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What is the difference
between vancomycin-susceptible S. aureus, VISA and VRSA?
Most isolates of S. aureus are
susceptible to vancomycin. The concentration of vancomycin required
to inhibit these strains (called the minimum inhibitory concentration
or MIC) is typically between 0.5 and 2 micrograms/ml. In contrast,
S. aureus isolates for which vancomycin MICs are 8-16
micrograms/ml are classified as vancomycin-intermediate, and isolates
for which vancomycin MICs are >32 micrograms/ml are classified
as vancomycin-resistant. The definitions for classifying isolates
of S. aureus are based on the laboratory breakpoints
published by NCCLS.
NCCLS list only susceptible disk diffusion
interpretive criteria (in mm) for vancomycin and Staphylococcus
spp. There has not been a sufficient number of non-susceptible
isolates to develop resistant and intermediate breakpoints. Organisms
for which the vancomycin zone diameters are >=15mm are considered
susceptible, although several studies show that this breakpoint
is unreliable for detecting VISA strains.
What is NCCLS?
NCCLS is a global, interdisciplinary, nonprofit,
standards-developing and educational organization that promotes
the development and use of voluntary consensus standards and guidelines
within the healthcare community (NCCLS-leave
CDC).
What are glycopeptide-intermediate
S. aureus (GISA)?
The term glycopeptide refers to a group of
antimicrobial agents that includes vancomycin and teicoplanin.
Since the first two VISA isolates in the United States were also
resistant to teicoplanin, the term glycopeptide-intermediate S.
aureus (GISA) was used to indicate this broader resistance
profile. While GISA may be a more specific term for strains intermediate
to both vancomycin and teicoplanin, not all VISA strains are intermediate
to teicoplanin; therefore, VISA is a more accurate and more widely
used term.
Why are VISA and VRSA
isolates important?
Vancomycin continues to be a critical antimicrobial
agent for treating infections caused by S. aureus strains
that are resistant to oxacillin (MRSA)
and other antimicrobial agents. The decreased susceptibility of
VISA and VRSA strains to vancomycin leaves clinicians with few
therapeutic options for treating these infections.
Can routine susceptibility
tests detect VISA and VRSA?
Not all susceptibility testing methods detect
VISA and VRSA isolates. Two out of three confirmed VRSA isolates
were not reliably detected by automated testing systems. In addition,
VISA isolates are not detected by disk diffusion. Methods that
do detect VISA and VRSA are the vancomycin screen agar plate (BHIA
with 6 µg/ml of vancomycin) and non-automated MIC methods
[reference broth microdilution, agar dilution, and Etest®
using a 0.5 McFarland standard to prepare inoculum (AB Biodisk,
Piscatway, NJ)]. Laboratories that use automated methods or disk
diffusion should also include a vancomycin screen plate for enhanced
detection of VISA and VRSA. If possible, laboratories should incorporate
the vancomycin screen agar plate for testing all S. aureus.
Alternatively, the screening may be limited to MRSA isolates,
since nearly all VISA and all VRSA were also MRSA. S. aureus
isolates which grow on the vancomycin screen agar plate should
be checked for purity and the organism identity confirmed. Vancomycin
susceptibility should be retested by a non-automated MIC method
incubated for a full 24 hours.
What is the vancomycin
agar screen test?
The vancomycin agar screen test uses commercially
prepared plates to screen pure cultures of bacteria for vancomycin
resistance. These plates contain brain heart infusion agar and
6 µg/ml of vancomycin. An inoculum of 1-10µl of a
0.5 McFarland suspension should be streaked or spotted onto the
agar surface (final concentration=105-106
CFU/ml). For quality control, laboratories should use S. aureus
ATCC 25923 as the susceptible control and Enterococcus faecalis
ATCC 51299 as the resistant control. Up to six isolates can be
tested per plate and quality control should be performed each
day of testing. Growth of 2 or more colonies is considered a positive
result. All staphylococci that grow on these plates should be
inspected for pure culture, and the original clinical isolates
should be tested by an MIC method for confirmation. Plates prepared
in-house using various lots of media performed inconsistently
and were inferior to those obtained commercially.
