, wurden Colistin ausgesetzt. Mithilfe des Epsilometertests wurde die minimale Hemmkonzentration (MHK) der Antibiotika für die zu untersuchenden Bakterienstämme vor und nach Colistineinfluss bestimmt. Es konnte ein signifikanter Rückgang der minimalen Hemmkonzentration nach Colistineinwirkung dokumentiert werden. Zu den Hauptresistenzmechanismen von Pseudomonas aeruginosa gehören die Effluxpumpen, welche die Antibiotika aus dem Bakterium ausschleusen. Für den Transport von Aminoglykosiden ist die MexXY-Pumpe verantwortlich, die in dieser Arbeit weiteruntersucht wurde. Durch eine quantitative Echtzeit-PCR unter Nutzung des Fluoreszenz-Resonanz-Energie-Transfers (FRET) wurde die Expression der Pumpe vor und nach Colistin verglichen. Es konnte nachgewiesen werden, dass durch Colistin die Expression reduziert wurde. Ein linearer Zusammenhang zwischen MHK-Veränderung und mexXY-Expressionslevel wurde anhand der Untersuchungsergebnisse nicht ermittelt. Es ist dementsprechend davon auszugehen, dass andere Resistenzmechanismen ebenfalls durch Colistin beeinflusst werden und so die MHK-Reduktion erklären können.

Chemotherapeutic treatment of Pseudomonas aeruginosa, a Gram-negative opportunistic pathogen, is substantially challenged by several membrane-spanning, multidrug-efflux pumps of the three-component RND family. Of these pumps, MexXY-OprM contributes to the intrinsic resistance of this organism by exporting clinically relevant antibiotics, most notably the ribosome-targeting aminoglycosides. Overproduction of MexXY-OprM is the most common mechanism providing pan-aminoglycoside resistance to P. aeruginosa cystic fibrosis clinical isolates. The mexXY genes are located in an operon, the expression of which is induced by ribosome-targeting antimicrobials. The mexXY operon is negatively regulated by MexZ, a repressor protein encoded by the divergently-transcribed gene mexZ. A second gene, PA5471, is also induced by ribosome-targeting antibiotics and is required for antibiotic induction of mexXY expression. One possibility is that PA5471 interacts with MexZ to alleviate repression of mexXY, thereby providing a mechanism for PA5471-dependent drug inducibility of mexXY. PA5471 interaction with MexZ was confirmed using a bacterial two-hybrid assay. To identify residues/regions of PA5471 important for interaction with MexZ, random chemical mutagenesis of the mexZ and PA5471 genes was carried out and the effects of these mutations on interaction of their protein products was assessed using the bacterial two-hybrid assay. Mutations of PA5471 that compromised interaction with MexZ included P68S, G76C, R216C, R221W, R221Q, G231D, and G252S, which occur within or in close proximity to a predicted surface-exposed α-helix of a PA5471 structural model that may contribute to the MexZ-interaction domain. Representative mutations P68S, G76C, R216C and R221W were placed into the chromosome of P. aeruginosa to assess their impact on drug-inducible mexXY expression. All of these mutations significantly reduced mexX upregulation in the presence of spectinomycin, where mutations R216C and R221W resulted in the near complete ablation of this antibiotic induction. These data suggest that PA5471 acts as a direct antirepressor of MexZ and that this interaction is key to mexXY upregulation in response to ribosome-targeting induction signals. / Thesis (Master, Microbiology & Immunology) -- Queen's University, 2013-02-26 13:32:39.307

Introdução. Pseudomonas aeruginosa é um patógeno clinicamente importante. Existem diversos mecanismos de resistência aos antimicrobianos em P. aeruginosa, dentre eles a produção de enzimas (β-lactamases) e sistemas de efluxo se destacam, uma vez que são capazes de conferir resistência aos carbapenêmicos. Objetivo. Avaliar os sistemas de efluxo MexAB-OprM e MexXY em isolados clínicos de P.aeruginosa de pacientes atendidos no Hospital de Clínicas de Porto Alegre-RS e relacionar a expressão destes sistemas com a CIM de meropenem em isolados produtores e não produtores de metalo-beta-lactamases (MBL). Metodologia. Um total de 86 isolados de P. aeruginosa com suscetibilidade reduzida aos carbapenêmicos foram avaliados. A hiperexpressão dos sistemas MexAB e MexXY foi determinada fenotipicamente utilizando inibidor seletivo da bomba (PAβN). MBLs foi determinada por PCR utilizando primers específicos. Resultados. O