Review

For reprint orders, please contact reprints@expert-reviews.com

Oral biofilms: a reservoir of

transferable, bacterial,
antimicrobial resistance
Expert Rev. Anti Infect. Ther. 8(12), 14411450 (2010)

Adam P Roberts1 and

Peter Mullany1
Department of Microbial Diseases,
UCL Eastman Dental Institute,
University College London, 256 Grays
Inn Road, London, WC1X 8LD, UK

Author for correspondence:

Tel.: +44 207 915 1044
Fax: +44 207 915 1127
adam.roberts@ucl.ac.uk
1

Oral microbes are responsible for dental caries and periodontal diseases and have also been
implicated in a range of other diseases beyond the oral cavity. These bacteria live primarily as
complex, polymicrobial biofilms commonly called dental plaque. Cells growing within a biofilm
often exhibit altered phenotypes, such as increased antibiotic resistance. The stable structural
properties and close proximity of the bacterial cells within the biofilm appears to be an excellent
environment for horizontal gene transfer, which can lead to the spread of antibiotic resistance
genes amongst the biofilm inhabitants. This article will present an overview of the different
types and amount of resistance to antibiotics that have been found in the human oral microbiota
and will discuss the oral inhabitants role as a reservoir of antimicrobial resistance genes. In
addition, data on the genetic support for these resistance genes will be detailed and the evidence
for horizontal gene transfer reviewed, demonstrating that the bacteria inhabiting the oral cavity
are a reservoir of transferable antibiotic resistance
Keywords : antibiotic resistance biofilms caries dental plaque horizontal gene transfer mobile genetic
elements oral biofilms periodontitis reservoir of resistance

Antibiotic resistance in pathogenic bacteria currently represents one of the greatest challenges
to modern medicine throughout the world. The
increase in morbidity and mortality due to hospital-acquired superbugs is annually increasing. In a recent EU report on the problem of
antibiotic resistance, it was stated that each year
approximately 25,000 patients die in the EU
from an infection with one of eight different
nosocomial, multidrug-resistant bacteria [101] .
In addition, economic implications for healthcare providers, in terms of increased patient stay
in hospitals, isolation procedures and additional
medical intervention are increasingly impinging on the available budgets. In the EU this has
resulted in extra healthcare costs and productivity losses of at least 1.5 billion each year [101] .
Similar figures are available for the USA [1] .
There are numerous ways that researchers and
clinicians can tackle this problem, including the
much needed discovery or generation of novel
antimicrobials, highlighted by the recent global
10 20 initiative, which aims to produce
ten new antibiotics by 2020 [102] . Another, not
mutually exclusive approach is to try and determine where the resistance comes from. With the
increasing use of antibiotics, it is important to
www.expert-reviews.com

10.1586/ERI.10.106

understand where the reservoirs of resistance are,

what genes they contain and more importantly
the possibilities for transfer of these resistances
to pathogenic microbes. This knowledge will be
of help in predicting emerging resistances among
pathogens [2] . Most pathogens do not intrinsically contain resistance genes, as has been demonstrated by the numerous completed genome
sequences of pathogenic bacteria, and it is only
the acquisition of such genes that leads them to
become the multiple antibiotic-resistant bacteria that are the scourge of modern healthcare
environments. These genes must be acquired
from somewhere and recent investigations have
identified the normal human microflora as one
such potential reservoir for these antibiotic resistance genes. Of clinical importance is the fact
that many of these antibiotic resistance genes
have been found to be located on mobile genetic
elements capable of broad host-range horizontal
gene transfer among different bacteria (Box1) .
This article will give an overview of our current understanding of the resistance found in
bacteria inhabiting the oral cavity, usually within
oral biofilms, and will highlight their potential
to transfer these resistance genes to other oral
and transient bacteria.

2010 Expert Reviews Ltd

ISSN 1478-7210

1441

Review

Roberts & Mullany

Box1. Mechanisms of gene transfer among bacteria.

DNA can transfer from one bacterial cell to another by one or more of three mechanisms; namely, transformation, conjugation and
transduction.
Transformation is the process whereby bacteria take up free DNA from the environment and incorporate it into their genome. The
source of the transforming DNA is usually lysed bacterial cells. Bacteria able to take up DNA by this process are termed competent.
Conjugation is the transfer of DNA (usually a conjugative/mobilizable plasmid or conjugative/mobilizable transposon) between two
metabolically active bacterial cells and requires intimate cell to cell contact for transfer to occur.
Transduction is the process in which bacterial DNA gets erroneously packaged into the heads of bacteriophage, when the phage infects
another bacterial cell the packaged DNA is incorporated into the new hosts genome.
An overview of these mechanisms is shown in Figure1.

The oral cavity

The oral cavity is one of the most bacterially colonized environments in the human body. The microbial diversity present
in the oral cavity is a result of the many different ecological
niches present, ranging from the hard, nonshedding surfaces
of the teeth, both above and below the gingival margin, and
the mucosal surfaces of the various soft tissues, such as the
tongue, cheek and the hard and soft palate. Each of these surfaces presents a different environment to bacteria; therefore,
the microbial populations found at each site are distinct [3] ,
particularly in the elderly [4] . In addition to the varied environment, there is an enormous range of growth substrates that the
resident bacteria encounter during ingestion of foods. It has
been shown that increases in dietary sugar, for example, can
push the population structure of the oral community to one
with predominantly more cariogenic streptococci, which can
subsequently lead to caries [5] . A recent study on the effect of
different drinks has shown that the number of species is significantly lower between coffee and wine drinkers compared with
the control group (water drinkers) [6] .
The numbers of different types of bacteria present in the oral
cavity are only recently beginning to be appreciated. Owing to the
fact that less than half of the species present can currently be cultured in the laboratory the use of next-generation, massively paralleled sequencing technologies are enabling researchers to gain a
more accurate estimate of the true species diversity. A recurring
theme among recent reports is that, whilst there is a core microbiome emerging, for example, streptococci are the predominant
species in a healthy mouth, there are significant interindividual
differences in the microflora detected in each study [79] .
Oral biofilms

