Minimum Inhibitory Concentrations Of Amikacin Research Articles

Nontuberculous mycobacterial ocular infections--comparing the clinical and microbiological characteristics between Mycobacterium abscessus and Mycobacterium massiliense.

PurposeTo analyze the clinical characteristics of nontuberculous mycobacterial (NTM) ocular infections and the species-specific in vitro antimicrobial susceptibility.Material and MethodsIn 2000 to 2011 at the National Taiwan University Hospital, multilocus sequencing of rpoB, hsp65 and secA was used to identify NTM isolates from ocular infections. The clinical presentation and treatment outcomes were retrospectively compared between species. Broth microdilution method was used to determine the minimum inhibitory concentrations of amikacin (AMK), clarithromycin (CLA), ciprofloxacin (CPF), levofloxacin (LVF), moxifloxacin (MXF) and gatifloxacin (GAF) against all strains. The activities of antimicrobial combinations were assessed by the checkerboard titration method.ResultsA total of 24 NTM strains (13 Mycobacterium abscessus and 11 Mycobacterium massiliense) were isolated from 13 keratitis, 10 buckle infections, and 1 canaliculitis cases. Clinically, manifestations and outcomes caused by these two species were similar and surgical intervention was necessary for medically unresponsive NTM infection. Microbiologically, 100% of M. abscessus and 90.9% of M. massiliense ocular isolates were susceptible to amikacin but all were resistant to fluoroquinolones. Inducible clarithromycin resistance existed in 69.3% of M. abscessus but not in M. massiliense isolates. None of the AMK-CLA, AMK-MXF, AMK-GAF, CLA-MXF and CLA-GAF combinations showed synergistic or antagonistic effect against both species in vitro.Conclusions M. abscessus and M. massiliense are the most commonly identified species for NTM ocular infections in Taiwan. Both species were resistant to fluoroquinolones, susceptible to amikacin, and differ in clarithromycin resistance. Combined antimicrobial treatments showed no interaction in vitro but could be considered in combination with surgical interventions for eradication of this devastating ocular infection.

Rapidly growing mycobacteria in Singapore, 2006–2011

Nontuberculous mycobacteria infection is a growing global concern, but data from Asia are limited. This study aimed to describe the distribution and antibiotic susceptibility profiles of rapidly growing mycobacterium (RGM) isolates in Singapore. Clinical RGM isolates with antibiotic susceptibility tests performed between 2006 and 2011 were identified using microbiology laboratory databases and minimum inhibitory concentrations of amikacin, cefoxitin, clarithromycin, ciprofloxacin, doxycycline, imipenem, linezolid, moxifloxacin, sulfamethoxazole or trimethoprim-sulfamethoxazole, tigecycline and tobramycin were recorded. Regression analysis was performed to detect changes in antibiotic susceptibility patterns over time. A total of 427 isolates were included. Of these, 277 (65%) were from respiratory specimens, 42 (10%) were related to skin and soft tissue infections and 36 (8%) were recovered from blood specimens. The two most common species identified were Mycobacterium abscessus (73%) and Mycobacterium fortuitum group (22%), with amikacin and clarithromycin being most active against the former, and quinolones and trimethoprim-sulfamethoxazole against the latter. Decreases in susceptibility of M. abscessus to linezolid by 8.8% per year (p 0.001), M. fortuitum group to imipenem by 9.5% per year (p 0.023) and clarithromycin by 4.7% per year (p 0.033) were observed. M. abscessus in respiratory specimens is the most common RGM identified in Singapore. Antibiotic options for treatment of RGM infections are increasingly limited.

Directed Evolution of Aminoglycoside Phosphotransferase (3′) Type IIIa Variants That Inactivate Amikacin but Impose Significant Fitness Costs

The rules that govern adaptive protein evolution remain incompletely understood. Aminoglycoside aminotransferase (3′) type IIIa (hereafter abbreviated APH(3′)-IIIa) is a good model enzyme because it inactivates kanamycin efficiently; it recognizes other aminoglycoside antibiotics, including amikacin, but not nearly as well. Here we direct the evolution of APH(3′)-IIIa variants with increased activity against amikacin. After four rounds of random mutation and selection in Escherichia coli, the minimum inhibitory concentration of amikacin rose from 18 micrograms/mL (wild-type enzyme) to over 1200 micrograms/mL (clone 4.1). The artificially evolved 4.1 APH(3′)-IIIa variant exhibited 19-fold greater catalytic efficiency (k cat/K M) than did the wild-type enzyme in reactions with amikacin. E. coli expressing the evolved 4.1 APH(3′)-IIIa also exhibited a four-fold decrease in fitness (as measured by counting colony forming units in liquid cultures with the same optical density) compared with isogenic cells expressing the wild-type protein under non-selective conditions. We speculate that these fitness costs, in combination with the prevalence of other amikacin-modifying enzymes, hinder the evolution of APH(3′)-IIIa in clinical settings.

