What are the treatment and prevention options for Respiratory Syncytial Virus (RSV) infection?

RSV Treatment and Prevention

Treatment of RSV Infection

RSV infection should be managed with supportive care only—do not use corticosteroids, bronchodilators, or antibiotics routinely, as these interventions provide no mortality, morbidity, or quality of life benefit. 1

Core Supportive Care Measures

• Maintain adequate hydration through oral, nasogastric, or intravenous routes as needed to ensure sufficient fluid intake 1, 2
• Provide supplemental oxygen only if oxygen saturation falls persistently below 90% 1, 2
• Use acetaminophen or ibuprofen for fever or pain management as needed 1
• Implement strict hand hygiene protocols to prevent transmission 1

Treatments to Avoid

The American Academy of Pediatrics definitively states that the following should NOT be used routinely in RSV bronchiolitis management:

• Corticosteroids: No prospective randomized trial has demonstrated decreased mortality or improved long-term outcomes 1, 2
• Bronchodilators and epinephrine: Not recommended as they provide no benefit 2
• Nebulized hypertonic saline: Not recommended 2
• Antibiotics: Only use if specific bacterial co-infection is documented 1, 2
• Chest physiotherapy: Not recommended 2
• Ribavirin: Reserve only for severely immunocompromised patients, hematopoietic stem cell transplant recipients, or mechanically ventilated infants with documented severe RSV infection 1

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Prevention Strategies

For High-Risk Infants: Palivizumab Prophylaxis

Palivizumab (15 mg/kg IM monthly) should be administered to specific high-risk pediatric populations during RSV season, providing a 45-55% reduction in RSV-related hospitalizations. 3, 4

Indications for Palivizumab

Premature infants:

• Infants born ≤28 weeks 6 days gestation who are <12 months old at RSV season start: up to 5 doses 5
• Infants born 29-31 weeks 6 days gestation who are <6 months old at RSV season start: up to 5 doses 5
• Infants born 32-34 weeks 6 days gestation who are <90 days old at RSV season start AND have risk factors (attends childcare OR has sibling <5 years old): maximum 3 doses 5

Chronic lung disease (CLD):

• Infants <24 months with CLD requiring medical therapy (supplemental oxygen, bronchodilator, diuretic, or chronic corticosteroid) within 6 months before RSV season: up to 5 doses 5, 4

Congenital heart disease (CHD):

• Children <24 months with hemodynamically significant cyanotic or acyanotic CHD, especially those receiving medication for congestive heart failure: up to 5 doses 5, 4

Other high-risk conditions:

• Infants with significant congenital airway abnormalities or neuromuscular disease compromising respiratory secretion handling: up to 5 doses during first year of life 5
• Children <24 months who are profoundly immunocompromised: may be considered 3

Palivizumab Administration Details

• Dosing: 15 mg/kg body weight given monthly by intramuscular injection, preferably in the anterolateral thigh 4
• Timing: First dose prior to RSV season commencement (typically November), then monthly through RSV season (typically through April) 5, 4
• Special consideration: Children undergoing cardiopulmonary bypass should receive an additional dose as soon as possible after the procedure, even if sooner than one month from previous dose 4
• Continue through infection: Children who develop RSV infection should continue monthly doses throughout RSV season 4

Important Limitations of Palivizumab

• Does NOT reduce mortality from RSV infection 3
• Does NOT decrease recurrent wheezing after RSV infection 3
• Only prevents RSV-specific disease, not other respiratory infections 3
• High cost without overall healthcare savings 5, 3
• The 2014 AAP guidelines emphasize that palivizumab provides minimal clinical benefit relative to its high cost and "cannot be considered as high-value health care" 5

For Pregnant Women: Maternal Vaccination

RSVpreF vaccine (Abrysvo) should be administered as a one-time dose at 32-36 weeks' gestation to prevent RSV-associated lower respiratory tract disease in infants <6 months of age. 3

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

Universal Prevention Measures for All Infants

All families should implement the following measures to reduce RSV transmission:

• Limit exposure to crowds and contagious settings (especially childcare centers) during RSV season whenever feasible 5
• Emphasize hand hygiene in all settings including home and healthcare facilities 5
• Restrict visitors with respiratory symptoms from contact with infants 5
• Encourage breastfeeding for all infants 5
• Eliminate tobacco smoke exposure completely, including second-hand and third-hand exposure 5
• Administer influenza vaccine to all infants ≥6 months and their contacts 5

Hospital Infection Control During RSV Season

Healthcare facilities should implement contact isolation precautions for RSV-infected patients:

• Hand hygiene: Wash hands after any contact with RSV-infected patients or contaminated surfaces, regardless of glove use 5
• Glove use: Wear gloves when handling RSV-infected patients or respiratory secretions; change gloves between patients 5
• Gown use: Wear gowns if clothing could be soiled by respiratory secretions; change before caring for another patient 5
• Staff restrictions: Restrict healthcare workers with acute upper respiratory symptoms (sneezing/coughing) from caring for high-risk patients 5
• Cohorting: During outbreaks, cohort RSV-infected patients and assign dedicated staff 5
• Rapid diagnosis: Use rapid diagnostic techniques during December-March for pediatric patients and immunocompromised adults with respiratory illness 5

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Common Pitfalls to Avoid

• Do not prescribe corticosteroids based on wheezing alone—RSV bronchiolitis does not respond to steroids despite the presence of wheezing 1
• Do not obtain routine chest radiographs or viral testing—diagnosis is clinical 2
• Do not administer palivizumab to infants who do not meet specific high-risk criteria—the cost-benefit ratio is unfavorable for healthy term infants 5
• Do not continue palivizumab beyond the specified number of doses for each risk category—efficacy of additional doses is not established 5