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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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Ramachandram DS, Kow CS, Hasan SS, Thiruchelvam K. Effect of intravenous immunoglobulin on mortality in hospitalized patients with COVID-19: A systematic review and meta-analysis of randomized controlled trials. Health Sci Rep 2024; 7:e2239. [PMID: 38983684 PMCID: PMC11230917 DOI: 10.1002/hsr2.2239] [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: 09/07/2023] [Revised: 06/18/2024] [Accepted: 06/25/2024] [Indexed: 07/11/2024] Open
Abstract
Background and Aims We performed a meta-analysis of randomized controlled trials (RCTs) to summarize the overall effect of intravenous immunoglobulin (IVIG) on mortality outcomes among hospitalized coronavirus disease 2019 (COVID-19) patients. Methods We systematically searched electronic databases up to June 1, 2023. Pooled odds ratio (OR) of mortality with a 95% confidence interval (CI) was generated using a random-effects model. The risk of bias was appraised using the Cochrane risk-of-bias Version 2 tool for randomized trials. Results Nine RCTs were included: three RCTs had an overall low risk of bias, four RCTs had some concerns in the overall risk of bias, and two RCTs trials had an overall high risk of bias. The use of IVIG indicated a significant reduction in the odds of mortality (pooled OR = 0.69; 95% CI 0.50-0.96) relative to nonuse of IVIG. Subgroup analysis in patients with a severe course of COVID-19 revealed no significant reduction in the odds of mortality (pooled OR = 0.58; 95% CI 0.29-1.16). Conclusions We suggest exercising caution when interpreting effectiveness of IVIG in reducing mortality among hospitalized patients with COVID-19. Our findings emphasize for larger trials with rigorous study designs to better understand the impact of IVIG, particularly in those with severe COVID-19.
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Affiliation(s)
| | - Chia Siang Kow
- School of PharmacyIMU UniversityKuala LumpurMalaysia
- School of Applied SciencesUniversity of HuddersfieldHuddersfieldUnited Kingdom
| | - Syed Shahzad Hasan
- School of Applied SciencesUniversity of HuddersfieldHuddersfieldUnited Kingdom
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Maor Y, Zimhony O. Hyperimmune Globulins in COVID-19. Curr Top Microbiol Immunol 2024. [PMID: 38877201 DOI: 10.1007/82_2024_277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024]
Abstract
The COVID-19 pandemic, resulting from the emergence of the novel coronavirus SARS-CoV-2, posed unprecedented challenges to global health systems as no proven therapy was available. Initially, COVID-19 convalescent plasma (CCP) from recovered COVID-19 patients showed promise as a therapeutic option. However, the efficacy of this approach was closely correlated with the neutralizing antibody titer in the administered plasma and thus effectiveness was not always guaranteed. In response, hyperimmune immunoglobulins (hIG) derived from CCP obtained by apheresis from recovered or vaccinated individuals emerged as a potential alternative. hIG were purified through stringent chromatographic processing from CCP units and displayed varying results in clinical trials, although it seems likely that they improved outcomes compared to placebo or CCP at day 28, particularly in unvaccinated patients. The variability in the effect of hIG likely stems from factors such as the timing of outcome assessment, the administered dose of hIG, the patients' immunological background, and the matching between the variant infecting patients and the neutralization ability of the immunoglobulin batch, which depended on the timing of the CCP collection. Despite logistical challenges and high production costs, hIG showcase advantages over CCP, offering versatility in administration routes and eliminating the need for blood matching, thus facilitating administration in the community, and allowing for variant-specific preparations. hIG appear to be of particular importance in the treatment of immunocompromised patients and patients with persistent COVID-19, although studies in these populations are lacking. Non-human alternatives, such as equine-derived hIG and recombinant hIG, may provide a solution to the logistical challenges of large-scale hIG preparation. Further study is needed to explore these avenues. Establishing the infrastructure for large-scale hIG production independent of plasma donations emerges as a strategic approach for future pandemics, justifying exploration and promotion by health authorities.
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Affiliation(s)
- Yasmin Maor
- Infectious Disease Unit, E. Wolfson Medical Center, Halochamim 62, 58100, Holon, Israel.
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Oren Zimhony
- Infectious Diseases Unit, Kaplan Medical Center, Rehovot, Israel
- Faculty of Medicine, Hebrew University and Hadassah, Jerusalem, Israel
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Focosi D, Franchini M, Maggi F, Shoham S. COVID-19 therapeutics. Clin Microbiol Rev 2024; 37:e0011923. [PMID: 38771027 PMCID: PMC11237566 DOI: 10.1128/cmr.00119-23] [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] [Indexed: 05/22/2024] Open
Abstract
SUMMARYSince the emergence of COVID-19 in 2020, an unprecedented range of therapeutic options has been studied and deployed. Healthcare providers have multiple treatment approaches to choose from, but efficacy of those approaches often remains controversial or compromised by viral evolution. Uncertainties still persist regarding the best therapies for high-risk patients, and the drug pipeline is suffering fatigue and shortage of funding. In this article, we review the antiviral activity, mechanism of action, pharmacokinetics, and safety of COVID-19 antiviral therapies. Additionally, we summarize the evidence from randomized controlled trials on efficacy and safety of the various COVID-19 antivirals and discuss unmet needs which should be addressed.
