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Public Health and Primary Care  |   December 2020
Remdesivir for the Treatment of Severe COVID-19: A Community Hospital's Experience
Author Notes
  • From Rocky Vista University College of Medicine (Mr. Lee) in Parker, Colorado; Arizona College of Osteopathic Medicine (Ms. Caine) in Glendale; and the Departments of Graduate Medical Education (Dr. Santarelli), Pharmacy (Dr. Dietrich), and Emergency Medicine (Mrs. Schritter and Dr. Ashurst) at Kingman Regional Medical Center in Kingman, Arizona. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Anthony Santarelli, PhD, Kingman Regional Medical Center, 3269 Stockton Hill Road, Kingman, Arizona, 86409-3619. Email: Anthony.Santarelli@azkrmc.com
     
Article Information
Public Health and Primary Care   |   December 2020
Remdesivir for the Treatment of Severe COVID-19: A Community Hospital's Experience
The Journal of the American Osteopathic Association, December 2020, Vol. 120, 926-933. doi:https://doi.org/10.7556/jaoa.2020.156
The Journal of the American Osteopathic Association, December 2020, Vol. 120, 926-933. doi:https://doi.org/10.7556/jaoa.2020.156
Abstract

Context: Following the emergence of the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), researchers sought safe and effective treatment modalities. Remdesivir is currently being evaluated for clinical efficacy and safety in patients with COVID-19.

Objective: To describe the clinical outcomes of COVID-19 patients following treatment with remdesivir at a community hospital.

Methods: A retrospective review of medical records was conducted in August 2020 for all patients given remdesivir while hospitalized for severe COVID-19 between May 1 and August 19, 2020. A convenience sample of consecutive patients with treatment including remdesivir, antibiotics, convalescent plasma, dexamethasone, or a combination of multiple drugs was included in the analysis. Patients receiving remdesivir were administered a 5-day treatment course. Patients with a glomerular filtration rate of less than 30 mL/min, those with liver function tests 5 times the normal reference range, and those who were pregnant were excluded from treatment with remdesivir. Differences in between men and women were detected with χ2 and independent samples t tests. The degree to which presenting symptoms influenced patient outcomes was analyzed with a stepwise logistic regression.

Results: Among the 76 patients who received remdesivir, the mean (95% confidence interval, CI) age was 63 years (59.8–66.2). Thirty-six (47.4%) were men and 40 (52.6%) were women. Forty-nine (64.5%) were White and 27 (35.5%) were nonWhite. The majority of patients (54; 71.1%) had at least 1 comorbid condition, with hypertension being the most common (43; 56.6%). The mean (95% CI) length of stay for patients who received remdesivir was 10.09 days (8.6–11.6) and the mean (95% CI) duration of oxygen therapy was 9.42 days (8.0–10.8). A total of 14 (18.4%) patients given remdesivir were admitted to the intensive care unit (ICU) with an mean (95% CI) length of stay of 9.29 days (5.6–13.0). Women administered remdesivir were more likely to be admitted to the ICU (11 [27.5%] vs 3 [8.3%]; P=.031). The mortality rate was 14 patients (18.4%), with no statistically significant difference observed between men (5; 13.9%) and women (9; 22.5%; P=.33). No significant difference was seen amongst sexes for duration of oxygen therapy (men, 8.0 days [6.2–9.8] vs women, 10.76 days [8.8–12.8]; P=.051) or length of stay (men, 8.61 days [6.7–10.5] vs women, 11.43 days [9.3–13.5]; P=.058). There was no statistically significant difference in pooled racial groups (White vs nonWhite) for in-hospital mortality, number admitted to the ICU, days spent in the ICU, duration of oxygen use, or length of stay.

Conclusion: Remdesivir may show clinical efficacy for the treatment of severe COVID-19 in a community setting. Although this was a small-scale study with limited patients, it represents a point of reference for the use of remdesivir at other community hospitals.