Some of the microbes present in oral biofilms are responsible for

two of the most common diseases to affect humans, dental caries
and inflammatory periodontal disease, which have been estimated
to affect up to 90% of the planets population [10] .
Development of oral biofilms begins when the newly exposed
surface of the tooth (following eruption of a new tooth or following mechanical removal of existing plaque by brushing or
scaling) is covered by an acquired pellicle. This process is estimated to take minutes [11] . The pellicle is composed of different
host-derived molecules, including mucins, proteins and agglutinins, which act as a source of receptors that are recognized by
1442

various oral bacteria. In addition, there are other host proteins,

for example, lysozyme and histatins, which are present in the
pellicle and are hypothesized to protect from bacterial colonization [12,13] . Bacteria that can recognize these receptors and
bind to the pellicle-covered surface of the tooth are known as
early colonizers and include Streptococcusspp., Actinomycesspp.,
Capnocytophaga spp., Eikenella spp., Haemophilus spp.,
Prevotellaspp., Propionibacteriumspp. and Veillonellaspp. [14] .
Subsequently the biofilm is colonized by the late colonizers, which
include Actinobacillusspp., Prevotellaspp., Eubacteriumspp.,
Porphorymonasspp. and Treponemaspp. Coaggregation between
pairs of early colonizers is common, however it is relatively rare
between late colonizers. Fusobacteriumnucleatum however is
able to coaggregate to all members of both the early and late
colonizers so far examined and also binds many host-derived
molecules found in the pellicle [15] .
As the attached bacterial cells grow and divide, many will start
to express a biofilm phenotype, which will include the secretion
of extracellular polymeric substances (EPS),which include poly
peptides, carbohydrates and nucleic acids. These EPS will eventually form the bulk of the mature biofilm structure [16] and afford
the cells and microcolonies growing within this matrix physical
stability from shear forces experienced within the oral cavity, such
as those from the flow of saliva and the action of the tongue and
other mucosal surfaces.
Oral diseases

The organisms present in oral biofilms are responsible for a

number of different diseases. Acid-producing streptococci,
such as Streptococcus mutans, are the primary cause of dental caries. In addition, oral biofilms contain other pathogens,
such as Tannerella forsythensis, Porphyromonas gingivalis and
Aggregatibacter (formerly Actinobacillus) actinomycetemcomitans,
that have all been shown to be involved in the formation of periodontal disease [17] . Periodontitis is complex in that there are a
number of different bacteria that are associated with the majority of (but not all) cases of the disease. A.actinomycetemcomitans
is the bacteria that most closely fulfils Kochs postulates as the
etiological agent of periodontitis and is most often associated
with the aggressive juvenile form of the disease [18] . The oral cavity provides an excellent portal to the rest of the body, either to
the alimentary canal or through the gingival surfaces following
cuts or abrasions sustained from brushing or eating, leading to
Expert Rev. Anti Infect. Ther. 8(12), (2010)

Oral biofilms: a reservoir of transferable, bacterial, antimicrobial resistance

short-term bacteremia [19] . In addition, oral bacteria can often be

isolated from the blood of dental patients following dental procedures, for example, tooth extraction, and many of the bacteria
isolated have been shown to cause endocarditis [20] .
In recent years, research has demonstrated associations of oral
bacteria with a range of other diseases and systemic conditions
such as coronary heart disease and a higher risk of preterm, lowbirthweight babies [21,22] . Similarly, recognition of the threats
posed by periodontal diseases to individuals with other chronic
diseases, such as diabetes [23] and hypertension [24] , are only just
beginning to be understood.
There is also an increasing amount of foreign implants, such as
dentures and bridges, being used. These share a common property with the surface of the tooth in that they are nonshedding.
Therefore this surface, once coated with the acquired pellicle,
will be readily colonized by bacteria, leading to the formation of
biofilms on these devices [25] that may compromise the comfort
and treatment of the patient.
The majority of bacteria living on the surfaces of the mouth
do so in symbiosis with the host [10] . The normal oral biofilm at
the gingival margin has beneficial effects as its constant presence provides colonization resistance for incoming and possibly
pathogenic microorganisms. This is illustrated by the fact that
disease is usually accompanied by a shift in the populations of
the predominant bacteria within oral biofilms when compared
with a healthy state [26] .
The use of antibiotics to treat periodontal disease

The treatment of periodontitis is quite different from the treatment of the majority of other diseases caused by bacterial infections due to the underlying polymicrobial nature of the disease.
There has been a wide variety of different antibiotics used to treat
periodontitis. These have been administered in different doses, in
combinations with other antibiotics and used both alone and in
combination with mechanical plaque removal [18] . Some of the
most common antibiotics that have been shown to result in the
required levels necessary to kill or inhibit bacterial growth in gingival crevicular fluid are amoxicillin and amoxicillin/clavulanic acid,
the tetracyclines, clindamycin and metronidazole. Dentists (in the
UK) prescribe amoxicillin, penicillin and metronidazole most often
with other antibiotics (including cephalosporins, tetracyclines and
macrolides) being prescribed less often [27] ; however, owing to the
polymicrobial nature of oral biofilms there is likely to be certain
species of bacteria present that are resistant to certain antibiotics.
Because of this, the outcome of identical treatment regimes may be
different for different patients and it is for this reason that combination therapies, such as metronidazole and amoxicillin, are now
becoming increasingly important [28,29] and are recommended to
be adjunctive with mechanical debridement [30] .
Intrinsic biofilm resistance to antimicrobials

Bacteria growing within biofilms often exhibit differing phenotypes compared with planktonically grown counterparts. One of
the most clinically important phenotypes is increased resistance
to antimicrobial compounds.
www.expert-reviews.com

Review

As the biofilm matures, the EPS surrounding the bacterial

cells will increase and can exclude antibiotics from the immediate vicinity of bacteria deep within the biofilm [31] . A similar
effect may occur with compounds that are secreted by bacteria that confer antimicrobial resistance, such as b-lactamases.
A high concentration of these compounds will form near to the
cells producing them if diffusion through the biofilm structure
is impeded by the EPS, providing a local and transient area of
relatively high resistance.
In addition, because of diffusion being hampered by the EPS,
nutrients and chemicals other than antimicrobials or resistance
proteins will also form gradients within the biofilms. Deep within
the biofilm, cells are likely to be less metabolically active than
those nearer the surface owing to the lack of nutrients reaching them. Many antibiotics act against metabolic targets such
as protein synthesis (e.g., tetracycline); therefore, if a cell is not
metabolically active it will be transiently resistant to the action
of these antibiotics. In addition, many antimicrobial compounds,
for example, mercury, are actively pumped into the bacterial cells
and therefore if metabolic activity is low a lower amount of the
antimicrobial will be pumped across the cell membrane, leading
to a reduced susceptibility to that agent.
Another important difference between bacteria grown in biofilms compared with planktonically grown cells is altered gene
expression. There is a multitude of different genes that are either
positively or negatively regulated when the bacteria are growing as
a biofilm compared with planktonically grown cultures [32] . The
complex regulatory networks controlling the expression of these
genes and their response to biofilm formation, and in some cases
the presence of antimicrobial compounds, are likely to control
apparatus such as efflux pumps, which will alter the sensitivity
to various antimicrobials [32,33] .
Oral commensal bacteria as a reservoir of transferable
resistance genes

