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The accessory gene regulator ( agr ) locus of  Staphylococcus aureus  is a quorum-sensing virulence regulator. Although there are many studies concerning the effect of dysfunctional  agr  on the outcomes of  S. aureus  infection, there is no systematic review to date. We systematically searched for clinical studies reporting outcomes of invasive  S. aureus  infections and the proportion of dysfunctional  agr  among their causative strains, and we performed a meta-analysis to obtain estimates of the odds of outcomes of invasive  S. aureus  infection with dysfunctional versus functional  agr . Of 289 articles identified by our research strategy, 20 studies were meta-analysed for crude analysis of the impact of dysfunctional  agr  on outcomes of invasive  S. aureus  infection. Dysfunctional  agr  was generally associated with unfavourable outcomes (OR 1.32, 95% CI 1.05–1.66), and the impact of dysfunctional  agr  on outcome was more prominent in invasive methicillin-resistant  S. aureus  (MRSA) infections (OR 1.54, CI 1.20–1.97). Nine studies were meta-analysed for the impact of dysfunctional  agr  on the 30-day mortality of invasive  S. aureus  infection. Invasive MRSA infection with dysfunctional  agr  exhibited higher 30-day mortality (OR 1.40, CI 1.03–1.90) than that with functional  agr . On the other hand, invasive MSSA infection with dysfunctional  agr  exhibited lower 30-day mortality (OR 0.51, CI 0.27–0.95). In the post hoc subgroup analysis by the site of MRSA infection, dysfunctional  agr  was associated with higher 30-day mortality in MRSA pneumonia (OR 2.48, CI 1.17–5.25). The effect of dysfunctional  agr  on the outcome of invasive  S. aureus  infection may vary depending on various conditions, such as oxacillin susceptibility and the site of infection. Dysfunctional  agr  was generally associated with unfavourable clinical outcomes and its effect was prominent in MRSA and pneumonia. Dysfunctional  agr  may be applicable for outcome prediction in cases of invasive MRSA infection with hardly eradicable foci such as pneumonia.

Dysfunctional accessory gene regulator (agr) as a prognostic factor in invasive Staphylococcus aureus infection: a systematic review and meta-analysis