REVIEW article

Front. Microbiol., 11 August 2015

Sec. Antimicrobials, Resistance and Chemotherapy

Volume 6 - 2015 | https://doi.org/10.3389/fmicb.2015.00828

Quantitative proteomic view associated with resistance to clinically important antibiotics in Gram-positive bacteria: a systematic review

  • National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University Yongin, South Korea

Abstract

The increase of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) poses a worldwide and serious health threat. Although new antibiotics, such as daptomycin and linezolid, have been developed for the treatment of infections of Gram-positive pathogens, the emergence of daptomycin-resistant and linezolid-resistant strains during therapy has now increased clinical treatment failures. In the past few years, studies using quantitative proteomic methods have provided a considerable progress in understanding antibiotic resistance mechanisms. In this review, to understand the resistance mechanisms to four clinically important antibiotics (methicillin, vancomycin, linezolid, and daptomycin) used in the treatment of Gram-positive pathogens, we summarize recent advances in studies on resistance mechanisms using quantitative proteomic methods, and also examine proteins playing an important role in the bacterial mechanisms of resistance to the four antibiotics. Proteomic researches can identify proteins whose expression levels are changed in the resistance mechanism to only one antibiotic, such as LiaH in daptomycin resistance and PrsA in vancomycin resistance, and many proteins simultaneously involved in resistance mechanisms to various antibiotics. Most of resistance-related proteins, which are simultaneously associated with resistance mechanisms to several antibiotics, play important roles in regulating bacterial envelope biogenesis, or compensating for the fitness cost of antibiotic resistance. Therefore, proteomic data confirm that antibiotic resistance requires the fitness cost and the bacterial envelope is an important factor in antibiotic resistance.

Introduction

Antibiotic resistance has posed a serious threat to the worldwide public health in the past two decades. The gradual increase in resistance rates of several important pathogens, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), multidrug-resistant (MDR) Pseudomonas aeruginosa, imipenem-resistant Acinetobacter baumannii, and third-generation cephalosporin-resistant Escherichia coli and Klebsiella pneumonia, has become an increasingly severe problem in many hospitals worldwide (Lee et al., 2013). However, the decline in novel antibiotics that are introduced in the market weakens the hope of overcoming this threat by the development of new antibiotics. Most of the antibiotic classes used in hospitals today were discovered during the period 1930–1960. Only two new systemic classes of antibiotics that were developed during the past 30 years were linezolid and daptomycin, which are used only in the treatment of Gram-positive pathogens (Lee et al., 2013). Because many Gram-positive pathogens increasingly develop resistance against currently available antibiotics such as methicillin and vancomycin, these new antibiotics have become valuable for the treatment of various infections of methicillin- or vancomycin-resistant S. aureus and Streptococcus pneumonia (Ament et al., 2002; Mendes et al., 2014). However, the emergence of daptomycin-resistant or linezolid-resistant strains has recently been described in some Gram-positive pathogens (Fischer et al., 2011; Mendes et al., 2014). In this review, we summarize resistance mechanisms to four clinically important antibiotics (methicillin, vancomycin, linezolid, and daptomycin) used in the treatment of Gram-positive pathogens, and highlights recent important studies using comparative proteomic tools to understand resistance mechanisms of these antibiotics in more detail.

Action and resistance mechanisms of methicillin, vancomycin, linezolid, and daptomycin resistance

Methicillin

Methicillin is a narrow-spectrum β-lactam antibiotic of the penicillin class. Like other β-lactam antibiotics, methicillin prevents the synthesis of bacterial cell walls by inhibiting peptidic cross-linkage between the linear peptidoglycan polymer chains, which provides rigidity to the cell wall of Gram-positive bacteria (Chambers, 1997) (Table 1). Methicillin and other β-lactam antibiotics are structural analogs of D-Ala-D-Ala, which is the terminus of a short amino acid chain attached in N-acetylmuramic acids; so, they interact with and irreversibly inhibit the transpeptidase enzyme [also called penicillin-binding protein (PBP)] that crosslinks the linear peptidoglycan polymer chains (Lee et al., 2012). This process leads to loss of osmotic integrity and makes the bacterial cells susceptible to lysis. Although most β-lactam antibiotics are inhibited by bacterial enzymes that hydrolyze the β-lactam ring (named β-lactamases), due to a modification of the original penicillin structure methicillin is resistant to β-lactamases (Lee et al., 2012). Therefore, since the late 1950s when methicillin was first introduced in markets, this antibiotic has been used to treat infections caused by Staphylococcus pathogens such as Staphylococcus aureus, most of which produces β-lactamase (Newsom, 2004).

Table 1

AntibioticsTargetMechanism of actionResistance mechanisms found by non-proteomic approaches
MethicillinTranspeptidase enzyme [penicillin-binding protein (PBP)]Inhibition of peptidoglycan biosynthesisExpression of penicillin-binding protein 2a (MecA), efflux pump
VancomycinD-Ala-D-Ala dipeptide terminus of the nascent peptidoglycanInhibition of peptidoglycan biosynthesisAlteration of the D-Ala-D-Ala dipeptide
Linezolid23S rRNAInhibition of translationAlteration of 23S rRNA
DaptomycinCell membraneThe formation of holes that leak intracellular ionsRemained to be elucidated

Modes of action of four clinically important antibiotics (methicillin, vancomycin, linezolid, and daptomycin) and resistance mechanisms to these antibiotics.

Today, methicillin is not as effective against these organisms due to resistance (Cordwell et al., 2002; Newsom, 2004). Although the resistance phenotype of methicillin is influenced by numerous factors, including mecA, glmM, fmtAB, murE, llm, β-lactamase (bla) regulatory elements, and fem factors (Chambers, 1997; Cordwell et al., 2002; Hao et al., 2012), one major reason for methicillin resistance is the expression of the mecA gene, encoding penicillin-binding protein 2a (PBP 2a) that is not inhibited by classical β-lactam antibiotics including methicillin (Katayama et al., 2004) (Table 1). PBP 2a works in a similar manner to other PBPs, but it is bound by β-lactams with very low affinity (Katayama et al., 2004). Expression of PBP 2a confers resistance to all β-lactams. A variety of factors such as MecI and MecR1 controlled the mecA expression (Chambers, 1997). Resistance to methicillin exhibited by strains lacking the mecA gene is associated with modifications in native PBPs, β-lactamase hyperproduction, or possibly a methicillinase (Chambers, 1997). In pathogenesis, it has been reported that some virulence factors (Panton-Valentine leukocidin, phenol-soluble modulin, arginine catabolic mobile element, and other toxin elements) and two-component regulation systems (agr, saeRS, and vraRS) involved in pathogenesis can enhance the fitness of methicillin-resistant pathogens (Hao et al., 2012).

Vancomycin

Vancomycin made by the soil bacterium Amycolatopsis orientalis is a member of the glycopeptide antibiotic class and has an important role in the treatment of serious infections caused by Gram-positive bacteria such as Staphylococcus and Streptococcus (Woodford, 1998). It is a complex compound consisting of a branched tricyclic glycosylated peptide and is a rare example of a halo-organic natural compound containing two covalently bonded chlorine atoms (Levine, 2006). Vancomycin inhibits the peptidoglycan synthesis by binding at the D-Ala-D-Ala dipeptide terminus of the nascent peptidoglycan in Gram-positive bacteria (Healy et al., 2000; Levine, 2006). This binding of vancomycin to the D-Ala-D-Ala prevents the peptidic cross-linking between the linear peptidoglycan polymer chains by inhibiting the proper interaction with the transpeptidase enzyme (Healy et al., 2000) (Table 1).

Most Gram-negative bacteria are intrinsically resistant to vancomycin because it cannot penetrate the outer membrane of Gram-negative bacteria. In Gram-positive bacteria, one mechanism of resistance to vancomycin is the alteration of the terminal amino acid residues (D-Ala-D-Ala), to which vancomycin binds (Table 1). The D-Ala-D-Ala dipeptide terminus of the nascent peptidoglycan is replaced by D-Ala-D-Lac or D-Ala-D-Ser. The D-Ala-D-Lac variation results in a 1000-fold decrease in the affinity between vancomycin and the peptide, and the D-Ala-D-Ser variation causes a 6-fold loss of affinity, most likely due to steric hindrance (Courvalin, 2005). These alterations of the D-Ala-D-Ala dipeptide terminus require the coordinate action of several enzymes encoded by the van genes. Alternative ligases catalyze the formation of the D-Ala-D-Lac peptide (VanA, B, and D type enzymes) or D-Ala-D-Ser peptide (VanC, E, and G type enzymes) in peptidoglycan synthesis. VanH protein (α-keto acid reductase) reduces pyruvate to D-Lac, and the D,D-dipeptidase VanX selectively removes the D-Ala-D-Ala produced by the native ligase to enhance the incorporation of the D-Ala-D-Lac or D-Ala-D-Ser into the peptidoglycan precursor. VanR and VanS constitute a two-component regulatory system that activates the transcription of the van gene cluster (Marcone et al., 2010).

Linezolid

Linezolid is a first synthetic oxazolidinone antibiotic used to treat infections caused by VRE and MRSA. Although the mechanism of action of linezolid is not fully understood, it seems to bind to the 50S subunit of the bacterial ribosome through interaction with the central loop of the 23S rRNA and block the formation of protein synthesis initiation complexes (Swaney et al., 1998; Ament et al., 2002) (Table 1). Because linezolid binds to the 23S portion of the 50S subunit different from the binding sites of other ribosome-binding antibiotics such as chloramphenicol, cross-resistance between linezolid and other protein synthesis inhibitors is highly rare (Herrmann et al., 2008). The crystal structures of linezolid bound to the 50S subunit in 2008 showed that linezolid binds to the A site of the 50S ribosomal subunit and induces a conformational change perturbing the correct positioning of tRNAs on the ribosome (Ippolito et al., 2008; Wilson et al., 2008).

Most Gram-negative bacteria have an intrinsic resistance to linezolid due to the high activity of efflux pumps, which actively pump linezolid out of the cell (Schumacher et al., 2007). In Gram-positive bacteria, the acquired resistance to linezolid was first reported in 1999 in multidrug-resistant Enterococcus faecium (Mendes et al., 2014). High-resolution structures of linezolid with the 50S ribosomal subunit showed that it binds to a deep cleft that is surrounded by the central loop of domain V of 23S rRNA (Long and Vester, 2012). Therefore, the most common resistance mechanism of Gram-positive bacteria to linezolid was a point mutation known as G2576T, in which the G2576 position of 23S ribosomal RNA is converted to thymine (Mendes et al., 2014). In addition to mutations in 23S rRNA, other mechanisms have been identified in Gram-positive bacteria, including a six base pair deletion in the ribosomal protein L4, mutations in the ribosomal protein L3, mutations in an RNA methyltransferase (encoded by the cfr gene) that methylates G2445 of the 23S rRNA, and mutations causing increased expression of ABC transporter genes (patA and patB).

