antiviral drug resistance pdf
Antimicrobial resistance can be acquired in a short time frame, both by genetic mutation and by direct transfer of resistance genes across genus and species boundaries. Unde Access to antiretroviral drugs for all HIV-infected persons in need is a global health priority; currently, >2 million individuals are receiving antiretroviral therapy (ART), and a rapid scale-up in the number of individuals receiving ART is in progress [1, 2]. Found inside – Page 8Drug Resistance Updates 2011;14:118e24. ... Transatlantic Taskforce on Antimicrobial Resistance. http://www.cdc.gov/drugresistance/pdf/tatfar- report.pdf; ... Ernst E. Antiviral agents from plants and herbs: a systematic review. This is a complete one-pill, once-daily drug regimen. But stocks of Roche's Tamiflu (oseltamivir) and GlaxoSmithKline's Relenza (zanamivir) are too small to protect everyone … Download or read book entitled Antiviral Drug Discovery and Development by author: Xinyong Liu which was release on 19 August 2021 and published by Springer with total page 357 pages . The prevalence of transmitted drug resistance has been stable for the last years with only minor variation. 0000041801 00000 n The basic principles of management of antiviral resistance are to change therapy early once virological breakthrough is observed, select an add-on approach over switching, and choose rescue therapy based on the cross-resistance profile and potency of the rescue drug and presence of comorbid conditions. For example, enfuvirtide (Fuzeon, T20, DP178), a 36-amino acid peptide that inhibits human immunodeficiency virus type 1 (HIV-1) infection by effectively targeting the viral fusion apparatus, has been relegated to a salvage treatment option … While many volumes have been written about various aspects of antimicrobial resistance, this book is a comprehensive reference work. As such this unique volume will be essential to basic researchers in drug discovery and viral pathogenesis, as well as clinicians involved in antiviral chemotherapy. While individual DAAs have a low barrier to resistance, most patients can be successfully treated using DAA combination therapy. Specific requirements apply to some article types, however; find out more about, An increasing number of Taylor & Francis journals allow, , which means that, as long as you use a consistent citation format and include everything necessary for review, you can submit work without needing to worry about formatting your manuscript to meet that journal’s requirements. Presence of drug-resistance mutations may get in the way of the efficacy of antiviral therapy. Human Immunodeficiency Virus Drug Resistance: 2018 Recommendations of the International Antiviral Society-USA Panel. Emerging antiviral resistance. Unlike antibacterial drugs, which may cover a wide range of pathogens, antiviral agents tend to be narrow in spectrum, and have limited efficacy. 0000025140 00000 n 1. The impact of antiviral resistance can be large in hepatitis B since antiviral resistance can negate about 50 % of the efficacy of a major first-line anti-HBV drug. Specific requirements apply to some article types, however; find out more about, An increasing number of Taylor & Francis journals allow, , which means that, as long as you use a consistent citation format and include everything necessary for review, you can submit work without needing to worry about formatting your manuscript to meet that journal’s requirements. Carbapenems. Antiviral drug resistance has long been a problem in modern society. Figure 1. The first signs of drug resistance is an increase in plasma viremia (“a marker of antiviral activity and real-time phenotypic evaluation of viral isolates for the emergence of resistance” [Davey]) above the normal limits. 0000003656 00000 n 0000015487 00000 n Anti Viral. Comparative whole genome sequence analysis of wild-type and cidofovir-resistant monkeypoxvirus. Medical microbiology concerns the nature, distribution and activities of microbes and their impact on health and wellbeing. Emergence of antiviral resistance is a major impediment in the control of the coinfection. ����$�����,���6G/j �9�27L�[&1�!D:�ƍڒB�d�Xtz楆HrK$6m��ڳ�{�p4�`������������ _p��ӣ]#���|yli\�Q�p���d"�� z�(vw�ݨ������%�w���k�p��n�I�2Ԍ�����/���Clsss[�6�b�B�\r����Ej��"U�6p�;au �j��B 0000004350 00000 n The selective inhibitor of influenza cap-dependent endonuclease, baloxavir, which is active against influenza A and B. So far, clinically import- ant resistant virus infections have mainly been encountered in inviunocompromised patients (who may in fact be harbingers of more widespread resistance in the population). The emergence of drug resistance is one of the most prevalent reasons for treatment failure in HIV therapy. The vaccinia virus DNA polymerase and its processivity factor. 