fenótipo de hiperexpressão dos sistemas de efluxo estudados foi observado em 34 (47,8%) dos 71 isolados negativos para a produção de MBL e em 14 (93.3%) dos 15 isolados MBL positivos. Na presença de PaβN, todos os isolados não produtores de MBL apresentaram uma redução da CIM para meropenem para valores na faixa de suscetibilidade. Entretanto, das 13 P. aeruginosa produtoras de MBL que diminuíram a CIM, essa redução não foi para valores dentro da faixa de sensibilidade. Conclusão. Os isolados de P. aeruginosa não produtores de MBL apresentam resistência ao meropenem devido a hiperexpressão de MexAB-OprM. Na presença de PaβN, independente de apresentarem produção de MBL, o CIM de meropenem reduziu para valores ≤ 8 mg/L. Contudo, quando isolados não apresentavam MBL, a CIM de meropenem reduziu para níveis de sensibilidade. / Introduction. Bacterial efflux pump systems are resistance mechanisms which may lead to therapeutic failure of antibiotic treatment since many antimicrobial agents are substrate for these mechanisms. The aim of the study was to evaluate the expression of the MexAB, MexXY pump efflux and to determine its influence on meropenem MIC in carbapenemase producing and non-producing P. aeruginosa. Methods. A total of 86 non-repetitive clinical isolates of P. aeruginosa with reduced susceptibility to carbapenems were evaluated. Overexperession of MexAB and MexXY efflux systems were evaluated phenotypically using the PAβN selective inhibitor. Metallo-β-lactamases (MBL) were detected by PCR using specific primers. Results. The efflux pump-overexpressed phenotype was observed in 34 (47.8%) MBL-negative and in 14 (93.3%) MBL-positive isolates. In the presence of the PaβN, all non-producers of MBL presented a reduction of meropenem MICs to the range of susceptibility. In contrast, the 13 P. aeruginosa MBL-producing isolates decreased meropenem MICs at least 16-fold but this reduction did not reach the range of susceptibility. Conclusion. P. aeruginosa non-MBL-producing showed resistance to meropenem due to overexpression of MexAB-OprM. In the presence of PaβN, the isolates harboring or not MBL genes, the meropenem MICs were reduced to values ≤8 mg/L. However, when the isolates harbor MBL genes, the meropenem MIC values were reduced to the susceptibility.

Introdução. Pseudomonas aeruginosa é um patógeno clinicamente importante. Existem diversos mecanismos de resistência aos antimicrobianos em P. aeruginosa, dentre eles a produção de enzimas (β-lactamases) e sistemas de efluxo se destacam, uma vez que são capazes de conferir resistência aos carbapenêmicos. Objetivo. Avaliar os sistemas de efluxo MexAB-OprM e MexXY em isolados clínicos de P.aeruginosa de pacientes atendidos no Hospital de Clínicas de Porto Alegre-RS e relacionar a expressão destes sistemas com a CIM de meropenem em isolados produtores e não produtores de metalo-beta-lactamases (MBL). Metodologia. Um total de 86 isolados de P. aeruginosa com suscetibilidade reduzida aos carbapenêmicos foram avaliados. A hiperexpressão dos sistemas MexAB e MexXY foi determinada fenotipicamente utilizando inibidor seletivo da bomba (PAβN). MBLs foi determinada por PCR utilizando primers específicos. Resultados. O fenótipo de hiperexpressão dos sistemas de efluxo estudados foi observado em 34 (47,8%) dos 71 isolados negativos para a produção de MBL e em 14 (93.3%) dos 15 isolados MBL positivos. Na presença de PaβN, todos os isolados não produtores de MBL apresentaram uma redução da CIM para meropenem para valores na faixa de suscetibilidade. Entretanto, das 13 P. aeruginosa produtoras de MBL que diminuíram a CIM, essa redução não foi para valores dentro da faixa de sensibilidade. Conclusão. Os isolados de P. aeruginosa não produtores de MBL apresentam resistência ao meropenem devido a hiperexpressão de MexAB-OprM. Na presença de PaβN, independente de apresentarem produção de MBL, o CIM de meropenem reduziu para valores ≤ 8 mg/L. Contudo, quando isolados não apresentavam MBL, a CIM de meropenem reduziu para níveis de sensibilidade. / Introduction. Bacterial efflux pump systems are resistance mechanisms which may lead to therapeutic failure of antibiotic treatment since many antimicrobial agents are substrate for these mechanisms. The aim of the study was to evaluate the expression of the MexAB, MexXY pump efflux and to determine its