MICA: Understanding how bacteria respond to efflux inhibition

Lead Research Organisation: University of Birmingham
Department Name: Institute of Microbiology and Infection


The number of infections in people and animals caused by antibiotic resistant bacteria are increasing to alarming proportions around the world, and new treatments are urgently needed. However, historically, it has proven very difficult to find antibiotics that can get into bacteria such as E. coli (called Gram-negative bacteria). Even when they penetrate into the cell, most get pumped out/exported (called 'effluxed'). This export is via a biological 'vacuum cleaner' that sucks substances out of the inside to the outside of the bacterial cell. A single system can transport many different types of antibiotics. Without such systems Gram-negative bacteria are killed by very low concentrations of antibiotics. The combination of restricted entry of drugs into the bacterial cell (called outer membrane permeability) and export by multidrug resistance (MDR) efflux systems are why so many antibiotics that are effective treatments for infections caused by Gram positive bacteria, such as Staphylococcus aureus, do not work against Gram negative bacteria. Efflux systems that transport antibiotics out of the cell are not only required to give antibiotic resistance but without them bacteria are unable to cause an infection or form a biofilm - a community of bacteria that live on surfaces in the host and environment. Efflux inhibitors make the bacterium very sensitive to antibiotics, make them less able to colonise or infect their hosts and less able to form a biofilm. Therefore, efflux inhibitors offer the potential to increase the effectiveness of currently available and new drugs.

Our aim is to investigate the hypothesis that drug-resistant bacteria can emerge even in the presence of an efflux inhibitor. In this project, we will build upon our preliminary data by determining when E. coli becomes resistant to a combination of an antibiotic and efflux inhibitor. We will identify how the bacteria become drug resistant and find out if this type of resistance already exists in bacteria isolated from people and animals. Using a model that reproduces drug levels over time in people, we will identify ways to suppress the emergence of antibiotic and efflux inhibitor resistance.

To achieve the project aim, there are two applicants, a scientist and a doctor, plus three expert collaborators from the pharmaceutical industry and two universities. We will work together to provide new scientific information and knowledge crucial to the drug discovery of efflux inhibitors. Ultimately, this research will have a health benefit on the treatment of patients with life-threatening infections caused by antibiotic resistant bacteria.

Technical Summary

Antibiotics are a cornerstone of modern medicine and used extensively by healthcare professionals. Therefore, antimicrobial resistance (AMR), especially by Gram-negative bacteria, poses a threat to human health. Furthermore, developing new antimicrobials has proved increasingly difficult over the past few decades. For Gram-negative bacteria this is due to combination of poor drug permeability coupled with active efflux. Therefore, one strategy to address the growing problem of AMR is to develop inhibitors of multidrug resistance (MDR) efflux pumps thereby sensitizing bacteria to already existing antimicrobials. Using efflux inhibitors in combination with antibiotics will increase and prolong their effectiveness.

This project will build upon our preliminary data that indicates that bacteria can become resistant to an efflux inhibitor alone and in combination with a fluoroquinolone antibiotic. In this project we will (1) investigate the bacterial response to efflux inhibition, (2) the conditions by which bacteria can evolve resistance, and (3) identify clinically relevant strategies to suppress resistance. We will do this using fluorescence based reporter systems that will detect transcription of RND MDR efflux pump and stress response genes in populations and single cells. We will use methods established in our laboratory including flow cytometry methods to (1) measure efflux activity in bacterial cells, and (2) sort populations of bacterial cells after exposure to drug +/- efflux inhibitor followed by whole genome sequencing. The mechanisms of resistance will be elucidated. We will also use established pharmacokinetic pharmacodynamic models to identify when resistance emerges and how it can be suppressed.

The work proposed in this project has significant implications for the treatment of bacterial infections.

