RSV: Treatment and Prevention
Treatment of Active RSV Infection
There is no specific antiviral treatment for RSV infection—management is entirely supportive. 1, 2
- Oxygen therapy should be provided to maintain oxygen saturation above 90% 2
- Hydration and nutrition should be maintained through nasogastric or intravenous routes if oral intake is inadequate 2
- Avoid ineffective therapies: Bronchodilators, epinephrine, nebulized hypertonic saline, corticosteroids, antibiotics, and chest physiotherapy are NOT recommended as they provide no benefit 2
- High-flow nasal cannula may be beneficial in severe cases requiring respiratory support 3
- Mechanical ventilation may be necessary in the most severe cases 3
The antiviral agent ribavirin has not been proven effective for RSV treatment 4. Most children recover within 1-2 weeks with supportive care alone 3.
Prevention: Palivizumab Prophylaxis for High-Risk Infants
Palivizumab is the primary pharmacologic prevention strategy for high-risk infants, reducing RSV hospitalization by 45-55%. 5, 6
Who Should Receive Palivizumab
Infants born before 29 weeks' gestation who are younger than 12 months at the start of RSV season should receive prophylaxis 7, 6
Infants with chronic lung disease (CLD) younger than 24 months who required medical therapy (supplemental oxygen, bronchodilators, diuretics, or corticosteroids) within 6 months before RSV season 5, 6
Infants with hemodynamically significant congenital heart disease (CHD) younger than 24 months, specifically those:
- Receiving medication for congestive heart failure 5, 6
- With moderate-to-severe pulmonary hypertension 5, 6
- With cyanotic heart disease 5, 6
Infants with pulmonary abnormalities or neuromuscular disease that impairs ability to clear upper airway secretions may be considered for prophylaxis 5, 6
Profoundly immunocompromised children younger than 24 months may be considered 7
Who Should NOT Receive Palivizumab
Palivizumab should NOT be given to infants with:
- Hemodynamically insignificant heart disease (secundum ASD, small VSD, mild pulmonic stenosis, uncomplicated aortic stenosis, mild coarctation, patent ductus arteriosus) 5, 6
- Adequately corrected cardiac lesions unless still requiring medication for congestive heart failure 5, 6
- Mild cardiomyopathy not receiving medical therapy 5, 6
- Cystic fibrosis (insufficient evidence for routine use) 5, 6
Dosing and Administration
Dose: 15 mg/kg intramuscularly every 30 days throughout RSV season 5, 6, 1
Maximum number of doses:
- 5 doses for infants with CLD, CHD, or born before 32 weeks' gestation 5
- 3 doses for infants born 32-34 weeks' 6 days gestation with risk factors (attends childcare OR has sibling <5 years old), given only until 90 days of age 5, 6
Timing:
- For most U.S. regions: initiate in November, continue monthly through March (5 total doses) 5
- Florida variations: Southeast Florida (Miami-Dade) begins in July; north-central and southwest Florida begin late September/early October; northwest Florida begins mid-November 5
Special circumstances:
- After cardiopulmonary bypass surgery: Give an additional 15 mg/kg dose as soon as medically stable, as bypass decreases serum levels by 58% 5, 6, 1
- Breakthrough RSV infection: Continue monthly prophylaxis as scheduled, since infants may be hospitalized multiple times with different RSV strains 5, 6
- Hospitalized infants: Give first dose 48-72 hours before discharge or promptly after discharge 5, 6
- Scheduled dose during hospitalization: Administer on schedule even if infant is hospitalized 5, 6
Administration technique:
- Inject intramuscularly in anterolateral thigh (NOT gluteal muscle due to sciatic nerve risk) 1
- Volumes >1 mL should be divided 1
- Single-dose vial without preservatives—discard unused portion 1
Important Limitations
Palivizumab does NOT reduce mortality from RSV 5, 6
Palivizumab does NOT decrease recurrent wheezing after RSV infection 5, 6
Palivizumab is extremely costly and economic analyses show no overall healthcare cost savings despite reducing hospitalizations 5
The 2014 AAP guidelines emphasize that palivizumab provides "minimal clinical reduction in RSV hospitalizations" and "cannot be considered high-value health care" given the high cost relative to modest benefits 5. However, it remains the only available pharmacologic prophylaxis for the highest-risk infants.
Vaccine Compatibility
Palivizumab does not interfere with routine childhood immunizations, which should proceed on schedule 5, 6
Prevention: Maternal RSV Vaccination
Pregnant women should receive RSVpreF vaccine (Abrysvo) as a one-time dose at 32-36 weeks' gestation to prevent RSV-associated lower respiratory tract disease in infants <6 months of age 7
Either maternal vaccination OR infant nirsevimab is recommended—both are not needed for most infants 7
Prevention: Adult RSV Vaccination
All adults ≥60 years should receive RSV vaccination regardless of previous infection history 8
Adults aged 50-59 years with risk factors (chronic respiratory disease, chronic heart disease, chronic kidney disease, diabetes, immunocompromised status, obesity, neurological conditions, or nursing home residence) should receive vaccination 8
Available vaccines:
- RSVPreF3 (Arexvy): 82.6% efficacy against lower respiratory tract disease, protection maintained for at least 3 seasons 8
- RSVpreF (Abrysvo): 65.1% efficacy, protection maintained for at least 2 seasons 8
Timing: Single intramuscular dose, preferably September-November before RSV season 8
Universal Prevention Measures for All Infants
Keep high-risk infants away from crowds and situations where exposure to infected people cannot be controlled 5, 6
Restrict participation in group childcare during RSV season for high-risk infants whenever feasible 5, 6
Practice meticulous hand hygiene—this is critical for all caregivers and family members 5, 6
Eliminate tobacco smoke exposure completely, including secondhand and thirdhand exposure 5, 6
Ensure influenza vaccination for all infants ≥6 months and their contacts (starting when infant is born) 5
Breastfeeding should be encouraged, though data on specific protection against RSV are conflicting 5
Healthcare infection control: