The utility of Etest for antimicrobial susceptibility testing of Yersinia pestis was evaluated in comparison with broth microdilution and disk diffusion for eight agents. Four laboratories tested 26 diverse strains and found Etest to be reliable for testing antimicrobial agents used to treat Y. pestis, except for chloramphenicol and trimethoprim-sulfamethoxazole. Disk diffusion testing is not recommended.Yersinia pestis is the etiologic agent of the plague and has potential for use as a biological weapon (1,13,(17)(18)(19)(20)23). Because of this, it is important that emerging drug resistance, whether natural or engineered, should be detectable using standardized methods that are easily implemented in multiple laboratories. The Clinical and Laboratory Standards Institute (CLSI) describes a reference broth microdilution (BMD) method for antimicrobial susceptibility testing of Y. pestis and provides MIC interpretive guidelines for eight antimicrobial agents (6). BMD uses cation-adjusted Mueller-Hinton broth (CAMHB) and requires incubation at 35°C for 24 h with an option for incubation for 48 h when growth at 24 h is insufficient for endpoint interpretation. Unfortunately, reference BMD is difficult to incorporate in many laboratories because it is relatively costly and laborious and requires the storage of panels in a frozen or dehydrated format. Several alternative susceptibility testing methods exist, including the disk diffusion and Etest methods. However, before these methods can be employed for a species, they must be evaluated and compared to BMD to determine correlations between the results obtained by comparisons of the methods.Y. pestis isolates are fastidious and may grow more slowly on artificial media than other common species of Enterobacteriaceae, and so susceptibility testing methods for Y. pestis have been difficult to standardize. Several methods are described in the literature. Disk diffusion testing has generally been performed on Mueller-Hinton agar (MHA), typically using 48 h of incubation at 35°C, but methodological descriptions are sometimes lacking in detail (10,16,24). The Etest method was employed by Wong et al. (25) using MHA with 5% sheep blood, incubation at 35°C, and an inoculum matching a no. 1 McFarland instead of the 0.5 McFarland standard used in most disk or Etest diffusion studies. Agar dilution, using MHA incubated at 27°to 30°C for 48 h, is the most common method reported in the literature (7,8,11,12,22). Broth macrodilution and microdilution methods have also been used with various incubation temperatures (2, 21).There are several attributes of disk diffusion and Etest methods that make them attractive alternative methods for susceptibility testing, including ease of storage and a long shelf life for the disks and strips. Also, these are agar-based methods and the endpoints can be easier to read than those of BMD. The Etest has the added benefit of producing an MIC result. In this report, we present results of a multicenter study comparing Etest and disk diffusion methods wi...