Macrolide Resistance in .

is a common commensal and an opportunistic pathogen. Suspected pneumococcal upper respiratory infections and pneumonia are often treated with macrolide antibiotics. Macrolides are bacteriostatic antibiotics and inhibit protein synthesis by binding to the 50S ribosomal subunit. The widespread use of macrolides is associated with increased macrolide resistance in , and the treatment of pneumococcal infections with macrolides may be associated with clinical failures. In , macrolide resistance is due to ribosomal dimethylation by an enzyme encoded by (B), efflux by a two-component efflux pump encoded by (E)/((D)) and, less commonly, mutations of the ribosomal target site of macrolides. A wide array of genetic elements have emerged that facilitate macrolide resistance in ; for example (B) is found on Tn, while the (E)/ operon is carried on the 5.4- or 5.5-kb Mega element. The macrolide resistance determinants, (B) and (E)/, are also found on large composite Tn-like elements most notably Tn, Tn, and Tn. Introductions of 7-valent and 13-valent pneumococcal conjugate vaccines (PCV-7 and PCV-13) have decreased the incidence of macrolide-resistant invasive pneumococcal disease, but serotype replacement and emergence of macrolide resistance remain an important concern.