ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, May 1999, p.

10621066
0066-4804/99/$04.0010
Copyright 1999, American Society for Microbiology. All Rights Reserved.

Vol. 43, No. 5

Distribution of Genes Encoding Resistance to Macrolides,

Lincosamides, and Streptogramins among Staphylococci
GERARD LINA,1* ALAIN QUAGLIA,1 MARIE-ELISABETH REVERDY,1 ROLAND LECLERCQ,2
FRANC
OIS VANDENESCH,1 AND JEROME ETIENNE1
Faculte de Medecine, Laboratoire de Bacteriologie, Centre National de Reference des Toxemies a
` Staphylocoques,
EA 1655, 69372 Lyon Cedex 08,1 and Service de Microbiologie, CHU Co
te de Nacre, 14033 Caen,2 France
Received 7 October 1998/Returned for modification 15 January 1999/Accepted 11 February 1999

The relative frequency of 10 determinants of resistance to macrolides, lincosamides, and streptogramins was
investigated by PCR in a series of 294 macrolide-, lincosamide-, and/or streptogramin-resistant clinical isolates
of Staphylococcus aureus and coagulase-negative staphylococci isolated in 1995 from 32 French hospitals.
Resistance was mainly due to the presence of ermA or ermC genes, which were detected in 259 strains (88%),
in particular those resistant to methicillin (78% of the strains). Macrolide resistance due to msrA was more
prevalent in coagulase-negative staphylococci (14.6%) than in S. aureus (2.1%). Genes related to linA/linA* and
conferring resistance to lincomycin were detected in one strain of S. aureus and seven strains of coagulasenegative staphylococci. Resistance to pristinamycin and quinupristin-dalfopristin was phenotypically detected
in 10 strains of S. aureus and in three strains of coagulase-negative staphylococci; it was always associated with
resistance to type A streptogramins encoded by vat or vatB genes and occurred in association with erm genes.
The vga gene conferring decreased susceptibility to type A streptogramins was present alone in three strains
of coagulase-negative staphylococci and in combination with erm genes in 10 strains of coagulase-negative
staphylococci. A combination of vga-vgb-vat and ermA genes was found in a single strain of S. epidermidis.
Genes related to vat and vgb have been described in S. cohnii
subsp. cohnii and were named vatC and vgbB, respectively (3).
The present investigation was undertaken to study the relative frequency of each MLS resistance determinant, by PCR, in
a series of 294 macrolide, lincosamide, and/or streptograminresistant clinical isolates of S. aureus and coagulase-negative
staphylococci obtained from 32 French hospitals.

Macrolide, lincosamide, and streptogramin (MLS) antibiotics are widely used in the treatment of staphylococcal infections. Resistance to macrolides (such as erythromycin) and
lincosamides (such as lincomycin and clindamycin) is prevalent
among staphylococci (9, 13, 28, 29). Resistance against streptogramins, which consist of two components, streptogramin
types A and B (e.g., pristinamycin IIA and IA, dalfopristin and
quinupristin) with synergistic activity, remains infrequent (23).
A number of genes conferring resistance to this group of antibiotics via a variety of mechanisms have been identified in
staphylococci. Three related determinants, ermA, ermB, and
ermC, have been identified which confer resistance to MLS
type B (MLSB) by target site alteration of the ribosome (11, 21,
29). This resistance is either inducible (strains are resistant to
14- and 15-membered ring macrolides and susceptible to 16membered ring MLSB) or constitutive (resistance includes 16membered ring MLSB). The msrA gene, first identified in
Staphylococcus epidermidis, confers the so-called MS phenotype (inducible resistance to 14- and 15-membered ring macrolides and resistance to streptogramin type B after induction
with erythromycin) by efflux (27); an msrA-related gene, msrB,
has been described in S. xylosus (25). The linA gene in S. haemolyticus and linA9 in S. aureus, which have a high degree of
homology, confer resistance to lincosamides only (8). Resistance to type A streptogramin antibiotics in staphylococci can
be due to two mechanisms: (i) the vga and vgaB genes encode
related ATP-binding proteins probably involved in active efflux
of the A compounds (2, 4) and (ii) the vat and vatB genes
encode related acetyltransferases (1). The vgb gene encoding a
lactonase inactivates the type B streptogramin antibiotics (5).

