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

Background There is limited data to support routine remdesivir use in the contemporary era of SARS-CoV-2 with widespread seropositivity. Methods 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. Results 4,774 patients were included in the analysis (3,323 pre-intervention; 1,451 post-intervention). Significantly fewer patients in the post-intervention group received remdesivir (37.7% pre-intervention vs 4.1% post-intervention, p<0.001). When medium-risk covariates were modeled, there was no difference in 14-day all-cause mortality between pre- and post-intervention groups (OR, 1.8; 95% CI 0.54 to 5.8, p = 0.34). Similarly, there was no difference in 28-day all-cause mortality, 30-day readmission, or LOS. 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 pre-intervention and higher association with these outcomes post-intervention. Similar outcomes were observed when high-risk value covariates were modeled. Conclusion Restriction of remdesivir use in immunocompetent patients across a large health system was not associated with an increased risk of mortality. Remdesivir use was associated with an unexpected increased risk of ICU admission and MV within the post-intervention group only, which is likely explained by the higher-risk patient population that received remdesivir. Prospective studies would be needed to definitively determine if highly vaccinated, immunocompetent patients benefit from remdesivir.