Management of immunosuppression therapy and COVID-19 therapy
Baseline immunosuppression therapy and its management are described in table 4. Overall, reduction was observed in 22 (39%) patients, and complete discontinuation was reported in 4 cases (7%). Considering individual therapies, antimetabolites were the most frequently discontinued drugs (18%), whereas calcineurin inhibitors (CNIs) were the most frequently reduced ones (16%).
Table 4  Baseline immunosuppression characteristics and modification during the infection
Baseline immunosuppression therapy  Overall, n (%)  No modification, n (%)  Reduction, n (%)  Discontinuation, n (%)
Single agent
CNIs  16 (28)  12 (75)  2 (12.5)  2 (12.5)
 Cyclosporine  3 (5)  2 (67)  0  1 (33)
 Tacrolimus  13 (29)  10 (77)  2 (15)  1 (8)
mTORi  2 (4)  1 (50)  0  1 (50)
 Everolimus  1 (2)  1 (100)  0  0
 Sirolimus  1 (2)  0  0  1 (100)
MMF  2 (3)  0  0  1 (100)
Steroid  1 (2)  1 (100)  0  0
Two or more agents
CNIs+MMF  21 (37)  7 (33)  6 (29)  8 (38)
 CNIs  –  –  5  1
 MMF  –  –  1  7
CNIs+mTORi  3 (5)  1 (33.3)  1 (33.3)  1 (33.3)
 CNIs  –  –  1  0
 mTORi  –  –  0  1
CNIs+steroids  9 (16)  1 (11.2)  4 (44.4)  4 (44.4)
 CNIs  –  –  4  4
 Steroids  –  –  0  0
CNIs+AZA  1 (2)  1 (100)  0  0
mTORi +MMF  2 (3)  1 (50)  0  1 (50)
 mTOR  –  –  0  1
 MMF  –  –  0  0
AZA, azathioprine; CNIs, calcineurin inihibitors, including cyclosporine and tacrolimus; MMF, mycophenolate mofetil; mTORi, mammalian target of rapamycin inhibitor, including sirolimus and everolimus. Concerning specific therapy for COVID-19, 19 (35%) patients received steroids, 22 (44%) hydroxychloroquine and 5 (9%) antivirals, including lopinavir/ritonavir (3 patients), darunavir/cobicistat and remdesivir. Only one patient was treated with tocilizumab, while two more patients were on immunomodulatory therapies because of concomitant comorbities (one on rituximab for active lymphoma and the other one on ruxolitinib for a graft vs host disease). Overall, 35 (63%) and 16 (29%) subjects received at least one and more than one antibiotic drug, respectively. Of those, 15 (27%) were treated with azithromycin as part of the standard care of COVID-19 therapy in some centres.24
As for respiratory support, oxygen therapy was required in more than half of the patients (30, 54%). Of those, the majority required only oxygen therapy through nasal cannula (18 patients, 32%), whereas 8 (14%) subjects received high-flow oxygen. Four (7%) patients required intubation and invasive mechanical ventilation (table 5).
Table 5  Therapeutic strategies for COVID-19 and outcomes
Study population  Results
Patients, n  57
Medications, n (%)
Steroids (for COVID-19)  19 (35)
Antibiotics  35 (63)
 Azitromycin  15 (27)
 >1 antibiotic  16 (29)
Antivirals  5 (9)
 Lopinavir/ritonavir  3 (5)
 Darunavir/cobicistat  1 (2)
 Remdesivir  1 (2)
Immunomodulator  3 (5)
 Tocilizumab  1 (2)
 Rituximab  1 (2)
 Ruxolitinib  1 (2)
Hydroxychloroquine  24 (44)
Oxygen therapy (higher intensity), n (%)
Overall  30 (54)
 Nasal cannula  18 (32)
 Non-invasive ventilation  8 (14)
 Invasive mechanical ventilation  4 (7)
Outcomes, n (%)
Death  7 (12)
ARDS  11 (19)
ICU admission  4 (7)
Hospitalisation (no ICU)  37 (65)
 Need for rehabilitation  7 (17)
Duration of hospitalisation, median (IQR)
Hospital stay  10 (7–22)
 ICU stay  16 (10–19)
Rehab stay  14 (11–15)
ARDS, acute respiratory distress syndrome; ICU, intensive care unit.