Group A Streptococcus (GAS) commonly infects the human oropharynx, but the initial molecular events governing this process are poorly understood. Saliva is a major component of the innate and acquired immune defense in this anatomic site. Although landmark studies were done more than 60 years ago, investigation of GAS-saliva interaction has not been addressed extensively in recent years. Serotype M1 GAS strain MGAS5005 cultured in human saliva grew to ϳ10 7 CFU/ml and, remarkably, maintained this density for up to 28 days. Strains of several other M-protein serotypes had similar initial growth patterns but did not maintain as high a CFU count during prolonged culture. As revealed by analysis of the growth of isogenic mutant strains, the ability of GAS to maintain high numbers of CFU/ml during the prolonged stationary phase in saliva was dependent on production of streptococcal inhibitor of complement (Sic) and streptococcal pyrogenic exotoxin B (SpeB). During cultivation in human saliva, GAS had growth-phase-dependent production of multiple proven and putative extracellular virulence factors, including Sic, SpeB, streptococcal pyrogenic exotoxin A, Mac protein, and streptococcal phospholipase A 2 . Our results clearly show that GAS responds in a complex fashion to growth in human saliva, suggesting that the molecular processes that enhance colonization and survival in the upper respiratory tract of humans are well under way before the organism reaches the epithelial cell surface.One hallmark of a successful microorganism is the ability to adapt to new host environments. Group A Streptococcus (GAS) causes a wide variety of diseases in humans, ranging from impetiginous skin lesions to invasive diseases, such as necrotizing fasciitis and meningitis. GAS is particularly suited to inhabit the human oropharynx, colonizing as many as onehalf of school-age children in nonepidemic periods and causing an estimated 15 million cases of pharyngitis in the United States each year (3,43). Moreover, the presence of GAS in the oropharynx generally is required for the subsequent development of rheumatic fever, the leading cause of preventable heart disease in children (10, 28).The oropharynx is the major site of entry for GAS into the human body and its main portal of transmission (19,43,46). Saliva is ubiquitous in the human oropharynx and is an essential part of both the acquired and innate immune defense systems (25,39). Landmark experiments conducted more than 60 years ago demonstrated the important role played by saliva in the establishment of GAS infection and the subsequent transmission of infectious organisms (18)(19)(20). These studies revealed that large numbers of live GAS were present in the saliva of individuals with GAS pharyngitis (19). Moreover, it was established that a major route for dissemination of GAS from infected individuals into the environment was via dispersal of aerosolized saliva (20). Other investigators have reported that pharyngitis patients with detectable levels of GAS in their saliva were more l...