Potentiation and Mechanism of Berberine as an Antibiotic Adjuvant Against Multidrug-Resistant Bacteria

Figures & data

Figure 1 Chemical structure of berberine. Adapted from Ai X, Yu P, Peng L, et al. Berberine: a review of its pharmacokinetics properties and therapeutic potentials in diverse vascular diseases. Front Pharmacol. 2021;12:762654. Creative Commons.²⁴

Table 1 The Effect of Sub-MIC Berberine on Antibiotics Against Common Multidrug-Resistant Bacteria

Bacteria Stains	Antibiotic	No. of Strains^a	Fold Decrease		<4 Fold Decrease (No.)	≥4 Fold Decrease (No.)	Unkown	FICI	Synergism (No.)	Additivity (No.)	Indifference (No.)	Antagonism (No.)	Unknown (No.)	References
Gram-negative bacteria
P. aeruginosa	IMP	1	8			1		0.38	1					[44]
P. aeruginosa	TOB	33	1~16	17		16		0.31~1.25	13	13	7			[42]
P. aeruginosa	TOB	3	2~8	1		2		0.31~0.75	2	1				[41]
P. aeruginosa	ABK	3	8			3		0.12	3					[41]
P. aeruginosa	AMK	3	4~8			3		0.38~0.5	3					[41]
P. aeruginosa	GEN	3	4			3		0.13~0.25	3					[41]
P. aeruginosa	AZM	10	4~16			10		0.06~0.25	10					[40]
A. baumannii	MEN	4	8~64			4		0.27~0.63	3	1				[45]
A. baumannii	SUL	4	2~8	1		3		0.31~0.75	3	1				[45]
A. baumannii	CIP	4	8~32			4		0.28~1.13	1	2	1			[45]
A. baumannii	TGC	4	2~16	1		3		0.56~0.75		4				[45]
Salmonella	CIP	1	4			1		0.75		1				[46]
K. pneumoniae	CIP	20						0.50~1.5	2	17	1			[47]
Gram-positive bacteria
MRSA	AMP	1	4			1		0.63		1				[48]
MRSA	OXA	1	8			1		0.50	1					[48]
MRSA	AZM	10	4~16			10		0.19~0.63	9	1				[49]
MRSA	LEV	10	2~8	1		9		0.38~0.75	9	1				[49]
MRSA	CLI	15	2~32	1		13	1	0.16~0.75	12	2			1	[50]
MRSA	RIF	15	16~64			14	1	0.27~0.52	13	1			1	[50]
MRSA	FA	30	1~8	22		8		0.19~2.00	6	15	9			[51]
C. difficile	VAN	9	1~32	3		6		0.56~1.50		8	1			[52]
Mycobacteria
M. avium complex	CLA	12	2~8192	1		10	1						1	[53]
M. abscessus	TMP/SXT	1	4			1		0.75		1				[54]
M. abscessus	CLA	1	4			1		0.75		1				[54]
M. abscessus	LZD	1	8			1		0.625		1				[54]
M. abscessus	AMI	1	2	1				1		1				[54]
M. abscessus	TOB	1	1	1				1.5			1			[54]
M. abscessus	DOX	1	1	1				1.5			1			[54]
M. abscessus	MIN	1	1	1				1.5			1			[54]
M. abscessus	TGC	1	2	1				1		1				[54]
M. abscessus	IMP	1	2	1				1		1				[54]
M. abscessus	FOX	1	2	1				1		1				[54]
M. abscessus	FEP	1	2	1				1		1				[54]
M. abscessus	AXO	1	1	1				1.5			1			[54]
M. abscessus	AUG	1	1	1				1.5			1			[54]
M. abscessus	CIP	1	2	1				1		1				[54]
M. abscessus	MXF	1	1	1				1.5			1			[54]

Notes: ^aOnly clinical strains were counted.

