Dataset Information

Clinical and microbiologic analysis of the risk factors for mortality in patients with heterogeneous vancomycin-intermediate Staphylococcus aureus bacteremia.

ABSTRACT: The prevalence of the heterogeneous vancomycin-intermediate Staphylococcus aureus (hVISA) phenotype among methicillin-resistant S. aureus (MRSA) blood isolates can reach 38%. hVISA bacteremia is known to be associated with vancomycin treatment failure, including persistent bacteremia. We conducted this study to evaluate risk factors for 12-week mortality in patients with hVISA bacteremia through a detailed clinical and microbiological analysis of a prospective cohort of patients with S. aureus bacteremia. All isolates were collected on the first day of bacteremia and subjected to population analysis profiling for hVISA detection, genotyping, and PCR analysis for 39 virulence factors. Of 382 patient with MRSA bacteremia, 121 (32%) had hVISA bacteremia. Deceased patients were more likely to have hematologic malignancy (P = 0.033), ultimately or rapidly fatal disease (P = 0.007), and a higher Pitt bacteremia score (P = 0.010) than surviving patients. The sequence type 239 (ST239) clonal type and definitive linezolid treatment were associated with a trend toward reduced mortality (P = 0.061 and 0.072, respectively), but a high vancomycin MIC (?2 mg/liter) was not associated with increased mortality (P = 0.368). In a multivariate analysis, ultimately or rapidly fatal disease (adjusted odds ratio [aOR], 2.80; 95% confidence interval [CI], 1.14 to 6.85) and a high Pitt bacteremia score (aOR, 1.26; 95% CI, 1.07 to 1.48) were independent risk factors for mortality. Hematologic malignancy was associated with a trend toward increased mortality (P = 0.094), and ST239 was associated with a trend toward reduced mortality (P = 0.095). Our study suggests that ST239 hVISA is a possible predictor of survival in hVISA bacteremia.

SUBMITTER: Chong YP

PROVIDER: S-EPMC4432213 | biostudies-literature | 2015

REPOSITORIES: biostudies-literature

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Clinical and microbiologic analysis of the risk factors for mortality in patients with heterogeneous vancomycin-intermediate Staphylococcus aureus bacteremia.

Chong Yong Pil YP Park Ki-Ho KH Kim Eun Sil ES Kim Mi-Na MN Kim Sung-Han SH Lee Sang-Oh SO Choi Sang-Ho SH Jeong Jin-Yong JY Woo Jun Hee JH Kim Yang Soo YS

Antimicrobial agents and chemotherapy 20150406 6

The prevalence of the heterogeneous vancomycin-intermediate Staphylococcus aureus (hVISA) phenotype among methicillin-resistant S. aureus (MRSA) blood isolates can reach 38%. hVISA bacteremia is known to be associated with vancomycin treatment failure, including persistent bacteremia. We conducted this study to evaluate risk factors for 12-week mortality in patients with hVISA bacteremia through a detailed clinical and microbiological analysis of a prospective cohort of patients with S. aureus b ...[more]

PMID: 25845875

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Project description:Vancomycin (VAN)-intermediate Staphylococcus aureus (VISA) and heterogeneous VISA (hVISA) isolates are considered to have emerged from VAN-susceptible S. aureus (VSSA) by spontaneous mutation during VAN exposure. We previously reported that laboratory mutant H14, obtained from VSSA strain Delta IP by exposure to imipenem (IPM), showed overexpression of the vraSR two-component system and a typical hVISA phenotype. In the present study, to elucidate the mechanism of VSSA conversion to hVISA, we further characterized strain H14 by determining its whole-genome sequence, morphology, cell wall synthetic activity, and gene expression. Genome sequencing revealed that H14 harbored a mutated vraS (designated vraS(H14)) that caused an amino acid substitution (S(329)-->L). This mutation is different from the VraS mutation (N(5)-->I) identified in representative clinical hVISA strain Mu3. However, H14 exhibited a phenotype similar to that of Mu3, including heterogeneous resistance to VAN, enhanced cell wall synthetic activity, and vraSR overexpression. Replacement of the vraS gene of DeltaIP with the mutated vraS(H14) gene confirmed that the S(329)-->L substitution was responsible for both the upregulation of vraSR and conversion to the hVISA phenotype. This conversion was also achieved by using the vraS gene of Mu3, which carries a mutation (N(5)-->I), but not with the native vraS gene of strain N315. Finally, we carried out a study to analyze the appearance of hVISA from VSSA by exposure of Delta IP to selective concentrations of VAN and beta-lactam antibiotics. A total of 8 and 5 hVISA isolates were detected among 50 isolates selected with VAN and IPM, respectively. Among the 13 hVISA mutants, mutation in vraSR was detected only in mutant strain H14, suggesting that additional mutational mechanisms can be responsible for evolution to the hVISA phenotype. We conclude that exposure not only to VAN but also to beta-lactams may select for reduced glycopeptide susceptibility in S. aureus.

