The duration of viral shedding is central to the guidance of decisions about isolation precautions and antiviral treatment. However, studies regarding the risk factors associated with prolonged shedding of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the impact of lopinavir/ritonavir (LPV/r) treatment on viral shedding remain scarce.
Data were collected from all SARS-CoV-2 infected patients who were admitted to isolation wards and had reverse transcription PCR conversion at the No. 3 People's Hospital of Hubei province, China, between 31 January and 9 March 2020. We compared clinical characteristics and SARS-CoV-2 RNA shedding between patients initiated with LPV/r treatment and those without. Logistic regression analysis was employed to evaluate the risk factors associated with prolonged viral shedding.
Of 120 patients, the median age was 52 years, 54 (45%) were male and 78 (65%) received LPV/r treatment. The median duration of SARS-CoV-2 RNA detection from symptom onset was 23 days (interquartile range 18–32 days). Older age (OR 1.03, 95% CI 1.00–1.05; p=0.03) and the lack of LPV/r treatment (OR 2.42, 95% CI 1.10–5.36; p=0.029) were independent risk factors for prolonged SARS-CoV-2 RNA shedding. Patients who initiated LPV/r treatment within 10 days from symptom onset, but not initiated from day 11 onwards, had significantly shorter viral shedding duration compared with those without LPV/r treatment (median 19 days
Older age and the lack of LPV/r treatment were independently associated with prolonged SARS-CoV-2 RNA shedding in patients with coronavirus disease 2019 (COVID-19). Earlier administration of LPV/r treatment could shorten viral shedding duration.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused substantial morbidity and mortality worldwide [
Thus, this study sought to assess the risk factors associated with prolonged viral shedding and the potential impact of earlier administration of LPV/r treatment on the duration of viral shedding in hospitalised non-critically ill patients with SARS-CoV-2 infection between 31 January and 9 March 2020.
This retrospective study included all patients who were admitted to the No. 3 People's Hospital of Hubei province (one of the designated hospitals during the COVID-19 outbreak in Wuhan, China) between 31 January 2020 and 9 March 2020. Eligible patients had laboratory-confirmed SARS-CoV-2 infection and had available RNA virological data to estimate the duration of viral shedding. Demographic, clinical, laboratory, treatment and successive virological data were extracted from electronic medical records using a standardised data collection sheet that was modified based on the World Health Organization/International Severe Acute Respiratory and Emerging Infection Consortium case record form. We assessed the severity of illness according to the Chinese management guideline for COVID-19 (sixth version) [
Laboratory identification of SARS-CoV-2 infection was made at Wuhan Jinyintan Hospital and No. 3 People's Hospital of Hubei province using a real-time reverse transcription PCR (RT-PCR) assay. The same methods as previously described were adopted, in which the detection reagents were provided by the local Center for Disease Control [
LPV/r (400 mg and 100 mg, orally, twice daily) was administered to the laboratory-confirmed cases at the discretion of the attending physicians at every isolation ward. The treatment duration was ≥10 days, according to the recommendations from the Chinese management guideline for COVID-19 (sixth version) [