Daptomycin

Daptomycin is a lipopeptide antibiotic consisting of a lipid molecule conjugated with anionic peptide and is a natural compound found in the soil bacterium Streptomyces roseosporus (Miao et al., 2005). Daptomycin absolutely requires Ca2+ for activity, making this agent a cationic antimicrobial peptide functionally (Baltz, 2009). The poorly calcium-decorated form of daptomycin is 10 times less active microbiologically than the heavily calcium-decorated form (Baltz, 2009). The calcium-bound daptomycin interacts with phosphatidylglycerol in the bacterial membrane and inserts into the cell membrane, leading to the formation of holes that leak intracellular ions (Pogliano et al., 2012). A loss of membrane potential causes inhibition of protein, DNA, and RNA synthesis, which results in bacterial cell death (Pogliano et al., 2012). Because of a distinct mechanism of action of daptomycin, it is used in the treatment of life-threatening infections caused by multiple drug-resistant Gram-positive bacteria (Baltz, 2009). Because vancomycin and daptomycin have molecular weight (MWs) of more than 1000 Da (vancomycin of 1449 Da and daptomycin of 1620 Da), they cannot penetrate the outer membrane of Gram-negative bacteria (Lee et al., 2013). Therefore, two antibiotics are used to control infections caused by Gram-positive bacteria.

Although daptomycin was clinically introduced in 2003, clinical treatment failures by the emergence of daptomycin-resistant strains during therapy have now been described (Hobbs et al., 2008; Fischer et al., 2011). Up to now, specific genetic determinant of the daptomycin-resistant strain remained to be elucidated, despite the finding of several phenotypic and genetic determinants (altered phospholipid synthesis, thickened cell walls, alteration of cell membrane fluidity, and the acquisition of mutations within the mprF or yycG gene) (Mishra et al., 2009; Fischer et al., 2011). The mprF gene encodes a dual functional enzyme that catalyzes the coupling of lysine to phosphatidylglycerol (PG) and transfers the lysyl-PG (LPG) to the outer leaflet of the membrane. The LPG is less acidic than PG, and membranes lacking LPG are more acidic than those containing PG and LPG (Baltz, 2009). Daptomycin-resistant strains with mprF mutations have membranes with increased levels of LPG (Jones et al., 2008). Therefore, the increased positive charge caused by increased LPG in the mprF mutant (gain-of-function) reduces the binding of Ca2+-bound daptomycin to bacterial membranes by a less favorable electrostatic interaction. YycG is a membrane spanning sensor histidine kinase of a two-component signal transduction system that partners with the YycF response regulator. YycFG functions as a master regulatory system for cell wall metabolism and biofilm formation and is the only two-component system required for viability in many Gram-positive bacteria (Winkler and Hoch, 2008; Baltz, 2009).

Comparative proteomic analyses of methicillin, vancomycin, linezolid, and daptomycin resistance

Quantitative proteomics have been considerably improved during the past decade and have been employed for investigation of the differences in whole protein expression dynamics of cells grown under a variety of growth conditions or stress conditions such as antibiotics (Radhouani et al., 2012). Therefore, by studies using quantitative proteomic approaches in the past few years, a considerable progress has recently been made in the study of antibiotic resistance mechanism. To summarize recent updates to understand the resistance mechanism to four clinically important antibiotics used in the treatment of Gram-positive pathogens, we used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) in our review (Figure 1) (Moher et al., 2009). We conducted a systematic literature search in the following databases: Medline via PubMed and Embase. We used keywords as search terms. We combined terms for selected indications (methicillin, vancomycin, linezolid, daptomycin, and proteomics). The literature search included all studies published in English between 2000 and 2015. We identified 13 proteomics studies comparing proteomic profiles in antibiotic-resistant and antibiotic-sensitive strains or exploring proteomic profiles in cells treated with or without antibiotics.

Figure 1

Methicillin

Two studies exploring proteomic profiles of methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) in the absence of methicillin were reported (Cordwell et al., 2002; Enany et al., 2014). Cordwell et al. compared the protein profiles between S. aureus strains COL (methicillin-resistant) and 8325 (methicillin-susceptible) in the absence of methicillin (Cordwell et al., 2002). Interestingly, among proteins previously known as resistance-related factors (e.g., mecA, glmM, fmtAB, murE, llm, bla, and fem factors), only FemA protein, which is known as a host-mediated factor essential for methicillin resistance in S. aureus (Berger-Bächi et al., 1989), was more highly expressed in methicillin-resistant cells (Cordwell et al., 2002). However, upon growth of both strains in the presence of Triton X-100 (TX-100), a detergent that has been shown to reduce methicillin resistance, no difference on the production of the essential methicillin-resistance factor FemA was detected (Cordwell et al., 2002). Instead, expression levels of stress-related proteins including cold-shock proteins (CspABC) and alkaline-shock protein 23 (Asp23) increased in the methicillin-resistant S. aureus strain COL (Cordwell et al., 2002). Notably, the amount of CspB, CspC, and Asp23 proteins was affected in cases of vancomycin and daptomycin antibiotics, despite being down-regulated in the vancomycin-resistant strain and up-regulated in the daptomycin-resistant strain (Table 7). This study also showed that three proteins linked to the alternative sigma factor σB, Asp23, anti-anti- σB factor RsbV, and conserved hypothetical protein SA0772, were also present at significantly higher levels in methicillin-resistant cells (Cordwell et al., 2002). In the presence of TX-100 weakening the methicillin resistance, the comparative proteomic analysis showed that proteins of the σB and SarA (a regulator of virulence genes) regulons are involved in methicillin resistance of S. aureus (Cordwell et al., 2002). The level of SarA protein also increased in vancomycin-resistant and daptomycin-resistant cells (Table 7). This study also showed that the stage V sporulation protein G (SpoVG), originally identified in Bacillus subtilis as being involved in the formation of the spore cortex (Matsuno and Sonenshein, 1999), was up-regulated in the methicillin-resistant S. aureus strain COL. In the non-sporulating S. aureus, SpoVG contributes to stimulate capsule synthesis, and was recently shown to regulate a small σB-subregulon comprising mainly excreted virulence factors including the highly up-regulated virulence factor EsxA (Schulthess et al., 2012). Recently, it has been reported that SpoVG was involved in resistance mechanisms to methicillin and glycopeptide (Schulthess et al., 2009). Together with this report, a comparative proteome analysis showed that the expression level of SpoVG increased in strains resistant to methicillin, vancomycin, and daptomycin (Table 5), indicating that SpoVG may be involved in resistance mechanisms to other antibiotics as well as methicillin and glycopeptide.

Another report explored proteome profiles of extracellular proteins in methicillin-sensitive and methicillin-resistant S. aureus (Enany et al., 2014). They identified some proteins increased in MRSA; Asp23 (10-fold more in MRSA than MSSA), alkyl hydroperoxide reductase subunit C (AhpC) (2-fold), D-lactate dehydrogenase (LdhD) (2-fold), general stress protein 20U (3-fold), L-lactate dehydrogenase (LdhA) (2-fold), pyruvate dehydrogenase E1 component beta subunit (PdhB) (2-fold), superoxide dismutase (SodA) (2-fold), triacylglycerol lipase precursor (LipA) (2-fold), triosephosphate isomerase (TpiA) (2-fold), and universal stress protein family protein (7-fold) (Enany et al., 2014). Notably, among them, most proteins (AhpC, SodA, LdhA, LipA, and TipA) also have altered expression levels in other antibiotic-resistant strains (Table 7). In addition, elongation factor G (encoded by the fusA gene) was also increased in MRSA. Our analysis showed that PusA is one of the three proteins affected in all four antibiotic-resistant strains (Table 5). Although elongation factor G is a major target of fusidic acid which has been used as a topical agent for skin infection and for some systemic infections caused by S. aureus (Howden and Grayson, 2006), and had a contribution to fusidic acid resistance mechanisms evolved in MRSA (Koripella et al., 2012), the relationship between elongation factor G and resistance mechanisms of other antibiotics has not yet been identified.

Vancomycin

There were two studies exploring proteomic profiles in vancomycin-susceptible S. aureus (VSSA) and vancomycin-intermediate S. aureus (VISA) with a minimal inhibitory concentration (MIC) of 4–8 μg/ml, one study exploring proteomic profiles in VSSA and heterogeneous vancomycin-intermediate S. aureus (hVISA) with a vancomycin MIC of ≤2 μg/ml, one study exploring proteomic profiles in VISA and vancomycin-resistant S. aureus (VRSA) with MIC of ≥8 μg/ml, one study analyzing global proteomes of vancomycin stress in S. aureus, and two studies examining vancomycin-induced proteomes of Enterococcus faecalis under vancomycin treatment (Pieper et al., 2006; Scherl et al., 2006; Drummelsmith et al., 2007; Wang et al., 2010; Chen et al., 2013; Hessling et al., 2013; Ramos et al., 2015). Many proteins previously known as resistance-related factors, including VanA, VanB, VanX, and VanR, were also identified in comparative proteomic analyses (Table 2). Scherl et al. (2006) showed that a total of 155 proteins are differentially expressed between two vancomycin-susceptible S. aureus strains (MRGR3 and 14-4Rev) and the vancomycin-intermediate S. aureus strain 14-4, and most proteins play a role in energy metabolism, cell envelope biosynthesis, protein turnover, amino acids transport, and metabolism, and inorganic ion transport. Genes or gene products known to be involved in resistance mechanisms to different antibiotics, such as PBP 2a (MecA), O-nucleotidyltransferase(9) [Ant(9)], UDP-N-acetylmuramyl tripeptide synthetase (MurE), and penicillin-binding methicillin resistant-related protein (FmtA), were up-regulated in the VISA strain (Scherl et al., 2006). All of them are involved in peptidoglycan biosynthesis. Levels of many other proteins involved in peptidoglycan metabolism also increased in the VISA strain, such as glycosyltransferase (SgtB) and CHAP (Cysteine, Histidine-dependent Amidohydrolases/Peptidases)-domain amidase (SsaA). SsaA belongs to the CHAP amidase family, members of which such as LysK and LytA have been shown to have D-alanyl-glycyl endopeptidase activity, cleaving between the crossbridge and the stem peptide (Delaune et al., 2011), and protein levels of SsaA were also changed in cases of methicillin and linezolid (Table 6), indicating the importance of this protein on peptidoglycan metabolism and antibiotic resistance.

Table 2

Biological processProtein nameGeneAntibioticsRegulationFrequency of differenceReferencesProtein description
Antibiotic inactivationBleomycin resistance proteinbleVanDown1Pieper et al., 2006Inhibition of bleomycin by a direct interaction
Kanamycin nucleotidyltransferasekntVanDown1Pieper et al., 2006Modification of kanamycin
Vancomycin resistance proteinvanAVanUp2Wang et al., 2010; Ramos et al., 2015Alteration of the D-Ala-D-Ala dipeptide
O-nucleotidyltransferase (9)ant(9)VanUp1Scherl et al., 2006Modification of vancomycin

Differentially expressed proteins identified by the quantitative proteomic approach: proteins involved in resistance mechanisms.

Tables 2–8: Met, methicillin; Van, vancomycin; Lin, linezolid; Dap, daptomycin; up, up-regulated in antibiotic-resistant strain or under antibiotic treatment; down, down-regulated in antibiotic-resistant strain or under antibiotic treatment.

