Background: S. pneumoniae is a major cause of meningitis, pneumonia and sepsis in children. In 2006 universal pneumococcal vaccination was recommended in Germany for all children up to their second birthday. We have compared the prevalence and outcome of IPD at a single hospital before and after the introduction of vaccination. Findings: 55 cases of IPD were identified over an 11 year period. Almost half of the patients were younger than 2 years of age. Most of the children were affected by pneumonia. The second highest incidence seen was for meningitis and sepsis. 17 patients exhibited additional complications. Significant pre-existing and predisposing disorders, such as IRAK 4 defect, ALPS or SLE were identified in 4 patients. Complete recovery was seen in 78% of affected children; 11% had a fatal outcome and 11% suffered from long term complications. Only 31% overall had been vaccinated. The most common serotype was 14. Serotypes not covered by any of the current vaccines were also found. Antibiotic treatment commenced with cephalosporins in over 90%. Conclusion: Frequency of IPD in our hospital did not decrease after initiation of the pneumococcal vaccination. This might be due to vaccinations not being administered satisfactorily as well as to poor education about the need of the vaccination. Pre-existing diseases must be monitored and treated accordingly and rare deficiencies taken into account when IPD takes a foudroyant course. In addition, antibiotic stewardship has been initiated at this hospital centre as a consequence of the high cephalosporin use detected in this study.

Die bakterielle Meningitis verursacht oft motorische Ausfälle, Anfälle, Hörverlust und kognitive Störungen trotz adäquater Antibiose. Streptococcus pneumoniae ist der häufigste Auslöser einer bakteriellen Meningitis des Erwachsenen und verursacht neuronale Apoptose im Hippocampus. Die Apoptose der Hippocampusneurone bei der experimentellen Pneumokokkenmeningitis war zum Teil durch Caspase-3 vermittelt und hing von der Entzündungsreaktion im Liquor ab. Sowohl Caspase-Inhibition als auch Hemmung der intrathekalen Entzündung reduzierten den neuronalen Zelltod. Jedoch konnte durch beide Therapiestrategien neuronaler Zelltod nicht komplett verhindert werden, was auf Caspase- und Entzündungs-unabhängige Zelltodmechanismen hinweist. Bakterielle Faktoren spielten eine wichtige Rolle für die neuronale Apoptose sowohl in vitro als auch in vivo. Pneumokokken induzierten neuronale Apoptose in vitro bei Abwesenheit von Entzündungszellen ohne jegliche Caspasenaktivierung. Vielmehr kam es dabei zu einem raschen intrazellulären Anstieg von Kalzium und reaktiven Sauerstoffradikalen sowie zu einer frühen Mitochondrienschädigung. Geschädigte Mitochondrien setzten den Apoptose-induzierenden Faktor AIF frei, welcher nach nukleärer Translokation zur Apoptose führte. Intrazytoplasmatische Injektion von anti-AIF Antikörpern blockierte die Apoptose. Diese Resultate belegen eine essentielle Rolle der Mitochondrienschädigung und AIF-Freisetzung bei der Pneumokokken-induzierten Apoptose. Als Haupttrigger neuronaler Apoptose konnten zwei Schlüsseltoxine sowohl in vitro als auch in vivo identifiziert werden: Pneumolysin und H2O2. Pneumolysin verursachte einen raschen Anstieg von intrazellulärem Kalzium, eine rasche Zerstörung von Mitochondrien und eine damit einhergehende Freisetzung von AIF. Kalzium-Chelation blockierte AIF-Freisetzung und Zelltod. In der experimentellen Pneumokokkenmeningitis verursachten Bakterien, in denen beide Toxine inaktiviert wurden, eine deutlich geringere neuronale Schädigung. Neue adjunktive Therapien für die Klinik könnten resultieren aus: Caspase-Inhibition, Blockade der Entzündung, anti-oxidative Strategien und Inaktivierung bakterieller Toxine. / Bacterial meningitis often causes motor deficits, seizures, hearing loss or cognitive impairment, despite adequate bacterial killing by antibiotics. Streptococcus pneumoniae is the most common cause of adult bacterial meningitis damaging the hippocampus by inducing neuronal apoptosis. Neuronal hippocampal apoptosis in experimental pneumococcal meningitis was mediated in part by caspase-3 and derived from the inflammatory response in the cerebrospinal fluid. Caspase inhibition and blocking of intrathecal inflammation significantly reduced