cPseudomonas aeruginosa is an opportunistic pathogen that causes considerable morbidity and mortality, specifically during intensive care. Antibiotic-resistant variants of this organism are more difficult to treat and cause substantial extra costs compared to susceptible strains. In the laboratory, P. aeruginosa rapidly developed resistance to five medically relevant antibiotics upon exposure to stepwise increasing concentrations. At several time points during the acquisition of resistance, samples were taken for whole-genome sequencing. The increase in the MIC of ciprofloxacin was linked to specific mutations in gyrA, parC, and gyrB, appearing sequentially. In the case of tobramycin, mutations in fusA, HP02880, rplB, and capD were induced. The MICs of the beta-lactam compounds meropenem and ceftazidime and the combination of piperacillin and tazobactam correlated linearly with beta-lactamase activity but not always with individual mutations. The genes that were mutated during the development of beta-lactam resistance differed for each antibiotic. A quantitative relationship between the frequency of mutations and the increase in resistance could not be established for any of the antibiotics. When the adapted strains are grown in the absence of the antibiotic, some mutations remained and others were reversed, but this reversal did not necessarily lower the MIC. The increased MIC came at the cost of moderately reduced cellular functions or a somewhat lower growth rate. In all cases except ciprofloxacin, the increase in resistance seems to be the result of complex interactions among several cellular systems rather than individual mutations.T he medical consequences of antibiotic resistance, such as fewer options for and increased costs of treating infectious diseases, are well recognized. The pathway to resistance consists of sequential mutations or acquisition of resistance genes driven by the selective pressure caused by antibiotic exposure (1). Once resistance has been acquired, the cell rarely reverses to become sensitive again, compensating for the metabolic costs instead (2, 3). The increased level of resistance caused by an antibiotic treatment typically prescribed by primary care physicians is very noticeable when subsequent further treatment is necessary (4). Hence, in order to limit the development of resistance when antibiotics have to be used, treatment protocols need to be devised to prevent this side effect. Rational design of such protocols requires knowledge of the molecular mechanisms that cause resistance. One of the central questions is whether similar mechanisms are operational for all drugs or whether resistance to each drug is induced in a distinct manner. Other basic questions center on evolutionary pathways to clinically significant resistance and the persistence of molecular changes after treatment.Molecular changes that cause the development and persistence of drug resistance can be identified by combining experimental evolution and whole-genome sequencing (WGS), provided that the proper c...