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

Treatment Approach for Adult RSV Infection

The management of adult RSV infection is primarily supportive care, as there are currently no specific antiviral treatments approved for routine use in adults, with prevention through vaccination being the most effective strategy for high-risk populations. 1

Prevention: The Primary Strategy

Vaccination is the cornerstone of RSV management in adults, as there are no specific treatments once infection occurs. 1

Who Should Be Vaccinated

• All adults ≥60 years of age should receive RSV vaccination 1
• Adults aged 50-59 years with risk factors including:
  • COPD or asthma 1
  • Heart failure or coronary artery disease 1
  • Diabetes mellitus 1
  • Chronic kidney disease or chronic liver disease 1
  • Immunocompromised states 1
  • Frailty, dementia, or nursing home residence 1

Vaccination Timing and Administration

• Preferably administer between September and November, though can be given any time 1
• Can be co-administered with influenza vaccine 1
• Two vaccines are available (RSVPreF3 and RSVpreF) with efficacy maintained for 2-3 seasons 1

Priority Groups if Vaccine Supply Limited

• Individuals ≥75 years of age (highest mortality risk) 1
• Adults aged 50-59 years with the risk factors listed above 1

Acute Infection Management: Supportive Care Only

General Supportive Measures

For established RSV infection in adults, treatment is entirely supportive as no antivirals are approved for routine use. 2, 3, 4

• Adequate hydration and fluid intake assessment 2
• Supplemental oxygen if SpO2 falls persistently below 90% 2
• Acetaminophen or ibuprofen for fever and pain management 2
• Nasal saline irrigation for symptomatic relief of upper respiratory symptoms 2

Respiratory Support Escalation

• Standard oxygen supplementation for hypoxemia 2, 5
• High-flow nasal oxygen (HFNO) may be considered in selected patients with hypoxemic respiratory failure in monitored settings with personnel capable of intubation 2, 4
• Non-invasive ventilation (NIV) is NOT recommended due to high failure rates and aerosol generation risk 2
• Early intubation and mechanical ventilation should be considered if respiratory distress worsens or oxygen requirements cannot be met 2, 5

What NOT to Do

• Do NOT use antibiotics routinely - only when specific bacterial co-infection is documented 2
• Do NOT use corticosteroids routinely 2
• Do NOT use bronchodilators unless documented clinical improvement occurs 2
• Do NOT use ribavirin in immunocompetent adults 2, 6

Special Population: Immunocompromised Adults

Immunocompromised patients require more aggressive management and are the ONLY adult population where antiviral therapy may be considered. 2, 6, 5

High-Risk Immunocompromised Groups

• Hematopoietic stem cell transplant (HSCT) recipients 2, 6
• Solid organ transplant recipients 2
• Active chemotherapy for malignancy 2
• HIV with significant immunosuppression 2
• Chronic high-dose corticosteroids or biologic immunosuppression 2

Antiviral Therapy for Immunocompromised Patients

Ribavirin is the only antiviral option, reserved exclusively for severely immunocompromised patients with lower respiratory tract involvement. 2, 6

Aerosolized Ribavirin

• Primary option for HSCT patients with RSV lower respiratory tract disease 2, 6
• Also for mechanically ventilated patients with documented severe RSV 2
• Monitor for bronchospasm, claustrophobia, and declining pulmonary function 2

Systemic Ribavirin (Oral or IV)

• Dosing schedule: 2
  • Day 1: 600 mg loading dose, then 200 mg every 8 hours
  • Day 2: 400 mg every 8 hours
  • Day 3 onward: Maximum 10 mg/kg every 8 hours
  • Renal adjustment: Maximum 200 mg every 8 hours if CrCl 30-50 mL/min
• Monitor for hemolysis, abnormal liver function, and declining renal function 2
• Avoid environmental exposure in pregnant healthcare workers (teratogenic) 2

Combination Therapy

• Consider adding IVIG or anti-RSV antibody preparations for allogeneic HSCT patients with lower respiratory tract disease 2, 6

Timing Considerations for Immunocompromised

• Defer conditioning therapy for patients with RSV planned for allogeneic HSCT 2
• Consider deferring chemotherapy for patients scheduled for hemato-oncological treatment 2

Infection Control: Critical for All Settings

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

• Alcohol-based hand rubs before and after patient contact 2
• Gowns for direct patient contact 2
• Droplet precautions reduce nosocomial transmission by 39-50% 2
• Education of personnel and family members about hand sanitation 2

Hospitalization Criteria

Consider hospitalization for: 2, 7

• Hypoxemia (SpO2 persistently <90%) 2
• Severe respiratory distress 2
• Inability to maintain adequate oral intake 2
• Underlying immunocompromised status with lower respiratory tract involvement 2
• Significant comorbidities (COPD, heart failure, advanced age) 7, 6

Common Pitfalls to Avoid

• Do not use palivizumab for treatment - it has NO therapeutic benefit and is only for prevention in high-risk infants 2
• Do not overuse antibiotics without evidence of bacterial co-infection 2
• Do not delay vaccination in eligible patients due to misconceptions about efficacy 1
• Do not underestimate disease severity in elderly patients - RSV causes approximately 10,000 deaths annually in adults >64 years in the US 6
• Do not miss the opportunity for prevention - most adult RSV disease goes unrecognized, making vaccination critical 6

Clinical Outcomes and Prognosis

• Median hospital length of stay is 6 days (range 3-9 days) 7
• 25-36% of hospitalized patients require ICU care across all risk groups 7
• 10-16% require skilled nursing care post-discharge 7
• Approximately 25% require social worker assistance after hospitalization 7
• Attack rates in nursing homes are 5-10% annually with pneumonia rates of 10-20% and mortality of 2-5% 6