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In a recent commentary, Paterson and Doi 1 addressed the need for universal definitions for the various degrees of antimicrobial resistance among gramnegative bacilli. In light of the recent evidence suggesting that polymyxins, a “rediscovered” category of antimicrobial agents 2 , and tigecycline, a new drug 3 , constitute valuable additions to the clinician’s armamentarium against highly resistant gram-negative bacteria, these authors proposed the term “extreme drug resistance” (XDR) to signify resistance of pathogens that are gram negative to all potentially effective antibiotics. They also narrowed the meaning of the already-used term “panresistance” to refer to pathogens that are specifically resistant to 7 antimicrobial agents (cefepime, ceftazidime, imipenem, meropenem, piperacillin-tazobactam, ciprofloxacin, and levofloxacin). Although we welcome the authors’ endeavor to suggest terms related to bacterial drug resistance, we would like to express our reservations regarding the proposed definitions and our consideration that the attribution of improper meaning to the aforementioned terms may increase the relevant confusion observed in the medical literature 4 , with potentially important implications for researchers, health care professionals, or even the public. The prefix “pan-” has its origin in the ancient Greek language, meaning “all” or “whole.” With this meaning, it is used in common English 5 and other languages. Of importance, it has been used for the generation of numerous combined biomedical terms, to denote the inclusion of all parts or aspects of an entity 6 . In this respect, the term “panresistance” or “pandrug resistance” (PDR) cannot be interpreted in a sense other than signifying resistance to all antibiotics 4,7-8 . In regard to the term “extreme drug resistance,” it was first used in the field of oncology/hematology to designate tumor cell colonies that exhibit significantly decreased responsiveness in vitro to a studied chemotherapeutic agent 9 . In the field of infectious diseases, “XDR” has been used to abbreviate “extensively drug resistant” Mycobacterium tuberculosis,defined by resistance to both rifampin and isoniazid, as well as to fluoroquinolones plus an injectable agent 10 . Presumably, Paterson and Doi 1 introduced the term “extreme drug resistance” for gram-negative bacteria to designate a wider resistance pattern than “extensive drug resistance.” Still, semantically, “extreme” cannot be more inclusive than “pan-,” meaning all. It should also be noted that, in the proposed definitions 1 , a category of highly resistant pathogens, with resistance patterns intermediate to those described in the authors’ commentary by the terms “panresistance” and “extreme drug resistance,” remains unclassified. The inevitable need to characterize these pathogens with either 1 of the 2 or other terms would eventually generate further confusion. In fact, apart from the term pandrug resistance, notable diversity has been observed as well in the medical literature regarding the use of the term “multidrug resistance” (MDR), which has rather arbitrarily been used to denote resistance of gram-negative pathogens to a varying number of antimicrobial agents 4,11 .

Pandrug Resistance (PDR), Extensive Drug Resistance (XDR), and Multidrug Resistance (MDR) among Gram-Negative Bacilli