Structural basis of drug efflux by the staphylococcal efflux pump QacA

The QacA DHA2 exporter from Staphylococcus aureus is a prototypical multidrug transporter that, like other bacterial efflux pumps, can extrude a wide range of cytotoxic compounds thus playing a crucial role in antimicrobial resistance. Here, we report crystal structures of wild-type QacA in three key conformational states: inward-open, outward-open and ethidium-bound, representing the first ligand-bound structure of a 14 transmembrane helices (TM) DHA2 transporter. In combination with computational and functional studies, these structures provide a mechanistic framework to understand drug recognition and extrusion. Structural analyses reveal remarkable adaptability within the binding pocket, including a ligand-induced deformation of TM5 that enables coordination of ethidium bromide in the outward-open state. Molecular dynamics simulations show spontaneous lipid entry into the transporter core and suggest that substrate binding from the inner membrane leaflet initiates a conformational transition to an outward-open state, stabilizing high-affinity interactions. Subsequent binding site protonation drives substrate extrusion. Together, these findings elucidate the structural dynamics and mechanistic underpinnings of QacA-mediated multidrug transport, highlighting conformational flexibility and proton-coupled electrostatic changes as key determinants of multidrug recognition and extrusion. This study provides a foundational framework for developing targeted inhibitors to combat bacterial multidrug resistance.