Antibiotic efficacy - context matters

- Antibiotic lethality involves processes downstream of primary target inhibition.
- Respiration and altered metabolism actively participate in antibiotic lethality.
- Environmental cues alter antibiotic efficacy via metabolism and stress responses.
- Systems approaches are important for studying antibiotics in complex environments.

Antibiotic lethality is a complex physiological process, sensitive to external cues. Recent advances using systems approaches have revealed how events downstream of primary target inhibition actively participate in antibiotic death processes. In particular, altered metabolism, translational stress and DNA damage each contribute to antibiotic-induced cell death. Moreover, environmental factors such as oxygen availability, extracellular metabolites, population heterogeneity and multidrug contexts alter antibiotic efficacy by impacting bacterial metabolism and stress responses. Here we review recent studies on antibiotic efficacy and highlight insights gained on the involvement of cellular respiration, redox stress and altered metabolism in antibiotic lethality. We discuss the complexity found in natural environments and highlight knowledge gaps in antibiotic lethality that may be addressed using systems approaches.