MATERIALS AND METHODS

Bacterial strains. A series of 2,091 staphylococcus isolates were collected in
1995 in France during a 3-week period. Isolates were from various clinical
specimens and were sent by 32 clinical microbiology laboratories located
throughout France. Initial identification as S. aureus or coagulase-negative staphylococci was based on colony and microscopic morphology, coagulase testing
with rabbit plasma (bioMerieux, Marcy lEtoile, France), and agglutination tests
with the Staphyslide test (bioMerieux). Coagulase-negative isolates were identified to the species level by using the ID 32 Staph gallery (bioMerieux). Strains
were stored at 270C in brain heart broth plus 30% glycerol.
Antibiotic susceptibility. A representative sampling of 602 isolates consisting
of 307 S. aureus and 295 coagulase-negative staphylococci was selected from the
total collection by choosing a similar proportion of isolates ('30%) in each
hospital. The MICs were determined by a standardized agar dilution technique
(26). Isolates were characterized by their response to oxacillin and to the MLS
resistance phenotype by determining the MICs of the following antibiotics:
oxacillin, erythromycin, dalfopristin (a streptogramin A), lincomycin, pristinamycin, quinupristin (a streptogramin B), and the streptogramin composed of the
two components dalfopristin and quinupristin. Oxacillin, erythromycin, and lincomycin were provided by Sigma (St. Louis, Mo.); dalfopristin, quinupristin,
pristinamycin, and quinupristin-dalfopristin were provided by Rhone-Poulenc
Rorer (Vitry sur Seine, France). MIC breakpoints were those of the CA-SFM
(10), namely, .2 mg/ml for oxacillin, .4 mg/ml for erythromycin, .8 mg/ml for
lincomycin, and .2 mg/ml for pristinamycin. Since no breakpoints have been
defined for quinupristin, dalfopristin, and quinupristin-dalfopristin by national
committees, the MIC breakpoints for resistance were considered to be $16
mg/ml for quinupristin and dalfopristin and $4 mg/ml for quinupristin-dalfopristin as recommended by Barry et al. (6) and as recently approved by the National
Committee for Clinical Laboratory Standards (25a).
PCR amplification of MLS resistance genes. Genomic DNA was extracted
from staphylococcal cultures (12) and used as a template for amplification.
Primers specific for vga and vat genes were used (23). The other primers were
designed from published GenBank sequences to provide specific PCR products
(Table 1). The linA9 gene displays 93% homology with linA (8), and the primers
defined in this study could not differentiate the two genes, which were referred
to as linA/linA9. These oligonucleotides were synthesized by Eurogentec (Sera-

* Corresponding author. Mailing address: Faculte

de Medecine,
Laboratoire de Bacteriologie, Centre National de Reference des Toxemies `a Staphylocoques, Rue Guillaume Paradin, 69372 Lyon Cedex
08, France. Phone: 33-478-77-86-57. Fax: 33-478-77-86-58. E-mail:
[email protected].
1062

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RESISTANCE GENES TO MLS ANTIBIOTICS AMONG STAPHYLOCOCCI

1063

TABLE 1. Sequences, primers, and PCR conditions used to detect MLS resistance determinants
Target
gene

ermAb

GenBank
accession
no.

K02987 59-GTTCAAGAAC
59-GGATCAGGAA
ermB
U35228 59-CCGTTTACGA
59-GAATCGAGAC
X54338 59-GCTAATATTG
ermCb
59-GGATCAGGAA
msrA
X52085 59-GGCACAATAA
59-AAGTTATATC
msrB
M91802 59-TATGATATCC
59-AAGTTATATC
linA/linA9
M14039 59-GGTGGCTGGG
59-GCTTCTTTTG
vga
M90056 59-CCAGAACTGC
59-AAGTTCGTTT
vgb
U19459 59-ACTAACCAAG
59-TTATTGCTTG
vat
L07778 59-CAATGACCAT
59-CTTCAGCATT
vatB
M20129 59-CCCTGATCCA
59-CTAAATCAGA
gyrA
59-AGTACATCGT
59-ATCACGTAAC
16S-23S spacer
59-TTGTACACAC
region
59-GGTACCTTAG
a
b

