A cquisition of resistance to antibiotics is mediated by four mechanisms, including drug detoxification, efflux and decreased cell wall permeability, decreased affinity of the target for the drug, and bypass of the target. For -lactams, detoxification of the antibiotics by -lactamases is widespread in nearly all bacterial phyla. In Gram-negative bacteria, -lactamase production is frequently associated with reduced permeability of the outer membrane and efflux. In the Firmicutes, this permeability barrier does not exist, and resistance is often due to production of targets displaying a lower affinity for the drug following horizontal gene transfer or acquisition of mutations. The remaining mechanism, bypass of the target, has been identified for the first time in mutants of Enterococcus faecium selected for their resistance to ampicillin in laboratory conditions (1). In these mutants, the classical targets of -lactams, the high-molecular-weight penicillin-binding proteins (PBPs) (2), are replaced by an L,D-transpeptidase (LDT) (3), which catalyzes the essential cross-linking step of peptidoglycan synthesis.PBPs and LDTs are structurally unrelated and catalyze formation of peptidoglycan cross-links by distinct catalytic mechanisms involving active-site serine and cysteine residues, respectively (3-5). In the first step of the cross-linking reaction, PBPs react with an acyl donor containing a stem pentapeptide, which displays the
¡D-iAsx-L-Lys3 ). Since LDTs are not inactivated by ampicillin (6, 7), the L,D-transpeptidation pathway conveys high-level resistance to this antibiotic with a MIC of Ͼ1,000 g/ml.Activation of the L,D-transpeptidation pathway has been obtained in a strain of E. faecium, D344S, deficient for production of low-affinity PBP5 following spontaneous deletion of the corresponding chromosomal gene (1,8). Starting with this hypersusceptible strain (MIC of ampicillin, 0.06 g/ml), five selection steps on increasing concentrations of ampicillin were required to obtain highly resistant mutant M512 (MIC, Ͼ1,000 g/ml) (Fig. 1B) (8). The selection procedure did not result in any modification in the sequence or level of production of the E. faecium Ldt fm (9). The enzyme was active in the parental strain but only contributed to formation of 3% of the cross-links due to limited amounts of its