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Vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus infections

Franklin D Lowy, MD
Section Editor
Daniel J Sexton, MD
Deputy Editor
Elinor L Baron, MD, DTMH


The emergence of Staphylococcus aureus with diminished vancomycin susceptibility was anticipated when vancomycin-resistant enterococci (VRE) were initially described in the late 1980s [1,2]. The expected mechanism of vancomycin resistance in S. aureus was plasmid-mediated transfer of the vanA gene cluster from VRE. It was a surprise, therefore, when the first reported case of diminished vancomycin susceptibility in a clinical isolate of S. aureus in 1997 was mediated not via acquisition of vanA by a strain of methicillin-resistant S. aureus (MRSA) but by an unusually thickened cell wall containing dipeptides capable of binding vancomycin, thereby reducing availability of the drug for intracellular target molecules [3-8]. This was the first observation of vancomycin-intermediate S. aureus (VISA). The predicted mechanism of vanA gene plasmid-mediated transfer from enterococci to S. aureus was later observed for the first time in 2002; this was the first description of vancomycin-resistant S. aureus (VRSA) [9,10].

Issues related to the mechanism, epidemiology, laboratory definitions, treatment, and prevention of S. aureus with reduced susceptibility to vancomycin will be reviewed here. Issues related to MRSA are discussed separately. (See related topics.)


Both the Clinical and Laboratory Standards Institute (CLSI) and the United States Food and Drug Administration (FDA) have established the following vancomycin minimum inhibitory concentration (MIC) interpretive criteria for S. aureus. The definitions have been modified in response to increasing reports of vancomycin treatment failure in infections due to strains with elevated MICs (2 mcg/mL), as well as to flag those isolates that are likely to be heteroresistant; the definitions prior to 2006 are noted in parentheses [11-13]. (See 'Heteroresistance' below.)

Vancomycin susceptible – ≤2 mcg/mL (≤4 mcg/mL)

Vancomycin intermediate – 4 to 8 mcg/mL (8 to 16 mcg/mL)


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Literature review current through: Sep 2016. | This topic last updated: Oct 1, 2015.
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