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Chlorhexidine leads to the evolution of antibiotic-resistant Pseudomonas aeruginosa

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Abstract

Antimicrobial resistance is a major public-health concern. We evaluate chlorhexidine role in selection of resistant Pseudomonas aeruginosa mutants and their antibiotic cross-resistance. Mutation frequency and mutation rate after short-term exposure to sub-inhibitory concentrations of chlorhexidine were compared to those after spontaneous chlorhexidine-exposure, in P. aeruginosa PAO1 strain. Chlorhexidine-resistant mutants were generated, either by serial passage in increasing chlorhexidine concentrations or by single exposure to lethal chlorhexidine concentration. The generated mutants were tested for cross-resistance to different antibiotics, by determination of minimum inhibitory concentrations (MIC). The accompanied phenotypic changes in membrane permeability, outer membrane proteins (OMP), and efflux function were evaluated. The effect of exposure to chlorhexidine on MexAB-OprM, MexEF-oprN, and MexXY efflux pumps expression was investigated. No significant change was recorded between the mutation frequencies and mutation rates after short-term exposure to sub-inhibitory concentrations of chlorhexidine and after spontaneous chlorhexidine-exposure, in P. aeruginosa PAO1 strain. Twelve stable mutants, with ≥ eight-fold increase in chlorhexidine MIC, were generated. Several mutants showed increase in the MIC of colistin, cefepime, ceftazidime, meropenem, ciprofloxacin, and amikacin; seven mutants expressed meropenem cross-resistance. This was accompanied by decreased outer membrane permeability and changes in OMP. Using efflux pump inhibitor, chlorhexidine resistance was reverted in most isolates. Exposure to sub-inhibitory concentration of chlorhexidine induced the expression of MexXY efflux pump. Some resistant mutants had overexpressed MexXY efflux pump. Chlorhexidine can select P. aeruginosa strains with antibiotic cross-resistance. This necessitates implementing special protocols for chlorhexidine use and re-evaluation of its benefit versus risk in personal-care products.

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Acknowledgements

The authors would like to thank Dr. Ahmed Sherif Attia (Cairo University) for providing P. aeruginosa PAO1 strain, Dr. Mohamed Abdel Halim Ramadan (Cairo University) for providing chlorhexidine hydrochloride, and Dr. Shahira Abdel Salam (Cairo University) for her technical assistance.

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Authors and Affiliations

  1. Department of Microbiology and Immunology, Faculty of Pharmacy, Cairo University, Cairo, 11562, Egypt

    Moustafa A. Tag ElDein, Aymen S. Yassin, Ossama El-Tayeb & Mona T. Kashef

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  1. Moustafa A. Tag ElDein
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  2. Aymen S. Yassin
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  3. Ossama El-Tayeb
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  4. Mona T. Kashef
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Contributions

Conceptualization, A.S.Y., O.E., and M.T.K.; methodology, M.A.T; formal analysis, M.A.T., A.S.Y., and M.T.K.; writing—original draft preparation, M.A.T.; writing—review and editing, A.S.Y. and M.T.K.; supervision, A.S.Y. and M.T.K. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Mona T. Kashef.

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This study was approved by the ethics committee of Faculty of Pharmacy, Cairo University (approval number: MI 1617).

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Tag ElDein, M.A., Yassin, A.S., El-Tayeb, O. et al. Chlorhexidine leads to the evolution of antibiotic-resistant Pseudomonas aeruginosa. Eur J Clin Microbiol Infect Dis 40, 2349–2361 (2021). https://doi.org/10.1007/s10096-021-04292-5

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