Phenotypical and genotypical surveillance of macrolide and lincosamide resistance in group B streptococcus in Belgium

Background: Constant increase of erythromycin (E) and clindamycin (C) resistance (R) has been observed worldwide among isolates of group B streptococci (GBS). In Belgium, through the 2000s, E R increased rapidly from 10% to up to 30%. Therefore phenotypical and molecular surveillance of E and C R has to be conducted.
Methods: 275 clinical isolates (N1) were obtained from a Belgian surveillance for invasive GBS disease in newborns (59 isolates with 32 early- and 27 late-onset diseases) and adults (216 strains) during 2008 to 2011 and 53 isolates (N2) from vagino-rectal colonization in pregnant women in 2010. E and C MICs were determined by using Etest® (EUCAST interpretive criteria). Furthermore, for the E R isolates, the inducible (iMLS), constitutive (cMLS) and M phenotypes were assessed by a double disk diffusion test; the distribution of genes encoding RNA methylases and efflux pumps was investigated by PCR.
Results: Of the N1 and N2 isolates, 92 (33.5%) and 15 (28.3%) were respectively R to E, with a higher rate among serotype V (p <0.001) and serotype IV (p <0.05). Among these 107 E-R isolates, 100 (93.5%) exhibited the MLS phenotype (R to E and CC): 73 were cMLS with E MIC50 >256 mg/L and 27 iMLS with E MIC50/MIC90 12/>256 mg/L. The M phenotype (R to E and S to C) was expressed by 7 (6.5%) of E R isolates with E MIC50/MIC90 4/12 mg/L. One colonizing strain presented a newly described resistance mechanism in GBS: the L phenotype (S to E and R to C) with a C MIC at 8 mg/L. For cMLS, the most common E R genotype was ermB (66%) (p <0.05) followed by ermTR (29%) and ermB+ermTR (5%). All iMLS isolates harbored an ermTR gene except 3 (2 with ermB, 1 with both ermB and ermTR); and all M phenotype were positive for mefA/B gene.
Conclusions:1) In Belgium, by year 2010, prevalence of macrolides R in GBS exceeded 30%, 2) MLS R phenotypes (target-site modification) were the majority mechanism; M phenotype (efflux R mechanism) was also prevalent. 3) E and C susceptibility testing and surveillance are mandatory to guide prophylaxis and treatment of serious GBS infections in penicillin-allergic patients (at high risk for anaphylaxis) but also to identify emergence of newly acquired resistance mechanisms such as the L phenotype.