Diversified repertoire of phage resistance in Klebsiella pneumoniae and bidirectional steering effects impacting antibiotic susceptibility

Bacteriophage (phage) therapy is rising as a promising anti-infective option to combat antimicrobial resistance; however, its clinical utilization is severely hindered by the potential emergence of phage resistance. Fortunately, certain phage resistance mechanisms can restore bacterial antibiotic susceptibility, making the combination of phages with antibiotics a potential strategic approach. Here, we demonstrated that phage resistance can also lead to increased antibiotic resistance and provided mechanistic insights into bacterial phage defense mechanisms. We discovered a repertoire of phage resistance mechanisms in Klebsiella pneumoniae, including the disruption of phage binding site (fhuA::Tn and tonB::Tn), extension of phage latent period (mnmE::Tn and rpoN::Tn) and increased mutation frequency (mutS::Tn and mutL::Tn). Different from the prevailing view that phage resistance re-sensitizes antibiotic-resistant bacteria, we revealed a bidirectional steering effect on the bacterial antibiotic susceptibility. Specifically, it was uncovered that, while rpoN::Tn became more susceptible to colistin, mutS::Tn and mutL::Tn caused increased resistance to rifampicin and colistin. Our findings highlight the diversified strategies utilized by K. pneumoniae to overcome phage infection and the parallel effect on the antibiotic susceptibility. Mechanism-guided phage steering represents a rational strategy that should be incorporated into phage therapy to better inform clinical decisions.