Viral rebound after nirmatrelvir–ritonavir treatment has implications for the clinical management and isolation of patients with COVID-19. We evaluated an unselected, population-wide cohort to identify the incidence of viral burden rebound and associated risk factors and clinical outcomes.

We did a retrospective cohort study of hospitalised patients with a confirmed diagnosis of COVID-19 in Hong Kong, China, for an observation period from Feb 26 to July 3, 2022 (during the omicron BA.2.2 variant wave). Adult patients (age ≥18 years) admitted 3 days before or after a positive COVID-19 test were selected from medical records held by the Hospital Authority of Hong Kong. We included patients with non-oxygen-dependent COVID-19 at baseline receiving either molnupiravir (800 mg twice a day for 5 days), nirmatrelvir–ritonavir (nirmatrelvir 300 mg with ritonavir 100 mg twice a day for 5 days), or no oral antiviral treatment (control group). Viral burden rebound was defined as a reduction in cycle threshold (Ct) value (≥3) on quantitative RT-PCR test between two consecutive measurements, with such decrease sustained in an immediately subsequent Ct measurement (for those patients with ≥3 Ct measurements). Logistic regression models were used to identify prognostic factors for viral burden rebound, and to assess associations between viral burden rebound and a composite clinical outcome of mortality, intensive care unit admission, and invasive mechanical ventilation initiation, stratified by treatment group.

We included 4592 hospitalised patients with non-oxygen-dependent COVID-19 (1998 [43·5%] women and 2594 [56·5%] men). During the omicron BA.2.2 wave, viral burden rebound occurred in 16 of 242 patients (6·6% [95% CI 4·1–10·5]) receiving nirmatrelvir–ritonavir, 27 of 563 (4·8% [3·3–6·9]) receiving molnupiravir, and 170 of 3787 (4·5% [3·9–5·2]) in the control group. The incidence of viral burden rebound did not differ significantly across the three groups. Immunocompromised status was associated with increased odds of viral burden rebound, regardless of antiviral treatment (nirmatrelvir–ritonavir: odds ratio [OR] 7·37 [95% CI 2·56–21·26], p=0·0002; molnupiravir: 3·05 [1·28–7·25], p=0·012; control: 2·21 [1·50–3·27], p<0·0001). Among patients receiving nirmatrelvir–ritonavir, the odds of viral burden rebound were higher in those aged 18–65 years (vs >65 years; 3·09 [1·00–9·53], p=0·050), those with high comorbidity burden (score >6 on the Charlson Comorbidity Index; 6·02 [2·09–17·38], p=0·0009), and those concomitantly taking corticosteroids (7·51 [1·67–33·82], p=0·0086); whereas the odds were lower in those who were not fully vaccinated (0·16 [0·04–0·67], p=0·012). In patients receiving molnupiravir, those aged 18–65 years (2·68 [1·09–6·58], p=0·032) or on concomitant corticosteroids (3·11 [1·23–7·82], p=0·016) had increased odds of viral burden rebound. We found no association between viral burden rebound and occurrence of the composite clinical outcome from day 5 of follow-up (nirmatrelvir–ritonavir: adjusted OR 1·90 [0·48–7·59], p=0·36; molnupiravir: 1·05 [0·39–2·84], p=0·92; control: 1·27 [0·89–1·80], p=0·18).

Viral burden rebound rates are similar between patients with antiviral treatment and those without. Importantly, viral burden rebound was not associated with adverse clinical outcomes.

Health and Medical Research Fund, Health Bureau, The Government of the Hong Kong Special Administrative Region, China.

For the Chinese translation of the abstract see Supplementary Materials section.