Planned Impact

There will be numerous beneficiaries of the programme of research, which will lead to academic, economic and social impact. These include
- The academic research community through research outputs and scientific publications generated by the applicants, researchers and project partners.
- The researchers, who will be provided with an excellent platform for pursuing successful careers, which in the long-term will contribute to the scientific advancement and economic prosperity of the UK. They will also be provided with a unique opportunity to work with project partners in their laboratories.
- The MRC and RCUK in general, by adding to the UK's capacity and research strength in antibiotic resistance and drug discovery research.
- Industry (small medium enterprises and the pharmaceutical industry), who will have the opportunity to build upon new and novel data about efflux inhibitors for antibacterial drug discovery as a basis for new treatments to address serious infection challenges.
- The public, though a programme of dissemination and engagement activities, will be told about our discoveries, which could impact on their health and wellbeing. Information about antibiotics has appeal and interest to a broad lay audience.
- Developing countries through established collaborations of the applicants with researchers in Africa and China in relation to mechanisms of antibiotic resistance and impact of resistance upon infection and treatment.
- Government departments including the Department of Health and Public Health England as well as NHS Trusts, who can use the knowledge gained about multi-drug efflux to help formulate evidence based policy in relation to national and global infection challenges.
This project will benefit the academic community by providing new scientific information about efflux inhibitors as well as resistance development and mechanisms. Therefore, data arising from our research will be of interest to several active academic research communities. They will be informed by presentations at national and international conferences, publication of data in international peer reviewed journals, and by researcher exchange. All staff engaged within the project will contribute to the generation and dissemination of academic outputs. This project presents an excellent opportunity for PDRFs to develop their careers within strong research teams located within institutions where PDRFs have been able, and mentored, to progress to independence, transitioning into PIs in their own right.
There is an urgent need for new antibiotics to treat Gram-negative bacterial infections. This project will provide new scientific data about antibiotic-efflux inhibitors. Thus our results will be directly applicable to the development of novel therapies providing commercial benefit; (1) resistance data will be crucial in helping to understand the mechanism of efflux and inform the design of inhibitors; (2) new understanding of the pharmacokinetics and pharmacodynamics of drug-inhibitor combinations will be obtained; and (3) strategies to suppress emergence of resistance to combinations will be proposed. Results will be shared with other commercial stakeholders by publication and conference presentations. Assisting the development of antibiotic-inhibitor combinations will increase the health and wealth of the UK population and economy.
Description DriveAB
Geographic Reach National 
Policy Influence Type Participation in a advisory committee
Description MRC Drug target and validation
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Participation in a advisory committee
Description Alasdair MacGowan 
Organisation University of Bristol
Department Bristol Research Unit
Country United Kingdom 
Sector Academic/University 
PI Contribution Provision of mutants, intellectual input and expertise.
Collaborator Contribution Performing experiments, intellectual input and expertise.
Impact -
Start Year 2017
Description Bartlomiej Waclaw 
Organisation University of Edinburgh
Department Centre for Synthetic and Systems Biology (SynthSys)
Country United Kingdom 
Sector Academic/University 
PI Contribution To provide chemical compounds and bacterial strains.
Collaborator Contribution Carry out specific experiments.
Impact -
Start Year 2017
Description Microbiotix Ltd 
Organisation Microbiotix Ltd
Country United States 
Sector Private 
PI Contribution Expertise, intellectual input, experiments with compounds provided by collaborator
Collaborator Contribution Provision of compounds for investigation, expertise, intellectual input
Impact -
Start Year 2017
Description Pia Abel Zur Wiesch 
Organisation UiT The Arctic University of Norway
Country Norway 
Sector Academic/University 
PI Contribution Expertise, intellectual input, experimental data
Collaborator Contribution Expertise, intellectual input, experimental strategy
Impact -
Start Year 2017
Description Rob Beardmore 
Organisation University of Exeter
Department Biosciences
Country United Kingdom 
Sector Academic/University 
PI Contribution Provision of data, intellectual input and expertise.
Collaborator Contribution Mathematical modelling
Impact -
Start Year 2017
Description Virginia Acha 
Organisation Association of the British Pharmaceutical Industry
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution Expertise, intellectual input
Collaborator Contribution Facilitate communication of data with end users
Impact -
Start Year 2017
Description Conference Talks 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact 08/09/16 Microbiology Society AGM Microbiology Society, London Prize winner lecture From outreach to basic research - addressing the crisis of AMR
28/09/16 Resistance and You! PHE, University of Manchester Speaker All about antibiotics - how they have changed our world
28/09/16 Resistance and You! PHE, University of Manchester Panel Chair Antibiotics and You!
07/11/16 Chevening leadership Foundation: R&D policy and strategies for innovation Chevening Foundation, London Speaker An overview of AMR, the scale of the problem and possible solutions
16/11/16 Plugging the Antibiotics Gap: A Medicinal Chemist's Perspective Royal Pharmaceutical Society, Alderley park, Cheshire Plenary speaker The global challenge of antibacterial drug resistance: what can be done?
13/01/17 Early Discovery of new antibiotics EU JPI AMR, Paris Panel Chair Analysis of the current European level portfolio: how to synergize the approaches, how to progress for new strategies / optimize funding around discovery
07/02/17 SHAMROCK annual lecture University of Sheffield Speaker Multi drug efflux systems: from basic research to discovering efflux inhibitors
23/03/17 Post Graduate Symposium Key note speaker University of Warwick MDR efflux 08/06/17 Daresbury IBM laboratory, Warrington 21-23/06/17 Hannover key note lecture Molecular basis of antibiotic permeability in Gram Negative bacteria. 4-5/07/17 AMR Award Holders Meeting Poster Presentation. 17/05/17 Pint of Science, Birmingham. 08/04/17 Roche Seminar MDR efflux systems basic research and discovery of new inhibitors. 24/10/17 UBM society , University of Birmingham, Loss of function of MDR efflux systems confers loss of virulence. 24/11/17 University of Upsalla, Sweden, Antibiotic resistance and why it matters to you. 21-22nd March 2019 - Garrod Lecture at the BSAC Spring Conference 2019, International Convention Centre, Birmingham.
Year(s) Of Engagement Activity 2016,2017,2019
Description Media actitivies 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact Professor Laura Piddock gave interviews to local, national and international media (TV, Radio and print). In the last 12 months this has included:
BBC Newsnight
BBC Radio 4
Live interview with Channel 4
Sky News live interviews
Numerous Interviews about teixobactin including The Jeremy Vine Show, BBC Radio 2 (Jan 2015)
• Provided quote to The Independent (March 2015)
• Provided quotes to The Times, The Telegraph and The Independent on 'AncientBiotics' (March 2015).
• Letter to The Times,' Britain faces an 'antibiotic Armageddon' (April 2015)
• Filming for Panorama (April 2015)
• Interview with BBC Radio 4 'The Report' (April 2015)
BBC R4 Today x3

