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Meijer SE, Paran Y, Belkin A, Brosh-Nissimov T. 'Persistent COVID-19 in immunocompromised patients - Israeli society of infectious diseases consensus statement on diagnosis and management': author's response. Clin Microbiol Infect 2024; 30:1211-1212. [PMID: 38823451 DOI: 10.1016/j.cmi.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/26/2024] [Indexed: 06/03/2024]
Affiliation(s)
- Suzy E Meijer
- Infectious Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yael Paran
- Infectious Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ana Belkin
- Sheba Medical Center, Tel Hashomer, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Brosh-Nissimov
- Infectious Diseases Unit, Samson Assuta Ashdod University Hospital, Ashdod, Israel; Faculty of Health Sciences, Ben Gurion University in the Negev, Beer Sheba, Israel
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Maraolo AE, Moriello NS, Gentile I. Re: Persistent COVID-19 in immunocompromised patients-Israeli Society of Infectious Diseases consensus statement on diagnosis and management by Meijer et al. Clin Microbiol Infect 2024; 30:1209-1210. [PMID: 38782259 DOI: 10.1016/j.cmi.2024.05.011] [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: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Alberto Enrico Maraolo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy.
| | - Nicola Schiano Moriello
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Ivan Gentile
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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Rosen EA, Krantz EM, McCulloch DJ, Wilson MH, Tverdek F, Escobar ZK, Drucker D, Sanchez E, Oshima MU, Mielcarek M, Gauthier J, Pergam SA, Hill JA, Liu C. COVID-19 Outcomes Among Hematopoietic Cell Transplant and Chimeric Antigen Receptor T-cell Recipients in the Era of SARS-CoV-2 Omicron Variants and COVID-19 Therapeutics. Transplant Cell Ther 2024:S2666-6367(24)00590-6. [PMID: 39179107 DOI: 10.1016/j.jtct.2024.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 08/09/2024] [Accepted: 08/12/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Recipients of cellular therapies, including hematopoietic cell transplant (HCT) and chimeric antigen receptor T-cell (CART) therapy, are at risk for poor outcomes from coronavirus disease 2019 (COVID-19). There are limited data describing outcomes among patients in the pre- and early post-cellular therapy period during the Omicron era when multiple antiviral therapeutics were widely available. OBJECTIVES Describe COVID-19 treatment and outcomes in patients diagnosed with COVID-19 during the pre- or early post-cellular therapy period. STUDY DESIGN This is a single-center retrospective cohort study of adult HCT and CART recipients diagnosed with COVID-19 in the pre- and early post-cellular therapy period who tested positive for COVID-19 at our cancer center between January 1, 2022 and March 1, 2023. Primary outcomes were 30-day COVID-19-related hospitalization and death. A secondary outcome was development of persistent COVID-19, defined by a positive SARS-CoV-2 polymerase chain reaction (PCR) 31-90 days after COVID-19 diagnosis. RESULTS Among 65 patients included, 52 (80%) received at least one COVID-19 therapeutic. The most common treatment after initial COVID-19 diagnosis was nirmatrelvir/ritonavir (29%), followed by monoclonal antibody therapy (26%) and remdesivir (11%). Of the 64 patients with at least 30 days of follow-up, 8 (12%) had at least one COVID-19-related hospitalization and one patient died, though cause of death was not due to COVID-19. Of the 8 patients hospitalized for COVID-19, one had severe disease and 7 had mild or moderate infection. Persistent COVID-19 was observed in 13/65 (20%) patients, with 4 patients requiring additional antiviral therapy. Three pre-cellular therapy patients had delays in receiving cellular therapy due to persistent COVID-19. CONCLUSIONS During the Omicron era, rates of 30-day COVID-19-related hospitalization and death were relatively low in this cohort of pre- and early post-HCT and CART recipients, the majority of whom received treatment with at least one antiviral agent. Persistent COVID-19 occurred in 1 in 5 patients in the peri-cellular therapy period and led to cellular therapy treatment delays in several patients, highlighting the need for new COVID-19 treatment strategies.
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Affiliation(s)
- Emily A Rosen
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
| | - Elizabeth M Krantz
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Denise J McCulloch
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Marie H Wilson
- Department of Quality, Fred Hutchinson Cancer Center, Seattle, WA USA
| | - Frank Tverdek
- Department of Pharmacy, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Zahra Kassamali Escobar
- Department of Pharmacy, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Darra Drucker
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Eduardo Sanchez
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Masumi Ueda Oshima
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Division of Hematology and Oncology, University of Washington, Seattle, WA, USA
| | - Marco Mielcarek
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Division of Hematology and Oncology, University of Washington, Seattle, WA, USA
| | - Jordan Gauthier
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Division of Hematology and Oncology, University of Washington, Seattle, WA, USA
| | - Steven A Pergam
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Joshua A Hill
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
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Meijer SE, Paran Y, Belkin A, Ben-Ami R, Maor Y, Nesher L, Hussein K, Rahav G, Brosh-Nissimov T. Persistent COVID-19 in immunocompromised patients-Israeli society of infectious diseases consensus statement on diagnosis and management. Clin Microbiol Infect 2024; 30:1012-1017. [PMID: 38642895 DOI: 10.1016/j.cmi.2024.04.009] [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: 01/05/2024] [Revised: 04/05/2024] [Accepted: 04/15/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Immunocompromised patients with impaired humoral immunity are at risk for persistent COVID-19 (pCOVID), a protracted symptomatic disease with active viral replication. OBJECTIVES To establish a national consensus statement on the diagnosis, treatment, management, isolation, and prevention of pCOVID in adults. SOURCES We base our suggestions on the available literature, our own experience, and clinical reasoning. CONTENT Literature on the treatment of pCOVID is scarce and consists of few case reports and case series. The available studies provide low-quality evidence for monoclonal antibodies, convalescent plasma, antiviral drugs, and immunomodulators. Different combination therapies are described. Continuous viral replication and antiviral treatment may lead to the development of mutations that confer resistance to therapy. IMPLICATIONS To reduce the risk of resistance and improve outcomes, we suggest treating pCOVID with a combination of antibody-based therapy and two antiviral drugs for duration of 5-10 days. Immunomodulatory therapy can be added in patients with an inflammatory clinical picture. In cases of treatment failure or relapse, prolonged antiviral treatment can be considered. For the prevention of pCOVID, we suggest active and passive vaccination and early initiation of treatment for acute COVID-19. Additional research on pCOVID treatment is urgently needed.
