The in vitro activities of 10 families of antimicrobial agents alone and in combination with a synthetic polycationic polymer, polyethylenimine (PEI), against a resistant clinical isolate of Pseudomonas aeruginosa were investigated by MIC assays, checkerboard testing, and killing curve studies. At a concentration of 250 nM, PEI (10 kDa) was not directly bactericidal or bacteriostatic; but when it was used in combination with novobiocin, ceftazidime, ampicillin, ticarcillin, carbenicillin, piperacillin, cefotaxime, chloramphenicol, rifampin, or norfloxacin, it significantly reduced the MICs of these antibiotics by 1.5-to 56-fold. However, the MICs of aminoglycosides, polymyxins, and vancomycins were increased by 1.2-to 5-fold when these drugs were combined with PEI; and the MICs of tetracycline, erythromycin, ciprofloxacin, and ofloxacin were not affected when these drugs were combined with PEI. In the killing curve studies, combinations of PEI with novobiocin, ceftazidime, chloramphenicol, or rifampin resulted in 5-to 8-log 10 CFU/ml reductions in bacterial counts when 25% of the MIC of each antibiotic was used. These results indicate that infections due to resistant Pseudomonas strains could be treated by the use of a synergistic combination of PEI and antimicrobial drugs.Over the past two decades, Pseudomonas aeruginosa has attracted attention as an opportunistic pathogen in hospitalized, immunocompromised, and cystic fibrosis patients (6,15,20). Despite aggressive antibiotic therapy, P. aeruginosa is rarely eradicated owing to its high level of intrinsic resistance to many drugs (14,19,27). This resistance is due to the effective permeability of the outer membrane (OM) of gram-negative bacteria to both hydrophobic antibiotics and high-molecular-weight hydrophilic drugs (for reviews, see references 4, 25, 28, and 30). Unlike most cell types, gram-negative bacteria surround themselves with a double membrane. The outermost of these two membranes is asymmetric, with the inner leaflet composed of glycerophospholipids and the outer leaflet predominantly composed of lipopolysaccharide (LPS). Tight interactions between the highly negatively charged LPS molecules are believed to form an effective barrier against hydrophobic compounds. For these polyanionic molecules to form a stable "tiled roof" on the surface of the OM, adjacent LPS molecules are linked electrostatically by divalent cations (Ca 2ϩ , Mg 2ϩ ) present in the OM. Polyethylenimine (PEI) is a weakly basic, aliphatic, nontoxic synthetic polymer which is polycationic owing to the presence of primary, secondary, and tertiary amino groups. It is well known that certain polycationic agents such as polymyxin and its derivatives polylysines and protamine can increase the permeability of the gram-negative bacterial OM to solutes that are normally unable to penetrate (25). Helander et al. found that, when it was applied alone, PEI has a strong permeabilizing effect but no bactericidal effect on gram-negative bacteria (8). Escherichia coli, P. aeruginosa, and Salmon...