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Huygens S, GeurtsvanKessel C, Gharbharan A, Bogers S, Worp N, Boter M, Bax HI, Kampschreur LM, Hassing RJ, Fiets RB, Levenga H, Afonso PM, Koopmans M, Rijnders BJA, Oude Munnink BB. Clinical and Virological Outcome of Monoclonal Antibody Therapies Across SARS-CoV-2 Variants in 245 Immunocompromised Patients: A Multicenter Prospective Cohort Study. Clin Infect Dis 2024; 78:1514-1521. [PMID: 38445721 PMCID: PMC11175671 DOI: 10.1093/cid/ciae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Immunocompromised patients (ICPs) have an increased risk for a severe and prolonged COVID-19. SARS-CoV-2 monoclonal antibodies (mAbs) were extensively used in these patients, but data from randomized trials that focus on ICPs are lacking. We evaluated the clinical and virological outcome of COVID-19 in ICPs treated with mAbs across SARS-CoV-2 variants. METHODS In this multicenter prospective cohort study, we enrolled B-cell- and/or T-cell-deficient patients treated with casirivimab/imdevimab, sotrovimab, or tixagevimab/cilgavimab. SARS-CoV-2 RNA was quantified and sequenced weekly, and time to viral clearance, viral genome mutations, hospitalization, and death rates were registered. RESULTS Two hundred and forty five patients infected with the Delta (50%) or Omicron BA.1, 2, or 5 (50%) variant were enrolled. Sixty-seven percent were vaccinated; 78 treated as outpatients, of whom 2 required hospital admission, but both survived. Of the 159 patients hospitalized at time of treatment, 43 (27%) required mechanical ventilation or died. The median time to viral clearance was 14 days (interquartile range, 7-22); however, it took >30 days in 15%. Resistance-associated spike mutations emerged in 9 patients in whom the median time to viral clearance was 63 days (95% confidence interval, 57-69; P < .001). Spike mutations were observed in 1 of 42 (2.4%) patients after treatment with 2 active mAbs, in 5 of 34 (14.7%) treated with actual monotherapy (sotrovimab), and 3 of 20 (12%) treated with functional monotherapy (ie, tixagevimab/cilgavimab against tixagevimab-resistant variant). CONCLUSIONS Despite treatment with mAbs, morbidity and mortality of COVID-19 in ICPs remained substantial. Combination antiviral therapy should be further explored and may be preferred in severely ICPs.
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Affiliation(s)
- Sammy Huygens
- Department of Internal Medicine, Section of Infectious Diseases and Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Corine GeurtsvanKessel
- Department of Viroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Arvind Gharbharan
- Department of Internal Medicine, Section of Infectious Diseases and Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Susanne Bogers
- Department of Viroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Nathalie Worp
- Department of Viroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marjan Boter
- Department of Viroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Hannelore I Bax
- Department of Internal Medicine, Section of Infectious Diseases and Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Linda M Kampschreur
- Department of Internal Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Robert-Jan Hassing
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Roel B Fiets
- Department of Internal Medicine, Amphia Hospital, Breda, The Netherlands
| | - Henriette Levenga
- Department of Internal Medicine, Groene Hart Gouda, Gouda, The Netherlands
| | - Pedro Miranda Afonso
- Department of Biostatistics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marion Koopmans
- Department of Viroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bart J A Rijnders
- Department of Internal Medicine, Section of Infectious Diseases and Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bas B Oude Munnink
- Department of Viroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Kinsella PM, Moso MA, Morrissey CO, Dendle C, Guy S, Bond K, Sasadeusz J, Slavin MA. Antiviral therapies for the management of persistent coronavirus disease 2019 in immunocompromised hosts: A narrative review. Transpl Infect Dis 2024; 26:e14301. [PMID: 38809102 DOI: 10.1111/tid.14301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 04/11/2024] [Accepted: 05/08/2024] [Indexed: 05/30/2024]
Abstract
Antiviral agents with activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have played a critical role in disease management; however, little is known regarding the efficacy of these medications in the treatment of SARS-CoV-2 infection in immunocompromised patients, particularly in the management of persistent SARS-CoV-2 positivity. This narrative review discusses the management of persistent coronavirus disease 2019 in immunocompromised hosts, with a focus on antiviral therapies. We identified 84 cases from the literature describing a variety of approaches, including prolonged antiviral therapy (n = 11), combination antivirals (n = 13), and mixed therapy with antiviral and antibody treatments (n = 60). A high proportion had an underlying haematologic malignancy (n = 67, 80%), and were in receipt of anti-CD20 agents (n = 51, 60%). Success was reported in 70 cases (83%) which varied according to the therapy type. Combination therapies with antivirals may be an effective approach for individuals with persistent SARS-CoV-2 positivity, particularly those that incorporate treatments aimed at increasing neutralizing antibody levels. Any novel approaches taken to this difficult management dilemma should be mindful of the emergence of antiviral resistance.
