Small-Colony Variants in Persistent and Recurrent Staphylococcus aureus Bacteremia

The small-colony variant (SCV) phenotype of Staphylococcus aureus is associated with intracellular persistence and reduced antimicrobial susceptibility, which can lead to therapeutic failure. Since SCVs grow slowly and have a confusing morphology, the identification of infections due to SCV is difficult. We have identified SCVs in two patients who presented with persistent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia complicated by surgical site infections after cardiothoracic surgery. Nine blood isolates were collected from the two patients for species identification, antimicrobial susceptibility testing, and phenotypic and genotypic characterization. Colonies on Columbia blood agar were pinpoint, nonpigmented, nonhemolytic, and reverted to normal colonies after 48 hr of incubation on Schaedler agar. Auxotrophy assays revealed hemin dependence. Susceptibility to vancomycin (minimal inhibitory concentrations 1.0 μg/mL) was confirmed by E-test and broth microdilution test. All the isolates were identified as MRSA by multiplex polymerase chain reaction specific for the mecA, femA, and 16S rRNA genes, and all had the same genotype: Multilocus sequence typing ST5, SCCmec type II, agr type II, and spa type t2460. Moreover pulsed-field gel electrophoresis typing revealed that all nine isolates belonged to the same clone. Mutations in the relA gene were not found, and none of the isolates was identified as hVISA by population analysis profiling-AUC ratio. A high level of suspicion is required to detect SCVs, and although it is not common, the possibility of the SCV phenotype has to be considered in persistent S. aureus bacteremia.