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Gregory E Edelstein

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Li Y, Choudhary MC, Regan J, Boucau J, Nathan A, Speidel T, Liew MY, Edelstein GE, Kawano Y, Uddin R, Deo R, Marino C, Getz MA, Reynolds Z, Barry M, Gilbert RF, Tien D, Sagar S, Vyas TD, Flynn JP, Hammond SP, Novack LA, Choi B, Cernadas M, Wallace ZS, Sparks JA, Vyas JM, Seaman MS, Gaiha GD, Siedner MJ, Barczak AK, Lemieux JE, Li JZ. SARS-CoV-2 viral clearance and evolution varies by type and severity of immunodeficiency. Sci Transl Med 2024;16:eadk1599. [PMID: 38266109 PMCID: PMC10982957 DOI: 10.1126/scitranslmed.adk1599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 12/18/2023] [Indexed: 01/26/2024]

Affiliation(s)

Yijia Li Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
Manish C. Choudhary Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
James Regan Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
Julie Boucau Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
Anusha Nathan Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA Program in Health Sciences and Technology, Harvard Medical School and Massachusetts Institute of Technology, Boston, MA 02115, USA
Tessa Speidel Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
May Yee Liew Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
Gregory E. Edelstein Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
Yumeko Kawano Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
Rockib Uddin Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
Rinki Deo Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
Caitlin Marino Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
Matthew A. Getz Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
Zahra Reynolds Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
Mamadou Barry Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
Rebecca F. Gilbert Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
Dessie Tien Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
Shruti Sagar Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
Tammy D. Vyas Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
James P. Flynn Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
Sarah P. Hammond Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
Lewis A. Novack Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
Bina Choi Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
Manuela Cernadas Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
Zachary S. Wallace Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
Jeffrey A. Sparks Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
Jatin M. Vyas Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
Michael S. Seaman Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
Gaurav D. Gaiha Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
Mark J. Siedner Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
Amy K. Barczak Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
Jacob E. Lemieux Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
Jonathan Z. Li Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA

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Edelstein GE, Boucau J, Uddin R, Marino C, Liew MY, Barry M, Choudhary MC, Gilbert RF, Reynolds Z, Li Y, Tien D, Sagar S, Vyas TD, Kawano Y, Sparks JA, Hammond SP, Wallace Z, Vyas JM, Barczak AK, Lemieux JE, Li JZ, Siedner MJ. SARS-CoV-2 Virologic Rebound With Nirmatrelvir-Ritonavir Therapy : An Observational Study. Ann Intern Med 2023;176:1577-1585. [PMID: 37956428 PMCID: PMC10644265 DOI: 10.7326/m23-1756] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open

Abstract

BACKGROUND

Data are conflicting regarding an association between treatment of acute COVID-19 with nirmatrelvir-ritonavir (N-R) and virologic rebound (VR).

OBJECTIVE

To compare the frequency of VR in patients with and without N-R treatment for acute COVID-19.

DESIGN

Observational cohort study.

SETTING

Multicenter health care system in Boston, Massachusetts.

PARTICIPANTS

Ambulatory adults with acute COVID-19 with and without use of N-R.

INTERVENTION

Receipt of 5 days of N-R treatment versus no COVID-19 therapy.

MEASUREMENTS

The primary outcome was VR, defined as either a positive SARS-CoV-2 viral culture result after a prior negative result or 2 consecutive viral loads above 4.0 log10 copies/mL that were also at least 1.0 log10 copies/mL higher than a prior viral load below 4.0 log10 copies/mL.

RESULTS

Compared with untreated persons (n = 55), those taking N-R (n = 72) were older, received more COVID-19 vaccinations, and more commonly had immunosuppression. Fifteen participants (20.8%) taking N-R had VR versus 1 (1.8%) who was untreated (absolute difference, 19.0 percentage points [95% CI, 9.0 to 29.0 percentage points]; P = 0.001). All persons with VR had a positive viral culture result after a prior negative result. In multivariable models, only N-R use was associated with VR (adjusted odds ratio, 10.02 [CI, 1.13 to 88.74]; P = 0.038). Virologic rebound was more common among those who started therapy within 2 days of symptom onset (26.3%) than among those who started 2 or more days after symptom onset (0%) (P = 0.030). Among participants receiving N-R, those who had VR had prolonged shedding of replication-competent virus compared with those who did not have VR (median, 14 vs. 3 days). Eight of 16 participants (50% [CI, 25% to 75%]) with VR also reported symptom rebound; 2 were completely asymptomatic. No post-VR resistance mutations were detected.

LIMITATIONS

Observational study design with differences between the treated and untreated groups; positive viral culture result was used as a surrogate marker for risk for ongoing viral transmission.

CONCLUSION

Virologic rebound occurred in approximately 1 in 5 people taking N-R, often without symptom rebound, and was associated with shedding of replication-competent virus.

PRIMARY FUNDING SOURCE

National Institutes of Health.

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Affiliation(s)

Gregory E Edelstein Brigham and Women's Hospital, Boston, Massachusetts (G.E.E., Y.K., J.A.S.)
Julie Boucau Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts (J.B., C.M.)
Rockib Uddin Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
Caitlin Marino Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts (J.B., C.M.)
May Y Liew Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
Mamadou Barry Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
Manish C Choudhary Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (M.C.C., J.Z.L.)
Rebecca F Gilbert Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
Zahra Reynolds Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
Yijia Li Brigham and Women's Hospital and Massachusetts General Hospital, Boston, Massachusetts, and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Y.L.)
Dessie Tien Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
Shruti Sagar Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
Tammy D Vyas Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
Yumeko Kawano Brigham and Women's Hospital, Boston, Massachusetts (G.E.E., Y.K., J.A.S.)
Jeffrey A Sparks Brigham and Women's Hospital, Boston, Massachusetts (G.E.E., Y.K., J.A.S.)
Sarah P Hammond Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
Zachary Wallace Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
Jatin M Vyas Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (J.M.V.)
Amy K Barczak Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, and Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (A.K.B.)
Jacob E Lemieux Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, and Broad Institute, Cambridge, Massachusetts (J.E.L.)
Jonathan Z Li Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (M.C.C., J.Z.L.)
Mark J Siedner Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, and Africa Health Research Institute, KwaZulu-Natal, South Africa (M.J.S.)

