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Infectious Diseases

Evaluating And Referring Patients For Outpatient Monoclonal Antibody Therapy For Coronavirus In The Emergency Department (Archived)

This article is made available for historical review, monoclonal antibody use is not currently indicated for this condition. Coronavirus disease 2019 (COVID-19), the illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has had a devastating effect on public health and the world economy. SARS-CoV-2 primarily affects the respiratory system, with the majority of transmission occurring from close contact with presymptomatic, asymptomatic, or symptomatic carriers. Since the

v1 · Reviewed Nov 7, 2026 by Automated Clinical Reviewer (Strict Verbatim v1)
  • Oxygen saturation < 94% on room air
  • Respiratory rate >30 breaths/minute
  • PaO2/FiO2 < 300 mmHg
  • Lung infiltrates present in >50% of the lung fields
  • Patients with severe clinical disease on presentation to the ED should be hospitalized and do not qualify for neutralizing monoclonal antibody treatment
  • An assessment of underlying risk factors is essential to the evaluation of a patient with COVID-19 infection.
  • The presence of any one of these factors in patients diagnosed with COVID-19 puts them at a higher risk of severe disease even if the initial presentation is mild.
  • Another important step in evaluating patients with COVID-19 in the emergency department (ED) is the determination of illness/symptom onset.
  • evaluation of dyspnea severity and its onset must be determined at the index evaluation in the ED.
  • This should be followed by the determination of oxygen saturation and an overall assessment of illness severity.
  • Several previously established serum markers have been used to document COVID-19 severity.
  • They include alanine transaminase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), C-reactive protein (CRP), procalcitonin, ferritin, D-dimer, and fibrinogen.
  • An elevated D-dimer is considered an independent marker of unfavorable disease progression.
  • All patients who present to the ED with moderate to severe COVID-19 disease should receive radiographic imaging.
  • The American College of Radiography recommends plain radiographs as the imaging test of choice
  • a soluble triggering receptor expressed on myeloid cells (sTREM-1) had high prognostic accuracy for 30-day intubation/mortality.
  • interleukin (IL) 6 measured at presentation to the ED had high accuracy for predicting 30-day oxygen requirement.
  • Monoclonal antibodies targeting the spike protein of the SARS-CoV-2 have yielded positive in vitro results.
  • They are considered a promising approach in managing nonhospitalized patients with mild to moderate COVID-19 who are at high risk of developing severe illness.
  • Sotrovimab was granted emergency use authorization from FDA in May 2021 for clinical use in non-hospitalized patients with mild to moderate COVID-19 illness who are at increased risk for developing severe disease and/or hospitalization.
  • Patients with mild disease severity and at high risk for disease progression due to risk factors can be discharged from the ED and referred to outpatient neutralizing monoclonal treatment centers.
  • Patients with mild disease and a high risk of disease progression should receive monoclonal antibody treatment even if initial laboratory and radiologic data are unremarkable regardless of their vaccination status.
  • Patients with moderate disease severity and mildly abnormal laboratory/radiologic data with risk factors for disease progression would benefit from discharge home and referral to outpatient monoclonal antibody treatment centers.
  • Use anti-SARS-CoV-2 monoclonal antibodies for mild to moderate COVID-19 disease in high-risk patients.
  • After a positive result, treatment with monoclonal antibodies should be started as soon as possible and should be within ten days of symptom onset.
sotrovimab
IV infusion
Adult
500 mg
Renal
Not specified in source
Duration
Not specified in source
  • Immunomodulating therapies, either alone or in combination with antiviral and antibody-based therapies, may be more effective when used in the later stage to combat the cytokine-mediated hyperinflammatory state that causes severe illness.
  • Patients with severe clinical disease on presentation to the ED should be hospitalized and do not qualify for neutralizing monoclonal antibody treatment; however, they may be candidates for anti-IL-6 receptor monoclonal antibodies.
  • It must not be administered to patients with known hypersensitivity to sotrovimab.
  • The FDA also cautions against the use of sotrovimab in hospitalized patients with COVID-19 requiring high flow oxygen or mechanical ventilation as it may be associated with worse clinical outcomes.
  • is not authorized for use in patients hospitalized with COVID-19, or who require supplemental oxygen therapy due to COVID-19, or who require increasing baseline oxygen therapy due to COVID-19 in those who were previously on chronic oxygen therapy at baseline due to non-COVID-19 related comorbidity.
  • Patients with COVID-19 who present to the ED with mild disease severity and do not have laboratory/radiologic data that portends a poor prognosis and do not have any risk factors for progression to severe disease can be discharged home with outpatient follow-up within 72 hours.
  • Patients with moderate disease and mild hypoxia (92% to 94% oxygen saturation on room air) would benefit from oxygen supplementation and discharge home with dexamethasone and outpatient follow-up within 24 hours.
  • Of the 199 patients evaluated in the study, 14 patients were recommended urgent ED re-evaluation at 2-week telephone follow-up, 44 patients had reattended ED at 20-day follow up, and 87 patients were identified with persistent symptoms requiring face-to-face evaluation at the 4-week telephone follow up.
  • They recommended the establishment of a COVID-19 follow-up clinic for patients discharged from the emergency department to provide "safety netting" after discharge.
  • Another recent study reported that COVID-19 patients diagnosed with mild symptoms and discharged from the ED had a 14.6% bounceback rate due to the illness's progression.
  • These studies highlight the importance of close clinical follow-up after discharge from the ED regardless of the treatment plan.
  • administration of monoclonal antibodies is associated with the risk of immune-mediated reactions, including anaphylaxis, serum sickness, and antibody generation.
  • The most frequently reported adverse effects of sotrovimab therapy were infusion-related immediate hypersensitivity reactions manifesting as pruritus, flushing, rash, and facial swelling.
  • Clinical worsening of COVID-19 after monoclonal antibody administration may include but is not limited to fever, fatigue, hypoxia or increased respiratory difficulty, arrhythmias, and altered mental status.
  • Considering monoclonal antibodies are commonly associated with infusion-related reactions, the patient should be monitored closely during the infusion and at least 1 to 2 hours after the infusion is complete.
  • review
    Evaluating And Referring Patients For Outpatient Monoclonal Antibody Therapy For Coronavirus In The Emergency Department (Archived). StatPearls [Internet] — Abdul Aleem, Olubunmi Olarewaju, Alexander Pozun — StatPearls Publishing, 2023

Decision support only. Verify against local protocols and current labeling. Source: www.ncbi.nlm.nih.gov