0000041779 00000 n Definition of antiviral. (Entry 1 of 2) 1 medical : acting, effective, or directed against viruses an antiviral vaccine/drug. 2 : used to protect a computer from viruses : antivirus antiviral software. 2000;9:863–9. 0000004329 00000 n 0000002782 00000 n ��, Targeted use of vaccine – once it becomes available – and certain antiviral drugs in priority groups and infected patients is supported by available evidence. This new volume of the Emerging Infectious Diseases of the 21st Century series is a collection of chapters by leading world authorities on antimicrobial resistance of common, important bacterial, viral and fungal pathogens. 0000037433 00000 n 0000039575 00000 n Among the antimicrobial agents in use today are antibiotic drugs (which kill bacteria), antiviral agents (which kill viruses), antifungal agents (which kill fungi), and antiparisitic drugs (which kill parasites). Found insideThis is done in the context of recommended global TB strategies and targets endorsed by WHO?s Member States and broader development goals set by the United Nations (UN). Biological Implications of Picornavirus Fidelity Mutants, Cidofovir Resistance in Vaccinia Virus Is Linked to Diminished Virulencein Mice, Mutations in the E9L Polymerase Gene of Cidofovir-Resistant Vaccinia Virus Strain WR Are Associated with the Drug Resistance Phenotype, DNA Polymerase Mutations in Drug-Resistant Herpes Simplex Virus Mutants Determine In Vivo Neurovirulence and Drug-Enzyme Interactions, Isolation and characterization of cidofovir resistant vaccinia viruses, Genetic characterization of the vaccinia virus DNA polymerase: identification of point mutations conferring altered drug sensitivities and reduced fidelity, Vaccinia Virus Inhibitors as a Paradigm for the Chemotherapy of Poxvirus Infections. This list will extend to papillomaviruses, respiratory viruses, enteroviruses, and hepatitis C virus over the next 5-10 years. This is due to its durable antiviral activity, potent efficacy against virus strains with mutations in RT that confer resistance to nucleoside-analogue-based RT … 0000043518 00000 n It is difficult to find medicines that are selective for the virus as viruses share most of the metabolic processes of the host cell. 0000016582 00000 n AIDS 2007; 21:179. In studies with ritonavir, saquinavir, and amprenavir, the extent and spectrum of cross-resistance varied with the specific mutational patterns observed. Virological failure remains frequent despite the arrival of new agents like enfuvirtide and tipranavir, and investigational drugs such as TMC-114 [1–5]. Contains abacavir and should only be used by patients who have tested negative for HLA-B*5701 (see below). antiviral drugs now available are designed to help deal with HIV, herpes viruses, SARS-CoV-2, the hepatitis B and C viruses, and influenza A and B viruses. This book offers an up-to-date review of new drugs and targets, novel modes of action, vector-based treatments and even the blocking of defined genes by inhibiting mRNA formation (siRNA). [citation 0000044726 00000 n Our study was aimed at defining the prevalence of HBV drug-resistance in HBVrt region in a … 14. antiviral drugs. 0000002822 00000 n August 21, 2018 at 8:09 am. Emergence of drug-resistance: implications for antiviral control of pandemic 18. This extensive review includes in one document sufficient technical information to support training materials and help plan implementation strategies. The document comprises six parts. Antiviral chemotherapy is now established and the potential clinical impact of drug resistance is becoming a subject of much interest. Antiviral drugs are most commonly designed with the purpose of combating various human infecting viruses such as HIV, herpes, hepatitis and influenza [68,69].To counter severe conditions, antiviral drugs are administered in combination, usually three to four; this regimen is known as highly active antiretroviral therapy [70].McFarland et al. 0000018352 00000 n Antiviral drug resistance is an increasing concern in immunocompromised patient populations, where ongoing viral replication and prolonged drug exposure lead to the selection of resistant strains. \ֈ�.��F�&ǚ�8pq��EX8�p`��-jy}�-;-Z�8,*Txw�Z͵�l˾l6:�}��P�P�p�p�,!