Table 3

Biological processProtein nameGeneAntibioticsRegulationFrequency of differenceReferencesProtein description
Energy production and conversionPyruvate dehydrogenase E1 component beta subunitpdhBMetUp1Enany et al., 2014Acetyl-CoA biosynthetic process from pyruvate
D-Lactate dehydrogenaseldhDMetUp1Enany et al., 2014Pyruvate metabolism
Formyltetrahydrofolate synthetasefhsVanUp1Pieper et al., 2006Glyoxylate and dicarboxylate metabolism and one carbon pool by folate
Succinyl-CoA synthetase alpha chainsucDVanUp1Pieper et al., 2006The citric acid cycle
Aconitate hydratasecitBVanUp(down)1(1)Pieper et al., 2006; Drummelsmith et al., 2007The citric acid cycle
Isocitrate dehydrogenasecitCVanUp1Drummelsmith et al., 2007The citric acid cycle
Citrate lyasecitFVanUp1Wang et al., 2010Acetyl-CoA metabolic process
ATP synthase γ chainatpGVanUp(down)2(1)Pieper et al., 2006; Scherl et al., 2006; Wang et al., 2010ATP formation
Pyruvate carboxylasepycAVanDown1Pieper et al., 2006Anaplerotic reaction
Malate:quinone oxidoreductase 1mqo2VanUp2Scherl et al., 2006; Drummelsmith et al., 2007The citric acid cycle
2-Dehydro-3-deoxyphosphogluconate aldolaseedaVanUp1Wang et al., 2010Glycolysis
Glyceraldehyde-3-phosphate dehydrogenasegapAVanUp(down)1(1)Wang et al., 2010; Ramos et al., 2015Glycolysis
Dihydrolipoamide succinyltransferaseodhBVanDown1Scherl et al., 2006The citric acid cycle and lysine degradation.
Glycerophosphoryl diester phosphodiesteraseglpQLinUp1Bernardo et al., 2004Glycerol and glycerophosphodiester degradation
Lactate oxidaselctOLinUp1Feng et al., 2011Lactate oxidation
Flavodoxin/nitric oxide synthaseflaVLinUp1Feng et al., 2011Flavodoxin biosynthesis
Gluconate 5-dehydrogenasegnoLinUp1Feng et al., 2011Gluconate oxidation
Phosphoglycolate phosphatasegphLinUp1Feng et al., 2011Glyoxylate and dicarboxylate metabolism
Enolase (2-phosphoglycerate dehydratase)edoDapUp1Fischer et al., 2011Glycolysis
Triose-phosphate isomerasetpiAMetUp1Enany et al., 2014Glycolysis
VanDown1Ramos et al., 2015
Alcohol dehydrogenaseadhEMetDown(up)1(1)Cordwell et al., 2002; Enany et al., 2014Fermentation
VanUp2Drummelsmith et al., 2007; Wang et al., 2010
Alcohol dehydrogenaseadhPMetUp1Enany et al., 2014Fermentation
LinUp1Feng et al., 2011
2,3-Bisphosphoglycerate-dependent phosphoglycerate mutasegpmAVanUp(down)2(1)Scherl et al., 2006; Drummelsmith et al., 2007; Chen et al., 2013Glycolysis
LinUp1Feng et al., 2011
Nitrate reductase α chainnarGVanDown1Pieper et al., 2006Anaerobic respiration
LinDown1Fischer et al., 2011
Phosphoglycerate kinasepgkVanDown2Pieper et al., 2006; Scherl et al., 2006Glycolysis
LinUp1Feng et al., 2011
Phosphopyruvate hydrataseenoVanUp1Scherl et al., 2006Glycolysis
DapUp1Fischer et al., 2011
Succinate dehydrogenase flavoprotein subunitsdhAVanUp1Scherl et al., 2006The citric acid cycle
DapDown1Fischer et al., 2011
Pyruvate dehydrogenase α subunitpdhAVanUp1Wang et al., 2010Acetyl-CoA biosynthetic process from pyruvate
DapUp1Fischer et al., 2011
Citrate synthase IIcitZVanUp1Drummelsmith et al., 2007The citric acid cycle
DapDown1Fischer et al., 2011
Succinyl-CoA synthetase β chainsucCVanUp2Pieper et al., 2006; Drummelsmith et al., 2007The citric acid cycle
DapDown1Fischer et al., 2011
AminoethyltransferasegcvTVanUp1Pieper et al., 2006Glycine cleavage
DapUp1Fischer et al., 2011
Glyceraldehyde-3-phosphate dehydrogenase 1gapALinUp1Feng et al., 2011Glycolysis
DapUp1Fischer et al., 2011
L-Lactate dehydrogenaseldhAMetUp1Enany et al., 2014Fermentation
VanDown(up)2(1)Pieper et al., 2006; Scherl et al., 2006; Wang et al., 2010
DapUp1Fischer et al., 2011
Fructose-bisphosphate aldolasefbaVanUp2Wang et al., 2010; Ramos et al., 2015Glycolysis
LinUp1Feng et al., 2011
DapUp1Fischer et al., 2011
Acetate kinaseackAMetUp1Enany et al., 2014Fermentation
VanUp(down)1(1)Scherl et al., 2006; Drummelsmith et al., 2007
DapUp1Fischer et al., 2011
Glucose-6-phosphate isomerasepgiVanDown(up)1(1)Pieper et al., 2006; Scherl et al., 2006Glycolysis
LinUp1Feng et al., 2011
DapUp1Fischer et al., 2011
Carbohydrate transport and metabolismABC transporter, ATP binding proteinstpCVanDown1Drummelsmith et al., 2007Carbohydrate transport
PTS transport system, fructose-specific IIABC componentfruAVanDown1Drummelsmith et al., 2007Fructose transport
ABC transporter, ATP binding proteinvraDVanUp1Drummelsmith et al., 2007Bacitracin tansport
Phosphoglycerate mutase 1pgmVanUp1Wang et al., 2010The breakdown of glycogen and metabolism of galactose and maltose
2,3-Bisphosphoglycerate-independent phosphoglycerate mutasegpmIVanUp1Drummelsmith et al., 2007Carbohydrate degradation
Glycerol kinaseglpKVanUp1Drummelsmith et al., 2007Carbohydrate degradation
Lactose PTS system repressorfruRLinUp1Feng et al., 2011Lactose transport
Glucosamine-6-phosphate isomerasenagBLinUp1Feng et al., 2011Glucosamine metabolism
Galactose-6-phosphate isomeraselacBLinUp1Feng et al., 2011Galactose metabolism
Tagatose-6-phosphate kinaselacCLinUp1Feng et al., 2011Tagatose metabolism
Tagatose 1,6-diphosphate aldolaselacDLinUp1Feng et al., 2011Tagatose metabolism
β-N-acetylhexosaminidasestrHLinUp1Feng et al., 2011Hexosamine metabolism
β-galactosidasebgaALinUp1Feng et al., 2011Lactose metabolism
PTS system transporter subunit IIBspr0563LinUp1Feng et al., 2011Carbohydrate transport
PTS system transporter subunit IIAspr0562LinUp1Feng et al., 2011Carbohydrate transport
PTS system transporter subunit IIBspr0060LinUp1Feng et al., 2011Carbohydrate transport
FructokinasescrKLinUp1Feng et al., 2011Fructose metabolism
GlucokinaseglcKVanDown1Scherl et al., 2006Glucose metabolism
LinUp1Feng et al., 2011
Catabolite control protein AccpAMetDown1Cordwell et al., 2002Carbon catabolite repression
VanUp1Wang et al., 2010
LinUp1Feng et al., 2011

Differentially expressed proteins identified by the quantitative proteomic approach: proteins involved in energy metabolism.