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Affiliation(s)
- Suzy E Meijer
- Infectious Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yael Paran
- Infectious Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ana Belkin
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Sheba Medical Center, Tel Hashomer, Israel
| | - Ronen Ben-Ami
- Infectious Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yasmin Maor
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Infectious Disease Unit, Edith Wolfson Medical Center, Holon, Israel
| | - Lior Nesher
- Infectious Disease Institute, Soroka University Medical Center, Beer Sheba, Israel; Faculty of Health Sciences, Ben Gurion University in the Negev, Beer Sheba, Israel
| | | | - Galia Rahav
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Sheba Medical Center, Tel Hashomer, Israel
| | - Tal Brosh-Nissimov
- Infectious Diseases Unit, Samson Assuta Ashdod University Hospital, Ashdod, Israel; Faculty of Health Sciences, Ben Gurion University in the Negev, Beer Sheba, Israel
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Gröning R, Walde J, Ahlm C, Forsell MNE, Normark J, Rasmuson J. Intravenous immunoglobulin therapy for COVID-19 in immunocompromised patients: A retrospective cohort study. Int J Infect Dis 2024; 144:107046. [PMID: 38615825 DOI: 10.1016/j.ijid.2024.107046] [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: 02/16/2024] [Revised: 04/03/2024] [Accepted: 04/07/2024] [Indexed: 04/16/2024] Open
Abstract
OBJECTIVES To investigate the effectiveness of intravenous immunoglobulin (IVIG) as treatment for COVID-19 in immunocompromised patients. METHODS This retrospective study investigated outcomes for immunocompromised, vaccine non-responsive, patients that between September 2022 and April 2023 received IVIG as treatment for COVID-19 in the region of Västerbotten, Sweden. We analyzed clinical data, viral load, and anti-SARS-CoV-2 IgG binding and neutralization levels of patient serum samples and IVIG production batches. Primary and secondary outcomes were clinical cure and viral clearance, respectively. RESULTS Sixteen patients were analyzed. After a median COVID-19 duration of 4 weeks, a median 60 g IVIG infusion increased SARS-CoV-2 binding and neutralizing antibody levels, with broad in vitro activity against tested variants. The treatment resulted in abrogation of viremia in all patients and general improvement in 15 survivors that all met the primary endpoint. Thirteen patients met the secondary endpoint at follow-up after a median of four months. Two subjects with persistent SARS-CoV-2 carriage relapsed but were successfully retreated with IVIG. CONCLUSIONS Antibodies in IVIG efficiently neutralized several SARS-CoV-2 variants. Treatment with IVIG was associated with clinical cure and viral clearance in immunocompromised patients. Our data suggests that IVIG could be a novel treatment alternative for COVID-19 for this patient category.
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Affiliation(s)
- Remigius Gröning
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Jonatan Walde
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Clas Ahlm
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | | | - Johan Normark
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Johan Rasmuson
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden.
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Franceschini E, Menozzi V, Todisco V, Pellegrino M, Cantergiani S, Dessilani A, Spadoni A, Romani F, Mazzocchi A, Santoro A, Meschiari M, Cervo A, Gilioli A, Bettelli F, Fregni‐Serpini G, Grottola A, Candoni A, Guaraldi G, Sarti M, Luppi M, Mussini C. Severe acute respiratory syndrome coronavirus 2 infection in patients with hematological malignancies in the Omicron era: Respiratory failure, need for mechanical ventilation and mortality in seronegative and seropositive patients. EJHAEM 2024; 5:505-515. [PMID: 38895079 PMCID: PMC11182402 DOI: 10.1002/jha2.867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 06/21/2024]
Abstract
Background Patients with hematological malignancies (HM) have a high risk of severe coronavirus disease 2019 (COVID-19), also in the Omicron period. Material and methods Retrospective single-center study including HM patients with severe acute respiratory syndrome Coronavirus 2 (SARS-CoV2) infection from January 2022 to March 2023. Study outcomes were respiratory failure (RF), mechanical ventilation (MV), and COVID-related mortality, comparing patients according to SARS-CoV2 serology. Results Note that, 112 patients were included: 39% had negative SARS-CoV2 serology. Seronegative were older (71.5 vs. 65.0 years, p = 0.04), had more often a lymphoid neoplasm (88.6% vs. 69.1%, p = 0.02), underwent anti-CD20 therapy (50.0% vs. 30.9% p = 0.04) and had more frequently a severe disease (23.0% vs. 3.0%, p = 0.02) than seropositive.Kaplan-Meier showed a higher risk for seronegative patients for RF (p = 0.014), MV (p = 0.044), and COVID-related mortality (p = 0.021). Negative SARS-CoV2 serostatus resulted in a risk factor for RF (hazards ratio [HR] 2.19, 95% confidence interval [CI] 1.03-4.67, p = 0.04), MV (HR 3.37, 95% CI 1.06-10.68, p = 0.04), and COVID-related mortality (HR 4.26, 95% CI 1.09-16.71, p = 0.04). Conclusions : HM patients with negative SARS-CoV2 serology, despite vaccinations and previous infections, have worse clinical outcomes compared to seropositive patients in the Omicron era. The use of serology for SARS-CoV2 diagnosis could be an easy tool to identify patients prone to developing complications.
