Resistance to macrolides and ketolides occurs mainly via alterations in RNA moieties of the drug-binding site. Using an A2058G mutant of Mycobacterium smegmatis, additional telithromycin resistance was acquired via deletion of 15 residues from protein L22. Molecular modeling, based on the crystal structure of the large ribosomal subunit from Deinococcus radiodurans complexed with telithromycin, shows that the telithromycin carbamate group is located in the proximity of the tip of the L22 hairpin-loop, allowing for weak interactions between them. These weak interactions may become more important once the loss of A2058 interactions destabilizes drug binding, presumably resulting in a shift of the drug toward the other side of the tunnel, namely, to the vicinity of L22. Hence, the deletion of 15 residues from L22 may further destabilize telithromycin binding and confer telithromycin resistance. Such deletions may also lead to notable differences in the tunnel outline, as well as to an increase of its diameter to a size, allowing the progression of the nascent chain.Ribosomes provide a target for several antibiotic families, among which is the macrolide-ketolide group. High-resolution crystal structures showed that macrolides and their derivatives bind to a specific pocket of the nascent protein exit tunnel (2,3,7,16,20,21,25,29), the universal feature of the large ribosomal subunit through which nascent proteins emerge. The same pocket is exploited by all members of the macrolide family, and effective inhibitory action is achieved when the drug consumes a significant portion of the tunnel cross-section (1, 31, 32). Typically, resistance to macrolides is acquired through either efflux or target-based alteration (methylation or mutation of nucleotides involved in drug binding [for reviews, see references 11 and 28]).Ketolides are an advanced generation of the macrolide antibiotics, which, in part, provide activity against macrolideresistant pathogens. They are semisynthetic derivatives of erythromycin, the first macrolide in use. Like erythromycin, ketolides are composed of a 14-membered macrolactone ring (Fig. 1). However, their macrolactone ring lacks a cladinose sugar and possesses a keto group at position 3, a cyclic carbamate, and an extended arm. Ketolides and macrolides share a similar, albeit not identical inhibitory mechanism. Owing to their more elaborated chemistry, in addition to their binding to the macrolide pocket, the ketolides extend further into the tunnel and interact with rather remote sites (2,20,29). Among ketolides, telithromycin carries an aryl-alkyl extension bound to its cyclic carbamate (Fig. 1). The crystal structure of the large ribosomal subunit from Deinococcus radiodurans (called D50S) in complex with telithromycin indicates that telithromycin interacts with 23S RNA domain II nucleotides (2, 29). This finding is consistent with a number of previous biochemical and mutagenesis studies showing that, in addition to nucleotides in domain V, domain II nucleotide A752 (Escherichia coli numbe...