Clinical and Experimental Medicine (2021) 21:167–179

https://doi.org/10.1007/s10238-020-00671-y

REVIEW ARTICLE

Emerging treatment strategies for COVID‑19 infection

Maria Gavriatopoulou1 · Ioannis Ntanasis‑Stathopoulos1 · Eleni Korompoki1,2 · Despina Fotiou1 ·
Magdalini Migkou1 · Ioannis‑Georgios Tzanninis3 · Theodora Psaltopoulou1 · Efstathios Kastritis1 ·
Evangelos Terpos1 · Meletios A. Dimopoulos1

Received: 23 July 2020 / Accepted: 20 October 2020 / Published online: 30 October 2020
© Springer Nature Switzerland AG 2020

Abstract
The new type of coronavirus (COVID-19), SARS-CoV-2 originated from Wuhan, China and has led to a worldwide pan-
demic. COVID-19 is a novel emerging infectious disease caused by SARS-CoV-2 characterized as atypical pneumonia. As
of July 1, 2020, more than 10 million people worldwide had been infected with SARS-CoV-2. The typical manifestations
of COVID-19 include fever, sore throat, fatigue, cough, and dyspnoea combined with recent exposure. Most of the patients
with COVID-19 have mild or moderate disease, however up to 5–10% present with severe and even life-threatening disease
course. The mortality rates are approximately 2%. Therefore, there is an urgent need for effective and specific antiviral
treatment. Currently, supportive care measures such as ventilation oxygenation and fluid management remain the standard
of care. Several clinical trials are currently trying to identify the most potent drug or combination against the disease, and
it is strongly recommended to enroll patients into ongoing trials. Antivirals can be proven as safe and effective only in the
context of randomized clinical trials. Currently several agents such as chloroquine, hydroxychloroquine, favipiravir, mono-
clonal antibodies, antisense RNA, corticosteroids, convalescent plasma and vaccines are being evaluated. The large numbers
of therapeutic interventions aim to define the most efficacious regimen. The aim of this article is to describe the treatment
strategies that have been used for COVID-19 patients and review all the available literature.

Keywords SARS-CoV-2 · COVID-19 · Antivirals · Convalescent plasma · Remdesivir · Vaccines

Introduction sore throat, fatigue, cough, and dyspnoea combined with

recent exposure. Due to interventions and control measures
The new type of coronavirus (COVID-19), SARS-CoV-2 from the governments around the world and the changes
originated from Wuhan, China and has led to a worldwide in personal behaviors (such as masks wearing and social
pandemic. The World Health Organization (WHO) has isolation), the number of new confirmed and suspected
declared that COVID-19 has become a global health con- cases has been decreasing globally. However, the risk of
cern. The typical symptoms of COVID-19 include fever, transmission has not been eliminated yet and the COVID-
19 outbreak remains a major challenge for clinicians. Most
of the patients with COVID-19 have mild or moderate dis-
Maria Gavriatopoulou, Ioannis Ntanasis-Stathopoulos have ease, however up to 5–10% present with severe and even life
contributed equally to this work.
threatening disease course. The mortality rates are approxi-
* Maria Gavriatopoulou mately 2%. Therefore, there is an urgent need for effective
mariagabria@gmail.com and specific antiviral treatment. Currently, supportive care
1
measures such as ventilation oxygenation and fluid manage-
Department of Clinical Therapeutics, School of Medicine,
National and Kapodistrian University of Athens, Alexandra
ment remain the standard of care. Several clinical trials are
General Hospital, 80 Vas. Sofias Avenue, 11528 Athens, currently trying to identify the most potent drug or combina-
Greece tion against the disease and it is strongly recommended to
2
Division of Brain Sciences, Imperial College London, enroll patients into ongoing trials. Antivirals can be proven
London, UK as safe and effective if so, only in the context of randomized
3
Department of Medicine, University Hospital Southampton clinical trials. Currently several agents such as chloroquine,
NHS Foundation Trust, Southampton, UK

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168 Clinical and Experimental Medicine (2021) 21:167–179

