One hundred of non duplicate Streptococcus pneumoniae resistant to erythromycin collected from three teaching hospitals in Tunisia from January 1998 to December 2004 were investigated to evaluate determine their resistance level to different macrolides and the mechanisms involved. Most erythromycin resistant S. pneumoniae were isolated from respiratory tract (34%). Eighty-three percent showed constitutive MLS(B) phenotype with high MICs of macrolides and lincosamides (MIC90 >256 microg/ml), 12% M phenotype with moderately increased MICs of macrolides (MIC90: 12 microg/ml) and low MICs of lincosamides (MIC90=0.75 microg/ml) and 5% inducible MLS(B) with high MICs of macrolides (MIC90 >256 microg/ml) and moderately increased MICs of lincosamides (MIC90=8 microg/ml). All strains were susceptible to quinupristun-dafopristin association and linezolid (MIC90=1 microg/ml). Strains belonging to MLS(B) phenotype were PCR positive for the erm B gene (88%). Twelve percent categorized as M phenotype carried the mef A gene. The rates of associated resistance were 68% to penicillin G, 53% to tetracyclines, 61% to cotrimoxazole, 21% to chloramphenicol and 13% to ciprofloxacin. MLS(B) constitutive phenotype conferring cross resistance to macrolides, lincosamides and streptogramins B with high level of resistance was the most prevalent. Thus, quinupristin-dalfopristin association and linezolid remain the most active molecules.