Are any modifications
required of routine disk diffusion and MIC methods when testing
vancomycin and staphylococci?
Testing should incorporate the following NCCLS
recommendations:
Inoculum: Use direct colony suspension
Incubation: 35°C, ambient air, for a full
24 hr.
Endpoint: Examine very closely for any indication
of growth
According to the newest NCCLS standards, a vancomycin-intermediate
or –resistant result for staphylococci isolate should be
verified by repeating the susceptibility tests and the organism
identification.
What special
steps should be taken when an S. aureus is suspected
of being a VISA or VRSA?
Please refer to the VISA/VRSA
testing algorithm, which presents a strategy of detecting
and confirming VISA and VRSA using appropriate test methods.
Should repeat
testing include any specific antimicrobial agents that might not
be included in the routine panel?
Yes. The following additional antimicrobial
agents should be testing against VISA and VRSA isolates. Clindamycin,
linezolid, quinupristin/dalfopristin, rifampin, and trimethoprim-sulfamethoxazole.
The public health department and the Centers for Disease Control
and Prevention will perform tests for these additional antimicrobial
agents. It is essential to send probable VISA and VRSA to the
institutions as quickly as possible, even if the laboratory has
the capability to test additional agents in-house so that a complete
evaluation of the situation can be performed.
How should
local clinical laboratories save presumptive VISA or VRSA isolates?
It is best to freeze isolates at -60°C
or lower in standard stock culture medium, such as Brucella broth
containing 15% glycerol, or in defibrinated sheep blood. However,
if a laboratory cannot do this, the isolate should be subcultured
to a non-selective agar slant (e.g., trypticase soy agar) and
incubated overnight at 35°C. The following day, the caps should
be tightened and the slants store at 2-8°C. Repeated subcultures
should be kept to a minimum prior to storage.
Are VISA and
VRSA isolates resistant to oxacillin?
All VRSA isolates were also MRSA and contained
mecA and most VISA isolates were oxacillin/methicillin-resistant.
However, two VISA isolates became oxacillin-susceptible upon repeat
isolation from the patient and one tested oxacillin-susceptible
but contained mecA.
What are the
mechanisms of resistance for VRSA and VISA?
All VRSA isolates contained the vanA vancomycin
resistance gene. The vanA gene is usually found in enterococci
and typically confers high-level vancomycin resistance (MICs=
512-1024µg/ml) to these organisms. Vancomycin-resistant
enterococci containing vanA were isolated from all patients
in addition to MRSA. It is likely that the vanA determinant
was transferred via plasmids from enterococci to a resident MRSA
strain, resulting in the VRSA.
The mechanism of decreased vancomycin susceptibility
in VISA strains is not fully understood. VISA cells have thicker
cell walls that contain many cell wall monomers capable of binding
vancomycin extracellularly. Vancomycin must reach the cell membrane
and bind to the growing cell wall complex to inhibit cell growth.
Should VISA
and VRSA be reported to the infection control team?
Yes. There is significant concern about the
spread of VISA and VRSA among patients because of limited treatment
options. If a VISA or VRSA is suspected, specific infection control
precautions need to be initiated by infection control personnel
to decrease the risk of transmission to others. It is critical
for laboratory workers to contact the infection control team immediately
when a VISA or VRSA is suspected. Additionally, laboratories should
notify the local and/or state health department and the Division
of Healthcare Quality Promotion, National Center for Infectious
Diseases, CDC, by telephone 800-893-0485 or by sending an email
to SEARCH@cdc.gov. The isolate
should be saved and sent to the health department and CDC for
confirmatory testing.
Where can I
learn more about antimicrobial susceptibility testing?
Recently CDC developed a training tool for laboratorians
to enhance their understanding and improve their proficiency in
performing antimicrobial susceptibility testing (M.A.S.T.E.R.).
To report or request testing of suspected VISA
or VRSA isolates, send an email to SEARCH@cdc.gov
with your contact information (i.e., name, title, telephone number,
laboratory or facility name, and a description of your testing
methods and results facility and/or laboratory name, telephone
number.)
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