The population structure (serotypes, pulsed-field gel electrophoresis [PFGE] types, and multilocus sequencing types) of 45 mef-positive Streptococcus pneumoniae isolates [carrying mef alone (n = 17) or with the erm(B) gene n = 28)] were studied. They were selected from among all erythromycin-resistant isolates (n = 244) obtained from a collection of 712 isolates recovered from different Spanish geographic locations in the prevaccination period from 1999 to 2003. The overall rates of resistance (according to the criteria of the CLSI) among the 45 mef-positive isolates were as follows: penicillin G, 82.2%; cefotaxime, 22.2%; clindamycin, 62.2%; and tetracycline, 68.8% [mainly in isolates carrying erm(B) plus mef(E); P < 0.001]. No levofloxacin or telithromycin resistance was found. Macrolide resistance phenotypes (as determined by the disk diffusion approximation test) were 37.7% for macrolide resistance [with all but one due to mef(E)] and 62.2% for constitutive macrolide-lincosamide-streptogramin B resistance [cMLS(B); with all due to mef(E) plus erm(B)]. Serotypes 14 (22.2%), 6B (17.7%), 19A (13.3%), and 19F (11.1%) were predominant. Twenty-five different DNA patterns (PFGE types) were observed. Our mef-positive isolates were grouped (by eBURST analysis) into four clonal complexes (n = 18) and 19 singleton clones (n = 27). With the exception of clone Spain(9V)-3, all clonal complexes (clonal complexes 6B, Spain(6B)-2, and Sweden(15A)-25) and 73.6% of singleton clones carried both the erm(B) and the mef(E) genes. The international multiresistant clones Spain(23F)-1 and Poland(6B)-20 were represented as singleton clones. A high proportion of mef-positive S. pneumoniae isolates presented the erm(B) gene, with all isolates expressing the cMLS(B) phenotype. A polyclonal population structure was demonstrated within our Spanish mef-positive S. pneumoniae isolates, with few clonal complexes overrepresented within this collection.