Streptococcus pyogenes infections often fail to respond to antibiotic therapy, leading to persistent throat carriage and recurrent infections. Such failures cannot always be explained by the occurrence of antibiotic resistance determinants, and it has been suggested that S. pyogenes may enter epithelial cells to escape antibiotic treatment. We investigated 289 S. pyogenes strains isolated from different clinical sources to evaluate their ability to form biofilm as an alternative method to escape antibiotic treatment and host defenses. Up to 90% of S. pyogenes isolates, from both invasive and noninvasive infections, were able to form biofilm. Specific emm types, such as emm6, appeared to be more likely to produce biofilm, although variations within strains belonging to the same type might suggest biofilm formation to be a trait of individual strains rather than a general attribute of a serotype. Interestingly, erythromycin-susceptible isolates formed a significantly thicker biofilm than resistant isolates (P < 0.05). Among resistant strains, those carrying the erm class determinants formed a less organized biofilm than the mef(A)-positive strains. Also, prtF1 appeared to be negatively associated with the ability to form biofilm (P < 0.01). Preliminary data on a selection of strains indicated that biofilm-forming isolates entered epithelial cells with significantly lower efficiency than biofilm-negative strains. We suggest that prtF1-negative macrolide-susceptible or mef(A)-carrying isolates, which are poorly equipped to enter cells, may use biofilm to escape antimicrobial treatments and survive within the host. In this view, biofilm formation by S. pyogenes could be responsible for unexplained treatment failures and recurrences due to susceptible microorganisms.Biofilm formation is recognized as an important virulence factor for both opportunistic pathogens (such as coagulase-negative staphylococci or enterococci) and "true" pathogens (such as Staphylococcus aureus or Pseudomonas aeruginosa) (32).Streptococcus pyogenes (group A streptococcus [GAS]) is an important human pathogen that causes a variety of clinical manifestations ranging from noninvasive diseases, such as pharyngitis and impetigo, to more-severe, invasive infections, including necrotizing fasciitis, sepsis, and toxic shock-like syndrome (14). A large number of secreted or cell-attached virulence factors expressed by this microorganism have been investigated so far (5, 14). As far as biofilm is concerned, streptococcal species such as Streptococcus gordonii and Streptococcus mutans are well-known biofilm formers (17, 26), and recent observations suggesting that biofilm may also have a role in S. pyogenes infections have been reported. HidalgoGrass and colleagues (24) have observed that structured communities appear to be present in necrotizing fasciitis lesions, and Neely et al. (30) found similar characteristics in a model of S. pyogenes myositis in zebrafish. Akiyama et al. (1) reported that S. pyogenes from a murine model of impetigo was embedded ...