Small-colony variant (SCV) strains of Staphylococcus aureusshow reduced antibiotic susceptibility and intracellular persistence, potentially explaining therapeutic failures. The activities of oxacillin, fusidic acid, clindamycin, gentamicin, rifampin, vancomycin, linezolid, quinupristin-dalfopristin, daptomycin, tigecycline, moxifloxacin, telavancin, and oritavancin have been examined in THP-1 macrophages infected by a stable thymidine-dependent SCV strain in comparison with normal-phenotype and revertant isogenic strains isolated from the same cystic fibrosis patient. The SCV strain grew slowly extracellularly and intracellularly (1-and 0.2-log CFU increase in 24 h, respectively). In confocal and electron microscopy, SCV and the normalphenotype bacteria remain confined in acid vacuoles. All antibiotics tested, except tigecycline, caused a net reduction in bacterial counts that was both time and concentration dependent. At an extracellular concentration corresponding to the maximum concentration in human serum (total drug), oritavancin caused a 2-log CFU reduction at 24 h; rifampin, moxifloxacin, and quinupristin-dalfopristin caused a similar reduction at 72 h; and all other antibiotics had only a static effect at 24 h and a 1-log CFU reduction at 72 h. In concentration dependence experiments, response to oritavancin was bimodal (two successive plateaus of ؊0.4 and ؊3.1 log CFU); tigecycline, moxifloxacin, and rifampin showed maximal effects of ؊1.1 to ؊1.7 log CFU; and the other antibiotics produced results of ؊0.6 log CFU or less. Addition of thymidine restored intracellular growth of the SCV strain but did not modify the activity of antibiotics (except quinupristin-dalfopristin). All drugs (except tigecycline and oritavancin) showed higher intracellular activity against normal or revertant phenotypes than against SCV strains. The data may help rationalizing the design of further studies with intracellular SCV strains.Small-colony variant (SCV) strains are increasingly recognized as a major cause of the persistence and recurrence of Staphylococcus aureus infections, and specific therapeutic options remain so far ill explored (58). Microbiologically, SCV strains constitute a naturally occurring subpopulation of bacteria with a series of metabolic alterations that confer a particular phenotype characterized by slow growth, reduced hemolytic activity, and auxotrophy for hemin, menadione, or thymidine. SCVs easily revert to the normal phenotype and therefore often escape detection. Moreover, even if stable, they remain difficult to recognize in routine testing unless specifically looked for (42). Genetically, the expression of virulence regulators (agr and sarA) or the alternative stress regulator sigB and its dependent virulence genes (hla and spa) is downregulated in SCV strains compared with isogenic normal strains (26, 38). Clinically, SCV strains are preferentially isolated in chronic infections of skin, soft tissues, joint, and bone (41,59,62), as well as in the respiratory tract of cystic fibrosis (CF) pati...