influence on meropenem MIC in carbapenemase producing and non-producing P. aeruginosa. Methods. A total of 86 non-repetitive clinical isolates of P. aeruginosa with reduced susceptibility to carbapenems were evaluated. Overexperession of MexAB and MexXY efflux systems were evaluated phenotypically using the PAβN selective inhibitor. Metallo-β-lactamases (MBL) were detected by PCR using specific primers. Results. The efflux pump-overexpressed phenotype was observed in 34 (47.8%) MBL-negative and in 14 (93.3%) MBL-positive isolates. In the presence of the PaβN, all non-producers of MBL presented a reduction of meropenem MICs to the range of susceptibility. In contrast, the 13 P. aeruginosa MBL-producing isolates decreased meropenem MICs at least 16-fold but this reduction did not reach the range of susceptibility. Conclusion. P. aeruginosa non-MBL-producing showed resistance to meropenem due to overexpression of MexAB-OprM. In the presence of PaβN, the isolates harboring or not MBL genes, the meropenem MICs were reduced to values ≤8 mg/L. However, when the isolates harbor MBL genes, the meropenem MIC values were reduced to the susceptibility.

Introdução. Pseudomonas aeruginosa é um patógeno clinicamente importante. Existem diversos mecanismos de resistência aos antimicrobianos em P. aeruginosa, dentre eles a produção de enzimas (β-lactamases) e sistemas de efluxo se destacam, uma vez que são capazes de conferir resistência aos carbapenêmicos. Objetivo. Avaliar os sistemas de efluxo MexAB-OprM e MexXY em isolados clínicos de P.aeruginosa de pacientes atendidos no Hospital de Clínicas de Porto Alegre-RS e relacionar a expressão destes sistemas com a CIM de meropenem em isolados produtores e não produtores de metalo-beta-lactamases (MBL). Metodologia. Um total de 86 isolados de P. aeruginosa com suscetibilidade reduzida aos carbapenêmicos foram avaliados. A hiperexpressão dos sistemas MexAB e MexXY foi determinada fenotipicamente utilizando inibidor seletivo da bomba (PAβN). MBLs foi determinada por PCR utilizando primers específicos. Resultados. O fenótipo de hiperexpressão dos sistemas de efluxo estudados foi observado em 34 (47,8%) dos 71 isolados negativos para a produção de MBL e em 14 (93.3%) dos 15 isolados MBL positivos. Na presença de PaβN, todos os isolados não produtores de MBL apresentaram uma redução da CIM para meropenem para valores na faixa de suscetibilidade. Entretanto, das 13 P. aeruginosa produtoras de MBL que diminuíram a CIM, essa redução não foi para valores dentro da faixa de sensibilidade. Conclusão. Os isolados de P. aeruginosa não produtores de MBL apresentam resistência ao meropenem devido a hiperexpressão de MexAB-OprM. Na presença de PaβN, independente de apresentarem produção de MBL, o CIM de meropenem reduziu para valores ≤ 8 mg/L. Contudo, quando isolados não apresentavam MBL, a CIM de meropenem reduziu para níveis de sensibilidade. / Introduction. Bacterial efflux pump systems are resistance mechanisms which may lead to therapeutic failure of antibiotic treatment since many antimicrobial agents are substrate for these mechanisms. The aim of the study was to evaluate the expression of the MexAB, MexXY pump efflux and to determine its influence on meropenem MIC in carbapenemase producing and non-producing P. aeruginosa. Methods. A total of 86 non-repetitive clinical isolates of P. aeruginosa with reduced susceptibility to carbapenems were evaluated. Overexperession of MexAB and MexXY efflux systems were evaluated phenotypically using the PAβN selective inhibitor. Metallo-β-lactamases (MBL) were detected by PCR using specific primers. Results. The efflux pump-overexpressed phenotype was observed in 34 (47.8%) MBL-negative and in 14 (93.3%) MBL-positive isolates. In the presence of the PaβN, all non-producers of MBL presented a reduction of meropenem MICs to the range of susceptibility. In contrast, the 13 P. aeruginosa MBL-producing isolates decreased meropenem MICs at least 16-fold but this reduction did not reach the range of susceptibility. Conclusion. P. aeruginosa non-MBL-producing showed resistance to meropenem due to overexpression of MexAB-OprM. In the presence of PaβN, the isolates harboring or not MBL genes, the meropenem MICs were reduced to values ≤8 mg/L. However, when the isolates harbor MBL genes, the meropenem MIC values were reduced to the susceptibility.