hippocampal neuronal cell death. However, both strategies did not prevent completely neuronal death indicating caspase- and inflammation-independent mechanisms. Bacterial factors play an essential role in neuronal apoptosis both in vivo and in vitro. Exposure of neurons to live pneumococci in vitro in the absence of inflammation induced rapid apoptosis, which was not associated with the activation of caspases. Rather, apoptosis was attributed to rapid increase of intracellular calcium and reactive oxygen species and early damage to mitochondria. This was followed by the release of apoptosis-inducing factor (AIF) from the mitochondria, its nuclear translocation and apoptosis. Furthermore, intracytoplasmatic microinjection of AIF-specific antiserum markedly impaired pneumococcus-induced apoptosis. These findings indicate that mitochondrial damage and AIF play a central role in brain cell apoptosis and bacterial pathogenesis. Two key toxins of Streptococcus pneumoniae inducing apoptosis were identified in in vitro and in vivo experiments: pneumolysin and hydrogen peroxide. Pneumolysin induced increases of intracellular calcium, damage of mitochondria and release of AIF. Chelating calcium effectively blocked AIF release and cell death. Infection with pneumococci unable to produce pneumolysin and hydrogen peroxide significantly reduced damage in experimental pneumococcal meningitis. New adjunctive therapeutic strategies in clinics may result from caspase-inhibition, blocking of inflammation, anti-oxidative strategies and inactivation of bacterial toxins.

Streptococcus pneumoniae ist ein gram-positives Bakterium und ein Krankheitserreger des Menschen. Ein Charakteristikum des Bakteriums ist, dass es Cholin-Reste in seine dicke Zellwand einbaut. Das Ziel meiner Doktorarbeit war herauszufinden, inwiefern diese Cholin-Reste zur Virulenz des Bakteriums während experimenteller Sepsis und Meningitis beitragen. Dabei konnte ich feststellen, das cholinierte Wildtyp-Bakterien hoch virulent waren, ungestört im Wirt wachsen konnten und letztendlich zu einer massiven Überaktivierung des Wirts-Immunsystems (gemessen anhand der Zytokine IL-1beta, IL-6, IL-12, TNFalpha) sowie zum Tode der Versuchtiere führten. Im Gegensatz dazu waren cholin-freie Bakterien nicht in der Lage eine permanente Infektion im Wirt zu etablieren. So wuchsen sie nur anfangs und wurden vom Wirts-Immunsystem kontrolliert und beseitigt, sodass alle Tiere überlebten. Die Injektion von cholin-freien und cholinierten, hoch aufgereinigten Zellwänden, führte zu der Schlussfolgerung, dass Cholin in der Zellwand ein Immunevasionsmechanismus der Bakterien sein muss. Ausserdem waren cholin-freie Bakterien in der Lage einen protektiven, serotyp-spezifischen Immunschutz im Wirt zu induzieren. / Streptococcus pneumonia is a major human pathogen. Since it is a gram positive bacterium it is characterized by the production of a thick cell wall. Being auxotrophic for choline, the pneumococcus attaches this aminoalcohol to its teichoic acids thus decorating its surface with choline-residues. The aim of this work was to investigate the role that these choline residues play in the virulence of the bacterium. By using an isogenic choline-containing and choline-free pair of S. pneumoniae I was able to demonstrate that surface bound choline is essential for the virulence of the bacterium in animal models of experimental sepsis and meningitis. In either model choline-containing bacteria were able to persistently grow within the host system, continuously stimulate the production of proinflammatory cytokines (IL-1beta, IL-6, IL-12, TNFalpha) and eventually led to the death of all infected animals within 24h. In contrast, choline-free bacteria showed only transient growth within the host and induced only moderate and limited expression of cytokines. Consequently, the bacterium was virtually avirulent and all animals survived. Intracisternal application of highly purified cholinated and choline-free cell wall preparations, induced a comparable activation of the immune system. These findings led to the conclusion that choline residues contribute to an immunevasion strategy that allows the bacteria to grow despite an ongoing immune response. Although being avirulent choline-free bacteria were able to induce serotype specific immunity in the animals.

