Recent work has shown that the efflux genes in Streptococcus pneumoniae that are responsible for acquired macrolide resistance can be distinguished as either mef(E) or mef(A). The genetic elements on which mef(A) and mef(E) are found also carry an open reading frame (ORF) that is 56% homologous to msr(A) in Staphylococcus. The prevalence of mef(A/E) and of the msr-like ORF [msr(D)] was evaluated in 153 mef ؉ S. pneumoniae clinical isolates collected in North America, Europe, Africa, and Asia from 1997 to 2002. Clinical isolates were screened with PCR primers specific for either mef(A) or mef(E) and for msr(D). mef(A), mef(E), and msr(D) were cloned from mef ؉ strains and transformed into a susceptible, competent strain of S. pneumoniae. The transformants were tested for antimicrobial susceptibilities and efflux pump induction. The results of this work demonstrated that mef(A) is more often isolated in parts of Europe, with some incidence in Canada, and that the msr-like gene alone can confer the efflux phenotype.Recent work has shown that the efflux genes in Streptococcus pneumoniae responsible for acquired macrolide resistance can be distinguished as either mef(E) or mef(A) (6). Originally, mef in S. pneumoniae had been labeled mef(E), while mef(A) had been reserved for Streptococcus pyogenes. The two mef genes show a 90% sequence homology between the start and stop codons, but they can be distinguished with specific primer sets. Due to sequence similarity, these genes were merged under mef(A) by Roberts et al. (16). However, for clarity in the present discussion, the genes will be referred to as mef(A) and mef(E). Whether there are sufficient differences in the epidemiology and/or function of the genes to return to separate designations has not been determined.The mef genes are carried on transposons comprised of additional open reading frames (ORFs). Both of these genetic elements also carry an ORF downstream from mef that is 56% homologous to the coding region of msr(A) in Staphylococcus. The upstream region of the msr-like gene in Streptococcus lacks the leader peptide found in the Staphylococcus msr(A) gene (17). The msr-like homologs found associated with either mef(A) or mef(E) have 98% sequence homology. Although the msr-like homolog is believed to be a part of the efflux system, it has not been previously studied independently in Streptococcus.mef(A) in S. pneumoniae has been previously described in Italy (6). Given our worldwide clinical isolate collection, we studied the prevalence rates of mef(A) versus that of mef(E) in S. pneumoniae isolates collected in Europe, Asia, and North and South America. The prevalence and geographic distributions of mef(A) versus mef(E) in 153 clinical isolates of mef ϩ S. pneumoniae from six regions of the world were evaluated in this study. The prevalence and function of the msr homolog were also evaluated. This gene has been given the designation msr(D) (M. Roberts, personal communication) and was shown to be capable of independent function when cloned and expressed i...