Collateral Sensitivity Strongly Connected Components in Real-World Clinical Surveillance Data: Retrospective Detection of Evolutionary Traps in WHO Priority Pathogens

Collateral sensitivity (CS) - resistance to one antibiotic inducing hypersensitivity to another - offers an evolutionary trap for multidrug-resistant pathogens. A strongly connected component (SCC) in the directed CS graph is a closed cycle in which every drug is reachable from every other. Prior evidence for CS SCCs is exclusively in vitro. We mined 104,337 susceptibility records from BV-BRC spanning four WHO critical-priority pathogens (Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa; 18,821 isolates), using Fisher's exact tests with Benjamini-Hochberg FDR correction, Tarjan's algorithm, and permutation testing (n = 1,000). Two species yielded qualifying SCCs. In K. pneumoniae (4,286 isolates), a 3-node SCC - imipenem, meropenem, tetracycline - was detected (empirical p = 0.001); both carbapenem-tetracycline edges are bidirectional (OR = 1.81-1.82, q < 0.002, n > 850 per edge). In E. coli (6,720 isolates), a bidirectional 2-node SCC links colistin and cefotaxime (OR = 10.13, 95% CI 2.82-46.12, q = 0.042, n = 87; permutation p = 0.008); with a fragility index of 1, we report it as a hypothesis, not an established effect size. The carbapenem signal is tetracycline-specific: tigecycline shows co-resistance (OR < 0.35), as its distinct RamA/AcrAB-TolC mechanism predicts. ORs of 2.2-2.7 persisted across independent year bands (2009-2014). S. aureus returned no qualifying SCC, but that null is power-limited: only 8% of testable pairs could detect the K. pneumoniae effect size. Prior clinical analyses characterised pairwise and three-way collateral effects; to our knowledge these are the first closed CS cycles identified in clinical surveillance data, motivating experimental follow-up.