There are many reports of individual bacterial isolates from the

oral cavity becoming resistant to one or more antibiotics, for
example, b-lactamases in Gram-negative respiratory and oral bacteria (reviewed in [34]), but these do not give us a comprehensive
view of the resistance genes and any cognate mobile genetic elements (Box2) within this environment as a whole. Here we review
the studies that have investigated the entire resistant cultivable
microflora and the metagenome from the oral environment for
resistance to specific antibiotics.
Studies on the cultivable oral flora

A study on children who had not received antibiotics in the preceding 3 months demonstrated that 15 out of 18 subjects had tetra
cycline-resistant bacteria in their oral cavity. The children were
highly unlikely to have come into direct contact with tetracycline
as it is not prescribed for children owing to undesirable side effects,
such as the discolouration of the teeth and nails [35] . The most
common gene identified in this cohort was tet(M), which encodes
a ribosomal protection protein, contained on Tn916/Tn1545-like
conjugative transposons in Streptococcus, Granulicatella, Veillonella
1443

Review

Roberts & Mullany

Box2. Mobile genetic elements responsible for the interbacterial transfer of resistance genes.
Plasmids usually exist as independently replicating units; however, on some occasions they will integrate into the bacterial chromosome.
They are grouped into incompatibility (Inc) groups based on their inability to coexist in the same cell. Plasmids from the same Inc group
usually have identical or similar replication/partition systems. Only one plasmid from one Inc group can stably exist in a cell at one time, if
another plasmid enters the cell belonging to the same Inc group, one plasmid will eventually be lost during cell division owing to mutual
interference of the replication process by the other plasmid, leading to an unequal amount of the two plasmids in the dividing cell.
Plasmids are found in both Gram-positive and Gram-negative organisms isolated from the oral cavity.
Conjugative transposons, also known as Integrative Conjugative Elements, are mobile elements that integrate into their hosts genome.
They encode all of the necessary information for intracellular transposition and intercellular conjugation. Some conjugative transposons
have a very broad host range. They are commonly found in Gram-positive and Gram-negative bacteria. The Tn916-like elements are very
common in oral bacteria. Conjugative transposons can carry accessory genes, which often encode antibiotic resistance.

and Neisseria isolates [36] . Tn916 is a paradigm of a large family

(the Tn916/Tn1545 family) of related promiscuous conjugative
transposons (Box2) that have been found in or have been introduced into over 30different genera of bacteria [37] , including
many commonly found in the oral cavity. In another study it was
found that 46 out of 47 children harbored tetracycline-resistant
bacteria, and that 56% of these were resistant to an additional
drug, usually erythromycin. Again the most common tetracycline resistance gene was tet(M), predominantly within the streptococci [38] . In a further study on the cultivable oral microflora of
children it was shown that in addition to tetracycline, resistance
to ampicillin, erythromycin and penicillin is also present [39] .
All of the antibiotic-resistant bacteria were identified to at least
genus level with the streptococci being the most resistant genus
isolated (Table1) . This study also demonstrated that resistance to
at least two different antibiotics was present in 111 (27.8%) of
the 432antibiotic-resistant organisms isolated from the 35subjects [39] . Studies on the oral flora of healthy adults, who had not
received antibiotics for the previous 3 months also demonstrated
the presence of many different tetracycline resistance genes [40] ,
the most common being tet(M) followed by tet(W), another
gene encoding a ribosomal protection protein originally discovered in the rumen anaerobic species Butyrivibriofibrisolvens
[41] . An endodontic study examining tetracycline-resistant root
canal isolates demonstrated that tet(M) was the most common
detectable gene and that it was also present on the Tn916-like
conjugative transposons. One Neisseriasp. isolate was capable of
transferring this mobile element to Enterococcusfaecalis itself
an endodontic pathogen [42] .
Macrolide-resistant bacteria have also been characterized from
the oral cavity [39,43,44] . Recently, however, the total cultivable
flora was assayed for resistance to erythromycin and the mef
and ermB genes were the most common. On average, 7% of the
cultivable microflora were resistant to erythromycin and carried
at least one erythromycin resistance gene [45] . The ermB genes in
many oral isolates are present on Tn916/Tn1545-like conjugative
transposons, which also contain tet(M) and aphA-3 conferring
tetracycline and kanamycin resistance, respectively [45] . Similar
results were found in other studies investigating the molecular
basis of resistance to macrolides in commensal viridansstreptococci and Gemellaspp.[4648] . These studies also demonstrated
that the majority of strains with an identifiable erythromycin
resistance gene contained the mef gene. Recently the mef gene
1444

has been found on a novel conjugative transposon Tn1207.3 in

Streptococcus pyogenes [49] . Also the results from these studies
show that ermB was again linked to Tn916/Tn1545-like conjugative transposons [48] . The observation that both mef and ermB
are contained within conjugative transposons that usually also
contain genes encoding tetracycline resistance proteins may go
some way to explain their broad distribution.
Metagenomic studies of the oral flora

Metagenomics is a powerful experimental approach that

bypasses the need to culture any of the inhabitants of a particular environment. Instead, the entire DNA from a particular
niche, in this case the oral cavity, is isolated and analyzed. One
such study, looking at various tetracycline and erythromycin
resistance genes present in the oral and fecal communities from
individuals from six different European countries showed that
tet(M) predominated in the oral environment [50] , agreeing
with cultivable studies described above. Conversely, for the
erythromycin resistance genes no particular gene was predominant in all locations. There was, however, a diverse range of
resistance genes detected for both antibiotics [50] . This study
also contained probes specific for the recombinase genes from
various common conjugative and mobilizable transposons. The
recombinase proteins are responsible for the excision and insertion of their cognate mobile elements [51] . Without exception
the probe for the Tn916 integrase gene hybridized strongly
to all oral samples screened. In five out of six samples the
hybridization to the Tn916 integrase probe was in excess of
that to tet(M) suggesting there is more Tn916 intTn present
than tet(M); this could be due to some Tn916-like elements in
the oral flora not containing tet(M) as an accessory gene [50] .
Functional studies aimed at isolating resistance genes from
the human microflora have also been carried out using a phenotypic screen of metagenomic libraries. DNA from the oral
and fecal cavity was cloned into a vector to make the metagenomic library. This was used to transform Escherichia coli and
transformants selected for on the basis of resistance to one
of 13 antimicrobials [52] . The insert DNA from the resistant
clones were sequenced and this showed that the majority of the
resistance genes found were new. The authors estimate that,
based on the uniqueness (in the sequenced clones) of many of
the novel antibiotic resistance genes, the full sequencing of the
library would reveal hundreds more novel resistance genes from
Expert Rev. Anti Infect. Ther. 8(12), (2010)

Oral biofilms: a reservoir of transferable, bacterial, antimicrobial resistance

Table 1. Number of isolates of different genera

resistant to antibiotics isolated from children.
Bacterial genus

AmpR

ErmR

PenR

TcR

Actinobacillus spp.

