Overcoming the energy-dependent barrier to aminoglycoside uptake: multimodal strategies to sensitize <i>Staphylococcus aureus</i> persisters

SUMMARY Persistent Staphylococcus aureus infections pose a major therapeutic challenge due to the formation of metabolically dormant persister cells that survive antibiotic exposure without acquiring genetic resistance. Despite their potent bactericidal activity, aminoglycosides fail against these persisters due to their reliance on energy-dependent uptake driven by the proton motive force (PMF). This review synthesizes emerging strategies designed to overcome this critical bottleneck. Metabolic stimulation using specific carbon sources or PMF-modulating agents reactivates membrane energetics, thereby restoring aminoglycoside uptake in dormant cells. Membrane-targeting adjuvants bypass PMF altogether, enabling antibiotic entry via biophysical remodeling and disruption of the lipid bilayer. Additionally, we discuss rationally engineered aminoglycoside hybrids, such as peptide-conjugated variants, that achieve self-directed, energy-independent penetration while preserving ribosomal targeting. Collectively, these approaches highlight that aminoglycoside failure against S. aureus persisters can be a modifiable physiological limitation rather than an issue of intrinsic resistance. The convergence of metabolic and membrane-based potentiation underscores the therapeutic potential of combinatorial regimens tailored to the unique bioenergetic state of persisters. Their clinical translation, combined with efforts to address toxicity, may transform the treatment landscape of recalcitrant S. aureus infections and mitigate the risk of relapse.