RSV Hospital Admission Criteria
Hospital admission for RSV infection should be based on clinical severity, risk factors, and the patient's ability to maintain adequate hydration and oxygenation at home.
Clinical Severity Indicators for Hospital Admission
- Respiratory distress - Signs include tachypnea, nasal flaring, grunting, retractions, or apnea (especially in premature infants who are more likely to present with apnea) 1
- Hypoxemia - Oxygen saturation <90-92% on room air or need for supplemental oxygen 2
- Dehydration - Inability to maintain adequate oral hydration 2
- Apnea - Particularly concerning in premature infants who have a significantly higher risk of apnea with RSV infection 1
- Radiographic findings - Presence of atelectasis, infiltrates, or hyperinflation (more common in premature infants) 1
High-Risk Patient Populations
Patients with the following conditions are at higher risk for severe RSV disease and should have a lower threshold for admission:
- Prematurity - Especially infants born before 29 weeks gestation 3
- Chronic lung disease (CLD) - Particularly those requiring medical therapy (supplemental oxygen, bronchodilators, diuretics, or corticosteroids) within 6 months before RSV season 2
- Congenital heart disease (CHD) - Especially hemodynamically significant CHD requiring medical therapy 2
- Neuromuscular disorders - Conditions that impair the ability to clear secretions from the upper airway 2
- Immunocompromised status - Including children receiving chemotherapy, HSCT or SOT recipients, or those with severe immunodeficiency 2
- Young age - Particularly infants <3 months of age, who have the highest hospitalization rates (25.1 per 1000 in 1-month-old infants) 4
- Comorbidities - Children with chronic lung disease, congenital heart disease, and cirrhosis/biliary atresia have significantly higher odds of severe RSV infection requiring intensive care 5
Specific Admission Criteria
- Age <3 months with RSV infection, especially if born prematurely 4
- Oxygen requirement to maintain saturation >90% 2
- Respiratory rate >70 breaths/minute or severe retractions 2
- Poor feeding or inability to maintain hydration status 2
- Apnea episodes - Any documented apnea with RSV infection 1
- Comorbid conditions - As listed above 5
ICU Admission Considerations
Consider ICU admission for patients with:
- Impending respiratory failure requiring mechanical ventilation or non-invasive positive pressure ventilation 5
- Severe hypoxemia despite supplemental oxygen 2
- Recurrent apnea 1
- Cardiovascular compromise 2
Prevention of Hospital-Acquired RSV
For patients already hospitalized:
- Contact isolation - Place patients with confirmed or suspected RSV infection in contact isolation 2
- Hand hygiene - Wash hands after contact with patients or respiratory secretions regardless of glove use 2
- Gloves and gowns - Wear when handling patients with RSV or their respiratory secretions 2
- Cohorting - During outbreaks, cohort patients and staff to prevent transmission 2
Common Pitfalls to Avoid
- Underestimating severity in premature infants - They often have longer hospital stays, higher physiologic instability scores, and greater need for ICU admission 1
- Overlooking atypical presentations in older children - During the COVID-19 pandemic, older children (24-59 months) showed increased hospitalization rates and need for mechanical ventilation with atypical complications 6
- Discharging too early - RSV can progress rapidly, particularly in high-risk infants 5
- Failing to consider prophylaxis - High-risk infants should be evaluated for palivizumab prophylaxis to prevent severe RSV disease 3
- Not recognizing lymphopenia as a risk factor - In immunocompromised patients, lymphopenia (especially counts <100 cells/mm³) is associated with progression to lower respiratory tract disease 2
Remember that most children hospitalized with RSV (67%) have no underlying comorbid conditions or history of preterm birth, indicating that all young children are at potential risk for severe disease requiring hospitalization 4.