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Despite emerging evidence that dysfunction in the accessory gene regulator (agr ) locus is associated with deleterious outcomes among patients treated with vancomycin for methicillin-resistantStaphylococcus aureus (MRSA) infections, factors predictive ofagr dysfunction have not been evaluated. This study describes the epidemiology ofagr dysfunction, identifies predictors ofagr dysfunction in MRSA isolates among those with MRSA bloodstream infections, and describes the relationship betweenagr dysfunction and other microbiologic phenotypes. A cross-sectional study of patients with MRSA bloodstream infections at two institutions in upstate New York was performed. Clinical data on demographics, comorbidities, disease severity, hospitalization history, and antibiotic history were collected. Microbiologic phenotypes, includingagr dysfunction, MIC values by broth microdilution (BMD) and Etest, and vancomycin heteroresistance (hVISA) were tested. Multivariable analyses were performed to identify factors predictive ofagr dysfunction. Among 200 patients with an MRSA bloodstream infection, the proportion of strains withagr dysfunction was 31.5%. The distribution of MICs determined by both BMD and Etest were equivalent acrossagr groups, and there was no association betweenagr dysfunction and the presence of hVISA. Severity of illness, comorbidities, and hospitalization history were comparable betweenagr groups. In the multivariate analysis, prior antibiotic exposure was the only factor of variables studied found to be predictive ofagr dysfunction. This relationship was predominantly driven by prior beta-lactam and fluoroquinolone administration in the bivariate analysis. Identifying these institution-specific risk factors can be used to develop a process to assess the risk ofagr dysfunction and guide empirical antibiotic therapy decisions.

Predictors of agr Dysfunction in Methicillin-Resistant Staphylococcus aureus (MRSA) Isolates among Patients with MRSA Bloodstream Infections