Since the coronavirus disease 2019 (COVID-19) pandemic began, more than 38 million people have been infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes it and more than 1,094,000 have died globally.1 In the United States, more than 7.9 million patients have been infected with SARS-CoV-2, causing more than 217,000 deaths.1 Based on the morbidity and mortality associated with COVID-19, researchers from across the globe are actively searching for safe and effective treatments for the disease. 
Remdesivir (Gilead Sciences, Inc.) was granted an emergency use authorization by the US Food and Drug Administration (FDA) on May 1, 2020 for the treatment of hospitalized patients with severe COVID-19.2 Remdesivir is a prodrug (a biological precursor that, when metabolized, forms the pharmacologically active drug) which forms an adenosine triphosphate analogue that inhibits viral RNA polymerase and replication.3-5 Remdesivir has been shown to have broad spectrum activity against filoviruses (Ebola) and coronaviruses (SARS-CoV and Middle East respiratory syndrome coronavirus [MERS-CoV]).3-5 Invitro and invivo research has demonstrated that remdesivir inhibits replication of SARS-CoV-2 within human airway epithelial cells and has verified its clinical and virologic efficacy in primate models.6-8 In clinical trials, remdesivir administration has been shown to reduce the time to clinical improvement in patients with COVID-19, with very few side effects.3-5 However, the majority of these trials have been conducted at large urban academic referral centers, which could make the results less generalizable to patients seen in a community setting. In this study, we report the outcomes of those admitted to a community hospital with severe COVID-19 who were given remdisivir. 
Methods
Setting
Kingman Regional Medical Center (KRMC) is a 214-bed community teaching hospital in northern Arizona that employs family and emergency medicine residents in an Accreditation Council for Graduate Medical Education-approved program. KRMC serves hospital district #1 of Mojave county, where the population is 76.7% White, 16.9% Hispanic or Latino, 3.0% American Indian, 1.3% African American or Black, and 1.2% Asian American.9 KRMC serves approximately 50,000 patients in the emergency department annually. All protocols and procedures conducted in this study were approved by the KRMC Institutional Review Board (IRB approval number: KRMC 0208). 
Protocol
In August 2020, we performed a retrospective review of the electronic medical records for a convenience sample of consecutive adults (18 years of age or older) with confirmed severe COVID-19 infection who were hospitalized and given remdesivir between May 29, 2020 and August 19, 2020. All cases of COVID-19 were confirmed by positive result on polymerase chain reaction testing of a nasopharyngeal sample. Severe COVID-19 infection was defined as any patient requiring oxygen therapy while hospitalized, and for all patients with severe COVID-19 infection, remdesivir was administered intravenously as a 200 mg loading dose on day 1, followed by a 100 mg maintenance dose administered daily on days 2 through 5 (or until hospital discharge or death). Patients with a glomerular filtration rate of less than 30 mL/min, those with liver function tests 5 times the normal reference range (aspartate aminotransferase, 14-36 U/L; alanine aminotransferase, 4-34 U/L), and those who were pregnant were excluded from treatment with remdesivir. Data were manually abstracted from electronic medical records records with the use of a quality-controlled protocol and structured abstraction tool that relied on a priori variable selection, systematic abstractor monitoring, and independent verification of intensive care unit (ICU) and mortality outcome variables.10 
Statistical Analysis
Statistical analysis was conducted using IBM SPSS statistics software, version 27 (IBM Corp.). Descriptive statistics for continuous (mean [95% CI]) and categorical (n[%]) variables were calculated for the total sample as well as for sex and race. To facilitate meaningful statistical comparisons, we pooled patients by race into White and nonWhite categories. Though this prohibits the comparison of individual racial groups, it did permit us to determine whether outcomes for patients who received remdesivir were equivalent among the racial majority and minority of patients presenting to the hospital. Independent samples t tests for continuous data and the Pearson chi-squared for categorical data were performed to determine differences between the group means and proportions. A stepwise binomial logistic regression was then used to calculate odds ratios and 95% CIs for both the mortality and ICU admission outcome variables. 
Results
Of the 7246 patients assessed for enrollment, a total of 76 patients were included in the final analysis (Figure). Of patients who were hospitalized and received remdesivir, 36 (47.4%) were men and 40 (52.6%) were women; 49 (64.5%) were White and 27 (35.5%) were pooled into a nonWhite group (Table 2). The mean age of patients receiving remdesivir for severe COVID-19 was 63 years (95% CI, 59.8-66.2) and had a mean weight of 94.3 kg (95% CI, 87.8-100.8). The most common presenting complaint was shortness of breath (66 patients; 86.8%), followed by cough (61; 80.3%) and fever (55; 72.4%). The majority of patients had 2 or more comorbid medical conditions (30; 39.5%). Hypertension was the most common comorbid condition (43; 56.6%). There was no difference between men and women in the frequency of comorbid conditions (26 with comorbid conditions [72%]; 28 women [70%]). 
Figure.
Flow chart demonstrating patient inclusion processes. A total of 7400 nasopharyngeal swabs for SARS-CoV-2 were performed at Kingman Regional Medical Center during the study period. Of the 433 patients testing positive for COVID-19 during that time, only 157 required hospitalization, with 76 meeting the clinical criteria for remdesivir administration under emergency use authorization.
Figure.
Flow chart demonstrating patient inclusion processes. A total of 7400 nasopharyngeal swabs for SARS-CoV-2 were performed at Kingman Regional Medical Center during the study period. Of the 433 patients testing positive for COVID-19 during that time, only 157 required hospitalization, with 76 meeting the clinical criteria for remdesivir administration under emergency use authorization.
Table 1.
Sample Patient Characteristics by Sex
Characteristic All (n=76)a Men (n=36; 47.37%)a Women (n=40; 52.63%)a
Ethnicity
 White 49 (64.5) 24 (66.7) 25 (62.5)
 Native American 6 (7.9) 1 (2.8) 5 (12.5)
 Hispanic or Latino 17 (22.4) 8 (22.2) 9 (22.5)
 Other 4 (5.3) 3 (8.3) 1 (2.5)
Patient presentation
 Mean age, years (95% CI)b 63 (59.8-66.2) 63 (58.1-67.9) 63 (58.3-67.7)
 Mean weight, kg (95% CI)b,c 94.3 (87.8-100.8) 102.7 (92.9-112.5) 86.7 (78.7-94.7)
 Smokers  19 (25.0) 9 (25.0) 10 (25.0)
 Fever 55 (72.4) 23 (63.9) 32 (80.0)
 Cough 61 (80.3) 28 (77.8) 33 (82.5)
 Altered smell 9 (11.8) 3 (8.3) 6 (15.0)
 Altered taste 7 (9.2) 2 (5.6) 5 (12.5)
 Diarrhea 19 (25.0) 9 (25.0) 10 (25.0)
 Chest pain  11 (14.5) 6 (16.7) 5 (12.5)
 Abdominal discomfort  7 (9.2) 4 (11.1) 3 (7.5)
 Shortness of breath 86.8 (66) 33 (91.7) 33 (82.5)
 Mean time from symptom onset, days (95% CI)b 6.93 (5.8-8.1) 7.7 (5.8-9.7) 6.3 (5.1-7.5)
Comorbid conditions
 None 22 (28.9) 10 (27.8) 12 (30.0)
 One 24 (31.6) 12 (33.3) 12 (30.0)
 Two or more 30 (39.5) 14 (38.9) 16 (40.0)
 Hypertension 43 (56.6) 24 (66.7) 19 (47.5)
 Congestive heart failure 7 (9.2) 5 (13.9) 2 (5.0)
 Type 2 diabetes 31 (40.8) 13 (36.1) 18 (45.0)
 Chronic obstructive pulmonary disease 13 (17.1) 5 (13.9) 8 (20.0)
Outcomes
 Mean duration of oxygen, days (95% CI)b 9.42 (8.0-10.8) 8.0 (6.2-9.8) 10.8 (8.8-12.8)
 Number admitted to the ICUc 14 (18.4) 3 (8.3) 11 (27.5)
 Mean ICU duration, days (95% CI)b,d 9.29 (5.6-13.0) 14.0 (3.6-24.4) 8.0 (4.3-11.7)
 Mortality 14 (18.4) 5 (13.9) 9 (22.5)
 Mean length of stay, days (95% CI)b 10.09 (8.6-11.6) 8.61 (6.7-10.5) 11.43 (9.3-13.5)

