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Clinical isolation and characterization of aminoglycoside-resistant small colony variants of Enterobacter aerogenes.

Small colony variants of Enterobacter aerogenes, as well as the parental large colony type, grew in blood drawn for cultures on three separate days from a patient who had received suboptimal gentamicin therapy. Minimum inhibitory concentrations of four aminoglycoside antibiotics were eight to more than 16 times higher for small colony variants than for the normal large colony type. Small colony variants had defective catalase activity, which may have interfered with oxidative metabolism and aminoglycoside uptake. Small colony variants reverted readily to the parental type in vitro in the absence of aminoglycosides. Clinically isolated small colony variants appeared similar to those selected in the presence of gentamicin in vitro, with respect to colony morphology, aminoglycoside resistance and catalase deficiency. The isolation of small colony variants during gentamicin therapy in vivo suggests that such variants may be a cause of treatment failure in patients receiving aminoglycosides.

Aminoglycosides

Sternoclavicular joint septic arthritis with small-colony variant Staphylococcus aureus.

Small-colony variants of Staphylococcus aureus may cause invasive disease in adults that is prolonged and refractory to standard therapies. We present a case of sternoclavicular arthritis with small-colony variant S. aureus that occurred in an 11-year-old child and discuss the importance of identification of these variants in the clinical microbiology laboratory.

Anti-Bacterial Agents

Outer membrane proteins of gentamicin induced small colony variants of Pseudomonas aeruginosa.

Small colony variants (SCVs) of Pseudomonas aeruginosa NCTC 6750 (WT) were repeatedly isolated in an in vitro kinetic model after exposure to gentamicin (GM). There were minor differences biochemically and in phage and serotyping between the wild type (WT) strain and SCVs. Changes in outer membrane protein profiles were found. SCVs were more resistant to polymixin and to a range of aminoglycosides (except kanamycin), but were more susceptible to a range of other antibiotics (hydrophilic and hydrophobic) with differing modes of action.

Bacterial Outer Membrane Proteins

Virulent gentamicin-induced small colony variants of Staphylococcus aureus.

Stable nonhemolytic small colony variants were isolated in pure culture from nine of 30 Staphylococcus aureus clinical strains after incubation of log10 7.0 cfu for 48 hr in MH broth containing 1.0 microgram/ml gentamicin. The variants resembled Staphylococcus epidermidis on blood agar, but they were positive for tube coagulase and thermostable nuclease at 24 hr and fermented mannitol slowly. The infectivity and virulence of four variants were compared to four parent S. aureus and three S. epidermidis strains in a rabbit model of endocarditis. Log10 5.0 cfu of the variant S. aureus, parent S. aureus, or S. epidermidis strains were injected intravenously into rabbits with intracardiac catheters. Quantitative culture of vegetations demonstrated endocardial infection in 47 of 49 (96%) animals injected with S. aureus variants, 44 of 44 injected with S. aureus parent strains, and four of 21 (19%) S. epidermidis-injected animals. The mortality rate in untreated animals within 4 days was five of 49 (10%) for variant S. aureus, 33 of 44 (75%) for parent S. aureus, and 0 of 21 for S. epidermidis. Small colony variants of S. aureus may be mistaken for S. epidermidis, but the variants are significantly more infective than S. epidermidis and are more likely to cause endocarditis. Gentamicin-induced S. aureus small colony variants are as infective but less virulent than their parent S. aureus strains.

Animals

Persistent and relapsing infections associated with small-colony variants of Staphylococcus aureus.

Small-colony variants (SCVs) of Staphylococcus aureus were cultured from five patients with persistent and relapsing infections. All five SCV strains were nonhemolytic and nonpigmented and grew very slowly on routine culture media in an ambient atmosphere. In several instances, these phenotypic characteristics led to the initial misidentification of the organisms in the clinical microbiology laboratory. All four strains available for further analysis were shown to be auxotrophs that reverted to normal growth and morphology in the presence of menadione, hemin, and/or a CO2 supplement. Similarly, these isolates were resistant to aminoglycosides under routine conditions but susceptible in the presence of the metabolic supplements. For two patients, the large and small colony forms isolated concurrently were indistinguishable when analyzed by pulsed field gel electrophoresis and thus represented phenotypic variants within individual clones. We propose a model relating the phenotypic characteristics of S. aureus SCVs with the clinical pattern of persistent and relapsing infection.

