What is the management and prevention of Respiratory Syncytial Virus (RSV) infection?

Management and Prevention of Respiratory Syncytial Virus (RSV) Infection

Palivizumab Prophylaxis for High-Risk Pediatric Patients

Palivizumab (Synagis) is indicated for prevention of serious RSV lower respiratory tract disease in specific high-risk pediatric populations, administered as 15 mg/kg intramuscularly monthly for a maximum of 5 doses during RSV season. 1

Eligible Patient Populations

Premature Infants:

• Infants born ≤28 weeks 6 days gestation who are <12 months of age at the start of RSV season qualify for prophylaxis 2
• Infants born 29-31 weeks 6 days gestation who are <6 months of age at start of RSV season qualify 2
• Infants born 32-34 weeks 6 days gestation qualify ONLY if they have specific risk factors (attending childcare or having a sibling <5 years old) AND are <90 days of age at start of RSV season 2

Chronic Lung Disease (CLD):

• Children <24 months with CLD who required medical therapy (supplemental oxygen, bronchodilators, diuretics, or chronic corticosteroids) within 6 months before RSV season start qualify for up to 5 doses 2, 1
• In the second year of life, only children with CLD requiring ongoing supplemental oxygen, chronic corticosteroid therapy, or diuretic therapy within 6 months of the second RSV season should be considered 2

Congenital Heart Disease (CHD):

• Children <24 months with hemodynamically significant cyanotic or acyanotic CHD benefit from prophylaxis 2, 1
• Highest priority: infants receiving medication for congestive heart failure, those with moderate-to-severe pulmonary hypertension, and those with cyanotic heart disease 2

Other Conditions:

• Profoundly immunocompromised children <24 months may be considered, particularly hematopoietic stem cell transplant recipients 2
• Infants with significant congenital airway abnormalities or neuromuscular disease compromising respiratory secretion handling may be considered for up to 5 doses in the first year 2

Conditions NOT Qualifying for Routine Prophylaxis

The following groups do NOT qualify for routine palivizumab prophylaxis:

• Children with Down syndrome (unless they meet criteria for cardiac disease or prematurity) 2
• Children with cystic fibrosis 2
• Prevention of nosocomial RSV in NICU/hospital settings 2
• Prevention of recurrent wheezing in later years 2

Dosing and Administration Protocol

Timing:

• Initiate prophylaxis in November for most U.S. regions, continuing monthly for 5 total doses to provide protection through April 2
• In north central and southwest Florida, initiate in late September to early October due to earlier RSV season onset 2
• For infants born during RSV season, administer fewer than 5 doses as needed to cover through season end (maximum 5 doses) 2

Special Circumstances:

• Children undergoing cardiopulmonary bypass should receive an additional dose as soon as possible after the procedure, even if sooner than one month from the previous dose, then resume monthly dosing 1
• Do NOT continue prophylaxis if breakthrough RSV hospitalization occurs 2

Administration Technique:

• Administer 15 mg/kg intramuscularly, preferably in the anterolateral thigh 1
• Avoid gluteal muscle due to sciatic nerve injury risk 1
• Volumes >1 mL should be divided into separate injections 1

Efficacy and Limitations

Proven Benefits:

• 55% reduction in RSV-related hospitalization in premature infants and those with CLD 2, 3
• 45% reduction in RSV-related hospitalization in infants with hemodynamically significant CHD 2, 3

Important Limitations:

• Palivizumab has NOT been shown to reduce mortality from RSV infection 2, 3
• Does NOT reduce recurrent wheezing after RSV infection 2, 3
• NOT effective for treatment of established RSV disease 1
• High cost without overall healthcare savings, making it cost-inefficient for broader populations 2

Maternal RSV Vaccination

Pregnant individuals should receive a single dose of RSVpreF vaccine (Abrysvo) at 32-36 weeks gestation to prevent RSV-associated lower respiratory tract disease in infants <6 months of age. 3

• Either maternal vaccination during pregnancy OR nirsevimab administration to the infant is recommended, but both are not needed for most infants 3

Adult RSV Vaccination

All adults ≥60 years should receive RSV vaccination regardless of previous infection history. 4

Adults aged 50-59 years should receive RSV vaccination if they have:

• Chronic respiratory disease 4
• Chronic heart disease 4
• Chronic kidney disease 4
• Diabetes 4
• Immunocompromised status 4
• Obesity 4
• Neurological conditions 4
• Residence in nursing home or long-term care facility 4

Available Vaccines:

• RSVPreF3 (Arexvy): 82.6% efficacy against RSV-associated lower respiratory tract disease in first season, with protection maintained for at least three seasons 4
• RSVpreF (Abrysvo): 65.1% efficacy in first season, with protection maintained for at least two seasons 4

Administration:

• Single intramuscular dose, preferably between September and November before RSV season 4
• Can be co-administered with influenza vaccine at different injection sites 4

Infection Control Measures

Hand hygiene is the most critical intervention to prevent nosocomial RSV spread and should be performed before and after direct patient contact, after contact with inanimate objects near the patient, and after removing gloves. 2

Alcohol-based hand rubs are preferred over antimicrobial soap for hand decontamination. 2

Environmental Considerations

All families with infants, especially high-risk infants, must implement these preventive measures:

• Limit exposure to contagious settings (childcare centers) where feasible during RSV season 2
• Strict hand hygiene in all settings including home and NICU 2
• Complete avoidance of tobacco smoke exposure (including second-hand and third-hand exposure) 2
• Encourage breastfeeding for all infants 2
• Restrict participation in group childcare during RSV season for high-risk infants whenever feasible 2

Hospital Infection Control

RSV can survive on hard surfaces for ≥6 hours, on gowns/tissues for 20-30 minutes, and on skin for up to 20 minutes, requiring strict environmental cleaning protocols. 2

• Secretions from infected patients contaminate beds, crib railings, tabletops, and toys 2
• Healthcare workers acquire infection through feeding, diaper changes, and playing with RSV-infected infants 2
• Restrict visitors to NICU during respiratory virus season 2

Supportive Care for Established RSV Disease

No specific antiviral therapy has proven effective for RSV bronchiolitis; management consists of supportive care including adequate nutrition and oxygen therapy. 5

• Ribavirin has not been proven effective 5
• Bronchodilators show variable results 5
• Corticosteroids are not effective 5

Clinical Pitfalls to Avoid

• Do NOT administer palivizumab to infants who do not meet specific eligibility criteria, as this represents poor value healthcare 2
• Do NOT use palivizumab for treatment of active RSV infection 1
• Do NOT administer more than 5 doses in continental United States, as this provides no additional benefit 2
• Do NOT use palivizumab to prevent nosocomial spread during outbreaks; focus on hand hygiene and infection control instead 2
• Do NOT delay live vaccines (MMR, varicella) in children receiving palivizumab, unlike with RSV-IGIV 5