Primer sequences

AATCAATACA GAG-39
AAGGACATTT TAC-39
AATTGGAACA GGTAAAGGGC-39
TTGAGTGTGC-39
TTTAAATCGT CAATTCC-39
AAGGACATTT TAC-39
GAGTGTTTAA AGG-39
ATGAATAGAT TGTCCTGTT-39
ATAATAATTA TCCAATC-39
ATGAATAGAT TGTCCTGTT-39
GGGTAGATGT ATTAACTGG-39
AAATACATGG TATTTTTCGA TC-39
TATTAGCAGA TGAA-39
CTCTTTTCGA CG-39
ATACAGGACC-39
TCAGCCTTCC-39
GGACCTGATC-39
TCGATATCTC C-39
AATAGCATAT ATCC-39 (vatB-1)
GCTACAAAGT G-39 (vatB-2)
CGTATACTAT ATGG-39
AGTTCAAGTGTG-39
CGCCCGTCA-39
ATGTTTCAGTTC-39

PCR fragment size

(nt)a

421
359
572
940
595
323

No. of PCR cycles

(conditions)

30 (30 s at 94C; 30 s at 52C;

1 min at 72C)
30 (30 s at 94C; 30 s at 55C;
1 min at 72C)
Same as for ermA
25 (1 min at 94C; 1 min at
50C; 90 s at 72C)
Same as for msrA

619

30 (30 s at 94C; 30 s at 57C;

1 min at 72C)
30 (30 s at 94C; 30 s at 54C;
1 min at 72C)
30 (1 min at 94C; 1 min at
53C; 2 min at 72C)
Same as for ermA

602

Same as for ermA

280

30 (30 s at 94C; 30 s at 55C;

1 min at 72C)
Same as for gyrA

470
734

492

Control strain(s) and

reference(s)

S. aureus HM1055 (19)

S. aureus CR5 80 (Tn1545) (31)
S. aureus HM290-1 (19)
S. aureus RN4220(pUL5054) (27)
S. aureus RN4220(pUL5054) (27)
S. haemolyticus BM4610 (7);
S. aureus BM4611 (8)
S. aureus BM3002 (4, 23)
S. aureus BM3002 (4, 23)
S. aureus BM3002 (4, 23)
E. coli LUG369(pLUG247); this
study
17
18

nt, nucleotide.
Genes detected by duplex PCR with a common primer oligonucleotide.

ing, Belgium). PCR was carried out on the 294 staphylococcal strains displaying
resistance to at least one of the MLS antibiotics, as well as on control strains for
each resistance determinant (Table 1), the reference S. aureus strains ATCC
25923 and ATCC 29213, and 20 strains susceptible to MLS (10 strains of S. aureus and 10 coagulase-negative staphylococcus strains) randomly selected from
the bacterial collection described above. In the absence of the reference strain
harboring the vatB gene, which is protected by a patent, a surrogate template for
vatB amplification was designed on a pCRII vector (Invitrogene, Leek, The
Netherlands) in Escherichia coli. This plasmid (pLUG247) consists of the sequence of the upstream and downstream primers separated by the tetracycline
resistance determinant tet(M). The PCR assays run on a GeneAmp PCR System
9600 (Perkin-Elmer, Saint-Quentin en Yvelines, France) were initialized by a
denaturation step (10 min at 94C) and finished with a final extension step
(10 min at 72C). Cycles were run as described in Table 1. DNA amplification of
gyrA for S. aureus (17) or the 16S-23S spacer region of the rDNA operon for
other species (18) was used to test the quality of the DNA extraction and for the
absence of PCR inhibitors. PCR products were analyzed by electrophoresis
through 1% agarose gels (Sigma, Saint Quentin Fallavier, France).