a Data is represented as n (%). Values for nominal scale data are represented as n (%).

b 95% CI are indicated for continuous variables.

c Indicates a significant effect of sex below the P=.05 criteria.

d Only computed for individuals admitted to the ICU.

Abbreviations: CI, confidence interval; ICU, intensive care unit.

Table 1.
Sample Patient Characteristics by Sex
Characteristic All (n=76)a Men (n=36; 47.37%)a Women (n=40; 52.63%)a
Ethnicity
 White 49 (64.5) 24 (66.7) 25 (62.5)
 Native American 6 (7.9) 1 (2.8) 5 (12.5)
 Hispanic or Latino 17 (22.4) 8 (22.2) 9 (22.5)
 Other 4 (5.3) 3 (8.3) 1 (2.5)
Patient presentation
 Mean age, years (95% CI)b 63 (59.8-66.2) 63 (58.1-67.9) 63 (58.3-67.7)
 Mean weight, kg (95% CI)b,c 94.3 (87.8-100.8) 102.7 (92.9-112.5) 86.7 (78.7-94.7)
 Smokers  19 (25.0) 9 (25.0) 10 (25.0)
 Fever 55 (72.4) 23 (63.9) 32 (80.0)
 Cough 61 (80.3) 28 (77.8) 33 (82.5)
 Altered smell 9 (11.8) 3 (8.3) 6 (15.0)
 Altered taste 7 (9.2) 2 (5.6) 5 (12.5)
 Diarrhea 19 (25.0) 9 (25.0) 10 (25.0)
 Chest pain  11 (14.5) 6 (16.7) 5 (12.5)
 Abdominal discomfort  7 (9.2) 4 (11.1) 3 (7.5)
 Shortness of breath 86.8 (66) 33 (91.7) 33 (82.5)
 Mean time from symptom onset, days (95% CI)b 6.93 (5.8-8.1) 7.7 (5.8-9.7) 6.3 (5.1-7.5)
Comorbid conditions
 None 22 (28.9) 10 (27.8) 12 (30.0)
 One 24 (31.6) 12 (33.3) 12 (30.0)
 Two or more 30 (39.5) 14 (38.9) 16 (40.0)
 Hypertension 43 (56.6) 24 (66.7) 19 (47.5)
 Congestive heart failure 7 (9.2) 5 (13.9) 2 (5.0)
 Type 2 diabetes 31 (40.8) 13 (36.1) 18 (45.0)
 Chronic obstructive pulmonary disease 13 (17.1) 5 (13.9) 8 (20.0)
Outcomes
 Mean duration of oxygen, days (95% CI)b 9.42 (8.0-10.8) 8.0 (6.2-9.8) 10.8 (8.8-12.8)
 Number admitted to the ICUc 14 (18.4) 3 (8.3) 11 (27.5)
 Mean ICU duration, days (95% CI)b,d 9.29 (5.6-13.0) 14.0 (3.6-24.4) 8.0 (4.3-11.7)
 Mortality 14 (18.4) 5 (13.9) 9 (22.5)
 Mean length of stay, days (95% CI)b 10.09 (8.6-11.6) 8.61 (6.7-10.5) 11.43 (9.3-13.5)

a Data is represented as n (%). Values for nominal scale data are represented as n (%).

b 95% CI are indicated for continuous variables.

c Indicates a significant effect of sex below the P=.05 criteria.

d Only computed for individuals admitted to the ICU.

Abbreviations: CI, confidence interval; ICU, intensive care unit.