Abbreviations: MIC, minimum inhibitory concentrations; MRSA, methicillin-resistant staphylococcus aureus; AMK, amikacin; ABK, arbekacin; GEN, gentamicin; AZM, azithromycin; SUL, sulbactam; TGC, tigecycline; CIP, ciprofloxacin; MEM, meropenem; AMP, ampicillin; OXA, oxacillin; LEV, levofloxacin; CLI, clindamycin; RIF, rifampicin; FA, fusidic acid; VAN, Vancomycin; TMP/SXT, trimethoprim/sulfamethoxazole; CLA, clarithromycin; LZD, linezolid; IMP, imipenem; FOX, cefoxitin; CIP, ciprofloxacin; MXF, moxifloxacin; DOX, doxycycline; MIN, minocycline; AMI, amikacin; TOB, tobramycin; AUG, amoxicillin/clavulanic acid; AXO, ceftriaxone; FEP, cefepime; TGC, tigecycline.

Figure 2 The synergistic mechanism of berberine (BER) in inhibiting antibiotic efflux. (A) BER inhibits the expression of efflux pump genes, preventing antibiotic efflux. In Pseudomonas aeruginosa, Acinetobacter xylosoxidans and Burkholderia cepacia, BER significantly reduces the expression of the MexXY multidrug efflux system, leading to a decrease in efflux of various antibiotics, including aminoglycosides (amikacin, arbekacin, gentamicin and tobramycin), β-lactams (cefepime and imipenem), macrolides (erythromycin), and lincosamides (lincomycin). (B) BER acts as a competitor in inhibiting antibiotic efflux. In Acinetobacter baumannii, BER enhances the expression of the AdeABC efflux pump gene adeB, and in multidrug-resistant Klebsiella pneumoniae, BER upregulates the expression of the acrA, acrB, tolC and acrR genes associated with the AcrAB-TolC efflux pump. BER exhibits a greater affinity for these efflux pumps and is preferentially pumped out, thereby reducing the efflux of other corresponding antibiotics. The figure was created with BioRender.com (https://app.biorender.com).

Figure 3 Berberine (BER) enhances antibiotic resistance by inhibiting the biofilm formation. (A) BER reduces the expression and quantity of type I fimbriae by affecting the expression of the fimA gene, thereby decreasing the activity and adhesion of Salmonella typhimurium. (B) BER affects the bacterial attachment, microcolony and biofilm maturation of Pseudomonas aeruginosa by reducing the levels of QS molecules and the expression of key genes involved in biofilm establishment and structural stability, such as lasI, lasR, rhlI, rhlR, eDNA and the alginate-related regulatory genes algG, algD and algR. (C) BER inhibits the attachment, microcolony formation and biofilm maturation, and promotes biofilm dispersal of Staphylococcus aureus by significantly downregulating the expression of genes associated with biofilm formation, such as srtA, agr, sarA, fnbA, rbf, lrgA, cidA and eno. These genes affect the production of polysaccharide intercellular adhesin (PIA), multiple extracellular proteases, and bacterial cell wall anchoring (CWA) proteins, etc. The figure was created with BioRender.com (https://app.biorender.com).

Ai X, Yu P, Peng L, et al. Berberine: a review of its pharmacokinetics properties and therapeutic potentials in diverse vascular diseases. Front Pharmacol. 2021;12:762654. doi:10.3389/fphar.2021.762654

 PubMed Web of Science ®Google Scholar

Su F, Wang J. Berberine inhibits the MexXY‑OprM efflux pump to reverse imipenem resistance in a clinical carbapenem‑resistant Pseudomonas aeruginosa isolate in a planktonic state. Exp Ther Med. 2018;15(1):467–472. doi:10.3892/etm.2017.5431

 PubMed Web of Science ®Google Scholar

Laudadio E, Cedraro N, Mangiaterra G, et al. Natural alkaloid berberine activity against Pseudomonas aeruginosa MexXY-mediated aminoglycoside resistance: in silico and in vitro studies. J Nat Prod. 2019;82(7):1935–1944. doi:10.1021/acs.jnatprod.9b00317

