The escalating challenge of vancomycin resistance in Staphylococcus aureus.

The glycopeptide antibiotic vancomycin is considered indispensable for the treatment of multidrug-resistant Staphylococcus aureus infections, and so the acquisition by these organisms of transmissible glycopeptide resistance elements from enterococci had been anticipated with apprehension. It was therefore a considerable surprise when vancomycin-intermediate S. aureus (VISA) clinical isolates were reported in 1997, with a novel, borderline-resistance phenotype acquired without genetic exchange. Clinical vancomycin-resistant S. aureus (VRSA) were not reported until 2002, expressing high level, transmissible resistance by virtue of vanA resistance determinants within enterococcal transposable elements residing on staphylococcal plasmids. This review will provide an update on the frustratingly variable characteristics of the VISA phenotype, focus on the progress made in understanding the molecular basis of the VISA resistance mechanism from the viewpoint of genetic regulation and cell wall stress response, and summarize the information currently available on VRSA. Finally, alternatives to vancomycin that are already available or nearing approval will be briefly reviewed, with attention to their limitations and potential for resistance development.

A microdilution plating method for population analysis of antibiotic-resistant staphylococci.

The microdilution plating method, using colony-forming units (CFU)/ml determinations from 10-microl droplets, was compared with the standard plate count in population analyses of methicillin-resistant and glycopeptide-intermediate Staphylococcus aureus (MRSA and GISA) strains. Efficiency of plating plots yielded similar population resistance profiles for both methods with MRSA class 1-4 strains, laboratory-selected GISA strains of varying susceptibilities, two clinical GISA strains, as well as susceptible strains. A single heterogeneous MRSA, plated by both methods in 41 trials with and without 50 microg/ml oxacillin present, demonstrated no significant difference between the results of the two methods of colony counting (p > 0.05, and r = 0.67). Standard plating and microdilution plating produced mean resistant subpopulation determinations of one cell in 1.19 x 10(4) and 1.36 x 10(4), respectively. Population analyses carried out by microdilution plating require one-fourth or fewer of the plates used for standard plating, and both plating and colony counting required less time to perform.

Characterization of passage-selected vancomycin-resistant Staphylococcus aureus strains of diverse parental backgrounds.

A series of 12 Staphylococcus aureus strains of various genetic backgrounds, methicillin resistance levels, and autolytic activities were subjected to selection for the glycopeptide-intermediate S. aureus (GISA) susceptibility phenotype on increasing concentrations of vancomycin. Six strains acquired the phenotype rapidly, two did so slowly, and four failed to do so. The vancomycin MICs for the GISA strains ranged from 4 to 16 microg/ml, were stable to 20 nonselective passages, and expressed resistance homogeneously. Neither ease of acquisition of the GISA phenotype nor the MIC attained correlated with methicillin resistance hetero- versus homogeneity or autolytic deficiency or sufficiency. Oxacillin MICs were generally unchanged between parent and GISA strains, although the mec members of both isogenic methicillin-susceptible and methicillin-resistant pairs acquired the GISA phenotype more rapidly and to higher MICs than did their susceptible counterparts. Transmission electron microscopy revealed that the GISA strains appeared normal in the absence of vancomycin but had thickened and diffuse cell walls when grown with vancomycin at one-half the MIC. Common features among GISAs were reduced doubling times, decreased lysostaphin susceptibilities, and reduced whole-cell and zymographic autolytic activities in the absence of vancomycin. This, with surface hydrophobicity differences, indicated that even in the absence of vancomycin the GISA cell walls differed from those of the parents. Autolytic activities were further reduced by the inclusion of vancomycin in whole-cell and zymographic studies. The six least vancomycin-susceptible GISA strains exhibited an increased capacity to remove vancomycin from the medium versus their parent lines. This study suggests that while some elements of the GISA phenotype are strain specific, many are common to the phenotype although their expression is influenced by genetic background. GISA strains with similar glycopeptide MICs may express individual components of the phenotype to different extents.