×
Table 2.
Sample Patient Characteristics by Ethnicity
Characteristic All (n=76)a White (n=49; 64.47%)a NonWhite (n=27; 35.53%)a
Sex
 Male 36 (47.4) 24 (49.0) 12 (44.4)
 Female 40 (54.8) 25 (51.0) 15 (55.6)
Patient presentation
 Mean age, years (95% CI)b 63 (59.8-66.2) 65.1 (61.3-68.9) 59.3 (53.6-65.0)
 Mean weight, kg (95% CI)b 94.3 (87.8-100.8) 92.9 (86.3-99.5) 96.9 (83.1-110.7)
 Smokers 19 (25.0) 14 (28.6) 5 (18.5)
 Feverc 55 (72.4) 31 (63.3) 24 (88.9)
 Cough 61 (80.3) 38 (77.6) 23 (85.2)
 Altered smell 9 (11.8) 4 (8.2) 5 (18.5)
 Altered taste 7 (9.2) 3 (6.1) 4 (14.8)
 Diarrheac 19 (25.0) 16 (32.7) 3 (11.1)
 Chest pain 11 (14.5) 9 (18.4) 2 (7.4)
 Abdominal discomfort 7(9.2) 5 (10.2) 2 (7.4)
 Shortness of breath 66 (86.8) 41 (83.7) 25 (92.6)
 Mean time from symptom onset, days (95% CI)b 6.93 (5.8-8.1) 7.27 (5.7-8.8) 6.33 (4.9-7.8)
Comorbid conditions
 None 22 (28.9) 14 (28.6) 8 (29.6)
 One 24 (31.6) 14 (28.6) 10 (37.0)
 Two or more 30 (39.5) 21 (42.9) 9 (33.3)
 Hypertensionc 43 (56.6) 32 (65.3) 11 (40.7)
 Congestive heart failure 7 (9.2) 6 (12.2) 1 (3.7)
 Type 2 diabetes 31 (40.8) 18 (36.7) 13 (48.2)
 Chronic obstructive pulmonary disease 13 (17.1) 9 (18.4) 4 (14.8)
Outcomes
 Mean duration of oxygen, days (95% CI)b 9.42 (8.0-10.8) 8.92 (7.0-10.8) 9.63 (7.7-11.6)
 Number admitted to the ICU 14 (18.4) 10 (20.4)  4 (14.8)
 Mean ICU duration, days (95% CI)b,d 9.29 (5.6-13.0) 8.90 (4.4-13.4) 10.25 (2.8-17.7)
 Mortality 14 (18.4) 8 (16.3) 6 (22.2)
 Mean length of stay, days (95% CI)b 10.09 (8.6-11.6) 10.12 (8.1-12.1) 10.04 (8.2-11.9)

a Data is represented as n (%). Values for nominal scale data are represented as n (%).

b 95% CI are indicated for continuous variables.

c Indicates a significant effect of sex below the P=.05 criteria.

d Only computed for individuals admitted to the ICU.

Abbreviations: CI, confidence interval; ICU, intensive care unit.

Table 2.
Sample Patient Characteristics by Ethnicity
Characteristic All (n=76)a White (n=49; 64.47%)a NonWhite (n=27; 35.53%)a
Sex
 Male 36 (47.4) 24 (49.0) 12 (44.4)
 Female 40 (54.8) 25 (51.0) 15 (55.6)
Patient presentation
 Mean age, years (95% CI)b 63 (59.8-66.2) 65.1 (61.3-68.9) 59.3 (53.6-65.0)
 Mean weight, kg (95% CI)b 94.3 (87.8-100.8) 92.9 (86.3-99.5) 96.9 (83.1-110.7)
 Smokers 19 (25.0) 14 (28.6) 5 (18.5)
 Feverc 55 (72.4) 31 (63.3) 24 (88.9)
 Cough 61 (80.3) 38 (77.6) 23 (85.2)
 Altered smell 9 (11.8) 4 (8.2) 5 (18.5)
 Altered taste 7 (9.2) 3 (6.1) 4 (14.8)
 Diarrheac 19 (25.0) 16 (32.7) 3 (11.1)
 Chest pain 11 (14.5) 9 (18.4) 2 (7.4)
 Abdominal discomfort 7(9.2) 5 (10.2) 2 (7.4)
 Shortness of breath 66 (86.8) 41 (83.7) 25 (92.6)
 Mean time from symptom onset, days (95% CI)b 6.93 (5.8-8.1) 7.27 (5.7-8.8) 6.33 (4.9-7.8)
Comorbid conditions
 None 22 (28.9) 14 (28.6) 8 (29.6)
 One 24 (31.6) 14 (28.6) 10 (37.0)
 Two or more 30 (39.5) 21 (42.9) 9 (33.3)
 Hypertensionc 43 (56.6) 32 (65.3) 11 (40.7)
 Congestive heart failure 7 (9.2) 6 (12.2) 1 (3.7)
 Type 2 diabetes 31 (40.8) 18 (36.7) 13 (48.2)
 Chronic obstructive pulmonary disease 13 (17.1) 9 (18.4) 4 (14.8)
Outcomes
 Mean duration of oxygen, days (95% CI)b 9.42 (8.0-10.8) 8.92 (7.0-10.8) 9.63 (7.7-11.6)
 Number admitted to the ICU 14 (18.4) 10 (20.4)  4 (14.8)
 Mean ICU duration, days (95% CI)b,d 9.29 (5.6-13.0) 8.90 (4.4-13.4) 10.25 (2.8-17.7)
 Mortality 14 (18.4) 8 (16.3) 6 (22.2)
 Mean length of stay, days (95% CI)b 10.09 (8.6-11.6) 10.12 (8.1-12.1) 10.04 (8.2-11.9)

a Data is represented as n (%). Values for nominal scale data are represented as n (%).

b 95% CI are indicated for continuous variables.

c Indicates a significant effect of sex below the P=.05 criteria.

d Only computed for individuals admitted to the ICU.