Aged

Fe-S cluster deficiency drives small colony variant formation in persistent infections.

INTRODUCTION: Small colony variants (SCVs) of Staphylococcus aureus (S. aureus) are associated with persistent infections and poor clinical outcomes. The mechanisms driving stable SCV formation remain poorly understood, particularly concerning metabolic adaptations. This study explores the in-host evolutionary dynamics of S. aureus and identifies a novel genetic determinant linked to SCV formation. OBJECTIVES: To investigate the genetic mutations and phenotypic adaptations underlying SCV formation, with a focus on the role of a novel mutation in the sufB gene, which is critical for Fe-S cluster biosynthesis. METHODS: Sequential isolates from a patient with recurrent infections were analyzed using whole-genome sequencing, antimicrobial susceptibility testing, and functional assays. The phylogenetic relationship of the isolates was determined, and specific mutations were identified. Functional assays included aconitase and glutamate synthase activity measurements, ATP level quantification, reactive oxygen species (ROS) production, and biofilm formation assays. In vivo pathogenesis was assessed using a murine catheter infection model. RESULTS: A novel frameshift mutation in sufB was identified, disrupting Fe-S cluster biosynthesis and impairing the TCA cycle and electron transport chain, leading to reduced ATP and ROS production. This metabolic reprogramming promoted stable SCV formation, characterized by slow growth, enhanced tolerance to antibiotics and neutrophil-mediated killing, and persistent inflammation in vivo. Restoration of sufB reversed these phenotypes, confirming its pivotal role in SCV-associated persistence. CONCLUSION: sufB is a novel genetic determinant of stable SCV formation through Fe-S cluster deficiency, driving metabolic shifts that enhance immune evasion and chronic infection. Our findings highlight antibiotic stewardship and suggest potential therapeutic strategies for managing persistent SCV-associated infections.

Staphylococcus aureus

A site-directed Staphylococcus aureus hemB mutant is a small-colony variant which persists intracellularly.

Although small-colony variants (SCVs) of Staphylococcus aureus have been recognized for many years, this phenotype has only recently been related to persistent and recurrent infections. Clinical S. aureus SCVs are frequently auxotrophic for menadione or hemin, two compounds involved in the biosynthesis of the electron transport chain elements menaquinone and cytochromes, respectively. While this observation as well as other biochemical characteristics of SCVs suggests a link between electron-transport-defective strains and persistent infections, the strains examined thus far have been genetically undefined SCVs. Therefore, we generated a stable mutant in electron transport by interrupting one of the hemin biosynthetic genes, hemB, in S. aureus by inserting an ermB cassette into hemB. We isolated a hemB mutant, due to homologous recombination, by growth at a nonpermissive temperature and selection for erythromycin resistance. This mutant showed typical characteristics of clinical SCVs, such as slow growth, decreased pigment formation, low coagulase activity, reduced hemolytic activity, and resistance to aminoglycosides. Additionally, the mutant was able to persist within cultured endothelial cells due to decreased alpha-toxin production. Northern and Western blot analyses showed that expression of alpha-toxin and that of protein A were markedly reduced, at both the mRNA and the protein level. The SCV phenotype of the hemB mutant was reversed by growth with hemin or by complementation with intact hemB. Hence, a defect in the electron transport system allows S. aureus SCVs to resist aminoglycosides and persist intracellularly.

Aminoglycosides

Selection of small-colony variants of Enterobacteriaceae by in vitro exposure to aminoglycosides: pathogenicity for experimental animals.

