Due to the greater in vitro activity of ciprofloxacin than that of levofloxacin against Pseudomonas aeruginosa, the likelihood of isolating a clinical strain of quinolone-resistant (QR) P. aeruginosa might be greater after exposure to levofloxacin than ciprofloxacin. We examined the risk of isolating QR P. aeruginosa in association with prior levofloxacin or ciprofloxacin exposure. A case-case-control study was conducted. Two groups of cases, one with nosocomial QR P. aeruginosa infections and one with nosocomial quinolone-susceptible (QS) P. aeruginosa infections, were compared to a control group of hospitalized patients without P. aeruginosa infections. Bivariable and multivariable analyses were used to determine risk factors for isolation of QR P. aeruginosa and QS P. aeruginosa. One hundred seventeen QR P. aeruginosa and 255 QS P. aeruginosa cases were identified, and 739 controls were selected. Exposures to ciprofloxacin were similar among all three groups (8% for controls, 9.4% for QR P. aeruginosa cases, and 7.5% for QS P. aeruginosa cases; P > 0.6). Levofloxacin use was more frequent in the QR P. aeruginosa cases than in the controls (35.9% and 22.1%, respectively; odds ratio [OR] ؍ 2.0; 95% confidence interval [CI] ؍ 1.3 to 3.0) and less frequent in QS P. aeruginosa cases (14.1% of QS P. aeruginosa cases; OR ؍ 0.6; 95% CI ؍ 0.4 to 0.9). In multivariable analysis, levofloxacin, but not ciprofloxacin, was a significant risk factor for isolation of QR P. aeruginosa (OR for levofloxacin ؍ 1.7 [95% CI ؍ 1.0 to 2.9]; OR for ciprofloxacin ؍ 1.2 [95% CI ؍ 0.6 to 2.5]). Levofloxacin was associated with a reduced risk of isolation of QS P. aeruginosa (OR ؍ 0.6; 95% CI ؍ 0.4 to 0.9), whereas ciprofloxacin had no significant effect (OR ؍ 1.0; 95% CI ؍ 0.6 to 1.8). In conclusion, the use of levofloxacin, but not ciprofloxacin, was associated with isolation of QR P. aeruginosa.Pseudomonas aeruginosa continues to be a major pathogen in nosocomial infections, ranking fifth among all organisms isolated and first among organisms causing infections in medical intensive care units (ICUs) in the United States (17, 23). P. aeruginosa causes a wide range of infections, some life threatening, such as bacteremia and pneumonia. In recent years, this organism has become increasingly resistant to various antimicrobial agents (6, 7).Among the fluoroquinolones, ciprofloxacin has been most commonly used for the treatment of infections caused by P. aeruginosa. Levofloxacin, a newer member of the quinolone class, also has activity against P. aeruginosa, albeit usually to a lesser degree, as evidenced by higher MICs than those of ciprofloxacin (5,16,22,24,27). With the widespread use of quinolones both in the hospital and in the community setting, resistance to ciprofloxacin and levofloxacin among P. aeruginosa isolates has emerged and continues to rapidly escalate (3, 4). However, data quantifying the impact of fluoroquinolone use on the risk of isolation of quinolone-resistant (QR) P. aeruginosa are limited and...