Exploiting evolutionary non-commutativity to prevent the emergence of bacterial antibiotic resistance

Abstract The increasing rate of antibiotic resistance and slowing discovery of novel antibiotic treatments presents a growing threat to public health. Here, we develop a Markov Chain model of evolution in asexually reproducing populations which is an encoding of the Strong Selection Weak Mutation model of evolution on fitness landscapes. This model associates the global properties of the fitness landscape with the algebraic properties of the Markov Chain transition matrix and allows us to derive general results on the non-commutativity and irreversibility of natural selection as well as antibiotic cycling strategies. Utilizing this formalism, we analyse 15 empirical fitness landscapes of E. coli under selection by di.erent beta-lactam antibiotics and demonstrate that the emergence of resistance to a given antibiotic can be both hindered and promoted by di.erent sequences of drug application. Further, we derive optimal drug application sequences with which we can probabilistically ‘steer’ the population through genotype space to avoid the emergence of resistance. This suggests a new strategy in the war against antibiotic.therapy.resistant organisms: drug sequencing to shepherd evolution through genotype space to states from which resistance cannot emerge and by which to maximize the chance of successful therapy. Background: The increasing rate of antibiotic resistance and slowing discovery of novel antibiotic treatments presents a growing threat to public health. Previous studies of bacterial evolutionary dynamics have shown that populations evolving on fitness landscapes follow predictable paths. In this article, we develop a general mathematical model of evolution and hypothesise that it can be used to understand, and avoid, the emergence of antibiotic resistance. Methods and Findings: We develop a Markov Chain model of evolution in asexually reproducing populations which is an encoding of the Strong Selection Weak Mutation model of evolution on fitness landscapes. This model associates the global properties of the fitness landscape with the algebraic properties of the Markov Chain transition matrix and allows us to derive general results on the non-commutativity and irreversibility of natural selection as well as antibiotic cycling strategies. Utilizing this formalism, we analyse 15 empirical fitness landscapes of E. coli under selection by different β-lactam antibiotics and demonstrate that the emergence of resistance to a given antibiotic can be both hindered and promoted by different sequences of drug application. We show that resistance to a given antibiotic is promoted in 61.4%, 68.6% and 70.3% of possible orderings of single, pair or triple prior drug administrations, respectively. Further, we derive optimal drug application sequences with which we can probabilistically ‘steer’ the population through genotype space to avoid the emergence of resistance. Conclusions: Our model provides generalisable results of interest to theorists studying evolution as well as providing specific, testable predictions for experimentalists to validate our methods. Further, these results suggest a new strategy in the war against antibiotic-therapy-resistant organisms: drug sequencing to shepherd an evolving population through genotype space to states from which resistance cannot emerge and from which we can maximize the likelihood of successful therapy using existing drugs. While our results are derived using a specific class of antibiotics, the method is generalisable to other situations, including the emergence of resistance to targeted therapy in cancer and how species could change secondary to changing climate or geographical movement.