Effective antiviral drugs are essential for early control of an influenza pandemic. It is therefore crucial to evaluate the possible threat posed by neuraminidase (NA) inhibitor-resistant influenza viruses with pandemic potential. Four NA mutations (E119G, H274Y, R292K, and N294S) that have been reported to confer resistance to NA inhibitors were each introduced into recombinant A/Vietnam/1203/04 (VN1203) H5N1 influenza virus. For comparison, the same mutations were introduced into recombinant A/Puerto Rico/8/34 (PR8) H1N1 influenza virus. The E119G and R292K mutations significantly compromised viral growth in vitro, but the H274Y and N294S mutations were stably maintained in VN1203 and PR8 viruses. In both backgrounds, the H274Y and N294S mutations conferred resistance to oseltamivir carboxylate (50% inhibitory concentration [IC 50 ] increases, >250-fold and >20-fold, respectively), and the N294S mutation reduced susceptibility to zanamivir (IC 50 increase, >3.0-fold). Although the H274Y and N294S mutations did not compromise the replication efficiency of VN1203 or PR8 viruses in vitro, these mutations slightly reduced the lethality of PR8 virus in mice. However, the VN1203 virus carrying either the H274Y or N294S mutation exhibited lethality similar to that of the wild-type VN1203 virus. The different enzyme kinetic parameters (V max and K m ) of avian-like VN1203 NA and human-like PR8 NA suggest that resistance-associated NA mutations can cause different levels of functional loss in NA glycoproteins of the same subtype. Our results suggest that NA inhibitor-resistant H5N1 variants may retain the high pathogenicity of the wild-type virus in mammalian species. Patients receiving NA inhibitors for H5N1 influenza virus infection should be closely monitored for the emergence of resistant variants.The highly pathogenic H5N1 influenza viruses have severely affected the poultry industry and posed a serious threat to human health, resulting in Ͼ50% fatality among more than 300 confirmed human cases (49). Although these viruses have yet to acquire efficient transmissibility between humans, their wide geographical dissemination, broad host range, and high pathogenicity raise concern about the severity of a possible pandemic. In the early stage of an influenza pandemic, unless antigenically matched vaccines are available, antivirals offer the best hope of preventing the spread of infection. The two classes of antivirals available for influenza prophylaxis and treatment are the adamantanes (amantadine and rimantadine), which target the M2 ion channel of influenza A virus, and neuraminidase (NA) inhibitors (NAIs) (oseltamivir and zanamivir), which target the NA glycoproteins of influenza A and B viruses.One of the disadvantages of antiviral therapy is the emergence of drug-resistant variants. Fully pathogenic and transmissible adamantane-resistant H1N1 and H3N2 influenza virus variants emerge rapidly posttreatment (15,17). Further, a high percentage of the recently isolated human H3N2 (4) and avian highly pathogenic H5N1 ...