Chlorhexidine exposure of clinical Klebsiella pneumoniae strains leads to acquired resistance to this disinfectant and to colistin

Int J Antimicrob Agents. 2019 Jun;53(6):864-867. doi: 10.1016/j.ijantimicag.2019.02.012. Epub 2019 Feb 26.


Chlorhexidine is widely used as a disinfectant in hospitals, which may impose a selective pressure on bacteria. This study aimed to determine whether continuous exposure to chlorhexidine could lead to adaptive resistance and cross-resistance as well as investigating potential resistance mechanisms. Three clinical Klebsiella pneumoniae strains susceptible to conventional antimicrobials were selected and were continuously cultured in broth with gradually increasing concentrations of chlorhexidine. Antimicrobial susceptibility was determined. Mechanisms of acquired resistance to chlorhexidine and colistin were analysed by PCR and reverse transcription quantitative PCR (RT-qPCR). Furthermore, fitness was assessed through growth curve assays. Increased resistance to chlorhexidine and colistin was observed in all strains. Expression of the cepA gene was upregulated in the adapted strains, suggesting that hyperexpression of CepA was probably the main mechanism of adaptive resistance to chlorhexidine. The amino acid substitutions Leu82Arg and Arg256Gly in PmrB were detected in all of the adapted strains, whilst Leu344Pro was only identified in one adapted strain, indicating that the PmrB substitution was responsible for the cross-resistant phenotype. Moreover, chlorhexidine adaptation might have an effect on bacterial growth.

Keywords: Adaptive resistance; Chlorhexidine; Colistin; Cross-resistance; Fitness; Klebsiella pneumoniae.

MeSH terms

  • Adaptation, Biological
  • Anti-Bacterial Agents / pharmacology*
  • Bacterial Proteins / genetics
  • Chlorhexidine / pharmacology*
  • Colistin / pharmacology*
  • DNA, Bacterial / genetics
  • Drug Resistance, Bacterial*
  • Gene Expression Regulation, Bacterial
  • Humans
  • Klebsiella pneumoniae / drug effects*
  • Klebsiella pneumoniae / growth & development
  • Microbial Sensitivity Tests
  • Mutation, Missense
  • Real-Time Polymerase Chain Reaction
  • Reverse Transcriptase Polymerase Chain Reaction
  • Serial Passage


  • Anti-Bacterial Agents
  • Bacterial Proteins
  • DNA, Bacterial
  • Chlorhexidine
  • Colistin