Streptococcus pneumoniae ist die häufigste Ursache für ambulant erworbene Pneumonien weltweit. Daher müssen die Wirts-Pathogen-Interaktionen erforscht werden, um neue Therapiestrategien zu entwickeln. In dieser Studie habe ich 1. den Typ I Interferon (IFN)-stimulierenden Signalweg des angeborenen Immunsystems in Pneumokokken-infizierten Wirtszellen sowie 2. dessen Bedeutung in der Pneumokokkenpneumonie untersucht. Humane und murine Makrophagen, aber nicht alveolare Epithelzellen, produzierten Typ I IFNs nach Infektion mit S. pneumoniae. Dieses war abhängig vom Virulenzfaktor Pneumolysin und erforderte sowohl die Phagozytose der Bakterien als auch die Ansäuerung der Endosomen. Die Induktion der Typ I IFNs wird durch einen zytosolischen Signalweg vermittelt, welcher wahrscheinlich DNA erkennt und sowohl das Adapterprotein STING als auch den Transkriptionsfaktor IRF3 aktiviert. Typ I IFNs, welche von infizierten Makrophagen gebildet wurden, regulierten die Expression von IFN-stimulierten Genen (ISGs) und Chemokinen in Makrophagen und co-kultivierten alveolaren Epithelzellen in vitro und in Mauslungen in vivo. In einem murinen Pneumoniemodell hatten die Typ I IFNs jedoch einen negativen Effekt für den Wirt. Mäuse mit einem Defekt im Typ I IFN-Rezeptor oder mit einem Knockout im Typ I und Typ II IFN-Rezeptor hatten eine signifikant geringere Bakterienlast in der Lunge und eine verminderte Reduktion der Körpertemperatur und des Körpergewichtes als wild-typ Mäuse. Diese Effekte waren nicht durch Änderungen in der Zellrekrutierung oder durch Änderungen der Zytokin-/Chemokinexpression erklärbar. Zusammenfassend lässt sich feststellen, dass Typ I IFNs durch Pneumokokken induziert werden, aber dass sie trotz einiger positiver Effekte auf die Expression von ISGs einen negativen Gesamteffekt in einem murinen Pneumoniemodell aufweisen. Ein detailliertes Verständnis der Typ I IFN-Antwort während der Pneumokokkeninfektion kann die Entwicklung neuer Therapiestrategien unterstützen. / Streptococcus pneumoniae is the leading cause of community-acquired pneumonia world-wide. A detailed understanding of the host-pathogen interactions is required in order to foster the development of new therapeutic strategies. Here, I (I) characterized an innate immune recognition pathway that senses pneumococcal infection and triggers the production of type I interferons (IFNs), and (II) examined the role of type I IFNs in pneumococcal pneumonia in mice. Human and murine macrophages, but not alveolar epithelial cells, produced type I IFNs after infection with S. pneumoniae. This induction was dependent on the virulence factor pneumolysin, the phagocytosis of the bacteria, and the acidification of the endosome. Moreover, it appeared to be mediated by a cytosolic DNA-sensing pathway involving the adaptor molecule STING and the transcription factor IRF3. Type I IFNs produced by S. pneumoniae-infected macrophages positively regulated the expression of IFN-stimulated genes (ISGs) and chemokines in macrophages and co-cultured alveolar epithelial cells in vitro and in mouse lungs in vivo. However, in a murine model of pneumococcal pneumonia, type I IFN signaling was detrimental to the host defense. Mice deficient in the type I IFN signaling or double deficient in type I and type II IFN signaling had a significantly reduced bacterial load in the lung and a diminished reduction of body temperature and body weight compared to wild-type mice. The decreased susceptibility of the knockout mice was unlikely to be attributable to alterations in cell recruitment or cytokine/chemokine production. In conclusion, type I IFNs are induced during pneumococcal infection. However, despite their positive effects on the expression of some ISGs and chemokines, they negatively affect the outcome of pneumococcal pneumonia in an in vivo mouse model. Targeting the type I IFN system could potentially be an effective way in enhancing the immune response in patients with S. pneumoniae pneumonia.

