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

Treatment and Prevention of Respiratory Syncytial Virus (RSV)

Prevention: Nirsevimab is Now the Primary Prophylaxis Strategy

For infants and young children, nirsevimab (Beyfortus) is recommended as first-line prophylaxis, administered as a single intramuscular dose before or during RSV season, providing superior protection compared to older monthly palivizumab regimens. 1

Nirsevimab Recommendations (2023 ACIP Guidelines)

Infants <8 months:

• All infants born during or entering their first RSV season should receive nirsevimab, regardless of gestational age or underlying conditions 1
• Single dose administered October through March in most continental U.S. regions 1
• Efficacy: 79% reduction in medically attended RSV-associated lower respiratory tract infection, 80.6% reduction in hospitalization, and 90% reduction in ICU admission 1

Children 8-19 months:

• Administer nirsevimab to those at increased risk for severe RSV disease entering their second RSV season 1
• This includes children with chronic lung disease, hemodynamically significant congenital heart disease, severe immunocompromise, or cystic fibrosis 1

Palivizumab: Reserved for Specific High-Risk Populations

Palivizumab remains an option only when nirsevimab is unavailable or for children with specific contraindications, as it requires monthly dosing and is significantly more costly 1

Current palivizumab indications (FDA-approved): 2

• Premature infants ≤35 weeks gestational age who are ≤6 months at RSV season start
• Children ≤24 months with bronchopulmonary dysplasia requiring medical treatment within previous 6 months
• Children ≤24 months with hemodynamically significant congenital heart disease

Dosing: 15 mg/kg intramuscularly monthly throughout RSV season (maximum 5 doses) 2

Important limitation: Palivizumab has NOT been shown to reduce mortality or recurrent wheezing after RSV infection 1, 3

Maternal RSV Vaccination Alternative

• RSVpreF vaccine (Abrysvo) administered at 32-36 weeks gestation provides passive immunity to infants <6 months 3
• Either maternal vaccination OR infant nirsevimab is recommended, but both are not needed for most infants 3

Treatment: Supportive Care Only

There is no effective antiviral treatment for RSV infection; management is entirely supportive. 1

Supportive measures include:

• Adequate hydration and nutrition 1
• Supplemental oxygen for hypoxemia 1
• Respiratory support (nasal cannula, CPAP, or mechanical ventilation) as needed based on severity

Ineffective therapies to avoid:

• Ribavirin has not proven effective 1
• Bronchodilators show variable and inconsistent results 1
• Corticosteroids are not effective 1

Non-Pharmacologic Prevention Strategies

All families with infants should implement these measures: 1

• Hand hygiene: Rigorous handwashing by all caregivers and contacts 1
• Avoid exposure: Limit contact with individuals with respiratory infections; restrict daycare attendance during RSV season for high-risk infants 1
• Eliminate tobacco smoke exposure: Complete avoidance of first-hand, second-hand, and third-hand smoke 1
• Breastfeeding: Encourage exclusive breastfeeding, though specific protective effect against RSV remains conflicting 1
• Influenza vaccination: All infants ≥6 months and their contacts should receive annual influenza vaccine 1

Adult RSV Vaccination

All adults ≥60 years should receive RSV vaccination (RSVPreF3 or RSVpreF) as a single dose, preferably September-November. 4

Adults 50-59 years with risk factors should also be vaccinated: 4

• Chronic respiratory disease, chronic heart disease, chronic kidney disease
• Diabetes, immunocompromised status, obesity
• Neurological conditions or nursing home residence

Vaccine efficacy: RSVPreF3 demonstrates 82.6% efficacy maintained for at least three seasons; RSVpreF shows 65.1% efficacy maintained for at least two seasons 4

Key Clinical Pitfalls to Avoid

• Do not use palivizumab for treatment of active RSV infection—it is prophylaxis only 2
• Do not administer both maternal RSV vaccine and infant nirsevimab unless specific high-risk conditions warrant dual protection 3
• Do not continue palivizumab beyond the recommended number of doses (cost-ineffective without circulating RSV) 1
• Do not delay nirsevimab administration—optimal protection requires dosing before RSV season begins 1