Bacillus sp.

Bacteroides sp.

Capnocytophaga spp.

Eubacterium sp.

Fusobacterium spp.

Granulicatella sp.

Haemophilus spp.

37

Leptotrichia sp.

Moraxella sp.

Neisseria spp.

14

14

10

Patsurella sp.

Porphyromonas spp.

Prevotella spp.

Stomatococcus sp.

Streptococcus spp.

41

36

37

38

Veillonella spp.

43

82

-: Genera not included in antibioitc resistance guidelines; AmpR: Ampicillin

resistance; ErmR: Erythromycin resistance; PenR: Penicillin resistance;
TcR:Tetracycline resistance.
Taken with permission from [36].

these environments. The sequence of the inserts from this study

also showed the presence of many transposase genes, indicating that some of the resistance genes were likely to be present
on mobile genetic elements [52] . Other previous metagenomic
studies have also revealed novel antibiotic resistance genes by
phenotypic screening of metagenomic libraries including the
tetracycline resistance gene tet(37), the product of which enzymatically breaks down tetracycline [53] and tet(32) encoding for
a ribosomal protection protein [54] .
Evidence for horizontal gene transfer of antibiotic
resistance in the oral cavity

For the oral microbiota to act as a reservoir for transferable antibiotic resistance the resistance genes must either be contained on
mobile genetic elements or be capable of being transferred into a
new host by transformation. Whole-genome sequencing and the
analysis of individual genes can determine the likelihood of particular genes being acquired by horizontal transfer as genes that
are more than 95% identical at the nucleotide level in diverse bacteria, for example, tet(M), are highly likely to have been acquired
in this way. There are many complete genome sequences [103,104]
with many more nearing completion which reveal the presence
of antibiotic resistance genes within putative mobile genetic elements (reviewed in [55]). However, functionality of the majority
of putative mobile elements discovered during genome sequencing
projects remains to be experimentally determined.
www.expert-reviews.com

Review

Evidence for transformation in the oral cavity

Successful transformation of a bacterial cell depends on physicochemical factors of the DNA molecules, such as their size, conformation and concentration of the transforming DNA and other
environmental factors, including UV light, salt, pH, temperature
and the presence of extracellular nucleases. In addition, there are
genetic hurdles to overcome for successful transformation, such
as the presence of restriction systems and the ability of the incoming DNA to either replicate autonomously or integrate into the
recipients genome [56] .
Transformation has no requirement for live donor cells as the
DNA released upon cell death is the principle source of transforming DNA (Figure1) . In addition, some bacteria can actively release
DNA into their environment [57] . Therefore, the rate-limiting steps
for transformation of bacteria growing in an oral biofilm is the longevity of DNA molecules in both the biofilm and the cytoplasm of
the transformed cell. Researchers have investigated the persistence
of Lactococcuslactis chromosomal and plasmid DNA (pVACMC1
and pIL253) in human saliva, and although partially degraded, the
DNA was still visible on an agarose gel after 3.5min incubation.
Furthermore demonstration of the presence of a 520-bp fragment
of the pVACMC1 DNA was demonstrated by PCR after 24h
of incubation in human saliva [58] . pVACMC1 could transform
Streptococcusgordonii DL1 after being incubated in saliva but with
a tenfold decrease in transformation efficiency after being incubated in saliva for 2min compared with untreated DNA [58] . Later
experiments demonstrated the transformation of S.gordonii by
pVACMC1 in the oral cavity of a human volunteer[59] . Another
study using the plasmid pUC18 demonstrated that it could transform E.coli to ampicillin resistance following 24h incubation in
clarified ovine saliva [60] . These studies show that DNA is able
to survive in saliva for a long enough period of time to be able to
transform competent bacteria.
A recent development in the study of biofilm biology is the observation that extracellular DNA is present within many of the biofilm
matrices investigated and is actually required for the formation of
some biofilms [61,62] . A more recent invitro study has demonstrated
that the genomic DNA of a Veillonelladispar strain carrying the conjugative transposon Tn916 was able to transform Streptococcusmitis
to tetracycline resistance within an oral biofilm grown in a fermentor [63] . It has also been demonstrated that some of the bacterial
DNA that can be isolated from human saliva is from bacteria not
normally considered to be members of the oral microflora, such as
Phytoplasmasp. [50] , which is normally associated with plants. This
observation demonstrates the presence of DNA from exogenous
sources in the oral cavity. Virtually any DNA that is found free in the
oral cavity, whether it is derived from oral bacteria or bacteria present on foodstuffs, is able to be a substrate for transformation. The
successful acquisition of resistance genes from the transient microflora may be a mechanism that enables the normal flora to build
up its reservoir. In addition, this reservoir of genes will be available
in the form of free DNA from dead biofilm residents to transient,
competent bacteria passing through the oral cavity. Therefore, it is
possible that broad host range gene transfer within, out of and into
oral biofilm inhabitants can occur by transformation.
1445

Review

Roberts & Mullany

Expert Rev. Anti Infect. Ther. Future Science Group (2010)

Figure1. Transfer of DNA between bacterial cells. The bacterial cells are

represented by the green and purple ovals. The DNA is represented by the helix.
Transposons and plasmids are either blue bars or circles. The arrows show the
direction of transfer of the DNA. (A) Transformation: the donor cell (top left) has
lysed and the DNA released into the environment. This can be taken up by
competent bacteria and incorporated into the recipient genome. (B) Conjugation
of plasmids through a pilus. (C) Conjugation of conjugative transposons
via a mating pore. (D)Transduction mediated by the injection of DNA by
abacteriophage.

