Thymidine-dependent small-colony variants (SCVs) of Staphylococcus aureus are frequently associated with persistent and recurrent infections in cystic fibrosis patients. The phenotypic appearance of S. aureus SCVs or normal-colony variants (NCVs) is postulated to be affected by the intracellular amount of dTMP. This hypothesis was proven by metabolic pathway assays revealing altered intracellular dTMP concentrations, followed by investigation of the associated phenotype. Inhibition of the staphylococcal thymidylate synthase, which generated intracellular dTMP from dUMP, using 5-fluorouracil and co-trimoxazole resulted in an SCV phenotype. Inhibition of a nucleoside transporter, which provided the bacterial cell with extracellular thymidine, caused growth inhibition of SCVs. In turn, reversion of SCVs to NCVs was achieved by supplying extracellular dTMP. High-performance liquid chromatography additionally confirmed the intracellular lack of dTMP in SCVs, in contrast to NCVs. Moreover, the dTMP concentration is postulated to influence the intracellular persistence of S. aureus. Cell culture experiments with cystic fibrosis cells revealed that clinical and co-trimoxazole-induced SCVs with a diminished amount of dTMP showed significantly better intracellular persistence than NCVs. In conclusion, these results show that the dTMP concentration plays a key role in both the phenotypic appearance and the intracellular persistence of S. aureus.Staphylococcus aureus is an important human pathogen and causes diseases ranging in severity from minor skin infections to life-threatening conditions, such as endocarditis, pneumonia, and sepsis (15, 16). Small-colony variants (SCVs) are naturally occurring subpopulations of S. aureus with distinctive phenotypic and pathogenic traits (22). In contrast to the normal-colony variant (NCV) of S. aureus, SCVs produce tiny, nonhemolytic colonies that are not pigmented or have minor pigmentation and they have altered expression of virulence genes and auxotrophism for distinct growth factors (12,21,23,28). With regard to pathogenic traits, S. aureus SCVs are associated with persistent, relapsing, and treatment-resistant infections and have been isolated from clinical specimens from patients with osteomyelitis, device-related infections, brain abscesses, soft tissue infections, and cystic fibrosis (CF) lung disease (1,4,14,25,30). The pathogenesis of S. aureus SCV infection is not fully understood; however, it has been shown that clinical SCVs persist longer in eukaryotic cells than corresponding S. aureus strains with the normal phenotype (2, 31). This intracellular survival of S. aureus SCVs is a sophisticated mechanism that probably contributes to pathogenicity insofar as the intracellular location provides a niche for the bacteria, where they are protected against host defenses and antibiotic therapy.With regard to auxotrophism for growth factors, two main groups of S. aureus SCVs are recovered from clinical specimens: (i) SCVs that are dependent on menadione or hemin, indicating defici...