Data are presented as median (interquartile range (IQR)) for continuous variables and number (percentage) for categorical variables. We employed the Mann–Whitney U-test or Kruskal–Wallis test for analysis of continuous variables, and the Chi-squared test or Fisher exact test for analysis of categorical variables. Univariate and adjusted multivariate logistic regression analyses were used to identify the risk factors associated with prolonged duration of SARS-CoV-2 RNA shedding. Prolonged viral shedding was defined as the duration of SARS-CoV-2 RNA shedding being >23 days. The cut-off was determined
From 31 January 2020 to 9 March 2020, 168 confirmed cases were admitted to our hospital. As of 9 March 2020, a total of 48 patients (28.6%) still tested positive for SARS-CoV-2 RNA and eight patients (4.8%) had died. The main characteristics of the patients who were included in and excluded from the final analyses are provided in
Characteristics of 120 hospitalised patients with SARS-CoV-2 infection in Wuhan
120 | 61 | 59 | ||
52 (35–63) | 48 (33–60) | 56 (42–65) | 0.04 | |
54 (45) | 30 (49.2) | 24 (40.7) | 0.35 | |
12 (10) | 5 (8.2) | 7 (11.9) | 0.50 | |
Hypertension | 32 (26.7) | 19 (31.1) | 13 (22.0) | 0.26 |
Diabetes | 10 (8.3) | 3 (4.9) | 7 (11.9) | 0.20 |
Cardiac disease¶ | 7 (5.8) | 3 (4.9) | 4 (6.8) | 0.72 |
Stroke | 3 (2.5) | 1 (1.6) | 2 (3.4) | 0.62 |
COPD or asthma | 2 (1.6) | 2 (3.2) | 0 (0) | |
Chronic renal insufficiency | 1 (0.8) | 0 | 1 (1.7) | |
Malignancy | 7 (5.8) | 4 (6.6) | 3 (5.1) | 0.73 |
0.36 | ||||
General | 89 (74.2) | 48 (78.7) | 41 (69.5) | |
Severe | 30 (25.0) | 13 (21.3) | 17 (28.8) | |
Critical | 1 (0.8) | 0 (0) | 1 (1.7) | |
White blood cell count ×109 cells·L−1 | 5.65 (4.14–7.33) | 0.57 | ||
<4 | 27 (22.7) | 16 (26.7) | 11 (18.6) | |
4–10 | 82 (68.9) | 39 (65) | 43 (72.9) | |
>10 | 10 (8.4) | 5 (8.3) | 5 (8.5) | |
Lymphocyte count ×109 lymphocytes·L−1 | 1.14 (0.81–1.55) | |||
<0.8 | 29 (24.3) | 18 (62.1) | 11 (37.9) | 0.15 |
Platelet count ×109 platelets·L−1 | 195 (144–269) | |||
<100 | 7 (5.9) | 5 (4.2) | 2 (1.0) | 0.44 |
Creatinine level μmol·L−1 | 61 (52–74) | |||
>133 | 4 (3.4) | 0 (0) | 4 (3.4) | |
AST level U·L−1 | 31 (24–42.4) | |||
>40 | 33 (27.7) | 14 (11.8) | 19 (16.0) | 0.18 |
Corticosteroid therapy | 54 (45.0) | 28 (45.9) | 26 (44.1) | 0.78 |
Lopinavir/ritonavir treatment | 78 (65) | 46 (75.4) | 33 (55.9) | 0.02 |
Antibiotics | 102 (85.0) | 52 (85.2) | 50 (84.7) | 0.77 |
High-flow nasal canula oxygen therapy | 21 (17.5) | 10 (16.4) | 11 (18.6) | 0.88 |
Noninvasive mechanical ventilation | 2 (1.7) | 0 (0) | 2 (3.4) | |
Invasive mechanical ventilation | 1 (0.8) | 0 (0) | 1 (1.7) | |
Viral shedding days | 23 (18–32) | 18 (15–20.5) | 32 (28–38) | <0.001 |
Symptom onset to temperature recovery days§ | 10 (6–15.5) | 7.5 (5–11) | 12 (8–20) | <0.001 |
Symptom onset to radiological recovery days | 17 (12–21) | 13.5 (11–18) | 20 (12–24) | <0.001 |
Hospital length of stay days | 21 (17–26) | 20 (15–24) | 22 (18–28) | 0.02 |
Data are presented as n, median (interquartile range) or n (%), unless otherwise stated. AST: aspartate aminotransferase. #: p-value represents comparisons between patients with prolonged viral shedding and those without; ¶: includes congestive heart disease and coronary atherosclerotic heart disease; +: data were available for 119 patients; §: data were from 99 patients.
The median duration of SARS-CoV-2 RNA shedding was 23 days (IQR 18–32 days). Only five patients (4.2%) had undetectable SARS-CoV-2 RNA within 10 days, 46 (38.3%) tested negative within 20 days, and 85 (70.8%) tested negative within 30 days from symptom onset. Most patients (86.7%) had undetectable SARS-CoV-2 RNA within 37 days after symptom onset, but a subgroup of 12 patients had detectable SARS-CoV-2 RNA up to 40 days after symptom onset (
Distribution of the number of patients with undetectable SARS-CoV-2 RNA by day after symptom onset.
In our study, a duration of SARS-CoV-2 RNA shedding of >23 days (above the median) was defined as prolonged viral shedding. The main characteristics for patients with prolonged viral shedding and those without are shown in
Multivariable logistic regression analysis of factors associated with duration of SARS-CoV-2 RNA detection in 120 hospitalised patients in Wuhan
Age | 1.02 (1.00–1.04) | 0.04 | 1.03 (1.00–1.05) | 0.03 |
Age ≥50 years | 2.13 (1.02–4.44) | 0.04 | 2.26 (1.07–4.78) | 0.03 |
Male sex | 0.71 (0.34–1.46) | 0.35 | 0.60 (0.28–1.28) | 0.19 |
Current smoking | 0.86 (0.23–3.18) | 0.82 | ||
Hypertension | 0.63 (0.28–1.42) | 0.26 | ||
Cardiac disease | 1.41 (0.30–6.57) | 0.67 | ||
Diabetes | 2.60 (0.64–10.59) | 0.18 | ||
Corticosteroid | 0.90 (0.44–1.85) | 0.78 | 0.80 (0.38–1.70) | 0.57 |
Lack of lopinavir/ritonavir | 2.59 (1.19–5.62) | 0.02 | 2.42 (1.10–5.36) | 0.03 |
OR >1 indicates that the variable increases the duration of SARS-CoV-2 RNA shedding. ORs in multivariable analysis were adjusted for age and sex. #: by use of the logistic regression model, with the cut-off determined according to the median duration of SARS-CoV-2 RNA shedding (23 days).
Of the 120 patients, 78 patients (65%) were administered LPV/r treatment. Patients receiving LPV/r treatment and those not receiving LPV/r treatment had similar baseline characteristics (
Comparison of clinical features of patients with SARS-CoV-2 infection who were treated with lopinavir/ritonavir (LPV/r) and without LPV/r, in Wuhan
78 | 42 | ||
50 (34–61) | 57 (36.5–66) | 0.11 | |
35 (44.9) | 19 (45.2) | 0.83 | |
8 (10.3) | 4 (9.5) | 0.74 | |
Hypertension | 19 (24.4) | 13 (31.0) | 0.39 |
Diabetes | 8 (10.3) | 2 (4.8) | 0.49 |
Cardiac disease# | 5 (6.4) | 2 (4.8) | 1.00 |
Stroke | 2 (2.6) | 1 (2.4) | 1.00 |
COPD or asthma | 1 (1.3) | 1 (2.4) | 0.34 |
Chronic renal insufficiency | 1 (1.3) | 0 (0) | |
Malignancy | 4 (5.1) | 3 (7.1) | 0.69 |
0.02 | |||
General | 53 (67.9) | 36 (85.7) | |
Severe | 25 (32.1) | 5 (11.9) | |
Critical | 0 (0) | 1 (2.4) | |
White blood cell count ×109 cells·L−1 | 0.32 | ||
<4 | 22 (28.2) | 5 (11.9) | |
4–10 | 49 (62.8) | 33 (78.6) | |
>10 | 7 (9.0) | 3 (7.1) | |
Lymphocyte count ×109 lymphocytes·L−1 | |||
<0.8 | 25 (32.6) | 4 (9.5) | 0.01 |
Platelet count ×109 platelets·L−1 | |||
<100 | 6 (7.7) | 1 (2.4) | 0.42 |
Creatinine level μmol·L−1 | |||
>133 | 1 (1.3) | 3 (7.1) | 0.11 |
AST level U·L−1 | |||
>40 | 21 (26.9) | 12 (28.6) | 0.87 |
Corticosteroid therapy | 44 (56.4) | 10 (23.8) | 0.001 |
Antibiotics | 73 (93.6) | 30 (71.4) | 0.001 |
High-flow nasal canula oxygen therapy | 17 (21.8) | 4 (9.5) | 0.13 |
Noninvasive mechanical ventilation | 1 (1.3) | 1 (2.4) | 1.00 |
Invasive mechanical ventilation | 1 (1.3) | 0 (0) | 1.00 |
Viral shedding days | 22 (18–29) | 28.5 (19.5–38) | 0.02 |
Hospital length of stay days | 23 (19–27) | 18.5 (13–22.5) | <0.01 |
Data are presented as n, median (interquartile range) or n (%), unless otherwise stated. AST: aspartate aminotransferase. #: includes congestive heart disease and coronary atherosclerotic heart disease.