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Affiliation(s)
- Paul M Kinsella
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Infectious Diseases, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | - Michael A Moso
- Department of Infectious Diseases, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | | | - Claire Dendle
- Monash Infectious Diseases, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Stephen Guy
- Department of Infectious Diseases, Eastern Health, Melbourne, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Katherine Bond
- Department of Microbiology, Royal Melbourne Hospital, Melbourne, Australia
- Victorian Infectious Diseases Reference Laboratory (VIDRL) at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Microbiology and Immunology, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | - Joseph Sasadeusz
- Department of Infectious Diseases, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Doherty Institute of Infection and Immunity, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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Wang X, Du W, Zhang D, Chen W, Zuo X. The effects of nirmatrelvir/ritonavir on tacrolimus levels in lung transplant recipients: A single-center study. Pulm Pharmacol Ther 2024; 84:102280. [PMID: 38065402 DOI: 10.1016/j.pupt.2023.102280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/02/2023] [Accepted: 12/03/2023] [Indexed: 03/11/2024]
Abstract
BACKGROUND Lung transplant recipients (LTRs) have a higher risk of hospitalization and mortality due to COVID-19 compared with the immunocompetent population. The use of nirmatrelvir/ritonavir (NR), an effective oral treatment for COVID-19, is quite challenging due to its potent drug-drug interactions with immunosuppressants and azole antifungals. As there are few clinical reports of the use of NR in LTRs, we measured tacrolimus levels in patients receiving NR in our hospital to improve safety when prescribing NR. METHODS In total, 48 adult LTRs who received NR between November 19, 2022, and January 19, 2023, at China-Japan Friendship Hospital were retrospectively included and followed for 20 days after initiating NR. Tacrolimus was held at least 12 h before initiating NR and re-administered based on the trough levels after completing NR treatment. All concomitant medications, drug concentrations, laboratory results, and genotypes were recorded and analyzed. RESULTS Most patients showed stable tacrolimus trough levels despite high individual variability. Four patients exhibited supratherapeutic trough levels of tacrolimus (more than 15 ng/mL). Two patients who received 0.5 mg of tacrolimus during NR treatment had trough levels below 3.0 ng/mL. In addition, we found that in 13 patients, the trough levels were 130% of baseline after cessation of tacrolimus, and logistic regression revealed that increased trough level was significantly associated with age more than 60 years. CONCLUSIONS NR can be safely used in LTRs with close monitoring of tacrolimus levels and appropriate dose adjustments. However, more attention should be paid to elderly patients, as NR may more severely affect their drug metabolism. Due to the limited sample size, further studies are needed to guide the optimal use of tacrolimus following treatment with NR and explore the risk factors significantly affecting the interactions between NR and tacrolimus.
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Affiliation(s)
- Xiaoxing Wang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wenwen Du
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Dan Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Wenhui Chen
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Lung Transplantation, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Xianbo Zuo
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, 100029, China.
