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

Treatment for RSV in Adults

Treatment for RSV in adults is primarily supportive care, as there are no FDA-approved antiviral therapies specifically for RSV in the adult population, with management focused on oxygen support, hydration, symptom control, and management of underlying comorbidities. 1

Primary Treatment Approach: Supportive Care

The cornerstone of RSV management in adults consists of:

• Oxygen supplementation to maintain adequate saturation, particularly in patients with hypoxemic respiratory failure 1
• Adequate hydration and fluid intake assessment for all patients 1, 2
• Analgesics such as acetaminophen or ibuprofen for fever and pain management 1, 2
• Nasal saline irrigation may provide symptomatic relief in adults with upper respiratory symptoms 1, 2

Management of Underlying Conditions

For patients with chronic cardiopulmonary disease:

• COPD or asthma exacerbations should be managed according to standard exacerbation protocols, as RSV commonly triggers disease exacerbation in these populations 1, 3
• Cardiovascular complications require close monitoring, as RSV infection increases risk of cardiac events in patients with heart failure or coronary artery disease 1
• Antibiotics should only be used when specific indications of bacterial co-infection exist, not empirically 1, 2

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, 3
• 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, 3
• Antigen detection tests are not recommended for adults due to poor sensitivity in this population 1

Special Population: Immunocompromised Adults

For severely immunocompromised adults with documented RSV infection, off-label treatment options exist:

Ribavirin Therapy

• Aerosolized ribavirin is the primary option for mechanically ventilated patients with documented severe RSV infection 1, 2
• Oral or intravenous ribavirin (10-30 mg/kg/day in 3 divided doses) can be used for patients unable to take oral medication 1, 2

Dosing schedule for systemic ribavirin: 1, 2

• 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

Combination Therapy

• Ribavirin combined with intravenous immunoglobulin (IVIG) may be considered based on observational data showing improved survival in severely immunocompromised patients 1, 4
• Combination therapy with IVIG or anti-RSV-enriched antibody preparations may be considered for allogeneic HSCT patients with lower respiratory tract disease 1, 2

Monitoring for Ribavirin Adverse Events

• Monitor for hemolysis, abnormal liver function tests, and declining renal function in patients receiving systemic ribavirin 2
• Monitor for claustrophobia, bronchospasm, nausea, conjunctivitis, and declining pulmonary function in patients receiving aerosolized ribavirin 2
• Avoid environmental exposure in pregnant healthcare workers due to teratogenic effects 2

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 1, 2
• Non-invasive ventilation (NIV) is generally NOT recommended due to high failure rates and risk of aerosol generation 1, 2
• Early intubation and mechanical ventilation should be considered if respiratory distress worsens or oxygen requirements cannot be met with standard supplementation 1, 2

Prevention: Vaccination Strategy

Two RSV vaccines are now available and represent the primary preventive strategy:

Age-Based Recommendations

• All adults aged ≥75 years should receive RSV vaccination regardless of comorbidities 5, 1, 3
• Adults aged 60-74 years with risk factors should receive vaccination 5, 1

Risk Factors for Adults Aged 60-74 Years (per CDC ACIP): 5

• Chronic cardiovascular disease (heart failure, coronary artery disease, congenital heart disease)
• Chronic lung or respiratory disease (COPD, emphysema, asthma, interstitial lung disease, cystic fibrosis)
• End-stage renal disease or dependence on hemodialysis
• Diabetes mellitus with complications or requiring insulin/SGLT2 inhibitor
• Neurologic or neuromuscular conditions causing impaired airway clearance
• Chronic liver disease (cirrhosis)
• Chronic hematologic conditions (sickle cell disease, thalassemia)
• Severe obesity (BMI ≥40 kg/m²)
• Moderate or severe immune compromise
• Residence in a nursing home

Vaccination Timing and Administration

• Vaccination should be administered between September and November, before or early in the RSV season 1, 3
• A single dose is recommended, which can be co-administered with seasonal influenza vaccine at different injection sites 1, 3

Infection Control Measures

• Hand hygiene is the single most important measure to prevent transmission and nosocomial spread 1, 2
• Alcohol-based hand rubs are preferred for hand decontamination 1, 2
• Gowns and gloves should be used for direct patient contact 1, 2
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 1, 2

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, 3
• Functional decline following RSV infection can be prolonged, particularly in frail elderly patients from skilled nursing facilities 1, 3
• Attack rates in nursing homes are approximately 5-10% per year, with pneumonia rates of 10-20% and death rates of 2-5% 6

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 1, 2, 3
• Avoid routine use of corticosteroids in RSV management unless treating underlying COPD or asthma exacerbation 1, 2
• Do NOT continue antiviral therapy empirically—RSV infection should be documented by rapid diagnostic method before or during the first 24 hours of treatment 2
• Avoid overuse of antibiotics when there is no evidence of bacterial co-infection 1, 2