Disparity between timed-kill and checkerboard methods for determination of in vitro bactericidal interactions of vancomycin plus rifampin versus methicillin-susceptible and -resistant Staphylococcus aureus

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Abstract
The role of rifampin as an adjunctive agent to vancomycin in the therapy of serious systemic staphylococcal infections remains controversial. Several in vitro studies utilizing differing methodologies to define the bactericidal interactions of vancomycin plus rifampin versus Staphylococcus aureus have yielded markedly disparate results. The in vitro bactericidal synergistic activities of vancomycin plus rifampin were examined versus 48 clinical isolates of S. aureus, both methicillin susceptible and resistant. Each strain was tested simultaneously in timed-kill curve and checkerboard systems. By timed-kill curve, vancomycin plus rifampin usually had either an indifferent (67%) or synergistic (19 to 29%) effect, with a frequency dependent on sampling times; bactericidal antagonism was infrequently noted after 48 h of incubation (4%). Indifference was seen as a prevention of rifampin resistance by vancomycin. Synergy was more commonly noted at 48 than at 24 h of incubation. The bactericidal interaction results were similar for both methicillin-susceptible and -resistant strains. In contrast to the killing curve data, the checkerboard technique uniformly demonstrated bactericidal antagonism of vancomycin plus rifampin against all 48 staphylococci. We conclude that the nature of the in vitro bactericidal interactions of vancomycin plus rifampin against S. aureus is difficult to establish in vitro. This fact relates to the markedly disparate findings, which depended on both the synergy technique utilized and the test system conditions employed. In vivo studies are required to delineate the bactericidal interaction potentials of vancomycin plus rifampin versus S. aureus.