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

RSV Treatment

For otherwise healthy infants and children with RSV infection, treatment is entirely supportive—no antiviral therapy is indicated. 1, 2 The cornerstone of management includes maintaining adequate hydration, providing supplemental oxygen if saturation falls persistently below 90%, and using antipyretics like acetaminophen or ibuprofen for fever control. 1, 2

Supportive Care for Immunocompetent Patients

The vast majority of RSV infections are mild and self-limited, requiring only symptomatic management. 3

• Hydration: Assess and maintain adequate fluid intake in all patients 1
• Oxygen therapy: Provide supplemental oxygen if SpO2 falls persistently below 90% in previously healthy infants 1
• Fever/pain management: Use acetaminophen or ibuprofen as needed 1
• Nasal saline irrigation: May provide symptomatic relief in adults with upper respiratory symptoms 1

What NOT to Do in Routine Cases

• Do NOT use ribavirin routinely in children with bronchiolitis 1, 3
• Do NOT use corticosteroids routinely for bronchiolitis management 1
• Do NOT prescribe antibiotics unless there is specific evidence of bacterial co-infection 1, 2
• Do NOT use palivizumab for treatment—it has no therapeutic benefit for established RSV infection and is only approved for prevention in high-risk infants 1, 2

Treatment for High-Risk and Immunocompromised Patients

For hematopoietic stem cell transplant (HSCT) patients and severely immunocompromised individuals with RSV lower respiratory tract infection, ribavirin is the primary antiviral option. 4, 3

Ribavirin Administration

Aerosolized ribavirin is FDA-approved for hospitalized infants and young children with severe lower respiratory tract RSV infection, though its use should be limited to truly severe cases. 3

• Indications for ribavirin: HSCT patients with RSV lower respiratory tract infectious disease (LRTID) or those at high risk for progression 4
• Aerosolized form: Primary option for mechanically ventilated patients with documented severe RSV infection 4, 3
• Systemic ribavirin: Can be administered orally or intravenously (10-30 mg/kg/day in 3 divided doses) for patients unable to take oral medication 4

Dosing Schedule for Systemic Ribavirin

• Day 1: Start with 600 mg loading dose, then 200 mg every 8 hours 4
• Day 2: 400 mg every 8 hours 4
• Day 3 onward: Increase to maximum of 10 mg/kg body weight every 8 hours 4
• Renal adjustment: For creatinine clearance 30-50 mL/min, maximum 200 mg every 8 hours 4

Monitoring for Ribavirin Adverse Events

• Aerosolized ribavirin: Monitor for claustrophobia, bronchospasm, nausea, conjunctivitis, and declining pulmonary function 4
• Systemic ribavirin: Monitor for hemolysis, abnormal liver function tests, and declining renal function 4
• Pregnancy precaution: Avoid environmental exposure in pregnant healthcare workers due to teratogenic effects 4

Combination Therapy for HSCT Patients

For allogeneic HSCT patients with RSV LRTID or at high risk for progression, consider combining ribavirin with immunoglobulin therapy. 4

• Aerosolized or systemic ribavirin may be combined with IVIG or anti-RSV-enriched antibody preparations 4
• Patients with RSV upper respiratory tract infectious disease (URTID) undergoing allogeneic HSCT or with risk factors for progression should be treated with ribavirin and IVIG 4

Timing Considerations for Immunocompromised Patients

• Defer conditioning therapy for patients with RSV respiratory tract infection planned for allogeneic HSCT 4
• Consider deferring chemotherapy for patients with RSV infection scheduled for hemato-oncological treatment 4
• Treatment is most effective when instituted within the first 3 days of clinical illness 3

Respiratory Support Escalation

High-flow nasal oxygen (HFNO) may be considered in selected patients with hypoxemic respiratory failure, but only in monitored settings with personnel capable of intubation. 1

• Non-invasive ventilation (NIV) is NOT recommended due to high failure rates and risk of aerosol generation 1
• Early intubation and mechanical ventilation should be considered if respiratory distress worsens or oxygen requirements cannot be met with standard supplementation 1
• Transfer to ICU if patient fails to maintain SaO2 >92% in FiO2 >60%, is in shock, or has severe respiratory distress with rising PaCO2 (>6.5 kPa) 1

Infection Control: Critical for All Settings

Hand hygiene is the single most important measure to prevent RSV transmission. 1, 2

• Perform hand decontamination before and after direct patient contact 1
• Use alcohol-based rubs if hands are not visibly soiled 1
• Wear gowns for direct contact with patients 1
• Use gloves with frequent changes to avoid spreading organisms 1
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 1

Hospitalization Criteria

• Severe respiratory distress, inability to maintain hydration, or oxygen saturation <90% despite supplemental oxygen 2
• Underlying conditions such as prematurity, chronic lung disease, congenital heart disease, or immunocompromised status warrant earlier hospitalization 2
• 75% of RSV hospitalizations occur in infants younger than 12 months 1, 2

Common Pitfalls to Avoid

• Overuse of antibiotics when there is no evidence of bacterial co-infection 1, 2
• Using palivizumab for treatment of established infection—it has no therapeutic benefit 1, 2
• Continuing bronchodilator therapy without documented clinical improvement 1
• Inadequate infection control measures leading to nosocomial transmission 1