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Affiliation(s)
- Erica Franceschini
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Valentina Menozzi
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Vera Todisco
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Mariachiara Pellegrino
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Samuele Cantergiani
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Andrea Dessilani
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Anna Spadoni
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Federico Romani
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Alice Mazzocchi
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Antonella Santoro
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Marianna Meschiari
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Adriana Cervo
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Andrea Gilioli
- Department of Medical and Surgical SciencesSection of HematologyUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Francesca Bettelli
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Giulia Fregni‐Serpini
- Department of Laboratory MedicineMolecular Virology and Microbiology UnitAOU Policlinico di ModenaModenaItaly
| | - Antonella Grottola
- Department of Laboratory MedicineMolecular Virology and Microbiology UnitAOU Policlinico di ModenaModenaItaly
| | - Anna Candoni
- Department of Medical and Surgical SciencesSection of HematologyUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Giovanni Guaraldi
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Mario Sarti
- Department of Laboratory MedicineClinical Microbiology LaboratoryModenaItaly
| | - Mario Luppi
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
| | - Cristina Mussini
- Department of Surgical, Medical, Dental, and Morphological Sciences, University of Modena and Reggio Emilia, Infectious Disease ClinicUniversity of Modena and Reggio EmiliaAOU Policlinico di ModenaModenaItaly
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Mikulska M, Oltolini C, Zappulo E, Bartoletti M, Frustaci AM, Visentin A, Vitale C, Mauro FR. Prevention and management of infectious complications in patients with chronic lymphocytic leukemia (CLL) treated with BTK and BCL-2 inhibitors, focus on current guidelines. Blood Rev 2024; 65:101180. [PMID: 38331696 DOI: 10.1016/j.blre.2024.101180] [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: 12/08/2023] [Revised: 01/27/2024] [Accepted: 01/31/2024] [Indexed: 02/10/2024]
Abstract
CLL is associated with an increased risk of infectious complications. Treatment with BTK or BCL-2 inhibitors does not seem to increase significantly the risk of opportunistic infections, but the role of combination therapies including BTK and/or BCL-2 inhibitors remains to be established. Various infectious complications can be successfully prevented with appropriate risk management strategies. In this paper we reviewed the international guidelines on prevention and management of infectious complications in patients with CLL treated with BTK or BCL-2 inhibitors. Universal pharmacological anti-herpes, antibacterial or antifungal prophylaxis is not warranted. Reactivation of HBV should be prevented in HBsAg-positive subjects. For HBsAg-negative/HBcAb-positive patients recommendations differ, but in case of combination treatment should follow those for other, particularly anti-CD20, agent. Immunization should be provided preferably before the onset of treatment. Immunoglobulin therapy has favourable impact on morbidity but not mortality in patients with hypogammaglobulinemia and severe or recurrent infections. Lack of high-quality data and heterogeneity of patients or protocols included in the studies might explain differences among the main guidelines. Better data collection is warranted.
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Affiliation(s)
- Malgorzata Mikulska
- Infectious Diseases Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | | | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele Milan, Italy; Infectious Disease Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | | | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy
| | - Candida Vitale
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Turin, Italy
| | - Francesca R Mauro
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
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Inbar T, Dann EJ, Kerner O, Stern A. Charting a path forward: Promising outcomes of convalescent plasma therapy in the care of severely B-cell depleted patients with persistent COVID-19. Transfusion 2024; 64:443-448. [PMID: 38327238 DOI: 10.1111/trf.17737] [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: 09/28/2023] [Revised: 12/24/2023] [Accepted: 12/24/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Patients with severe B-cell depletion related to hematological malignancies or B-cell targeted therapy suffer from impaired antibody responses to SARS-CoV-2 and are at risk for prolonged COVID-19. In this population, COVID-19 convalescent plasma (CCP) may provide passive immunity, enhance immune response, and promote virus neutralization. This study evaluated outcomes of B-cell depleted patients with persistent COVID-19 treated with CCP. STUDY DESIGN AND METHODS This analysis included all consecutive severely B-cell depleted patients with persistent COVID-19, receiving CCP at Rambam between 01.2022-02.2023. Persistent COVID-19 was defined as the presence of symptoms for ≥14 days in patients with negative SARS-CoV-2 nucleocapsid antibody test results. RESULTS Twenty patients met inclusion criteria, 17 of whom had hematological malignancies, two suffered from rheumatoid arthritis and one had both. Twelve patients received anti-CD-20 treatment, one - CAR-T cells and three underwent stem cell transplantation. The median duration of COVID-19 symptoms was 27.5 days (range 14-97); 12 patients had mild-to-moderate COVID-19 and 8 had severe infection. Sixteen patients required hospitalization. The majority of patients received other COVID-19 therapies before CCP. Within a median of two days (range 1-16) post-infusion, 19/20 patients clinically improved. No CCP-associated adverse events were documented. COVID-19 symptoms recurred in 3 of the improved patients. Two patients died from COVID-19 on days 1 and 90 following the first CCP infusion. DISCUSSION In severely B-cell depleted patients with persistent COVID-19, CCP is safe and associated with rapid clinical improvement. This subset of immunocompromised patients could particularly benefit from CCP administration.
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Affiliation(s)
- Tsofia Inbar
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- Blood Bank and Apheresis Unit, Rambam Health Care Campus, Haifa, Israel
| | - Eldad J Dann
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- Blood Bank and Apheresis Unit, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Omer Kerner
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Anat Stern
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
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9
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D’Abramo A, Vita S, Beccacece A, Navarra A, Pisapia R, Fusco FM, Matusali G, Girardi E, Maggi F, Goletti D, Nicastri E. B-cell-depleted patients with persistent SARS-CoV-2 infection: combination therapy or monotherapy? A real-world experience. Front Med (Lausanne) 2024; 11:1344267. [PMID: 38487021 PMCID: PMC10937561 DOI: 10.3389/fmed.2024.1344267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/09/2024] [Indexed: 03/17/2024] Open
Abstract
Objectives The aim of the study was to describe a cohort of B-cell-depleted immunocompromised (IC) patients with prolonged or relapsing COVID-19 treated with monotherapy or combination therapy. Methods This is a multicenter observational retrospective study conducted on IC patients consecutively hospitalized with a prolonged or relapsing SARS-CoV-2 infection from November 2020 to January 2023. IC COVID-19 subjects were stratified according to the monotherapy or combination anti-SARS-CoV-2 therapy received. Results Eighty-eight patients were enrolled, 19 under monotherapy and 69 under combination therapy. The study population had a history of immunosuppression (median of 2 B-cells/mm3, IQR 1-24 cells), and residual hypogammaglobulinemia was observed in 55 patients. A reduced length of hospitalization and time to negative SARS-CoV-2 molecular nasopharyngeal swab (NPS) in the combination versus monotherapy group was observed. In the univariable and multivariable analyses, the percentage change in the rate of days to NPS negativity showed a significant reduction in patients receiving combination therapy compared to those receiving monotherapy. Conclusion In IC persistent COVID-19 patients, it is essential to explore new therapeutic strategies such as combination multi-target therapy (antiviral or double antiviral plus antibody-based therapies) to avoid persistent viral shedding and/or severe SARS-CoV-2 infection.
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Affiliation(s)
- Alessandra D’Abramo
- National Institute for Infectious Diseases “Lazzaro Spallanzani” IRCCS, Rome, Italy
| | - Serena Vita
- National Institute for Infectious Diseases “Lazzaro Spallanzani” IRCCS, Rome, Italy
| | - Alessia Beccacece
- National Institute for Infectious Diseases “Lazzaro Spallanzani” IRCCS, Rome, Italy
| | - Assunta Navarra
- National Institute for Infectious Diseases “Lazzaro Spallanzani” IRCCS, Rome, Italy
| | - Raffaella Pisapia
- Infectious Diseases Unit, "D. Cotugno" Hospital, AORN dei Colli, Naples, Italy
| | | | - Giulia Matusali
- National Institute for Infectious Diseases “Lazzaro Spallanzani” IRCCS, Rome, Italy
| | - Enrico Girardi
- National Institute for Infectious Diseases “Lazzaro Spallanzani” IRCCS, Rome, Italy
| | - Fabrizio Maggi
- National Institute for Infectious Diseases “Lazzaro Spallanzani” IRCCS, Rome, Italy
| | - Delia Goletti
- National Institute for Infectious Diseases “Lazzaro Spallanzani” IRCCS, Rome, Italy
| | - Emanuele Nicastri
- National Institute for Infectious Diseases “Lazzaro Spallanzani” IRCCS, Rome, Italy
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Brosh-Nissimov T, Ma'aravi N, Leshin-Carmel D, Edel Y, Ben Barouch S, Segman Y, Cahan A, Barenboim E. Combination treatment of persistent COVID-19 in immunocompromised patients with remdesivir, nirmaltrevir/ritonavir and tixegavimab/cilgavimab. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024; 57:189-194. [PMID: 37805361 DOI: 10.1016/j.jmii.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/01/2023] [Accepted: 09/17/2023] [Indexed: 10/09/2023]
Abstract
We present a retrospective study on the treatment outcomes of severely immunocompromised patients with persistent COVID-19. The study analyzed data from 14 patients who received a combination of tixegavimab/cilgavimab and antiviral medications. Response was evaluated based on symptom improvement, PCR cycle-threshold values, and C-reactive protein levels. Eleven patients achieved complete clinical and virological resolution, while three showed partial responses. The study suggests a potential association between non-response and tixegavimab/cilgavimab neutralization. The findings underscore the need for tailored treatment approaches and further research on optimal strategies for managing persistent COVID-19, as well as the development of antivirals and variant-specific monoclonal antibodies.
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Affiliation(s)
- Tal Brosh-Nissimov
- Samson Assuta Ashdod University Hospital, Ashdod, Israel; Faculty of Health Sciences, Ben Gurion University in the Negev, Beer Sheba, Israel.
| | - Nir Ma'aravi
- Samson Assuta Ashdod University Hospital, Ashdod, Israel
| | | | - Yonatan Edel
- Samson Assuta Ashdod University Hospital, Ashdod, Israel; Faculty of Health Sciences, Ben Gurion University in the Negev, Beer Sheba, Israel
| | - Sharon Ben Barouch
- Samson Assuta Ashdod University Hospital, Ashdod, Israel; Faculty of Health Sciences, Ben Gurion University in the Negev, Beer Sheba, Israel
| | - Yafit Segman
- Samson Assuta Ashdod University Hospital, Ashdod, Israel; Faculty of Health Sciences, Ben Gurion University in the Negev, Beer Sheba, Israel
| | - Amos Cahan
- Samson Assuta Ashdod University Hospital, Ashdod, Israel
| | - Erez Barenboim
- Samson Assuta Ashdod University Hospital, Ashdod, Israel
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11
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Shafat T, Grupel D, Porges T, Abuhasira R, Belkin A, Deri O, Oster Y, Zahran S, Horwitz E, Horowitz NA, Khatib H, Batista MV, Cortez AC, Brosh‐Nissimov T, Segman Y, Ishay L, Cohen R, Atamna A, Spallone A, Chemaly RF, Ramos‐Ramos JC, Chowers M, Rogozin E, Oren NC, Keske Ş, Barchad OW, Nesher L. An international multicenter study comparing COVID-19 omicron outcomes in patients with hematological malignancies treated with obinutuzumab versus rituximab. Cancer Med 2024; 13:e6997. [PMID: 38400683 PMCID: PMC10891459 DOI: 10.1002/cam4.6997] [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: 10/18/2023] [Revised: 01/23/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES Hematological malignancy (HM) patients treated with anti-CD20 monoclonal antibodies are at higher risk for severe COVID-19. A previous single-center study showed worse outcomes in patients treated with obinutuzumab compared to rituximab. We examined this hypothesis in a large international multicenter cohort. METHODS We included HM patients from 15 centers, from five countries treated with anti-CD20, comparing those treated with obinutuzumab (O-G) to rituximab (R-G) between December 2021 and June 2022, when Omicron lineage was dominant. RESULTS We collected data on 1048 patients. Within the R-G (n = 762, 73%), 191 (25%) contracted COVID-19 compared to 103 (36%) in the O-G. COVID-19 patients in the O-G were younger (61 ± 11.7 vs. 64 ± 14.5, p = 0.039), had more indolent HM diagnosis (aggressive lymphoma: 3.9% vs. 67.0%, p < 0.001), and most were on maintenance therapy at COVID-19 diagnosis (63.0% vs. 16.8%, p < 0.001). Severe-critical COVID-19 occurred in 31.1% of patients in the O-G and 22.5% in the R-G. In multivariable analysis, O-G had a 2.08-fold increased risk for severe-critical COVID-19 compared to R-G (95% CI 1.13-3.84), adjusted for Charlson comorbidity index, sex, and tixagevimab/cilgavimab (T-C) prophylaxis. Further analysis comparing O-G to R-G demonstrated increased hospitalizations (51.5% vs. 35.6% p = 0.008), ICU admissions (12.6% vs. 5.8%, p = 0.042), but the nonsignificant difference in COVID-19-related mortality (n = 10, 9.7% vs. n = 12, 6.3%, p = 0.293). CONCLUSIONS Despite younger age and a more indolent HM diagnosis, patients receiving obinutuzumab had more severe COVID-19 outcomes than those receiving rituximab. Our findings underscore the need to evaluate the risk-benefit balance when considering obinutuzumab therapy for HM patients during respiratory viral outbreaks.
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Affiliation(s)
- Tali Shafat
- Infectious Diseases Institute, Soroka University Medical Center, and the Faculty of Health SciencesBen‐Gurion University of the NegevBeer‐ShevaIsrael
- Clinical Research Center, Soroka University Medical Center, and the Faculty of Health SciencesBen‐Gurion University of the NegevBeer‐ShevaIsrael
- Department of Infectious Diseases, Infection Control and Employee HealthThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Respiratory Viruses (ESGREV)BaselSwitzerland
| | - Daniel Grupel
- Department of Clinical Microbiology and Infectious DiseasesHadassah Medical CenterJerusalemIsrael
- Faculty of MedicineHebrew UniversityJerusalemIsrael
| | - Tzvika Porges
- Hematology Department, Soroka University Medical Center, and the Faculty of Health SciencesBen‐Gurion University of the NegevBeer‐ShevaIsrael
| | - Ran Abuhasira
- Clinical Research Center, Soroka University Medical Center, and the Faculty of Health SciencesBen‐Gurion University of the NegevBeer‐ShevaIsrael
| | - Ana Belkin
- Internal Medicine D and Infectious Diseases UnitSheba Medical CenterRamat‐GanIsrael
- Sackler Faculty of MedicineTel Aviv UniversityRamat‐AvivIsrael
| | - Ofir Deri
- Internal Medicine TSheba Medical CenterRamat‐GanIsrael
| | - Yonatan Oster
- Department of Clinical Microbiology and Infectious DiseasesHadassah Medical CenterJerusalemIsrael
- Faculty of MedicineHebrew UniversityJerusalemIsrael
| | - Shadi Zahran
- Department of Clinical Microbiology and Infectious DiseasesHadassah Medical CenterJerusalemIsrael
- Faculty of MedicineHebrew UniversityJerusalemIsrael
| | - Ehud Horwitz
- Department of Clinical Microbiology and Infectious DiseasesHadassah Medical CenterJerusalemIsrael
- Faculty of MedicineHebrew UniversityJerusalemIsrael
| | - Netanel A. Horowitz
- Department of Hematology and Bone Marrow TransplantationRambam Health Care CampusHaifaIsrael
| | - Hazim Khatib
- Department of Hematology and Bone Marrow TransplantationRambam Health Care CampusHaifaIsrael
| | - Marjorie Vieira Batista
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Respiratory Viruses (ESGREV)BaselSwitzerland
- Department of Infectious DiseasesAC Camargo Cancer CenterSão PauloSão PauloBrazil
| | - Anita Cassoli Cortez
- Department of Hematology and Cell TherapyAC Camargo Cancer CenterSão PauloSão PauloBrazil
| | - Tal Brosh‐Nissimov
- Infectious Diseases UnitSamson Assuta Ashdod University HospitalAshdodIsrael
- The Faculty of Health SciencesBen‐Gurion University of the NegevBeer‐ShevaIsrael
| | - Yafit Segman
- The Faculty of Health SciencesBen‐Gurion University of the NegevBeer‐ShevaIsrael
- Hematology InstituteSamson Assuta Ashdod University HospitalAshdodIsrael
| | - Linor Ishay
- Rappaport Faculty of MedicineTechnionHaifaIsrael
- Hillel Yaffe Medical CenterHaderaIsrael
| | - Regev Cohen
- Rappaport Faculty of MedicineTechnionHaifaIsrael
- Hillel Yaffe Medical CenterHaderaIsrael
| | - Alaa Atamna
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Respiratory Viruses (ESGREV)BaselSwitzerland
- Infectious Diseases Unit, Rabin Medical CenterBeilinson HospitalPetah TikvaIsrael
| | - Amy Spallone
- Department of Infectious Diseases, Infection Control and Employee HealthThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Respiratory Viruses (ESGREV)BaselSwitzerland
| | - Roy F. Chemaly
- Department of Infectious Diseases, Infection Control and Employee HealthThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Respiratory Viruses (ESGREV)BaselSwitzerland
| | - Juan Carlos Ramos‐Ramos
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Respiratory Viruses (ESGREV)BaselSwitzerland
- Infectious Disease UnitInternal Medicine Service. CIBERINFEC. Hospital Universitario La PazMadridSpain
| | - Michal Chowers
- Meir Medical CentreKfar SabaIsrael
- Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Evgeny Rogozin
- Infectious Diseases unitShamir (Assaf Harofeh) Medical CenterBe'er Ya'akovIsrael
| | - Noga Carmi Oren
- Infectious Diseases unitShamir (Assaf Harofeh) Medical CenterBe'er Ya'akovIsrael
| | - Şiran Keske
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Respiratory Viruses (ESGREV)BaselSwitzerland
- Department of Infectious DiseasesVKV American HospitalIstanbulTurkey
| | | | - Lior Nesher
- Infectious Diseases Institute, Soroka University Medical Center, and the Faculty of Health SciencesBen‐Gurion University of the NegevBeer‐ShevaIsrael
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Respiratory Viruses (ESGREV)BaselSwitzerland
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12
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Gentile I, Foggia M, Silvitelli M, Sardanelli A, Cattaneo L, Viceconte G. Optimizing COVID-19 treatment in immunocompromised patients: early combination therapy with remdesivir, nirmatrelvir/ritonavir and sotrovimab. Virol J 2023; 20:301. [PMID: 38102675 PMCID: PMC10724917 DOI: 10.1186/s12985-023-02269-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/12/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Morbidity and mortality are higher in immunocompromised patients affected by COVID-19 than in the general population. Some authors have successfully used antiviral combination, but never in the early phase of the infection. METHODS We conducted a retrospective cohort study to determine the efficacy and safety of the combination of two antivirals, with and without a monoclonal antibody (mAb), in both the early (within 10 days of symptoms) and in a later phase (after 10 days) of SARS-CoV-2 infection in immunocompromised patients admitted to our Facility. RESULTS We treated 11 patients (seven in an early phase and four in a late phase of COVID-19) with 10 days of intravenous remdesivir plus five days of oral nirmatelvir/ritonavir, also combined with sotrovimab in 10/11 cases. Notably, all the "early" patients reached virological clearance at day 30 from the end of the therapy and were alive and well at follow-up, whereas the corresponding numbers in the "late" patients were 50% and 75%. Patients in the "late" group more frequently needed oxygen supplementation (p = 0.015) and steroid therapy (p = 0.045) during admission and reached higher COVID-19 severity (p = 0.017). DISCUSSION The combination of antiviral and sotrovimab in the early phase of COVID-19 is well tolerated by immunocompromised patients and is associated with 100% of virological clearance. Patients treated later have lower response rates and higher disease severity, but whether therapy plays a causative role in such findings has yet to be determined.
