Efflux (microbiology)
Active efflux is a mechanism responsible for extrusion of toxic substances and antibiotics outside the cell. Its importance lies in its contribution to bacterial antimicrobial resistance. Efflux systems function via an energy-dependent mechanism (Active transport) to pump out unwanted toxic substances through specific efflux pumps. Some efflux systems are drug-specific  while others may accommodate multiple drugs and thus contribute significantly to bacterial multidrug resistance (MDR).

# Efflux in bacteria

## Bacterial efflux pumps
Efflux pumps are proteinaceous transporters localized in the cytoplasmic membrane of all kind of cells. They are active transporters meaning that they require a source of chemical energy to perform their function. Some are primary active transporters utilizing Adenosine triphosphate hydrolysis as a source of energy, while others are secondary active transporters (uniporters, symporters or antiporters) in which transport is coupled to an electrochemical potential difference created by pumping out hydrogen or sodium ions outside the cell.
Bacterial efflux transporters are  classified into five major superfamilies, based on the amino acid sequence  and the energy source used to export their substrates:
- The major facilitator superfamily (MFS);
- The ATP-binding cassette superfamily (ABC);
- The small multidrug resistance family (SMR);
- The resistance-nodulation-cell division superfamily (RND); and
- The multidrug and toxic compound extrusion family (MATE).
Of these only the ABC superfamily are primary transporters, the rest being secondary transporters utilizing proton or sodium gradient as a source of energy.  While MFS dominates in Gram positive bacteria , the RND family is unique to Gram-negatives.

## Function
Although antibiotics are the most clinically important substrates of efflux systems, it is probable that most efflux pumps have other natural physiological functions. Examples include:
- The E.coli AcrAB  efflux system which has a physiologic role of pumping out bile acids and fatty acids to lower their toxicity.
- The MFS family Ptr pump in Streptomyces pristinaespiralis appears to be an autoimmunity pump for this organism when it turns on production of pristinamycins I and II.
- The AcrABTolC system in E.coli is suspected to have a role in the transport of the calcium-channel components in the E. coli membrane.
- The MtrCDE system plays a  protective role by providing resistance to faecal lipids in rectal isolates of Neisseria gonorrhoeae.
- The AcrAB efflux system of Erwinia amylovora  is important for this organism's virulence, plant (host) colonization and resistance to plant toxins.
The ability of efflux systems to recognize a large number of compounds  other than their natural substrates is probably because substrate recognition is based on physicochemical properties, such as hydrophobicity, aromaticity and ionizable character rather than on defined chemical properties, as in classical enzyme-substrate or ligand-receptor recognition. Because most antibiotics are amphiphilic molecules - possessing both hydrophilic and hydrophobic characters, they are easily recognized by many efflux pumps.

## Impact on antimicrobial resistance
The impact of efflux mechanisms on antimicrobial resistance is large, this is usually attributed to the following:
- The genetic elements encoding efflux pumps may be encoded on chromosomes and/or plasmids, thus contributing to both intrinsic (natural) and acquired resistance respectively. As an intrinsic mechanism of resistance, efflux pump genes can survive a hostile environment ( for example in the presence of antibiotics) which allows for the selection of mutants  that over-express these genes. Being located on transpoable genetic elements as plasmids or transposons is also advantageous for the microorganisms as it allows for the easy spread of efflux genes between distant species.
- Antibiotics can act as inducers and regulators of the expression of some efflux pumps.
- Expression of several efflux pumps in a given bacterial species may lead to a broad spectrum of resistance when considering the shared substrates of some multi-drug efflux pumps,  where one efflux pump may confer resistance to a wide range of antimicrobials.

# Efflux in eukaryotes

# Efflux inhibitors
Several trials are currently being conducted to develop drugs that can be co-administered with antibiotics to act as inhibitors for the efflux-mediated extrusion of antibiotics. None of the efflux  inhibitors tested is yet in clinical use. However, some of them are used to determine the efflux prevalence in clinical isolates. Its shown that Verapamil can inhibit P-glycoprotein mediated efflux which can increase oral absorption of some compounds.