The cefazolin inoculum effect in methicillin-susceptible Staphylococcus aureus blood isolates: their association with dysfunctional accessory gene regulator (agr)

•Type A was the only detected β-lactamase in MSSA isolates exhibiting the CIE.•The CIE was more common in MSSA isolates with dysfunctional agr.•The CIE was observed only in MSSA isolates with agr group I or III.•The CIE was more prevalent in isolates with dysfunctional agr among those with type A β-lactamase.

We evaluated the clinical significance of the cefazolin inoculum effect (CIE) in methicillin-susceptible Staphylococcus aureus (MSSA) isolates. In total, 146 isolates were recovered from patients with MSSA bacteremia at 9 hospitals in Korea. The CIE was observed in 16 MSSA isolates, and while type A was the only detected β-lactamase in MSSA isolates exhibiting the CIE, no strains expressing type B, C, or D β-lactamases exhibited this effect. The CIE was only observed in agr group III and I isolates and was significantly more common in isolates with agr dysfunction than in those with functional agr (P < 0.001). Even among isolates producing type A β-lactamase, the CIE was also prevalent in isolates with dysfunctional agr than in isolates with functional agr (P = 0.025). This study demonstrates an association between the CIE of MSSA isolates and agr dysfunction, in addition to those between the CIE and type A β-lactamase.