Management of SARS-CoV-2 and Persistent Viral Detection in Solid Organ Transplant Recipients

Purpose of Review We explore the challenges of managing solid organ transplant recipients (SOTRs) during the COVID-19 pandemic, with a focus on prolonged viral detection in immunosuppressed individuals. Recent Findings SOTR guidelines recommend three mRNA vaccine doses with additional booster dosing and continued protective post-vaccination measures. COVID-19 therapies are similar for SOTRs and non-SOTRs, although drug-drug interactions limit the use of some such as nirmatrelvir/ritonavir (NIM-RTV). Inpatient treatment options include remdesivir and steroids; outpatient antiviral options include NIM-RTV or remdesivir. Whereas molnupiravir has not been withdrawn in the USA, it is no longer available in Europe due to safety and efficacy concerns, along with selection mutagenesis. Prolonged viral replication in immunosuppressed patients presents the risk of future variant generation and concern for transmission. Summary SOTR COVID-19 guidelines emphasize vaccination and protective measures; persistently positive cases remain a challenge. Medications promoting selection mutagenesis are ill-advised for those already at risk of incubating variants capable of immunologic escape.