Vancomycin is the standard of care for the treatment of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections. Infections with vancomycin-nonsusceptible MRSA, including vancomycin-intermediate S. aureus (VISA) and heterogeneous VISA (hVISA), are clinically challenging and are associated with poor patient outcomes. The identification of VISA in the clinical laboratory depends on standard susceptibility testing, which takes at least 24 h to complete after isolate subculture, whereas hVISA is not routinely detected in clinical labs. We therefore sought to determine whether VISA and hVISA can be differentiated from vancomycin-susceptible S. aureus (VSSA) using the spectra produced by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Strains of MRSA were characterized for vancomycin susceptibility phenotype by broth microdilution and modified population analysis. We tested 21 VISA, 21 hVISA, and 38 VSSA isolates by MALDI-TOF MS. Susceptibility phenotypes were separated by using a support vector machine (SVM) machine learning algorithm. The resulting model was validated by leave-one-out cross validation. Models were developed and validated by using spectral profiles generated under various subculture conditions, as well as with and without hVISA strains. Using SVM, we correctly identified 100% of the VISA and 97% of the VSSA isolates with an overall classification accuracy of 98%. Addition of hVISA to the model resulted in 76% hVISA identification, 100% VISA identification, and 89% VSSA identification, for an overall classification accuracy of 89%. We conclude that VISA/hVISA and VSSA isolates are separable by MALDI-TOF MS with SVM analysis.
Delayed initiation of appropriate antibiotic therapy results in increased mortality rates for patients with sepsis (1-6). Staphylococcus aureus is a pathogen frequently isolated from patients with sepsis, with worse clinical outcomes noted for patients with methicillin-resistant S. aureus (MRSA) (7). Vancomycin remains the standard of care for the treatment of invasive infections with MRSA (8, 9). Infections with vancomycin-nonsusceptible isolates are associated with prolonged bacteremia, longer hospital stays, and greater rates of clinical treatment failure than infections with vancomycin-susceptible S. aureus (VSSA) (10, 11).Vancomycin nonsusceptibility falls into two related phenotypes: vancomycin-intermediate S. aureus (VISA) and heterogeneous VISA (hVISA). The VISA phenotype is reliably detected by broth microdilution, and these strains are characterized by a vancomycin MIC of 4 or 8 g/ml. Reliance on susceptibility testing to identify the VISA phenotype therefore delays the identification of these strains and thus the initiation of appropriate antimicrobial therapy. Because only a subpopulation of cells of hVISA strains (Յ10 Ϫ5 to 10 Ϫ6 ) have vancomycin MICs in the intermediate range, hVISA isolates frequently test susceptible to vancomycin (i.e., MICs of Յ2 g/ml) by broth microdilution methods, which typically tes...