What is the treatment for Respiratory Syncytial Virus (RSV) infection?

RSV Treatment

Treatment for RSV infection is primarily supportive care—there is no routinely recommended antiviral therapy for most patients, with the exception of select immunocompromised populations where ribavirin may be considered. 1, 2

General Management for All Patients

The cornerstone of RSV treatment consists of supportive measures:

• Maintain adequate hydration through oral fluids or intravenous support as needed 1, 2
• Provide supplemental oxygen if oxygen saturation falls persistently below 90-92% 1, 2
• Use antipyretics (acetaminophen or ibuprofen) for fever control and pain management 2
• Consider nasal saline irrigation for symptomatic relief of upper respiratory symptoms in adults 2

What NOT to Do

Several interventions have no proven benefit and should be avoided:

• Do not use palivizumab for treatment of established RSV infection—it is only approved for prevention in high-risk infants and has no therapeutic benefit once infection has occurred 1, 2
• Do not routinely prescribe antibiotics unless there is clear evidence of bacterial co-infection 1, 2
• Do not use corticosteroids routinely in bronchiolitis management 2
• Do not use ribavirin routinely in otherwise healthy children with bronchiolitis 2

Antiviral Therapy for Select High-Risk Populations

While most patients receive only supportive care, certain immunocompromised patients may benefit from antiviral treatment:

Immunocompromised Patients (HSCT Recipients, Lung Transplant Recipients)

• Aerosolized ribavirin is the primary treatment option for RSV lower respiratory tract infection in hematopoietic stem cell transplant patients, though based mainly on observational data 3, 2, 4
• Oral ribavirin may be an effective and easier-to-administer alternative that can reduce progression to lower respiratory tract infection and mortality 3
• Systemic ribavirin (oral or intravenous) can be used for patients unable to take oral medication 2
• Combination therapy with intravenous immunoglobulin or anti-RSV-enriched antibody preparations may be considered 2

FDA-Approved Ribavirin Indications

The FDA has approved aerosolized ribavirin (VIRAZOLE) specifically for hospitalized infants and young children with severe lower respiratory tract infections due to RSV 4. Key points include:

• Treatment should be initiated early in the course of severe disease 4
• RSV infection must be documented by rapid diagnostic methods (immunofluorescence or ELISA) before or during the first 24 hours of treatment 4
• The vast majority of RSV infections are mild and self-limited, not requiring antiviral treatment 4
• Treatment decisions should be based on severity, with consideration of underlying conditions such as prematurity, immunosuppression, or cardiopulmonary disease 4

Important caveat: Despite FDA approval, ribavirin has minimal clinical benefit and significant drug toxicity, which is why it is not recommended for routine clinical use in most guidelines 5. Its use should be reserved for the most severe cases in immunocompromised hosts.

Hospitalization Criteria

Admit patients with:

• Severe respiratory distress or inability to maintain hydration 1
• Oxygen saturation <90% despite supplemental oxygen 1
• High-risk underlying conditions including prematurity, chronic lung disease, congenital heart disease, or immunocompromised status 1

Infection Control Measures

• Hand hygiene is the single most important measure to prevent transmission and nosocomial spread 2
• Alcohol-based hand rubs are preferred for hand decontamination 2
• Educate personnel and family members on proper hand sanitation 2
• Cohort or isolate infected patients to minimize nosocomial transmission 5

Prevention Strategies

While not treatment per se, prevention is critical given the limited treatment options:

• RSV vaccination is recommended for adults ≥60 years and those ≥50 years with risk factors 2
• Palivizumab prophylaxis may be administered to high-risk infants with prematurity, congenital heart disease, or severe combined immunodeficiency during RSV season 2
• Avoid passive smoke exposure in infants 2
• Encourage breastfeeding to decrease risk of lower respiratory tract disease 2

Emerging Therapies

Several new antiviral agents (presatovir, ALS-008176, RSV604) and monoclonal antibodies are in various phases of clinical development, which may expand treatment options in the future 3. However, none are currently available for routine clinical use.

Common Pitfalls

• Overusing antibiotics when bacterial co-infection is not documented 1, 2
• Attempting to treat with palivizumab after infection has already occurred 1, 2
• Inadequate infection control leading to nosocomial transmission 2
• Continuing bronchodilator therapy without documented clinical improvement 2