Alleviating the burden of tuberculosis (TB) requires an understanding of the genetic basis that determines the emergence of drug-resistant mutants. PA-824 (pretomanid) is a bicyclic nitroimidazole class compound presently undergoing the phase III STAND clinical trial, despite lacking identifiable genetic markers for drug-specific resistant Mycobacterium tuberculosis. In the present study, we aimed to characterize the genetic polymorphisms of spontaneously generated PA-824-resistant mutant strains by surveying drug metabolism genes for potential mutations. Of the 183 independently selected PA-824-resistant M. tuberculosis mutants, 83% harbored a single mutation in one of five nonessential genes associated with either PA-824 prodrug activation (ddn, 29%; fgd1, 7%) or the tangential F 420 biosynthetic pathway (fbiA, 19%; fbiB, 2%; fbiC, 26%). Crystal structure analysis indicated that identified mutations were specifically located within the protein catalytic domain that would hinder the activity of the enzymes required for prodrug activation. This systematic analysis conducted of genotypes resistant to PA-824 may contribute to future efforts in monitoring clinical strain susceptibility with this new drug therapy.T uberculosis (TB) remains a major global health concern, with Ͼ8 million new cases and 1.8 million deaths occurring annually (WHO). This pandemic is exacerbated by the pervasive spread of multidrug-resistant (MDR)-TB that challenges clinicians to fight a disease with a limited arsenal of resources. The bicyclic 4-nitroimidazole chemotype has yielded two promising candidates, delamanid (OPC67683) and pretomanid (PA-824), which actively inhibit both nonreplicating and rapidly growing bacilli under aerobic and anaerobic conditions (1). Both drugs are undergoing clinical evaluation and FDA approval is pending for the treatment of MDR-TB. In 2013, delamanid received conditional marketing authorization by the European Medicines Agency (EMA) for use in adult patients deprived of other treatment options (2). PA-824 is in the phase III STAND clinical trial, and at this stage of the development pipeline, it would be beneficial to monitor the genetic basis of resistant clinical strains as they emerge in the wake of future implementation into a treatment protocol.Bicyclic 4-nitroimidazoles are prodrugs that require metabolic activation by a deazaflavin (cofactor F 420 )-dependent nitroreductase (Ddn) (3). Ddn (Rv3547) converts the prodrugs into three primary metabolites, a des-nitroimidazole and two unstable byproducts (4). Ddn is likely a membrane-bound protein (5) that is involved in a protective mechanism under oxidative stress (6). The major mechanism of action of nitroimidazole in active disease under aerobic conditions is to hinder the formation of mycolic acids, and under anaerobic conditions, the mechanism involves the induction of respiratory poisoning (4, 7). By inhibiting the formation of ketomycolates, a class of mycolic acids, nitroimidazole interferes with Mycobacterium tuberculosis cell wall formation, ...