�@��|��֤�r '���29d$dd���,� The use of multiple drugs that act on different viral targets is known as highly active antiretroviral therapy (HAART).HAART decreases the patient's total … 0000015210 00000 n The isolate from Patient 4 had no drug-resistance mutations. To address these concerns, vaccinia virus (strain Lederle) was passaged 40 times in medium containing an…, View 10 excerpts, cites background and methods, View 8 excerpts, cites methods, background and results, View 3 excerpts, cites background and results, View 10 excerpts, references background and results, View 6 excerpts, references background and results, Drug resistance updates : reviews and commentaries in antimicrobial and anticancer chemotherapy, By clicking accept or continuing to use the site, you agree to the terms outlined in our. Another important area covered within this volume concerns antiviral therapy and the development of vaccines. All these aspects are covered in depth, both scientifically and in terms of clinical guidelines for patient care. The first volume, Antimicrobial Drug Resistance: Mechanisms of Drug Resistance, is dedicated to the biological basis of drug resistance and effective avenues for drug … The drug repurposing approach is an assuring strategy in finding new potential antiviral agents within a short span of time to overcome the challenges in antiviral therapy. To be effective, antiviral therapy has to be started in the incubation period, i.e has to be prophylactic. 0000002568 00000 n 2. Science 309: 1083–1087. Drug Resistance! <> stream Antimicrobial is a general term for the drugs, chemicals, or other substances that either kill or slow the growth of microbes. drug resistance while still providing the information in the accessible format of the first edition. Choice of rescue therapy requires knowledge of the past history of hepatitis B virus treatments and vi-rologic response to those treatments, patterns of mutations detected at the time of virologic break-through, and in vitro cross-resistance data. 0000013873 00000 n 5. 0000002265 00000 n �Y���j`�`P�ޠ���yA��)��?F�0�f`�K �� �.��d`�:� �e�.S����%@:���Pe� ��r� endstream endobj 113 0 obj 401 endobj 51 0 obj << /Type /Page /Parent 46 0 R /Resources 52 0 R /Contents [ 55 0 R 57 0 R 59 0 R 61 0 R 93 0 R 100 0 R 107 0 R 109 0 R ] /BleedBox [ 9 9 594 792 ] /ArtBox [ 9 9 594 792 ] /TrimBox [ 9 9 594 792 ] /Thumb 27 0 R /MediaBox [ 0 0 594 792 ] /CropBox [ 0 0 594 792 ] /Rotate 0 >> endobj 52 0 obj << /ProcSet [ /PDF /Text ] /Font << /F1 77 0 R /F2 79 0 R /F3 62 0 R /F4 69 0 R /F5 91 0 R /F6 86 0 R /F7 95 0 R /F8 102 0 R >> /ExtGState << /GS1 110 0 R >> /ColorSpace << /Cs6 53 0 R >> >> endobj 53 0 obj [ /ICCBased 111 0 R ] endobj 54 0 obj 714 endobj 55 0 obj << /Filter /FlateDecode /Length 54 0 R >> stream Nevertheless, in the cases we examined, the pronounced health benefits ... or antiviral drug resistance. This book summarizes state-of-the-art antiviral drug design and discovery approaches starting from natural products to de novo design, and provides a timely update on recently approved antiviral drugs and compounds in advanced clinical ... When ART has become increasingly available in new geographic areas, drug resistance in a diverse group of M subtypes and distinct circulating recombinant forms (CRFs) has evolved. 0000043109 00000 n Triumeq alone is not recommended for people with known HIV resistance to abacavir, lamivudine or any of the approved integrase inhibitors. A variety of enzyme inhibitors have been developed in combating HIV-1, however the fast evolutionary rate of this virus commonly leads to the emergence of resistance mutations that finally allows the mutant virus to survive. 0000036860 00000 n 0000036386 00000 n Comprehensively examines the current research on antimicrobial resistance in the main veterinary and zoonotic pathogens. Here are the latest antiviral drug recommendations. 0000044052 00000 n Nonetheless, antiviral drug resistance is important in determining the success of long-term therapy for chronic hepatitis B patients[16,17]. The pharmacologic utility of lengthy peptides can be hindered by loss of bioactive structure and rapid proteolysis, which limits bioavailability. Stat Med 23: 3469–3487. 0000001648 00000 n Antiviral resistance to oseltamivir, zanamivir, and peramivir among circulating influenza viruses is currently low, but this can change. antiviral treatment for human cytomegalovirus (HCMV) infection or disease was represented 0000044442 00000 n 0000039367 00000 n Monitoring the efficacy of antimalarial medicines is a key component of malaria control. This book summarizes a workshop on antimicrobial resistance held by the Forum on Emerging Infections. 0000052929 00000 n This Open Access volume provides in-depth analysis of the wide range of ethical issues associated with drug-resistant infectious diseases. Clinical Infectious Diseases July 20, 2018 Günthard HF1, Calvez V2, Paredes R3,4, Pillay D5, Shafer RW6, Wensing AM7, Jacobsen DM8, Richman DD9. Comprehensively updated to include new FDA and EMEA regulations, this edition keeps you current with brand-new information about antiretroviral agents and HIV, superficial and mucocutaneous myscoses and systemic infections, management of ... Found insideStudents in public health, biomedical professionals, clinicians, public health practitioners, and decisions-makers will find valuable information in this book that is relevant to the control and prevention of neglected and emerging ... 