Evaluation in vitro of the efficacy of colistin methanesulfonate against biofilm-forming multidrug-resistant Pseudomonas aeruginosa (MDRP)

The aim of this study was to evaluate in vitro the efficacy of clinically using colistin methanesulfonate against biofilm-forming multidrug-resistant Pseudomonas aeruginosa (MDRP), with minimum inhibitory concentrations (MICs) of ciprofloxacin, imipenem, and amikacin showing ≥4, 16, and 32μg/ml, respectively, by disk diffusion susceptibility testing (CLSI document M100-S21). The minimum eradication biofilm concentration (MBEC) of colistin methanesulfonate for strain MDRP-YMD isolated from a patient's urine, which formed a biofilm on plastic pegs attached to a microplate lid, was compared with that of P. aeruginosa ATCC27853 for quality control testing with MICs of ciprofloxacin, imipenem, and amikacin showing ≤1, 4, and 16μg/ml, respectively. In an uneven biofilm approximately 10μm thick, as determined with confocal laser scanning microscopy (CLSM), ratios of MBEC to MIC of colistin methanesulfonate against strains MDRP-YMD and ATCC27853 were 10.5 and 8.0, whereas those of minimum bactericidal concentration (MBC) to MIC in planktonic cells were 1.0 and 2.0μg/ml, respectively. Morphological examination using scanning electron microscopy and CLSM verified that embedded cells in biofilm matrices of the two strains were disrupted and died under the MBEC. Therefore, bactericidal effects of colistin methanesulfonate on biofilm-forming cells of strain MDRP-YMD as well as strain ATCC27853 were significantly decreased compared with those on the planktonic cells.

Ethidium bromide transport across Mycobacterium smegmatiscell-wall: correlation with antibiotic resistance

BackgroundActive efflux systems and reduced cell-wall permeability are considered to be the main causes of mycobacterial intrinsic resistance to many antimicrobials. In this study, we have compared the Mycobacterium smegmatis wild-type strain mc2155 with knockout mutants for porins MspA (the main porin of M. smegmatis) and MspC, the efflux pump LfrA (the main efflux pump system of M. smegmatis) and its repressor LfrR for their ability to transport ethidium bromide (EtBr) on a real-time basis. This information was then correlated with minimum inhibitory concentrations (MICs) of several antibiotics in the presence or absence of the efflux inhibitors chlorpromazine, thioridazine and verapamil.ResultsIn the absence of porins MspA and MspC, accumulation of ethidium bromide decreased and the cells became more resistant to several antibiotics, whereas the knockout mutant for the LfrA pump showed increased accumulation of EtBr and increased susceptibility to EtBr, rifampicin, ethambutol and ciprofloxacin. Moreover, the efflux inhibitors caused a reduction of the MICs of streptomycin, rifampicin, amikacin, ciprofloxacin, clarithromycin and erythromycin in most of the strains tested.ConclusionsThe methodology used in this study demonstrated that porin MspA plays an important role in the influx of quaternary ammonium compounds and antibiotics and that efflux via the LfrA pump is involved in low-level resistance to several antimicrobial drugs in M. smegmatis. The results obtained with this non-pathogenic mycobacterium will be used in future studies as a model for the evaluation of the activity of the same efflux inhibitors on the susceptibility of multidrug resistant strains of Mycobacterium tuberculosis to isoniazid and rifampicin.