hydroxychloroquine, favipiravir, monoclonal antibodies, assess the time for seroconversion and its correlation with
antisense RNA, corticosteroids, convalescent plasma and disease severity and antibody titers, additional longitudinal
vaccines are being evaluated. The large numbers of thera- studies evaluating large numbers of serum samples from
peutic interventions aim to define the most efficacious regi- COVID-19 patients, with a broad spectrum of clinical symp-
men. The aim of this article is to describe the treatment toms, are needed.
strategies that have been used for COVID-19 patients and Until recently, case series were mostly reported (32 pts in
review all the available literature. total) with different disease severity [11–13]. Patients were
administered other treatment regimens concurrently and 90%
Convalescent plasma experienced positive outcomes [14]. The superimposition
of effects mediated by other antiviral treatments, antibiotics
Plasma from patients that have been cured from COVID-19 and glucocorticoids administered concomitantly with con-
infection, namely convalescent plasma, is a treatment with valescent plasma should be taken into consideration in the
considerable historical background in other infectious dis- evaluation of these results.
eases, but still explorative in the context of SARS-CoV-2. In the first peer-reviewed study of convalescent plasma,
In a pandemic era, convalescent plasma could constitute an 19 of 25 patients (76%) with severe COVID-19 who received
easily accessible source of antiviral antibodies. convalescent plasma saw at least 1 point of clinical improve-
Convalescent plasma may offer various beneficial actions ment based on WHO’s ordinal scale measuring illness
in COVID-19 disease. First and foremost, the apparent severity [15]. A randomized clinical trial of 103 patients
mechanism pertains to the fact that antibodies from conva- with severe COVID-19 published in JAMA by researchers
lescent plasma can suppress viremia. Similarly to the strate- from China showed a nonsignificant clinical improvement
gies implemented in the SARS epidemic, theoretically, the in 51.9% of patients compared with improvement in 43.1%
administration of convalescent plasma at the early stage of of patients who received standard treatment (p = 0.26) [15].
the disease would be more effective [1]. Viremia peak is However, the trial was halted early due to the decrease in
noted in the first week of infection in the majority of viral COVID-19 patients in China during the study period, which
illnesses and a primary immune response of the host is usu- could have contributed to the study being underpowered to
ally developed by days 10–14 of infection [2] (beginning detect a clinically significant result. A recent analysis of
somewhat earlier according to other researchers) [3], signal- 5000 patients with severe or life threatening COVID-19
ing the clearance of the viruses. Other potential mechanisms who received convalescent plasma according to the “US
include antibody-dependent cellular cytotoxicity, comple- FDA Expanded Access Program for COVID-19 conva-
ment activation and phagocytosis (ADCP) [4]. Secondarily, lescent plasma” reported a 7-day mortality rate of 14.9%
the presence of non-neutralizing antibodies binding to the [16]. Donor selection according to the antibody titers or the
pathogens may also be helpful [5]. potency of the neutralizing antibodies may further enhance
In any case, the administered antibody modifies inflam- the efficacy of convalescent plasma administration [17].
matory response and this can be optimally achieved during A pivotal, controversial point seems to pertain to the time
the early response, even at the asymptomatic stage [6]. It of convalescent plasma administration in COVID-19, that
has also been suggested that, apart from the direct anti-viral should be as early as possible, to maximize efficacy, but at
properties, plasma components can provide other beneficial the same time oriented to severe cases. To this direction, the
actions, such as restoring coagulation factors [7]. examination of risk markers, integrating clinical (gender,
So far information on immune response to SARS-CoV-2 age, comorbidities), biochemical aspects in a comprehensive
is rather limited. According to studies in process, a detailed risk stratification, can provide a valuable tool about decision
analysis of 9 cases with mild upper respiratory tract symp- making, tracing promptly those patients with forthcoming
toms revealed that seroconversion occurred 6–12 days after poor prognosis, who would need most the early intervention
onset of symptoms, while antibodies were not detectable with convalescent plasma. Emerging markers with such a
between day 3 and 6; after 2 weeks, all patients showed potential, are lymphocytopenia, elevated procalcitonin, fer-
neutralizing antibodies. Seroconversion coincided with a ritin, D-dimer and C-reactive protein [18].
slow but steady decline of sputum viral load [8]. In another In line with the published case series concerning the
study, the majority of PCR-confirmed SARS-CoV-2-infected optimal timing of convalescent plasma administration, a
persons seroconverted 2 weeks after disease onset [9]. A recent review by Tiberghien et al. [3] has presented a strat-
study on 173 COVID-19 patients showed that the presence egy of administration for high-risk patients (older than 70
of antibodies was less than 40% within the first week from or dependent on oxygen with a baseline oxygen satura-
disease onset, increasing to 94.3% for IgM and 79.8% for tion < 94%). According to preliminary remarks by the afore-
IgG on day 15 after onset; higher titer of total antibodies mentioned research team, early treatment with convalescent
correlated with worse clinical classification [10]. To further plasma (not later than day 5) should be preferred, at any case

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before seroconversion for SARS-CoV-2, which may occur placebo for up to 10 days. The primary outcome was time to
on days 6–12. Another matched control study has suggested recovery, and this was defined as either discharge from the
that the survival benefit of convalescent plasma may be more hospital or hospitalization only for infection-control. 1063
pronounced among non-intubated patients compared with patients were randomized. The safety monitoring commit-
those requiring mechanical ventilation [19]. The need for tee recommended early unblinding on the basis of data that
early administration is in line with observations in other dis- showed shorter time to recovery in the remdesivir arm. 538
eases, such as pneumococcal pneumonia, where no benefit patients were assigned to remdesivir and 521 to placebo.
is noted if the antibody is administered after day 3 of the The remdesivir group had a median recovery time of 11 days
disease [4, 20]. (95% CI 9 to 12), as compared with 15 days (95% CI 13 to
Convalescent plasma administration seems to be a safe 19) in those who received placebo (rate ratio for recovery,
procedure, free from serious adverse effects. Meticulous 1.32; 95% CI 1.12 to 1.55; p < 0.001). The mortality estima-
selection of donors can minimize the risk of TRALI syn- tion with Kaplan–Meier by 14 days was 7.1% with remde-
drome. Another potentially concerning phenomenon per- sivir and 11.9% with placebo (hazard ratio for death, 0.70;
tains to antibody-dependent enhancement (ADE) of coro- 95% CI 0.47 to 1.04). 114 of 541 patients in the remdesivir
navirus entry; this has been reported in viral diseases and group reported serious adverse events [24]. Another ongoing
refers to an enhancement of disease in the presence of cer- phase 3 randomized, double-blind, placebo-controlled, mul-
tain antibodies [21]. A pertinent analysis of more than 5000 ticenter study is evaluating the efficacy and safety of remde-
patients with severe or life threatening COVID-19 infection sivir in 452 hospitalized adult patients with severe respira-
who received convalescent plasma showed that less than 1% tory disease [ClinicalTrials.gov Identifier: NCT04257656].
of the patients experienced a serious adverse event in the The results of this trial are anticipated. On May 1, 2020, The
first 4 h following the infusion. Severe adverse events with a US FDA based on the results of the ACTT trial issued an
potential, but not definitive, relation to convalescent plasma EUA of remdesivir on April 29th 2020 to allow emergency
included mortality (n = 4), transfusion-associated circula- use of the agent for severe COVID-19 (confirmed or sus-
tory overload (TACO; n = 7), transfusion-related acute lung pected) in hospitalized adults and children. A phase 1b trial
injury (TRALI; n = 11), and severe allergic transfusion reac- of an inhaled nebulized version was initiated in late June
tions (n = 3) [16]. Nevertheless, in view of the high titers of 2020 to determine if remdesivir can be used on an outpatient
neutralizing antibodies that convalescent plasma includes basis and at earlier stages of the disease. Post ACTT trial
against the same virus (SARS-Cov-2), as well as the previ- announcement the results from a smaller randomized trial
ously documented, safe experience in SARS and MERS, which was conducted in China were reported. This was a
the occurrence of ADE does not seem to represent a major randomized, double-blind, placebo-controlled, multicenter
problem, but surveillance is warranted [4]. trial (n = 237; 158 remdesivir and 79 placebo; 1 patient with-
drew) which demonstrated that remdesivir was not associ-
Remdesivir ated with statistically significant clinical benefit, measured
as time to clinical improvement, in adults hospitalized with
Remdesivir is an RNA-dependent polymerase inhibitor severe disease. Although not statistically significant, patients
tested for efficacy in treatment of SARS-CoV-2 infection receiving remdesivir had a numerically faster time to clinical
and has demonstrated the most promising anti-viral thera- improvement than those receiving placebo among patients
peutic results. Unlike other nucleotide analogues, remdesivir with symptom duration of less than 10 days. The authors
is a phosphoramidate prodrug with broad-spectrum activity concluded this trend in reduction in time to clinical improve-
against many viruses, such as Filoviridae, Paramyxoviridae, ment in those treated earlier requires confirmation in larger
Pneumoviridae, and Orthocoronavirinae (SARS-CoV and studies [25]. The open-label phase 3 SIMPLE trial (n = 397)
Middle East respiratory syndrome coronavirus [MERS- in hospitalized patients with severe COVID-19 disease not
CoV]) [22, 23]. Remdesivir was initially developed by requiring mechanical ventilation demonstrated similar
Gilead Sciences in 2017 as treatment for Ebola virus infec- improvement in clinical condition with the 5-day remdesivir
tion. Several phase 3 trials were initiated to evaluate the role regimen compared with the 10-day regimen on day 14 (OR:
of remdesivir for severe and moderate disease in the USA, 0.75 [95% CI 0.51–1.12]). In this study, 65% of patients
South Korea and China. Recently the results of a double- who received a 5-day course of remdesivir showed a clinical
blind, randomized, placebo-controlled trial of intravenous improvement of at least 2 points on the 7-point ordinal scale
remdesivir in adults hospitalized with Covid-19 disease at day 14, compared with 54% of patients who received a
and evidence of lower respiratory tract involvement were 10-day course. The study demonstrates that possibly some
reported (ACCT-1 trial). Patients were randomly assigned patients could be treated with a 5-day regimen, which could
to receive either remdesivir (200 mg loading dose on day significantly expand the number of patients who could be
1, followed by 100 mg daily for up to 9 additional days) or treated with the current supply of remdesivir. The trial is

