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Cunningham et al.
Critical Care (2020) 24:91

https://doi.org/10.1186/s13054-020-2818-6
EDITORIAL Open Access
Treatment of COVID-19: old tricks for new

challenges
Anne Catherine Cunningham1* , Hui Poh Goh1 and David Koh1,2
Challenges in treating COVID-19 Convalescent plasma: one of the forgotten

Coronavirus disease (COVID-19), which appeared in De- immunologically based strategies
cember 2019, presents a global challenge, particularly in Passive immunization has been successfully used to treat
the rapid increase of critically ill patients with pneumo- infectious diseases. A meta-analysis demonstrated a sig-
nia and absence of definitive treatment. To date, over nificant reduction in mortality and viral load in studies
81,000 cases have been confirmed, with over 2700 using convalescent plasma for the treatment of severe
deaths. The mortality appears to be around 2%; early acute viral respiratory infections, including those caused
published data indicate 25.9% with SARS-CoV-2 pneu- by related coronaviruses (SARS-CoV and MERS-CoV)
monia required ICU admission and 20.1% developed [5]. Serious adverse events were not reported. Eighty
acute respiratory distress syndrome [1]. SARS patients were treated with convalescent plasma dur-
There is presently no vaccine or specific anti-viral drug ing the last major outbreak. A significantly better outcome
regime used to treat critically ill patients. The manage- was obtained with earlier transfusion (before day 14), and
ment of patients mainly focuses on the provision of sup- no immediate adverse events were observed.
portive care, e.g., oxygenation, ventilation, and fluid A feasibility intervention study of convalescent plasma for
management. Combination treatment of low-dose sys- MERS-CoV infection treatment failed to identify sufficient
tematic corticosteroids and anti-virals and atomization high-titer plasma from patients with confirmed/suspected
inhalation of interferon have been encouraged as part of MERS, their close family members, or healthcare workers
critical COVID-19 management [2]. Other reported exposed to MERS (n = 12 reactive ELISA/443 serum tested).
therapeutic agents that are used for the treatment of ser- Two fresh-frozen plasma units (250–350 mL/unit) would be
iously ill patients have been noted in Table 1. required for each enrolled MERS patient (NCT02190799).
Table 1 Potential treatment options of COVID-19

Classes Potential treatment options Reference
Anti-viral > 85% of patients received anti-viral agents, including oseltamivir (75 mg every 12 h orally), ganciclovir (0.25 g every 12 h [1]
intravenously), and lopinavir/ritonavir tablets (400/100 mg twice daily). Remdesivir is currently under trials at more than
ten medical institutions in Wuhan and has been known to prevent MERS-CoV.
Anti-malarial An old anti-malarial, chloroquine phosphate, has been effective in inhibiting the exacerbation of pneumonia due to its [3]
anti-viral and anti-inflammatory activities.
Herbal There was widespread use of Traditional Chinese Medicine during the last SARS-COV outbreak and it is currently being [4]
treatments used in China. The five most commonly used herbs were Astragali Radix (Huangqi), Glycyrrhizae Radix Et Rhizoma (Gancao),
Saposhnikoviae Radix (Fangfeng), Atractylodis Macrocephalae Rhizoma (Baizhu), and Lonicerae Japonicae Flo.
* Correspondence: [email protected]
1
Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah (PAPRSB), Institute of
Health Sciences, Universiti Brunei Darussalam, Jalan Tungku Link, Gadong
BE1410, Brunei
Full list of author information is available at the end of the article
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Cunningham et al. Critical Care (2020) 24:91 Page 2 of 2
Encouragingly, anti-MERS CoV titers measured by ELISA Authors’ information

correlated with microneutralization (MN) assays [6]. David Koh is a Distinguished Professor of Occupational Health and Medicine,
Anne Catherine Cunningham is an Associate Professor of Immunology, and
There are currently over 30,000 recovered COVID-19 Hui Poh Goh is a lecturer in Pharmacy.
patients, who could present a valuable resource of conva-
lescent plasma for health care providers. China National Funding
None
Biotec Group Co has claimed that 10 seriously ill patients
receiving this immunoglobulin therapy demonstrated im- Availability of data and materials
proved oxygenation and reduced inflammation and viral Not applicable
load [7]. High-titer specific antibodies should be able to Ethics approval and consent to participate
bind to SARS-CoV-2 and neutralize the viral particles, Not applicable
block access to uninfected cells, and activate potent
Competing interests
effector mechanisms (e.g., complement activation and The authors declare that they have no competing interests.
phagocytosis).
Author details
1
Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah (PAPRSB), Institute of
Potential risks and ethical considerations Health Sciences, Universiti Brunei Darussalam, Jalan Tungku Link, Gadong
It should be noted that treatment with human immuno- BE1410, Brunei. 2Saw Swee Hock School of Public Health, National University
of Singapore, Singapore, Singapore.
globulin has been associated with significantly increased
same-day thrombotic event risk (0.04 to 14.9%) [8]. Received: 26 February 2020 Accepted: 6 March 2020
These data indicate the potential value of evaluating the
effectiveness of early intervention therapy with convales- References
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Acknowledgements
Transfus 2016;14:152–7. https://doi.org/10.2450/2015.0131-15.
None
Authors’ contributions Publisher’s Note

AC highlighted the potential use of immune plasma for treatment and Springer Nature remains neutral with regard to jurisdictional claims in
drafted the MS. HPG contributed to the discussion and revised and published maps and institutional affiliations.
formatted the MS. DK is leading the research on COVID-19 Pandemic Pre-
paredness and contributed to the discussion and revised the draft. All
authors read and approved the final manuscript.

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Cunningham et al.

Critical Care (2020) 24:91

EDITORIAL Open Access

Treatment of COVID-19: old tricks for new

Challenges in treating COVID-19 Convalescent plasma: one of the forgotten

Table 1 Potential treatment options of COVID-19

Encouragingly, anti-MERS CoV titers measured by ELISA Authors’ information

Authors’ contributions Publisher’s Note

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