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Snell LB, McGreal-Bellone A, Nye C, Gage S, Bakrania P, Williams TGS, Aarons E, Botgros A, Douthwaite ST, Mallon P, Milligan I, Moore C, O’Kelly B, Underwood J, de Barra E, Nebbia G. A Multinational Case Series Describing Successful Treatment of Persistent Severe Acute Respiratory Syndrome Coronavirus 2 Infection Caused by Omicron Sublineages With Prolonged Courses of Nirmatrelvir/Ritonavir. Open Forum Infect Dis 2024; 11:ofad612. [PMID: 38269048 PMCID: PMC10807981 DOI: 10.1093/ofid/ofad612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/06/2023] [Indexed: 01/26/2024] Open
Abstract
The optimum treatment for persistent infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not known. Our case series, across 5 hospitals in 3 countries, describes 11 cases where persistent SARS-CoV-2 infection was successfully treated with prolonged courses (median, 10 days [range, 10-18 days]) of nirmatrelvir/ritonavir (Paxlovid). Most cases (9/11) had hematological malignancy and 10 (10/11) had received CD20-depleting therapy. The median duration of infection was 103 days (interquartile range, 85-138 days). The majority (10/11) were hospitalized, and 7 (7/11) had severe/critical disease. All survived and 9 of 11 demonstrated viral clearance, almost half (4/9) of whom received nirmatrelvir/ritonavir as monotherapy. This case series suggests that prolonged nirmatrelvir/ritonavir has a role in treating persistent infection.
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Affiliation(s)
- Luke B Snell
- Department of Infectious Diseases, King’s College London, London, UK
- Directorate of Infection, Guy’s & St Thomas’ National Health Service Foundation Trust, London, UK
| | | | - Clemency Nye
- Microbiology Department, Public Health Wales, Cardiff, UK
| | - Sarah Gage
- Department of Infectious Diseases, University Hospital of Wales, Cardiff, UK
| | - Prijay Bakrania
- Directorate of Infection, Guy’s & St Thomas’ National Health Service Foundation Trust, London, UK
| | - Tom G S Williams
- Directorate of Infection, Guy’s & St Thomas’ National Health Service Foundation Trust, London, UK
| | - Emma Aarons
- Directorate of Infection, Guy’s & St Thomas’ National Health Service Foundation Trust, London, UK
| | - Alina Botgros
- Directorate of Infection, Guy’s & St Thomas’ National Health Service Foundation Trust, London, UK
| | - Samuel T Douthwaite
- Directorate of Infection, Guy’s & St Thomas’ National Health Service Foundation Trust, London, UK
| | - Patrick Mallon
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland
| | - Iain Milligan
- Directorate of Infection, Guy’s & St Thomas’ National Health Service Foundation Trust, London, UK
| | - Catherine Moore
- Wales Specialist Virology Centre, Public Health Wales, Cardiff, UK
| | - Brendan O’Kelly
- Department of Infectious Diseases, Beaumont Hospital, Dublin, Ireland
- Infectious Diseases, Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - Jonathan Underwood
- Department of Infectious Diseases, University Hospital of Wales, Cardiff, UK
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Eoghan de Barra
- Department of Infectious Diseases, Beaumont Hospital, Dublin, Ireland
- Department of International Health and Tropical Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Ireland
| | - Gaia Nebbia
- Department of Infectious Diseases, King’s College London, London, UK
- Directorate of Infection, Guy’s & St Thomas’ National Health Service Foundation Trust, London, UK
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Focosi D, Maggi F, D'Abramo A, Nicastri E, Sullivan DJ. Antiviral combination therapies for persistent COVID-19 in immunocompromised patients. Int J Infect Dis 2023; 137:55-59. [PMID: 37778409 DOI: 10.1016/j.ijid.2023.09.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVES After the third year of the COVID-19 pandemic, most of the severe COVID-19 burden falls upon immunocompromised patients who cannot mount an endogenous immune response after both vaccination and/or natural infection. They also experience persistent SARS-CoV-2 infection with high viral loads often unsuccessfully managed by the standard antiviral monotherapy regimen initially validated for treatment of COVID-19 immunocompetent patients, only. The off-label prescription of such monotherapy regimens in immunocompromised patients is likely to drive the emergence of treatment-related immune escape, relapses, excess morbidity, and mortality from both COVID-19 and delayed treatment of the underlying disorders. A possible treatment approach to mitigate such consequence is based on combined antiviral therapies. METHODS We searched PubMed for case reports, case series and clinical trials reporting the usage of combined antiviral therapies for COVID-19. RESULTS In this narrative review, we show that combinations of either small molecule antivirals or small molecule antiviral plus passive immunotherapies are safe and effective in small cohorts reported so far. CONCLUSION Considering the progressive loss of efficacy of all authorized anti-spike monoclonal antibodies, promising regimen options are reserved to combinations of small molecule antivirals and COVID-19 convalescent plasma from vaccinated donors.