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continuing with an enrollment goal of 6000 patients [26]. the addition of azithromycin [31]. This study was severely
Similarly, the phase 3 SIMPLE II trial in patients with mod- criticized due to several limitations and flaws [32]. The
erate COVID-19 disease showed that 5 days of remdesivir same study group based on these results designed another
treatment was 65% more likely to yield clinical improvement trial, non-randomized observational, which evaluated the
at day 11 than standard of care (p = 0.18). These data show role of hydroxychloroquine combined with azithromycin
that early intervention with a 5-day treatment course can in 80 patients diagnosed with COVID-19 [33]. The study
significantly improve clinical outcomes. The first published reported encouraging clinical outcomes and 83% of the
report regarding remdesivir compassionate use described patients achieved negative nasopharyngeal swab by day 7.
clinical improvement in 36 of 53 hospitalized patients (68%) As in the previous study there was no comparison group and
with severe COVID-19. At baseline, 30 patients (57%) were again several limitations reduced the strength of the report
receiving ventilation and 4 (8%) extracorporeal membrane significantly [33]. A different group from France reported
oxygenation (ECMO) [27]. Additional data for compassion- that there was no benefit with the combination of hydroxy-
ate use of remdesivir were released on July 10, 2020 and chloroquine and azithromycin in 11 patients with COVID-19
demonstrated that remdesivir treatment was associated with [34]. In another retrospective observational French study 84
significantly improved clinical recovery and a 62% reduc- hospitalized patients were treated with hydroxychloroquine
tion in the risk of mortality compared with standard of care. within the first 48 h of admission. 20% of these patients
Findings from the comparative analysis showed that 74.4% were also treated with azithromycin. The above-mentioned
of remdesivir-treated patients recovered by day 14 versus patients were compared with a control group of 89 patients.
59% of patients receiving standard of care. The mortality Hydroxychloroquine treatment with or without azithromycin
rate in patients treated with remdesivir in the analysis was did not reduce admissions to intensive care units or death
7.6% at day 14 compared with 12.5% among patients not at day 21 after hospital admission. Importantly, 7 patients
taking remdesivir (adjusted OR 0.38; 95% CI 0.22–0.68, treated with hydroxychloroquine developed QT prolonga-
p = 0.001). tion and treatment discontinuation was required [35]. An
open-label, randomized trial compared hydroxychloroquine
Hydroxychloroquine with or without azithromycin plus the standard of care to standard of care alone in China.
150 patients were enrolled in total, 75 in each group. The
Hydroxychloroquine is a well- known old-fashioned drug hydroxychloroquine group showed a mild benefit in symp-
used for several decades for the treatment of rheumatoid tom resolution, however there was no benefit in negativity
arthritis, systemic lupus erythematosus and malaria prophy- achievement of SARS-CoV-2 on molecular nasopharyn-
laxis [28, 29]. Hydroxychloroquine is a 4-aminoquinolone geal tests [35]. A large observational study was performed
compound and the hydroxyl analogue of chloroquine. in New York, where the investigators compared the clinical
Hydroxychloroquine and chloroquine belong to the 4-ami- outcomes in COVID-19 hospitalized patients who either
noquinoline class and both have a basic side chain that dis- received hydroxychloroquine or not. Most of the patients
tinguish these compounds from the 4-aminoquinoline core treated with hydroxychloroquine received the first dose
structure [28]. Although hydroxychloroquine has demon- within 48 h of admission. The multivariable analysis did not
strated an antiviral mechanism of action in vitro, there were demonstrate significant differences for intubation or death
limited data available regarding its potential efficacy in the among the two groups [36]. An international study pub-
clinical setting. In vitro studies have shown that hydroxy- lished in The Lancet of 96,032 patients hospitalized for
chloroquine was active against SARS-CoV-2 with a mul- COVID-19 found a higher risk of mortality and de-novo
tifactorial mechanism of action [30] and this became the clinically significant ventricular arrhythmias in patients who
rationale for further use in both treatment and prevention of received hydroxychloroquine or chloroquine with or without
COVID-19 infection. Another study had also reported that azithromycin compared with no therapy. However, this study
hydroxychloroquine was more potent against SARS-CoV-2 was retracted by The Lancet on June 4, 2020, due to ques-
than chloroquine, and therefore, most studies were designed tions raised about the clarity of the data. Finally, hydroxy-
based on these results [30]. The past few months several chloroquine was investigated as postexposure prophylaxis
studies investigated the role of hydroxychloroquine, with or and was found not to be effective in preventing patients from
without azithromycin, for the treatment of COVID-19 and developing COVID-19 after taking the drug within 4 days
these data have become recently available. A small, non- of a high-risk exposure [37]. All these reports raised several
randomized study was conducted in France, which enrolled questions and controversy regarding the role of hydroxy-
20 patients with severe COVID-19 disease. All 20 patients chloroquine in the COVID-19 setting. Most of these reports
were treated with hydroxychloroquine, with or without had significant limitations and were based on exceedingly
azithromycin. This study reported that hydroxychloroquine small case series. Large, randomized, controlled clinical tri-
reduced SARS-CoV-2 load and the effect was enhanced by als were more than necessary to address all these questions.

