What are the treatment guidelines for Respiratory Syncytial Virus (RSV) infection in adults?

Adult RSV Guidelines

All adults aged ≥75 years should receive a single lifetime dose of RSV vaccine, and adults aged 60-74 years with chronic conditions (COPD, asthma, heart failure, coronary artery disease, diabetes, chronic kidney disease, or immunocompromise) should also be vaccinated, with treatment remaining primarily supportive care as no FDA-approved antivirals exist for adults. 1, 2

Vaccination Recommendations

Age-Based Guidelines

Primary vaccination targets:

• All adults ≥75 years should receive RSV vaccination regardless of comorbidities due to significantly elevated hospitalization rates, severe disease risk, and mortality 1, 3
• Adults aged 60-74 years with risk factors should receive vaccination 1, 3
• Adults aged 50-59 years with risk factors can only receive RSVPreF3 (Arexvy), as this is the only vaccine approved for this age group 1, 3

High-Risk Medical Conditions Warranting Vaccination (Ages 60-74)

Respiratory conditions:

• COPD, which increases RSV hospitalization risk 3.2-13.4 times compared to those without COPD 4, 1
• Asthma, which increases hospitalization risk 2.0-3.6 times 4, 1
• Bronchiectasis, interstitial lung disease, and chronic respiratory failure 3

Cardiovascular conditions:

• Heart failure, which increases RSV hospitalization risk 4.0-33.2 times 4, 1
• Coronary artery disease, which increases risk 3.7-7.0 times 4, 1

Metabolic and renal conditions:

• Diabetes mellitus, particularly with complications 1, 3
• Chronic kidney disease, especially end-stage renal disease 1, 3
• Chronic liver disease 1, 3

Other high-risk conditions:

• Chronic neurological or neuromuscular diseases 1, 3
• Severe obesity (BMI ≥40 kg/m²) 3
• Immunocompromised status (solid organ transplant, hematopoietic stem cell transplant, malignancies, immunosuppressive medications, HIV) 3, 2
• Residents of nursing homes or long-term care facilities 1, 3

Administration Guidelines

Dosing schedule:

• A single lifetime dose only is recommended; no revaccination is needed 1, 3
• Protection lasts at least two consecutive RSV seasons 3
• Adults who have already received any RSV vaccine should not receive another dose 3

Optimal timing:

• Administer between September and November, before or early in the RSV season, to maximize protection 1, 3
• Can be given at any time of year if needed 3
• Can be co-administered with influenza vaccine at different injection sites 1, 3

Prioritization if supply is limited:

• Adults ≥75 years should receive priority 1, 3
• Those with multiple comorbidities should be prioritized 1, 3
• Long-term care facility residents should be prioritized 3

Clinical Considerations for Vaccination

• Patient attestation is sufficient evidence of risk factors; extensive medical documentation should not be required 1, 3
• Previous RSV infection does not confer long-lasting immunity and does not contraindicate vaccination 1, 3

Treatment Guidelines

Current Treatment Approach

No specific antiviral therapy exists:

• Treatment for RSV in adults is primarily supportive care, as there are no FDA-approved antiviral treatments for RSV in adults 2, 5, 6
• Aerosolized ribavirin was licensed but use is limited due to efficacy, safety, and cost concerns 5

Supportive care management:

• For patients with underlying COPD or asthma, manage exacerbations according to standard protocols 2
• Assess functional status, as RSV can cause significant functional decline, particularly in frail elderly patients 2
• Monitor for respiratory failure and pneumonia, which are serious complications in older adults 2

Diagnostic Considerations

Testing recommendations:

• Nucleic acid-based testing (RT-PCR) is recommended for diagnosis, particularly in high-risk patients 2, 7
• Testing is especially important in immunocompromised patients (transplant recipients, malignancies, chronic immunosuppression, HIV) 2
• Testing from a single respiratory tract site may result in underdetection 7

Clinical recognition challenges:

• RSV cannot be distinguished from other acute viral infections on clinical grounds alone with sufficient precision 7
• RSV is identified in 6-11% of outpatient respiratory tract infections in older adults 7
• Accounts for 4-11% of adults hospitalized with respiratory tract infections 7

Clinical Outcomes and Disease Burden

Severity in Adults

Hospitalization and mortality:

• 6-15% of hospitalized adults with RSV are admitted to intensive care 7
• Mortality rates range from 1-12% in hospitalized adults, with 4.6% in those aged 60-74 years and 6.1% in those ≥75 years 2, 7
• RSV accounts for 10.6% of hospitalizations for pneumonia and 11.4% for COPD exacerbations 1, 3

Disease exacerbations:

• 80.4% of hospitalized patients with COPD experience disease exacerbation during RSV infection 4
• 49.5% of patients with asthma experience exacerbation 4
• Exacerbations are more common with RSV than influenza (COPD exacerbations: OR = 1.7; asthma exacerbations: OR = 1.5) 4

Long-term sequelae:

• Functional decline can be prolonged, particularly in frail elderly patients 2
• Patients with dementia have higher mid- to long-term mortality following RSV infection (aHR = 1.86) 2
• Deterioration of underlying diseases (heart failure, COPD) is common 7

Common Pitfalls

• Underrecognition of RSV burden: The disease burden in older adults has historically been underrecognized compared to influenza, despite causing similar severity 1, 7
• Lack of fever: Patients hospitalized with RSV are frequently without fever, unlike influenza, which may delay diagnosis 7
• Patients on systemic corticosteroids are at highest risk for hospitalization and should be prioritized for vaccination 2