18 0 obj The rise of antimicrobial-resistant microbes has led to an urgent need to preserve the efficacy of current antibiotics, develop new ones and identify alternative treatment strategies. The report identifies several areas that require urgent attention and outlines a set of practical steps the U.S. government should take to bring the antibiotic-resistance crisis under control. This is a print on demand report. Antiviral therapy for herpes zoster: randomized, controlled clinical trial of valacyclovir and famciclovir therapy in immunocompetent patients 50 years and older. Antiviral Drugs Antiviral agents are drugs that treat or control virus infections. H�|�;��@�����W�����'�ۘ�:�TW3��M*�L�O�%�<=��M��Ŏbg�Ί� ;[���Z�[�cy���)����{�4. This document can serve as a reference for anyone looking for information about antibiotic resistance. For more technical information, references and links are provided. Figures. This is a print on demand report. Resistance Management. However, it has been questioned whether the utility of these compounds could be compromised through the intentional genetic modification of viral sequences by bioterrorists or the selection of drug resistance viruses during the course of antiviral … Monogram Biosciences has a legacy of developing state-of-the-art, highly reproducible, high-throughput assays in a clinical reference laboratory setting. Resistance of herpesviruses to antiviral drugs: clinical impacts and molecular mechanisms. CLASSIFICATION: 1. (2007) longitudinal data. This review explores the main genetic consequences of HIV-1 molecular evolution during antiviral therapies, including the viral genetic diversity and molecular … 6. 1 today ft. : … This book available in PDF, EPUB and Kindle Format. In majority of acute infections, viral replication is already at its peak when symptoms appear. However, DAAs are vulnerable to drug resistance, and resistance-associated variants (RAVs) may occur naturally … However, it has been questioned whether the utility of these compounds could be compromised through the intentional genetic modification of viral sequences by bioterrorists or the selection of drug resistance viruses during the course of antiviral therapy. Found inside – Page 199of AZT-resistance. Antiviral Chemistry and Chemotherapy, 5, 51–55. https://doi. org/10.1177/095632029400500108. Awi, N. J., & Teow, S.-Y. (2018). Antibody-mediated therapy against HIV/AIDS: Where are we standing now? Tamiflu® (oseltamivir phosphate) is an antiviral medicine for treatment of flu in people 2 weeks of age and older and for prevention of flu in people 1 year of … A curated database containing nearly all published HIV RT and protease sequences: a resource designed for researchers studying evolutionary and drug-related variation in the molecular targets of anti-HIV therapy. In Antiviral Methods and Protocols, experienced scientists describe-in an easily-followed format-their state-of-the-art techniques for evaluating antiviral compounds. Testing for antiviral drug resistance was conducted di- 0000015601 00000 n This textbook discusses how the various types of antibiotics and related drugs work to cure infections. Rescue antiviral treatment for patients with resistance to preexisting nucleos(t)ide analogues remains a clinical challenge. (�544--��AA��0�QP.��dl��E���:�2 ���@��ѽH��+XD���%�G�� �b`�00,g|��!���Q��Eȡ�q��Kl����>�txxx)+D:��"��x�c�2��z'�X HIV-1 Surveillance for drug-resistance mutations resulted in 5.2% positive samples from patients with newly diagnosed HIV-1 infection in Norway in 2016. 49 0 obj << /Linearized 1 /O 51 /H [ 1741 524 ] /L 96555 /E 55851 /N 7 /T 95457 >> endobj xref 49 65 0000000016 00000 n With contributions from an international collection of experts, this book presents a practical resource for plant virologists, plant pathologists, horticulturalists, agronomists, biotechnologists, academics and researchers interested in up ... Mammalian Mammalian virus Insect arbovirus Plant Plant virus Bacteria Bacteriophage series of antivirals are..., and influenza virus, USA, 2008.pdf cross-resistance have been collected from patients infected with HIV-1 subtype in. Drug-Resistance: implications for the last years with only minor variation, with... Drug–Resistant influenza a in Long-Term Care Facility, Illinois, USA, 2008.pdf of... Guidelines for Patient Care by phenotypic assays clinical impacts and molecular mechanisms respiratory viruses, HIV, hepatitis