Pseudomonas aeruginosa est un pathogène opportuniste majeur de l'Homme capable de mettre en jeu tout un ensemble de mécanismes pour résister aux antibiotiques. Parmi eux, le système d'efflux actif MexXY(OprM) s'oppose, lorsqu'il est surproduit, à l'accumulation intracellulaire de différents composés dont certains, comme les aminosides et les fluoroquinolones, sont largement utilisés dans le traitement des infections à P. aeruginosa. Chez les souches cliniques, la surproduction de la pompe MexXY résulte de mutations soit dans le gène répresseur de l'opéron mexXY, mexZ (mutants agrZ) soit dans des loci génétiques encore inconnus (mutants agrUI). Au cours de ce travail, nous avons carcatérisés deux types de mutants agr W dérivés de la souche de référence PAO 1. Les premiers, agr WI, présentent une augmentation de la résistance aux antibiotiques substrats de la pompe Mex.XY comparable à celle observée chez les mutants agrZ tandis que les seconds, agrW2, sont en plus résistants aux carbapénèmes et aux peptides cationiques ( colistine ). Par une approche de séquençage à haut débit des génomes, nous avons identifié chez les mutants agrWI une mutation dans deux des quatre allèles codant pour la sous-unité ribosomale 23S et chez les mutants agrW2 une mutation dans le régulateur de réponse d'un système à deux composants dénommé ParR. A l'aide d'expériences de RT-qPCR, d'inactivation et de complémentation génique deux voies distinctes d'activation de MexXY/OprM ont été identifiées. Parallèlement, la comparaison des transcriptomes globaux des mutants agrWI, agrW2 avec celui de la souche PAOl nous a permis de mieux comprendre dans quel processus cellulaire s'intègre la pompe Mex.XY /OprM. / Pseudomonas aeruginosa is a nosocomial pathogen naturally resistant to many antibiotics thanks to numerous resistant mechanisms. Among them, overproduction of the MexXY/OprM efflux system leads to decrease significantly the susceptibility of P. aeruginosa to aminoglycosides and fluoroquinolones. In clinical strains, upregulation of this pump often results from mutations occurrinJ in mexZ ( agrZ mutants), the local repressor gene of the mexXY operon. Analysis of MexXY­overproducing mutants selected in vitro from the reference strain PAO 1 led to identification of two new classes of mutants (agrWmutants) harboring an intact mexZ gene. The first, named agrWI mutants, shows an increase resistance to Mex.XY substrates similar to that observed in agrZ mutants while the second, dubbed agrW2, are more resistant to carbapenems and cationic peptides (colistin) in addition to aminoglycosides and fluoroquinolones. Whole-genome sequencing experiments revealed in agrWI mutants a mutation in two of the four alleles encoding the 23S ribosomal subunit and in agr W2 mutants, a mutation in the response regulator of a two-component system called ParR. By using RT-qPCR, inactivation and complementation experiments, two distinct activation pathway of the MexXY /OprM efflux system have been identified. Meanwhile, transcriptomic profiles of agrWJ and agrW2 mutants compared with the PAOl reference strain has allowed us to better understand the physiologie function of the MexXY/OprM efflux pump

Chez P. aeruginosa, la surproduction constitutive du système MexXY/OprM s'accompagne d'une augmentation de larésistance aux aminosides, fluoroquinolones et à certaines (3-lactamines. La caractérisation des mécanismes génétiquesconduisant à la surproduction de cette pompe parmi une collection de 57 isolats cliniques non redondants a permisd'identifier 3 types de mutations affectant, soit le gène mexZ dont le produit réprime l'opéron mexXY (mutants agrZ,77,2%), soit les gènes parRS codant pour un système à deux composants (mutants agrWl, 8,8%) ou d'autres cibles dontl'inactivation perturbe la synthèse protéique et entraîne la surexpression du gène PA5471 dont le produit, ArmZ, est unanti-répresseur de MexZ (mutants agrWl,\4%). Si certaines populations de P. aeruginosa tendent à devenir plusrésistantes aux aminosides en surproduisant le système MexXY/OprM, d'autres évoluent paradoxalement vers unehypersensibilité aux p-lactamines sous l'effet de mutations inactivant MexAB-OprM (MexAB-). L'analyse