The evolution of diverse antimicrobial responses in vancomycin-intermediate Staphylococcus aureus and its therapeutic implications
Staphylococcus aureus bacteremia is typically treated empirically with vancomycin, with therapy later tailored based on susceptibility results. However, these tests occur before vancomycin exposure and do not account for adaptation during empiric treatment that can alter S. aureus susceptibility to first-line drugs. To investigate these collateral drug responses, we experimentally evolved 18 methicillin-susceptible S. aureus (MSSA) populations under increasing vancomycin concentrations until they achieved intermediate resistance. Genomic sequencing revealed two distinct adaptive pathways characterized by mutations in the WalKR regulon, affecting cell wall metabolism, or rpsU, impacting translational stress responses. These pathways correlated with divergent collateral sensitivity profiles to first-line antibiotics. By developing a Collateral Response Score (CRS), we quantified the probability and magnitude of these responses, demonstrating that evolutionary dynamics critically influence resistance outcomes. Our findings suggest a probabilistic approach to antimicrobial therapy, advocating for rapid genomic diagnostics alongside susceptibility testing to better anticipate and respond to evolutionary changes. SignificanceAntibiotic treatment can influence bacterial evolution, altering the effectiveness of subsequent therapies by inducing collateral resistance or sensitivity. This study reveals that evolution toward vancomycin-intermediate resistance in the pathogen Staphylococcus aureus proceeds through at least two distinct evolutionary pathways: one characterized by alterations in cell wall metabolism and another by changes in global stress response. These adaptive trajectories result in contrasting collateral sensitivities to first-line antibiotics. By introducing the Collateral Response Score, we assess the uncertainty in these outcomes, providing a probabilistic framework to evaluate how past antibiotic exposure shapes future treatment responses. Further validation studies are needed; however, we believe that improved forecasting of pathogen evolution can enhance antibiotic stewardship, inform therapeutic decisions, and ultimately improve patient outcomes.