Past exam of the genetics course of the University of Cambridge / 2024 / Paper 1 / 6 / Solution

Susceptibility of an isolated bacterium and failure to clear an infection measure different things. The scenario does not establish a particular resistance gene or a real species-specific mechanism. First distinguish antibiotic resistance, an increased ability to grow at inhibitory drug concentrations, from antibiotic tolerance, slower killing without the corresponding increase in the growth-inhibiting concentration, and bacterial persistence, survival of a subpopulation in an otherwise susceptible population.

One explanation is a reversible physiological state. Slowly growing or metabolically altered bacteria can survive an antibiotic whose lethal action depends on the active process it targets. Regrown survivors can then recover the original susceptibility. Nathalie Q. Balaban and colleagues directly followed individual bacteria and showed switching between growth states associated with persistence. The important inference is phenotypic heterogeneity, not that all survivors must share one dormant state or one toxin-antitoxin pathway.^[ref]

A second explanation is the local infection environment. Biofilms can generate heterogeneous growth conditions, altered penetration and protected reservoirs; intracellular localization can separate bacteria from otherwise adequate extracellular drug exposure. Nutrient limitation, oxygen conditions, pH and host stress can change physiology or drug activity. Conversely, a laboratory sample may miss a resistant minority, mixed infection or an inducible phenotype, so apparent susceptibility should not be treated as proof that every bacterium at every site has the same response.

Triggers can include changes imposed by the host environment, entry into a slow-growth state, or stress associated with prior exposure. These are alternative hypotheses: the question supplies no data selecting one. Bacteria surviving because exposure never reached an effective level are also different from bacteria surviving an adequately delivered exposure. Persistence may pre-exist exposure rather than being induced by it.

At the level of investigation, compare inhibition of growth with survival over time, examine whether the phenotype persists after regrowth, and assess population heterogeneity and protected infection sites. A high-level response to treatment failure is to identify the reservoir and exposure problem, establish which organism and phenotype are actually present, and consider approaches addressing that mechanism rather than assuming that simply increasing the same drug will solve it. Removal of a colonized foreign-body reservoir, where relevant, addresses a different cause from a change in antimicrobial choice. The information supplied is insufficient to name an effective drug regimen or infer a single molecular trigger.