Table 4

Biological processProtein nameGeneAntibioticsRegulationFrequency of differenceReferencesProtein description
Amino acid transport and metabolismThreonine deaminaseilvAMetDown1Cordwell et al., 2002Threonine metabolism
Aspartate kinaselysCVanUp1Hessling et al., 2013Biosynthesis of lysine, methionine, threonine
Aspartate semialdehyde dehydrogenaseAsdVanUp1Hessling et al., 2013Biosynthesis of lysine, methionine, threonine
Dihydrodipicolinate synthasedapAVanUp1Hessling et al., 2013Biosynthesis of lysine
Tetrahydrodipicolinate acetyltransferasedapDVanUp1Hessling et al., 2013Biosynthesis of lysine
Diaminopimelate decarboxylaselysAVanUp1Hessling et al., 2013Biosynthesis of lysine
Arginine deiminasearcAVanDown1Ramos et al., 2015Arginine metabolism
4-Hydroxy-tetrahydrodipicolinate reductasedapBVanUp1Hessling et al., 2013Biosynthesis of lysine
Cystathionine β-lyasemetCVanUp1Wang et al., 2010Biosynthesis of methionine
Cystathionine γ-synthasemetBVanUp1Drummelsmith et al., 2007Biosynthesis of methionine
Chorismate mutasearoAVanDown1Drummelsmith et al., 2007Biosynthesis of aromatic amino acids
Urease α subunitureCVanUp1Drummelsmith et al., 2007Urea metabolism
Urease accessory proteinureEVanUp2Scherl et al., 2006; Drummelsmith et al., 2007Urea metabolism
Branched-chain amino acids aminotransferaseilvEVanDown2Pieper et al., 2006; Scherl et al., 2006Biosynthesis of branched-chain amino acids
Aetylornithine aminotransferase 2argDVanUp1Pieper et al., 2006Biosynthesis of lysine
Amino acid ABC transporter amino acid-binding proteinglnHLinUp1Feng et al., 2011Glutamine transport
Tryptophan synthase subunit αtrpALinDown1Feng et al., 2011Biosynthesis of aromatic amino acids
Asparagine synthetaseasnALinDown1Feng et al., 2011Biosynthesis of asparagine
AminotransferaseaspCLinUp1Feng et al., 2011Biosynthesis of lysine, methionine, threonine
Carbamate kinasearcCVanDown2Scherl et al., 2006; Ramos et al., 2015Allantoin degradation
LinUp1Feng et al., 2011
1-Pyrroline-5-carboxylate dehydrogenaserocAVanUp1Scherl et al., 2006Proline degradation
DapDown1Fischer et al., 2011
Serine hydroxymethyltransferaseglyAVanDown1Drummelsmith et al., 2007Biosynthesis of glycine
DapUp1Fischer et al., 2011
Glutamine synthetase type 1glnALinDown1Feng et al., 2011Nitrogen assimilation
DapDown1Fischer et al., 2011
Nucleotide transport and metabolismBifunctional pyrimidine regulatory protein /uracil phosphoribosyltransferasepyrRMetDown1Cordwell et al., 2002Salvage pathways of pyrimidine ribonucleotides
Purine nucleoside phosphorylasedeoDVanDown1Pieper et al., 2006Guanosine nucleotides de novo biosynthesis
Putative purine biosynthesis proteinpurSVanUp1Pieper et al., 2006Purine biosynthesis
Adenylosuccinate synthetasepurAVanUp1Pieper et al., 2006Purine biosynthesis
Phosphoribosylaminoimidazole carboxylasepurKVanUp1Pieper et al., 2006Purine biosynthesis
Phosphoribosylglycinamidine synthase IpurQVanUp1Pieper et al., 2006Purine biosynthesis
Phosphoribosylglycinamidine synthase IIpurLVanUp1Pieper et al., 2006Purine biosynthesis
Phosphoribosylglycinamide formyltransferasepurNVanUp1Pieper et al., 2006Purine biosynthesis
Phosphoribosykaminoimidazole carboxylase, catalytic subunitpurEVanUp1Pieper et al., 2006Purine biosynthesis
GMP synthaseguaAVanDown2Scherl et al., 2006; Ramos et al., 2015Biosynthesis of guanosine nucleotides
The pur operon repressorpurRLinUp1Feng et al., 2011Purine biosynthesis
Ribose-phosphate pyrophosphokinaseprsVanUp2Scherl et al., 2006; Drummelsmith et al., 2007Purine biosynthesis
LinUp1Feng et al., 2011
AmidophosphoribosyltransferasepurFVanUp1Pieper et al., 2006Purine biosynthesis
DapUp1Fischer et al., 2011
Phosphoribosylamine-glycine ligasepurDVanUp1Pieper et al., 2006Purine biosynthesis
DapDown1Fischer et al., 2011
Phosphoribosylglycinamidine cyclo-ligasepurMVanUp1Pieper et al., 2006Purine biosynthesis
DapDown1Fischer et al., 2011
GMP reductaseguaCVanUp1Pieper et al., 2006The purine salvage pathway
DapDown1Fischer et al., 2011
DihydroorotasepyrCVanDown1Drummelsmith et al., 2007Pyrimidine biosynthesis
DapDown1Fischer et al., 2011
Carbamoyl phosphate synthase large subunitcarBVanDown1Scherl et al., 2006Pyrimidine biosynthesis
DapUp1Fischer et al., 2011
Phosphoribosylaminoimidazole-succinocarboxamide synthasepurCVanUp1Pieper et al., 2006Purine biosynthesis
DapUp1Fischer et al., 2011
Adenylosuccinate lyasepurBMetUp1Enany et al., 2014Purine biosynthesis
VanUp2Pieper et al., 2006
DapUp1Fischer et al., 2011
Bifunctional purine biosynthesis proteinpurHVanUp1Pieper et al., 2006Purine biosynthesis
LinDown1Feng et al., 2011
DapUp1Fischer et al., 2011
Uracil phosphoribosyltransferaseuppVanDown2Scherl et al., 2006; Drummelsmith et al., 2007Salvage pathways of pyrimidine ribonucleotides
LinDown1Feng et al., 2011
DapUp1Fischer et al., 2011
Coenzyme transport and metabolism3-Hydroxy-3-methylglutaryl-CoA synthasemvaSMetUp1Cordwell et al., 2002Isoprenoid biosynthesis
Thiamin-biosynthesis proteinthiLMetUp1Cordwell et al., 2002Thiamin biosynthesis
δ-aminoevulinic acid dehydratasehemBVanDown1Pieper et al., 2006Heme biosynthesis
Molybdopterin converting factor subunit 2moaEVanDown1Pieper et al., 2006Molybdenum cofactor biosynthesis
2-Dehydropantoate 2-reductasepanEVanDown1Drummelsmith et al., 2007Pantothenate and coenzyme A biosynthesis
6-Pyruvoyl tetrahydrobiopterin synthaseptpSVanUp1Drummelsmith et al., 2007Tetrahydrobiopterin biosynthesis
Phosphopantetheine adenylyltransferasecoaDVanUp1Drummelsmith et al., 2007Pantothenate and coenzyme A biosynthesis
Coenzyme A disulfide reductasecdrVanDown1Scherl et al., 2006Pantothenate and coenzyme A biosynthesis
Hydroxyethylthiazole kinasethiMLinUp1Feng et al., 2011Thiamin biosynthesis
3-Methyl-2-oxobutanoate hydroxymethyltransferasepanBMetUp1Enany et al., 2014Pantothenate and coenzyme A biosynthesis
VanDown(up)1(1)Drummelsmith et al., 2007; Wang et al., 2010
Bifunctional 5,10-methylene-tetrahydrofolate dehydrogenase/5,10-methylene-tetrahydrofolate cyclohydrolasefolDVanUp1Pieper et al., 2006N10-formyl-tetrahydrofolate biosynthesis
DapUp1Fischer et al., 2011
6,7-Dimethyl-8-ribityllumazine synthaseribHLinUp1Feng et al., 2011Flavin biosynthesis
DapUp1Fischer et al., 2011
Pyridoxal biosynthesis lyasepdxSLinDown2Drummelsmith et al., 2007; Feng et al., 2011Pyridoxal 5′-phosphate biosynthesis.
DapUp1Fischer et al., 2011
Inorganic ion transport and metabolismABC protein/substrate binding protein subunit—metal ion transportlmbLinUp1Feng et al., 2011Metal ion transport
Non-heme iron-containing ferritindprLinUp1Feng et al., 2011Iron tansport
Iron-compound ABC transporter permeasefatDLinUp1Feng et al., 2011Iron tansport
Lipoprotein similar to streptococcal adhesinpsaALinUp1Feng et al., 2011Manganese transport; pneumococcal attachment
DapDown1Fischer et al., 2011

Differentially expressed proteins identified by the quantitative proteomic approach: proteins involved in amino acid, nucleotide, coenzyme, and inorganic ion metabolisms.

They also identified several regulatory systems contributing to the VISA phenotype, such as the two-component system (VraSR) regulating expression of a set of genes involved in the cell wall biosynthesis or degradation (Boyle-Vavra et al., 2013), the signal transduction protein TRAP acting on quorum sensing (Gov et al., 2004), the DivIVA protein known to regulate cell division in B. subtilis (Perry and Edwards, 2004), and putative transcription factors SA2296 and SarH1. VraSR (vancomycin resistance associated regulator) was up-regulated under vancomycin treatment (Kuroda et al., 2003) and in the VISA strain when compared with an isogenic vancomycin-susceptible strain (Kuroda et al., 2000). In addition, inactivation of the vraSR gene increased vancomycin susceptibility (Kuroda et al., 2003). Interestingly, VraSR was also induced by other antibiotic classes that target the cell wall, including β-lactam (Gardete et al., 2006; Yin et al., 2006), mersacidin (Sass et al., 2008), certain cationic peptides (Pietiäinen et al., 2009), and daptomycin (Muthaiyan et al., 2008). Inactivation of the vraSR gene attenuates resistance to various antibiotics, such as vancomycin (Kuroda et al., 2003; Gardete et al., 2006), daptomycin (Mehta et al., 2012), and β-lactams (Kuroda et al., 2003; Boyle-Vavra et al., 2006; Gardete et al., 2006). The expression of many genes, such as ctpA, drp35, fmtA, opuD, pbp2, prsA, sgtB, and vraX, is regulated by VraSR (Utaida et al., 2003; McAleese et al., 2006; Dengler et al., 2011). Among them, FmtA is typically known as a factor involved in methicillin-resistant phenotype of S. aureus (Fan et al., 2007), and PrsA (foldase precursor) was recently reported to be involved in both glycopeptide and oxacillin resistance in S. aureus (Jousselin et al., 2012). Similarly, at three independent studies of comparative proteomic analysis, it has been proven that the expression level of PrsA is up-regulated in VISA when compared with VSSA (Table 5), indicating that proteomic studies can support the identification of targets involved in antibiotic resistance. They also identified another important protein VraX (a hypothetical protein which encodes a 55-amino acids protein) differentially expressed between vancomycin-susceptible S. aureus strains and the vancomycin-intermediate S. aureus strain 14-4 (Scherl et al., 2006). This gene was up-regulated by multiple cell wall and/or membrane active compounds (bacitracin, d-cycloserine, oxacillin, tunicamycin, flavomycin, fosfomycin, teicoplanin, vancomycin, daptomycin, lysostaphin, epicatechin gallate, ranalexin, and antimicrobial peptides) (Utaida et al., 2003; Pietiäinen et al., 2009; Dengler et al., 2011; Cuaron et al., 2013). The vraX gene belongs to the vra operon together with the vraA gene encoding for a long chain fatty acid-CoA ligase, which was up-regulated in the VISA. Additionally, this gene seems to be involved in resistance mechanism to vancomycin (Hanaki et al., 1998; Buntaran et al., 2013). Finally, stress-related proteins such as proteinases (CtpA), methionine sulfoxide reductase A (MsrA2), and the methionine sulfoxide reductase regulator MsrR, were over-expressed in the vancomycin-intermediate S. aureus strain 14-4 (Scherl et al., 2006). In other studies, MsrA2 was also up-regulated in hVISA (Chen et al., 2013).