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Clinical and Experimental Medicine (2021) 21:167–179 171

More than 25 active hydroxychloroquine COVID-19 clinical initiation was 5 days. The results of this study showed that
trials were currently ongoing in the United States, includ- the combination therapy was more effective as the median
ing the large National Institutes of Health (NIH) clinical time from treatment initiation to negative nasopharyngeal
trial—the ORCHID Study [NCT04332991]. On March 28, swab was 7 days [IQR 5–11] for the combination group
2020, the U.S. FDA approved chloroquine or hydroxychlo- and 12 days [8–15] for the control group; (hazard ratio 4.37
roquine for emergency use to treat COVID-19. On April [95% CI 1.86–10.24], p = 0.0010). The authors suggested
24, 2020, the U.S. Food and Drug Administration issued a that early triple antiviral therapy might be effective in mild
cautioning statement against use of hydroxychloroquine or to moderate illness. The combination of lopinavir-ritonavir
chloroquine for COVID-19 patients outside of the hospital with or without ribavirin has been recommended as a treat-
setting or a clinical trial due to risk of the induced arryth- ment option for novel coronavirus, especially in countries
mias. On June 15, 2020, due to accumulating negative data, that have been hit hard by the disease.
the FDA revoked the emergency authorization (EUA) use of In a trial by Cao et al., patients with oxygen saturation of
chloroquine or hydroxychloroquine as a potential COVID- 94% or less (while they were breathing ambient air or a ratio
19 treatment. The agency reported that the legal criteria for of the partial pressure of oxygen to the fraction of inspired
issuing a EUA are no longer met. On June 20, 2020, the oxygen (Fio2) was less than 300 mm Hg) were randomly
National Institute of Health announced the discontinuation assigned in a 1:1 ratio to receive either lopinavir–ritonavir
of the ORCHID trial, which evaluated the efficacy and safety (400 mg and 100 mg, respectively) twice a day for 14 days,
of the drug for hospitalized COVID-19 patients because the in addition to standard of care, or standard of care alone [2].
study failed to prove any clear benefit favoring the drug arm. A total of 199 patients underwent randomization with 99
patients receiving the combination lopinavir–ritonavir and
Lopinavir‑ritonavir and other anti‑viral agents 100 receiving standard of care. The primary endpoint was
time to clinical improvement and was not met in terms of
Lopinavir-ritonavir is an HIV protease inhibitor and is indi- the study. No benefit was observed since time to clinical
cated in combination with other antiretroviral products for improvement was same in both arms (16 days). Mortality at
the treatment of human immunodeficiency virus (HIV-1) 28 days was similar in both groups as well as the percentages
infected adults, adolescents and children above the age of of patients with detectable viral RNA at various time points.
2 years. In 2004, an open label study suggested that the The authors conclude that the combination showed no ben-
addition of lopinavir–ritonavir to ribavirin reduced the risk efit in hospitalized patients with severe COVID-19 illness
of adverse clinical outcomes (defined as acute respiratory and future trials may help to confirm or exclude the clinical
distress syndrome [ARDS] or death) as well as viral load benefit of the combination. The study was not blinded, and
among patients with SARS [38]. The comparison arm in this might have affected the assessment of clinical improve-
this study was a historical control group that was treated ment. The study was also underpowered to highlight small
only with ribavirin. The main limitations of the study were effects.
that it was an open label study without randomization design In another study the efficacy and safety of the combina-
and patients were concurrently treated with glucocorticoids tion lopinavir/ritonavir was assessed in patients with mild/
and ribavirin, making the pure effect of lopinavir-ritonavir moderate COVID-19 in comparison to arbidol [40]. Arbidol
difficult to assess. Lopinavir-ritonavir has also showed activ- is an anti-influenza drug targeting the viral hemagglutinin
ity both in vitro and in animal models against Middle East (HA) and can effectively block the fusion of influenza virus
respiratory syndrome and it is now studied in humans with with its host cell. It has efficiently inhibited SARS-CoV-2
MERS in combination with recombinant interferon 1b in a infection in vitro and therefore was used in the context of a
study that has completed accrual. The results of the study clinical trial against COVID-19. The study was randomized
are anticipated. and enrolled 86 patients with mild/moderate disease, 34
In a phase 2 study recently published in ‘The Lancet’ were randomly assigned to receive LPV/r, 35 to arbidol and
[39], a total of 127 patients, with mild to moderate COVID- 17 received no antiviral medication (control group). The
19 infection were randomized 2:1 to receive either a 14-day primary endpoint was the rate of positive-to-negative con-
combination of lopinavir 400 mg and ritonavir 100 mg every version of SARS-CoV-2 with RT-PCR. There were no differ-
12 h, ribavirin 400 mg every 12 h, and three doses of 8 mil- ences between the two groups both in primary and second-
lion international units of interferon beta-1b on alternate ary endpoints, the rates of antipyresis, cough alleviation, or
days (combination group) or 14 days of lopinavir 400 mg improvement of chest CT at days 7 or 14. Lopinavir-ritonavir
and ritonavir 100 mg every 12 h (control group). The pri- or arbidol monotherapy failed to improve the clinical out-
mary endpoint was time to achieve negative nasopharyngeal comes of hospitalized patients with mild/moderate COVID-
swab for SARS-CoV-2 with RT-PCR. The median number of 19 infection versus supportive care. The study had quite a
days from symptom onset to study enrolment and treatment small sample size and this was the main limitation.