Transduction in the oral cavity

One of the main barriers to the activity of bacteriophage in oral

biofilms is the access to the cells within the EPS substances
secreted by the biofilm residents themselves [64] .
Little is known about the effect of phage and the extent to
which transduction contributes to genetic exchange within oral
biofilms, however, there are some studies that indicate transduction may by occurring within the oral cavity. In one study,
three distinct bacteriophages were isolated from enriched human
saliva, however, none of the bacteriophage could infect any of
the oral pathogens tested but did infect Proteusmirabilis, also
isolated from the saliva. The P.mirabilis cells were thought to
have been transient in the samples tested, either introduced on
food materials or transported manually to the mouth [65] . In
a study investigating endodontic Enterococcusfaecalis isolates,
lysogeny was demonstrated and bacteriophage were isolated in
four of the ten strains [66] . In another study, bacteriophage specific for E.faecalis were isolated from the saliva of seven out
of 31 volunteers [67] . If bacteriophage-mediated cell lysis of the
P.mirabilis or the E.faecalis occurred within the oral cavity,
this DNA released would be available for transforming other
naturally competent bacteria.
1446

Additional evidence for the involvement of bacteriophage in the transfer of

DNA among residents of oral biofilms
comes from studies carried out in vitro.
For example, tetracycline resistance present on Tn916 and chloramphenicol resistance present on plasmid pKT210 has been
transferred between A.actinomycetemcomitans by the generalized transducing phage
Aa23 [68] . Additional evidence that
A. actinomycetemcomitans bacteriophage
may be transducing DNA between bacteria in the oral environment comes from
the direct isolation of bacteriophage particles from subgingival plaque from periodontitis patients [68,69] . In a recent study
investigating the differential gene expression of Treponemadenticola, a pathogenic
oral spirochaete, growing either as part of a
biofilm or planktonically, researchers demonstrated the upregulation of various prophage genes and transposases in the biofilm samples [70] . In addition, functional
bacteriophage were isolated from this
bacterium and the authors hypothesized
that there is a larger potential for genetic
mobility when T.denticola is growing as
part of a biofilm [70] .
Conjugation in the oral cavity

Conjugative plasmids and conjugative

transposons (particularly of the Tn916-like
family) have been found in many different oral bacteria. Some of these mobile elements are transferable
invitro [55] . Both conjugative transposons and conjugative plasmids have been transferred from oral donor bacteria to recipients
of different species and genera [45,71,72] . To determine if transfer
can occur in more complex environments that mimic the oral
cavity, fermentor studies that allow growth of oral biofilms from
an inoculum of saliva or a defined consortia of known and characterized oral species have been carried out. The constant depth
film fermentor (CDFF) has been used to demonstrate that transient bacteria may be able to act as a donor to oral bacteria in
the short time that they are present in the oral cavity. Tn5397 (a
conjugative transposon carrying tet[M]) in a B.subtilis donor can
transfer to a streptococcal recipient growing as part of an artificial
oral biofilm in the CDFF [73] . The B.subtilis donor could not be
recovered from the biofilms 24h after inoculation, showing that
even though the donor bacteria are no longer present, the genetic
information contained within them can persist. Further work has
demonstrated transfer of native Tn916-like elements between oral
streptococci grown in the CDFF [74] . However, DNase was not
included in the growth medium fed into the fermentor during
these experiments and therefore it is not possible to distinguish
between transformation and conjugation.
Expert Rev. Anti Infect. Ther. 8(12), (2010)

Oral biofilms: a reservoir of transferable, bacterial, antimicrobial resistance

Tn916-like conjugative transposons have been shown to be

common in tetracycline-resistant Veillonellaspp. and some of
these were transferable within a mixed species consortia consisting
of 21tetracycline-sensitive members [75] .
Invivo transfer of a Tn916-like conjugative transposon, Tn6002,
has been reported. The element was hypothesized to have been
transferred from Streptococcusoralis to Streptococcuscristatus during systemic doxycycline treatment for periodontitis [76] . Another
study has shown that the conjugative plasmid pAM81 was capable
of transfer between Streptococcusgordonii and E.faecalis in the
root canals of human teeth exvivo [77] . The transfer of plasmids
is often stimulated by pheromones, molecules that are produced
by the bacteria which are intercellular signaling molecules. Often,
when there is enough of the molecule present (such as in a biofilm
where there is a high cell density), a signaling cascade will result in
the transfer of plasmid or chromosomal elements [78] . Horizontal
transfer of DNA, stimulated by intercellular signaling molecules,
is one of many consequences of interbacterial communication,
which also includes development of the biofilms themselves [14,15] .
These results are highly indicative that gene transfer is occurring
within the oral community, possible by all three mechanisms of
horizontal gene transfer. In addition researchers and clinicians
alike must remember that the individual mechanisms of horizontal
gene transfer are not mutually exclusive and it is likely that the
same region of DNA could be transferred by more than one mechanism. The transfer of resistance to, from and within a human
reservoir highlights the need for rigorous control of antibiotic use.
Expert commentary & five-year view

While there is an increasing wealth of evidence supporting the idea

that oral bacteria are a reservoir of antibiotic resistance genes, how
extensive this is will only be determined when complete oral meta
genomes have been sequenced. The ultimate proof of transferability,
however, requires that gene transfer experiments are performed.

Review

Acquired antibiotic resistance can persist in the environment even in the absence of selective pressure (antibiotics)[79] .
Presumably this is due to low fitness costs associated with acquisition of mobile elements carrying resistance genes. This has
been demonstrated for both plasmids and transposons. A more
thorough understanding of these metabolic burdens and the
way host cells evolve to cope with the acquisition of foreign
DNA is likely to be facilitated with the improved and increasingly cheap molecular techniques currently on, or coming to,
the market.
Recently various transcriptional and translational regulatory
systems have been described for a variety of different mobile
genetic elements that contain antibiotic resistance genes and a
common theme emerging from the studies is that these elements
are able to control their transcription and only express genes when
they sense certain, as yet ill-defined, environmental cues that can
promote their transfer. The continued research in this area will
allow an understanding of what triggers their transfer and give
insights into how to control, or stop it occurring.
Financial & competing interests disclosure

The authors have received financial support from the Commission of the
European Communities, specifically the Infectious Diseases research domain
of the Health theme of the 7th Framework Programme, contract 241446,
The effects of antibiotic administration on the emergence and persistence
of antibiotic-resistant bacteria in humans and on the composition of the
indigenous microbiotas at various body sites. The authors have no other
relevant affiliations or financial involvement with any organization or
entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment,
consultancies, honoraria, stock ownership or options, expert testimony,
grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this
manuscript.