Abbreviations: CI, confidence interval; ICU, intensive care unit.

×
The mean length of stay for patients who received remdesivir was 10.09 days (95% CI, 8.63-11.55), with the mean duration of oxygen therapy being 9.42 days (95% CI, 8.03-10.81). Men had a mean length of stay of 8.61 days (95% CI, 6.71-10.51), while women had a mean length of stay of 11.43 days (95% CI, 9.32-13.54; P=.058). Men also required fewer days of oxygen therapy compared with women (8.0 days and 95% CI, 6.16-9.84 vs 10.76 days and 95% CI, 8.75-12.77; P=.051). A total of 14 patients (18.4%) were admitted to the intensive care unit; these patients had a mean length of stay of 9.29 days (95% CI, 5.58-13). Women were more likely to be admitted to the intensive care unit (11 [27.5%] vs 3 [8.3%]; P=.031). Total in-hospital mortality included 14 patients (18.4%), with women accounting for 9 of those (11.8%). There were no adverse events reported in patients who received remdesivir. 
In our pooled comparison by race, White patients had a mean age of 65.06 years (95% CI, 61.29-68.83) while the mean age of nonWhite patients was 59.26 years (95% CI, 53.53-64.99). NonWhite patients were more likely to experience fever (24 [88.9%] vs 31 [63.3%]; P=.017), while White patients experienced a higher incidence of diarrhea (16 [32.7%] vs 3 [11.1%]; P=.038). The majority of those admitted to the ICU were White (Table 2). There was no difference noted for mean days spent in intensive care unit between White and nonWhite patients (8.90 days and 95% CI, 4.42-13.38 vs 10.25 days and 95% CI, 2.77-17.73 days; P=.76) and no difference in mortality (8 [57.1%] vs 6 [42.9%]; P=.53). White patients had a mean length of stay of 10.12 days (95% CI, 8.1-12.14), vs 10.04 days (95% CI, 8.15-11.93) for nonWhite patients (P=.96). No difference was noted for the mean duration of oxygen therapy between White and nonWhite patients (8.92 days and 95% CI, 7.03-10.81 days vs 9.63 days and 95% CI, 7.67-11.59; P=.64) 
Table 3 provides the results of the stepwise logistic regression for ICU admission. The variable accounting for the greatest predicative power toward ICU admission and entered in step 1 was sex. In step 2, a presentation to the emergency department with fever met statistical criteria for inclusion. Only sex (step 1, P=.041; step 2, P=.020) significantly predicted the odds of being admitted to the ICU. Accounting for the covariation of sex and fever increased the odds ratio of women being admitted to the ICU from 4.2 to 5.8. A similar analysis was completed for the outcome of mortality; however, no variable was statistically significant. 
Table 3.
Stepwise Binomial Logistic Regression Model for Admission to the ICUa
Examination B Standard error Wald X2 Odds ratio (95% CI) P value
ICU admission
Logistic regression step 1
 Sex 1.43 0.70 4.17 4.17 (1.06-16.43) .041
Logistic regression step 2
 Sex 1.76 0.76 5.42 5.81 (1.32-25.52) .020
 Fever 1.31 0.69 3.56 3.69 (0.95-14.35) .059

a ICU admission is predicted by a combination of sex and presentation to the emergency department with a fever.

Table 3.
Stepwise Binomial Logistic Regression Model for Admission to the ICUa
Examination B Standard error Wald X2 Odds ratio (95% CI) P value
ICU admission
Logistic regression step 1
 Sex 1.43 0.70 4.17 4.17 (1.06-16.43) .041
Logistic regression step 2
 Sex 1.76 0.76 5.42 5.81 (1.32-25.52) .020
 Fever 1.31 0.69 3.56 3.69 (0.95-14.35) .059

a ICU admission is predicted by a combination of sex and presentation to the emergency department with a fever.

