Heteroresistance in Enterobacter cloacae complex caused by cell-to-cell variation in transient gene duplication-amplification events

Heteroresistance in bacteria describes a subpopulational phenomenon of transient antibiotic resistance variation among cells of a generally susceptible population. Here, we investigated the molecular mechanisms and phenotypic characteristics underlying heteroresistance to ceftazidime (CAZ) in a clinical Enterobacter cloacae complex strain (ECC). We identified a plasmid-borne gene duplication-amplification (GDA) event of a region harboring an ampC gene encoding a β-lactamase blaDHA-1 as the key determinant of heteroresistance. Individual colonies exhibited variations in the copy number of the genes resulting in resistance level variation which correlated with growth onset (lag times) and growth rates in the presence of CAZ, analysed in linear models. GDA copy number heterogeneity occurred within single resistant colonies, demonstrating heterogeneity of GDA on the single-cell level. The interdependence between GDA, lag time and antibiotic treatment and the strong plasticity underlying heteroresistance underlines the high risk for misdetection of antimicrobial heteroresistance and subsequent treatment failure.