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Affiliation(s)
- Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples "AOU Federico II", Via Sergio Pansini,5, Naples, 80131, Italy
| | - Maria Foggia
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples "AOU Federico II", Via Sergio Pansini,5, Naples, 80131, Italy
| | - Maria Silvitelli
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples "AOU Federico II", Via Sergio Pansini,5, Naples, 80131, Italy
| | - Alessia Sardanelli
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples "AOU Federico II", Via Sergio Pansini,5, Naples, 80131, Italy
| | - Letizia Cattaneo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples "AOU Federico II", Via Sergio Pansini,5, Naples, 80131, Italy
| | - Giulio Viceconte
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples "AOU Federico II", Via Sergio Pansini,5, Naples, 80131, Italy.
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13
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Pasquini Z, Toschi A, Casadei B, Pellegrini C, D'Abramo A, Vita S, Beccacece A, Bussini L, Chionsini MC, Dentale N, Cantiani A, Lazzarotto T, Bartoletti M, Nicastri E, Zinzani P, Giannella M, Viale P. Dual combined antiviral treatment with remdesivir and nirmatrelvir/ritonavir in patients with impaired humoral immunity and persistent SARS-CoV-2 infection. Hematol Oncol 2023; 41:904-911. [PMID: 37452579 DOI: 10.1002/hon.3206] [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: 04/21/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
Despite global vaccination efforts, immunocompromized patients remain at high risk for COVID-19-associated morbidity. In particular, patients with impaired humoral immunity have shown a high risk of persistent infection. We report a case series of adult patients with B cell malignancies and/or undergoing B cell targeting therapies with persisting SARS-CoV-2 infection and treated with a combination antiviral therapy of remdesivir and nirmatrelvir/ritonavir, in three Italian tertiary academic hospitals. A total of 14 patients with impaired adaptive humoral immunity and prolonged SARS-CoV-2 infection were treated with the dual antiviral therapy. The median age was 60 (IQR 56-68) years, and 11 were male. Twelve patients had B cell lymphoma, one patient had chronic lymphocytic leukemia and one patient had multiple sclerosis. Thirteen out of 14 patients had received prior B cell-targeting therapies, consisting of anti-CD20 monoclonal antibodies in 11 patients, and chimeric antigen receptor T therapy in 2 patients. The median time between diagnosis and therapy start was 42.0 (IQR 35-46) days. Seven patients had mild, 6 moderate and one severe disease. Nine patients had signs of interstitial pneumonitis on chest computed tomography scans before treatment. The median duration of nirmatrelvir/ritonavir and remdesivir combination therapy was 10 days. All patients showed resolution of COVID-19-related symptoms after a median of 6 (IQR 4-11) days and viral clearance after 9 (IQR 5-11) days. Combination therapy with remdesivir and nirmatrelvir/ritonavir is a promising treatment option for persistent COVID-19 in immunocompromized patients with humoral immunity impairment, worthy of prospective comparative trials.
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Affiliation(s)
- Zeno Pasquini
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alice Toschi
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Beatrice Casadei
- Institute of Hematology "L. e A. Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Cinzia Pellegrini
- Institute of Hematology "L. e A. Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alessandra D'Abramo
- National Institute for Infectious Diseases "Lazzaro Spallanzani", IRCCS, Rome, Italy
| | - Serena Vita
- National Institute for Infectious Diseases "Lazzaro Spallanzani", IRCCS, Rome, Italy
| | - Alessia Beccacece
- National Institute for Infectious Diseases "Lazzaro Spallanzani", IRCCS, Rome, Italy
| | - Linda Bussini
- Infectious Disease Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Maria Clara Chionsini
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Nicola Dentale
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessia Cantiani
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Tiziana Lazzarotto
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Michele Bartoletti
- Infectious Disease Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Emanuele Nicastri
- National Institute for Infectious Diseases "Lazzaro Spallanzani", IRCCS, Rome, Italy
| | - Pierluigi Zinzani
- Institute of Hematology "L. e A. Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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14
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Kang SW, Kim JW, Kim JY, Lim SY, Jang CY, Chang E, Yang JS, Kim KC, Jang HC, Kim D, Shin Y, Lee JY, Kim SH. Virological characteristics and the rapid antigen test as deisolation criteria in immunocompromised patients with COVID-19: A prospective cohort study. J Med Virol 2023; 95:e29228. [PMID: 38009999 DOI: 10.1002/jmv.29228] [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: 05/01/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023]
Abstract
There are limited data supporting current Centers for Disease Control and Prevention guidelines for the isolation period in moderate to severely immunocompromised patients with coronavirus disease 2019 (COVID-19). Adult COVID-19 patients who underwent solid organ transplantation (SOT) or received active chemotherapy against hematologic malignancy were enrolled and weekly respiratory samples were collected. Samples with positive genomic real-time polymerase chain reaction results underwent virus culture and rapid antigen testing (RAT). A total of 65 patients (40 with hematologic malignancy and 25 SOT) were enrolled. The median duration of viable virus shedding was 4 weeks (interquartile range: 3-7). Multivariable analysis revealed that B-cell depletion (hazard ratio [HR]: 4.76) was associated with prolonged viral shedding, and COVID-19 vaccination (≥3 doses) was negatively associated with prolonged viral shedding (HR: 0.22). The sensitivity, specificity, positive predictive value, and negative predictive value of RAT for viable virus shedding were 79%, 76%, 74%, and 81%, respectively. The negative predictive value of RAT was only 48% (95% confidence interval [CI]: 33-65) in the samples from those with symptom onset ≤20 days, but it was as high as 92% (95% CI: 85-96) in the samples from those with symptom onset >20 days. About half of immunocompromised COVID-19 patients shed viable virus for ≥4 weeks from the diagnosis, and virus shedding was prolonged especially in unvaccinated patients with B-cell-depleting therapy treatment. RAT beyond 20 days in immunocompromised patients had a relatively high negative predictive value for viable virus shedding.
