An Update on the Role of Penicillin Binding Protein-4 (PBP4) in β-Lactam Resistance of Staphylococcus aureus

Staphylococcus aureus remains to be one of the leading causes of global mortality. The most common class of antibiotics used to treat S. aureus infections are Next-Generation β-lactams (NGBs), as they are highly efficacious and have low adverse effects. NGB resistance in S. aureus is classically attributed to Penicillin-Binding Protein-2a (PBP2a), but previous studies from our group have also implicated altered expression of Penicillin-Binding Protein-4 (PBP4) with high-level NGB resistance. PBP4 is the only low-molecular mass (LMM) PBP present in S. aureus; it is also the only known LMM PBP with transpeptidase activity, giving it the unique ability to bring about peptidoglycan cross-linking. In this article, we review some of the recent findings from our group, which reveal that mutations associated with PBP4 lead to altered protein expression and NGB resistance in both MSSA and MRSA backgrounds. We discuss the clinical relevance of PBP4-associated mutations, particularly in Methicillin Resistant Lacking mec (MRLM) isolates, as well as the combined effect of altered expression of PBP4 and GdpP. Finally, this review summarizes the potential role played by PBP4 in S. aureus virulence. Together, we highlight the increasing relevance of PBP4 as a mediator of NGB resistance and discuss its potential to be an important factor during infection diagnosis and therapy.