Tracking the in vivo evolution of multidrug resistance in Staphylococcus aureus by whole-genome sequencing

doi:10.1073/pnas.0609839104

Tracking the in vivo evolution of multidrug resistance in Staphylococcus aureus by whole-genome sequencing

*Physics Department, Cornell University, Ithaca, NY 14850;
^†Center for Studies in Physics and Biology and
^‡Laboratory of Microbiology, The Rockefeller University, New York, NY 10021;
^§Department of Microbiology, Tianjin Medical University, Tianjin 300070, People's Republic of China;
^¶Laboratory of Molecular Genetics, Instituto de Tecnologia Química e Biológica, Universidade Nova de Lisboa, Oeiras, Portugal;
^‖United States Department of Energy Joint Genomic Institute, Walnut Creek, CA 94598; and
**Howard Hughes Medical Institute, Janelia Farm Research Campus, Ashburn, VA 20146

Edited by John J. Mekalanos, Harvard Medical School, Boston, MA, and approved April 13, 2007 (received for review November 6, 2006)

Abstract

The spread of multidrug-resistant Staphylococcus aureus (MRSA) strains in the clinical environment has begun to pose serious limits to treatment options. Yet virtually nothing is known about how resistance traits are acquired in vivo. Here, we apply the power of whole-genome sequencing to identify steps in the evolution of multidrug resistance in isogenic S. aureus isolates recovered periodically from the bloodstream of a patient undergoing chemotherapy with vancomycin and other antibiotics. After extensive therapy, the bacterium developed resistance, and treatment failed. Sequencing the first vancomycin susceptible isolate and the last vancomycin nonsusceptible isolate identified genome wide only 35 point mutations in 31 loci. These mutations appeared in a sequential order in isolates that were recovered at intermittent times during chemotherapy in parallel with increasing levels of resistance. The vancomycin nonsusceptible isolates also showed a 100-fold decrease in susceptibility to daptomycin, although this antibiotic was not used in the therapy. One of the mutated loci associated with decreasing vancomycin susceptibility (the vraR operon) was found to also carry mutations in six additional vancomycin nonsusceptible S. aureus isolates belonging to different genetic backgrounds and recovered from different geographic sites. As costs drop, whole-genome sequencing will become a useful tool in elucidating complex pathways of in vivo evolution in bacterial pathogens.

Footnotes

^††To whom correspondence should be addressed. E-mail: tomasz{at}mail.rockefeller.edu
Author contributions: A.T. designed research; M.M.M., S.W.W., and Y.Z. performed research; K.S., P.R., D.B., and E.R. contributed new reagents/analytic tools; M.M.M. H.d.L., E.M., and E.D.S. analyzed data; and M.M.M., E.D.S., and A.T. wrote the paper.
The authors declare no conflict of interest.
This article is a PNAS Direct Submission.
↵ ‡‡ Flayhart, D., Hanlon, A., Wakefield, T., Ross, T., Borio, L., Dick, J. (2001) in Abstracts of the 101st General Meeting of the American Society of Microbiology, May 20–24, 2001, Orlando, FL, Abstr. A-39.
This article contains supporting information online at www.pnas.org/cgi/content/full/0609839104/DC1.
Abbreviations:

MIC,

minimal inhibitory concentration;

MRSA,

multidrug-resistant S. aureus;

VISA,

vancomycin intermediate-resistant S. aureus.