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Affiliation(s)
- Sung-Woon Kang
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Won Kim
- Center for Emerging Virus Research, National Institute of Infectious Diseases, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Ji Yeun Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - So Yun Lim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Choi-Young Jang
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Euijin Chang
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Sun Yang
- Center for Emerging Virus Research, National Institute of Infectious Diseases, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Kyung-Chang Kim
- Center for Emerging Virus Research, National Institute of Infectious Diseases, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Hee-Chang Jang
- Center for Emerging Virus Research, National Institute of Infectious Diseases, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Dasol Kim
- Center for Emerging Virus Research, National Institute of Infectious Diseases, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Younmin Shin
- Center for Emerging Virus Research, National Institute of Infectious Diseases, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Joo-Yeon Lee
- Center for Emerging Virus Research, National Institute of Infectious Diseases, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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15
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Faxén L, Edvinsson M. Persistent SARS-CoV-2 infection in patients with B-cell deficiency: a case series of successful antiviral treatment of four patients. Ups J Med Sci 2023; 128:9807. [PMID: 37849689 PMCID: PMC10578053 DOI: 10.48101/ujms.v128.9807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 10/19/2023] Open
Abstract
Persistent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in immunocompromised patients remains a major medical challenge. Diagnosing the syndrome is difficult as symptoms may mimic other diseases and treatment guidelines are lacking. We describe a case series of four patients with persistent SARS-CoV-2 infection that all had an underlying B-cell deficiency due to rituximab treatment (in one case in combination with epcoritamab). In all four patients, it was initially difficult to recognize the persistent disease, leading to a duration of illness between 45 and 242 days. Two patients were only positive for SARS-CoV-2 by polymerase chain reaction (PCR) in the nasopharynx at the beginning of the disease but were later repeatedly negative. However, when bronchoalveolar lavage was performed, a positive SARS-CoV-2 PCR was revealed from the lower airways in both patients. The difficulties establishing diagnosis contributed to these two patients' long disease course. The longest disease duration was in the patient treated with rituximab and epcoritamab, who also responded poorly to single standard antiviral treatment. This patient ultimately cleared the infection after administering a combination treatment with remdesivir and nirmatrelvir/ritonavir. After a confirmed diagnosis, the other three patients cleared the infection when they were finally treated with antivirals. Increasing clinicians' awareness of this condition is important as it might be treatable once diagnosed. Further studies are warranted to define the condition and treatment strategy with greater precision.
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Affiliation(s)
- Lisa Faxén
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University Hospital, Uppsala, Sweden
| | - Marie Edvinsson
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University Hospital, Uppsala, Sweden
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16
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Longo BM, Venuti F, Gaviraghi A, Lupia T, Ranzani FA, Pepe A, Ponzetta L, Vita D, Allice T, Gregorc V, Frascione PMM, De Rosa FG, Calcagno A, Bonora S. Sequential or Combination Treatments as Rescue Therapies in Immunocompromised Patients with Persistent SARS-CoV-2 Infection in the Omicron Era: A Case Series. Antibiotics (Basel) 2023; 12:1460. [PMID: 37760757 PMCID: PMC10525462 DOI: 10.3390/antibiotics12091460] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Prolonged SARS-CoV-2 infections are widely described in immunosuppressed patients, but safe and effective treatment strategies are lacking. We aimed to outline our approach to treating persistent COVID-19 in patients with immunosuppression from different causes. In this case series, we retrospectively enrolled all immunosuppressed patients with persistent SARS-CoV-2 infections treated at our centers between March 2022 and February 2023. Patients received different sequential or combination regimens, including antivirals (remdesivir, nirmatrelvir/ritonavir, or molnupiravir) and/or monoclonal antibodies (mAbs) (tixagevimab/cilgavimab or sotrovimab). The main outcome was a complete virological response (negative SARS-CoV-2 RT-PCR on nasopharyngeal swabs) at the end of treatment. Fifteen patients were included as follows: eleven (11/15; 73%) with hematological disease and four (4/15; 27%) with recently diagnosed HIV/AIDS infection. Six patients (6/15; 40%) received a single antiviral course, four patients (4/15; 27%) received an antiviral and mAbs sequentially, and two patients (13%) received three lines of treatment (a sequence of three antivirals or two antivirals and mAbs). A combination of two antivirals or one antiviral plus mAbs was administered in three cases (3/15, 20%). One patient died while still positive for SARS-CoV-2, while fourteen (14/15; 93%) tested negative within 16 days after the end of treatment. The median time to negativization since the last treatment was 2.5 days. Both sequential and combination regimens used in this study demonstrated high efficacy and safety in the high-risk group of immunosuppressed patients.
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Affiliation(s)
- Bianca Maria Longo
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, “Amedeo di Savoia” Hospital, ASL “Città di Torino”, 10060 Turin, Italy (F.V.); (D.V.); (F.G.D.R.)
| | - Francesco Venuti
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, “Amedeo di Savoia” Hospital, ASL “Città di Torino”, 10060 Turin, Italy (F.V.); (D.V.); (F.G.D.R.)
| | - Alberto Gaviraghi
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, “Amedeo di Savoia” Hospital, ASL “Città di Torino”, 10060 Turin, Italy (F.V.); (D.V.); (F.G.D.R.)
| | - Tommaso Lupia
- Unit of Infectious Diseases, Cardinal Massaia Hospital, 14100 Asti, Italy
| | - Fabio Antonino Ranzani
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, “Amedeo di Savoia” Hospital, ASL “Città di Torino”, 10060 Turin, Italy (F.V.); (D.V.); (F.G.D.R.)
| | - Andrea Pepe
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, “Amedeo di Savoia” Hospital, ASL “Città di Torino”, 10060 Turin, Italy (F.V.); (D.V.); (F.G.D.R.)
| | - Laura Ponzetta
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, “Amedeo di Savoia” Hospital, ASL “Città di Torino”, 10060 Turin, Italy (F.V.); (D.V.); (F.G.D.R.)
| | - Davide Vita
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, “Amedeo di Savoia” Hospital, ASL “Città di Torino”, 10060 Turin, Italy (F.V.); (D.V.); (F.G.D.R.)
| | - Tiziano Allice
- Microbiology and Molecular Biology Laboratory, “Amedeo di Savoia” Hospital, ASL “Città di Torino”, 10060 Turin, Italy;
| | - Vanesa Gregorc
- Unit of Oncology and Haematology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Candiolo, Italy
| | | | - Francesco Giuseppe De Rosa
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, “Amedeo di Savoia” Hospital, ASL “Città di Torino”, 10060 Turin, Italy (F.V.); (D.V.); (F.G.D.R.)
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126 Turin, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, “Amedeo di Savoia” Hospital, ASL “Città di Torino”, 10060 Turin, Italy (F.V.); (D.V.); (F.G.D.R.)
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, “Amedeo di Savoia” Hospital, ASL “Città di Torino”, 10060 Turin, Italy (F.V.); (D.V.); (F.G.D.R.)
