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DOI: 10.3201/eid1708.102004
Suggested citation for this article: Eshaghi A, Patel SN, Sarabia A, Higgins RR, Savchenko A, Stojios PJ, et al. Multidrug-resistant pandemic (H1N1) 2009 infection in immunocompetent child. Emerg Infect Dis. 2011 Aug; [Epub ahead of print]

Multidrug-Resistant Pandemic (H1N1) 2009 Infection in Immunocompetent Child

AliReza Eshaghi, Samir N. Patel, Alicia Sarabia, Rachel R. Higgins, Alexei Savchenko, Peter J. Stojios, Yan Li, Nathalie Bastien, David C. Alexander, Donald E. Low, and Jonathan B. Gubbay
Author affiliations: Ontario Agency for Health Protection and Promotion, Toronto, Ontario, Canada (A. Eshaghi, S.N. Patel, R.R. Higgins, D.C. Alexander, D.E. Low, J.B. Gubbay); The Credit Valley Hospital, Mississauga, Ontario, Canada (A. Sarabia); University of Toronto, Toronto (A. Savchenko, P.J. Stojios, D.C. Alexander, D.E. Low, J.B. Gubbay); Public Health Agency of Canada, Winnipeg, Manitoba, Canada (Y. Li, N. Bastien); Mount Sinai Hospital, Toronto (D.E. Low, J.B. Gubbay); and The Hospital for Sick Children, Toronto (J.B. Gubbay)


Recent case reports describe multidrug-resistant influenza A pandemic (H1N1) 2009 virus infection in immunocompromised patients exposed to neuraminidase inhibitors because of an I223R neuraminidase mutation. We report a case of multidrug-resistant pandemic (H1N1) 2009 bearing the I223R mutation in an ambulatory child with no previous exposure to neuraminidase inhibitors.

The neuraminidase inhibitors (NAIs) oseltamivir and zanamivir are antiviral agents approved for treatment of infections caused by pandemic (H1N1) 2009 influenza virus. Since the 2008–09 influenza season, almost all seasonal influenza (H1N1) viruses have been oseltamivir resistant because of an H275Y (histidine to tyrosine NA mutation, N1 NA numbering) mutation. Despite widespread use of oseltamivir during the 2009 pandemic, NAI resistance is rare in pandemic (H1N1) 2009 viruses (1). Zanamivir resistance is also rare in influenza viruses. A Q136K (glutamine to lysine mutation, N2 NA numbering) mutation conferring zanamivir resistance in influenza (H1N1) viruses has been described in an in vitro study but has not been detected in clinical specimens from patients (2). An influenza B strain carrying a R152K (arginine to lysine) mutation and resistant to oseltamivir and zanamivir has been reported (3).


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