Various TV interviews syndicated worldwide including to CNN.
Global media coverage (quoted >200 times) following the WHO's report on 30 April 2014.
Federation of Infection Societies annual meeting: interview for short film: What is the cost of not developing another antibacterial drug
Numerous print and online media interviews including The Times, The Telegraph, The Daily Mail, The Daily Express, The Metro. Quotations have often been repeated in worldwide media including in USA print media.
BBC Horizon (broadcast 22 May 2014)
Swiss National Science Foundation (SNSF) National Research Programme (NRP) Steering Committee with the title "Antimicrobial Resistance: a one-health approach"
Plenary lecture at the 'Stimulating Antimicrobial Innovation' one day meeting at the NHLI, Imperial College London on October 22nd 2015. This is being organised by the Academy of Pharmaceutical Sciences GB, through the focus group on Microbiology and Anti-infectives.
Board of Examiners in Biochemistry and Biotechnology at Imperial College London, I am writing to invite you to join us as an External Examiner for our BSc courses commencing with the 2015/16 academic year
Invitation to be a panellist at BioInfect 2015
Guest lecture on antibiotic resistance for a new course we are developing as part of the University of Glasgow online learning course.
Plenary Lecture Invitation: Research Day-St George's University of London 2 Dec talk on the subject of 'The challenges of AMR' at the launch of our new EPSRC funded AMR 'Bridging the Gaps' launch event University of Loughborough 7 Dec
Swedish Research Council review panel to evaluate applications for a Networking call to bring together researchers from Sweden and India on e-Science for Life Science and Antibiotic resistance in a 'One Health' perspective
Science Foundation Ireland review panel, Dublin SFI Investigators Programme 25th and 26th of February 2016.
European Science Foundation Invitation to join Review Panel on AXA postdoctoral fellowships 2016 meetings in Feb and May 2016
ZIBI Interdisciplinary Center for Infection Biology and Immunity
Symposium Therapeutic Resistances in Infectious Disease - Status Quo and Future Challenges, Berlin (June 27/28, 2016
Science Representative of the Buckinghamshire Federation of Women's Institutes to warmly invite you to speak at our science Investigation and Discovery Day on 7 March, in Aylesbury
Invitation to Convene and speak in symposium: 2016 ASM Microbe plenary session
Plenary lecture on AMR at the IPS conference September 2016
'Turn your nose up' campaign with the Farms not Factories organisation
Took part in a written panel interview which will appear in Future Medicinal Chemistry's upcoming New Frontiers in Antimicrobial Drug Discovery special issue
• Interviewed by Bloomberg News, Australia
• Invited to interview with The Naked Scientist
Flix Interactive about a Wellcome Trust funded project on an antimicrobial resistance computer game
• Release of BSAC policies on antimicrobial use in animals and humans (May).
• Interviewed by The Atlantic on the O'Neill Report, LJVP, (May).
• Interviewed by BBC Radio 4 Today programme (1:22), LJVP (May).
• Interviewed by BBC2 Victoria Derbyshire programme (May).
• Interviewed by BBC Radio 4 Today programme (2:25) LJVP, (May).
• Interviewed by BBC World on superbugs, LJVP, (May).
• Invited to interview by Good Morning Britain about the O'Neill Report, LJVP, (May)
• Interviewed by Kevin Fong, National Geographic, LJVP (May).
• Interviewed by Bang! Oxford University's Science Magazine, LJVP (May).
• Interviewed by a 7th grader for a project on antibiotic resistance, LJVP (May).
