Mutations in apicoplast rRNA genes are associated with clindamycin resistance and impair the ability of malaria parasites to infect mosquitoes

Drug resistance hampers malaria treatment and control. Resistance to nearly all clinically used antimalarials has emerged and spread globally. With multi-drug-resistant parasites now on the rise, understanding resistance mechanisms, and their ability to spread, is crucial for optimal treatment and control strategies. Clindamycin is an apicoplast-targeting antimalarial used as a partner compound in second-line treatment combinations, but mechanisms of clindamycin resistance remain largely unexplored, and it is unclear whether resistant parasites could spread readily. We selected in vitro for clindamycin resistance in African and Southeast Asian strains of Plasmodium falciparum. All resistant lines carried mutations in the apicoplast-encoded large ribosomal subunit RNA (23S rRNA), reminiscent of clindamycin resistance mechanisms found in bacteria. We recovered three different mutations, all located in the peptidyl transferase region of apicoplast 23S rRNA. Each 23S rRNA mutation was associated with >20-fold resistance, although some mutants grew extremely poorly in vitro and therefore may lack clinical relevance in vivo. We assessed how well our most vigorously growing 23S rRNA mutant could infect Anopheles mosquitoes and found a modest reduction in vector infectivity, indicating that high-level clindamycin resistance is likely to be transmissible in the field. This is in contrast to atovaquone resistance, which exhibits a total block to transmission (and hence spread), and azithromycin resistance, which does not significantly impact P. falciparum development in the mosquito.