Macrolide resistance mechanisms among Streptococcus pneumoniae isolated over 6 years of Canadian Respiratory Organism Susceptibility Study (CROSS) (1998-2004)

Background: Resistance to macrolides in Streptococcus pneumoniae arises primarily due to Erm( B) or Mef( A). Erm( B) typically confers high-level resistance to macrolides, lincosamides and streptogramin B ( MLSB phenotype), whereas Mef( A) confers low-level resistance to macrolides only ( M phenotype). The purpose of this study was to investigate the incidence of macrolide resistance mechanisms in Canadian isolates of S. pneumoniae obtained between 1998 and 2004. Furthermore, the genetic relatedness, serotype distribution and antibiotic susceptibility profile among S. pneumoniae isolates with dual erythromycin ribosomal methylase [ Erm( B)] and efflux pump [ Mef( A)] were analysed. Methods: A total of 865 macrolide-resistant ( erythromycin MIC >= 1 mg/L) S. pneumoniae isolates were collected from the Canadian Respiratory Organism Susceptibility Study ( CROSS) from 1998 to 2004. The presence of erm( B) and mef( A) was determined for each isolate by PCR; mutations in the genes coding for L4 and L22 ribosomal proteins and for 23S rRNA were identified by DNA sequencing. Each isolate containing both erm( B)- and mef( A)- mediated macrolide resistance was genotyped by PFGE and serotyped using the Quellung reaction with antisera. Results: Of the 865 isolates studied, 404 ( 46.7%) were mef( A)- positive, 371 ( 42.9%) were erm( B)positive, 50 ( 5.8%) were positive for both mef( A) and erm( B) and 40 ( 4.6%) were negative for both mef( A) and erm( B). Of the macrolide-resistant isolates negative for both mef( A) and erm( B), 22 ( 2.5%) contained 23S rRNA A2058G, A2059G or A2059C mutations, 7 ( 0.8%) contained 23S rRNA A2058G or A2059G mutations along with an S20N mutation in L4 ribosomal protein, and 1 isolate contained an E30K ribosomal protein mutation alone. Of the macrolide-resistant strains positive for both mef( A) and erm( B), 36 ( 72%) were multidrug-resistant ( macrolide-, penicillin- and trimethoprim/sulfamethoxazole-resistant), 39 ( 78%) isolates belonged to serotype 19A or 19F and 36 ( 72%) belonged to one clonal complex ( >= 80% genetic relatedness) genetically related to the Taiwan 19F-14 clone. Conclusions: The prevalence of efflux-based macrolide resistance in S. pneumoniae in Canada remained steady between 1998 and 2004. Macrolide resistance due to erm( B) decreased over the same time period, with a rapid increase in isolates with both erm( B) and mef( A) macrolide resistance.