Table 5

Biological processProtein nameGeneAntibioticsRegulationFrequency of differenceReferencesProtein description
Replication, recombination and repairInitiation-control proteinyabAVanUp1Ramos et al., 2015Replication
Topoisomerase IV subunit BparEVanDown1Pieper et al., 2006Replication
DNA gyrase subunit BgyrBVanDown1Pieper et al., 2006Replication
Single-stranded DNA binding proteintraMVanDown1Pieper et al., 2006Replication
Formamidopyrimidine-DNA glycosylasemutMLinUp1Feng et al., 2011DNA repair
Single-stranded DNA-binding proteinssbBLinDown1Feng et al., 2011Replication
DNA-entry nucleaseendALinUp1Feng et al., 2011DNA repair
Recombinase ArecAVanUp1Wang et al., 2010Recombination
DapUp1Fischer et al., 2011
Endonuclease IVnfoVanUp1Wang et al., 2010DNA repair
DapDown1Fischer et al., 2011
Sporulation and cell divisionAnti-anti-σB factorrsbVMetUp1Cordwell et al., 2002Sporulation
Cell division proteinmraZVanUp1Pieper et al., 2006Cell division
Cell division proteindivIVAVanUp1Scherl et al., 2006Cell division
Cell division proteinftsZVanUp1Wang et al., 2010Cell division
DapUp1Fischer et al., 2011
Regulatory protein SpoVGspoVGMetUp1Cordwell et al., 2002Sporulation
VanUp1Pieper et al., 2006
DapUp1Fischer et al., 2011
TranscriptionDNA-directed RNA polymerase subunit deltarpoELinUp1Feng et al., 2011
Transcription elongation factorgreAVanDown1Pieper et al., 2006Trnascription
LinUp1Feng et al., 2011
Translation, ribosomal structure and biogenesis5-methylaminomethyl-2-thiouridylate)-methyltransferasetrmUVanUp1Wang et al., 2010tRNA modification
16S rRNA processing proteinrimMLinDown1Feng et al., 2011Ribosome maturation
AcetyltransferaserimLLinUp1Feng et al., 2011Ribosome modification
Methionine aminopeptidasemapLinUp1Feng et al., 2011Amino-terminal maturation
Ribosomal subunit interface proteinspr2011LinUp1Feng et al., 2011Ribosome regulation
Ribosomal protein S4rpsDDapUp1Fischer et al., 2011Ribosomal subunit protein
Ribosomal protein S10rpsJMetUp1Enany et al., 2014Ribosomal subunit protein
DapUp1Fischer et al., 2011
Ribosomal protein S13rpsMMetUp1Enany et al., 2014Ribosomal subunit protein
DapUp1Fischer et al., 2011
Ribosomal protein S3rpsCMetUp1Enany et al., 2014Ribosomal subunit protein
DapUp1Fischer et al., 2011
Ribosomal protein L7/L12rplLMetUp1Enany et al., 2014Ribosomal subunit protein
DapUp1Fischer et al., 2011
Translational initiation factor IF-2infBVanDown1Pieper et al., 2006Translation
DapUp1Fischer et al., 2011
Essential GTPaseeraVanDown1Pieper et al., 2006Ribosome maturation
DapUp1Fischer et al., 2011
Ribosomal protein L2rplBVanDown1Hessling et al., 2013Ribosomal subunit protein
DapUp1Fischer et al., 2011
GTP-binding proteinengAVanDown1Scherl et al., 2006Ribosome maturation
DapUp1Fischer et al., 2011
Ribosomal protein S18rpsRLinUp1Feng et al., 2011Ribosomal subunit protein
DapUp1Fischer et al., 2011
Ribosomal protein L3rplCLinUp1Bernardo et al., 2004Ribosomal subunit protein
DapUp1Fischer et al., 2011
Ribosomal protein L27rpmALinUp1Bernardo et al., 2004Ribosomal subunit protein
DapUp1Fischer et al., 2011
Ribosomal protein L22rplVLinUp1Bernardo et al., 2004Ribosomal subunit protein
DapUp1Fischer et al., 2011
Ribosomal protein S9rplILinUp1Bernardo et al., 2004Ribosomal subunit protein
DapUp1Fischer et al., 2011
Ribosomal protein L15rplOLinUp1Bernardo et al., 2004Ribosomal subunit protein
DapUp1Fischer et al., 2011
Ribosomal protein L13rplMLinUp1Bernardo et al., 2004Ribosomal subunit protein
DapUp1Fischer et al., 2011
Ribosomal protein L4rplDLinUp1Bernardo et al., 2004Ribosomal subunit protein
DapUp1Fischer et al., 2011
Ribosomal protein L1rplALinUp2Bernardo et al., 2004; Feng et al., 2011Ribosomal subunit protein
DapUp1Fischer et al., 2011
30S ribosomal protein S1rpsAMetUp1Enany et al., 2014Ribosomal subunit protein
VanDown1Drummelsmith et al., 2007
DapUp1Fischer et al., 2011
Ribosomal protein L14rplNMetUp1Enany et al., 2014Ribosomal subunit protein
VanDown1Hessling et al., 2013
DapUp1Fischer et al., 2011
Ribosomal protein L21rplUMetUp1Enany et al., 2014Ribosomal subunit protein
LinUp2Bernardo et al., 2004; Feng et al., 2011
DapUp1Fischer et al., 2011
Ribosomal protein S6rpsFMetUp1Enany et al., 2014Ribosomal subunit protein
LinUp1Feng et al., 2011
DapUp1Fischer et al., 2011
Ribosomal protein L6rplFVanDown1Hessling et al., 2013Ribosomal subunit protein
LinUp1Bernardo et al., 2004
DapUp1Fischer et al., 2011
Ribosomal protein S2rpsBVanUp1Wang et al., 2010Ribosomal subunit protein
LinUp(down)1(1)Bernardo et al., 2004; Feng et al., 2011
DapUp1Fischer et al., 2011
Elongation factor TutufVanDown(up)1(1)Drummelsmith et al., 2007; Wang et al., 2010Translation
LinUp2Bernardo et al., 2004; Feng et al., 2011
DapUp1Fischer et al., 2011
50S ribosomal protein L20rplTVanUp1Drummelsmith et al., 2007Ribosomal subunit protein
LinDown1Feng et al., 2011
DapUp1Fischer et al., 2011
Elongation factor TstsfVanDown1Pieper et al., 2006Translation
LinUp1Feng et al., 2011
DapDown1Fischer et al., 2011
Translational elongation factor GfusAMetUp1Enany et al., 2014Translation
VanDown(up)1(1)Drummelsmith et al., 2007; Wang et al., 2010
LinUp1Bernardo et al., 2004
DapUp1Fischer et al., 2011
Post-translational modification, protein turnover, chaperonesATP-dependent Clp protease proteolytic subunitclpPMetUp1Cordwell et al., 2002Protein degradation
Preprotein translocasesecYVanUp1Scherl et al., 2006Protein translocation
ATP-dependent chaperone proteinclpBVanUp1Hessling et al., 2013Protein degradation
AminopeptidasepepSVanDown1Drummelsmith et al., 2007Protein degradation
Foldase precursorprsAVanUp3Scherl et al., 2006; Drummelsmith et al., 2007; Hessling et al., 2013Chaperone
ChaperonegroSVanUp1Pieper et al., 2006Chaperone
Methionine sulfoxide reductase AmsrAVanUp2Scherl et al., 2006; Chen et al., 2013Protein modification
Carboxy-terminal processing peptidasectpAVanUp1Scherl et al., 2006Protein processing
Cell wall-associated serine proteinase precursorprtALinUp1Feng et al., 2011Protein degradation
Methionine sulfoxide reductase BSA1256MetUp1Cordwell et al., 2002Protein modification
VanUp1Scherl et al., 2006
Glutamyl-aminopeptidasepepAVanUp1Wang et al., 2010Protein degradation
LinUp1Feng et al., 2011
ChaperonednaKVanUp(down)2(1)Scherl et al., 2006; Drummelsmith et al., 2007; Wang et al., 2010Chaperone
LinUp1Bernardo et al., 2004
Signal peptidase BspsBVanUp2Scherl et al., 2006; Drummelsmith et al., 2007Cleavage of signal peptide
DapDown1Fischer et al., 2011
Peptide methionine sulfoxide reductase regulatormsrRVanUp1Scherl et al., 2006Protein modification
DapDown1Fischer et al., 2011
PeptidaseftsHVanUp2Scherl et al., 2006; Drummelsmith et al., 2007Protein degradation
DapDown1Fischer et al., 2011

Differentially expressed proteins identified by the quantitative proteomic approach: proteins involved in replication, cell division, transcription, translation, and protein turnover.

Pieper et al. showed that purine ribonucleotide biosynthesis (PRNBS) pathway enzymes, which are under the control of the PurR regulator, strongly increased in protein abundance in the vancomycin-resistant S. aureus strain VP32 having a vancomycin MIC of 32 μg/ml when compared with the vancomycin-intermediate S. aureus strain HIP5827 (MIC = 8 μg/ml) (Pieper et al., 2006). Notably, among them, several proteins such as amidophosphoribosyltransferase (PurF), phosphoribosylamine-glycine ligase (PurD), phosphoribosylglycinamidine cyclo-ligase (PurM), phosphoribosylaminoimidazole-succinocarboxamide synthase (PurC), adenylosuccinate lyase (PurB), and bifunctional purine biosynthesis protein (PurH), were also changed in protein abundance in cases of other antibiotics such as daptomycin and linezolid (Table 4). Microarray transcription analysis of clinical VISA isolates already showed that among the 35 genes with increased transcription in vancomycin-resistant S. aureus strain VP32 when compared with those of their VISA parent strains HIP5827 and P100, 15 were involved in purine biosynthesis or transport (Mongodin et al., 2003). They hypothesized that increased energy (ATP) is required to generate the thicker cell walls that characterize resistant mutants (Mongodin et al., 2003). However, contrary to these results, other comparative proteomic analyses between vancomycin-susceptible strains and vancomycin-intermediate S. aureus strains did not show similar results (Scherl et al., 2006; Drummelsmith et al., 2007; Chen et al., 2013). Therefore, these results imply that VRSA may more efficiently compensate for a fitness cost of antibiotic resistance such as ATP requirement than VISA.

Abundance changes were also found in proteins such as the single-stranded DNA binding protein (TraM), DNA gyrase subunit B (GyrB), and topoisomerase IV subunit B (ParE), which catalyze or influence the fidelity of DNA replication and repair (Table 5). This result is consistent with the increasing evidence that exposure to antibiotics in bacteria leads to increased mutation rates in the genome, to favor their survivals under antibiotic pressure (Napolitano et al., 2000; Friedberg et al., 2002; Pieper et al., 2006). Expression levels of many enzymes involved in energy metabolisms, including L-lactate dehydrogenase (LdhA), glucose-6-phosphate isomerase (Pgi), succinyl-CoA synthetase (SucCD), phosphoglycerate kinase (Pgk), nitrate reductase alpha chain (NarG), and aconitate hydratase (CitB), were also changed. In fact, comparative proteomic analyses show that proteins involved in energy metabolism, protein synthesis, and envelope biogenesis, most frequently exhibit abundance change in antibiotic-resistant strains (Table 3). In many cases, proteins playing a role in energy metabolism were up-regulated in antibiotic-resistant strains (Table 3). This phenomenon may be explained by a prior hypothesis that increased energy (ATP) is required to generate the thicker cell walls or to pump antibiotics out of the cell using efflux pumps. This study also showed the changes of proteins involved in cell envelope biogenesis, such as D-Ala-D-Ala ligase (Ddl), D-Ala-D-Lac ligase (VanA), peptidoglycan hydrolase (LytM), cell division and cell wall biosynthesis protein (MraZ), putative cell wall transglycosylase (SceD), and glucosamine-fructose-6-phosphate aminotransferase (GlmS) (Pieper et al., 2006).

Similar to prior reports, Drummelsmith et al. showed the high level inductions of cell wall metabolism-related proteins such as MecA, LytM, GlmS, and SceD in the VISA type strain Mu50 when compared with the vancomycin-sensitive strain CMRSA-2 (Drummelsmith et al., 2007). In particular, they selected SceD for further study based on its high level of induction (approximately 16-fold) in VISA, and relative sceD mRNA expression levels were compared between 25 VSSA and VISA clinical isolates by real-time RT-PCR (Drummelsmith et al., 2007). The sceD mRNA was significantly induced in all VISA isolates relative to all VSSA strains, and they suggest that SceD expression level could serve as a molecular diagnostic marker for the rapid detection of VISA (Drummelsmith et al., 2007). Interestingly, SceD was also up-regulated in both daptomycin-resistant (Song et al., 2013) and linezolid-resistant strains (Bernardo et al., 2004), suggesting the importance of this protein in antibiotic resistance. They also identified other proteins involved in cell envelope metabolism as a highly up-regulated protein in VISA; UDP-GlcNAc 1-carboxyvinyltransferase 1 (MurA), bifunctional autolysin (Atl), immunodominant antigen A (IsaA), UDP-glucose/GDP-mannose dehydrogenase (CapO), and UDP-N-acetyltalosamine 2-epimerase (CapG) (Table 6). Among them, IsaA was also up-regulated in VISA at other two studies (Scherl et al., 2006; Chen et al., 2013). In addition, its expression level increased in both methicillin-resistant and daptomycin-resistant strains (Cordwell et al., 2002; Fischer et al., 2011), and decreased in linezolid-resistant strains (Bernardo et al., 2004), suggesting the importance of this protein. The housekeeping protein IsaA is a highly immunogenic, non-covalently cell wall-bound lytic transglycosylase that is co-regulated with a glycylglycine endopeptidase LytM (Stapleton et al., 2007; Lorenz et al., 2011). S. aureus has two putative peptidoglycan hydrolases, IsaA and SceD, and SceD can compensate for the loss of IsaA (Stapleton et al., 2007). The fact that both peptidoglycan hydrolases (IsaA and SceD) are involved in antibiotic resistance strongly indicates the importance of cell wall dynamics in antibiotic resistance mechanism.