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In a small randomized controlled trial held in China, molecular weight heparin (LMWH) which should be with-
chloroquine was compared to lopinavir/ritonavir in treating held when there is active bleeding, when platelet count is
COVID-19 in 22 hospitalized patients, none of the patients less than 25 × 109/L, or fibrinogen less than 0.5 g/L [47,
enrolled was critically ill [41]. Among the 22 randomized 50–52]. Unfractionated heparin or reduced dose LMWH
patients, 10 received chloroquine and 12 received lopina- should be administered when creatinine clearance less than
vir/ritonavir. Both agents showed similar efficacy in terms 30 mL/minute and fondaparinux in patients with a history
of negative SARS-CoV-2 PCR test results at specific time- of heparin-induced thrombocytopenia [51]. A multimodal
points, CT scan improvement and days of hospitalization. approach combining pharmacological and mechanical
The main limitations of the trial were the very small sample means should be applied in critically ill patients.
size and the participants fairly young age. Direct oral anticoagulants (DOACs) and Vitamin K
The NIH Panel for COVID-19 Treatment Guidelines antagonists should be avoided as there might be unknown
that have been recently updated (16 Jun 2020) recommends drug-drug interactions with investigational therapies and
against the use of lopinavir/ritonavir or other HIV protease antivirals administered. Some groups opt for a stepped-up
inhibitors in COVID-19 infection. This is due to unfavora- approach with intermediate dose LMWH in ICU-critically
ble pharmacodynamic data and mainly due to the fact that ill patients but data are currently insufficient to support such
clinical trials have not demonstrated a clear clinical benefit an approach outside the context of clinical trials [47, 53].
in patients with COVID-19 [42]. Therapeutic dose anticoagulation has also been proposed by
Favilavir/Avifavir or Avigan is an oral antiviral drug some centers for the critically ill patients and others advo-
approved in Japan for influenza, also used for Ebola virus cate stepping up from prophylactic or intermediate-dose to
infection. In a randomized, open label trial conducted in a full dose regimen in patients with deteriorating pulmonary
China 240 patients were randomized to receive either Favi- status or ARDS but the data are very limited [46]. Ongoing
piravir (116 assessed) or Arbidol (120 assessed) [43]. Pri- randomized clinical trials (NCT04345848, Hep-COVID,
mary endpoint, defined as clinical recovery rate at Day 7, and PROTECT COVID 19) aim to assess the efficacy and
was not significantly different between the Favipiravir group safety of more intense intermediate- to therapeutic-dose
(71/116) and the Arbidol group (62/120) (p = 0.1396). There versus prophylactic-dose LMWH. Routine discharge on
are several ongoing clinical trials evaluating safety and effi- VTE prophylaxis is not currently required unless set criteria
cacy of favilavir against other antivirals in China, Japan, are met; regulatory approved regimens such as Direct oral
Canada and avifavir in Russia. Darunavir/Cobicistat and anticoagulants (DOACs) can be used [51, 53]. Some early
Darunavir/Ritonavir [44] have also been tested in a rand- data suggest that LWMH or heparin thromboprophylaxis
omized controlled trial of 30 patients in China which showed is associated with reduced mortality in critically ill SARS-
that darunavir/cobicistat was not effective in the treatment COV-2 patients when D-dimer levels are more than 6 times
of COVID-19. There are no data from clinical trials that the upper limit of normal [47, 50, 52, 54]. When VTE is
support the use of other HIV protease inhibitors to treat suspected or confirmed patients should receive therapeutic
COVID-19, such as Atazanavir. dose anticoagulation for at least 3 months [55].
Instead of administering a single drug, combination of The rationale behind fibrinolysis in severely ill SARS-
antivirals with different mechanisms of action may be more COV-2 infected patients lies in the coagulopathy observed
effective. The adverse event profile of these drugs should and data that link fibrin deposition in the pulmonary vas-
not be underestimated. culature is associated with ARDS development [52, 56]. In
one case series alteplase administration followed by intra-
Thromboprophylaxis and fibrinolysis venous heparin in 3 critically ill patients with ARDS led to
an improvement of the PaO2/FiO2 (P/F) ratio which was
Venous thromboembolism (VTE) and particularly pul- however only transient [56]. Other fibrinolytics including
monary embolism (PE) have emerged as a significant risk defibrotide are currently being evaluated but safety issues
associated with SARS-CoV-2 severe infection which is including bleeding remains a concern [56, 57].
multi-fold higher compared to other viral pneumonias/acute
respiratory distress syndromes. Reported incidence reaches
25–27% [45, 46]. Abnormal levels of hypercoagulability The potential role of antifibrotic therapy
markers and poor scoring on standard VTE assessment
risk-assessment tools is associated with worse prognosis [47, The risk factors correlated with COVID-19 are shared with
48].Specific risk-stratification VTE assessment tools are not those of idiopathic pulmonary fibrosis suggesting that these
available yet and the current recommendation is to apply patients might be at increased risk for severe disease. It is
a universal pharmacological thromboprophylactic strategy assumed that the pandemic will increase the fibrotic lung
for all hospitalized patients [49]. The preferred agent is low disease. Therefore, the available antifibrotics (nintedanib and

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Clinical and Experimental Medicine (2021) 21:167–179 173