 PubMed Web of Science ®Google Scholar

Morita Y, Nakashima KI, Nishino K, et al. Berberine is a novel type efflux inhibitor which attenuates the MexXY-mediated aminoglycoside resistance in pseudomonas aeruginosa. Front Microbiol. 2016;7:1223. doi:10.3389/fmicb.2016.01223

 PubMed Web of Science ®Google Scholar

Li Y, Huang J, Li L, Liu L. Synergistic activity of berberine with azithromycin against Pseudomonas Aeruginosa isolated from patients with cystic fibrosis of lung in vitro and in vivo. Cell Physiol Biochem. 2017;42(4):1657–1669. doi:10.1159/000479411

 PubMedGoogle Scholar

Li X, Song Y, Wang L, et al. A potential combination therapy of berberine hydrochloride with antibiotics against multidrug-resistant Acinetobacter baumannii. Front Cell Infect Microbiol. 2021;11:660431. doi:10.3389/fcimb.2021.660431

 PubMed Web of Science ®Google Scholar

Shi C, Li M, Muhammad I, et al. Combination of berberine and ciprofloxacin reduces multi-resistant Salmonella strain biofilm formation by depressing mRNA expressions of luxS, rpoE, and ompR. J Vet Sci. 2018;19(6):808. doi:10.4142/jvs.2018.19.6.808

 PubMed Web of Science ®Google Scholar

Zhou XY, Ye XG, He LT, et al. In vitro characterization and inhibition of the interaction between ciprofloxacin and berberine against multidrug-resistant Klebsiella pneumonia e. J Antibiot. 2016;69(10):741–746. doi:10.1038/ja.2016.15

 PubMed Web of Science ®Google Scholar

Yu HH, Kim KJ, Cha JD, et al. Antimicrobial activity of berberine alone and in combination with ampicillin or oxacillin against methicillin-resistant Staphylococcus aureus. J Med Food. 2005;8(4):454–461. doi:10.1089/jmf.2005.8.454

 PubMed Web of Science ®Google Scholar

Zuo GY, Li Y, Han J, Wang GC, Zhang YL, Bian ZQ. Antibacterial and synergy of berberines with antibacterial agents against clinical multi-drug resistant isolates of Methicillin-Resistant Staphylococcus aureus (MRSA). Molecules. 2012;17(9):10322–10330. doi:10.3390/molecules170910322

 PubMed Web of Science ®Google Scholar

Xia S, Ma L, Wang G, et al. In vitro antimicrobial activity and the mechanism of berberine against methicillin-resistant Staphylococcus aureus isolated from bloodstream infection patients. IDR. 2002;15:1933–1944. doi:10.2147/IDR.S357077

 Google Scholar

Liang RM, Yong XL, Duan YQ, et al. Potent in vitro synergism of fusidic acid (FA) and berberine chloride (BBR) against clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA). World J Microbiol Biotechnol. 2014;30(11):2861–2869. doi:10.1007/s11274-014-1712-2

 PubMed Web of Science ®Google Scholar

Wultańska D, Piotrowski M, Pituch H. The effect of berberine chloride and/or its combination with vancomycin on the growth, biofilm formation, and motility of Clostridioides difficile. Eur J Clin Microbiol Infect Dis. 2020;39(7):1391–1399. doi:10.1007/s10096-020-03857-0

 PubMed Web of Science ®Google Scholar

Menichini M, Lari N, Rindi L. Effect of efflux pump inhibitors on the susceptibility of Mycobacterium avium complex to clarithromycin. J Antibiot. 2020;73(2):128–132. doi:10.1038/s41429-019-0245-1

 PubMed Web of Science ®Google Scholar

Tseng CY, Sun MF, Li TC, Lin CT. Effect of coptis chinensis on biofilm formation and antibiotic susceptibility in Mycobacterium abscessus. Evid Based Compl Alter Med. 2020;2020:1–9. doi:10.1155/2020/9754357

 Web of Science ®Google Scholar