Introduction In the laboratory, susceptibility is most often measured using a disk diffusion test.

Antibiotic solutions of particular concentrations are dried onto filter paper disks. The MIC is the lowest concentration of the agent that completely inhibits visible growth as judged by the naked eye, disregarding a single colony or a thin haze within the area of the inoculated spot. A trailing endpoint with a small number of colonies growing on concentrations several dilutions above that which inhibits most organisms should be investigated by subculture and retesting. Such trailing endpoints may indicate contamination, resistant variants, b-lactamase-producing organisms, or, if incubation is prolonged, regrowth of susceptible organisms following deterioration of the agent. With sulfonamides and trimethoprim, endpoints may be seen as a reduction in growth, and a haze of growth may be seen at several dilutions above the actual MIC. The MBC is measured by inoculating the broths used for MIC determinations onto drug-free medium. The MBC is the first dilution at which no growth is observed. Cidal drugs have MBC values that are close to the MIC value for particular organisms. With static agents, the MIC is much lower than the MBC. Most antibiotics are given as single agents. There are, however, occasions when two or more drugs are used in combination. Antimicrobial agents may affect each other when used in combination. The effect may simply be additive. In some cases the activity of one drug enhances that of a second drug. This is referred to as synergy. Alternatively, drugs may interfere with each other - antagonism. Penicillins and bacteriostatic drugs such as tetracyclines are antagonistic, since penicillins require actively growing cells and static drugs prevent cell growth. In contrast, aminoglycosides are synergistic when used in combination with penicillins. This is important when considering antimicrobial therapy, for example for endocarditis. In this condition, it is essential that the antimicrobial regime is bactericidal, since the bacteria become walled off inside vegetations. Dilution methods are used to determine the minimum inhibitory concentrations (MICs) of antimicrobial agents and are therefore methods for antimicrobial susceptibility testingagainst which other methods, such as disk diusion, are calibrated.MIC methods are widely used in the comparative testing of new agents. In clinical laboratories they are used to establish the susceptibility of organisms that give equivocalresults in disk tests, for tests on organismswhere disk tests maybe unreliable, and when a more accurate result is required for clinical management. The minimum bactericidal concentration (MBC) is the lowest concentration in ug/mL of a drug that results in more than 99.9% killing of the bacteria being tested. Indications for determination

of bactericidal activity are few, but would include serious infections in immunocompromised patients requiring antibiotic levels lethal to the infecting organism, or infections located in a site that is difficult to reach with antibiotics. Some cases of endocarditis, osteomyelitis, meningitis, and sepsis in neutropenic patients are examples of indications.

Bactericidal antibiotics are generally regarded as superior to bacteriostatic agents for treatment of most infections. However, clinical data in support of this viewpoint are lacking except for relatively few infections, namely endocarditis, meningitis, bacteremia in a neutropenic host, and possibly osteomyelitis. Even for these infections most supporting data are drawn from empirical experience, case series, and results from animal models of infection, rather than from welldesigned comparative clinical trials. Given this strong presumption of the superiority of bactericidal over bacteriostatic agents, a clinical trial to directly test this hypothesis for the treatment infections where bactericidal activity is likely to make a difference would be considered unethical. In addition, bactericidal activity is not an invariable property of an antibiotic; it can depend upon the organism and the growth conditions. Many antibiotics, and especially beta-lactams, require that cells be growing and dividing in order to have a bactericidal action. Slow growth impairs bactericidal activity. Conditions in the host at the site of infection that favor no growth or slow growth of bacteria will negate an antibiotics bactericidal action. Thus, whether a bactericidal or a bacteriostatic effect is achieved can vary depending on not only the antibiotic but also the organism and conditions of growth.