RESULTS
MLS resistance phenotypes. A total of 294 strains including
144 S. aureus and 150 coagulase-negative staphylococci exhibited resistance to at least one of the MLS antibiotics. Resistance to oxacillin was detected in 103 of the 144 S. aureus
strains and in 100 of the 143 coagulase-negative staphylococcus
strains. For MLSB-resistant staphylococci, a single MLS-inducible phenotype was demonstrated in 46 S. aureus strains and
43 coagulase-negative staphylococcus strains, and constitutive MLSB resistance was found in 82 S. aureus strains and
56 coagulase-negative staphylococcus strains (Table 2). The
inducible phenotype was predominant in methicillin-susceptible S. aureus (MSSA, 82%), and the constitutive phenotype
was predominant in methicillin-resistant S. aureus (MRSA,
83%). Resistance to MLS antibiotics, including pristinamycin
and quinupristin-dalfopristin, was detected in 10 S. aureus strains
and 3 coagulase-negative staphylococcus strains; these 13
strains were also resistant to methicillin. Resistance to erythromycin but not to other MLS antibiotics was observed in 3
strains of S. aureus and 17 strains of coagulase-negative staphylococci. Other resistance phenotypes were found in 3 strains

of S. aureus and 31 strains of coagulase-negative staphylococci

and are detailed in Table 3.
Prevalence of erm genes. A total of 294 strains were tested
for the presence of MLS resistance genes, and 259 (88%)
contained one or more of the erm genes consistent with an
erythromycin resistance phenotype, mainly in strains resistant
to methicillin (78% of the strains). The most prevalent erm
gene in S. aureus strains was ermA, which was detected alone in
63.2%, mainly in MRSA expressing an MLSB constitutive phenotype, whereas ermC was found as a single MLS resistance
gene in 25% of the S. aureus strains, essentially in MSSA with
an MLSB inducible phenotype (Table 2). For the coagulasenegative staphylococci, the most prevalent gene was ermC; it
was detected alone in 44% of the strains with an MLSB inducible or constitutive phenotype, one which was either susceptible or resistant to methicillin. ermA genes were detected in
18% of the coagulase-negative staphylococcus strains, essentially those resistant to methicillin. The ermB gene was seldom
detected in staphylococci (one strain of S. aureus and one
coagulase-negative Staphylococcus strain). Combination of various erm genes was detected in six strains of coagulase-negative
staphylococci only (Tables 2 and 3).
Prevalence of other resistance genes. Other determinants
encoding resistance to MLS antibiotics were more frequently
detected in coagulase-negative staphylococci (51 strains, 34%)
than in S. aureus (16 strains, 11.1%) (Table 3). The msrA gene
was detected alone in 3 S. aureus strains and 17 strains of
coagulase-negative staphylococci, conferring resistance to
erythromycin but apparently not to streptogramin type B. This
gene was detected in combination with a methylase gene in five
other coagulase-negative staphylococcus strains and with the
linA/linA9 genes in two isolates, in each case conferring a resistance phenotype which was the combination of the individual phenotypes (Table 3). The linA/linA9 genes were never
detected alone in S. aureus but rather in combination with
ermC in one strain, giving a resistance phenotype which was the
addition of an MLSB-inducible resistance due to the erm gene

1064

LINA ET AL.

ANTIMICROB. AGENTS CHEMOTHER.

TABLE 2. Distribution of erm genes among MLSB-resistant staphylococcal isolates
No. (%) of strains with:

Straina (no.)

ermA 1 ermB

ermA 1 ermC

ermB

ermC

S. aureus (144)
MLSB inducible
MSSA
MRSA
MLSB constitutive
MSSA
MRSA
Total
MSSA
MRSA

91 (63.2)
14 (9.8)
5 (3.5)
9 (6.3)
77 (53.5)
3 (2.1)
74 (51.4)

1 (0.7)
0
0
0
1
1
0

36 (25.0)
32 (22.2)
26 (18.2)
6 (4.2)
4 (2.8)
3 (2.1)
1 (0.7)

8 (5.6)
83 (57.6)

1 (0.7)
0

29 (20.1)
7 (4.9)

Coagulase-negative staphylococci (150)

MLSB inducible
MSCNS
MRCNS
MLSB constitutive
MSCNS
MRCNS
Total
MSCNS
MRCNS

27 (18.0)
10 (6.6)
1 (0.7)
9 (6.0)
17 (11.3)
1 (0.7)
16 (10.7)