Proteasomen, die die proteolytisch aktiven Untereinheiten LMP7, LMP2 und MECL1 inkorporieren, nennt man Immunoproteasomen. Während einer Immunreaktion führen diese regulierende sowie modulierende Funktionenaus. Sie sind konstitutiv exprimiert in Zellen hämatopoetischen Ursprungs, ein Bestandteil des angeborenen Immunsystems, die die erste Angriffsfront gegen pathogene Mikroorganismen ausbilden. Um die Bedeutung des Immunoproteasoms für die angeborene Immunantwort bei einer Streptococcus pneumoniae Infektion auf zu zeigen, charakterisierten wir den Krankheitsverlauf einer bakteriellen Pneumonie und analysierten lokale aber auch systemische Immunreaktionen in LMP7 ko Mäusen mit Hilfe eines S. pneumoniae Infektionsmodels. Die hier generierten Daten zeigten einen fortgeschrittenen Krankheitsverlauf in LMP7 ko Mäuse, der in einer systemischen inflammatorischen Immunreaktion endete und sich in klinischen Parametern, wie physiologische Kondition, spezifische diagnostische Marker und Immunsuppression, andeutete. Der Zustand der Sepsis entwickelte sich vermutlich aufgrund einer erhöhten bakteriellen Last im Blut und führte zu einer vorzeitigen Mortalität infizierter LMP7 ko Tiere. Obwohl die Fähigkeit von LMP7 ko Leukozyten ex vivo Bakterien zu eliminieren nicht beeinträchtigt war, zeigten LMP7 ko Mäuse in vivo eine verminderte Genexpression immunmodulierender Moleküle, wie Pentraxine, Fikoline und Kollektine. Diese Moleküle fördern die Aufnahme, Elimination und Degradation pathogener Mikroorganismen. Die reduzierte Expression opsonierender Moleküle wurde begleitet von einer veränderten proteasomalen Zusammensetzung in murinen Makrophagen und Lebergewebe. Zusammengefasst lässt sich sagen, dass diese Ergebnisse eine bisher unbekannte Rolle von Immunoproteasomalen Untereinheiten bei der Regulierung der angeborenen Immunantwort auf extrazelluläre bakterielle Infektionen unterstreichen. / Immunoproteasomes, harboring the active site subunits LMP7, LMP2, and MECL1 exert protective, regulatory or modulating functions during infection-induced immune responses. Immunoproteasomes are constitutively expressed in hematopoietic derived cells, constituting the first line of defense against invading pathogens. To clarify the impact of immunoproteasomes on the innate immune response against Streptococcus pneumoniae, we characterized the progression of disease and analyzed the local as well as systemic innate immune response in LMP7 ko mice by using a S. pneumoniae infection model. Data showed that mice deficient in LMP7 suffered from a more severe case of pneumonia which ended in a systemic inflammatory response indicated by aggravated clinical signs, diagnostic parameters, and immune suppression. The systemic inflammatory response probably established in consequence of an increased bacteremia and resulted in early mortality. Although, bacterial killing efficiency of LMP7 ko leukocytes was unaffected ex vivo, LMP7 ko mice exhibited a reduction in the transcription of genes encoding immune modulating molecules such as pentraxins, ficolins, and collectins, which facilitate opsonophagocytosis. The reduced expression of opsonins was accompanied by an affected subunit composition of proteasomes in murine macrophages and liver. In summary these results highlight an unsuspected role for immuno-subunits in modulating the innate immune response to extracellular bacterial infections.

