Yaru Wang,1,* Yanwen Sun,2,* Guang Chen,3,* Xin Cheng4 

1Department of Gynecology and Obstetrics, Affiliated Nanshan Hospital of Shenzhen University, Shenzhen, 518000, People’s Republic of China; 2Department of Medical Laboratory, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310018, People’s Republic of China; 3Department of Clinical Laboratory, Weifang People’s Hospital, Weifang, 261000, People’s Republic of China; 4Department of Laboratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215006, People’s Republic of China

*These authors contributed equally to this work

Correspondence: Xin Cheng, Department of Laboratory Medicine, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Gusu District, Suzhou, 215006, People’s Republic of China, Email 15735537628@163.com

Abstract: Heterogeneous vancomycin-intermediate and vancomycin-intermediate Staphylococcus aureus (hVISA and VISA) presents significant therapeutic challenges due to high treatment failure rates and limited options. Conventional monotherapies, including daptomycin and linezolid, are often compromised by cross-resistance and inconsistent efficacy. Combination therapies incorporating β-lactams, quinolones, or lipopeptides with vancomycin exploit synergistic mechanisms (eg, the “seesaw effect”) but exhibit variable success depending on bacterial strain, drug concentration, and experimental models. Novel antimicrobials, such as next-generation glycopeptides (LY333328, oritavancin, YV4465), synthetic agents (pyridyl disulfides, alpha-amyrin), and natural derivatives (plant flavonoids, cyanobacterial metabolites), have demonstrated enhanced activity against VISA/hVISA by disrupting membranes, suppressing virulence, or reversing resistance. Antimicrobial peptides and non-classical agents (eg, nybomycin, telomycin) further expand therapeutic options by targeting RNA degradation, biofilms, or toxin production. Additionally, advanced drug delivery systems, including nanoemulsions and nanoliposomes, improve drug stability, biofilm penetration, and localized efficacy. Despite these promising advances, clinical translation remains challenging, requiring rigorous validation of synergistic mechanisms, optimized dosing strategies, and resistance mitigation approaches. Continued innovation in antimicrobial development is essential to address the growing threat of multidrug-resistant Staphylococcus aureus infections.

Keywords: hVISA, VISA, monotherapy, combination therapy, novel antimicrobials, drug delivery system