pirfenidone) might have a role in SARS-Cov-2 therapeutics Non‑steroidal anti‑inflammatory drugs (NSAIDs)
(NCT04338802, NCT04282902).
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely
used as painkillers and antipyretic agents. Although NSAIDs
Interleukin‑6 (IL‑6) receptor antagonists are effective drugs for symptom relief during the course of
and complement antagonists viral and bacterial infections, their use has been linked to
higher rates of cardiovascular events [65, 66]. Consequently,
The rationale behind the use of IL-6 receptor antagonists short-term administration of NSAID in respiratory tract
in the treatment of SARS-CoV-2-associated disease lies in infections remains questionable. The first concerns regard-
the evidence in support of the role of cytokine release syn- ing NSAID use in patients with COVID-19 raised in March
drome in the most severe manifestations of COVID-19 and 2020 with a study showing that angiotensin converting
the central part of IL-6 as a proinflammatory cytokine in this enzyme 2 (ACE-2) activity can be increased by ibuprofen
syndrome [58–60]. [67]. It is largely known that SARS-CoV-2 binds to target
Use of IL-6 antagonists is not currently included in treat- cells through the angiotensin converting enzyme 2 (ACE-
ment guidelines for SARS-Co-V infection as there is a lack 2) receptor which is mainly expressed in epithelial cells of
of robust clinical data in support for or against their use. the respiratory tract, kidney and blood vessels. It has been
A randomized, double-blind, placebo-controlled phase hypothesized that increased expression of ACE-2 receptor
III trial is about to start to evaluate safety and efficacy of linked to ibuprofen use may facilitate SARS-CoV-2 infec-
intravenous siltuximab (IL-6 monoclonal antibody) plus tion and that ACE-2 stimulating drugs such as NSAIDs may
standard of care in patients with SARS-CoV-2-associated increase the risk of suffering from more severe COVID-19
ARDS. Results of the observational cohort study in 188 [67, 68]. NSAIDs use has been also implicated in delaying
patients (NCT04322188) were released online demonstrat- the resolution of inflammation by inhibiting cyclo-oxyge-
ing a significantly lower 30d-day mortality rate in the sil- nases [69] and is associated with nephrotoxicity, bleedings
tuximab treated patients (n = 30) versus controls (n = 188) and gastrointestinal complications [70]. Although several
who received best supportive care. Some protocols include studies have linked ibuprofen with negative outcomes dur-
recommendations for the use of tocilizumab, another mono- ing the course of respiratory infections it is possible that
clonal IL-6 antibody. Two retrospective studies of 21 and they are subject to a number of biases [71]. Confounding
51 patients, respectively, in patients with SARS-Co-V and by disease severity may serve as a potential risk of bias
ARDS demonstrated some clinical benefit as adjunct to considering that patients with more severe disease are
standard of care treatment [58, 61] Another single center more likely to use NSAIDs for symptom relief compared to
study of 154 COVID-19 patients requiring mechanical ven- patients with mild symptoms. Nevertheless some authori-
tilation evaluated efficacy and safety of tocilizumab and the ties, have suggested that paracetamol should be considered
drug was associated with lower mortality despite high occur- first-line antipyretic agent, if not contraindicated, with ibu-
rence of infections [62]. Multiple randomized, multicenter profen reserved for individuals who are unable to tolerate
clinical trials are currently ongoing to assess its use either paracetamol until ongoing trials further clarify harms and
as a single agent or in combination treatments. benefits of NSAIDs in people with COVID-19 [72]. LIBER-
Based on the hypothesis that viral infections activate ATE Trial in COVID-19 (LIBERATE) is an ongoing ran-
coagulation and complement cascades, triggering ARDS, domized phase 4 double blinded controlled trial (Clinical-
antiCD5-a complement monoclonal antibody eculizumab, Trials.gov: NCT04334629) testing Lipid Ibuprofen Versus
was combined with a JAK1/2 inhibitor, ruxolitinib in 17 Standard of Care for Acute Hypoxemic Respiratory Failure
patients and the combination demonstrated significant clini- Due to COVID-19. The study aims to evaluate the reduction
cal benefit [63]. in severity and progression of lung injury with three doses
of lipid ibuprofen in patients with SARS-CoV-2 infections
providing more pragmatic evidence of the role of ibuprofen
Monoclonal antibodies use in COVID-19.

Several neutralizing SARS-CoV-2 monoclonal antibod- Systemic corticosteroids

ies are currently evaluated in the setting of clinical trials.
These antibodies target specific regions of the viral spike, The efficacy of corticosteroids on inflammatory organ injury
are mainly IgG1 subtype and are characterized by long half- in viral pneumonias remains controversial [73]. SARS-
life. This indicates that could be administered in a single CoV-2 infection often presents with a biphasic pattern: a
infusion. However, the bioavailability in tissues and organs first viremic phase lasting 7–10 days, followed in approx-
affected by COVID-19 remains unknown [64]. imately 20% of patients by a second inflammatory phase

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174 Clinical and Experimental Medicine (2021) 21:167–179

characterized by cytokine storm and respiratory failure [74]. supplemental oxygen can be considered. However, routine
Considering that host immune response plays a key role in corticosteroid use, especially in patients with mild symp-
the pathophysiological effects of organ failure in viral pneu- toms or at the early stages of the disease may be avoided
monias it has been hypothesized that corticosteroids might unless they are indicated for another reason such as exacer-
have an effect on pulmonary and systemic inflammation. bation of asthma or chronic obstructive pulmonary disease
Previous studies reported negative or neutral effects of (COPD), septic shock or ARDS in an individual basis.
corticosteroids on viral pneumonias caused by SARS-CoV,
MERS-CoV or influenza [75–78]. Observational stud- Bronchodilators/vasodilators
ies have shown more secondary infections, delayed viral
clearance, increased mortality and more adverse effects Wheezing has been not indicated as a common symptom
such as psychosis, hyperglycaemia and avascular necrosis of COVID-19 [83–85]. Bronchodilators should certainly be
with steroid treatment [78]. However, the hyperinflamma- administered whenever indicated but should not be ordered
tory response frequently seen in COVID-19 has been not as standard of care. Nebulizers are associated with aerosoli-
confirmed in other viral infections. In addition, the use of zation increasing the risk of SARS-CoV-2 transmission and
corticosteroids may have a role in acute respiratory distress should be avoided, especially in cases without an evidence-
syndrome (ARDS), a severe complication of SARS-CoV-2 based benefit [86]. In patients with suspected or documented
infection. COVID-19, nebulized bronchodilator therapy using metered
Recently, a non-blinded randomized controlled trial of dose inhalers (MDIs) with spacer devices rather than nebu-
non-COVID-19 patients with ARDS under lung-protective lizers should be reserved for acute bronchospasm such as
mechanical ventilation reported a benefit of high-dose dexa- asthma [87] or exacerbation of chronic obstructive pulmo-
methasone treatment (n = 139) compared to routine inten- nary disease [COPD] exacerbation. If nebulized therapy
sive care (n = 138). At 60 days, 21% of patients in the dexa- is used, patients should be in an airborne infection isola-
methasone group and 36% of patients in the control group tion room, and healthcare workers should use appropriate
died (between-group difference − 15.3% [− 25.9 to − 4.9]; personal protection equipment (PPE). According to recent
p = 0.0047) without significant differences in adverse events guidelines, aerosol-generating procedures on ICU patients
between the two groups [79]. A retrospective cohort analysis with COVID-19 should be performed in a negative pressure
of patients with COVID-19 who developed ARDS (41.8% room and the healthcare workers performing aerosol proce-
of patients) showed that treatment with methylprednisolone dures should use fitted respirator masks (N95 respirators,
was associated with a decreased risk of death (HR 0.38; FFP2, or equivalent), (best practice statement) [88].
95% CI 0.20–0.72) [80]. A single-center retrospective cohort Patients with severe hypoxemia may benefit from pul-
study reported that hospitalized COVID-19 patients treated monary vasodilators by improving ventilation-perfusion
with steroids (n = 396) had a lower mortality rate than those mismatch and decreasing pulmonary vascular pressure. Pul-
who did not receive steroids (n = 67), 13.9% vs. 23.9% monary vasodilators may be, especially useful for patients
(HR 0.51, 95% CI 0.27–0.96, p = 0.044) [81]. The recently with decompensated or acute pulmonary arterial hyperten-
published Randomized Evaluation of COVID-19 Therapy sion [88]. However, these agents do not reduce mortality in
(RECOVERY) trial, an open label randomized controlled all-cause ARDS and should not be used instead of proved
trial compering dexamethasone (6 mg daily for 10 days) therapies. There is no evidence supporting the use of pul-
versus standard of care, terminated enrollment early due to monary vasodilators in COVID-19 patients. A meta-analysis
a mortality benefit with dexamethasone [82]. Hospitalized of 13 RCTs (1243 patients) on inhaled nitric oxide (NO) in
patients with COVID-19 randomized to dexamethasone arm non-COVID-19 patients with ARDS failed to show signifi-
(n = 2104) had lower rates of 28-day mortality compared cant effect on mortality (RR 1.04; 95% CI 0.9 to 1.19), and
to the standard of care arm (n = 4321) (RR 0.83, 95% CI reported increased risk of acute kidney injury (RR 1.59; 95%
0.74–0.92, p = 0.0007). Dexamethasone reduced deaths in CI 1.17 to 2.16). Although inhaled nitric oxide resulted in
ventilated patients (RR 0.65, 95% CI 0.48–0.88, p = 0.0003) a transient improvement in oxygenation for the first 24 h,
and patients receiving supplemental oxygen (RR 0.80, 95% the positive effect disappeared beyond 24 h [89]. The most
CI 0.67–0.96, p = 0.0021), but not in patients who did not commonly used agents are inhaled nitric oxide gas and aero-
require respiratory support (RR 1.22, 95% CI 0.86–1.75, solized epoprostenol, administered by continuous inhalation.
p = 0.15). The benefit of dexamethasone was apparent in Inhaled NO may be preferred because of less frequent need
patients being treated more than 7 days after symptom onset of filter changes, decreasing exposure of healthcare workers
as inflammatory lung complications are likely to have been caring of COVID-19 patients. Inhaled vasodilators should
more common after the first week from symptom onset. only be administered through a closed system to reduce aero-
Based on current evidence low-dose systemic steroids for solization. Improvement in oxygenation with inhaled vaso-
selected COVID-19 patients who are critically ill or require dilators is typically seen within a few hours after initiation