Stability and antimicrobial effect of amikacin-loaded solid lipid nanoparticles

Solid lipid nanoparticles (SLNs) of amikacin were designed in this study for pulmonary delivery to reduce the dose or its administration intervals leading to reduction of its toxicities especially in long term treatment. Nanoparticles of amikacin were prepared from cholesterol by solvent diffusion technique and homogenization. The size, zeta potential, loading efficiency, and release profile of the nanoparticles were studied. The conventional broth macrodilution tube method was used to determine the minimum inhibitory concentration (MIC) and minimum bacteriostatic concentration (MBC) of amikacin SLNs with respect to Pseudomonas aeruginosa in vitro. To guarantee the stability of desired SLNs, they were lyophilized using cryoprotectants. Results showed that considering the release profile of amikacin from the studied nanocarrier, MIC and MBC of amikacin could be about two times less in SLNs of amikacin compared to the free drug. Therefore, fewer doses of amikacin in SLNs can clear the infection with less adverse effects and more safety. Particle size enlargement after lyophilization of desired SLNs after two months storage was limited in comparison with non-lyophilized particles, 996 and 194 nm, respectively. Zeta potential of lyophilized particles was increased to +17 mV from +4 mV before lyophilization. Storage of particles in higher temperature caused accelerated drug release.

Distribution of 16S rRNA methylases among different species of Gram-negative bacilli with high-level resistance to aminoglycosides

16S rRNA methylases confer high-level resistance to most aminoglycosides in Gram-negative bacteria. Seven 16S rRNA methylase genes, armA, rmtA, rmtB, rmtC, rmtD, rmtE and npmA, have been identified since 2003. We studied the distribution of methylase genes in more than 200 aminoglycoside-resistant Gram-negative clinical isolates collected in 2007 at our hospital in Shanghai, China. 16S rRNA methylase genes were amplified by polymerase chain reaction (PCR) among 217 consecutive clinical isolates of Gram-negative bacilli resistant to gentamicin and amikacin by a disk diffusion method. 16S rRNA methylase genes were present in 97.5% (193/198) of clinical isolates highly resistant to amikacin (≥512μg/ml), with armA and rmtB detected in 67.2 and 30.3% of strains, respectively, while no 16S rRNA methylase genes were detected in 19 strains with amikacin minimum inhibitory concentration (MIC) ≤256μg/ml. armA or rmtB genes were detected in 100% of 104 strains of Enterobacteriaceae, and these two genes were equally represented (49 vs. 55 strains). Genes for armA or rmtB were detected in 94.7% (89/94) of Acinetobacter baumannii and Pseudomonas aeruginosa strains, and armA was predominant (84 vs. 5 strains with rmtB). No rmtA, rmtC, rmtD or npmA genes were found. Enterobacterial repetitive intergenic consensus sequence (ERIC-PCR) indicated that armA and rmtB genes were spread by both horizontal transfer and clonal dissemination.

Minimum Inhibitory Concentration and Postantibiotic Effect of Amikacin for Equine Isolates of Methicillin‐Resistant Staphylococcus aureus In Vitro

To report the minimum inhibitory concentration (MIC) of amikacin sulfate for equine clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA) and characterize the initial kill and duration of the postantibiotic effect (PAE) for selected strains. Experimental study. Isolates of MRSA (n=35) had their amikacin MIC determined using the E-test agar diffusion method. Two isolates with MICs>256 microg/mL limit were further characterized using broth macrodilution. Six distinct isolates with amikacin MICs of 32, 48, 128 (2 isolates) and 500 (2 isolates) microg/mL had PAE determinations made over a range of amikacin concentrations from 31.25-1000 microg/mL using standard culture-based techniques. Median MIC of the 35 isolates was 32 microg/mL (range 2 to >256 microg/mL). Mean PAE of selected MRSA strains had an overall mean (all amikacin doses) of 3.43 hours (range 0.10-9.57 hours). PAE for MRSA exposed to amikacin at 1000 microg/mL was 6.18 hours (range 3.30-9.57 hours), significantly longer than that for all other concentrations (P<.0001). There was no statistically significant effect of isolate MIC on PAE. Isolates had a wide range of MIC; however, growth of all 6 selected strains were inhibited within the range of concentrations tested, including 2 strains with MICs of 500 microg/mL. PAE duration was not influenced by the MIC of amikacin but was significantly longer with treatment at 1000 microg/mL than at lower concentrations. Clinical isolates of MRSA are susceptible to amikacin at concentrations achieved by regional perfusion: however, the modest duration of PAE observed suggest that further laboratory and in vivo evaluation be conducted before recommending the technique for clinical use.

