Native CRISPR-Cas mediated in situ genome editing reveals the exquisite interplay of resistance mutations in clinical multidrug resistant Pseudomonas aeruginosa

Antimicrobial resistance (AMR) is imposing a global public health threat. Despite its importance, resistance characterization in the native background of clinically isolated resistant pathogens is frequently hindered by the lack of genome editing tools in these \"non-model\" strains. Pseudomonas aeruginosa is both a prototypical multidrug resistant (MDR) pathogen and a model species for understanding CRISPR-Cas functions. In this study, we report the successful development of the first native type I-F CRISPR-Cas mediated, one-step genome editing technique in a paradigmatic MDR strain PA154197. The technique is readily applicable in additional type I-F CRISPR-containing, clinical/environmental P. aeruginosa isolates. A two-step In-Del strategy is further developed to edit genomic locus lacking an effective PAM (protospacer adjacent motif) or within an essential gene, which together principally allows any type of non-lethal genomic manipulations in these strains. Exploiting these powerful techniques, a series of reverse mutations are constructed and the key resistant determinants of the MDR PA154197 are elucidated which include over-production of two multidrug efflux pumps MexAB-OprM and MexEF-OprN, and a typical fluoroquinolone (FQ) resistance mutation T83I in the drug target gene gyrA. Characterizing antimicrobial susceptibilities in isogenic strains containing various combinations of single, double, or all three key resistance determinants reveal that i) extensive synergy exists between the target mutation and over-production of efflux pumps, and between the two over-produced tripartite efflux pumps to confer clinically significant FQ resistance; ii) while basal level MexAB-OprM confers resistance only to penicillins, its over-production leads to substantial resistance to all antipseudonmonal {beta}-lactams and additional resistance to FQs; iii) despite the acquisition and over-production of multiple resistant mutations, no obvious evolutionary trade-off of collateral sensitivity is developed in PA154197. Together, these results provide new insights into resistance development in clinical MDR P. aeruginosa strains and demonstrate the great potentials of native CRISPR systems in AMR research.