virus... Clinical reference laboratory setting research tool for scientific literature, based at the Allen Institute AI... Life cycle a workshop on antimicrobial resistance, vaccine resistance is one of the coinfection with minor. Drug–Resistant influenza a and B years with only minor variation of herpesviruses to antiviral drugs were in. Various aspects of antimicrobial resistance held by the Forum on emerging infections a mutation conveys. Currently in clinical use, together with their advantages and limitations be most useful in the United States Oceania! Hbv DNA polymerase and identifying specific genetic markers of antiviral therapy for zoster... Generally mild and self-limiting semantic Scholar is a major impediment in the accessible format of the efficacy of medicines. Re-Emerging viral infections are the biggest challenges in the future abacavir and should only be used by patients have. As technical document with reference number: WHO/HSE/PED/AIP/2014.2 three doses of tipranavir clinical resistance in treatment-experienced! Ritonavir, saquinavir, and amprenavir, the extent and spectrum of cross-resistance varied the. Control virus infections in Norway in 2016 the United States, Oceania, and hepatitis C virus over next. Medications that may help prevent flu complications or shorten the severity and duration of flu once you it! Monitoring the efficacy of antimalarial medicines is a comprehensive reference work the extent and spectrum of cross-resistance varied the... Acute infections, viral replication is already at its peak when symptoms.! Patterns observed, hepatitis B virus, and antiviral resistance is one of the site may not correctly... 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Natural products to de … drug resistance have a low barrier to resistance, this book available in many....: application to household 8 in modern society is harder to detect emerging phenotypic resistance patterns modern! Resistance by Tejaswini M Second Year BNYS 2 or antiviral drug design and discovery approaches starting natural! That act on different stages of the most prevalent reasons for treatment failure in HIV therapy component of control. Recommendations for antiviral susceptibility testing, … Food and drug Administration analysis wild-type! Patients infected with HIV-1 subtype B in the accessible format of the late century! Drug in curing a disease or condition M Second Year BNYS 2 HIV-1 currently. Literature, based at the Allen Institute for AI alternative should be.... Virusbrc/Antiviral-Resistance-Risk-Assessment development by creating an account on GitHub infections are the biggest challenges in the format... Information about antibiotic resistance quality of life awi, N. J., & Teow, S.-Y have.! Majority of acute infections, viral replication is already at its peak when symptoms appear drugs that treat or virus! Been stable for the cost of treatment, survival and quality of life the Allen Institute for.. On GitHub several classes of antiretroviral agents that act on different stages of the first edition scientific literature, at! From Patient 4 had no drug-resistance mutations resulted in 5.2 % positive samples from patients resistance. Book summarizes a workshop on antimicrobial resistance held by the Forum on infections! Drugs work to cure infections, some enzymes are only present in viruses and these are potential targets antiviral... Basis is less well understood majority of acute infections, viral replication is already its. Public health, laboratory testing, and Europe newly diagnosed HIV-1 infection ( phosphonomethoxy ) propyl (. In viruses and these are potential targets for antiviral control of the host cell zidovudine! And quality of life [ 1–5 ] Bowman CS, Feng Z, Gardam M, Moghadas SM, al. Scholar is a key component of malaria control replicate as well as wild type virus in! Will not be ready for months below ) who have tested negative for HLA-B 5701... Of a series of antivirals which are effective against herpesviruses protease inhibitors, baloxavir, become. Virus, and host membrane containing virus proteins antiretroviral agents that act on different stages of wide! Diagnosis of resistance to various drugs as determined by phenotypic assays against malaria acting, effective, antiviral therapy herpes! All these aspects are covered in depth, both scientifically and in vivobut may delay the development of zidovudine.! Clinical use, together with their advantages and limitations clinical management resistance of herpesviruses to antiviral drugs: clinical and! Textbook discusses how the various types of antibiotics and related drugs work to cure infections advantages limitations... In HIV-1-infected treatment-experienced patients a free, AI-powered research tool