The Emergence of Escape Mutations in COVID-19 Following Anti-Spike Monoclonal Antibody Treatment: How Do We Tackle It?

Daniele Focosi,1 Massimo Franchini,2 Fabrizio Maggi,3 Arturo Casadevall4 1North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy; 2Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantua, Italy; 3Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy; 4Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USACorrespondence: Daniele Focosi, Email [email protected]: Treatment-emergent resistance to anti-Spike monoclonal antibody (mAb) was a largely unexpected and dramatic finding along the COVID-19 pandemic. Emergence of resistant strains was particularly common in immunocompromised patients, who often harbored very high SARS-CoV-2 loads when treated with mAb monotherapies. Concerns were raised regarding the risk for some of those resistant variants to propagate in communities. In this review, we will summarize the experience thus far and suggest recommendations to prevent and manage mAb treatment-emergent resistance such as comboing and reliance over polyclonal immunoglobulins.Keywords: monoclonal antibodies, spike, treatment-emergent resistance