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

RSV Prevention and Treatment

Prevention Strategies

For high-risk pediatric populations, palivizumab prophylaxis provides targeted protection with a 55% reduction in RSV-related hospitalizations, but is recommended only for specific groups due to high cost and minimal impact on mortality or long-term outcomes. 1

Palivizumab Immunoprophylaxis Indications

Recommended groups for prophylaxis:

• Infants born before 29 weeks' gestation who are younger than 12 months at the start of RSV season (maximum 5 monthly doses) 2, 3

• Infants with chronic lung disease (CLD/bronchopulmonary dysplasia) requiring medical treatment within the previous 6 months and who are ≤24 months of age at the beginning of RSV season (maximum 5 doses) 1, 3

• Infants with hemodynamically significant congenital heart disease who are ≤24 months of age at the beginning of RSV season (maximum 5 doses), including those with acyanotic heart disease requiring medication for congestive heart failure, moderate-to-severe pulmonary hypertension, and cyanotic heart disease 1, 3

• Infants born 32-34 weeks' gestation qualify only if they meet specific risk criteria: attending child care OR having ≥1 sibling younger than 5 years living in the household, AND are born within 3 months before or during RSV season (maximum 3 doses, only until 90 days of age) 1

Groups that should NOT receive prophylaxis:

• Infants with hemodynamically insignificant heart disease (secundum atrial septal defect, small ventricular septal defect, uncomplicated lesions) 1
• Infants with adequately corrected cardiac lesions not requiring heart failure medications 1
• Infants with cystic fibrosis (insufficient evidence for routine use) 1

Dosing and Administration

Administer 15 mg/kg intramuscularly monthly throughout RSV season (typically November through April in the northern hemisphere), with the first dose given before season onset 3, 1

• Inject preferably in the anterolateral thigh; avoid gluteal muscle due to sciatic nerve risk 3
• Volumes >1 mL should be divided into separate injections 3
• After cardiopulmonary bypass, administer an additional dose as soon as medically stable (even if <1 month from previous dose), as serum levels decrease by 58% post-bypass 1, 3
• Continue monthly dosing even if breakthrough RSV infection occurs, as multiple RSV strains may co-circulate 1

Alternative Prevention: Maternal Vaccination

Pregnant individuals should receive RSVpreF vaccine (Abrysvo) as a one-time dose at 32-36 weeks' gestation to prevent RSV-associated lower respiratory tract disease in infants <6 months of age 2

• Either maternal vaccination OR infant nirsevimab is recommended, but both are not needed for most infants 2

Adult Vaccination

All adults ≥60 years should receive RSV vaccination regardless of previous infection history 4

• Adults aged 50-59 years with chronic respiratory disease, chronic heart disease, chronic kidney disease, diabetes, immunocompromised status, obesity, neurological conditions, or nursing home residence should also be vaccinated 4
• Single intramuscular dose administered September-November before RSV season 4
• Available vaccines: RSVPreF3 (Arexvy) with 82.6% efficacy, and RSVpreF (Abrysvo) with 65.1% efficacy against lower respiratory tract disease 4

Non-Pharmacologic Prevention

Critical preventive measures for all infants:

• Strict hand hygiene in all settings, especially during respiratory virus season 1
• Limit exposure to contagious settings (child care centers) when feasible 1
• Encourage breastfeeding 1
• Eliminate tobacco smoke exposure (first-hand, second-hand, and third-hand) 1
• Restrict visitors to neonatal ICUs during RSV season 1

Treatment of Established RSV Infection

RSV treatment is entirely supportive; no pharmacologic interventions improve mortality, morbidity, or quality of life outcomes. 5

Supportive Care Measures

• Maintain adequate hydration and assess fluid intake 5
• Provide supplemental oxygen if oxygen saturation falls persistently below 90% 5
• Use analgesics (acetaminophen or ibuprofen) for fever or pain management 5
• Implement strict hand hygiene protocols 5

Interventions to AVOID

Do NOT use corticosteroids routinely in RSV bronchiolitis management, as no prospective randomized trial has demonstrated decreased mortality or improved long-term outcomes 5

Do NOT prescribe antibiotics unless specific indications of bacterial co-infection exist 5

Do NOT use ribavirin routinely, except for severely immunocompromised patients, hematopoietic stem cell transplant recipients, or mechanically ventilated infants with documented severe RSV infection 5

Palivizumab is NOT indicated for treatment of established RSV disease; it is for prevention only 3, 1

Important Clinical Considerations

Cost-Effectiveness Concerns

The American Academy of Pediatrics acknowledges that palivizumab cannot be considered high-value health care due to minimal clinical benefit relative to high cost 1

• Most RSV hospitalizations last only 2-3 days 1
• No measurable effect on mortality has been demonstrated 1, 2
• No significant decrease in recurrent wheezing after RSV infection 1, 2

Timing and Seasonality

RSV season duration varies by region (13-23 weeks median), with peak activity mid-December to early February in most areas 1

• Five monthly doses provide >6 months of protective serum concentrations; more than 5 doses are not recommended 1
• Infants born during RSV season require fewer than 5 doses to achieve season-end protection 1

Age-Related Risk

75% of pediatric RSV hospitalizations occur in infants <12 months of age, with the majority in the first 90 days after birth 1, 5

• Chronologic age is the single most important risk factor for RSV hospitalization 1
• Less than 20% of hospitalizations occur during the second year of life 5