The antimicrobial efflux system encoded by the operon mef(E)-mel on the mobile genetic element MEGA in Streptococcus pneumoniae and other Gram-positive bacteria is inducible by macrolide antibiotics and antimicrobial peptides. Induction may affect the clinical response to the use of macrolides. We developed mef(E) reporter constructs and a disk diffusion induction and resistance assay to determine the kinetics and basis of mef(E)-mel induction. Induction occurred rapidly, with a >15-fold increase in transcription within 1 h of exposure to subinhibitory concentrations of erythromycin. A spectrum of environmental conditions, including competence and nonmacrolide antibiotics with distinct cellular targets, did not induce mef(E). Using 16 different structurally defined macrolides, induction was correlated with the amino sugar attached to C-5 of the macrolide lactone ring, not with the size (e.g., 14-, 15-or 16-member) of the ring or with the presence of the neutral sugar cladinose at C-3. Macrolides with a monosaccharide attached to C-5, known to block exit of the nascent peptide from the ribosome after the incorporation of up to eight amino acids, induced mef(E) expression. Macrolides with a C-5 disaccharide, which extends the macrolide into the ribosomal exit tunnel, disrupting peptidyl transferase activity, did not induce it. The induction of mef(E) did not require macrolide efflux, but the affinity of macrolides for the ribosome determined the availability for efflux and pneumococcal susceptibility. The induction of mef(E)-mel expression by inducing macrolides appears to be based on specific interactions of the macrolide C-5 saccharide with the ribosome that alleviate transcriptional attenuation of mef(E)-mel.Macrolides are broad-spectrum antibiotics with complex macrocyclic 14-, 15-, or 16-member lactone rings that bind in the peptide exit tunnel of bacterial ribosomes and inhibit protein synthesis. Macrolides are often recommended as the empirical first-line treatment for upper respiratory bacterial infections, including pneumococcal infections and communityacquired pneumonia. However, bacterial resistance to macrolides is expanding worldwide in Gram-positive bacteria and is now present in almost a third of all invasive Streptococcus pneumoniae isolates (14). The two most common mechanisms of macrolide resistance in bacterial pathogens are modification of the bacterial ribosome, either by methylation or mutation, and extrusion of the drugs from the bacterial cell by an efflux pump. Genes of the erm (erythromycin ribosomal methylases) family of rRNA methylases confer high-level resistance to lincosamides and streptogramins, as well as macrolides (the MLS B phenotype), and can be constitutive or inducible. In the inducible form, resistance develops only after exposure of the bacterium to the macrolide.The best-studied mechanism of inducible MLS B resistance involves the erm(C) gene found in S. aureus and other Grampositive pathogens (4,32,33). Translation of erm(C) is attenuated in the absence of inducers due to...