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Affiliation(s)
- Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
| | - Massimo Franchini
- Division of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy
| | - Fabrizio Maggi
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome, Italy
| | - Shmuel Shoham
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Kumar A, Tripathi P, Kumar P, Shekhar R, Pathak R. From Detection to Protection: Antibodies and Their Crucial Role in Diagnosing and Combatting SARS-CoV-2. Vaccines (Basel) 2024; 12:459. [PMID: 38793710 PMCID: PMC11125746 DOI: 10.3390/vaccines12050459] [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: 03/13/2024] [Revised: 04/20/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024] Open
Abstract
Understanding the antibody response to SARS-CoV-2, the virus responsible for COVID-19, is crucial to comprehending disease progression and the significance of vaccine and therapeutic development. The emergence of highly contagious variants poses a significant challenge to humoral immunity, underscoring the necessity of grasping the intricacies of specific antibodies. This review emphasizes the pivotal role of antibodies in shaping immune responses and their implications for diagnosing, preventing, and treating SARS-CoV-2 infection. It delves into the kinetics and characteristics of the antibody response to SARS-CoV-2 and explores current antibody-based diagnostics, discussing their strengths, clinical utility, and limitations. Furthermore, we underscore the therapeutic potential of SARS-CoV-2-specific antibodies, discussing various antibody-based therapies such as monoclonal antibodies, polyclonal antibodies, anti-cytokines, convalescent plasma, and hyperimmunoglobulin-based therapies. Moreover, we offer insights into antibody responses to SARS-CoV-2 vaccines, emphasizing the significance of neutralizing antibodies in order to confer immunity to SARS-CoV-2, along with emerging variants of concern (VOCs) and circulating Omicron subvariants. We also highlight challenges in the field, such as the risks of antibody-dependent enhancement (ADE) for SARS-CoV-2 antibodies, and shed light on the challenges associated with the original antigenic sin (OAS) effect and long COVID. Overall, this review intends to provide valuable insights, which are crucial to advancing sensitive diagnostic tools, identifying efficient antibody-based therapeutics, and developing effective vaccines to combat the evolving threat of SARS-CoV-2 variants on a global scale.
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Affiliation(s)
- Anoop Kumar
- Molecular Diagnostic Laboratory, National Institute of Biologicals, Noida 201309, India
| | - Prajna Tripathi
- Department of Microbiology and Immunology, Weill Cornell Medical College, New York, NY 10021, USA;
| | - Prashant Kumar
- R. Ken Coit College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA
| | - Ritu Shekhar
- Department of Molecular Genetics and Microbiology, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Rajiv Pathak
- Department of Genetics, Albert Einstein College of Medicine, Bronx, New York, NY 10461, USA
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Franchini M, Focosi D. Hyperimmune Plasma and Immunoglobulins against COVID-19: A Narrative Review. Life (Basel) 2024; 14:214. [PMID: 38398723 PMCID: PMC10890293 DOI: 10.3390/life14020214] [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: 11/20/2023] [Revised: 01/28/2024] [Accepted: 01/30/2024] [Indexed: 02/25/2024] Open
Abstract
Since late 2019, the new SARS-CoV-2 virus belonging to the Coronaviridae family has been responsible for COVID-19 pandemic, a severe acute respiratory syndrome. Several antiviral therapies, mostly derived from previous epidemics, were initially repurposed to fight this not rarely life-threatening respiratory illness. Among them, however, the only specific antibody-based therapy available against SARS-CoV-2 infection during the first year of the pandemic was represented by COVID-19 convalescent plasma (CCP). CCP, collected from recovered individuals, contains high levels of polyclonal antibodies of different subclasses able to neutralize SARS-CoV-2 infection. Tens of randomized controlled trials have been conducted during the last three years of the pandemic to evaluate the safety and the clinical efficacy of CCP in both hospitalized and ambulatory COVID-19 patients, whose main results will be summarized in this narrative review. In addition, we will present the current knowledge on the development of anti-SARS-CoV-2 hyperimmune polyclonal immunoglobulins.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, 46100 Mantua, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, 56124 Pisa, Italy;
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Maor Y, Zimhony O. Reply to Focosi et al. Clin Infect Dis 2023; 77:1357-1358. [PMID: 37398995 DOI: 10.1093/cid/ciad403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/28/2023] [Indexed: 07/04/2023] Open
Affiliation(s)
- Yasmin Maor
- Infectious Disease Unit, Wolfson Medical Center, Holon, Israel and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oren Zimhony
- Infectious Diseases Unit, Kaplan Medical Center, Rehovot, Israel
- Faculty of Medicine, Hebrew University and Hadassah, Jerusalem, Israel
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Focosi D, Franchini M, Nicastri E, Sullivan DJ, Casadevall A. Convalescent Plasma Versus Hyperimmune Immunoglobulins. Clin Infect Dis 2023; 77:1356-1357. [PMID: 37399022 DOI: 10.1093/cid/ciad406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 06/28/2023] [Indexed: 07/04/2023] Open
Affiliation(s)
- Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
| | - Massimo Franchini
- Division of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy
| | - Emanuele Nicastri
- Division of Infectious Diseases, National Institute for Infectious Diseases "Lazzaro Spallanzani," Rome, Italy
| | - David J Sullivan
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Arturo Casadevall
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Bellusci L, Golding H, Khurana S. Comparison of SARS-CoV-2 Hyperimmune Immunoglobulins Following Infection Plus Vaccination vs Infection. JAMA Netw Open 2023; 6:e2327307. [PMID: 37540517 PMCID: PMC10403779 DOI: 10.1001/jamanetworkopen.2023.27307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/23/2023] [Indexed: 08/05/2023] Open
Abstract
This cross-sectional study compares the neutralizing titers of convalescent plasma and hyperimmune anti–SARS-CoV-2 intravenous immunoglobulins against circulating Omicron subvariants.
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Affiliation(s)
- Lorenza Bellusci
- Division of Viral Products, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Hana Golding
- Division of Viral Products, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Surender Khurana
- Division of Viral Products, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
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