Mechanisms of resistance to quinolones were characterized in Pseudomonas aeruginosa strains isolated after Tn5 insertional mutagenesis and in resistant strains that emerged during pefloxacin therapy of experimental aortic endocarditis. Quinolone resistance achieved in in vitro-selected mutants Qr_1 and Qr-2 was associated with cross-resistance to several groups of antimicrobial agents, including ,-lactams, tetracycline, and chloramphenicol. A significant reduction of norfloxacin uptake was also observed. After ether permeabilization of the cells, DNA synthesis of these two isolates was as susceptible to norfloxacin as DNA synthesis of the parent strain (PAO1). These results indicate that alteration of outer membrane permeability is the primary determinant of resistance in these isolates. This altered cell permeability was correlated with reduction of outer membrane protein G (25.5 kilodaltons) and loss of a 40-kilodalton outer membrane protein in strain Qr_l. Resistance to quinolones that emerged during experimental endocarditis therapy was associated with both modification of outer membrane permeability (decreased uptake of norfloxacin) and decreased susceptibility of DNA synthesis to norfloxacin. Resistance was limited to quinolones and chloramphenicol. For these strains, norfloxacin inhibitory doses (50%) for DNA synthesis were identical to the drug MICs, suggesting that despite the identification of a permeability change, perhaps due to changes of lipopolysaccharide, the alteration of the quinolone intracellular target(s) susceptibility constitutes the primary determinant of resistance. Also, two distinct levels of norfloxacin resistance of DNA synthesis were found in these isolates, indicating that at least two distinct alterations of the drug target(s) are possible in P. aeruginosa.New fluoroquinolones, such as ciprofloxacin and norfloxacin, have potent antimicrobial activity against gram-positive and gram-negative bacteria, including Pseudomonas aeruginosa (48). Biochemical and genetic evidence has designated the DNA gyrase (subunit A) as the intracellular target of these drugs. Bacterial DNA gyrase is a tetramer of two of each of the subunits, A and B, encoded by the gyrA and gyrB genes, respectively. DNA gyrase catalyzes DNA supercoiling, which serves important functions in DNA replication, recombination, and repair (12). Inhibition of DNA gyrase activities by quinolones leads to inhibition of DNA synthesis, but the mechanisms by which quinolones induce cell death and the exact molecular interactions existing between quinolones, DNA gyrase, and DNA are not clear (24).Mutational resistance to fluoroquinolones in gram-negative bacteria such as Escherichia coli and P. aeruginosa has been associated with modification of the intracellular target of the drug (DNA gyrase) or alteration of outer membrane permeability (21,25,42,48).In E. coli, mutations that affect both gyrase subunits, leading to various levels of resistance to fluoroquinolones and nalidixic acid, have been described (24), while in P. aeruginos...