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.<br /> 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.