The broad-spectrum fluoroquinolone ciprofloxacin is a bactericidal antibiotic targeting DNA topoisomerase IV and DNA gyrase encoded by the parC and gyrA genes. Resistance to ciprofloxacin in Streptococcus pneumoniae mainly occurs through the acquisition of mutations in the quinolone resistance-determining region (QRDR) of the ParC and GyrA targets. A role in low-level ciprofloxacin resistance has also been attributed to efflux systems. To look into ciprofloxacin resistance at a genome-wide scale and to discover additional mutations implicated in resistance, we performed whole-genome sequencing of an S. pneumoniae isolate selected for resistance to ciprofloxacin in vitro (128 g/ml) and of a clinical isolate displaying low-level ciprofloxacin resistance (2 g/ml). Gene disruption and DNA transformation experiments with PCR fragments harboring the mutations identified in the in vitro S. pneumoniae mutant revealed that resistance is mainly due to QRDR mutations in parC and gyrA and to the overexpression of the ABC transporters PatA and PatB. In contrast, no QRDR mutations were identified in the genome of the S. pneumoniae clinical isolate with low-level resistance to ciprofloxacin. Assays performed in the presence of the efflux pump inhibitor reserpine suggested that resistance is likely mediated by efflux. Interestingly, the genome sequence of this clinical isolate also revealed mutations in the coding region of patA and patB that we implicated in resistance. Finally, a mutation in the NAD(P)H-dependent glycerol-3-phosphate dehydrogenase identified in the S. pneumoniae clinical strain was shown to protect against ciprofloxacin-mediated reactive oxygen species.
Streptococcus pneumoniae is a major Gram-positive pathogen responsible for pneumonia, bacteremia, otitis media, and meningitis leading to considerable morbidity and mortality among children and elderly individuals (1). Penicillin, a -lactam antibiotic, has long been the mainstay against pneumococcal infections (2, 3), but the worldwide spread of antibiotic-resistant clones over the past decades has impaired its usefulness for dealing with S. pneumoniae infections (4-6). The rates of resistance against -lactams and macrolides among S. pneumoniae isolates have translated into an increased usage of fluoroquinolone antibiotics in the treatment of respiratory diseases (7-10).Fluoroquinolones are part of a class of synthetic broad-spectrum antibiotics that inhibit DNA synthesis in bacteria by targeting DNA gyrase (GyrA and -B subunits) and topoisomerase IV (ParC and -E subunits), two enzymes that are vital for DNA supercoiling and chromosome segregation, respectively (11,12). Although the worldwide prevalence of fluoroquinolone-resistant S. pneumoniae remains low in relation to -lactam resistance (Յ1%) (13-15), the dissemination of successful resistant clones has nonetheless increased the prevalence in some countries (16,17). Resistance to fluoroquinolones in S. pneumoniae arises in a stepwise fashion and results from alterations in the target binding site due to...