Streptococcus pneumoniae (the pneumococcus) is a bacterial pathogen responsible for >1.6 million annual deaths globally. Pneumococcal penicillin-resistance is conferred by acquisition of ‘altered’ penicillin-binding protein (pbp) genes. The first penicillin-nonsusceptible pneumococci were identified in the late 1960s. Global pneumococcal penicillin-nonsusceptibility rates rapidly increased in the 1980s/90s. Since 2000, protein-conjugate vaccines, targeting 7, 10 or 13 of the ≥94 different pneumococcal capsule types (serotypes), have been introduced in many countries. Following vaccine implementation there has been a decline in vaccine-type pneumococcal disease and an increase in non-vaccine-type disease. These epidemiological changes result from “serotype replacement” and/or “serotype switching”. The former describes the expansion of non-vaccine-type clones in the absence of vaccine-type pneumococci. The latter describes serotype change following recombination at the capsule polysaccharide synthesis (cps) locus. To fully understand how pneumococci respond to vaccine- and antibiotic-induced selective pressures, we must better understand the evolutionary history of this pathogen. This thesis describes the study of a global collection of 426 pneumococci, dated 1937 - 2007. Serotype, genotype and penicillin-susceptibility data were collected. Nucleotide sequences of three pbp genes (for 389 isolates) and whole-genome sequences (for 96 isolates) were also generated. The data demonstrated the long-term persistence of certain clones within pneumococcal populations, and that pbp and large-fragment (>30 kb) cps ± pbp recombination was occurring prior to both widespread antibiotic use and vaccine implementation. The data highlighted the promiscuous nature of the globally-distributed PMEN1 clone and its contribution to the spread of pneumococcal penicillin-resistance. PMEN1 also donated multiple, large regions (1.7 - 32.3 kb) of its genome to at least two un-related clones. Finally, six “Tn916-like” genetic elements, conferring resistance to non-penicillin antibiotics, were newly identified. These included two of the oldest ever described. These results provided a unique insight into the history of pneumococcal evolution and the importance of genetic recombination.

Phosphoglucosamine mutase (GlmM) is an enzyme of bacterial cell wall biosynthesis. The main aim of this thesis was to find out, whether gene glmM is essential for viability of Streptococcus pneumoniae. Therefore, we prepared merodiploid strain containing two copies of glmM; the genomic gene and ectopic copy under control of zinc inducible promoter. Subsequently, depletion strain was prepared by deletion of genomic copy of glmM. This strain was further used for analysis of viability and phenotype features in the medium containing various concentrations of zinc ions, an inducer of ectopic glmM expression. We found out, that the viability of this strain was strictly dependent on the concentration of inducer and further, that depletion of GlmM resulted in remarkable morphological defects. The rescue of mutant strain was observed after addition of inducer up to the level of the control sample. These results have provided the evidence of glmM essentiality for S. pneumoniae viability. Furthermore, we analyzed, whether phosphorylation of key amino acid residues, S99 and S101, is essential for GlmM functionality. Four different strains were prepared by means of site-directed mutagenesis expressing glmM with substitutions of key serine residues for alanine or glutamic acid. Since deletion of chromosomal locus in...

Spr0334, new protein of cell division in Streptococcus pneumoniae Streptococcus pneumoniae is an important human pathogen. The geonome of this bacteria encodes a single gene for eukaryotic-like serine / threonine protein kinase called StkP. StkP regulates many physiological processes such as pathogenesis, competence for genetic transformation, resistance to various stresses and resistance to antibiotics. It also affects the transcription of many genes involved in cell wall biosynthesis, pyrimidine metabolism, DNA repair and iron uptake. Recent studies have shown that StkP is located in the cell division septum and significantly regulates cell division and morphology. Its substrates include, among others, cell division protein DivIVA, FtsZ and FtsA. Analysis of phosphoproteome maps of wild type and ΔstkP mutant strain of S. pneumoniae showed that in vivo StkP phosphorylates several putative substrates including the protein Spr0334. Mass spectrometry analysis identified phosphorylation sites of the protein Spr0334: threonine 67 and threonine 78. Furthermore, it was found that the protein Spr0334 is located in the cell division septum, which led to the hypothesis that it could be newly identified cell division protein in S. pneumoniae. The main aim of this thesis was to describe the function of the...