1 (0.7)
0
0
0
1
1
0

66 (44.0)
31 (20.7)
14 (9.3)
17 (11.3)
35 (23.3)
7 (4.7)
28 (18.7)

1 (0.7)
0
0
0
1 (0.7)
0
1 (0.7)

3 (2.0)
1 (0.7)
1 (0.7)
0
2 (1.3)
0
2 (1.3)

1 (0.7)
1 (0.7)
1 (0.7)
0
0
0
0

2 (1.3)
25 (16.7)

1 (0.7)
0

21 (14.0)
45 (30.0)

0
1 (0.7)

1 (0.7)
2 (1.3)

1 (0.7)

a
b

Other genotypeb

ermB 1 ermC

ermA

16 (11.1)

51 (34.0)

MSCNS, methicillin-susceptible coagulase-negative staphylococci; MRCNS, methicillin-resistant coagulase-negative staphylococci.

See Table 3 for more details.

plus a constitutive resistance to lincomycin due to linA/linA9. In

two strains of S. epidermidis, linA/linA9 was the single resistance
gene present and was associated with a methylase gene in three
strains.

Resistance to dalfopristin was associated with the presence

of the vga gene alone in three coagulase-negative staphylococcus strains, one of which was also resistant to lincomycin (Table 3). The presence of vga alone was not associated with

TABLE 3. Distribution of msrA, linA/linA9, vga, vgb, vat, and vatB resistance genes among staphylococcal isolatesa
Gene

msrA

S. aureus (n 5 144)
No. (%)

3 (2.1)

Resistance phenotype

MSSA or MRSA, M

Coagulase-negative staphylococci (n 5 150)

No. (%)

Resistance phenotype

17 (11.3)

MSCNS, M
MRCNS, M
MRCNS, M
MSCNS, M
MSCNS, M
MSCNS, MLS inducible
MRCNS, MLS inducible
MRCNS, MLS constitutive
MSCNS, MLS inducible
MRCNS, L
MRCNS, M, L
MRCNS, M, L
MSCNS, L
MRCNS, MS inducible, L constitutive
MRCNS, MS inducible, L constitutive
MRCNS, SgA
MRCNS, SgA, L
MRCNS, MLS constitutive, SgA
MRCNS, MLS constitutive, SgA
MSCNS, MLS inducible
MRCNS, MLS constitutive, SgA
MRCNS, MLS constitutive, SgA, Pr, QD

S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.
S.

epidermidis (2)
epidermidis (1)
haemolyticus (10)
saprophyticus (2)
hominis (2)
hominis (1)
haemolyticus (2)
haemolyticus (1)
hominis (1)
epidermidis (2)
epidermidis (1)
haemolyticus (1)
hominis (1)
epidermidis (1)
haemolyticus (1)
epidermidis (2)
haemolyticus (1)
epidermidis (6)
haemolyticus (1)
epidermidis (1)
epidermidis (1)
epidermidis (1)

MRCNS, MLS constitutive, SgA, Pr, QD

MSCNS, L, SgA
MRCNS, L, SgA
MSCNS, M
MRCNS, SgA
MSCNS, MLS constitutive

S.
S.
S.
S.
S.
S.

epidermidis (2)
sciuri (3)
sciuri (1)
saprophyticus (1)
warneri (1)
warneri (1)

msrA 1 ermA

3 (2.0)

msrA 1 ermC

2 (1.3)

linA/linA9
linA/linA9 1 msrA

2 (1.3)
2 (1.3)

linA/linA9 1 ermA
linA/linA9 1 ermC
linA/linA9 1 ermB 1 ermC
vga

1 (0.7)

MSSA, MS inducible, L constitutive

1 (0.7)
1 (0.7)
1 (0.7)
3 (2.0)

vga 1 ermA

8 (5.3)

vga 1 ermA 1 ermC

vga 1 vgb 1 vat 1 ermA
vatB 1 ermA

1 (0.7)
1 (0.7)

vatB 1 ermC
No resistance gene

10 (7.6)
1 (0.7)
1 (0.7)

MRSA, MLS constitutive, SgA, Pr, QD

MRSA, MLS constitutive
MRSA, L, SgA

2 (1.3)
4 (2.7)
1 (0.7)
1 (0.7)
1 (0.7)

Species (no.)

a
Abbreviations: M, macrolides; MSCNS, methicillin-susceptible coagulase-negative staphylococci; MRCNS, methicillin-resistant coagulase-negative staphylococci;
L, lincosamides; MS, macrolides-streptogramin B; SgA, streptogramin A; Pr, pristinamycin; and QD, quinupristin-dalfopristin.