Small-colony variants of gram-negative genera of Enterobacteriaceae were selected by in vitro exposure to gentamicin. These variants were shown to have decreased susceptibility in vitro to aminoglycosides. They were lethal for mice following intraperitoneal injection, with the LD50 (50% lethal dose) being the same as, or slightly less than, that for the parent organism. Variants of strain no. 2401 of Proteus mirabilis caused urinary tract infection in mice after implantation into their bladders. Although the variants grew somewhat less rapidly than did parent organisms, both parent and variant colonies alkalinized urine at the same rate. Electron microscopic study showed no differences between colonies of parents and variants. These studies indicated that small-colony variants of Enterobacteriaceae are pathogenic for experimental animals. Further, they may cause disease in humans and should not necessarily be regarded as only laboratory curiosities.

Aminoglycosides

Phenotypic selection of small-colony variant forms of Staphylococcus epidermidis in the rat model of endocarditis.

Four pathogenic strains of Staphylococcus epidermidis (sensu strictu)-EC, RP62A, LW, and HBSN--exhibited a mixed population of colony phenotypes when plated onto a high-salt, low-glucose agar ("Memphis agar"). When compared with challenge inocula, significant shifts in colony populations to the small-colony variant forms occurred for all four strains for isolates recovered from infected vegetations of rats with catheter-induced endocarditis. Various colony phenotypes of the HBSN strain were compared in virulence studies by using the rat model of endocarditis. The infectivity rate of the small-colony variant forms was significantly less than that of either the normal parent form (P less than .05) or the mixed phenotypic inoculum (P less than .05). These data indicate that the small-colony variant forms may be selected for, once endocardial infections are established, and that the small-colony variant forms alone are much less able to initiate and/or sustain intracardiac infections in experimental endocarditis.

Animals

Decreased susceptibility to antibiotic killing of a stable small colony variant of Staphylococcus aureus in fluid phase and on fibronectin-coated surfaces.

The frequency of small colony variants of staphylococci associated with persistent, antibiotic resistant and relapsing infections is probably underestimated. These variants demonstrate decreased metabolism, leading to slow growth, increased resistance to cell-wall-active antibiotics, and decreased uptake of aminoglycoside antibiotics. This altered phenotype arises from defects in menadione and haemin biosynthesis resulting in impaired electron transport and decreased ATP concentrations. The recent acquisition of a stable small colony variant (SCV strain JB1), generated from strain 6850 of Staphylococcus aureus, allowed us to study the susceptibilities to antibiotic killing of parent and variant strains. Because differences in susceptibilities have been found between unattached and surface-adherent organisms, we tested both strains in solid and fluid-phase assays. Suspensions of SCV strain JB1 exposed to 8 x MIC of either oxacillin, vancomycin or fleroxacin, exhibited lower reductions in viable counts than the parent strain 6850, especially when high bacterial concentrations (1-2 x 10(7) cfu/mL) of either strain were tested. Susceptibility to antibiotic killing of bacteria attached to fibronectin-coated coverslips was markedly influenced by their growing or nongrowing state on the surface. In the latter condition, surface-bound SCV organisms were highly resistant to the bactericidal action of oxacillin or vancomycin in contrast to the parental strain which was normally eliminated by each antimicrobial agent. In conclusion, the decreased susceptibility of the stable SCV strain of S. aureus to bactericidal concentrations of antibiotics may help to explain the persistence of such organisms in chronic infections.

Anti-Bacterial Agents

In vitro and In vivo characterization of a small-colony variant of the primary form of photorhabdus luminescens MD (Enterobacteriaceae)

A small-colony variant (Vsm) of the primary form (Vp) of Photorhabdus luminescens MD from in vitro and in vivo cultures is described. Unlike the primary form, Vp, the Vsm variant is not the preferred diet of its nematode symbiont, a Heterorhabditis sp., does not support development and reproduction of the nematode, and is less pathogenic than Vp to Galleria mellonella larvae. Vsm cells were carried by 25% of infective juveniles, but they comprised a very low percentage ( approximately 0.4%) of the total cells carried by the juvenile. In vitro subculture and in vivo injection into the larvae with either Vp or Vsm always produced a mixture of both Vp and Vsm. In nematode-bacterium-infected G. mellonella larvae, the Vp population in the hemocoel was high (4 x 10(9) to 5 x 10(9) CFU/g of wet insect tissue) at 24 h after infection, decreased about 10-fold by 48 h, and then regained a high level at day 5 before decreasing at day 7 and then remaining relatively constant through day 15 postinfection. The Vsm population, under the same conditions as those of Vp, increased gradually to a high level (9 x 10(8) CFU/g of wet insect tissue) at day 5 postinfection and then declined gradually through day 15.

