Aspirin enhances the antibacterial activity of colistin against multidrug-resistant Pseudomonas aeruginosa

Multidrug-resistant (MDR) Pseudomonas aeruginosa (PSA), recently reclassified by the World Health Organization (WHO) as a high-priority antimicrobial-resistant pathogen, continues to impose a substantial global health burden due to escalating resistance and stagnant therapeutic innovation. Colistin retains critical clinical utility against MDR P. aeruginosa infections; however, its dose-limiting nephrotoxicity and neurotoxicity necessitate strategies to optimise therapeutic indices. This study investigated the molecular mechanism underlying the synergistic activity of aspirin in potentiating colistin efficacy against MDR P. aeruginosa. In vitro analyses revealed marked synergistic bactericidal activity (FIC index <= 0.5), with metabolomic profiling demonstrating suppression of key metabolic pathways integral to bacterial membrane biogenesis, including glycerophospholipid metabolism and fatty acid biosynthesis. Ultrastructural imaging confirmed irreversible disruption of membrane integrity via combined treatment. In a rat model of P. aeruginosa-induced pneumonia, colistin-aspirin co- administration demonstrated superior efficacy to monotherapy, significantly reducing pulmonary bacterial load (3 to 4-log CFU/g reduction vs colistin alone; p < 0.01), attenuating histopathological injury, and suppressing pro-inflammatory cytokine levels (IL-6, IL-8, TNF-alpha) by 30-47%. Critically, this synergy enabled a reduction of colistin dosing to one-sixteenth while maintaining bactericidal potency. These findings provide mechanistic insights into aspirin-mediated colistin sensitisation and evidence supporting combinatorial regimens to circumvent colistin toxicity barriers. This work establishes a rational foundation for clinical translation of repurposed aspirin-colistin therapy against MDR P. aeruginosa infections.