Table 6

Biological processProtein nameGeneAntibioticsRegulationFrequency of differenceReferencesProtein description
Cell wall, membrane, envelope biogenesisAcyl carrier proteinacpPMetUp1Enany et al., 2014Membrane biosynthesis
2-C-methyl-D-erythritol 4-phosphate cytidylyltransferaseispDMetUp1Enany et al., 2014Isoprenoid biosynthesis
Capsular polysaccharide synthesis enzymecap8HVanUp1Scherl et al., 2006Capsular polysaccharide biosynthesis
Isopentenyl-diphosphate delta-isomerasefniVanDown1Drummelsmith et al., 2007Biosynthesis of isoprenoids
Malonyl CoA-ACP transacylasefabDVanDown1Scherl et al., 2006Fatty acid biosynthesis
Teichoic acid biosynthesis protein BtagBVanUp1Scherl et al., 2006Teichoic acid biosynthesis
Capsular polysaccharide synthesis protein Cap5DcapDVanUp1Scherl et al., 2006Capsular polysaccharide biosynthesis
Capsular polysaccharide synthesis protein Cap5McapMVanUp2Scherl et al., 2006; Hessling et al., 2013Capsular polysaccharide biosynthesis
Capsular polysaccharide synthesis protein Cap5AcapAVanUp1Scherl et al., 2006Capsular polysaccharide biosynthesis
UDP-glucose/GDP-mannose dehydrogenasecapOVanUp1Drummelsmith et al., 2007Capsular polysaccharide biosynthesis
D-alanine-d-alanine ligaseddlVanUp3Pieper et al., 2006; Hessling et al., 2013; Ramos et al., 2015Peptidoglycan biosynthesis
D-alanine-d-alanine dipeptidaseddpXVanUp1Ramos et al., 2015Peptidoglycan biosynthesis
D-alanine-d-lactate dipeptidasevanXVanUp1Wang et al., 2010Peptidoglycan biosynthesis
D-alanine-d-lactate ligasevanBVanUp1Wang et al., 2010Peptidoglycan biosynthesis
Surface determinant protein AisdAVanDown2Scherl et al., 2006; Drummelsmith et al., 2007
UDP-N-acetyltalosamine 2-epimerasecapGVanUp1Drummelsmith et al., 2007Capsular polysaccharide biosynthesis
GlycosyltransferasesgtBVanUp1Scherl et al., 2006
Penicillin binding protein 2AmecAVanUp2Scherl et al., 2006; Drummelsmith et al., 2007Peptidoglycan biosynthesis
Peptidoglycan hydrolaselytMVanUp2Pieper et al., 2006; Drummelsmith et al., 2007Peptidoglycan degradation
UDP-N-acetylmuramyl tripeptide synthetasemurEVanUp1Scherl et al., 2006Peptidoglycan biosynthesis
Enoyl-CoA hydratasephaBLinDown1Feng et al., 2011Fatty acid β-oxidation
3-Ketoacyl-ACP reductasefabGLinDown1Feng et al., 2011Fatty acids biosynthesis
Acetyl-CoA carboxylase biotin carboxyl carrier protein subunitaccBLinDown1Feng et al., 2011Fatty acid biosynthesis
Acetyl-CoA carboxylase subunit αaccALinDown1Feng et al., 2011Fatty acid biosynthesis
Control of cell shape; membrane-associated proteinmreBHDapUp1Wecke et al., 2009Control of cell shape
Squalene synthasecrtNDapDown1Fischer et al., 2011Isoprenoid biosynthesis
Glucosamine-fructose-6-phosphate aminotransferaseglmSVanUp2Pieper et al., 2006; Drummelsmith et al., 2007Peptidoglycan biosynthesis
DapUp1Fischer et al., 2011
UDP-GlcNAc 1-carboxyvinyltransferase 1murAVanUp1Drummelsmith et al., 2007Peptidoglycan biosynthesis
DapDown1Fischer et al., 2011
3-Oxoacyl-ACP synthase IIfabFVanUp2Scherl et al., 2006; Wang et al., 2010Fatty acid biosynthesis
DapUp1Fischer et al., 2011
Bifunctional N-acetylglucosamine-1-phosphate uridyltransferase/glucosamine-1-phosphate acetyltransferaseglmULinUp1Feng et al., 2011Peptidoglycan biosynthesis
DapUp1Fischer et al., 2011
CHAP (Cysteine, Histidine-dependent Amidohydrolases/Peptidases)-domain amidasessaAMetUp1Cordwell et al., 2002Peptidoglycan degradation
VanUp2Scherl et al., 2006; Drummelsmith et al., 2007
LinDown1Bernardo et al., 2004
Triacylglycerol lipase precursorlipAMetUp1Enany et al., 2014Lipoate biosynthesis
LinUp1Bernardo et al., 2004
DapDown1Fischer et al., 2011
AminoacyltransferasefemAMetUp1Cordwell et al., 2002Peptidoglycan biosynthesis
VanUp2Scherl et al., 2006; Hessling et al., 2013
DapUp1Fischer et al., 2011
Penicillin-binding protein 1pbpAMetUp1Cordwell et al., 2002Peptidoglycan biosynthesis
VanUp1Scherl et al., 2006
DapDown1Fischer et al., 2011
Hydroxymyristoyl ACP dehydratasefabZMetUp1Enany et al., 2014Fatty acid biosynthesis
VanDown1Drummelsmith et al., 2007
LinDown1Feng et al., 2011
DapDown1Fischer et al., 2011

Differentially expressed proteins identified by the quantitative proteomic approach: proteins involved in envelope biogenesis.

To identify the resistance mechanisms of hVISA with a vancomycin MIC of ≤2 μg/ml, Chen et al. compared proteomic profiles of six pairs of isogenic hVISA and VSSA strains and unrelated hVISA (n = 24) and VSSA stains (n = 30) (Chen et al., 2013). They identified five proteins up-regulated in the hVISA strains; IsaA, MsrA, Asp32, 2,3-bisphosphoglycerate-dependent phosphoglycerate mutase (GpmA), and AhpC. Consistent with this result, MsrA was up-regulated in a prior study using comparative proteomics (Scherl et al., 2006) and in the DNA microarray study, and the msrA gene was also over-expressed in VISA strains (Cui et al., 2005). MsrA, catalyzing the reversible oxidation-reduction of methionine sulfoxide to methionine, has a key function as a repair enzyme for proteins inactivated by oxidation (Chen et al., 2013). The msrA gene is highly induced by cell wall-active antibiotics, such as oxacillin and vancomycin (Chen et al., 2013). The increased level of MsrA can enhance peptidoglycan biosynthesis which results in cell wall thickening, and gene knockout of the msrA gene weakened vancomycin and β-lactam resistance of S. aureus strains (Cui et al., 2005). In addition, MsrA is involved in virulence in several bacteria (Sasindran et al., 2007). Taken together, these observations suggest the important role of methionine sulfoxide in antibiotic resistance. Although in other studies, the abundance of GpmA, which plays a physiological role in glycolysis, has been reported to be changed in VISA (Table 3), its exact role in antibiotic resistance has not been determined. AhpC, an alkyl hydroperoxide reductase subunit C, plays an important role in oxidative-stress resistance of S. aureus (Cosgrove et al., 2007). Interestingly, it was reported that AhpC is up-regulated in strains resistant to methicillin, vancomycin, and daptomycin antibiotics (Table 7). However, up to now, there is no report investigating the direct role of AhpC in antibiotic resistance. It is noteworthy that several proteins involved in oxidative-stress resistance, such as AhpC, SodA, catalase (KatA), and superoxide dismutase (SodM), show the abundance change of proteins in antibiotic-resistant strains (Table 7), and in most cases, their expression is up-regulated. In spite of these interesting results, the relationship between these proteins and antibiotic resistance was not determined.

Table 7

Biological processProtein nameGeneAntibioticsRegulationFrequency of differenceReferencesProtein description
General stress-related proteinsCold shock proteincspAMetUp1Cordwell et al., 2002Cold shock tolerance
Dps family proteindpsVanDown1Ramos et al., 2015Protection of DNA from damage
Two-component regulator proteinvanRVanUp1Ramos et al., 2015The VanS/VanR two-component system in response to extracellular glycopeptide antibiotic
Lactoylglutathione lyasegloAVanUp1Wang et al., 2010Methylglyoxal degradation
Cell stress stimulon response regulatorvraRVanUp2Scherl et al., 2006; Drummelsmith et al., 2007The two-component regulatory system VraS/VraR involved in the control of the cell wall peptidoglycan biosynthesis
HTH-type transcriptional regulatorsarSVanDown1Drummelsmith et al., 2007Transcriptional regulator that controls expression of some virulence factors in a cell density-dependent manner
Accessory gene regulator AagrAVanDown2Scherl et al., 2006; Drummelsmith et al., 2007The regulation of virulence proteins
Signal transduction protein TRAPtraPVanUp1Scherl et al., 2006A major regulator of staphylococcal pathogenesis
Thioredoxin reductasetrxBVanDown1Drummelsmith et al., 2007Thioredoxin pathway
Competence proteincglALinDown1Feng et al., 2011Competence regulation
Competence proteincglBLinDown1Feng et al., 2011Competence regulation
Phosphate transporterphoULinDown1Feng et al., 2011Phosphate starvation
Conserved membrane protein; phage-shock protein A homolog (three-component regulatory system)liaIHDapUp1Wecke et al., 2009Regulation of membrane permeability
Undecaprenyl pyrophosphate phosphatasebcrCDapUp1Wecke et al., 2009Bacitracin resistance
Superoxide dismutasesodMMetUp2Cordwell et al., 2002; Enany et al., 2014Resistance to oxidative stress
VanDown1Drummelsmith et al., 2007
Competence damage-inducible protein AcinAVanUp1Pieper et al., 2006Competence regulation
LinDown1Feng et al., 2011
Two-component sensor histidine kinasevraSVanUp1Scherl et al., 2006The two-component regulatory system VraS/VraR involved in the control of the cell wall peptidoglycan biosynthesis
DapUp1Fischer et al., 2011
Staphylococcus accessory regulator AsarAVanUp1Drummelsmith et al., 2007Regulation of the virulence factors
DapUp1Fischer et al., 2011
GTP pyrophosphokinaserelAVanDown1Drummelsmith et al., 2007Stringent response
DapUp2Wecke et al., 2009; Fischer et al., 2011
Choline dehydrogenasebetAVanUp1Scherl et al., 2006Glycine betaine biosynthesis
DapDown1Fischer et al., 2011
GTP-sensing transcriptional pleiotropic repressorcodYLinUp1Feng et al., 2011Transcription regulation in response to the GTP level
DapUp1Fischer et al., 2011
Alkaline shock protein 23asp23MetUp2Cordwell et al., 2002; Enany et al., 2014Alkaline pH tolerance
VanDown1Hessling et al., 2013
DapUp1Fischer et al., 2011
CatalasekatAMetUp1Cordwell et al., 2002Resistance to oxidative stress
VanUp1Scherl et al., 2006
DapUp1Fischer et al., 2011
Superoxide dismutasesodAMetUp2Cordwell et al., 2002; Enany et al., 2014Resistance to oxidative stress
VanUp1Wang et al., 2010
LinUp1Feng et al., 2011
Cold shock proteincspBMetUp1Cordwell et al., 2002Cold shock tolerance
VanDown1Drummelsmith et al., 2007
DapUp1Fischer et al., 2011
Cold shock proteincspCMetUp1Cordwell et al., 2002Cold shock tolerance
VanDown1Drummelsmith et al., 2007
DapUp1Fischer et al., 2011
Alkyl hydroperoxide reductase subunit CahpCMetUp1Enany et al., 2014Resistance to oxidative stress
VanUp2Scherl et al., 2006; Chen et al., 2013
DapUp1Fischer et al., 2011
Virulence-related proteinsSecreted virulence factoresxAVanDown1Drummelsmith et al., 2007Pathogenesis
Extracellular ECM and plasma binding proteinsspVanUp1Scherl et al., 2006Pathogenesis
Cell surface-associated proteinsdrEVanDown1Hessling et al., 2013Pathogenesis
Clumping factor AclfAVanDown1Hessling et al., 2013Pathogenesis
Secretory extracellular matrix and plasma binding proteinempbpVanDown1Hessling et al., 2013Pathogenesis
Enterotoxin type IseiVanDown1Hessling et al., 2013Pathogenesis
Cysteine protease precursorsspB1VanDown1Hessling et al., 2013Pathogenesis
LeukotoxinlukDVanDown1Hessling et al., 2013Pathogenesis
LeukotoxinlukEVanDown1Hessling et al., 2013Pathogenesis
Phospholipase ChlbVanDown1Hessling et al., 2013Pathogenesis
HysAhysAVanDown1Hessling et al., 2013Pathogenesis
γ-hemolysin, component ChlgCVanDown1Hessling et al., 2013Pathogenesis
LipasegehVanDown1Hessling et al., 2013Pathogenesis
Accessory protein ZsarZVanDown1Hessling et al., 2013Pathogenesis
α-hemolysinSAV1163LinDown1Bernardo et al., 2004Pathogenesis
Respiratory response proteinsrrAMetUp1Cordwell et al., 2002Pathogenesis
VanDown1Scherl et al., 2006
Fibrinogen-binding proteinefbMetUp1Enany et al., 2014Pathogenesis
VanDown1Hessling et al., 2013
Immunoglobulin G binding protein AspaVanDown2Pieper et al., 2006; Drummelsmith et al., 2007Pathogenesis
LinDown1Bernardo et al., 2004
Bifunctional autolysinatlVanUp1Drummelsmith et al., 2007Pathogenesis; Cell wall biogenesis/degradation
LinDown1Bernardo et al., 2004
DapUp1Fischer et al., 2011
Immunodominant antigen AisaAMetUp1Cordwell et al., 2002Pathogenesis; Cell wall biogenesis/degradation
VanUp3Scherl et al., 2006; Drummelsmith et al., 2007; Chen et al., 2013
LinDown1Bernardo et al., 2004
DapUp1Fischer et al., 2011

