Simultaneous Inhibition of CytochromeOxidase and ATP Synthase for Complete Eradication of.

The clinical utility of bedaquiline (BDQ), a first-in-class ATP synthase inhibitor and cornerstone of modern multidrug-resistant tuberculosis (MDR-TB) therapy, is compromised by a delayed onset of bactericidal killing and the emergence of resistance. This tolerance is linked tometabolic heterogeneity and functional redundancy within its electron transport chain (ETC), notably the activity of the cytochromeoxidase (Cyt). We hypothesized that cotargeting the cytochromeoxidase and the FF-ATP synthase would induce potent, synergistic killing by completely disrupting bacterial energetics. Our results demonstrate that this combination drives rapid, synergistic bactericidal activity within 09 days and complete clearance within 12 days. Mechanistic studies revealed that Cyt-inhibitor ND-011992 blocks the respiratory redundancy that permits survival under BDQ pressure, leading to catastrophic ATP depletion and a substantial arrest of oxygen consumption. This potentiation was equally effective against nonreplicating, hypoxic bacilli and eradicated 90% of intracellular bacteria in a macrophage model. These findings provide critical proof-of-concept that targeting compensatory respiratory pathways can overcome phenotypic drug tolerance. Thus, this validates Cytas a high-value target and outlines a potent, sterilizing combination regimen capable of countering the heterogeneity that sabotages current TB therapies.