×
Discussion
This study contributes to the current literature on the efficacy of remdesivir for the treatment of severe COVID-19 by providing an account of its use at a community hospital. In our patient population, the mean number of days hospitalized (10.09) was longer than previously-reported median of 7 days following a 5-day course of remdesivir for the treatment of COVID-19.5 Mortality in our study (18.4%) was also higher than reported in previous literature when patients were treated with a 5-day course of remdesivir (8%).5 The exact reasons for these mean increased rates of mortality and length of stay are unclear, but could be directly related to a higher percentage of our study population having comorbid conditions such as hypertension (56.6%) as compared with the previous data (43%).11 Previous literature has also shown that comorbid conditions are strongly correlated with COVID-19 disease severity and mortality.12,13 
Previous reports have shown that men infected with COVID-19 experience worse clinical outcomes than women14; men specifically have higher rates of hospitalization, intensive care admission, and mortality. Despite similar rates of comorbid conditions men in our study had lower rates of poor clinical outcomes, including lower mortality, intensive care admission, mean duration of oxygen therapy, and mean length of stay than women. Large randomized controlled trials will be needed to determine a true treatment effect of remdesivir for severe COVID-19 in the community setting.5,11 
Research has shown that people of color are disproportionally affected by COVID-19 and have worse clinical outcomes following treatment.15-17 In our study, we documented no clinical difference between White and nonWhite patients who received remdesivir for severe COVID-19 in a community setting. This data is consistent with prior literature noting that there is no difference amongst racial groups for the rate of recovery from severe COVID-19 after being given remdesivir.4 Although no treatment effect could be determined with the lack of a placebo control group in this report, further studies should focus on the treatment effects of remdesivir amongst patients of different racial groups. 
Limitations
A limitation to the study is that only the charts of patients presenting to a single community hospital in Northern Arizona were reviewed. This could make our data less generalizable to other community hospitals across the country due to the study's primary location and the racial demographics of the area, as other community hospitals may not align to the demographics in Northern Arizona. Also, our retrospective sample size was small, which meant that we pooled diverse racial groups into a nonWhite classification to verify the outcomes associated with remdesivir among people of color. Further, treatment was selected at attending physician's discretion and numerous modalities were used during the study time period. Therefore, no comparisons could be made to a standard of care cohort and the exact treatment effect of remdesivir cannot be effectively determined based upon this retrospective chart review. Using multiple treatment modalities, including convalescent plasma and dexamethasone, could have altered the outcomes. 
Conclusion
Remdesivir may show clinical efficacy for the treatment of severe COVID-19 in a community setting. This extends to both men and women; however, it may prove more effective among men. In this community-based observation study, there was no evidence to suggest a change in outcomes associated with remdesivir by patient race. Although this was a small-scale study with limited patients, it represents a point of reference for the use of remdesivir at other community hospitals. 
Author Contributions
Drs Santarelli and Ashurst and Student Drs Lee and Caine provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; Drs. Santarelli, Ashurst, and Dietrich, Student Dr Lee, and nurse Schritter drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 
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Figure.
Flow chart demonstrating patient inclusion processes. A total of 7400 nasopharyngeal swabs for SARS-CoV-2 were performed at Kingman Regional Medical Center during the study period. Of the 433 patients testing positive for COVID-19 during that time, only 157 required hospitalization, with 76 meeting the clinical criteria for remdesivir administration under emergency use authorization.
Figure.
Flow chart demonstrating patient inclusion processes. A total of 7400 nasopharyngeal swabs for SARS-CoV-2 were performed at Kingman Regional Medical Center during the study period. Of the 433 patients testing positive for COVID-19 during that time, only 157 required hospitalization, with 76 meeting the clinical criteria for remdesivir administration under emergency use authorization.
Table 1.
Sample Patient Characteristics by Sex
Characteristic All (n=76)a Men (n=36; 47.37%)a Women (n=40; 52.63%)a
Ethnicity
 White 49 (64.5) 24 (66.7) 25 (62.5)
 Native American 6 (7.9) 1 (2.8) 5 (12.5)
 Hispanic or Latino 17 (22.4) 8 (22.2) 9 (22.5)
 Other 4 (5.3) 3 (8.3) 1 (2.5)
Patient presentation
 Mean age, years (95% CI)b 63 (59.8-66.2) 63 (58.1-67.9) 63 (58.3-67.7)
 Mean weight, kg (95% CI)b,c 94.3 (87.8-100.8) 102.7 (92.9-112.5) 86.7 (78.7-94.7)
 Smokers  19 (25.0) 9 (25.0) 10 (25.0)
 Fever 55 (72.4) 23 (63.9) 32 (80.0)
 Cough 61 (80.3) 28 (77.8) 33 (82.5)
 Altered smell 9 (11.8) 3 (8.3) 6 (15.0)
 Altered taste 7 (9.2) 2 (5.6) 5 (12.5)
 Diarrhea 19 (25.0) 9 (25.0) 10 (25.0)
 Chest pain  11 (14.5) 6 (16.7) 5 (12.5)
 Abdominal discomfort  7 (9.2) 4 (11.1) 3 (7.5)
 Shortness of breath 86.8 (66) 33 (91.7) 33 (82.5)
 Mean time from symptom onset, days (95% CI)b 6.93 (5.8-8.1) 7.7 (5.8-9.7) 6.3 (5.1-7.5)
Comorbid conditions
 None 22 (28.9) 10 (27.8) 12 (30.0)
 One 24 (31.6) 12 (33.3) 12 (30.0)
 Two or more 30 (39.5) 14 (38.9) 16 (40.0)
 Hypertension 43 (56.6) 24 (66.7) 19 (47.5)
 Congestive heart failure 7 (9.2) 5 (13.9) 2 (5.0)
 Type 2 diabetes 31 (40.8) 13 (36.1) 18 (45.0)
 Chronic obstructive pulmonary disease 13 (17.1) 5 (13.9) 8 (20.0)
Outcomes
 Mean duration of oxygen, days (95% CI)b 9.42 (8.0-10.8) 8.0 (6.2-9.8) 10.8 (8.8-12.8)
 Number admitted to the ICUc 14 (18.4) 3 (8.3) 11 (27.5)
 Mean ICU duration, days (95% CI)b,d 9.29 (5.6-13.0) 14.0 (3.6-24.4) 8.0 (4.3-11.7)
 Mortality 14 (18.4) 5 (13.9) 9 (22.5)
 Mean length of stay, days (95% CI)b 10.09 (8.6-11.6) 8.61 (6.7-10.5) 11.43 (9.3-13.5)

a Data is represented as n (%). Values for nominal scale data are represented as n (%).

b 95% CI are indicated for continuous variables.

c Indicates a significant effect of sex below the P=.05 criteria.

d Only computed for individuals admitted to the ICU.