Pharmacokinetics and lung delivery of PDDS-aerosolized amikacin (NKTR-061) in intubated and mechanically ventilated patients with nosocomial pneumonia

IntroductionAminoglycosides aerosolization might achieve better diffusion into the alveolar compartment than intravenous use. The objective of this multicenter study was to evaluate aerosol-delivered amikacin penetration into the alveolar epithelial lining fluid (ELF) using a new vibrating mesh nebulizer (Pulmonary Drug Delivery System (PDDS), Nektar Therapeutics), which delivers high doses to the lungs.MethodsNebulized amikacin (400 mg bid) was delivered to the lungs of 28 mechanically ventilated patients with Gram-negative VAP for 7-14 days, adjunctive to intravenous therapy. On treatment day 3, 30 minutes after completing aerosol delivery, all the patients underwent bronchoalveolar lavage in the infection-involved area and the ELF amikacin concentration was determined. The same day, urine and serum amikacin concentrations were determined at different time points.ResultsMedian (range) ELF amikacin and maximum serum amikacin concentrations were 976.1 (135.7-16127.6) and 0.9 (0.62-1.73) μg/mL, respectively. The median total amount of amikacin excreted in urine during the first and second 12-hour collection on day 3 were 19 (12.21-28) and 21.2 (14.1-29.98) μg, respectively. During the study period, daily through amikacin measurements were below the level of nephrotoxicity. Sixty-four unexpected adverse events were reported, among which 2 were deemed possibly due to nebulized amikacin: one episode of worsening renal failure, and one episode of bronchospasm.ConclusionsPDDS delivery of aerosolized amikacin achieved very high aminoglycoside concentrations in ELF from radiography-controlled infection-involved zones, while maintaining safe serum amikacin concentrations. The ELF concentrations always exceeded the amikacin minimum inhibitory concentrations for Gram-negative microorganisms usually responsible for these pneumonias. The clinical impact of amikacin delivery with this system remains to be determined.Trial RegistrationClinicalTrials.gov Identifier: NCT01021436.

Extensively Drug‐ResistantMycobacterium tuberculosisduring a Trend of Decreasing Drug Resistance from 2000 through 2006 at a Medical Center in Taiwan

Drug resistance rates are one of the most important aspects in the national tuberculosis (TB) control program, and drug-resistant TB, especially extensively drug-resistant (XDR) TB, is not well understood in Taiwan. The objectives of this study were to investigate the prevalence of drug resistance from 2000 through 2006 and to identify XDR TB isolates to elucidate the clinical characteristics of patients with XDR TB at National Taiwan University Hospital. The prevalence of drug resistance among clinical, nonduplicate Mycobacterium tuberculosis isolates was analyzed. Testing of susceptibility to antituberculosis agents, including isoniazid, rifampicin, ethambutol, streptomycin, rifabutin, ofloxacin, ethinamide, and para-aminosalicylic acid, was performed using the proportional method. Minimum inhibitory concentrations of amikacin, capreomycin, isepamycin, linezolid, cycloserine, ciprofloxacin, levofloxacin, moxifloxacin, and gemifloxacin were determined for 40 available multidrug-resistant M. tuberculosis isolates. Significant decreasing trends in rates of resistance to isoniazid, ethambutol, and at least 1 of the 3 first-line agents were observed among 2625 M. tuberculosis isolates from 2000 through 2006. Among these 2625 isolates, 150 (5.7%) were multidrug resistant, and 10 M. tuberculosis isolates (0.4%) fulfilled the definition of XDR M. tuberculosis. Nine (90%) of 10 patients with XDR TB had a previous history of TB and received anti-TB treatment before acquisition of XDR TB. The remaining high prevalence of multidrug-resistant TB and the presence of XDR TB during a trend of decreasing drug resistance are alarming. Continuous surveillance of clinical isolates of M. tuberculosis is needed to identify XDR TB, especially in patients who have a history of TB and have received prior anti-TB treatment.