Streptococcus pneumoniae encodes single serine/threonine protein kinase StkP and its cognate protein phosphatase PhpP. This signalling couple phosphorylates/dephosphorylates many target proteins involved in various cellular processes. So far, only few ot them was characterized in detail. Global phosphoproteomic analysis in the ∆stkP mutant strain background resulted in the identification of protein Spr0175 as phosphorylated on threonine 7. The main aim of this work was to characterize this new substrate. The ∆spr0175 mutant strains were prepared in the wild type genetic background Rx and R6 and then monitored for their growth and cell morphology. Mutant strains exhibited morphological defects revealing potential involvement of Spr0175 in the process of cell division. In the wild type D39 the deletion was unsuccesful, which may entail possible essentiality of Spr0175 in D39 strain. The results obtained also confirmed that the Spr0175 is modified in in vitro and in vivo conditions at threonine 7. In vitro study also confirmed minor phosphorylation at T4 residue. By using co-immunoprecipitation assay we demonstrated that Spr0175 protein can form oligomeric structures. Another aim of this work was cellular localization of Spr0175. By using fluorescent microscopy we showed that GFP-Spr0175 fusion...

Streptococcus pneumoniae is a leading cause of pneumonia, bacteremia, meningitis, otitis media and sinusitis, and is responsible for significant morbidity and mortality worldwide. The burden of pneumococcal disease has been greatly impacted by the high prevalence of HIV, especially in developing countries. Macrolides are commonly used for the treatment of pneumococcal infections with the resulting effect of increasing resistance. Pneumococci develop resistance to macrolides predominantly by two mechanisms; target modification and drug efflux. Target modification occurs through the acquisition of an erm(B) gene (MLSB phenotype) or through ribosomal mutation, and drug efflux occurs through the acquisition of a mef(A) gene (M phenotype). Alternative protein synthesis-inhibiting antibiotics such as linezolid and telithromycin have been developed in response to the increasing level of antibiotic resistance. In this study, novel mechanisms of resistance to protein synthesis-inhibiting antibiotics, and the current prevalence and epidemiology of macrolide resistance in South Africa were investigated. Two clinical isolates of S. pneumoniae resistant to macrolides, linezolid and chloramphenicol were identified in the PROTEKT surveillance study and the ABCs program of the CDC. The isolates were found to each contain a 6 bp deletion, resulting in the deletion of two amino acids from a highly conserved region of ribosomal protein L4 (64PWRQ67 to 64P_Q67 and 67QKGT70 to 67Q_T70). The genes encoding the mutant ribosomal proteins transformed susceptible strain R6 to macrolide, linezolid and chloramphenicol resistance, proving that the ii deletions conferred the resistance on the isolates, and indicating that these antibiotics share a common binding site. Growth studies of the R6 transformants showed increased mass doubling times, suggesting that the L4 mutations were associated with a fitness cost, but the original strains showed evidence of fitness compensation. The L4 mutations in these isolates represent a novel mechanism of cross-resistance to macrolides, linezolid and chloramphenicol. A macrolide-resistant clinical isolate of S. pneumoniae with mutations in 23S rRNA showed a heterogeneous phenotype and genotype. A mutant gene encoding 23S rRNA from this isolate transformed susceptible strain R6 to resistance. Transformants displayed similar heterogeneity to the isolate. Culture of resistant strain R6 in the presence of antibiotic maintained resistance, however culture of the strain in the absence of antibiotic pressure resulted in a reversion to susceptibility. By DNA sequencing, gene conversion was shown to occur between the wild-type and mutant 23S rRNA alleles. Growth studies indicated that the resistant phenotype was associated with a fitness cost. Therefore, under antibiotic selective pressure alleles converted to the mutant form, and in the absence of selective pressure alleles reverted to wild-type, in