Discordance of vancomycin minimum inhibitory concentration for methicillin-resistant Staphylococcus aureus at 2 g/mL between Vitek II, -test, and Broth Microdilution.

BACKGROUND

Vancomycin, the first line antibiotic for methicillin-resistant (MRSA) bacteremia, is often administered inappropriately when MIC is greater than 2 µg/mL, including 'susceptible' strains. This study assessed the discordance of vancomycin minimum inhibitory concentration (MIC) for methicillin-resistant (MRSA).

METHODS

In total, 229 MRSA isolates from blood cultures collected between 2009 and 2015 at a tertiary hospital in Taiwan were examined. The MICs of vancomycin were measured using Vitek 2, -test, and standard broth microdilution at the level of 2 µg/mL.

RESULTS

The geometric mean of the MICs of hospital-acquired MRSA was higher than that of community-acquired MRSA ( < 0.001), with the exact agreement rates (with broth microdilution) at 2 µg/mL being 53.6% in Vitek 2 and 86.7% in -test. Overall, -test (98.1%) had more categorical accordance than did Vitek 2 (94.0%;  = 0.026). Vitek 2 had a tendency to overestimate MRSA in high-MIC isolates, whereas E-test inclined underestimation in low-MIC isolates. Surprisingly, the discordance rates of MRSA vancomycin MICs were higher in hospital-acquired isolates (13.3%-17.0%) than in community-acquired isolates (6.2%-7.0%).

CONCLUSION

The Infectious Diseases Society of America recommends the use of alternative antimicrobial agents when vancomycin MIC is ≥ 2 µg/mL; in this study, only 53.6% of the isolates tested using Vitek 2 showed a high MIC in the broth microdilution method. Accurate identification of the resistance profile is a key component of antimicrobial stewardship programs. Therefore, to reduce inappropriate antibiotic use and mitigate the emergence of resistant strains, we recommend using complementary tests such as -test or Broth microdilution to verify the MIC before administering second-line antibiotics.

STRENGTHS

(1) We compared the categorical agreement between different methods measuring MRSA MICs level. (2) Physicians should incorporate this information and consider a complementary test to verify the appropriateness of the decision of shifting vancomycin to second-line antibiotic treatment to improve patients' prognosis. (3) MRSA-vancomycin MICs at a cutoff of 2 µg/mL obtained using Vitek II exhibited a higher sensitivity level and negative predictive value than those obtained using -test in the prediction of categorical agreement with standard broth microdilution.

LIMITATION

(1) Our research was based on a single hospital-based study. (2) The MRSA strains in this study were stored for more than 12 months after isolation. (3) We did not collect information on clinical prognosis.