48* Nebulized SLIT™ Amikacin in the treatment of cystic fibrosis patients with chronic Pseudomonas aeruginosa lung infection in Serbia and Hungary

SLITTM Amikacin is a sustained-release lipid formulation of amikacin for inhalation, being developed for the treatment of P. aeruginosa (Pa) infections in CF patients. A Phase Ia/IIb clinical study was conducted with a total of 13 patients treated for 14 days with 500mg qd SLIT Amikacin by nebulization. Patients were naive to inhaled antibiotics. Pseudomonas isolates at screening had amikacin minimum inhibitory concentration (MIC) values of 16 ug/mL. The drug was safe and well tolerated with no nephrotoxicity to date. Systemic exposure to SLIT Amikacin was very low. Final data analysis showed clinically relevant improvement in FEV1 and a decreased bacterial density. The absolute change (mean) in FEV-1 liters at days 14 (post last dose), 28 and 42 (28 day follow-up) were 0.26, 0.24 and 0.31. There appeared to be a trend for decreased CFUs that correlated with improvements in FEV-1. The results demonstrate once a day treatment with nebulized SLIT Amikacin is safe and elicits a clinically relevant effect on pulmonary function and Pa density of CF patients.

Effect of oregano essential oil on chicken lactobacilli andE. coli

The effect of the oregano essential oil (EO) on lactobacilli and E. coli isolated from chicken was showed in the series of in vitro and in vivo experiments. Minimum inhibitory concentrations of amikacin, apramycin, streptomycin, neomycin against E. coli strains increased after oral application of EO.

In vitro effect of chlorhexidine and amikacin on oral gram-negative bacilli from bone marrow transplant recipients

Prophylactic use of chlorhexidine (CHX) mouthrinses has been shown to benefit the oral health status of bone marrow transplant recipients and other immunosuppressed persons and to reduce systemic complications of oral origin. However, a problem that often emerges with these patients is oropharyngeal and lower respiratory tract colonization by opportunistic aerobic or facultative gram-negative bacilli (GNB). Trends in four studies indicated that CHX rinses may predispose these persons to oral colonization by GNB such as the enterobacteria, Klebsiella pneumoniae and Enterobacter cloacae. Since GNB are generally susceptible to broad-spectrum aminoglycoside antibiotics such as amikacin, the in vitro sensitivities of K. pneumoniae, E. cloacae, Pseudomonas aeruginosa, and Escherichia coli ATCC reference strains and K. pneumoniae and E. cloacae oral clinical isolates to combinations of CHX and amikacin were determined by means of a disk diffusion sensitivity assay on Mueller-Hinton agar. The amikacin minimum inhibitory concentrations for all GNB tested were much lower (⩽4.69 to ⩽9.37 μg/ml) than those for CHX (⩽18.75 to ⩽300 μg/ml), and combinations of CHX and amikacin gave larger growth inhibition zones than CHX alone. No antibacterial antagonism between CHX and amikacin was found, and their solubilities were compatible. Therefore use of topical amikacin in conjunction with CHX rinses may reduce oral colonization by GNB in severely immunocompromised patient populations.

In vitro activity of ciprofloxacin (Bay o 9867).

The in vitro activities of ciprofloxacin (Bay o 9867) and seven comparative antimicrobial agents against 664 aerobic and facultatively anaerobic bacterial isolates were studied. Minimal inhibitory concentrations (MICs) of ciprofloxacin were less than or equal to 2 micrograms/ml for Enterobacteriaceae, less than or equal to 8 micrograms/ml for nonfermentative gram-negative bacilli, less than or equal to 4 micrograms/ml for gram-positive cocci, less than or equal to 0.03 micrograms/ml for Aeromonas hydrophila and Pasteurella multocida, and less than or equal to 1 microgram/ml for Listeria monocytogenes. MICs for multi-drug-resistant Enterobacteriaceae and Pseudomonas aeruginosa were less than or equal to 4 micrograms/ml. Ciprofloxacin MICs were consistently 0 to 4 (usually 2 to 3) dilution steps lower than those of a related drug, norfloxacin (P less than 0.0001). For most species, they were lower than MICs of cefotaxime, aztreonam, theinamycin, mezlocillin, trimethoprim-sulfamethoxazole, and amikacin. With all eight drugs, increasing the inoculum size by 100-fold had a variable effect on MICs which was species related. Ciprofloxacin is a potent broad-spectrum new antimicrobial agent.

