The polysaccharide intercellular adhesin (PIA) is an important factor in the colonization of medical devices by Staphylococcus epidermidis. The genes encoding PIA production are organized in the icaADBC (intercellular adhesion) operon. To study the function of the individual genes, we have established an in vitro assay with UDP-N-acetylglucosamine, the substrate for PIA biosynthesis, and analyzed the products by thin-layer chromatography and mass spectrometry. IcaA alone exhibited a low N-acetylglucosaminyltransferase activity and represents the catalytic enzyme. Coexpression of icaA with icaD led to a significant increase in activity. The newly identified icaD gene is located between icaA and icaB and overlaps both genes. N-Acetylglucosamine oligomers produced by IcaAD reached a maximal length of 20 residues. Only when icaA and icaD were expressed together with icaC were oligomer chains that react with PIA-specific antiserum synthesized. IcaA and IcaD are located in the cytoplasmic membrane, and IcaC also has all the structural features of an integral membrane protein. These results indicate a close interaction between IcaA, IcaD, and IcaC. Tunicamycin and bacitracin did not affect the in vitro synthesis of PIA intermediates or the complete PIA biosynthesis in vivo, suggesting that a undecaprenyl phosphate carrier is not involved. IcaAD represents a novel protein combination among -glycosyltransferases.In recent years, Staphylococcus epidermidis has emerged as a frequent cause of nosocomial infections in association with indwelling medical devices such as intravascular catheters, cerebrospinal fluid shunts, prosthetic heart valves, prosthetic joints, artificial pacemakers, and chronic ambulatory peritoneal dialysis catheters (reviewed in Refs. 1 and 2). The virulence of S. epidermidis in these infections is thought to be based on its ability to colonize medical devices by forming a biofilm composed of multilayered cell clusters embedded in a slime matrix (3). As shown by electron microscopy studies, surface colonization takes place in two steps (4). The first step is primary adhesion of some bacteria, which is followed by proliferation of the cells to multilayered clusters. Factors reported to contribute to primary attachment of S. epidermidis cells to a polymer surface include unspecific hydrophobic interactions (5, 6), a capsular polysaccharide/adhesin (PS/A) (7, 8), proteinaceous cell-surface antigens (SSP-1 and SSP-2) (9, 10), and the autolysin AtlE identified by our group (11).A characteristic feature of the second phase of biofilm formation is intercellular adhesion, which results in the formation of large cell clusters by clinical S. epidermidis strains. This reaction is associated with the production of the polysaccharide intercellular adhesin (PIA) 1 located at the cell surface (12). PIA consists of two structurally related homoglycans, polysaccharides I and II, composed of at least 130 2-deoxy-2-amino-Dglucopyranosyl residues that are mostly (Ͼ80%) N-acetylated. The residues are -1,6-linked (13), ...