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

Luke B Snell; Aimee McGreal-Bellone; Clemency Nye; Sarah Gage; Prijay Bakrania; Tom G S Williams; Emma Aarons; Alina Botgros; Samuel T Douthwaite; Patrick Mallon; Iain Milligan; Catherine Moore; Brendan O'Kelly; Jonathan Underwood; Eoghan de Barra; Gaia Nebbia

doi:10.1093/ofid/ofad612

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. 2023 Dec 7;11(1):ofad612. doi: 10.1093/ofid/ofad612. eCollection 2024 Jan.

Authors

Luke B Snell^{1

2}, Aimee McGreal-Bellone³, Clemency Nye⁴, Sarah Gage⁵, Prijay Bakrania², Tom G S Williams², Emma Aarons², Alina Botgros², Samuel T Douthwaite², Patrick Mallon⁶, Iain Milligan², Catherine Moore⁷, Brendan O'Kelly^{3

8}, Jonathan Underwood^{5

9}, Eoghan de Barra^{3

10}, Gaia Nebbia^{1

2}

Affiliations

¹ Department of Infectious Diseases, King's College London, London, UK.
² Directorate of Infection, Guy's & St Thomas' National Health Service Foundation Trust, London, UK.
³ Department of Infectious Diseases, Beaumont Hospital, Dublin, Ireland.
⁴ Microbiology Department, Public Health Wales, Cardiff, UK.
⁵ Department of Infectious Diseases, University Hospital of Wales, Cardiff, UK.
⁶ Centre for Experimental Pathogen Host Research, University College Dublin, Dublin, Ireland.
⁷ Wales Specialist Virology Centre, Public Health Wales, Cardiff, UK.
⁸ Infectious Diseases, Our Lady of Lourdes Hospital, Drogheda, Ireland.
⁹ Division of Infection and Immunity, Cardiff University, Cardiff, UK.
¹⁰ Department of International Health and Tropical Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Ireland.

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.

Keywords: COVID-19; Immunocompromise; SARS-CoV-2.