Differentially expressed proteins identified by the quantitative proteomic approach: proteins involved in stress response.

Hassling et al. analyzed proteomic profiles of vancomycin-susceptible S. aureus strain COL under the sublethal vancomycin exposure (4.5 μg/ml) (Hessling et al., 2013). They found the specific increase of proteins involved in the synthesis of lysine which are essential for the synthesis of the peptidoglycan precursor pentapeptide; aspartate kinase (LysC), aspartate semialdehyde dehydrogenase (Asd), dihydrodipicolinate synthase (DapA), 4-hydroxy-tetrahydrodipicolinate reductase (DapB), diaminopimelate decarboxylase (LysA), and tetrahydrodipicolinate acetyltransferase (DapD). An increase of lysine synthesis proteins can lead to an overall increase of peptidoglycan synthesis. Induction of genes involved in lysine synthesis under cell wall stress conditions have been documented before by two transcriptome studies (Kuroda et al., 2003; Sobral et al., 2007). Consistent with the previous report (Scherl et al., 2006), this report also showed that several proteins regulated by the two-component system VraSR increased in amount after vancomycin addition (Hessling et al., 2013). Additionally, they identified two important regulators (the alternative sigma factor σB and the two-component system SaeRS regulating numerous virulence genes) that play a role in vancomycin stress response. The cluster of proteins under positive σB control mainly increased, whereas negatively regulated proteins primarily decreased in amount after vancomycin addition (Hessling et al., 2013). The induction of σB regulon by vancomycin has been found in another report (Chen et al., 2013). Increase of the σB activity has also been observed in strains resistant to teicoplanin (Bischoff and Berger-Bächi, 2001) or methicillin (Cordwell et al., 2002). Hassling et al. also found decreased expression levels of most proteins with a virulence related function (Hessling et al., 2013). However, because the great majority of virulence genes in previous transcriptome studies under cell wall stress in S. aureus have been shown to be up-regulated (Kuroda et al., 2003; Utaida et al., 2003; Sobral et al., 2007), the role of virulence genes in antibiotic resistance needs to be determined.

Lastly, Wang et al. and Ramos et al. performed proteomic analysis of vancomycin-resistant E. faecalis strains (V583, V306, and SU18) under 64 μg/ml vancomycin treatment (Wang et al., 2010; Ramos et al., 2015). Vancomycin induced expression of vancomycin resistance-related proteins such as VanA, VanX, D-Ala-D-Ala dipeptidase (DdpX), VanR, and VanB (Wang et al., 2010; Ramos et al., 2015). Distinctively, Wang et al. found that six proteins (Pgm, Ldh, Gap-2, RpsB, EF2076, and sex pheromone cAD1 precursor lipoprotein) exhibited clear post-translational modifications and vancomycin induced phosphorylation of Ser/Thr in Ldh, Gap-2, and sex pheromone cAD1 precursor lipoprotein (EF3256) (Wang et al., 2010). Ramos et al. showed that metabolism-related proteins, such as TipA, GMP synthase (GuaA), and glyceraldehyde-3-phosphate dehydrogenase (GapB), were down-regulated under vancomycin treatment (Ramos et al., 2015).

Linezolid

There was one study exploring comparative proteomic profiles in linezolid-susceptible S. pneumonia strains and linezolid-resistant S. pneumonia strains, and one study analyzing global proteomes of a linezolid- susceptible S. aureus under linezolid stresses (Bernardo et al., 2004; Feng et al., 2011). Through the comparison between linezolid-susceptible S. pneumonia strains (1974 and R6) with linezolid MICs of 0.5–0.75 μg/ml and linezolid-resistant S. pneumonia strains (1974M2-LZD and R6M2-LZD) with MIC of 32 μg/ml, Feng et al. showed that the proteomic and transcriptomic approaches were poorly correlated with previously known resistance factors (23S rRNA, ribosomal proteins L3 and L4, RNA methyltransferase Cfr, and ABC transporter PatA and PatB), as modulated proteins rarely had significant concomitant changes at the expression level (Feng et al., 2011). They found increased expression of proteins involved in the metabolism and transport of carbohydrates in linezolid-resistant S. pneumoniae strains (Feng et al., 2011). Through inactivation of target genes in the linezolid-resistant strains (1974M2-LZD and R6M2-LZD), they identified two ABC transporter substrate-binding proteins (Spr0083 and Spr1527) and the catabolite control protein A (CcpA) as factors associated with resistance to linezolid (Feng et al., 2011). CcpA is known to function as the global regulator controlling the efficient utilization of sugars through carbon catabolite repression (CCR) in Gram-positive bacteria (Stülke and Hillen, 2000). Inactivation of the ccpA gene in S. aureus affected growth, glucose metabolism, and expression of virulence genes (Seidl et al., 2006). CcpA inactivation was also linked to the down-regulation of glycolytic genes in Bacillus cereus (van der Voort et al., 2008; Feng et al., 2011). Therefore, the increased level of CcpA may cause the increased expression of glycolytic enzymes in linezolid-resistant S. pneumonia strains. In S. aureus, the correlation between antibiotic resistance and CcpA has already been reported, as CcpA inactivation significantly reduced the oxacillin resistance levels in MRSA and the teicoplanin resistance level in a glycopeptide-intermediate-resistant S. aureus strain (Seidl et al., 2006). Table 3 shows the possibility that CcpA may also be involved in methicillin and vancomycin resistance. Together with CcpA, inactivation of two ABC transporters putatively involved in the sugar transport (Spr0083 and Spr1527) also reduced resistance to linezolid of S. pneumonia (Feng et al., 2011). Notably, S. pneumoniae is predicted to be highly dependent on external sugars to fulfill its energy requirements by substrate-level phosphorylation as it lacks functional electron transport chain and tricarboxylic acid cycle (Tettelin et al., 2001; Feng et al., 2011). This process eventually leads to the formation of lactate and acetate by the lactate dehydrogenase and lactate oxidase enzymes and these proteins were also found to be overexpressed in linezolid-resistant S. pneumonia strains (Tettelin et al., 2001; Feng et al., 2011). Therefore, these results imply increased energy requirements associated with resistance mechanism to linezolid in S. pneumonia (Feng et al., 2011). To sustain a fitness cost associated with resistance mechanisms such as the 23S rRNA mutations (Besier et al., 2008), S. pneumonia seems to select an increased metabolism of sugars as a secondary adaptation.

This study also showed that several genes involved in the biosynthesis of fatty acids, including enoyl-CoA hydratase (PhaB), 3-ketoacyl-ACP reductase (FabG), acetyl-CoA carboxylase biotin carboxyl carrier protein subunit (AccB), acetyl-CoA carboxylase subunit alpha (AccA), and hydroxymyristoyl-ACP dehydratase (FabZ), were down-regulated in linezolid-resistant strains (Feng et al., 2011). Whether this is directly related to linezolid resistance remains to be established, but it is intriguing that the cell wall inhibitor penicillin also causes a down-regulation of several genes of this pathway in S. pneumoniae (Rogers et al., 2007; Feng et al., 2011). Interestingly, expression levels of FabZ are changed in all cases of the four antibiotics (Table 6), even though its expression increased in methicillin-resistant strains and decreased in strains resistant to other antibiotics. Many numbers of ribosomal proteins were found to be overexpressed or down-regulated in linezolid-resistant strains, but whether this pattern is due to the mechanism of action of linezolid (which targets the ribosome) remains to be established. Although recent several lines of evidence indicate the presence of functional selective ribosomal subpopulations that exhibit variations in the RNA or the protein components and modulate the translational program in response to environmental changes (Byrgazov et al., 2013), it is difficult to obtain any information from variation patterns of ribosomal proteins in this study.

Bernardo et al. compared the change of proteomic profiles of a linezolid- susceptible S. aureus strain ATCC 29213 (MIC = 2.5 μg/ml) under linezolid stresses (12.5, 25, 50, and 90% of MIC) (Bernardo et al., 2004). They found that linezolid reduced in a dose-dependent manner the secretion of specific virulence factors, including bifunctional autolysin (Atl), immunoglobulin G binding protein A (Spa), and α-hemolysin (SAV1163), CHAP-domain amidase (SsaA), and immunodominant antigen A (IsaA). This result is similar to the proteomic result that analyzes protein profiles of S. aureus under the sublethal vancomycin exposure (Hessling et al., 2013).

