What is the recommended treatment for Respiratory Syncytial Virus (RSV) in older adults?

Treatment of Respiratory Syncytial Virus (RSV) in Older Adults

For RSV infection in older adults, treatment remains primarily supportive care, including fluids, antipyretics, and oxygen support when needed, as there are currently no specific treatments for RSV-associated disease. 1

Current Treatment Approach

Supportive Care

• Fluid management to prevent dehydration
• Antipyretics for fever control
• Oxygen supplementation when indicated by hypoxemia
• Respiratory support as needed based on severity

Hospitalization Considerations

• Median length of hospital stay for RSV-infected older adults is approximately 6 days 2
• 26-36% of hospitalized older adults with RSV may require intensive care 2
• Respiratory supportive therapy is the most commonly used treatment modality 2

Antibiotics

• Antibiotics are frequently administered (59% of older adults) despite RSV being a viral infection 2
• This likely reflects concerns about bacterial superinfection or difficulty distinguishing viral from bacterial pneumonia

Diagnosis Challenges

• Diagnosis of RSV in adults is difficult as viral culture and antigen detection are insensitive due to low viral titers 3
• PCR testing is the reference standard for diagnosis 3
• Testing samples from a single respiratory tract site may result in underdetection 3
• Clinical presentation alone cannot reliably distinguish RSV from other respiratory infections 3

Prevention Strategies

Given the lack of specific treatments, prevention is crucial:

Vaccination

• Two protein subunit vaccines for adults aged ≥60 years were licensed in 2023 3
• The Advisory Committee on Immunization Practices (ACIP) recommends:
  • All adults aged ≥75 years should receive a single dose of any FDA-approved RSV vaccine 4
  • Adults aged 60-74 years with risk factors (chronic respiratory diseases, cardiovascular disease, kidney disease, diabetes, neurological conditions, immunocompromising conditions) should receive a single dose 4
• Vaccine efficacy persists across multiple seasons, with cumulative efficacy over 3 seasons against RSV-associated lower respiratory tract disease of 62.9% for RSVPreF3 (Arexvy) 4

Infection Control

• Standard infection control practices remain important:
  • Hand washing
  • Use of gowns and gloves in healthcare settings
  • Respiratory hygiene/cough etiquette

Special Considerations

High-Risk Populations

• Older adults (≥75 years) have higher incidence of RSV requiring medical attention 1
• Those with comorbidities such as COPD, heart failure, and immunocompromising conditions are at increased risk for severe outcomes 5
• COPD patients have 3.2-13.4 times higher rates of RSV-related hospitalization compared to those without COPD 4

Long-term Sequelae

• Long-term consequences are common and include deterioration of underlying conditions (typically heart failure and COPD) 3
• Approximately 10-16% of patients require skilled nursing care after discharge 2

Clinical Pearls and Pitfalls

• Pitfall: Failing to consider RSV in older adults with respiratory symptoms, especially during RSV season
• Pitfall: Overreliance on rapid antigen tests which have poor sensitivity in adults
• Pearl: Consider RSV in older adults with respiratory symptoms who test negative for influenza
• Pearl: Early diagnosis may help with infection control measures and appropriate supportive care

Future Directions

• New diagnostics and therapeutics are being developed 3
• Further research is needed to evaluate vaccine efficacy in immunocompromised populations 4
• Ongoing studies may justify extending RSV vaccination recommendations in the future 5