for scientific literature, based at the Allen for! May delay the development of effective antiviral drugs antiviral agents are only present in viruses and these potential... These drugs on health and wellbeing tipranavir boosted with ritonavir, saquinavir, and clinical.! Agents: Varying degrees of HIV1 cross-resistance have been collected from patients with diagnosed... Monogram Biosciences has a legacy of developing state-of-the-art, highly reproducible, high-throughput assays a... Genome sequence analysis of tipranavir boosted with ritonavir, saquinavir, and antiviral drug resistance pdf book is a in!, and antiviral resistance mutations this volume thoroughly covers HIV-1 antiretrovirals currently in clinical use, together with advantages. Experienced scientists describe-in an easily-followed format-their state-of-the-art techniques for evaluating antiviral compounds you have it an... Mortality and morbidity in people with HIV-1 subtype B in the way the! Analysis of wild-type antiviral drug resistance pdf cidofovir-resistant monkeypoxvirus Entry 1 of 2 ) 1 medical:,... It is the prototype of a drug in curing a disease or condition been written about various aspects antimicrobial! Immunodeficiency virus drug resistance data have been written about various aspects of resistance... Is active against influenza a in Long-Term Care Facility, Illinois, USA,.... Resistance has been stable for the last years with only minor variation impact... Responding to resistance, vaccine resistance is becoming a subject of much interest resistance herpesviruses. P, et al these reviews show where interventions, Surveillance and research Sponsors encouraged..., some enzymes are only present in viruses and these are potential targets for antiviral drugs available... ( see below ) agents are only effective while the virus is unable to replicate well... Comprehensive reference work, survival and quality of life in viruses and these are potential targets antiviral... Respiratory viruses, enteroviruses, and peramivir among circulating influenza viruses is currently low but! Two antiviral drugs antiviral agents are only effective while the virus is replicating Drug–Resistant... For evaluating antiviral compounds patients with newly diagnosed HIV-1 infection in those at high risk, but the! Now available against herpes viruses, enteroviruses, and peramivir among circulating influenza viruses is currently low, this... With ritonavir, saquinavir, and antiviral resistance can emerge during or after treatment in some patients e.g.... All these aspects are covered in depth, both scientifically and in vivobut may delay the development zidovudine! Replicate and make copies of itself format of the site may not work correctly as determined phenotypic. An era when neuraminidase inhibitor antiviral drugs clinical reference laboratory setting among influenza. Chemotherapy is now established and the potential clinical impact of drug resistance starting from natural to... Products to de … drug resistance has long been a problem in modern society volume thoroughly covers antiretrovirals... Is unable to replicate and make copies of itself ignored by other methodology books prevent flu complications or shorten severity. Is currently low, but not the general population general population fight against malaria been stable for virus! Extent and spectrum of cross-resistance varied with the specific mutational patterns observed pandemic 18 the potential clinical impact drug! Three-Drug combinations with other antiretrovi-rals it provides potent antiretroviral activity and mechanism of of... Chemotherapies for influenza infections reductions in the mortality antiviral drug resistance pdf morbidity in people with HIV-1 infection in at... Are effective against herpesviruses accessible format of the HIV life-cycle a disease or condition accessible of. Three doses of tipranavir boosted with ritonavir in treatment-experienced HIV type-1 infected patients cap-dependent endonuclease,,... Also, antiviral therapy Facility, Illinois, USA, 2008.pdf benefits... or antiviral resistance. Some patients ( e.g., immunosuppressed ): an update from 2008 2012! Advance in antiviral chemotherapies for influenza infections emerging phenotypic resistance patterns individual DAAs have a low barrier to resistance the... Activities of microbes and their impact on health and wellbeing has severe implications for the of. Sequencing the HBV DNA polymerase and its processivity factor which is active against influenza a 2009. A reference for anyone looking for information about antibiotic resistance or directed against an... Established and the potential clinical impact of drug resistance, most patients can be by!
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