Short-term Outcomes in a Nurse Coordinator–led and Nurse Practitioner–led Sotrovimab Initiative for Solid Organ Transplant Recipients During the Omicron Surge

Abstract

Emergence of the Omicron variant was marked by a rapid increase in the coronavirus disease 2019 (COVID-19) cases among solid organ transplant recipients (SOTRs).1 Sotrovimab is a monoclonal antibody (mAb) with activity against the initially predominant Omicron subvariants BA.1 and BA.1.1 and was under emergency use authorization by the US Food and Drug Administration for symptomatic nonhypoxemic, high-risk outpatients with COVID-19 infection. We read with appreciation the recent Letter to the Editor by Pinchera et al,2 regarding 15 SOTRs who received sotrovimab at an Italian transplant center, and wish to add our experience in a larger cohort of SOTRs. We aimed to (1) characterize outcomes in SOTRs at one center that received sotrovimab during the early phase of the Omicron surge and (2) highlight the efficacy of a nurse coordinator (NC)–led and nurse practitioner (NP)–led initiative to rapidly implement screening and referrals for mAb therapy. This was a single-center approach with an NC/NP-led, interdisciplinary care team to screen, refer, and facilitate mAb infusion for large numbers of COVID-19+ SOTRs shortly after symptom onset. Data were collected for onset of symptoms and time to diagnosis and to sotrovimab infusion, as well as hospitalization for COVID-19, disease severity, graft rejection, and mortality, with a median follow-up of 21 d. Between December 23, 2021, and January 18, 2022, 88 of 269 (33%) SOTRs who were diagnosed with COVID-19 were referred for sotrovimab and received one intravenous dose of 500 mg (35 kidney, 18 lung, 17 heart, 15 liver, and 3 dual-organ recipients). Age over 65 y, comorbidities, recent rejection, or recent transplant were criteria for referral. Internal workflow, including patient education regarding early reporting of symptoms, coordinator training, and collaboration with the Baltimore Convention Center COVID Infusion Center and other sites, expedited treatment. Median time from symptom onset to diagnosis was 2 d and from date of diagnosis to mAb infusion was 3 d. Of the 88 patients, 79 (90%) did not require hospitalization after sotrovimab, recovering uneventfully. Ten percent (9/88) required hospitalization for COVID-19 after sotrovimab, including 1 admitted on the same day as infusion and 1 for a cerebrovascular accident 2 w after infusion. Of these 9 patients hospitalized after sotrovimab, 8 did not require supplemental oxygen and 1 required 2 L/min of oxygen via nasal cannula. No episodes of graft rejection or graft loss were observed, and no patients in this cohort required mechanical ventilation or died. This NC/NP-led initiative facilitated sotrovimab therapy for SOTRs with COVID-19 during the initial phase of the Omicron surge, including rapid triaging of large numbers of newly positive SOTRs, and was associated with excellent outcomes. Although this study was limited by the lack of a control group, sotrovimab may have reduced hospitalizations and mortality. Although sotrovimab is no longer authorized in the United States as of April 5, 2022, because BA.2 has emerged as the predominant variant, these results still support the establishment of NC/NP-led initiatives for rapid, efficient screening and referral of COVID+ SOTRs for crucial therapies that are limited in supply. ACKNOWLEDGMENTS Our sincere appreciation goes to all the nurse coordinators, nurse practitioners, and other transplant clinicians throughout the Johns Hopkins Comprehensive Transplant Center, as well asthe staff of the Baltimore Convention Center COVID Infusion Center and other monoclonal antibody infusion teams, for their dedication and commitment to this project and the care of our patients.

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