Daptomycin

There were one study examining comparative proteomic profiles in daptomycin-susceptible and daptomycin-resistant S. aureus strains, and one study analyzing global proteomes of daptomycin-susceptible B. subtilis under daptomycin stress (Wecke et al., 2009; Fischer et al., 2011). Unlike other three antibiotics (methicillin, vancomycin, and linezolid), specific genetic determinant of the daptomycin-resistant strain was not determined. Probable daptomycin resistance-related proteins (MprF, YycG, RpoB, and RpoC) identified in previous reports (Jones et al., 2008; Baltz, 2009) were not identified in comparative proteomic analyses (Tables 2–8). In 2011, Fisher et al. compared proteomic profiles in the daptomycin-susceptible S. aureus strain 616 with a daptomycin MIC of 0.5 μg/ml and the daptomycin-resistant S. aureus strain 701 with MIC of 2 μg/ml (Fischer et al., 2011). Comparative proteomics and transcriptomic approach revealed a differential abundance of proteins in various functional categories, including cell wall-associated targets and biofilm formation proteins (Fischer et al., 2011). Phenotypically, daptomycin-susceptible strains, and daptomycin-resistant strains showed major differences in their ability to develop bacterial biofilms in the presence of the antibacterial lipid, oleic acid (Fischer et al., 2011). Transcriptomic approach showed different expressions of some important genes, such as the key genes (yycFGHI) affecting cell membrane lipid homeostasis, cell wall metabolism and biofilm formation, and two-component regulation system genes (agr, saeRS, and vraRS) involved in pathogenesis of methicillin-resistant strains (Fischer et al., 2011). However, through proteomic research, only several proteins, including Asp23, 3-oxoacyl-ACP synthase II (FabF), GTP-sensing transcriptional pleiotropic repressor (CodY), and PurH, was identified as proteins involved in daptomycin resistance.

Table 8

Biological processProtein nameGeneAntibioticsRegulationFrequency of differenceReferencesProtein description
General function prediction onlyMetal-dependent hydrolaseSA1529MetDown1Cordwell et al., 2002Protein degradation
Aldehyde dehydrogenaseSAV2122MetUp1Enany et al., 2014Energy metabolism
Putative transaldolasetalVanDown1Drummelsmith et al., 2007Energy metabolism
Putative transcription factorSA2296VanUp1Scherl et al., 2006Gene expression
Penicillin binding methicillin resistant-related proteinfmtAVanUp1Scherl et al., 2006Peptidoglycan biosynthesis
Putative cell wall transglycosylasesceDVanUp1Pieper et al., 2006Peptidoglycan degradation
LinUp1Bernardo et al., 2004
ABC protein/substrate binding protein subunit—Sugar transportspr0083LinUp1Feng et al., 2011Carbohydrate transport
ABC protein/substrate binding protein subunit—sugar transportspr1527LinUp1Feng et al., 2011Carbohydrate transport
Maltose/maltodextrin-binding proteinSA0207DapDown1Fischer et al., 2011Carbohydrate transport
Function unknownUnknownSA1238MetUp1Cordwell et al., 2002Unknown
UnknownSA1051MetUp1Cordwell et al., 2002Unknown
UnknownSA0940MetUp1Cordwell et al., 2002Unknown
UnknownSA1868MetUp1Cordwell et al., 2002Unknown
UnknownSA1813MetUp1Cordwell et al., 2002Unknown
UnknownSA2302MetDown1Cordwell et al., 2002Unknown
UnknownSA0759MetDown1Cordwell et al., 2002Unknown
UnknownSA1812MetUp1Cordwell et al., 2002Unknown
UnknownSA0587MetUp1Cordwell et al., 2002Unknown
UnknownSA0772MetUp1Cordwell et al., 2002Unknown
UnknownSA0587MetUp1Cordwell et al., 2002Unknown
UnknownSA1455MetUp1Cordwell et al., 2002Unknown
UnknownSA0919MetDown1Cordwell et al., 2002Unknown
UnknownSA1709MetDown1Cordwell et al., 2002Unknown
UnknownSA0022VanDown1Scherl et al., 2006Unknown
UnknownSA2113VanUp1Scherl et al., 2006Unknown
UnknownvraXVanUp1Scherl et al., 2006Unknown
UnknownSA0423LinDown1Bernardo et al., 2004Unknown
UnknownSAV0719LinDown1Bernardo et al., 2004Unknown
Unknownspr1987LinDown1Feng et al., 2011Unknown
Unknownspr0033LinUp1Feng et al., 2011Unknown
Unknownspr0125LinDown1Feng et al., 2011Unknown
Unknownspr0895LinUp1Feng et al., 2011Unknown
Unknownspr0618LinUp1Feng et al., 2011Unknown
Unknownspr0997LinDown1Feng et al., 2011Unknown
Unknownspr1332LinUp1Feng et al., 2011Unknown
Unknownspr1693LinUp1Feng et al., 2011Unknown
Unknownspr1726LinUp1Feng et al., 2011Unknown
Unknownspr1758LinDown1Feng et al., 2011Unknown
Unknownspr2029LinDown1Feng et al., 2011Unknown
Unknownspr0174LinUp1Feng et al., 2011Unknown
Unknownspr0370LinUp1Feng et al., 2011Unknown
UnknownSA0269DapDown1Fischer et al., 2011Unknown
UnknownSA0591VanUp1Scherl et al., 2006Unknown
UnknownSA1528MetDown1Cordwell et al., 2002Unknown
DapDown1Fischer et al., 2011

Differentially expressed proteins identified by the quantitative proteomic approach: proteins of unknown function.

Wecke et al. searched proteins induced by daptomycin, through the proteomic approach of a daptomycin-susceptible B. subtilis strain W168 under daptomycin treatment of sublethal amount (1 μg/ml) (Wecke et al., 2009). They identified LiaI and LiaH proteins exclusively and strongly induced (429-fold) by daptomycin. This result is in good agreement with data analyzing genes induced by daptomycin through transcriptome profiling (Muthaiyan et al., 2008). LiaH is a conserved membrane protein similar to a phage shock protein A (PspA) of E. coli, and its expression is regulated by the cell envelope stress-sensing two-component system LiaRS (Jordan et al., 2006; Hachmann et al., 2009; Wecke et al., 2009). Inactivation of liaH leads to 3-fold increased susceptibility to daptomycin and this susceptibility was further exacerbated in cells additionally lacking the paralogous gene pspA (Hachmann et al., 2009). In E. coli, the pspA gene is induced upon phage infection, osmotic shock, exposure to ethanol, or temperature increase, and functions to help cells manage the impacts of agents impairing cell membrane function (Joly et al., 2010). A recent report showed that deletion of the response regulator LiaR regulating expression of liaIH in daptomycin-resistant E. faecalis reversed resistance to daptomycin, and resulted in hypersusceptibility to daptomycin (Reyes et al., 2015). Therefore, these results indicate that LiaR is a master regulator protecting cell membrane to diverse antimicrobial agents, through regulating expression of various genes such as the liaH gene (Reyes et al., 2015).

Conclusion

Although specific genetic determinants of resistance mechanisms to methicillin, vancomycin, and linezolid were identified through non-proteomic approaches (e.g., van genes in vancomycin resistance) (Table 1), recent comparative proteomic methods provide new opportunities to understand the antibiotic resistance mechanism. In particular, in the case of recently used antibiotics such as daptomycin, specific genetic determinant(s) of antibiotic resistance was not fully determined through non-proteomic approaches. Therefore, quantitative proteomic methods can be a good tool to find an important protein involved in daptomycin resistance. Actually, a proteomic research identified LiaH as a highly induced protein by daptomycin treatment (Muthaiyan et al., 2008) and a subsequent report showed that the expression level of this protein is important to daptomycin-resistant phenotype (Reyes et al., 2015). These results show that quantitative proteomic analysis can be used as an effective tool to find novel resistance mechanisms.

Interestingly, comparative proteomic approaches in methicillin, linezolid, and daptomycin, except for vancomycin, were poorly correlated with known resistance-related factors found by non-proteomic approaches (Table 2). This result may be caused by a lack of comparative proteomic studies in three antibiotics, or imply the existence of novel resistance mechanisms different from previously known resistance mechanisms found by non-proteomic approaches. Through summarizing recent data of comparative proteomic researches of four clinically important antibiotics, we can find proteins of which expression levels are changed only in the resistance mechanism to specific antibiotic, such as LiaH in daptomycin resistance and PrsA in vancomycin resistance. It is necessary to determine whether these proteins affect antibiotic resistance through regulating previously known resistance-related determinants or by a novel mechanism. Another interesting result is that many proteins identified by comparative proteomic analyses seem to be simultaneously involved in resistance mechanism to two or more antibiotics (Tables 2–8). These proteins include cold shock proteins (CspABC), sporulation protein G (SpoVG), alkyl hydroperoxide reductase subunit C (AhpC), L-lactate dehydrogenase (LdhA), triacylglycerol lipase precursor (LipA), superoxide dismutase (SodA), catalase (KatA), elongation factor G (FusA), CHAP-domain amidase (SsaA), two component system (VraSR), penicillin binding methicillin resistant-related protein (FmtA), adenylosuccinate lyase (PurB), glucose-6-phosphate isomerase (Pgi), catabolite control protein A (CcpA), putative cell wall transglycosylase (SceD), immunodominant antigen A (IsaA), bifunctional autolysin (Atl), the σB regulon, and hydroxymyristoyl-ACP dehydratase (FabZ). These proteins can be divided into two groups, proteins involved in bacterial envelope regulation and proteins compensating for a fitness cost of antibiotic resistance. Proteins such as LipA, VraSR, FmtA, SsaA, SceD, IsaA, Atl, and FabZ, are directly or indirectly involved in envelope regulation. In order to modify or thicken the bacterial cell wall for antibiotic resistance, cells require abundant energy, and proteins involved in stress adaptation are necessary to neutralize various damages by antibiotic. To sustain these fitness costs associated with resistance mechanisms, proteins involved in energy metabolism (LdhA, FusA, Pgi, PurB, and CcpA) and stress-related proteins (CspABC, SpoVG, AhpC, SodA, KatA, and the σB regulon) seem to be identified in resistance mechanisms to several antibiotics. Therefore, these proteomic results confirm that antibiotic resistance requires a fitness cost.

Detailed studies on the mechanism by which these proteins affect antibiotic resistance are required. In particular, because these proteins can act as the global factor affecting resistance mechanisms to most antibiotics, it is necessary to examine whether they affect resistance mechanism of other antibiotics having different action modes. These studies will provide important clues for understanding and managing antibiotic resistance.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Statements

Acknowledgments

This study was supported by the National Research Laboratory Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (No. 2011-0027928); the Cooperative Research Program for Agriculture Science and Technology Development (No. PJ01103103) of Rural Development Administration in Republic of Korea; and the National Research Foundation of the Ministry of Education, Republic of Korea (2012R1A1A2044184).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Summary

Keywords

quantitative proteomics, methicillin resistance, vancomycin resistance, linezolid resistance, daptomycin resistance

Citation

Lee C-R, Lee JH, Park KS, Jeong BC and Lee SH (2015) Quantitative proteomic view associated with resistance to clinically important antibiotics in Gram-positive bacteria: a systematic review. Front. Microbiol. 6:828. doi: 10.3389/fmicb.2015.00828

Received

04 June 2015

Accepted

27 July 2015

Published

11 August 2015

Volume

6 - 2015

Edited by

Antonio C. M. Correia, Universidade de Aveiro, Portugal

Reviewed by

Dmitri Debabov, NovaBay Pharmaceuticals, USA; Annalisa Pantosti, Istituto Superiore di Sanità, Italy

Copyright

*Correspondence: Sang Hee Lee, National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, 116 Myongjiro, Yongin, Gyeonggido 17058, South Korea

†These authors have contributed equally to this work.

This article was submitted to Antimicrobials, Resistance and Chemotherapy, a section of the journal Frontiers in Microbiology

Disclaimer

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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