VOL. 43, 1999

RESISTANCE GENES TO MLS ANTIBIOTICS AMONG STAPHYLOCOCCI

resistance to pristinamycin and quinupristin-dalfopristin. The

vga gene was detected in combination with a methylase gene in
10 strains of coagulase-negative staphylococci but had no phenotypic consequence in one (MIC of dalfopristin, 2 mg/ml).
Resistance to pristinamycin and quinupristin-dalfopristin was
detected in 10 strains of S. aureus and in 3 strains of coagulasenegative staphylococci and was associated with resistance
genes such as ermA and vatB (in the 10 strains of S. aureus) or
ermA, vat, vga, and vgb (in the three coagulase-negative staphylococcus strains). The presence of the vatB gene had no phenotypic consequence in one strain of S. aureus (MIC of dalfopristin, 0.5 mg/ml; MIC of quinupristin-dalfopristin, 0.25 mg/
ml; MIC of pristinamycin, 1 mg/ml). No resistance genes were
detected in a strain of S. aureus, in four strains of S. sciuri which
were resistant to lincomycin and streptogramin A, and in two
S. warneri strains (Table 3). No MLS resistance genes were
detected in 20 strains which were susceptible to MLS antibiotics.
DISCUSSION
We have studied the distribution of MLS resistance determinants by PCR in clinical staphylococcal isolates resistant at
least to one of the MLS antibiotics with primers specific for 10
resistance genes. PCR was not performed for vgaB, vgbB, and
vatC since the sequence of these genes was not available at the
time of the study (2, 3). It cannot be ruled out that some of
these genes may be present in resistant strains of the present
study, notably those with no detectable resistance genes (Table
3). msrB from S. xylosus (25) was not detected in any of the
staphylococcus strains studied. Resistance to MLS was predominantly due to the presence of two evolutionary variants of
the erm determinant, but with different distributions depending on the type of staphylococci (coagulase positive or negative) and the antibiotic resistance pattern (methicillin resistant
or susceptible). When a single resistance determinant was
present in S. aureus, the ermA gene was more common in
MRSA (57.6%), mainly in strains with a constitutive expression, than in MSSA (5.6%), whereas ermC was predominant in
MSSA (20.1%), mainly in strains with an inducible expression,
and less so in MRSA (4.9%).
Analysis of strains from Denmark isolated from 1959 to 1988
indicated that the ermA and ermC genes were responsible for
erythromycin resistance in 98% of 428 S. aureus isolates (32).
ermA was part of transposon Tn554 (30) in the chromosome,
whereas ermC was found on plasmids (29). In coagulase-negative staphylococci, ermC was more common in methicillinresistant coagulase-negative staphylococci (30%), but the ermA
gene was detected in a rather high percentage of methicillinresistant coagulase-negative staphylococci (16.7%); the most
common gene in methicillin-susceptible coagulase-negative
staphylococci was ermC (14.0%). These results confirmed those
of Eady et al. (14), who documented the predominance of
ermC in a large series of clinical and commensal coagulasenegative staphylococci. As previously described (14), ermB was
present in a minority of strains but was formerly found in only
animal strains (14, 29). Association of different erm genes was
not detected in S. aureus and very rarely in coagulase-negative
staphylococci (five strains). The erm genes were also detected
in combination with other resistance genes such as msrA, linA/
linA9, vga, vgb, vat, and vatB but only in a limited number of
strains (12 S. aureus strains and 20 coagulase-negative staphylococcus strains).
Macrolide resistance due to msrA was more prevalent in
coagulase-negative staphylococci (total of 14.6%) than in
S. aureus (2.1%). Eady et al. (14) considered that their re-

