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

Treatment of Acute RSV Bronchiolitis

For acute RSV bronchiolitis in otherwise healthy patients, treatment is purely supportive—antibiotics, bronchodilators, corticosteroids, and ribavirin should NOT be used routinely. 1

Supportive Care: The Foundation of Management

The cornerstone of RSV bronchiolitis management is supportive therapy, as no specific antiviral treatment has proven beneficial for the general population. 1

Hydration and Nutrition

• Ensure adequate fluid intake through oral, nasogastric, or intravenous routes as needed 2, 3
• Monitor hydration status closely, particularly in infants with increased work of breathing who may have difficulty feeding 3

Oxygen Therapy

• Provide supplemental oxygen if saturation falls persistently below 90% in previously healthy infants 2, 3
• Maintain oxygen saturation above 90% 3
• As clinical status improves, continuous SpO2 monitoring is not routinely needed, though infants with hemodynamically significant heart or lung disease require close monitoring during oxygen weaning 2

Symptomatic Relief

• Use acetaminophen or ibuprofen for fever or pain management 2
• Nasal saline irrigation may provide symptomatic relief for upper respiratory symptoms 2

What NOT to Use: Evidence-Based Avoidance

Antibiotics

Antibacterial medications should only be used when specific bacterial co-infection is documented. 1, 2 The evidence is clear:

• Studies show bacterial co-infection rates of only 0-3.7% in RSV bronchiolitis 1
• When serious bacterial infection occurs, it is most commonly urinary tract infection rather than bacteremia or meningitis 1
• Treat documented bacterial infections in the same manner as in the absence of bronchiolitis 1

Bronchodilators and Corticosteroids

• Routine use of bronchodilators is not justified and should not be offered 1
• Corticosteroids should NOT be used routinely in bronchiolitis management 2
• There is no role for inhaled bronchodilator or expectorant therapy 1

Ribavirin in General Population

Ribavirin should NOT be used routinely in children with bronchiolitis. 1, 2, 4 The evidence shows:

• Only marginal benefit, if any, in most patients 1, 4
• Cumbersome delivery requirements, potential health risks for caregivers, and high cost 1, 4
• Studies showed inconsistent results: 7 of 11 trials demonstrated some improvement (often subjective), while 4 showed no benefit 4

High-Risk Populations: When to Consider Ribavirin

Ribavirin may be considered ONLY in highly selected situations involving documented severe RSV disease in: 1, 4

Hematopoietic Stem Cell Transplant (HSCT) Recipients

• Aerosolized ribavirin is the primary treatment option: 2g for 2 hours every 8 hours or 6g over 18 hours daily for 7-10 days 4
• Oral ribavirin (600-800 mg twice daily) is an effective alternative that may reduce progression to lower respiratory tract infection 4
• Systemic ribavirin can be given intravenously (10-30 mg/kg/day in 3 divided doses) for patients unable to take oral medication 2, 4
• Consider combination therapy with IVIG or anti-RSV-enriched antibody preparations for allogeneic HSCT patients 2, 4

Other Immunocompromised Patients

Consider ribavirin for: 2, 4

• Solid organ transplant recipients (particularly lung transplant) with RSV pneumonia
• Patients with active chemotherapy and significant immunosuppression
• Those with hemodynamically significant cardiopulmonary disease in the setting of severe RSV infection

Ribavirin Monitoring Requirements

When ribavirin is used, monitor for: 2, 4

• Aerosolized form: claustrophobia, bronchospasm, nausea, conjunctivitis, declining pulmonary function
• Systemic form: hemolysis, abnormal liver function tests, declining renal function
• Avoid environmental exposure in pregnant healthcare workers due to teratogenic effects 2, 4

Infection Control: Critical to Prevent Nosocomial Spread

Hand decontamination before and after patient contact is the single most important measure to prevent RSV transmission. 1, 2

Hand Hygiene Protocol

• Decontaminate hands before and after direct patient contact, after contact with objects near the patient, and after removing gloves 1, 2
• Use alcohol-based rubs if hands are not visibly soiled (preferred method) 1, 2
• Alternative: wash with antimicrobial soap 1

Additional Infection Control Measures

• Use gloves with frequent changes to avoid spreading organisms 2
• Wear gowns for direct patient contact 2
• Educate personnel and family members about prevention strategies 1, 2
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 2

Common Pitfalls to Avoid

1. Do NOT use palivizumab for treatment—it has no therapeutic benefit for established RSV infection and is only approved for prophylaxis in high-risk infants 2, 4, 5

2. Do NOT prescribe antibiotics without documented bacterial co-infection—this is a major driver of inappropriate antibiotic use 1

3. Do NOT continue bronchodilator therapy without documented clinical improvement—there is no evidence of benefit 1, 2

4. Do NOT use ribavirin routinely in previously healthy children—the evidence does not support benefit and exposes patients to unnecessary risks and costs 1, 2, 4

Clinical Course and Prognosis

• RSV bronchiolitis is self-limited, lasting no more than 3 weeks 1
• When cough persists beyond 3 weeks, other diagnoses must be considered 1
• Mortality rate is <1% and occurs predominantly in high-risk children 6
• By 2 years of age, virtually all children have been infected by RSV 1, 6