Journal Article

Small colony variants in staphylococcal infections: diagnostic and therapeutic implications.

The discovery of S. aureus small colony variants as persistent and intracellular has provided new insight into the understanding of pathogenesis associated with staphylococcal diseases. Survival advantages are afforded to SCVs on the basis of their ability to hide within host cells, which provide protection from the immune system and some antibiotics. In addition, because most clinical SCVs are defective in electron transport, their uptake of positively charged antimicrobial substances is reduced. The atypical clinical microbiologic characteristics make identification and susceptibility testing difficult. SCVs have been recovered from patients with unusually persistent infections, particularly those patients with long disease-free intervals, and from patients who are chronically exposed to aminoglycosides and TMP-SMZ, suggesting that these clinical situations are those in which SCVs should be suspected and the clinical laboratory should carefully search for them.

Anti-Bacterial Agents

Staphylococcus aureus small colony variants are induced by the endothelial cell intracellular milieu.

Recent studies have reported that Staphylococcus aureus small colony variants (SCVs) can cause highly persistent infections in humans and in cultured endothelial cells. To understand the process by which SCVs of S. aureus appear in subjects who have not received antibiotic treatment, bovine endothelial cells were coincubated with a wild S. aureus strain for 72 h in the presence of lysostaphin. Intracellular bacteria were harvested and screened for stable SCVs. Intracellular bacteria developed the SCV phenotype at a greater rate than control bacteria not exposed to endothelial cells: The intracellular induction rate was approximately 10(-3) versus a spontaneous rate of <10(-7). This observation suggest that SCVs are induced by the intracellular milieu and suggest a possible mechanism for the intriguing pathophysiology of tissue persistence of staphylococci.

Animals

[Development of gentamicin-resistant Small Colony Variants of S. aureus after implantation of gentamicin chains in osteomyelitis as a possible cause of recurrence].

AIM: Recently, S. aureus small colony variants (SCVs) were reported to persist within cultured endothelial cells and to cause persistent and antibiotic resistant infections in humans. Because gentamicin can very reproducably select for electron transport deficient SCVs as shown in earlier in vitro experiments, we searched for SCVs in a patient with chronic osteomyelitis, who received gentamicin beads. METHOD: Special culture and identification procedures for determination of SCVs were used, including testing of the S. aureus specific nuc gene, pulsed field gel electrophoresis (PFGE) as a typing method and characterization of the auxotrophism of the SCVs. RESULTS: In a case of a 34-year-old patient with chronic osteomyelitis who had previously been treated with gentamicin beads, menadione auxotrophic S. aureus SCVs as well as wild type S. aureus were recovered in multiple bone specimen. All different colony types isolated from simultaneous or from sequential specimen were shown to be clonal by PFGE. CONCLUSION: Recovery of S. aureus SCVs from a patient treated with gentamicin beads suggests that the slow release of gentamicin into the local environment may be an efficient way to select for and/or induce SCVs. These data should alert physicians to also consider SCVs when a treatment failure occurs in a patient that has received gentamicin beads.

Adult

Persistent infection with small colony variant strains of Staphylococcus aureus in patients with cystic fibrosis.

In a 34-month prospective study to determine the prevalence of Staphylococcus aureus small colony variants (SCVs) in cystic fibrosis (CF) patients, S. aureus SCVs or SCVs plus normal S. aureus were recovered from 26 of 78 patients; 27 patients harbored only normal S. aureus. By pulsed-field gel electrophoresis, clonal identity was demonstrated of SCV and normal strains isolated at the same time and of multiple S. aureus SCV and normal strains in consecutive specimens from individual patients. All S. aureus SCVs were resistant to antifolate antibiotics, while the corresponding parent strains were susceptible, and in 11 of 12 SCV/normal pairs, gentamicin was less active against S. aureus with the SCV phenotype than against the normal isolate. Analysis of the underlying auxotrophism of SCVs revealed hemin, thymidine, and/or menadione dependencies. Thus, S. aureus SCVs are highly prevalent in respiratory secretions of CF patients, persist over extended periods, and may contribute to S. aureus persistence in CF patients.

