1249. Metabolomic Profile of Heterogeneous Vancomycin-Intermediate Staphylococcus aureus (hVISA) in Latin-American MRSA Isolates

Abstract Background Vancomycin (VAN) is a first-line therapeutic option in severe infections caused by MRSA in Latin-America (LA). Development of reduced susceptibility to VAN has been associated with multiple changes in genes encoding pathways for cell wall metabolism and envelope stress responses. Nevertheless, a detailed and coherent mechanistic model to explain the phenotype remains elusive. To gain further insights into the hVISA phenotype, we sought to explore the metabolomic profile of hVISA isolates from LA. Methods The undirected profile of intracellular S. aureus metabolites was analysed in four clinical isolates (two hVISA and two VSSA [Vancomycin susceptible S. aureus]) belonging to the Chilean/Cordobes clone-ST5 (the predominant hVISA lineage in LA), and two reference strains Mu3 and N315. The metabolites were obtained in mid-exponential growth phase in trypticase soy broth in five independent replicates. The metabolites were determined by reverse phase liquid chromatography and hydrophilic interaction. The metabolic profile was determined by variable importance in the projection score (VIP > 1). The differences between hVISA and VSSA were maximized by orthogonal partial least squares discriminant analysis (OPLS-DA) and the affected metabolic pathways were identified with MetaboAnalyst. Results Among the differences identified in the metabolic profiles of hVISA respect to VSSA, 69 metabolites were relevant. Of these, 47 were fatty acids (including glycerol), 7 amino acids and 6 nucleosides (Table 1). These changes mainly impact the biosynthesis of amino acids derived from pyruvate since tyrosine, valine and leucine, had a reduction of 34%, 57% and 41% in hVISA compared to VSSA, respectively, which suggests alterations of the acid cycle tricarboxylic (TCA). Additionally, a reduction in purine and pyrimidine metabolism in hVISA was identified with reduction of nucleosides and dinucleotides derived from the pentose phosphate pathway. Table 1. Metabolites with higher VIP scores in the comparison of the hVISA and VSSA profile Conclusion We were able to observe metabolic alterations in TCA, pentose phosphate pathway and purine intermediates in hVISA-ST5 isolates. Our results support that gluconeogenesis and biosynthesis of carbohydrates and nucleic acids are the main pathways involved in the reduced susceptibility to VAN as reported in VISA isolates. Disclosures Cesar A. Arias, M.D., MSc, Ph.D., FIDSA, Entasis Therapeutics (Grant/Research Support)MeMed Diagnostics (Grant/Research Support)Merk (Grant/Research Support) Lorena Diaz, PhD , Nothing to disclose

