Into the Unknown: Practical Remdesivir Restriction in the Era of Widespread SARS-CoV-2 Seropositivity.

Abstract

There are limited data to support routine remdesivir use in the contemporary era of severe acute respiratory syndrome coronavirus 2 with widespread seropositivity. A restriction of remdesivir among adult immunocompetent patients was implemented across an 8-hospital health system. A pre-post quasi-experimental design was used to compare patients 12 months pre-intervention (June 2022-May 2023) to 12 months post-intervention (July 2023-June 2024). The primary outcome was 14-day all-cause mortality. A total of 4774 patients were included in the analysis (3323 pre-intervention, 1451 post-intervention). Significantly fewer patients in the post-intervention group received remdesivir (37.7% pre-intervention versus 4.1% post-intervention; P < .001). When medium-risk covariates were modeled, there was no difference in 14-day all-cause mortality between pre- and post-intervention groups (odds ratio, 1.8; 95% confidence interval: .54-5.8; P = .34). There was no difference in 28-day all-cause mortality, 30-day readmission, or length of hospital stay. Intensive care unit (ICU) admission and mechanical ventilator (MV) use were different between groups. Remdesivir use was associated with a lower risk of ICU admission and MV use pre-intervention and a higher association with these outcomes post-intervention. Similar outcomes were observed with high-risk value covariates. Restriction of remdesivir use in immunocompetent patients was not associated with an increased risk of mortality. Remdesivir use was associated with an unexpected increased risk of ICU admission and MV use within the post-intervention group, likely explained by the higher-risk patient population that received remdesivir. Prospective studies are needed to definitively determine if highly immunocompetent patients benefit from remdesivir.