d'unecollection de 275 souches isolées de 36 patients CF nous a permis d'identifier des souches MexAB- hypersensibles à laticarcilline (37%) et des souches MexAB- non hypersensibles en raison d'une surproduction de la B-lactamase AmpC(16%). Au total, 53% des isolats sont apparus déficients dans le système MexAB-OprM. L'étude de l'activité ou de laproduction de divers facteurs de virulence a indiqué que la perte de fonction de MexAB-OprM n'était pas associée àcelle de caractères de virulence. Au final, notre travail apporte un éclairage nouveau sur la capacité de P. aeruginosa àmoduler l'activité de ses pompes d'efflux pour s'adapter à diverses situations cliniques. / Pseudomonas aeruginosa is a nosocomial pathogen naturally resistant to many antibiotics thanks to numerous resistantmechanisms. Among them, overproduction of the MexXY/OprM efflux System leads to decrease significantly thesusceptibility of P. aeruginosa to aminoglycosides, fluoroquinolones and some p-lactams. Characterization of geneticmechanisms leading to overproduction of this pump from a collection of 57 non-redundant clinical isolates enable toidentified three types of mutations affecting either the gene mexZ whose product represses mexXY operon (agrZmutants, «=77. 2%), or genes parRS encoding a two component System (agrW2 mutants, w=8.8%) or other targetswhose inactivation disturbs protein synthesis and results in overexpression of the gene PA547I, whose product ArmZ isan anti-repressor of MexZ protein (agrWl mutants, n= 14%). If some populations of A aeruginosa are becoming moreresistant to aminoglycosides by overproducing MexXY/OprM system, others develop an hypersensitivity to P-lactamsas a resuit of mutations inactivating MexAB-OprM efflux system (MexAB-). The analysis of 275 strains isolated from36 CF patients allowed us to identify MexAB- strains hypersensitive to ticarcillin (37%) and non-MexABhypersensitive strains due to an overproduction of the p-lactamase AmpC (16%). In fine, 53% of the isolates appeareddeficient in MexAB-OprM. The study of various virulence factors indicated that the loss of function of MexAB-OprMin P. aeruginosa was not associated with virulence of the strains. To conclude, our work highlight on the ability ofP. aeruginosa to modulate the activity of its efflux pumps in order to adapt to various clinical environments

Pseudomonas aeruginosa ist ein gramnegatives Bakterium, welches insbesondere bei abgeschwächter Immunabwehr schwere Infektionen auslösen kann. Es besitzt eine hohe intrinsische Resistenz gegenüber Antibiotika, so dass nur eine begrenzte Anzahl von Antimikrobiotika wie beispielsweise Aminoglykoside für die Behandlung zur Verfügung steht. Unter Antibiotikatherapie wird zudem eine schnelle Resistenzentwicklung beobachtet, daher ist die Weiterentwicklung und Optimierung der Therapieoptionen von großer Bedeutung. Die vorliegende Arbeit untersucht den Einfluss von Colistin auf die Aminoglykosidresistenz bei Pseudomonas aeruginosa. 25 Bakterienstämme, die zu Beginn gegenüber Amikacin, Tobramycin und Gentamicin resistent waren, wurden Colistin ausgesetzt. Mithilfe des Epsilometertests wurde die minimale Hemmkonzentration (MHK) der Antibiotika für die zu untersuchenden Bakterienstämme vor und nach Colistineinfluss bestimmt. Es konnte ein signifikanter Rückgang der minimalen Hemmkonzentration nach Colistineinwirkung dokumentiert werden. Zu den Hauptresistenzmechanismen von Pseudomonas aeruginosa gehören die Effluxpumpen, welche die Antibiotika aus dem Bakterium ausschleusen. Für den Transport von Aminoglykosiden ist die MexXY-Pumpe verantwortlich, die in dieser Arbeit weiteruntersucht wurde. Durch eine quantitative Echtzeit-PCR unter Nutzung des Fluoreszenz-Resonanz-Energie-Transfers (FRET) wurde die Expression der Pumpe vor und nach Colistin verglichen. Es konnte nachgewiesen werden, dass durch Colistin die Expression reduziert wurde. Ein linearer Zusammenhang zwischen MHK-Veränderung und mexXY-Expressionslevel wurde anhand der Untersuchungsergebnisse nicht ermittelt. Es ist dementsprechend davon auszugehen, dass andere Resistenzmechanismen ebenfalls durch Colistin beeinflusst werden und so die MHK-Reduktion erklären können.