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Affiliation(s)
- Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy.
| | - Fabrizio Maggi
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome, Italy
| | - Alessandra D'Abramo
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome, Italy
| | - Emanuele Nicastri
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome, Italy
| | - David J Sullivan
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Şimşek-Yavuz S. COVID-19: An Update on Epidemiology, Prevention and Treatment, September-2023. INFECTIOUS DISEASES & CLINICAL MICROBIOLOGY 2023; 5:165-187. [PMID: 38633552 PMCID: PMC10986731 DOI: 10.36519/idcm.2023.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/19/2023] [Indexed: 04/19/2024]
Abstract
After a downward trend for more than 12 months, the incidence of COVID-19 has increased in the last months. Although COVID-19 is not as frequent as in the first years of the pandemic, case numbers are still very high, and it causes a significant number of deaths. COVID-19 is not seen with a predictable frequency, at least two times more deadly than the flu, continues as an epidemic, and has not reached the endemic level yet. Currently, the Omicron strains EG.5 and XBB.1.16 are dominant worldwide. Although BA.2.86 and FLip variants, including FL.1.5.1 are not widespread at the moment, both were shown to be highly immune-evasive and require close monitoring. Prevention of COVID-19 relies on vaccinations, surveillance, proper ventilation of enclosed spaces, isolation of patients, and mask usage. Currently, monovalent COVID-19 vaccines, including XBB.1.5 Omicron SARS-CoV-2, are recommended for both primary and booster vaccinations against COVID-19. Monovalent vaccines, including only original SARS-CoV-2 strain, and bivalent vaccines, including original virus plus BA4/5 variant, are no longer recommended against COVID-19. Booster vaccination with XBB.1.5 containing vaccine should be prioritized for patients at high risk for severe COVID-19. Bacillus Calmette-Guérin (BCG) vaccination does not seem to be effective in preventing COVID-19. At the current phase of the pandemic, nirmatrelvir/ritonavir, remdesivir, molnupiravir, sotrovimab (for patients from XBB.1.5 variant dominant settings), and convalescent plasma can be considered for the treatment of high-risk early-stage outpatients with COVID-19, while hospitalized patients with more severe disease can be treated with dexamethasone, anti cytokines including tocilizumab, sarilumab, baricitinib, and tofacitinib and antithrombotic agents including enoxaparin. Remdesivir oral analogues and ensitrelvir fumarate are promising agents for treating acute COVID-19, which are in phase trials now; however, ivermectin, fluvoxamine, and metformin were shown to be ineffective.
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Affiliation(s)
- Serap Şimşek-Yavuz
- Department of Infectious Diseases and Clinical Microbiology, İstanbul University School of Medicine, İstanbul, Türkiye
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7
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Richier Q, Hueso T, Tiberghien P, Lacombe K. [COVID-19: Still a place for the convalescent plasma? Focus on the immunocompromised patients]. Rev Med Interne 2023; 44:467-471. [PMID: 37689526 DOI: 10.1016/j.revmed.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/29/2023] [Indexed: 09/11/2023]
Affiliation(s)
- Q Richier
- Sorbonne université, Paris, France; Service de maladies infectieuses, hôpital Saint-Antoine, AP-HP, 75012 Paris, France.
| | - T Hueso
- Service d'hématologie clinique, hôpital Avicenne, Sorbonne université Paris-Nord, AP-HP, Bobigny, France
| | - P Tiberghien
- Établissement français du sang, La Plaine Saint-Denis, France; Établissement français du sang, UMR 1098 Right Inserm, université de Franche-Comté, Besançon, France
| | - K Lacombe
- Sorbonne université, Paris, France; Service de maladies infectieuses, hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Institut Pierre-Louis épidémiologie et santé publique, Inserm UMR-S1136, Paris, France
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