order to regain fitness. Through gene conversion the pneumococcus has the ability to rapidly adapt to the environment, with implications for susceptibility testing and patient treatment. A rare clinical isolate of S. pneumoniae, highly resistant to telithromycin, was received from the Canadian Bacterial Surveillance Network and was investigated for the mechanism of resistance. The isolate was found to contain an erm(B) gene iii with a truncated control peptide, as well as a mutant ribosomal protein L4, containing a number of mutations. Transformation of susceptible strain PC13, containing a wild-type erm(B) gene, with the mutant erm(B) gene decreased the susceptibility of PC13 to telithromycin, but did not confer high-level resistance. Transformation of PC13 with the mutant L4 gene or a fragment of the L4 gene containing only the 69GTG71 to TPS mutation, conferred high-level resistance on PC13. In contrast, transformation of R6, which did not contain an erm(B) gene, with the L4 gene or L4 fragment only conferred reduced telithromycin susceptibility. High-level telithromycin resistance was therefore conferred by a combination of an erm(B) gene with a 69GTG71 to TPS mutation in a highly conserved region of ribosomal protein L4. The combination of mechanisms inhibited the binding of telithromycin to the ribosome, whereas neither mechanism individually was sufficient. A telithromycin-resistant clinical isolate of S. pneumoniae was received from the PROTEKT surveillance study and was investigated for the resistance mechanism. The isolate was found to contain a 136 bp deletion in the regulatory region of erm(B). This mutant gene was shown, by transformation studies, to confer resistance on susceptible strain PC13. Expression of erm(B) on the transcriptional level was quantified by real-time reverse transcription PCR. In the presence of erythromycin and telithromycin, erm(B) expression was significantly higher in the mutant PC13 strain than the wild-type strain. Growth studies showed that the mutant PC13 strain had a shorter lag phase than the wild-type strain in the presence of erythromycin. Telithromycin resistance was conferred by the mutant iv erm(B) gene that was expressed at a higher level than the wild-type gene, most likely resulting in higher ribosomal methylation levels sufficient to hinder telithromycin binding. Macrolide resistance in invasive pneumococcal disease in South Africa for the period 2000 to 2005 was investigated through a national laboratory-based surveillance system. Viable isolates (n=15982) collected during the six-year period were phenotypically characterised, by determination of MICs and serotyping. Two hundred and sixty random isolates from 2005 were genotypically screened for the presence of erm(B) and mef(A). Macrolide resistance increased significantly from 9% in 2000 to 14% in 2005. Resistant isolates were received from all provinces of South Africa, with Gauteng and the Western Cape having the highest incidence. Serotype 14 was the most common macrolide-resistant serotype and 96% of macrolide-resistant isolates in 2005 were serotypes included in the 7-valent pneumococcal conjugate vaccine and serotype 6A. Macrolide resistance was significantly higher in children <5 than in individuals 5 years and older. The majority of strains (75%) over the six-year period displayed the MLSB phenotype. Of the 260 strains genotypically screened, 57% were positive for erm(B), 27% were positive for mef(A), 15% contained both erm(B) and mef(A), and 1% were negative for both genes and were found to contain ribosomal mutations. Eighty percent of isolates containing both erm(B) and mef(A) were serotype 19F and were found to be clonal by PFGE and MLST. These multidrug-resistant isolates were related to the Taiwan19F-14 global clone. v Many protein synthesis-inhibiting antibiotics share overlapping binding sites on the large ribosomal subunit. Alterations in 23S rRNA and ribosomal proteins L4 and L22, within the binding pocket, confer resistance and often cross-resistance to many of these antibiotics. The ability of the pneumococcus to develop resistance and the global spread of resistant strains highlights the importance of monitoring resistance levels and understanding resistance mechanisms.