1065

ported proportion of one-third of 221 coagulase-negative

staphylococcus strains harboring msrA was biased since they
selected for their study a greater proportion of strains with a
macrolide-resistant phenotype. It also appeared in this study
(14) that msrA was most commonly encountered in S. hominis
and S. cohnii, whereas in our study it was detected more frequently in S. haemolyticus (Table 3). This difference could
simply reflect the different distribution of the coagulase-negative staphylococcal species in the two studies. Coagulase-negative staphylococci harboring both erm and msrA accounted for
3.3% of our strains, and a similar proportion (3.6%) was reported by Eady et al. (14). We detected no S. aureus with such
combinations of resistance mechanisms. Three S. aureus strains
harboring determinants encoding different mechanisms, an esterase activity hydrolyzing macrolides, and a macrolide efflux
system were reported (24, 33).
The incidence of staphylococci with lincomycin resistance
but without resistance to macrolides and streptogramins is
usually low. Leclercq et al. (20) reported an incidence of
0.2% in S. aureus (2,100 strains screened), 4.6% in S. epidermidis (240 strains screened), and 8% in S. cohnii (50 strains
screened). In our study, we detected a single strain of S. aureus and seven strains of coagulase-negative staphylococci
with linA/linA9, most frequently in association with an erm
gene (Table 3). Such a combination has not been reported
before.
Resistance to pristinamycin and quinupristin-dalfopristin
was phenotypically detected in 10 S. aureus strains (seven isolates from the same hospital and possibly of the same clone)
and 3 coagulase-negative staphylococcus isolates. The prevalence of pristinamycin-resistant staphylococci can be higher in
hospitals where pristinamycin is used extensively, as reported
previously for an Algerian hospital (22). The prevalence of
pristinamycin resistance remains usually low in most French
hospitals (,5%) (16, 23), as is probably the case for quinupristin-dalfopristin resistance since we found a complete concordance between pristinamycin and quinupristin-dalfopristin
resistance. Resistance to pristinamycin and quinupristin-dalfopristin in staphylococci is usually associated with an accumulation of various genes such as vga, vat, and vgb on different
plasmids in association with methylase genes (22). The vat
gene initially cloned from plasmid pIP680 was shown to be
contiguous to a vgb gene (5); both genes were also simultaneously detected on different plasmids harbored by independent S. aureus and S. simulans isolates (15), which in several
cases also harbored the vga determinant (1). Such a combination of vga-vgb-vat genes previously described in S. aureus and
in coagulase-negative staphylococci (1, 22) was found in our
series in an S. epidermidis strain and was associated with an erm
gene (Table 3). Allignet et al. (1) reported also the association
of pristinamycin resistance with the presence of the vatB gene
mostly in S. aureus; in our series, it was found in 10 S. aureus
strains resistant to pristinamycin and quinupristin-dalfopristin
and was always associated with the ermA gene.
Given the distribution and prevalence of the various MLS
resistance genes in this collection of clinical isolates of staphylococci, it appears that resistance stricto sensu to pristinamycin and quinupristin-dalfopristin remains low due to the low
incidence of resistance to streptogramin type A (vat or vatB
genes), a necessary but not necessarily sufficient condition for
resistance to quinupristin-dalfopristin or pristinamycin. In every other combination of resistance genes, pristinamycin and
quinupristin-dalfopristin are either not affected (i.e., presence
of erm-inducible and/or linA/linA9) or only partially affected in
one component (i.e., presence of erm-constitutive, msrA, or
vga). In cases where the activity of the B compounds is re-

1066

LINA ET AL.

ANTIMICROB. AGENTS CHEMOTHER.

duced, the bactericidal efficacy of pristinamycin and quinupristin-dalfopristin remains to be evaluated as well as its clinical
efficacy. However, at present, these promising molecules (pristinamycin for oral use and quinupristin-dalfopristin for intravenous use) are potentially fully active in a large proportion of
cases.
ACKNOWLEDGMENTS
We are grateful to Chantal Nervi, Martine Rougier, Annie Martra,
and Yvonne Benito for technical assistance and to Patrice Courvalin
for providing reference strains.
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