The role of the Panton-Valentine leucocidin toxin in staphylococcal disease: a systematic review and meta-analysis

Lancet Infect Dis. 2013 Jan;13(1):43-54. doi: 10.1016/S1473-3099(12)70238-4. Epub 2012 Oct 26.


Background: Invasive community-onset staphylococcal disease has emerged worldwide associated with Panton-Valentine leucocidin (PVL) toxin. Whether PVL is pathogenic or an epidemiological marker is unclear. We investigate the role of PVL in disease, colonisation, and clinical outcome.

Methods: We searched Medline and Embase for original research reporting the prevalence of PVL genes among Staphylococcus aureus pneumonia, bacteraemia, musculoskeletal infection, skin and soft-tissue infection, or colonisation published before Oct 1, 2011. We calculated odds ratios (ORs) to compare patients with PVL-positive colonisation and each infection relative to the odds of PVL-positive skin and soft-tissue infection. We did meta-analyses to estimate odds of infection or colonisation with a PVL-positive strain with fixed-effects or random-effects models, depending on the results of tests for heterogeneity.

Results: Of 509 articles identified by our search strategy, 76 studies from 31 countries met our inclusion criteria. PVL strains are strongly associated with skin and soft-tissue infections, but are comparatively rare in pneumonia (OR 0·37, 95% CI 0·22-0·63), musculoskeletal infections (0·44, 0·19-0·99), bacteraemias (0·10, 0·06-0·18), and colonising strains (0·07, 0·01-0·31). PVL-positive skin and soft-tissue infections are more likely to be treated surgically than are PVL-negative infections, and children with PVL-positive musculoskeletal disease might have increased morbidity. For other forms of disease we identified no evidence that PVL affects outcome.

Interpretation: PVL genes are consistently associated with skin and soft-tissue infections and are comparatively rare in invasive disease. This finding challenges the view that PVL mainly causes invasive disease with poor prognosis. Population-based studies are needed to define the role of PVL in mild, moderate, and severe disease and to inform control strategies.

Funding: None.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Bacterial Toxins / genetics*
  • Bacterial Toxins / metabolism*
  • Exotoxins / genetics*
  • Exotoxins / metabolism*
  • Humans
  • Leukocidins / genetics*
  • Leukocidins / metabolism*
  • Soft Tissue Infections / genetics
  • Soft Tissue Infections / metabolism
  • Soft Tissue Infections / microbiology
  • Staphylococcal Infections / genetics*
  • Staphylococcal Infections / metabolism*
  • Staphylococcal Infections / microbiology
  • Staphylococcal Skin Infections / genetics
  • Staphylococcal Skin Infections / metabolism
  • Staphylococcal Skin Infections / microbiology
  • Staphylococcus aureus / genetics*
  • Staphylococcus aureus / metabolism*


  • Bacterial Toxins
  • Exotoxins
  • Leukocidins
  • Panton-Valentine leukocidin