Les antibiotiques sont des molécules incontournables dans le traitement des infections bactériennes. L’émergence et la dissémination de la résistance aux antibiotiques chez la pathogène opportuniste Pseudomonas aeruginosa, ont amené l’Organisation Mondiale de la Santé à déclarer indispensable le développement de nouvelles approches thérapeutiques pour lutter contre cette bactérie. Bien que certaines alternatives aient été envisagées, la préservation de l’activité d’antibiotiques majeurs tels que les aminosides et la colistine est primordiale. La caractérisation des mécanismes de résistance à ces médicaments est nécessaire pour la mise au point de nouvelles molécules et mieux prendre en charge les patients. Dans ce contexte, nous montrons que des mutations dans le gène fusA1 (codant le facteur d’élongation EF-G1A) et dans l’opéron pmrAB (système à deux composants PmrAB) entrainent une augmentation de la résistance aux aminosides chez des mutants isolés au laboratoire et des souches issues de patients, atteints ou non, de mucoviscidose. Certaines substitutions d’acide aminé dans EF-G1A accroissent les niveaux de résistance de 2 à 16 fois aux quatre sous-classes d’aminosides. Par ailleurs, des changements d’acide aminé dans le système à deux composants PmrAB activent l’expression des gènes PA4773-PA4774-PA4775, et la production de norspermidine et de spermidine. La synthèse de ces polyamines va de pair avec une baisse de 4 à 16 fois de la sensibilité aux aminosides à noyan 2-désoxystreptamine bisubstitué en 4,6 (gentamicine, amikacine et tobramycine). De plus, il apparaît que la résistance des mutants pmrB à la colistine est en partie dépendante de la pompe d’efflux MexXY(OprM), un système impliqué dans la résistance naturelle, adaptative ou acquise aux aminosides. Enfin, nous montrons que les mutants pmrB surproduisent des alcaloïdes contenant un motif azétidine, par une voie de synthèse non-ribosomale et dépendante du quorum sensing. Ces alcaloïdes diminuent la virulence de P. aeruginosa dans le modèle Galleria mellonella. / Antibiotics are invaluable drugs to combat bacterial infections. Emergence and spread of antibiotic resistance in the opportunistic pathogen Pseudomonas aeruginosa have led the World Health Organization to consider as a crucial priority the development of new therapeutic approaches to fight this bacterium. In addition to other alternatives, preservation of activity of major antibiotics such as aminoglycosides and colistin is primordial. Consequently, characterization of the resistance mechanisms to these drugs is a prerequisite to design novel molecules, and improve patient care. In this context, we show that mutations in gene fusA1 (encoding elongation factor EF-G1A) and in operon pmrAB (two-component system PmrAB) lead to an increased resistance to aminoglycosides in in vitro-selected mutants and strains isolated from cystic fibrosis (CF) and non-CF patients. Certain amino acid substitutions in EF-G1A confer a 2- to 16-fold increased resistance to the four aminoglycoside subclasses. On the other hand, amino acid variations in two-component system PmrAB activate the expression of genes PA4773-PA4774-PA4775, and production of norspermidine and spermidine. This upregulated polyamine biosynthesis is associated with a 4- to 16-fold decreased susceptibility to 4,6-di-substituted deoxystreptamine aminoglycosides (gentamicin, amikacin and tobramycin). Moreover, our work reveals that the acquired resistance of pmrB mutants to colistin partially depends upon pump MexXY(OprM), a system that otherwise mediates intrinsic, adaptive and acquired resistance to aminoglycosides. Finally, we show that pmrB mutants overproduce azetidine-containing alkaloids by a quorum-sensing-regulated, nonribosomal peptide synthetase pathway. These alkaloids impair the virulence of P. aeruginosa in a Galleria mellonella infection model.