Human infections by avian influenza A(H7N9) virus entail substantial morbidity and mortality. Treatment of infected patients with the neuraminidase (NA) inhibitor oseltamivir was associated with emergence of viruses carrying NA substitutions. In the NA inhibition (NI) assay, R292K conferred highly reduced inhibition by oseltamivir, while E119V and I222K each caused reduced inhibition. To facilitate establishment of laboratory correlates of clinically relevant resistance, experiments were conducted in ferrets infected with virus carrying wild-type or variant NA genes recovered from the A/Taiwan/1/2013 isolate. Oseltamivir treatment (5 or 25 mg/kg/dose) was given 4 hours post-infection followed by twice daily treatment for 5 days. Treatment of ferrets infected with wild-type virus resulted in a modest dose-dependent reduction (0.7-1.5 log10TCID50) in nasal wash viral titers and inflammation response. Conversely, treatment failed to significantly inhibit the replication of R292K or E119V viruses. A small reduction of viral titers was detected on day 5 in ferrets infected with the I222K virus. Propensity for oseltamivir resistance emergence was assessed in oseltamivir-treated animals infected with wild-type virus; emergence of R292K virus was detected in 3 of 6 ferrets within 5-7 days post-infection. Collectively, we demonstrate that R292K, E119V and I222K reduced the inhibitory activity of oseltamivir not only in the NI assay, but also in infected ferrets, judged particularly by viral loads in nasal washes, and may signal the need for alternative therapeutics. Thus, these clinical outcomes measured in the ferret model may correlate with clinically relevant oseltamivir resistance in humans.

IMPORTANCE: This report provides more evidence for using the ferret model to assess susceptibility of influenza A(H7N9) viruses to oseltamivir, the most prescribed anti-influenza drug. The information gained can be used to assist in the establishment of laboratory correlates of human disease and drug therapy. The rapid emergence of viruses with R292K in treated ferrets correlates well with the multiple reports on this NA variant in treated human patients. Our findings highlight the importance for discovery and characterization of new antiviral drugs with different mechanism of action and the use of combination treatment strategies against emerging viruses with pandemic potential such as avian H7N9 virus, particularly against those carrying drug resistance markers