RSV Treatment in Adults

Treatment for RSV infection in adults is primarily supportive care, as there are no FDA-approved antiviral medications for RSV in adults. 1, 2

Supportive Care Management

The cornerstone of RSV treatment in adults consists of:

Oxygen therapy for patients with hypoxemia or respiratory distress 3, 4
Hydration and symptom management including antipyretics for fever and medications for cough 5, 6
Monitoring for respiratory failure requiring ICU admission (occurs in 9-15% of hospitalized adults) and mechanical ventilation (needed in 9% of cases) 4
Management of underlying chronic conditions, particularly COPD and asthma exacerbations according to standard protocols 1

For severely immunocompromised adults (bone marrow transplant recipients, solid organ transplant patients, those with hematologic malignancies):

Off-label ribavirin (aerosolized or oral) combined with intravenous immunoglobulin has been used based on observational data showing improved survival 7, 5, 6
Early bronchoscopy is valuable for diagnosis in immunosuppressed patients due to low viral titers in nasal secretions 6
Treatment should be initiated early, ideally before progression to lower respiratory tract disease 7

However, the evidence supporting ribavirin use remains limited to observational studies, and it is not FDA-approved for this indication 7.

Adults at highest risk for severe outcomes who warrant aggressive supportive care include:

Patients on systemic corticosteroids (highest hospitalization risk) 1
Adults ≥75 years regardless of comorbidities 2
Those with chronic cardiopulmonary disease (COPD, asthma, heart failure) 7, 2
Nursing home residents (attack rates 5-10% annually with 2-5% mortality) 5, 6

RT-PCR testing is the reference standard and should be performed in high-risk adults, particularly those ≥60 years with comorbidities or immunocompromise 1, 8
Viral culture and antigen detection are insensitive in adults due to low viral titers 6, 8
Testing is especially important because RSV symptoms (nasal congestion, cough, wheezing, low-grade fever) are nonspecific and difficult to distinguish from influenza 4, 8

Vaccination is now the primary preventive strategy and should be prioritized over treatment:

All adults ≥75 years should receive a single lifetime dose of RSV vaccine 2
Adults 60-74 years with risk factors (COPD, asthma, heart failure, diabetes, chronic kidney disease, immunocompromise) should be vaccinated 2
Adults 50-59 years with risk factors can receive RSVPreF3 (Arexvy) 2
Administer between September and November before RSV season; can be co-administered with influenza vaccine at different sites 1, 2

Without RSV-specific antivirals, outcomes in hospitalized adults include:

Mortality rates of 1-12% in hospitalized adults, with 4.6% in those 60-74 years and 6.1% in those ≥75 years 1, 4, 8
Median hospital stay of 6 days (mean 10.8 days) 4
Long-term functional decline, particularly in frail elderly patients 1
Exacerbation of underlying conditions including heart failure and COPD 8

Empiric antibiotics are frequently prescribed (78% of cases) but should be avoided unless bacterial co-infection is documented 4
Anti-influenza therapy is often inappropriately given (36% of cases) when RSV is the causative pathogen 4
Underdiagnosis occurs because RSV testing is not routinely performed in adults, leading to missed opportunities for infection control 8