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Clinical and Experimental Medicine (2021) 21:167–179 175

of administration. Inhaled prostacyclins such as ilioprost COVID19 have certain peculiarities. COVID-19 patients
have not been tested yet in severe ARDS. Based on very may present with a particular dissociation between the
low quality of evidence, current guidelines suggest initiation degree of hypoxemia and loss of lung volume (compli-
(trial) of inhaled pulmonary vasodilators as a rescue therapy ance) and response to positive end expiratory pressure
in mechanically ventilated adults with COVID-19, severe (PEEP) [95] possibly due to the distinguished pattern of
ARDS and hypoxemia, despite optimizing ventilation and “endothelitis”, vascular injury and microangiopathy [96].
other rescue strategies. In the absence of rapid improvement However, COVID-19 can also induce refractory hypoxemia
in oxygenation the treatment should be de-escalated [88]. and/or hypercapnia, despite optimal management strategy
Ongoing trials are under way (NOSARSCOVID; clinical- (including muscle relaxation, prone position, and pulmonary
trials.gov; NCT04290871) to provide more evidence on the vasodilators) with subsequent remarkable high in-hospital
effect of inhaled NO in severe acute respiratory syndrome mortality.
in COVID-19 patients. In this specific group of critical ill COVID-19 patients,
where there is no further treatment option, extracorporeal
Mechanical ventilation/high nasal flow/ECMO membrane oxygenation (ECMO) has been considered to
have an important role as a rescue therapy in treatment strat-
Acute hypoxemic respiratory failure is one of the most com- egy to increase survival. Results emerging from the ELSO
mon clinical manifestations that determine clinical outcome registry demonstrate that ECMO is feasible and it has been
in COVID-19 patients. Although the majority of patients applied with safety and efficacy in more than 1000 COVID-
with COVID-19 infection have an asymptomatic or mild 19 patients with severe refractory ARDS with a remarkable
respiratory disease, a small but significant proportion of ICU/hospital discharge rate of more than 50% [43].
patients present acute respiratory distress syndrome (ARDS)
requiring hospital and/or intensive care unit (ICU) admission
and support with mechanical ventilation [90]. Vaccines
The value of noninvasive ventilation has not been fully
clarified yet, but most COVID-19 centers use (at least as a Vaccine development is complex, lengthy and expensive
trial) high flow nasal cannula (HFNC)/noninvasive positive process. Attrition rates are high and multiple candidates are
pressure ventilation (NIPPV) in mild to moderate ARDS and required, with multiple steps, pauses for checks and data
reserve endotracheal intubation and mandatory mechanical analysis to lead eventually to a licence production [97]. A
ventilation for more severe ARDS patients. While there is new “pandemic paradigm” is required to include a plat-
a theoretical risk of healthcare personnel and patients con- form that can provide scalable, technological flexibility and
tamination by using HFNC/NIPPV, there are substantial versatility with large scale production of a vaccine that is
benefits mostly shown from previous meta-analysis [91, efficacious, safe and well-tolerated allowing fast starts and
92]. These meta-analyses have recently demonstrated that parallel step execution. The development cycle of a vaccine
HFNC reduces the rate of intubation compared with con- production against SARS-CoV-2 is moving remarkably fast
ventional oxygen therapy but also compared with NIPPV in given the major pandemic issue that has emerged and major
acute hypoxemic respiratory failure. Based on this evidence, international vaccine funding agencies are supporting the
the European Society of Intensive Care Medicine (ESICM) multitude of innovative ongoing efforts.
recommends its use in COVID-19 patients; however, there SARS-CoV-2 is composed of an single-stranded,
is strong recommendation of close monitoring for signs of positive-sense RNA enveloped molecule surrounded by
respiratory status deterioration and early intubation in a con- functional and structural proteins which include protein
trolled setting, when HNF/NIPPV are applied in COVID-19 E(envelope), protein S(spike), protein M (membrane),
patients [88]. Protein N(nucleocapsid) [98]. The viral genome of SARS-
The exact number of patients requiring mechanical ven- CoV-2 was published only 4 weeks into the outbreak dem-
tilation is not clear yet; Recent observational data published onstrating tis genomic and phylogenetic similarity to SARS-
from the Italian COVID-19 experience in Lombardy region CoV but also several bat coronaviruses [99].
and from New York City have shown that most critical ill Current approaches include the classical inactivated and
COVID-19 positive patients admitted in ICU required inva- attenuated vaccines, the viral protein S subunit, virus like
sive mechanical ventilation (> 80%) and presented a high particles (VLP), viral vector-based vaccines and the newer
hospital mortality rate (~ 50%) [93, 94]. DNA- and RNA-based vaccines [42, 100]. Given the prior
Mechanical ventilation management includes protective experience with SARS-CoV vaccine development in 2003
ventilation and recruitability studies with lung mechan- targeting the S subunit, some SARS-CoV-2 vaccines entered
ics assessment. The latter seems to have a central role in human clinical trials directly providing a head start [42,
mechanical ventilation strategy as ARDS phenotypes in 101].