• Interviewed by the Daily Mail Good Health, LJVP (May).
• Provided comment to Science Media Centre on colistin-resistant bacteria in US woman, LJVP (May).
• Invited to attend the UK premier of the documentary "Clean Hands", 28th June, London, LJVP (May).
• Invited to interview by The Los Angeles Times, LJVP (June).
• BBC Radio 4 'In our Time' programme, Penicillin, 9th June 2016, LJVP (June).
• Invited to interview by "Sputnik - Orbiting the World with George Galloway", LJVP (June)
• Invited to write an article for The Conversation, LJVP (June).
• Reviewed and edited the script for a cartoon series generated by the Dundee Design School, LJVP (June).
• Invited to write an article for the Spanish newspaper 'El País, LJVP (June).
• Provided a quote to the British Medical Journal for a feature on the impact of NICE sepsis guidance on antibiotic subscribing, LJVP (June).
• Provided NICHE with Antibiotic Action posters.
• Invited to join expert panel for Innovate UK and Department of Health Funding competition: antimicrobial resistance, 29th November (Oct)
• Invited by the Food Standards Agency and the Universities of Southampton and Newcastle, to participate in a joint antimicrobial resistance workshop. (Oct)
• Invited to give a plenary lecture on antimicrobial resistance at the St George's Annual Research Day. (Oct)
• Interviewed by the Sunday Express. (Oct)
• Interview with Strategy& for a 'State of the Nation report' into AMR research & development in the UK. (Oct)
• Invited to provide quotes to the Bureau of Investigative Journalism on the topic of antimicrobial resistance. (Oct)
• Attended the 75th anniversary of penicillin, 7 November, University of Oxford. (LJVP)
• Invited to appear and provide expertise in a BBC4 documentary with Michael Moseley
• Supplement in the Guardian (Media Planet) under the One Health Agenda
• Twitter: True Stories on video joint release with PHE (stories embargoed by PHE plus BBC Radio 4 stories and Tony Maxwell videos
• Interview with Good Housekeeping magazine for WAAW
• Invited to provide a comment on 'everyday germs in the home, their effects and how you can reduce the risk of illness' for a campaign run by Domestic Innovations. (July)
• Working with BBC Five Live on concerns in relation to availability of antibiotics via online pharmacies.
• Invited to provide comment for a story the Guardian are covering that looks at an antibiotic that kills Staphylococcus aureus. (July)
• Invited to interview with TIME magazine about the anthrax outbreak in Russia
• To provide expertise on a script for a feature film under development by Neon Films
• To provide a quote for the cover of a forthcoming science book by the Royal Society of Chemistry 'The Microbes Fight Back: Antibiotic Resistance'
• Interviewed by James Gallagher, BBC Health website - UN Resolution. (Sept)
• Interview with BBC Radio 5 Live Drive - UN Resolution. (Sept)
• Interviewed with Deutsche Welle Television, Berlin - UN Resolution. (Sept)
• Interviewed by The Lancet Infectious Disease on UN Resolution to be published in November. (Sept)
• Interview with BBC World Service - The Inquiry to discuss the antibiotics crisis, following the recent UN meeting.
• Interview with BBC News - UN Resolution. (Sept).
• BBC News filming for Antibiotic Awareness Week (Oct 2018).

Promotion of Antibiotic Action (AA) being led by Prof. Laura Piddock. Antibiotic Action is a global initiative by the British Society for Antimicrobial Chemotherapy (BSAC) to highlight the threat to world health from multi-drug resistant bacteria and lobby for urgent action to develop new antimicrobial treatments
Year(s) Of Engagement Activity 2011,2012,2013,2014,2015,2016,2017,2018,2019