Panton-Valentine Leukocidin (PVL) Is a Key Determinant of Outcome in Patients with Hospital-Acquired CONTACT INFORMATION:

Vance G. Fowler Jr., MD

Department of Medicine

K-2188 Pneumonia (HAP) Due to Methicillin-Susceptible Staphylococcus aureus (MSSA) Duke University Medical Center
Box 3281 Medical Center
Durham, NC 27710
Phone: 919-684-6854
Batu K. Sharma-Kuinkel,1,2 Martin E .Stryjewski,1,3 Thomas H. Rude,1,2 Fredric C. Genter,4 Steven L. Barriere,4 G. Ralph Corey,1,2 Vance G .Fowler Jr,1,2 Fax: 919-684-8902
1Duke Clinical Research Institute, Durham, NC, USA; 2Duke University Medical Center, Durham, NC, USA; 3Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina; 4Theravance, Inc., South San Francisco, CA, USA E-mail: fowle003@mc.duke.edu

F. MSSA pvl + isolates by amount of a-haemolysin produced:

C. Association between other putative virulence genes of
Amount of a-haemolysin CURE FAILURE TOTAL p-value

Abstract Methods MSSA isolates and clinical outcome: >10 HU/ml

<= 10HU/ml
3 (60%)
9 (56.25%)
2 (40%)
7 (43.75%)
5
16
1.000

Background: Study Design: TOTAL 12 (57.14%) 9 (42.85%) 21

The impact of pvl on the outcome of patients with Staphylococcus aureus pneumonia  The ATTAIN I and II were two identical phase 3, randomized, double-blinded, parallel-group, multinational trials ( 0015 and
G. MSSA pvl + isolates by amount of d-lysin produced:
is unresolved. Using a large collection of contemporary, geographically diverse isolates 0019) studying the efficacy and safety of intravenous telavancin versus vancomycin for the treatment of hospital- acquired
from 2 multinational clinical trials, this study evaluated associations between pvl CURE FAILURE TOTAL
pneumonia ( HAP).
Delta lysine -Ve 1(33.33%) 2 (66.66%) 3
presence and clinical outcome in patients with S. aureus hospital-acquired pneumonia  S. aureus isolates were obtained from 127 centers in 34 countries.
Delta lysine +ve 11(61.11%) 7 (38.88%) 18
(HAP).  Only the patients with monomicrobial S. aureus HAP with available patient outcome (cure/failure/survival) data were
Methods: Total 12 (57.14%) 9 (42.85%) 21
included in the study.
The ATTAIN (Assessment of Telavancin for Hospital-acquired Pneumonia) clinical
H. Clonal complex distribution among pvl + isolates :
trials were two identical phase 3, randomized, double-blinded, multinational trials Molecular Biological Assays: TOTAL MSSA
studying the efficacy and safety of intravenous telavancin vs vancomycin for the  Genomic DNA was prepared as previously described7. Clonal Complex Numbers CURE FAILURE Clonal Complex Numbers CURE FAILURE
treatment of HAP, with a focus on infections due to S. aureus. Isolates were included in  The multiplex polymerase chain reaction (PCR), as described earlier, was used to screen bacterial genes encoding CC5 14 12 2 CC5 3 2 1
the current study if the patient had monomicrobial S. aureus HAP and patient outcome putative virulence determinants (eg. adhesins, toxins, and agr group I-IV)7 . CC8 22 14 8 CC8 3 1 2
(cure/failure) was available. The presence of 33 putative virulence determinants was  The isolates were classified as Staphylococcal chromosomal mec (SCCmec) type I, II III, or IV by multiplex PCR. CC15 4 4 0 CC15 3 3 0
assessed using multiplex PCR.  Alpha hemolysin activity was measured by quantitative analysis of rabbit RBC hemolysis as described earlier with little CC22 1 1 0 CC22 0 0 0
Results: CC30 6 5 1 CC30 3 2 1
modifications9.
CC45 1 1 0 CC45 1 1 0
287 S. aureus isolates were included from 127 centers in 34 countries (173 methicillin  Delta hemolysin assay was done to test the integrity of the agr locus and to rule out the possibility of agr dysfunction
CC88 2 1 1 CC88 2 1 1
resistant [MRSA], 114 MSSA). Of these, 59 were pvl + (38 MRSA, 21 MSSA). among the less virulent strains. Delta hemolysin activity on sheep blood agar plates was determined as described CC97 2 0 2 CC97 2 0 2
Stratifying by MRSA status, patients with pvl + and pvl - HAP had similar severity of elsewhere10 . CC101 1 1 0 CC101 1 1 0
illness at baseline. Among MRSA-infected patients, outcomes between pvl + and pvl -  The clonal complex of the isolates was determined by Multi Locus Sequence Typing ( MLST). Genomic DNA of all the CC121 3 1 2 CC121 3 1 2
infections were similar. However, patients with pvl + MSSA HAP had significantly lower isolates was extracted using an ultraclean microbial DNA kit and MLST was performed using 7 pairs of housekeeping Singleton 1 1 0 Singleton 0 0 0
rates of cure (57.1% vs 90.3%; p<0.001) and Kaplan-Meier survival at 28 day (80.1% genes as described by Enright et al11. Total 57 41 16 Total 21 12 9
vs 97.8%; p=0.001). This finding persisted after adjustment for multiple potential
Background
confounding variables. No other genes were associated with clinical outcome.
Conclusions:
Results D. Cure rates among patients with MRSA and MSSA
pneumonia according to presence or absence of pvl :
Conclusions
In this study, patients with pvl + MSSA HAP were significantly more likely to fail p<0.001 1. PVL is the key virulence determinant in MSSA HAP.
B. Outcome of patients with MSSA pneumonia stratified by p=1.000
treatment or die than patients infected with pvl - MSSA, despite having the same A. Characteristics of the study populations: 100 2. Patients with pvl + MSSA HAP had significantly lower rates of cure (57.1% vs
severity of infection at the time of enrollment. The presence of pvl is significantly clinically relevant characteristics:
90.3%; p<0.001) and 28 day survival (80.1% vs 97.8%; p=0.001) than patients
80
associated with poor outcome in MSSA HAP. Cure rates by PVL status
with pvl – MSSA HAP, despite having a similar severity of illness at baseline.
60 3. This finding persisted after adjustment for multiple potential confounding