Key issues
The oral microflora is extremely diverse and many inhabitants live within oral biofilms.
The normal oral flora contains many different antibiotic resistance genes.
Many of these antibiotic resistance genes are located on mobile genetic elements.
The biofilm environment is ideal for horizontal gene transfer.
Treatment with antibiotics selects for resistant strains and can also promote the mobility of mobile elements conferring this resistance.
Gene transfer in many different biofilm environments and of many different mobile genetic elements has been demonstrated.
The normal commensal oral flora acts as a reservoir of transferable antibiotic resistance genes, which are available to transientinhabitants.
Moreover, it is possible that these transient inhabitants act as donors of resistance genes to the normal oral flora.
HandelsmanJ. Call of the wild: antibiotic
resistance genes in natural environments.
Nat. Rev. Microbiol. 8, 251259 (2010).

References
Papers of special note have been highlighted as:
of interest
of considerable interest
1

So AD, Gupta N, Cars O. Tackling

antibiotic resistance. Br. Med. J. 340,
10911092 (2010).

Allen HK, Donato J, Wang HH,

Cloud-Hansen KA, Davies J,

www.expert-reviews.com

Aas JA, Paster BJ, Stokes LN, Olsen I,

Dewhirst FE. Defining the normal
bacterial flora of the oral cavity. J.Clin.
Microbiol. 43, 57215732 (2005).

Preza D, Olsen I, Willumsen T, Grinde B,

Paster BJ. Diversity and site-specificity of

the oral microflora in the elderly. Eur.

J.Clin. Microbiol. Infect. Dis. 28,
10331040 (2009).
5

Parisotto TM, Steiner-Oliveira C, DuqueC,

Peres RC, Rodrigues LK, Nobre-dos-Santos
M. Relationship among microbiological
composition and presence of dental plaque,
sugar exposure, social factors and different
stages of early childhood caries. Arch. Oral
Biol. 55, 365373 (2010).

1447

Review

Roberts & Mullany

Signoretto C, Bianchi F, Burlacchini G,

Sivieri F, Spratt D, Canepari P. Drinking
habits are associated with changes in the
dental plaque microbial community.
J.Clin. Microbiol. 48, 347356 (2010).

20

Lockhart PB, Brennan MT, Thornhill M

etal. Poor oral hygiene as a risk factor for
infective endocarditis-related bacteremia.
J.Am. Dent. Assoc. 140, 12381244
(2009).

32

Yamanaka T, Furukawa T, MatsumotoMashino C etal. Gene expression profile

and pathogenicity of biofilm-forming
Prevotella intermidia strain 17. BMC
Microbiol. 16, 11 (2009).

Zaura E, Keijser BJ, Huse SM, CrielaardW.

Defining the healthy core microbiome of
oral microbial communities. BMC
Microbiol. 9, 259 (2009).

21

33

Nasidze I, Li J, Quinque D, Tang K,

Stoneking M. Global diversity in the
human salivary microbiome. Genome Res.
19, 636643 (2009).

Seymour GJ, Ford PJ, Cullinan MP,

Leishman S, Yamazaki K. Relationship
between periodontal infections and
systemic disease. Clin. Microbiol. Infect.
13(Suppl. 4), 310 (2007).

Chang YM, Jeng WY, Ko Tp etal.

Structural study of TcaR and its complexes
with multiple antibiotics from Staphylococcus
epidermidis. Proc. Natl Acad. Sci. USA 107,
86178612 (2010).

22

Kinane D, Bouchard P; Group E of

European Workshop on Periodontology.
Periodontal Diseases and Health:
Consensus Report of the Sixth European
Workshop on Periodontology. J.Clin.
Periodontol. 35(Suppl. 8), 333337 (2008).

34

Roberts MC. Antibiotic resistance in oral/

respiratory bacteria. Crit. Rev. Oral Biol.
Med. 9, 522540 (1998).

35

Akcam M, Artan R, Akcam FZ, Yilmaz A.

Nail discoloration induced by doxycycline.
Pediatr. Infect. Dis. J. 24, 845846 (2005).

36

Lancaster H, Bedi R, Wilson M, MullanyP.

The maintenance in the oral cavity of
children of tetracycline-resistant bacteria
and the genes encoding such resistance.
J.Antimicrob. Chemother. 56, 524531
(2005).

Bik EM, Long CD, Armitage GC etal.

Bacterial diversity in the oral cavity of 10
healthy individuals. ISME J. 4, 962974
(2010).

10

Pihlstrom BL, Michalowicz BS,

JohnsonNW. Periodontal diseases. Lancet
366, 18091820 (2005).

11

Hannig M. Ultrastructural investigation of

pellicle morphogenesis at two different
intraoral sites during a 24-h period. Clin.
Oral Investig. 3, 8895 (1999).

12

13

14

Hannig C, Hannig M, Attin T. Enzymes in

the acquired enamel pellicle. Eur. J.Oral
Sci. 113, 213 (2005).
Siqueira WL, Margolis HC,
HelmerhorstEJ, Mendes FM, Oppenheim
FG. Evidence of intact histatins in the
invivo acquired enamel pellicle. J.Dent.
Res. 89, 626630 (2010).
Kolenbrander PE, Palmer RJ Jr,
PeriasamyS, Jakubovics NS. Oral
multispecies biofilm development and the
key role of cellcell distance. Nat. Rev.
Microbiol. 8, 471480 (2010).

Good review of the developmental

properties of oral biofilms.

15

Kolenbrander PE, Andersen RN,

BlehertDS, Egland PG, Foster JS, Palmer
RJ Jr. Communication among oral bacteria.
Microbiol. Mol. Biol. Rev. 66, 486505
(2002).

16

Stephens C. Microbiology: breaking down

biofilms. Curr. Biol. 12, R132R134
(2002).

17

Socransky SS, Haffajee AD. Dental

biofilms: difficult therapeutic targets.
Periodontol. 2000 28, 1255 (2002).

18

Walker CB, Karpinia K, Baehni P.

Chemotherapeutics: antibiotics and other
antimicrobials. Periodontol. 2000 36,
14665 (2004).

19

Lucas VS, Gafan G, Dewhurst S,

RobertsGJ. Prevalence, intensity and nature
of bacteraemia after toothbrushing. J.Dent.
36, 481487 (2008).

1448

23

Simpson TC, Needleman I, Wild SH,

Moles DR, Mills EJ. Treatment of
periodontal disease for glycaemic control in
people with diabetes. Cochrane Database
Syst. Rev. 5, CD004714 (2010).