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176 Clinical and Experimental Medicine (2021) 21:167–179

The first vaccine to enter clinical trials as early as Feb- USA). A live-attenuated vaccine with swapped optimized
ruary 2020, is a novel experimental RNA-based vaccine codons with non-optimized codons is under development
(mRNA-1273) which uses part of the S protein genetic code. by Codagenix in collaboration with Serum institute in India.
It is being developed by Moderna Therapeutics (Cambridge, Antigen presenting cells modified by lentiviral vectors and
MA, USA), a pharmaceutical company working already acting as “minigenes” that express portions of SARS-Cov-2
on the SARS-CoV and MERS-CoV vaccines allowing the based on dendritic cells, form the basis of two other vac-
clinical development to skip certain animal testing based cines under development by the Shenzhen Geno-Immune
on earlier studies. The interim analysis results of the phase Medical Institute.
I clinical trial were released recently; the report included Which of these strategies will be most efficacious remain
45 participants (age 18–55) who received two intramus- to be seen and despite immense efforts to rapidly develop a
cular injections (at 28 days) of three dose levels (25, 100, vaccine for large scale production, the clinical trial stages
250 µgs). The 100 and 250 microgram doses lead to high and regulatory hurdles are necessary to ensure short- and
levels of virus-neutralizing antibodies and the 100mcg dose long-term safety and efficacy. Challenges in this process
had the maximum immunogenicity with minimum reac- include determining which approach can induce the opti-
togenicity. The trial has expanded to include adults over mal immune response, potential exacerbation of lung disease
55 years of age and includes 120 participants [102]. The and finally establishing that the protection inferred from the
phase II clinical trial on safety, reactogenicity and immuno- SARS and MERS experienced actually holds.
genicity of the two different doses began enrollment in May The H1N1 experience has made clear the need for novel
2020 and a phase III trial is being prepared to launch soon development and manufacturing platforms that can be
(NCT04283461) [42]. adapted to new emerging pathogens (“X”). Vaccine and
Inovio Pharmaceuticals’, already working on a novel biotech companies have been investing in such approaches
DNA vaccine for MERS, (Plymouth Meeting, PA, USA) in recent years. In addition financial instruments are required
[42, 103, 104] has developed INO-4800 using the S gene. It that can support pandemic vaccine development. To ensure
has entered phase I clinical trials and is administered intra- herd immunity there is a need for a global instrument which
dermally using electroporation. A phase II/III clinical trial is responsible for large-scale development, manufacturing
is expected this summer. CanSino Biologics (Tianjin, China) and deployment of licenced vaccines [106].
have developed a vaccine based on their adenovirus vac-
cine platform built for Ebola vaccine and on the S subunit.
Ad5-nCov is understudy in a phase I clinical trial [104]. Conclusion
(NCT04313127) The results of the phase I/II trial single-
blind randomized trial of a chimpanzee adenovirus-vectored COVID-19 is a novel emerging infectious disease caused
vaccine (ChAdOx1 nCoV-19) expressing the SARS-CoV-2 by SARS-CoV-2 characterized as atypical pneumonia. As
spike protein compared with a meningococcal conjugate of July 1, 2020, more than 10 million people worldwide
vaccine (MenACWY) as a control were recently released. had been infected with SARS-CoV-2. Advances in preven-
All participants in the non-randomized prime boost group tion and effective management of COVID-19 will require
(n = 19) at both dose levels had neutralizing activity follow- basic and clinical investigation and public health and clini-
ing a booster dose and antibody responses correlated with cal interventions. The pathogenesis of the new coronavi-
ELISA assessed antibody levels. No serious adverse events rus is still not well defined. Most patients present with a
were observed and the results for the randomized cohort are self-limited course, however, a few will experience severe
awaited [105]. or even fatal disease. COVID-19 is defined as a multisys-
A large number of different vaccines are currently in temic disease. The basic pathogenesis involves two des-
pre-clinical development. A new oral SARS-Cov-2 vaccine crete compounds; a severe lung inflammation and immune
uses food-grade safe Saccharomyces cerevisiae as a carrier deficiency, both of which are related to an inappropriate
targeting the S protein (Tianjin University). mRNA-based immune response and increased production of cytokines.
vaccines at different stages of development are also under- Thus, treatment approaches currently investigated include
way; BTN162 (developed by BioTech, Mainz, Germany) antiviral and anti-proinflammatory cytokines, anti-infectious
encapsulates the nucleic acid in 80 nm ionizable, glycol- and life support therapies, monoclonal antibodies and pas-
lipid nanoparticles and is expected to enter clinical trial test- sive immunotherapy, especially in patients with severe dis-
ing soon [103]. Other mRNA vaccines are being developed ease. However, although the therapeutic strategy against the
by CureVac (Tübingen, Germany) and Pfizer (New York, disease is of high importance the main way to prevent virus
NY, USA). Intranasal, recombinant adenovirus-based vac- spread is the development of an effective and safe vaccine
cines are being developed Altimmune Inc. (Gaithersburg, widely available.
MD, USA) and Johnson and Johnson (New Brunswick, NJ,

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Clinical and Experimental Medicine (2021) 21:167–179 177

Funding None. 19. Liu S, Lin H-M, Baine I et al. Convalescent plasma treatment
of severe COVID-19: a matched control study. https​://doi.
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els of infection and development of passive antibody therapy.
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