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Li Y, Choudhary MC, Regan J, Boucau J, Nathan A, Speidel T, Liew MY, Edelstein GE, Kawano Y, Uddin R, Deo R, Marino C, Getz MA, Reynold Z, Barry M, Gilbert RF, Tien D, Sagar S, Vyas TD, Flynn JP, Hammond SP, Novack LA, Choi B, Cernadas M, Wallace ZS, Sparks JA, Vyas JM, Seaman MS, Gaiha GD, Siedner MJ, Barczak AK, Lemieux JE, Li JZ. SARS-CoV-2 Viral Clearance and Evolution Varies by Extent of Immunodeficiency. medRxiv 2023:2023.07.31.23293441. [PMID: 37577493 PMCID: PMC10418302 DOI: 10.1101/2023.07.31.23293441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]

Affiliation(s)

Yijia Li Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Manish C Choudhary Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
James Regan Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
Julie Boucau Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
Anusha Nathan Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA Program in Health Sciences and Technology, Harvard Medical School and Massachusetts Institute of Technology, Boston, MA 02115, USA
Tessa Speidel Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
May Yee Liew Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Broad Institute of MIT and Harvard, Cambridge, MA, USA
Gregory E Edelstein Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
Yumeko Kawano Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
Rockib Uddin Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Broad Institute of MIT and Harvard, Cambridge, MA, USA
Rinki Deo Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
Caitlin Marino Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
Matthew A Getz Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
Zahra Reynold Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Mamadou Barry Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Rebecca F Gilbert Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Dessie Tien Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Shruti Sagar Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Tammy D Vyas Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
James P Flynn Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
Sarah P Hammond Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Lewis A Novack Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
Bina Choi Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
Manuela Cernadas Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
Zachary S Wallace Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Jeffrey A Sparks Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
Jatin M Vyas Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
Michael S Seaman Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
Gaurav D Gaiha Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
Mark J Siedner Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Amy K Barczak Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
Jacob E Lemieux Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Broad Institute of MIT and Harvard, Cambridge, MA, USA
Jonathan Z Li Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA

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Edelstein GE, Boucau J, Uddin R, Marino C, Liew MY, Barry M, Choudhary MC, Gilbert RF, Reynolds Z, Li Y, Tien D, Sagar S, Vyas TD, Kawano Y, Sparks JA, Hammond SP, Wallace Z, Vyas JM, Barczak AK, Lemieux JE, Li JZ, Siedner MJ. SARS-CoV-2 virologic rebound with nirmatrelvir-ritonavir therapy. medRxiv 2023:2023.06.23.23288598. [PMID: 37425934 PMCID: PMC10327262 DOI: 10.1101/2023.06.23.23288598] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]

Abstract

Objective

To compare the frequency of replication-competent virologic rebound with and without nirmatrelvir-ritonavir treatment for acute COVID-19. Secondary aims were to estimate the validity of symptoms to detect rebound and the incidence of emergent nirmatrelvir-resistance mutations after rebound.

Design

Observational cohort study.

Setting

Multicenter healthcare system in Boston, Massachusetts.

Participants

We enrolled ambulatory adults with a positive COVID-19 test and/or a prescription for nirmatrelvir-ritonavir.

Exposures

Receipt of 5 days of nirmatrelvir-ritonavir treatment versus no COVID-19 therapy.

Main Outcome and Measures

The primary outcome was COVID-19 virologic rebound, defined as either (1) a positive SARS-CoV-2 viral culture following a prior negative culture or (2) two consecutive viral loads ≥4.0 log10 copies/milliliter after a prior reduction in viral load to <4.0 log10 copies/milliliter.

Results

Compared with untreated individuals (n=55), those taking nirmatrelvir-ritonavir (n=72) were older, received more COVID-19 vaccinations, and were more commonly immunosuppressed. Fifteen individuals (20.8%) taking nirmatrelvir-ritonavir experienced virologic rebound versus one (1.8%) of the untreated (absolute difference 19.0% [95%CI 9.0-29.0%], P=0.001). In multivariable models, only N-R was associated with VR (AOR 10.02, 95%CI 1.13-88.74). VR occurred more commonly among those with earlier nirmatrelvir-ritonavir initiation (29.0%, 16.7% and 0% when initiated days 0, 1, and ≥2 after diagnosis, respectively, P=0.089). Among participants on N-R, those experiencing rebound had prolonged shedding of replication-competent virus compared to those that did not rebound (median: 14 vs 3 days). Only 8/16 with virologic rebound reported worsening symptoms (50%, 95%CI 25%-75%); 2 were completely asymptomatic. We detected no post-rebound nirmatrelvir-resistance mutations in the NSP5 protease gene.

Conclusions and Relevance

Virologic rebound occurred in approximately one in five people taking nirmatrelvir-ritonavir and often occurred without worsening symptoms. Because it is associated with replication-competent viral shedding, close monitoring and potential isolation of those who rebound should be considered.

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