Project description:Although methicillin (meticillin)-resistant Staphylococcus aureus (MRSA) strains with reduced susceptibility to vancomycin (RVS-MRSA; including vancomycin-intermediate S. aureus [VISA] and heterogeneous VISA [hVISA]) have been linked with vancomycin treatment failure, it is unclear whether they are more pathogenic than vancomycin-susceptible MRSA (VS-MRSA). We prospectively assessed patients with clinical MRSA isolates during a 10-month period to determine clinical status (infection versus colonization) and therapeutic outcome before correlating these findings with the results of detailed in vitro assessment of vancomycin susceptibility, including population analysis profile (PAP) testing. hVISA and VISA were defined by standard PAP criteria (area-under-the-curve ratio compared to that of the reference hVISA strain Mu3 [>or=0.9]) and routine CLSI criteria (vancomycin MIC, 4 to 8 microg/ml), respectively. Among the 117 patients assessed, 58 had RVS-MRSA isolates (56 hVISA and 2 VISA) and 59 had VS-MRSA isolates; the patient demographics and comorbidities were similar. RVS-MRSA was associated with a lower rate of infection than VS-MRSA (29/58 versus 46/59; P = 0.003), including a lower rate of bacteremia (3/58 versus 20/59, respectively; P < 0.001). The cure rates in RVS-MRSA and VS-MRSA groups were not statistically different (16/26 versus 31/42; P = 0.43), but the post hoc assessment of treatment regimes and study size made detailed conclusions difficult. The results of the macro method Etest correlated well with the PAP results (sensitivity, 98.3%, and specificity, 91.5%), but broth microdilution and our preliminary RVS-MRSA detection method correlated poorly. All isolates were susceptible to linezolid and daptomycin. These data suggest that detailed prospective laboratory identification of RVS-MRSA isolates may be of limited value and that, instead, such in vitro investigation should be reserved for isolates from patients who are failing appropriate anti-MRSA therapy.

Project description:BackgroundVancomycin-intermediate Staphylococcus aureus (VISA) and heterogeneous VISA (hVISA) are associated with vancomycin treatment failure, and are becoming an increasing public health problem. Therefore, we undertook this study of 91 published studies and made subgroup comparisons of hVISA/VISA incidence in different study years, locations, and types of clinical samples. We also analyzed the genetic backgrounds of these strains.MethodsA systematic literature review of relevant articles published in PubMed and EMBASE from January 1997 to August 2014 was conducted. We selected and assessed journal articles reporting the prevalence rates of hVISA/VISA.ResultsThe pooled prevalence of hVISA was 6.05% in 99,042 methicillin-resistant S. aureus (MRSA) strains and that of VISA was 3.01% in 68,792 MRSA strains. The prevalence of hVISA was 4.68% before 2006, 5.38% in 2006-2009, and 7.01% in 2010-2014. VISA prevalence was 2.05%, 2.63%, and 7.93%, respectively. In a subgroup analysis of different isolation locations, the prevalence of hVISA strains was 6.81% in Asia and 5.60% in Europe/America, and that of VISA was 3.42% and 2.75%, respectively. The frequencies of hVISA isolated from blood culture samples and from all clinical samples were 9.81% and 4.68%, respectively, and those of VISA were 2.00% and 3.07%, respectively. The most prevalent genotype was staphylococcal cassette chromosome mec (SCCmec) II, which accounted for 48.16% and 37.74% of hVISA and VISA, respectively. Sequence Type (ST) 239 was most prevalent.ConclusionThe prevalence of hVISA/VISA has been increasing in recent years, but has been grossly underestimated. Its incidence is higher in Asia than in Europe/America. hVISA is isolated from blood culture samples more often than from other samples. These strains are highly prevalent in epidemic MRSA strains. This study clarifies the epidemiology of hVISA/VISA and indicates that the detection of these strains and the control of nosocomial infections must be strengthened.

Project description:The prevalence of heterogeneous vancomycin-intermediate Staphylococcus aureus (hVISA) among 1,012 vancomycin-susceptible methicillin (meticillin)-resistant S. aureus isolates collected from 14 cities in China from 2005 to 2007 was 13 to 16%, as determined by a combination of (i) measurement by the modified population analysis profile-area under the curve method (PAP-AUC) and (ii) estimation from the measured sensitivity and specificity of a screening method. Two hundred isolates from blood were chosen as a subset for measurement of the sensitivities and the specificities of several previously described screening methods by using the results of PAP-AUC as the reference. During this testing, one isolate was found to be a vancomycin-intermediate S. aureus (VISA) strain so was not used in the evaluation of the screening tests. Of the other 199 isolates, 26 (13.1%) were hVISA, as assessed by PAP-AUC. A screening cascade of culturing the isolates on brain heart infusion agar containing teicoplanin (5 mg/liter) and then subjecting the positive isolates to a macro-Etest method was applied to the 812 non-blood isolates, yielding 149 positive results. From these results and by adjusting for sensitivity (0.423) and specificity (0.861), the prevalence was estimated to be 15.7%. The precision of that estimate was assessed by reapplying the screening cascade to 120 randomly selected isolates from the 812 non-blood isolates and simultaneously determining their heterogeneous vancomycin-intermediate susceptibility status by PAP-AUC. Because PAP-AUC is impractical for use with large numbers of isolates, the screening-based estimation method is useful as a first approximation of the prevalence of hVISA. Of the 27 VISA or hVISA isolates from blood, 22.2% and 74.1% were staphylococcal chromosome cassette mec types II and III, respectively, while 77.8% and 22.2% were agr type 1 and agr type 2, respectively; the MIC ranges were 0.5 to 4 mg/liter for vancomycin and 0.25 to 1 mg/liter for daptomycin.

Dataset Information

Clinical and microbiologic analysis of the risk factors for mortality in patients with heterogeneous vancomycin-intermediate Staphylococcus aureus bacteremia.

Publications

Clinical and microbiologic analysis of the risk factors for mortality in patients with heterogeneous vancomycin-intermediate Staphylococcus aureus bacteremia.

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