What is the management approach for Respiratory Syncytial Virus (RSV) infection in adults?

Management of RSV in Adults

Primary Treatment Approach

Treatment for RSV in adults is primarily supportive care, as there are no FDA-approved antiviral treatments specifically for RSV in adults, with management focused on oxygen support, hydration, and symptom control. 1, 2

Supportive Care Measures

• Oxygen supplementation should be provided to maintain adequate saturation, particularly in patients with hypoxemic respiratory failure 3
• Adequate hydration and fluid intake assessment is essential for all patients with RSV infection 3
• Analgesics such as acetaminophen or ibuprofen can be used for fever and pain management 3
• Nasal saline irrigation may provide symptomatic relief in adults with upper respiratory symptoms 3

Management of Underlying Conditions

• For patients with COPD or asthma exacerbations, manage according to standard exacerbation protocols, as RSV commonly triggers disease exacerbation in these populations 4, 1
• Cardiovascular complications should be monitored closely, as RSV infection increases risk of cardiac events in patients with heart failure or coronary artery disease 4
• Antibiotics should only be used when specific indications of bacterial co-infection exist, not empirically 3, 5

Diagnostic Approach

• Nucleic acid-based testing (RT-PCR) is the recommended diagnostic method for RSV in adults, particularly those at high risk for severe disease 1
• Testing is especially important in immunocompromised patients, including those with solid organ or hematopoietic stem cell transplants, hematological malignancies, chronic immunosuppressive therapy, or HIV infection 1
• Antigen detection tests are not recommended for adults due to poor sensitivity in this population 4

Special Populations: Immunocompromised Adults

Ribavirin Therapy

For severely immunocompromised adults (particularly hematopoietic stem cell transplant recipients), off-label ribavirin combined with intravenous immunoglobulin may be considered based on observational data showing improved survival. 1, 3

• Aerosolized ribavirin is the primary option for mechanically ventilated patients with documented severe RSV infection 3, 6
• Oral or intravenous ribavirin (10-30 mg/kg/day in 3 divided doses) can be used for patients unable to take oral medication 3
• Dosing schedule for systemic ribavirin: Day 1: 600 mg loading dose, then 200 mg every 8 hours; Day 2: 400 mg every 8 hours; Day 3 onward: increase to maximum of 10 mg/kg every 8 hours 3
• Combination therapy with IVIG or anti-RSV-enriched antibody preparations may be considered for allogeneic HSCT patients with lower respiratory tract disease 3

Monitoring for Ribavirin Adverse Effects

• Monitor for hemolysis, abnormal liver function tests, and declining renal function with systemic ribavirin 3
• Monitor for bronchospasm, nausea, and declining pulmonary function with aerosolized ribavirin 3
• Avoid environmental exposure in pregnant healthcare workers due to teratogenic effects 3

Respiratory Support Escalation

• High-flow nasal oxygen (HFNO) may be considered in selected patients with hypoxemic respiratory failure in monitored settings with personnel capable of intubation 3, 7
• Non-invasive ventilation (NIV) is generally NOT recommended due to high failure rates and risk of aerosol generation 3
• Early intubation and mechanical ventilation should be considered if respiratory distress worsens or oxygen requirements cannot be met with standard supplementation 3

Prevention: Vaccination Strategy

Two RSV vaccines (RSVPreF3/Arexvy and RSVpreF/Abrysvo) are now available and recommended for prevention in older adults. 1, 2

Vaccination Recommendations

• All adults aged ≥75 years should receive RSV vaccination regardless of comorbidities 1, 3
• Adults aged 60-74 years with risk factors (chronic cardiopulmonary disease, diabetes, chronic kidney disease, immunocompromised status, nursing home residence) should receive vaccination 1, 3
• Adults aged 50-59 years at increased risk may receive vaccination 1
• Vaccination should be administered between September and November, before or early in the RSV season 1
• A single dose is recommended, which can be co-administered with seasonal influenza vaccine at different injection sites 1

High-Risk Populations Requiring Priority Vaccination

• Residents of nursing homes or long-term care facilities 1
• Patients with COPD, asthma, heart failure, or coronary artery disease 4, 1
• Patients on systemic corticosteroids (highest risk for hospitalization) 1
• Immunocompromised patients 1

Infection Control

• Hand hygiene is the single most important measure to prevent transmission and nosocomial spread 3
• Alcohol-based hand rubs are preferred for hand decontamination 3
• Gowns and gloves should be used for direct patient contact 3
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 3

Clinical Outcomes and Prognosis

• Mortality rates in hospitalized elderly patients range from 4.6% in those aged 60-74 years to 6.1% in those ≥75 years 1
• Median hospital length of stay is approximately 6 days (mean 10.8 days) 5
• 15% of hospitalized adults require ICU care and 9% require mechanical ventilation 5
• Functional decline following RSV infection can be prolonged, particularly in frail elderly patients from skilled nursing facilities 1

Critical Pitfalls to Avoid

• Do NOT use palivizumab for treatment of established RSV infection in adults—it has no therapeutic benefit and is only approved for prevention in high-risk infants 3
• Avoid routine use of corticosteroids in RSV management unless treating underlying COPD or asthma exacerbation 3
• Do NOT routinely use antibiotics without evidence of bacterial co-infection, though they are frequently prescribed empirically 5
• Do NOT continue antiviral therapy empirically—RSV infection should be documented by rapid diagnostic method before or during the first 24 hours of treatment 3, 6