Neuraminidase inhibitors (NAIs) are antivirals designed to target conserved residues at the neuraminidase (NA) enzyme active site in influenza A and B viruses. The conserved residues that interact with NAIs are under selective pressure, but only a few have been linked to resistance. In the A/Wuhan/359/95 (H3N2) recombinant virus background, we characterized seven charged, conserved NA residues (R118, R371, E227, R152, R224, E276, and D151) that directly interact with the NAIs but have not been reported to confer resistance to NAIs. These NA residues were replaced with amino acids that possess side chains having similar properties to maintain their original charge. The NA mutations we introduced significantly decreased NA activity compared to that of the A/Wuhan/359/95 recombinant wild-type and R292K (an NA mutation frequently reported to confer resistance) viruses, which were analyzed for comparison. However, the recombinant viruses differed in replication efficiency when we serially passaged them in vitro; the growth of the R118K and E227D viruses was most impaired. The R224K, E276D, and R371K mutations conferred resistance to both zanamivir and oseltamivir, while the D151E mutation reduced susceptibility to oseltamivir only (ϳ10-fold) and the R152K mutation did not alter susceptibility to either drug. Because the R224K mutation was genetically unstable and the emergence of the R371K mutation in the N2 subtype is statistically unlikely, our results suggest that only the E276D mutation is likely to emerge under selective pressure. The results of our study may help to optimize the design of NAIs.Analysis of the influenza virus neuraminidase (NA) active site revealed residues that are conserved in all NA subtypes (6), including catalytic sites (R118, D151, R152, R224, E276, R292, R371, and Y406) (in N2 numbering) that directly interact with the substrate and framework sites (E119, R156, W178, S179, D/N198, I222, E227, H274, E277, N294, and E425) that support the catalytic residues (3,7,8,16). The design of NA inhibitors (NAIs) was based on the conserved structure of the NA active site (36). NAIs interrupt the virus replication cycle by preventing the release of virus from infected cells and may interfere with the initiation of infection (6, 24).The optimal design of an antimicrobial compound requires an understanding of the molecular mechanisms that confer resistance to that agent. NAIs interact with multiple residues in the NA active site, but NA mutations selected from in vitro or in vivo experiments are limited to several conserved or semiconserved residues: R292K and E119G/A/D/V in N9 and N2 subtypes; H274Y in the N1 subtype; and E119G, D198N, R152K in influenza B virus NA (12,26,27). Influenza virus variants with the N294S mutation in NA were recently isolated after oseltamivir treatment from patients infected with either H3N2 or H5N1 influenza viruses (20,21). In addition, broad screening for the susceptibility of influenza virus to NAIs also identified viruses with natural variations at several conserved or...