# Increase of macrolide resistance among Streptococcus pyogenes pharyngitis driven by a mef(A)-msr(D)/emm2-ST55 lineage in Portugal (2014–2019)

## TL;DR

This study tracks the rise of macrolide-resistant Streptococcus pyogenes in Portugal, showing how a specific lineage became dominant in 2019.

## Contribution

Identifies a new mef(A)-msr(D)/emm2-ST55 lineage driving increased macrolide resistance in pharyngitis cases in Portugal.

## Key findings

- Macrolide resistance peaked at 9% in 2019 due to the rapid spread of mef(A)-msr(D)-positive emm2-ST55 isolates.
- Resistant isolates showed lower genetic diversity and minimal overlap with susceptible lineages.
- Tetracycline resistance was commonly linked to tet(M) and tet(O) genes co-located with erm genes.

## Abstract

Increases in macrolide resistance occurred recently among Streptococcus pyogenes (Group A Streptococcus, GAS) in some countries. While the importance of monitoring the clinical and molecular epidemiology of non-invasive GAS is increasingly recognized, most surveillance focuses on invasive infections, since culture is rarely performed in tonsillo-pharyngitis. We determined the antimicrobial susceptibility and characterized the macrolide-resistant lineages of 2,002 pharyngeal isolates recovered in a Portuguese hospital in 2014–2019. There were seasonal variations in the numbers of recovered isolates, with peaks shifting between March–July and October–December, but consistently low numbers in August and September. Macrolide-resistant and macrolide-susceptible GAS presented independent seasonal and clonal dynamics, with resistant isolates showing lower genetic diversity and minimal overlap with susceptible lineages. Overall, 84 (4%), 77 (4%), and 52 (3%) isolates were resistant to erythromycin, clindamycin, and tetracycline, respectively. Until 2018, macrolide resistance was mainly due to an internationally disseminated emm77-ST63 lineage carrying erm(A) and tet(O) in ICESp2905 and an emm75-ST49 lineage carrying mef(A)-msr(D) in a novel ɸ1207.3 variant. In 2019, resistance peaked at 9% due to the rapid expansion of mef(A)-msr(D)-positive emm2-ST55 isolates, replacing previous lineages. Other minor resistant lineages carried mostly erm(B) in a diversity of mobile genetic elements, including emm75-ST150, emm9-ST75, emm11-ST403, emm12-ST36, emm76-ST50, and emm77-ST399 [erm(T)]. Tetracycline resistance was associated with the genes tet(M) and tet(O), in most cases co-located in the same genetic elements as the erm genes. This study reveals clonal changes among macrolide-resistant GAS driving fluctuations in macrolide resistance and associated phenotypes.