Abbreviations: CI, confidence interval; ICU, intensive care unit.

Table 1.
Sample Patient Characteristics by Sex
Characteristic All (n=76)a Men (n=36; 47.37%)a Women (n=40; 52.63%)a
Ethnicity
 White 49 (64.5) 24 (66.7) 25 (62.5)
 Native American 6 (7.9) 1 (2.8) 5 (12.5)
 Hispanic or Latino 17 (22.4) 8 (22.2) 9 (22.5)
 Other 4 (5.3) 3 (8.3) 1 (2.5)
Patient presentation
 Mean age, years (95% CI)b 63 (59.8-66.2) 63 (58.1-67.9) 63 (58.3-67.7)
 Mean weight, kg (95% CI)b,c 94.3 (87.8-100.8) 102.7 (92.9-112.5) 86.7 (78.7-94.7)
 Smokers  19 (25.0) 9 (25.0) 10 (25.0)
 Fever 55 (72.4) 23 (63.9) 32 (80.0)
 Cough 61 (80.3) 28 (77.8) 33 (82.5)
 Altered smell 9 (11.8) 3 (8.3) 6 (15.0)
 Altered taste 7 (9.2) 2 (5.6) 5 (12.5)
 Diarrhea 19 (25.0) 9 (25.0) 10 (25.0)
 Chest pain  11 (14.5) 6 (16.7) 5 (12.5)
 Abdominal discomfort  7 (9.2) 4 (11.1) 3 (7.5)
 Shortness of breath 86.8 (66) 33 (91.7) 33 (82.5)
 Mean time from symptom onset, days (95% CI)b 6.93 (5.8-8.1) 7.7 (5.8-9.7) 6.3 (5.1-7.5)
Comorbid conditions
 None 22 (28.9) 10 (27.8) 12 (30.0)
 One 24 (31.6) 12 (33.3) 12 (30.0)
 Two or more 30 (39.5) 14 (38.9) 16 (40.0)
 Hypertension 43 (56.6) 24 (66.7) 19 (47.5)
 Congestive heart failure 7 (9.2) 5 (13.9) 2 (5.0)
 Type 2 diabetes 31 (40.8) 13 (36.1) 18 (45.0)
 Chronic obstructive pulmonary disease 13 (17.1) 5 (13.9) 8 (20.0)
Outcomes
 Mean duration of oxygen, days (95% CI)b 9.42 (8.0-10.8) 8.0 (6.2-9.8) 10.8 (8.8-12.8)
 Number admitted to the ICUc 14 (18.4) 3 (8.3) 11 (27.5)
 Mean ICU duration, days (95% CI)b,d 9.29 (5.6-13.0) 14.0 (3.6-24.4) 8.0 (4.3-11.7)
 Mortality 14 (18.4) 5 (13.9) 9 (22.5)
 Mean length of stay, days (95% CI)b 10.09 (8.6-11.6) 8.61 (6.7-10.5) 11.43 (9.3-13.5)

a Data is represented as n (%). Values for nominal scale data are represented as n (%).

b 95% CI are indicated for continuous variables.

c Indicates a significant effect of sex below the P=.05 criteria.

d Only computed for individuals admitted to the ICU.

Abbreviations: CI, confidence interval; ICU, intensive care unit.

×
Table 2.
Sample Patient Characteristics by Ethnicity
Characteristic All (n=76)a White (n=49; 64.47%)a NonWhite (n=27; 35.53%)a
Sex
 Male 36 (47.4) 24 (49.0) 12 (44.4)
 Female 40 (54.8) 25 (51.0) 15 (55.6)
Patient presentation
 Mean age, years (95% CI)b 63 (59.8-66.2) 65.1 (61.3-68.9) 59.3 (53.6-65.0)
 Mean weight, kg (95% CI)b 94.3 (87.8-100.8) 92.9 (86.3-99.5) 96.9 (83.1-110.7)
 Smokers 19 (25.0) 14 (28.6) 5 (18.5)
 Feverc 55 (72.4) 31 (63.3) 24 (88.9)
 Cough 61 (80.3) 38 (77.6) 23 (85.2)
 Altered smell 9 (11.8) 4 (8.2) 5 (18.5)
 Altered taste 7 (9.2) 3 (6.1) 4 (14.8)
 Diarrheac 19 (25.0) 16 (32.7) 3 (11.1)
 Chest pain 11 (14.5) 9 (18.4) 2 (7.4)
 Abdominal discomfort 7(9.2) 5 (10.2) 2 (7.4)
 Shortness of breath 66 (86.8) 41 (83.7) 25 (92.6)
 Mean time from symptom onset, days (95% CI)b 6.93 (5.8-8.1) 7.27 (5.7-8.8) 6.33 (4.9-7.8)
Comorbid conditions
 None 22 (28.9) 14 (28.6) 8 (29.6)
 One 24 (31.6) 14 (28.6) 10 (37.0)
 Two or more 30 (39.5) 21 (42.9) 9 (33.3)
 Hypertensionc 43 (56.6) 32 (65.3) 11 (40.7)
 Congestive heart failure 7 (9.2) 6 (12.2) 1 (3.7)
 Type 2 diabetes 31 (40.8) 18 (36.7) 13 (48.2)
 Chronic obstructive pulmonary disease 13 (17.1) 9 (18.4) 4 (14.8)
Outcomes
 Mean duration of oxygen, days (95% CI)b 9.42 (8.0-10.8) 8.92 (7.0-10.8) 9.63 (7.7-11.6)
 Number admitted to the ICU 14 (18.4) 10 (20.4)  4 (14.8)
 Mean ICU duration, days (95% CI)b,d 9.29 (5.6-13.0) 8.90 (4.4-13.4) 10.25 (2.8-17.7)
 Mortality 14 (18.4) 8 (16.3) 6 (22.2)
 Mean length of stay, days (95% CI)b 10.09 (8.6-11.6) 10.12 (8.1-12.1) 10.04 (8.2-11.9)

