A Multinational Case Series Describing Successful Treatment of Persistent Severe Acute Respiratory Syndrome Coronavirus 2 Infection Caused by Omicron Sublineages With Prolonged Courses of Nirmatrelvir/Ritonavir

Abstract

The optimum treatment for persistent infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not known. Our case series, across 5 hospitals in 3 countries, describes 11 cases where persistent SARS-CoV-2 infection was successfully treated with prolonged courses (median, 10 days [range, 10-18 days]) of nirmatrelvir/ritonavir (Paxlovid). Most cases (9/11) had hematological malignancy and 10 (10/11) had received CD20-depleting therapy. The median duration of infection was 103 days (interquartile range, 85-138 days). The majority (10/11) were hospitalized, and 7 (7/11) had severe/critical disease. All survived and 9 of 11 demonstrated viral clearance, almost half (4/9) of whom received nirmatrelvir/ritonavir as monotherapy. This case series suggests that prolonged nirmatrelvir/ritonavir has a role in treating persistent infection.

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

Figure 1.

Time series for each case, displaying cycle threshold (Ct) values of SARS-CoV-2 on reverse-transcription quantitative polymerase chain reaction over time for 7 cases. Cases without follow-up testing data (n = 2) and cases where upper respiratory tract sampling was consistently negative (n = 2) are not shown. Sampling date is presented in relation to the start date of the final course of nirmatrelvir/ritonavir. Samples are shown up to 90 days prior to this final course. Samples reported as not detected are set to Ct = 46 for the purpose of graphical representation. Multiple platforms were used for testing, and no correction or normalization between platforms was conducted.