Emergence in a Burn Center of Populations of Bacteria Resistant to Gentamicin, Tobramycin, and Amikacin: Evidence for the Need for Changes in Zone Diameter Interpretative Standards

From July 1974 through June 1976, a number of isolates of Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa from the Burn Center exhibited a shift to smaller zone diameters with gentamicin than did isolates from the general hospital population. Although many had zone diameters >/=13 mm and would have been considered susceptible by this breakpoint, they were found to have minimal inhibitory concentrations (MICs) of >/=8 mug of gentamicin per ml by agar dilution testing. Zone diameters and MICs of gentamicin, tobramycin, and amikacin were subsequently compared for 168 isolates from both the Burn Center and general hospital. The results revealed many isolates that fell into presently used gentamicin- and tobramycin-"susceptible" categories by disk diffusion tests but were resistant by MIC. The data indicated that criteria for gentamicin disk diffusion testing should include an intermediate or indeterminate category, and that the limits of the intermediate category for tobramycin and amikacin should be expanded.

Amikacin in the treatment of gram-negative pneumonia

A clinical efficacy study of amikacin in the treatment of 15 adults with nonbacteremic, gram-negative bacillary pneumonia is presented. All patients had serious underlying illnesses (11 organic heart disease, five chronic obstructive pulmonary disease, one cancer); 11 had undergone major surgical procedures. All had required respiratory assistance during their hospitalization and all had recently received other antibiotics. Thirteen of 15 patients showed clinical improvement with amikacin therapy; the pathogen was also eradicated in 10 of the 13. The mean minimum inhibitory concentration of amikacin for the 17 isolated pathogens was 3.13 μg/ml. The mean peak serum concentration of amikacin was 17.7 μg/ml. No evidence of ototoxiclty or nephrotoxicity was seen. Seventy-three case reports submitted to the manufacturer by multiple investigators of patients with gram-negative pneumonia, treated with amikacin, are also reviewed. All isolated pathogens were sensitive to both amikacin and gentamicin. Fifty-four (74 per cent) of these patients showed improvement with amikacin therapy.

Chemically Defined Antimicrobial Susceptibility Test Medium for Pseudomonas aeruginosa

A chemically defined growth medium containing physiological concentrations of magnesium and calcium ions was utilized in a microdilution procedure for antimicrobial drug susceptibility testing of Pseudomonas aeruginosa. Determinations of growth end points were simplified by use of sodium citrate as a sole carbon source and bromothymol blue as a pH indicator. Growth of the test organisms was detectable by a change in the indicator color from green to blue after alkalinization of the medium due to citrate utilization. Minimal inhibitory concentrations of amikacin, carbenicillin, gentamicin, and tobramycin were determined on 100 recent clinical isolates of Pseudomonas. Parallel determinations using the microdilution procedure and a conventional tube-broth dilution technique incorporating Mueller-Hinton broth with identical magnesium and calcium content generally agreed within one twofold dilution. Modal minimal inhibitory concentrations for susceptible strains using the microdilution method were: amikacin, 6 mug/ml; carbenicillin, 50 mug/ml; gentamicin, 1.5 mug/ml; tobramycin, 1.5 mug/ml. This modified microdilution technique allowed rapid, definitive minimal inhibitory concentration determinations, using growth end points defined by a color indicator change.

In vitro susceptibility of clinically important bacteria to amikacin: correlation of results of broth dilution and disk sensitivity tests and effect of medium composition.

Minimal inhibitory concentrations of amikacin for 296 strains of gram-positive and gram-negative bacteria determined in Mueller-Hinton broth by the method recommended by the International Collaborative Study Group confirmed previous observations that amikacin is effective against current clinical isolates sensitive to gentamicin and that strains moderatly sensitive or resistant to gentamicin are often inhibited by clinically achievable concentrations. A simple linear regression analysis was used for comparison of zone sizes obtained with 10-mug disks of amikacin with minimal inhibitory concentrations obtained by the tube dilution technique. For 152 strains, including seven species of Enterobacteriaceae, the correleation coefficient (r) was -0.79 on Oxoid diagnostic senstivity test agar (which yields zone sizes similar to those obtained on Mueller-Hinton medium) and -0.78 on Oxoid isotonic sensitest agar (which contains cations in isotonic concentrations); the figures were -0.74 and -0.66, respectively, for 80 strains of Pseudomonas aeruginosa. Zone sizes for enteric gram-negative bacilli were on the average 2-3 mm smaller on isotonic sensitest agar than on diagnostic sensitivity test agar, and about 6 mm smaller for strains of P. aeruginosa and Providencia. Minimal inhibitory concentrations of amikacin can be estimated satisfactorily by extrapolation of results of agar diffusion tests, but the composition of the medium, particularly its calcium and magnesium content, should be defined precisely.