Distribution of time to the initiation of lopinavir/ritonavir (LPV/r) treatment from symptom onset.
The cumulative proportions of patients with detectable SARS-CoV-2 RNA over time, by day after symptom onset, comparing patients without lopinavir/ritonavir (LPV/r) treatment with a) patients initiating LPV/r treatment <10 days from symptom onset, and b) patients initiating LPV/r treatment >10 days from symptom onset.
Viral shedding has commonly been used as a proxy measure for infectivity. Therefore, identification of the duration of viral shedding would be central to inform control policies and antiviral treatment in patients with COVID-19. In the current study of 120 hospitalised non-critically ill patients with COVID-19, we have for the first time identified that older age and the lack of LPV/r treatment were independent risk factors for prolonged viral shedding. We have also found that an initial administration of LPV/r treatment within 10 days from symptom onset, but not afterwards, could shorten the duration of SARS-CoV-2 RNA shedding. However, we did not observe an impact of comorbidities and corticosteroid use on the duration of viral shedding.
As an emerging novel coronavirus, data on the duration of SARS-CoV-2 RNA shedding have been limited. Our previous study reported a median duration of SARS-CoV-2 RNA shedding of 19.5 days [
Our results demonstrated that older age was independently associated with prolonged SARS-CoV-2 RNA shedding. Previous studies have shown that older age is a risk factor for SARS-CoV-2 infection and has been associated with a greater risk of development of acute respiratory distress syndrome and mortality [
Lopinavir, an HIV-1 protease inhibitor, was administered in combination with ritonavir to increase drug bioavailability of lopinavir [
Our investigation has some limitations. First, the presence of SARS-CoV-2 RNA does not necessarily indicate the production of infectious virus. Secondly, owing to triage strategies, almost all patients in our hospital were categorised as having general and severe COVID-19; therefore, extrapolating these findings to critically ill patients needs caution. Thirdly, the estimation of the duration of SARS-CoV-2 RNA shedding was limited by the type of respiratory specimen, the frequency of respiratory specimen collection and the lack of quantitative viral RNA detection. Fourthly, we excluded fatal cases from the final analysis because all of them had detectable SARS-CoV-2 RNA until death, and the time to death could not accurately reflect the duration of viral shedding; therefore, the association between viral shedding and mortality could be not assessed. Finally, interpretation of our findings was limited by the sample size and the lack of genetic analysis of the host. Further large-scale cohort studies are still needed to better define the risk factors for prolonged viral shedding, including testing the effect of corticosteroid use, in patients with COVID-19.
In summary, older age and the lack of LPV/r treatment correlate with prolonged SARS-CoV-2 RNA shedding. Earlier administration of LPV/r treatment may shorten the duration of SARS-CoV-2 RNA shedding. Randomised clinical trials to determine the effectiveness of LPV/r treatment in non-critically ill patients with COVID-19 are needed.
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We thank Wei-jie Guan (State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China) for his assistance in language editing during revision.
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Author contributions: Y-H. Gao designed the project. D. Yan, X-Y. Liu and B-T. Dan carried out the data collection. Y-H. Gao, Y-N. Zhu and L. Huang analysed the data and prepared the figures. Y-H. Gao, D. Yan, Y-N. Zhu and L. Huang drafted the manuscript. All the authors have revised the manuscript critically, approved the version submitted for publication and have agreed to be accountable for all aspects of the work.
Conflict of interest: D. Yan has nothing to disclose.
Conflict of interest: X-Y. Liu has nothing to disclose.
Conflict of interest: Y-N. Zhu has nothing to disclose.
Conflict of interest: L. Huang has nothing to disclose.
Conflict of interest: B-T. Dan has nothing to disclose.
Conflict of interest: G-J. Zhang has nothing to disclose.
Conflict of interest: Y-H. Gao has nothing to disclose.