What are the treatment and prevention options for Respiratory Syncytial Virus (RSV) infection?

Treatment and Prevention Options for Respiratory Syncytial Virus (RSV) Infection

For RSV infection, prevention through palivizumab prophylaxis in high-risk infants and vaccination in adults ≥60 years is recommended, while treatment remains primarily supportive care as no specific antiviral therapy has proven widely effective.

Prevention Strategies

Palivizumab Prophylaxis for High-Risk Infants

Palivizumab is indicated for prevention of serious lower respiratory tract disease caused by RSV in specific high-risk pediatric populations:

• Infants born before 29 weeks, 0 days' gestation who are 6 months of age or younger at the beginning of RSV season 1
• Children with chronic lung disease (CLD) who required medical therapy within 6 months before the start of RSV season and who are 24 months of age or younger 2, 1
• Children with hemodynamically significant congenital heart disease (CHD) who are 24 months of age or younger 2, 3
• Children with pulmonary abnormality or neuromuscular disease that impairs the ability to clear secretions from the upper airways 1

Dosing and Administration

• Recommended dose: 15 mg/kg body weight by intramuscular injection, administered monthly throughout the RSV season 3
• Maximum of 5 doses for most eligible infants 2
• For infants born between 32 weeks 0 days and 34 weeks 6 days gestation with qualifying risk factors, a maximum of 3 doses is recommended 2
• Children who undergo cardiac bypass should receive an additional dose after the procedure due to a 58% decrease in palivizumab serum concentration 2, 1

Efficacy

• Palivizumab reduces RSV-related hospitalization by 55% overall in high-risk infants 2, 4
• In children with hemodynamically significant CHD, hospitalization rates were reduced by 45% 2
• Palivizumab is not effective for treatment of established RSV disease 3

RSV Vaccination for Adults

• RSV vaccination is recommended for all adults aged ≥60 years, regardless of previous infection history 5
• For adults aged 50-59 years, vaccination is recommended if they have risk factors such as chronic respiratory or heart disease, diabetes, or immunocompromised status 5
• Two RSV vaccines are available for adults: RSVPreF3 (Arexvy) and RSVpreF (Abrysvo) 5
• A single intramuscular dose is recommended, preferably administered between September and November 5

General Preventive Measures

• Keep high-risk infants away from crowds and situations where exposure to infected people cannot be controlled 1
• Restrict participation in group child care during RSV season when feasible 1
• Practice careful hand hygiene 2, 1
• Ensure all eligible infants and their contacts receive influenza vaccine and other age-appropriate immunizations 1
• Eliminate exposure to tobacco smoke 2, 1
• Breastfeeding should be encouraged for all infants, although evidence for specific protection against RSV is conflicting 2

Treatment Approaches

RSV has no specific curative treatment, and management is primarily supportive:

• Supportive care is the mainstay of management for RSV infection 6
• Adequate nutrition and oxygen therapy as needed 7
• In severe cases requiring hospitalization:
  • Oxygen therapy for hypoxemia 6
  • High flow nasal cannula may be beneficial in moderate to severe cases 6
  • Mechanical ventilation may be necessary in severe cases 6

Treatments with Limited Evidence

• Antiviral therapies such as Ribavirin have not proven to be consistently effective in RSV infection 7
• Bronchodilators show variable results 7
• Corticosteroids have not been found to be consistently effective 7

Special Considerations

Cost-Effectiveness

• Palivizumab is an effective but costly intervention 2
• Optimal cost benefit is achieved during peak RSV outbreak months 2
• Economic analyses have failed to demonstrate overall savings in healthcare dollars if all at-risk infants receive prophylaxis 2

Breakthrough Infections

• If a child receiving palivizumab prophylaxis experiences a breakthrough RSV hospitalization, monthly prophylaxis should be discontinued due to the extremely low likelihood of a second RSV hospitalization in the same season 1

Seasonal Timing

• In most areas of the United States, RSV season typically begins in November and continues through April 2
• Regional variations exist, particularly in Florida where the season may begin earlier 2
• Prophylaxis should be timed according to local RSV circulation patterns 2

Common Pitfalls to Avoid

• Failure to administer an additional dose of palivizumab after cardiac bypass surgery 1
• Early initiation or continuation of monthly immunoprophylaxis during months when RSV is not circulating widely (not cost-effective) 2
• Using palivizumab for treatment of established RSV disease (not indicated) 3
• Administering palivizumab to children who do not meet eligibility criteria 2
• Neglecting general preventive measures while focusing solely on pharmaceutical interventions 2, 1