. Prediction metrics of the ML pipeline for the detection of the CzIE in MSSA isolates from the training-test cohort. Predictions are shown accordingly to the model and K-mer sizes tested. Conclusion. The ML approach is a promising genomic application to detect the CzIE in MSSA isolates of a variety of sources, bypassing phenotypic testing. Further validation is needed to evaluate its possible utility in clinical settings.
Disclosures. Jonathon C. McNeil, MD, Agency for Healthcare Research and Quality (Research Grant or Support)Allergan (Grant/Research Support)Nabriva (Grant/Research Support, Other Financial or Material Support, Site PI for a multicenter trial) Anthony R. Flores, MD, MPH, PhD, Nothing to disclose Sheldon L. Kaplan, MD, Pfizer (Research Grant  Background. Vancomycin (VAN) is a first-line therapeutic option in severe infections caused by MRSA in Latin-America (LA). Development of reduced susceptibility to VAN has been associated with multiple changes in genes encoding pathways for cell wall metabolism and envelope stress responses. Nevertheless, a detailed and coherent mechanistic model to explain the phenotype remains elusive. To gain further insights into the hVISA phenotype, we sought to explore the metabolomic profile of hVISA isolates from LA.
Methods. The undirected profile of intracellular S. aureus metabolites was analysed in four clinical isolates (two hVISA and two VSSA [Vancomycin susceptible S. aureus]) belonging to the Chilean/Cordobes clone-ST5 (the predominant hVISA lineage in LA), and two reference strains Mu3 and N315. The metabolites were obtained in mid-exponential growth phase in trypticase soy broth in five independent replicates. The metabolites were determined by reverse phase liquid chromatography and hydrophilic interaction. The metabolic profile was determined by variable importance in the projection score (VIP > 1). The differences between hVISA and VSSA were maximized by orthogonal partial least squares discriminant analysis (OPLS-DA) and the affected metabolic pathways were identified with MetaboAnalyst.
Results. Among the differences identified in the metabolic profiles of hVISA respect to VSSA, 69 metabolites were relevant. Of these, 47 were fatty acids (including glycerol), 7 amino acids and 6 nucleosides (Table 1). These changes mainly impact the biosynthesis of amino acids derived from pyruvate since tyrosine, valine and leucine, had a reduction of 34%, 57% and 41% in hVISA compared to VSSA, respectively, which suggests alterations of the acid cycle tricarboxylic (TCA). Additionally, a reduction in purine and pyrimidine metabolism in hVISA was identified with reduction of nucleosides and dinucleotides derived from the pentose phosphate pathway. Table 1. Metabolites with higher VIP scores in the comparison of the hVISA and VSSA profile Conclusion. We were able to observe metabolic alterations in TCA, pentose phosphate pathway and purine intermediates in hVISA-ST5 isolates. Our results support that gluconeogenesis and biosynthesis of carbohydrates and nucleic acids are the main pathways involved in the reduced susceptibility to VAN  Background. Vancomycin-resistant enterococci (VRE) are nosocomial pathogens with extensive intrinsic and acquired antimicrobial resistance (AMR) mechanisms. We report a case in which intraabdominal (IA) and blood cultures grew linezolid and daptomycin resistant VRE (DLVRE).
Methods. We report a case of DLVRE bacteremia after prolonged treatment with linezolid and daptomycin.
Results. The patient was a 65-year-old female with a history of multiple abdominal surgeries who presented for elective incisional hernia repair. Her post-operative course was complicated by the development of loculated IA abscesses. A drain was placed into the largest abscess, and aspiration cultures were polymicrobial containing vancomycin-resistant E. faecium (Isolate 1). The patient was treated meropenem, fluconazole and linezolid for 6 weeks. Clinical and radiographic improvement was achieved. However, 4 days after competing antibiotics she developed recurrent abdominal pain and a leukocytosis. Daptomycin was chosen out of concern for long-term linezolid toxicity and IA cultures demonstrated new linezolid resistance (Isolate 2, LVRE). After an additional three weeks of therapy, she developed a catheter-associated bloodstream infection (CLABSI). Blood cultures revealed daptomycin-resistant LVRE bacteremia (Isolate 3, DLVRE). She was started empirically on a combination of ceftaroline and daptomycin, her PICC line removed, and her blood cultures cleared. Her antibiotic course is presented in Figure 1 and resistance patterns of the VRE in Table 1.

Conclusion.
In this patient, an IA abscess known to harbor VRE developed resistance to both linezolid and daptomycin during prolonged treatment with both agents. Ultimately, the patient experienced an episode of CLABSI DLVRE. Limited data exists on appropriate antibiotic choice in such challenging situations. Based on prior clinical and experimental data, we elected to use daptomycin in conjunction with ceftaroline for synergy, and the patient achieved the desired clinical response, clearance of her blood cultures and diminishing size of her IA abscess. Further work is needed to elucidate the best course of treatment for patients with VRE requiring long-term antibiotic therapy and for those who have developed extensively drug-resistant E. faecium. Background. The spread of carbapenem resistant Pseudomonas aeruginosa and carbapenemase-producing Enterobacterales (CPE) has had a great impact on morbidity and mortality. COVID-19 pandemic has favoured the selection of these microorganisms because of the excessive and prolonged use of broad-spectrum antibiotics and the outbreaks related to patient transfer between hospitals and inadequate use of personal protective equipment. Therefore, detection is considered essential for their control. Our aim was to compare conventional phenotypic synergy tests and two lateral flow immunoassays for detecting carbapenemases in Enterobacterales and P. aeruginosa.