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17
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Mikulska M, Sepulcri C, Dentone C, Magne F, Balletto E, Baldi F, Labate L, Russo C, Mirabella M, Magnasco L, Di Grazia C, Ghiggi C, Raiola AM, Giacobbe DR, Vena A, Beltramini S, Bruzzone B, Lemoli RM, Angelucci E, Bassetti M. Triple Combination Therapy With 2 Antivirals and Monoclonal Antibodies for Persistent or Relapsed Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Immunocompromised Patients. Clin Infect Dis 2023; 77:280-286. [PMID: 36976301 DOI: 10.1093/cid/ciad181] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/16/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Severely immunocompromised patients are at risk for prolonged or relapsed Coronavirus Disease 2019 (COVID-19), leading to increased morbidity and mortality. We aimed to evaluate efficacy and safety of combination treatment in immunocompromised COVID-19 patients. METHODS We included all immunocompromised patients with prolonged/relapsed COVID-19 treated with combination therapy with 2 antivirals (remdesivir plus nirmatrelvir/ritonavir, or molnupiravir in case of renal failure) plus, if available, anti-spike monoclonal antibodies (mAbs), between February and October 2022. The main outcomes were virological response at day 14 (negative Severe Acute Respiratory Syndrome Coronavirus 2 [SARS-CoV-2] swab) and virological and clinical response (alive, asymptomatic, with negative SARS-CoV-2 swab) at day 30 and the last follow-up. RESULTS Overall, 22 patients (Omicron variant in 17/18) were included: 18 received full combination of 2 antivirals and mAbs and 4 received 2 antivirals only; in 20 of 22 (91%) patients, 2 antivirals were nirmatrelvir/ritonavir plus remdesivir. Nineteen (86%) patients had hematological malignancy, and 15 (68%) had received anti-CD20 therapy. All were symptomatic; 8 (36%) required oxygen. Four patients received a second course of combination treatment. The response rate at day 14, day 30, and last follow-up was 75% (15/20 evaluable), 73% (16/22), and 82% (18/22), respectively. Day 14 and 30 response rates were significantly higher when combination therapy included mAbs. Higher number of vaccine doses was associated with better final outcome. Two patients (9%) developed severe side effects (bradycardia leading to remdesivir discontinuation and myocardial infarction). CONCLUSIONS Combination therapy including 2 antivirals (mainly remdesivir and nirmatrelvir/ritonavir) and mAbs was associated with high rate of virological and clinical response in immunocompromised patients with prolonged/relapsed COVID-19.
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Affiliation(s)
- Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Sepulcri
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Dentone
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Federica Magne
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Elisa Balletto
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Federico Baldi
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Laura Labate
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Russo
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Michele Mirabella
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Laura Magnasco
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carmen Di Grazia
- Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Ghiggi
- Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Anna Maria Raiola
- Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Daniele Roberto Giacobbe
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Antonio Vena
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Bianca Bruzzone
- Department of Health Sciences, Hygiene Unit, Ospedale Policlinico San Martino, University of Genoa, Genova, Italy
| | - Roberto M Lemoli
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, Clinic of Hematology, University of Genoa, Genova, Italy
| | - Emanuele Angelucci
- Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Matteo Bassetti
- Division of Infectious Diseases, Department of Health Sciences, University of Genoa, Genoa, Italy
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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18
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Múñez-Rubio E, Calderón-Parra J, Fernández-Cruz A, Moreno-Torres V, Blanco-Alonso S, Ramos-Martínez A. Re: 'the unique COVID-19 presentation of patients with B cell depletion' by Belkin et al. Clin Microbiol Infect 2023; 29:272-273. [PMID: 36309327 PMCID: PMC9605786 DOI: 10.1016/j.cmi.2022.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Elena Múñez-Rubio
- Infectious Diseases Unit, Internal Medicine Department. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Majadahonda, Madrid, Spain.
| | - Jorge Calderón-Parra
- Infectious Diseases Unit, Internal Medicine Department. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain,Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Majadahonda, Madrid, Spain
| | - Ana Fernández-Cruz
- Infectious Diseases Unit, Internal Medicine Department. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain,Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Majadahonda, Madrid, Spain
| | - Víctor Moreno-Torres
- Infectious Diseases Unit, Internal Medicine Department. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain,Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Majadahonda, Madrid, Spain
| | | | - Antonio Ramos-Martínez
- Infectious Diseases Unit, Internal Medicine Department. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain,Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Majadahonda, Madrid, Spain,Medicine Department, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
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19
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Baldi F, Dentone C, Mikulska M, Fenoglio D, Mirabella M, Magnè F, Portunato F, Altosole T, Sepulcri C, Giacobbe DR, Uras C, Scavone G, Taramasso L, Orsi A, Cittadini G, Filaci G, Bassetti M. Case report: Sotrovimab, remdesivir and nirmatrelvir/ritonavir combination as salvage treatment option in two immunocompromised patients hospitalized for COVID-19. Front Med (Lausanne) 2023; 9:1062450. [PMID: 36698815 PMCID: PMC9868302 DOI: 10.3389/fmed.2022.1062450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/12/2022] [Indexed: 01/10/2023] Open
Abstract
COVID-19 in immunocompromised patients is difficult to treat. SARS-CoV-2 interaction with the host immune system and the role of therapy still remains only partly understood. There are no data regarding the use of monoclonal antibodies and the combination of two antivirals in fighting viral replication and disease progression. We report the cases of two patients, both treated with rituximab for non-Hodgkin lymphoma and granulomatosis with polyangiitis, respectively, and both hospitalized for COVID-19 with positive SARS-CoV-2 RNAemia, who were successfully treated with a salvage combination therapy with sotrovimab, remdesivir and nirmatrelvir/ritonavir.
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Affiliation(s)
- Federico Baldi
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Infectious Diseases Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy,*Correspondence: Federico Baldi,
| | - Chiara Dentone
- Infectious Diseases Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
| | - Malgorzata Mikulska
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Infectious Diseases Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
| | - Daniela Fenoglio
- Department of Internal Medicine, Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy,Biotherapy Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
| | - Michele Mirabella
- Infectious Diseases Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
| | - Federica Magnè
- Infectious Diseases Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
| | - Federica Portunato
- Infectious Diseases Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
| | - Tiziana Altosole
- Department of Internal Medicine, Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - Chiara Sepulcri
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Infectious Diseases Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
| | - Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Infectious Diseases Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy,Daniele Roberto Giacobbe,
| | - Chiara Uras
- Department of Internal Medicine, Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - Graziana Scavone
- Biotherapy Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
| | - Lucia Taramasso
- Infectious Diseases Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
| | - Andrea Orsi
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Hygiene Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
| | - Giuseppe Cittadini
- General Radiology, Polyclinic San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Gilberto Filaci
- Department of Internal Medicine, Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy,Biotherapy Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Infectious Diseases Unit, Polyclinic San Martino Hospital (IRCCS), Genoa, Italy
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