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hVISA/VISA: diagnostic and

Expert Rev. Anti Infect. Ther. 7(1), 13 (2009)

Judit Szab Genetic analysis of vancomycin-intermediate Staphylococcusaureus

Department of Medical strains has provided further evidence that vancomycin resistance
Microbiology, Medical develops due to changes of several loss-of-function mutations
and Health Science
Center, University of
Debrecen, P.O.B. 17, Vancomycin is considered the gold- As the VISA/VRSA isolates are also
H-4012 Debrecen, standard treatment for infections caused resistant to teicoplanin, the term glyco
Tel.: +36 5241 4948
by methicillin-resistant Staphylococcus peptide-intermediate or glycopeptide-
Fax: +36 5241 4948 aureus (MRSA). In recent years, reduced r esistant S. aureus is a technically susceptibility of S.aureus to vancomycin more accurate term; however, the term
has emerged. This problem seems to be VISA/VRSA is more widely used. In the
based on the increased use of vancomycin, USA, where teicoplanin is not available, the
with characteristic poor tissue penetration, term VISA/VRSA is routinely applied [5] .
slow bactericidal activity and risk of neph- Patients most at risk of infection by
rotoxicity resulting lack of elimination of hVISA, VISA and VRSA appear to be
MRSA from the patient [1] . those with previous exposure to vancomy-
cin. Treatment options for infections due
Vancomycin-intermediate S.aureus to MRSA with reduced susceptibility to
and heterogeneous vancomycin are limited. Rapid and correct
vancomycin-intermediate S.aureus identification of patients harboring VISA,
According to the Clinical and Laboratory hVISA and VRSA, as well as the prompt
Standards Institute (CLSI), vancomycin- infection-control protocols, are very impor-
intermediate S.aureus (VISA) are those tant in controlling the dissemination and
isolates with a MIC between 4 and selection of these strains [1] .
8 mg/l, whereas heterogeneous VISA
(hVISA) strains appear to be sensitive Mechanism of resistance of
to vancomycin with susceptible range of hVISA/VISA
12mg/l, but containing subpopulation Strains of VISA have been observed to have
of vancomycin-intermediate daughter cells lower growth rates and thicker cell walls
(MIC4g/ml). Vancomycin-resistant than susceptible strains [4] . More murein
S. aureus (VRSA) are defined as those monomers and more layers of peptido
having MICs of at least 16mg/l [2] . glycan are considered to be present in the
cell wall of VISA strains [3] .
Humans are the main reservoir Genetic analysis of VISA strains has
of hVISA/VISA strains, which are provided further evidence that vancomy-
capable of colonizing the cin resistance develops due to changes of
environment and persisting, several loss-of-function mutations affect-
ing important cell wall biosynthesis and
despite repeated and concerted
intermediary metabolism genes [6] .
eradication efforts.
The agr operon in S. aureus coordi-
The first hVISA strain was isolated in nates many critical virulence pathways.
Japan in 1996 [3] . Since 1996, hVISA and Activation of the agr operon induces the
VISA strains have increased in Europe, production of secreted virulence factors,
Asia and the USA, including over 100cases such as hemolysins, exoproteins and exo-
[4] . VRSA strains are still rare, and the first toxins, and decreases the production of
case was documented in 2002. cell-associated virulence factors, such as 10.1586/14787210.7.1.1 2009 Expert Reviews Ltd ISSN 1478-7210 1

Editorial Szab

adhesins. Expression of agr is inversely related to fibronectin- MuellerHinton broth. A 200-l sample is plated onto a BHI agar,
binding protein production, which offers selective advantage and vancomycin and teicoplanin E-test strips are applied there-
for the adherence to biomedical devices (e.g., catheters) and after. Plates are incubated for 48h and then evaluated for growth
nasal colonization of patients or staff members. Under vanco- according to the CLSI. The newest available double-sided strip
mycin exposure, loss of function of agr provides the selection of is the combined vancomycin and teicoplanin strip, known as the
hVISA/VISA strains [7] . glycopeptide-resistance detection strip. This E-test is performed
As a result of the loss of agr function: on MuellerHinton plates, rather then BHI. The inoculum is
Biofilm production increases 0.5McFarland and the incubation period is 48h. The cut-off values
after 48h were teicoplanin of at least 12mg/l, or both teicoplanin
Autolysis due to the expression of murein hydrolase decreasing and vancomycin of at least 8mg/l. The standard vancomycin MIC
The activity of d-hemolysin either decreases or stops completely is at least 6mg/l for VISA and at least 4mg/l for hVISA. The spe-
cificity and the sensitivity of the glycopeptide-resistance detection
Cell wall synthesis changes (thicker cell wall) test is 94 and 95%, respectively [9] .