% Cure Rate
Introduction 40 variables.
4. None of the 33 other virulence genes tested in the study were associated with
20
 Staphylococcus aureus is the most important cause of life-threatening bacterial clinical outcome.
infections in the present developed world including USA1. 0
pvl + pvl - pvl + pvl - 5. agr dysfunction has no impact on outcome of patients with S. aureus
 The role of Panton-Valentine Leukocidin ( PVL) in the pathogenesis of Hospital- MRSA MSSA Hospital-Acquired Pneumonia.
Acquired Pneumonia ( HAP) is very conflicting and not well understood2,3,4,5,6. 6. The differential in amount of alpha haemolysin production has no impact on
 PVL is a beta pore forming bi-component cytotoxin , encoded by two contiguous and outcome of patients with S. aureus Hospital-Acquired Pneumonia.
E. Estimated K-M survival at 28 days among patients
co-transcribed genes carried on a bacteriophage, causing pores in the membranes 7. Differential in mortality among patients with S. aureus Hospital-Acquired
with MRSA and MSSA pneumonia according to
of the infected cells leading to its necrosis or apoptosis7. Pneumonia is not due to a single pvl-constitutive S. aureus clone.
presence or absence of pvl :
 Hospital acquired pneumonia ( HAP) or nosocomial pneumonia is the second most p=0.001
common nosocomial infection in United States and the leading cause of morbidity
and mortality from nosocomial infections 8. 1
p=0.834 References

Estimated K-M Survival at 28 days

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0.8
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6. Olsen RJ et al. Am J. Pathol 2010; 176:1346-54
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0.2
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independently associated with worse outcome and death among the patients with S. 8. Dean N. Hosp Pract 2010; 38:7-15
aureus pneumonia. Despite the similar characteristics of patients at the time of 9. Kernodle DS et al. J. Infec Dis 1995; 172:410-9
0
enrolment, the significant difference in the outcome was found even after the pvl + pvl - pvl + pvl -
10.Sakoula G et al. Antimicrob Agents Chemother 2002; 46:1492-502
MRSA MSSA
adjustment for multiple factors. 11.Enright MC et al. J Clin Microbiol 2000; 38:1008-15

DUKE MEDICINE
This study was supported by a grant from Theravance, Inc. South San Francisco; CA.