The dynamic distribution of genetic tandem amplifications in a heteroresistant Escherichia coli population revealed by ultra-deep long read sequencing

Antibiotic heteroresistance, characterized by rare resistant subpopulations of bacteria within a susceptible main population, is associated with treatment failure and often caused by tandem amplification of resistance genes. Here, we investigated how the distribution of tandem amplifications affects heteroresistance using an approach combining genetic engineering and ultra-deep Nanopore sequencing to accurately quantify the distribution of tandem amplification copy numbers on plasmids down to frequencies of 10^-5. Using an Escherichia coli isolate, we describe the direct relation between the distribution of tandem amplifications increasing the copy number of a bla_SHV gene and a heteroresistance phenotype to piperacillin-tazobactam, and reveal how this distribution expands under antibiotic pressure and partially reverts upon its removal. Mathematical modeling indicates that indirect resistance and fitness cost of amplifications influence the dynamic distribution of tandem amplifications. These findings provide insights into amplification-mediated phenotypes and enhance possibilities for the development of improved therapeutic and diagnostics strategies for heteroresistance.