a Data is represented as n (%). Values for nominal scale data are represented as n (%).

b 95% CI are indicated for continuous variables.

c Indicates a significant effect of sex below the P=.05 criteria.

d Only computed for individuals admitted to the ICU.

Abbreviations: CI, confidence interval; ICU, intensive care unit.

Table 2.
Sample Patient Characteristics by Ethnicity
Characteristic All (n=76)a White (n=49; 64.47%)a NonWhite (n=27; 35.53%)a
Sex
 Male 36 (47.4) 24 (49.0) 12 (44.4)
 Female 40 (54.8) 25 (51.0) 15 (55.6)
Patient presentation
 Mean age, years (95% CI)b 63 (59.8-66.2) 65.1 (61.3-68.9) 59.3 (53.6-65.0)
 Mean weight, kg (95% CI)b 94.3 (87.8-100.8) 92.9 (86.3-99.5) 96.9 (83.1-110.7)
 Smokers 19 (25.0) 14 (28.6) 5 (18.5)
 Feverc 55 (72.4) 31 (63.3) 24 (88.9)
 Cough 61 (80.3) 38 (77.6) 23 (85.2)
 Altered smell 9 (11.8) 4 (8.2) 5 (18.5)
 Altered taste 7 (9.2) 3 (6.1) 4 (14.8)
 Diarrheac 19 (25.0) 16 (32.7) 3 (11.1)
 Chest pain 11 (14.5) 9 (18.4) 2 (7.4)
 Abdominal discomfort 7(9.2) 5 (10.2) 2 (7.4)
 Shortness of breath 66 (86.8) 41 (83.7) 25 (92.6)
 Mean time from symptom onset, days (95% CI)b 6.93 (5.8-8.1) 7.27 (5.7-8.8) 6.33 (4.9-7.8)
Comorbid conditions
 None 22 (28.9) 14 (28.6) 8 (29.6)
 One 24 (31.6) 14 (28.6) 10 (37.0)
 Two or more 30 (39.5) 21 (42.9) 9 (33.3)
 Hypertensionc 43 (56.6) 32 (65.3) 11 (40.7)
 Congestive heart failure 7 (9.2) 6 (12.2) 1 (3.7)
 Type 2 diabetes 31 (40.8) 18 (36.7) 13 (48.2)
 Chronic obstructive pulmonary disease 13 (17.1) 9 (18.4) 4 (14.8)
Outcomes
 Mean duration of oxygen, days (95% CI)b 9.42 (8.0-10.8) 8.92 (7.0-10.8) 9.63 (7.7-11.6)
 Number admitted to the ICU 14 (18.4) 10 (20.4)  4 (14.8)
 Mean ICU duration, days (95% CI)b,d 9.29 (5.6-13.0) 8.90 (4.4-13.4) 10.25 (2.8-17.7)
 Mortality 14 (18.4) 8 (16.3) 6 (22.2)
 Mean length of stay, days (95% CI)b 10.09 (8.6-11.6) 10.12 (8.1-12.1) 10.04 (8.2-11.9)

a Data is represented as n (%). Values for nominal scale data are represented as n (%).

b 95% CI are indicated for continuous variables.

c Indicates a significant effect of sex below the P=.05 criteria.

d Only computed for individuals admitted to the ICU.

Abbreviations: CI, confidence interval; ICU, intensive care unit.

×
Table 3.
Stepwise Binomial Logistic Regression Model for Admission to the ICUa
Examination B Standard error Wald X2 Odds ratio (95% CI) P value
ICU admission
Logistic regression step 1
 Sex 1.43 0.70 4.17 4.17 (1.06-16.43) .041
Logistic regression step 2
 Sex 1.76 0.76 5.42 5.81 (1.32-25.52) .020
 Fever 1.31 0.69 3.56 3.69 (0.95-14.35) .059

a ICU admission is predicted by a combination of sex and presentation to the emergency department with a fever.

Table 3.
Stepwise Binomial Logistic Regression Model for Admission to the ICUa
Examination B Standard error Wald X2 Odds ratio (95% CI) P value
ICU admission
Logistic regression step 1
 Sex 1.43 0.70 4.17 4.17 (1.06-16.43) .041
Logistic regression step 2
 Sex 1.76 0.76 5.42 5.81 (1.32-25.52) .020
 Fever 1.31 0.69 3.56 3.69 (0.95-14.35) .059

a ICU admission is predicted by a combination of sex and presentation to the emergency department with a fever.

×