Adolescent

Characteristics of quinolone-induced small colony variants in Staphylococcus aureus.

Exposure of Staphylococcus aureus to 1 x MIC of the quinolone antibiotic pazufloxacin for 24 h, followed by plating on drug-free media, led to the emergence of small colony variants (SCVs) in addition to large colony variants (LCVs). However, following incubation with 0.25 or 4 x MIC of pazufloxacin, only LCVs were obtained. The SCVs were half as susceptible to pazufloxacin or ciprofloxacin as wild-type S. aureus, while the susceptibilities of LCVs were essentially unchanged. The reduced susceptibilities of SCVs did not result from mutations in the quinolone-resistance-determining regions of DNA gyrase and topoisomerase IV, since the sequences of these genes were identical to those of the wild-type. However, the SCVs accumulated pazufloxacin and ciprofloxacin to a lesser degree than did wild-type. Furthermore, their susceptibility to quinolones was almost unaffected by reserpine or verapamil, suggesting that the reduced uptake resulted from decreased permeability, rather than from an active efflux pump. The ability of various quinolones to induce emergence of SCVs in S. aureus, correlated with the presence of carbon-bonded substituents at the C-7 position of a quinoline or naphthyridine nucleus, or with the presence of a benzoxazine nucleus. In conclusion, pazufloxacin-induced SCVs represent a mutant that one might expect to be rapidly eliminated in vivo and, hence, not to survive as a quinolone-resistant pathogen. This finding suggests a novel approach for development of future quinolones.

Animals

Staphylococcal small colony variants have novel mechanisms for antibiotic resistance.

Over the past 4 years, a variant subpopulation of Staphylococcus aureus has been characterized that is defective in electron transport. These organisms grow slowly and are typical of the previously described small colony variants (SCVs). Indeed, many earlier papers included data that are consistent with defective respiratory activity in SCVs. We present a hypothesis that serves as biochemical basis for the development of SCVs. These variants are particularly interesting because they have been associated with very persistent infections, and they are more resistant to many antibiotics than normal S. aureus. Because of their slow growth, atypical colonial morphology, and unusual biochemical profile, they are easily missed or misidentified in the clinical laboratory. This is of some significance, as this subpopulation is more resistant to antibiotics than the parent population from which they arose. When an infection is particularly resistant to therapy, persists for a long period, or fails to respond to apparently adequate antimicrobial therapy, clinicians and clinical laboratory personnel should consider special efforts to search for SCVs.

Animals

Chronic prosthetic hip infection caused by a small-colony variant of Escherichia coli.

From two different specimens of a chronic prosthetic hip infection taken at an interval of 2 months a slow-growing gram-negative bacterium was isolated in pure culture. The strain grew with the typical features of a small-colony variant (SCV). 16S rRNA sequencing identified the bacterium as Escherichia coli. Biochemical characterization demonstrated multiple phenotypic alterations of a mutant carrying a defect in the heme biosynthetic pathway (Hem-): (i) catalase and nitrate reductase reactions were both negative, (ii) a negative benzidine reaction demonstrated the lack of heme-containing cytochromes, and (iii) growth stimulation under anaerobic conditions as well as gentamicin resistance indicated defective aerobic respiration. PCR and Southern hybridization demonstrated that the mutation of the SCV of E. coli was localized in the hemB gene and was most likely due to a deletion of the hemB gene. On blood agar plates revertants were recognized growing as normal-sized colonies between the dominant small colonies of the strain. Feeding experiments indicated that the revertants but not the small colonies were permeable for hemin. A strong antibody response against the infecting SCV of E. coli was found. To our knowledge, this is the first report of a Hem- E. coli strain as the etiological agent of a chronic bacterial infection.

Escherichia coli