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J Med Microbiol 58 (2009), 376-380; DOI: 10.1099/jmm.0.006486-0
© 2009 Society for General Microbiology
ISSN 0022-2615

Case Report

In vivo development of heterogeneous glycopeptide-intermediate Staphylococcus aureus (hGISA), GISA and daptomycin resistance in a patient with meticillin-resistant S. aureus endocarditis

Andrew Kirby1,2, Kavya Mohandas1, Caroline Broughton2, Timothy J. Neal1, Godfrey W. Smith1, Pearl Pai3 and Carlos Nistal de Paz1

1 Department of Medical Microbiology, Royal Liverpool & Broadgreen University Hospital Trust, Prescot Street, Liverpool, Merseyside L7 8XP, UK

2 Department of Infection & Host Defence, Liverpool University, 8th Floor Duncan Building, Daulby Street, Liverpool L69 3GA, UK

3 Department of Nephrology, Royal Liverpool & Broadgreen University Hospital Trust, Prescot Street, Liverpool, Merseyside L7 8XP, UK

Correspondence
Andrew Kirby
amk{at}liv.ac.uk

Received September 10, 2008
Accepted November 12, 2008

We report a patient who developed a meticillin-resistant Staphylococcus aureus (MRSA) central venous catheter infection complicated by infective endocarditis. The patient was initially treated with glycopeptides, which led to the development of heterogeneous glycopeptide resistance, the detection of which required the use of a macro Etest screening test. Subsequently, the causative strain, confirmed by PFGE as a UK epidemic MRSA-15, was treated with daptomycin, and again resistance developed in vivo. The development in vivo of resistance to both these agents suggests that the resistance mechanisms may be associated. We suggest that the clinician managing MRSA infection should anticipate daptomycin resistance when reduced glycopeptide susceptibility is detected.

Abbreviations: BSAC, British Society for Antimicrobial Chemotherapy; hGISA, heterogeneous glycopeptide-intermediate Staphylococcus aureus; i.v., intravenous; MRSA, meticillin-resistant S. aureus; TOE, transoesophageal echocardiograph; TTE, transthoracic echocardiogram.






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