Laboratory diagnosis of VISA & hVISA strains Treatment of hVISA/VISA cases

Traditionally, the agar disk-diffusion test has been used to meas- The hVISA/VISA infections are usually associated with poorer
ure glycopeptide susceptibility, but this method is not suitable for patient outcomes. The mortality rate for hVISA/VISA patients
large molecules, such as vancomycin, because the diffusion of this is approximately 75% [6] .
antibiotic into agar is too slow [8] . Heterogeneous VISA seems to be the stage that precedes the
An incorrect classification of MRSA as sensitive to glycopeptide development of VISA, therefore, when the vancomycin MIC
antibiotics may occur, since glycopeptide MICs are dependent on is greater than 1mg/l, alternative therapies should be consid-
test conditions. To date, no standardized technique for identifying ered to avoid the possibility of treatment failure and selection of
hVISA strains has been established [4] . hVISA/VISA strains.
A variety of different screening plates have been described.
Some studies were screened with MuellerHinton agar instead of
brainheart infusion (BHI) agar. Others applied a different inocu-
Currently, there are no formal recommendations
regarding treatment of hVISA/VISA, and the future
lum size (100 vs 10l), while others used different concentration
of bacterial suspension (2.0 vs 0.5 McFarland). Several studies role of experimental and available antibiotics
screened with plates containing vanomycin 6, 5 or 4g (or teico- isunknown.
planin) per ml [4] . The sensitivity was varied between 58 and 98%,
while the specificity was observed between 68 and 97%. The most Currently available drugs with activity against hVISA/VISA
suitable screening method seems to be the MuellerHinton agar strains are linezolid, quinupristin/dalfopristin, trimethoprim/
plate containing teicoplanin 5g with 10l of 2.0McFarland sulfamethoxazole, the lipopeptide daptomycin and the tetracy-
bacterial suspension incubated for 48h [9] . cline derivative tigecycline. Of these, trimethoprim/sulfamethox-
azole and daptomycin are bactericidal. Trimethoprim/sulfameth-
To date, no standardized technique for identifying oxazole is recommended in therapy only for skin and soft-tissue
hVISA strains has been established infections caused by hVISA/VISA strains. Experimental drugs
with bactericidal activity against hVISA/VISA isolates include the
Acceptable methods used to detect VISA/hVISA are nonauto- lipoglycopeptide dalbavancin, the semisynthetic glycopeptide ori-
mated. The most precise method of determination of heteroresist- tavancin, the glycolipodepsipeptide ramoplanin and a new broad-
ance is a population-analysis profile, as follows. After 24h incuba- spectrum cephalosporin, ceftobiprole. The invitro activities of
tion in BHI, cultures were diluted in saline to 10 -3 and 10 -6, and these drugs have been examined, although the clinical efficacy
spiral plated on to BHI agar plates containing vancomycin 0.5, 1, has not yet been established.
2, 2.5 and 4mg/l. Colonies were counted after 48h incubation Currently, there are no formal recommendations regarding
at 37C and the viable count was used to calculate an AUC. To treatment of hVISA/VISA, and the future role of experimental
distinguish VISA, hVISA and vancomycin-sensitive S.aureus, a and available antibiotics is unknown [6] .
ratio of the AUC of test strains divided by the corresponding AUC
for control strain was calculated. The criteria used for detection of Control of dissemination of hVISA/VISA strains
hVISA and VISA were AUC ratios of at least 0.9 and at least 1.3, Humans are the main reservoir of hVISA/VISA strains, which
respectively [10] . The routine use of this method in a laboratory is are capable of colonizing the environment and persisting, despite
time consuming and expensive; therefore, there is an urgent need repeated and concerted eradication efforts. Fundamental hygiene
for a simpler laboratory screening technique. habits are the primary defense against dissemination of the bac-
The macro E-test method may be one possible way to iden- teria, including wearing a gown on entry into the patients room,
tify true hVISA strains under routine laboratory conditions. use of an alcohol rub when washing hands on exiting the room,
The strains are grown overnight to a 2.0 McFarland standard in one-to-one nursing and routine contact investigation while the

2 Expert Rev. Anti Infect. Ther. 7(1), (2009)

hVISA/VISA: diagnostic & therapeuticproblems Editorial

patient is in hospital. Active communication between the clini- Financial & competing interests disclosure
cian and the microbiology laboratory is essential if these strains The author has no relevant affiliations or financial involvement with any
are not to be missed. organization or entity with a financial interest in or financial conflict with
Early, appropriate detection of resistance, prudent use of antibi- the subject matter or materials discussed in the manuscript. This includes
otics, including vancomycin, and stringent infection control proce- employment, consultancies, honoraria, stock ownership or options, expert
dures may all be critical to controlling of infection and colonization testimony, grants or patents received or pending, or royalties.
of hVISA/VISA strains [6] . No writing assistance was utilized in the production of this manuscript.

5 Gould IM. Clinical relevance of increasing 10 Yusof A, Engelhardt A, Karlsson A et al.

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