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Staphylococcus aureus bacteremia with reduced susceptibility to vancomycin

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


Failure of treatment for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with vancomycin should prompt consideration of infection due to S. aureus with reduced susceptibility to vancomycin, either de novo or emergent.

Reduced S. aureus susceptibility to vancomycin may occur via increased vancomycin minimum inhibitory concentration (MIC; known as "MIC creep"), cell wall alterations (as in the case of vancomycin-intermediate S. aureus [VISA]), or plasmid-mediated gene transfer (as in the case of vancomycin-resistant S. aureus [VRSA]). (See 'Overview of mechanisms' below.)

Issues related to the definitions, mechanism, epidemiology, and treatment of S. aureus bacteremia with reduced susceptibility to vancomycin will be reviewed here. Other issues related to S. aureus infection are discussed separately. (See "Clinical approach to Staphylococcus aureus bacteremia in adults" and "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of bacteremia" and "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Prevention and control".)


MIC breakpoints — The Clinical and Laboratory Standards Institute (CLSI) and the US Food and Drug Administration (FDA) have established the following vancomycin minimum inhibitory concentration (MIC) interpretive criteria for S. aureus. The definitions were 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 [1-3].

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

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Literature review current through: Nov 2017. | This topic last updated: Jun 29, 2017.
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