24

Desvarieux M, Demmer RT, Jacobs DR Jr

etal. Periodontal bacteria and hypertension:
the oral infections and vascular disease
epidemiology study (INVEST).
J.Hypertens. 28, 14131421 (2010).

25

Busscher HJ, Rinastiti M,

SiswomihardjoW, van der Mei HC.
Biofilm formation on dental restorative and
implant materials. J.Dent. Res. 89, 657665
(2010).

Children who had not received tetracycline

harbored considerable amounts of
tetracycline-resistant bacteria.
37

Roberts AP, Mullany P. A modular master

on the move: the Tn916 family of mobile
genetic elements. Trends Microbiol. 17,
251258 (2009).

38

Lancaster H, Ready D, Mullany P, SprattD,

Bedi R, Wilson M. Prevalence and
identification of tetracycline-resistant oral
bacteria in children not receiving antibiotic
therapy. FEMS Microbiol. Lett. 228, 99104
(2003).

39

Ready D, Bedi R, Spratt DA, Mullany P,

Wilson M. Prevalence, proportions, and
identities of antibiotic-resistant bacteria in
the oral microflora of healthy children.
Microb. Drug Resist. 9, 367372 (2003).

40

Villedieu A, Diaz-Torres ML, Hunt N etal.

Prevalence of tetracycline resistance genes in
oral bacteria. Antimicrob. Agents Chemother.
47, 878882 (2003).

41

Scott KP, Barbosa TM, Forbes KJ, FlintHJ.

High-frequency transfer of a naturally
occurring chromosomal tetracycline
resistance element in the ruminal anaerobe
Butyrivibrio fibrisolvens. Appl. Environ.
Microbiol. 63, 34053411 (1997).

26

Marsh PD. Plaque as a biofilm:

pharmacological principles of drug delivery
and action in the sub- and supragingival
environment. Oral Dis. 9(Suppl. 1), 1622
(2003).

27

Sweeney LC, Dave J, Chambers PA,

Heritage J. Antibiotic resistance in general
dental practice a cause for concern?
J.Antimicrob. Chemother. 53, 567576
(2004).

28

Slots J. Selection of antimicrobial agents in

periodontal therapy. J.Periodontal Res. 37,
389398 (2002).

29

van Winkelhoff AJ, Winkel EG.

Antibiotics in periodontics: right or
wrong? J.Periodontol. 80, 15551558
(2009).

Interesting discussion on the use of

antibiotics in periodontics.

30

Herrera D, Alonso B, Len R, Roldn S,

Sanz M. Antimicrobial therapy in
periodontitis: the use of systemic
antimicrobials against the subgingival
biofilm. J.Clin. Periodontol. 35(Suppl. 8),
4566 (2008).

42

Rossi-Fedele G, Scott W, Spratt D,

Gulabivala K, Roberts AP. Incidence and
behaviour of Tn916-like elements within
tetracycline-resistant bacteria isolated from
root canals. Oral Microbiol. Immunol. 21,
218222 (2006).

31

Mah T-FC, OToole GA. Mechanisms of

biofilm resistance to antimicrobial agents.
Trends Microbiol. 9, 3439 (2001).

43

Sefton AM. Macrolides and changes in the

oral flora. Int. J.Antimicrob. Agents
11(Suppl.1), S23S29 (1999).

Expert Rev. Anti Infect. Ther. 8(12), (2010)

Oral biofilms: a reservoir of transferable, bacterial, antimicrobial resistance

44

45

46

47

48

49

50

Ioannidou S, Tassios PT, KotsoviliTseleniA, Foustoukou M, Legakis NJ,

Vatopoulos A. Antibiotic resistance rates
and macrolide resistance phenotypes of
viridans group streptococci from the
oropharynx of healthy Greek children. Int.
J.Antimicrob. Agents 17, 195201 (2001).
Villedieu A, Diaz-Torres ML, Roberts AP
etal. Genetic basis of erythromycin
resistance in oral bacteria. Antimicrob.
Agents Chemother. 48, 22982301 (2004).
Luna VA, Coates P, Eady EA, Cove JH,
Nguyen TT, Roberts MC. A variety of
Gram-positive bacteria carry mobile mef
genes. J. Antimicrob. Chemother. 44, 1925
(1999).
Aracil B, Miambres M, Oteo J, Torres C,
Gmez-Garcs JL, Als JI. High prevalence
of erythromycin-resistant and clindamycinsusceptible (M phenotype) viridans group
streptococci from pharyngeal samples: a
reservoir of mef genes in commensal
bacteria. J.Antimicrob. Chemother. 48,
592594 (2001).
Cerd Zolezzi P, Laplana LM, Calvo CR,
Cepero PG, Erazo MC, Gmez-Lus R.
Molecular basis of resistance to macrolides
and other antibiotics in commensal
viridans group streptococci and Gemella
spp. and transfer of resistance genes to
Streptococcus pneumoniae. Antimicrob.
Agents Chemother. 48, 34623467 (2004).
Santagati M, Iannelli F, Cascone C etal.
The novel conjugative transposon
Tn1207.3 carries the macrolide efflux gene
mef(A) in Streptococcus pyogenes. Microb.
Drug Resist. 9, 243247 (2003).
Seville LA, Patterson AJ, Scott KP etal.
Distribution of tetracycline and
erythromycin resistance genes among
human oral and fecal metagenomic DNA.
Microb. Drug Resist. 15, 159166 (2009).

55

Roberts AP, Mullany P. Genetic basis of

horizontal gene transfer among oral bacteria.
Periodontol. 2000 42, 3646 (2006).

56

Ogunseitan OA. Bacterial genetic exchange

in nature. Sci. Prog. 78, 183204 (1995).

57

Johnsborg O, Eldholm V, Hvarstein LS.

Natural genetic transformation: prevalence,
mechanisms and function. Res. Microbiol.
158, 767778 (2007).

58

Mercer DK, Scott KP, Bruce-Johnson WA,

Glover LA, Flint HJ. Fate of free DNA and
transformation of the oral bacterium
Streptococcus gordonii DL1 by plasmid
DNA in human saliva. Appl. Environ.
Microbiol. 65, 610 (1999).

