The biology of cytomegalovirus drug resistance

Abstract

Purpose of review: This review assesses recently published data on cytomegalovirus (CMV) antiviral drug resistance.

Recent findings: Resistance is typically encountered after prolonged ganciclovir treatment for posttransplant primary CMV infection and is diagnosed by the detection of characteristic mutations in the viral UL97 kinase and UL54 DNA polymerase genes in clinical specimens. One of seven canonical UL97 mutations is detected in most cases of ganciclovir resistance, but many viral sequence variants of unknown relevance are being reported after drug exposure in vitro and in vivo. Rapid technical advances in recombinant phenotyping have shown that many of these variants confer no detectable drug resistance, whereas some unusual resistance mutations are newly confirmed. All currently marketed CMV antiviral drugs, including foscarnet and cidofovir, target the viral DNA polymerase, and cross-resistance may result from some UL54 mutations. To decrease cross-resistance and toxicity, there is an ongoing effort to develop anti-CMV drugs with different resistance pathways and alternative targets, such as the UL97 kinase or UL56-UL89 terminase enzymes.

Summary: An increasing volume of information correlating CMV genotypes and drug susceptibility phenotypes is becoming available. This will improve the interpretation of sequence-based assays currently used for clinical diagnosis and guide the development of new antiviral drugs.

Figure 1

Map of the CMVUL54 DNA polymerase gene showing conserved functional domains, ranges of codons containing drug resistance mutations, and the locations of drug resistance mutations and non-resistant sequence variants newly described since the recent review [3]. Phenotype details are in Tables 1 and 2. ▲ denotes the D301N and A987G mutations which confer dual GCV/CDV resistance. ● denotes the 981–982 deletion and Q578H mutations which confer triple GCV/CDV/FOS resistance.