59

60

Mercer DK, Scott KP, Melville CM,

GloverLA, Flint HJ. Transformation of an
oral bacterium via chromosomal integration
of free DNA in the presence of human
saliva. FEMS Microbiol. Lett. 200, 163167
(2001).
Duggan PS, Chambers PA, Heritage J,
Forbes JM. Survival of free DNA encoding
antibiotic resistance from transgenic maize
and the transformation activity of DNA in
ovine saliva, ovine rumen fluid and silage
effluent. FEMS Microbiol. Lett. 191, 7177
(2000).

61

Whitchurch CB, Tolker-Nielsen T,

RagasPC, Mattick JS. Extracellular DNA
required for bacterial biofilm formation.
Science 295, 1487 (2002).

Identifies the importance of DNA in

biofilm architecture.

62

Harmsen M, Lappann M, Knchel S,

Molin S. Role of extracellular DNA during
biofilm formation by Listeria monocytogenes.
Appl. Environ. Microbiol. 76, 22712279
(2010).

Review

68

Willi K, Sandmeier H, Kulik EM, Meyer J.

Transduction of antibiotic resistance
markers among Actinobacillus
actinomycetemcomitans strains by temperate
bacteriophages Aa phi 23. Cell Mol. Life
Sci. 53, 904910 (1997).

69

Sandmeier H, van Winkelhoff AJ, Br K,

Ankli E, Maeder M, Meyer J. Temperate
bacteriophages are common among
Actinobacillus actinomycetemcomitans
isolates from periodontal pockets.
J.Periodontal Res. 30, 418425 (1995).

70

Mitchell HL, Dashper SG, Catmull DV

etal. Treponema denticola biofilm-induced
expression of a bacteriophage, toxinantitoxin systems and transposases.
Microbiology 156, 774788 (2010).

Highlights transcriptional differences

between planktonic and biofilm growing
Treponema denticola cells. Bacteriophage
and transposase genes were found to be
upregulated in biofilm growth.

71

Lancaster H, Roberts AP, Bedi R, Wilson

M, Mullany P. Characterization of Tn916S,
a Tn916-like element containing the
tetracycline resistance determinant tet(S).
J.Bacteriol. 186, 43954398 (2004).

72

Roe DE, Braham PH, Weinberg A,

RobertsMC. Characterization of
tetracycline resistance in Actinobacillus
actinomycetemcomitans. Oral Microbiol.
Immunol. 10, 227232 (1995).

73

Roberts AP, Pratten J, Wilson M, MullanyP.

Transfer of a conjugative transposon, Tn5397
in a model oral biofilm. FEMS Microbiol.
Lett. 177, 6366 (1999).

Represents the first report of gene transfer

in invitro grown oral biofilms of
conjugative transposons.

63

74

Mullany P, Roberts AP, Wang H,

Mechanism of integration and excision in
conjugative transposons. Cell Mol. Life Sci.
59, 20172022 (2002).

Hannan S, Ready D, Jasni AS, Rogers M,

Pratten J, Roberts AP. Transfer of antibiotic
resistance by transformation with eDNA
within oral biofilms. FEMS Immunol. Med.
Microbiol. 59, 345934 (2010).

Roberts AP, Cheah G, Ready D, Pratten J,

Wilson M, Mullany P. Transfer of Tn916like elements in microcosm dental plaques.
Antimicrob. Agents Chemother. 45,
29432946 (2001).

64

75

52

Sommer MO, Dantas G, Church GM.

Functional characterization of the
antibiotic resistance reservoir in the human
microflora. Science 325, 128131 (2009).

Sutherland IW. The biofilm matrix-an

immobilized but dynamic microbial
environment. Trends Microbiol. 9, 222227
(2001).

65

53

Diaz-Torres ML, McNab R, Spratt DA.

Novel tetracycline resistance determinant
from the oral metagenome. Antimicrob.
Agents Chemother. 47, 14301432 (2003).

Hitch G, Pratten J, Taylor PW. Isolation of

bacteriophages from the oral cavity. Lett.
Appl. Microbiol. 39, 215219 (2004).

Ready D, Pratten J, Roberts AP, Bedi R,

Mullany P, Wilson M. Potential role of
Veillonella spp. as a reservoir of transferable
tetracycline resistance in the oral cavity.
Antimicrob. Agents Chemother. 50,
28662868 (2006).

76

66

Stevens RH, Porras OD, Delisle AL.

Bacteriophages induced from lysogenic root
canal isolates of Enterococcus faecalis. Oral
Microbiol. Immunol. 24, 278284 (2009).

Warburton PJ, Palmer RM, Munson MA,

Wade WG. Demonstration of invivo transfer
of doxycycline resistance mediated by a novel
transposon. J.Antimicrob. Chemother. 60,
973980 (2007).

67

Bachrach G, Leizerovici-Zigmond M,
Zlotkin A, Naor R, Steinberg D.
Bacteriophage isolation from human saliva.
Lett. Appl. Microbiol. 36, 5053 (2003).

51

54

Warburton P, Roberts AP, Allan E,

SevilleL, Lancaster H, Mullany P.
Characterization of tet(32) genes from the
oral metagenome. Antimicrob. Agents
Chemother. 53, 273276 (2009).

www.expert-reviews.com

First report of antibiotic resistance gene

transfer, mediated by a conjugative
transposon among bacteria in a human
following antibiotic therapy.

1449

Review
77

78

Roberts & Mullany

Sedgley CM, Lee EH, Martin MJ,

Flannagan SE. Antibiotic resistance gene
transfer between Streptococcus gordonii and
Enterococcus faecalis in root canals of teeth
exvivo. J.Endod. 34, 570574 (2008).

79

Manson JM, Hancock LE, Gilmore MS.

Mechanism of chromosomal transfer of
Enterococcus faecalis pathogenicity island,
capsule, antimicrobial resistance, and other
traits. Proc. Natl Acad. Sci USA 107,
1226912274 (2010).

1450

Pallecchi L, Bartoloni A, Paradisi F,

Rossolini GM. Antibiotic resistance in the
absence of antimicrobial use: mechanisms
and implications. Expert Rev. Anti Infect.
Ther. 6, 725732 (2008).
Comprehensive overview of antibiotic
resistance in communities where antibiotics
are not often encountered.

Websites
101

European Medicines Agency

www.ema.europa.eu/pdfs/human/
antimicrobial_resistance/EMEA-576176
2009.pdf

102

Infectious Disease Society of America

www.idsociety.org/10x20.htm

103

NCBI, Genomic BLAST

www.ncbi.nlm.nih.gov/sutils/genom_table.
cgi

104

Human Oral Microbiome Database

www.homd.org

Expert Rev. Anti Infect. Ther. 8(12), (2010)