What is the treatment approach for viral infections?

Treatment Approach for Viral Infections

The treatment of viral infections is primarily supportive care with symptom management, as most viral infections are self-limited, while specific antiviral therapy should be reserved for select pathogens (influenza, herpes viruses, hepatitis B, HIV) where FDA-approved medications exist. 1, 2

General Supportive Care Measures

All patients with viral infections require supportive management as the foundation of treatment:

• Bed rest during the acute phase is essential for recovery 1
• Paracetamol (acetaminophen) is preferred over NSAIDs for fever and symptom relief, taken only while symptoms are present rather than routinely for temperature reduction 1
• Adequate hydration with regular fluid intake (limited to no more than 2 liters per day) is crucial 1
• Monitor vital signs including heart rate, pulse oximetry, respiratory rate, and blood pressure, particularly in severe cases 1
• Nutritional support with protein-rich foods (ideal energy intake of 25-30 kcal/kg/day and protein intake of 1.5 g/kg/day) supports immune function 1

Respiratory Symptom Management

For cough:

• Honey is first-line treatment for cough in adults 1
• Avoid lying flat on the back as this makes coughing ineffective 1
• Short-term codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution can be considered if cough becomes distressing despite simple measures 1

For breathlessness:

• Teach controlled breathing techniques including pursed-lip breathing 1
• Position sitting upright to increase peak ventilation 1
• Lean forward with arms bracing to improve ventilatory capacity 1
• Relax and drop shoulders to reduce anxiety-related hunched posture 1

Specific Antiviral Therapy

Influenza

Oseltamivir (Tamiflu) 75 mg orally twice daily should be initiated within 48 hours of symptom onset for treatment of influenza in appropriate patients 3. For prophylaxis post-exposure, oseltamivir 75 mg once daily for 7 days is indicated 3.

Herpes Simplex Virus (HSV) and Varicella Zoster Virus (VZV)

Acyclovir or valacyclovir prophylaxis is recommended for all patients with hematological malignancies or those receiving immunosuppressive therapy 4. For active VZV reactivation, valacyclovir or IV acyclovir should be used 4.

Cytomegalovirus (CMV)

Oral valganciclovir is the treatment of choice for CMV reactivation, with IV ganciclovir or foscarnet as alternatives 4. Valganciclovir may be used in patients with preserved bone marrow function 4.

Hepatitis B Virus (HBV)

Lamivudine prophylaxis should be initiated prior to chemotherapy in HBsAg-positive patients and continued for up to 8 weeks after completion to prevent reactivation 4.

COVID-19

Lopinavir/ritonavir (2 capsules orally twice daily) can be considered as antiviral therapy, though evidence is limited 4. Alpha-interferon atomization inhalation (5 million U twice daily) is another option 4.

Prevention Strategies

Nonpharmacological interventions are strongly recommended for preventing viral transmission:

• Mask use and hand hygiene are strong recommendations for prevention of viral respiratory transmission 4
• Gloves, gowns, and eye protection are recommended in healthcare settings 4
• Social distancing is recommended though aggregate evidence level varies 4
• Saline nasal washing and gargling are options in selected populations 4

Critical Pitfalls to Avoid

Avoid blind or inappropriate antibiotic use unless there is clear evidence of secondary bacterial infection 4, 1. Antibiotics do not treat viral infections and contribute to antimicrobial resistance 4.

Do not delay antiviral therapy when indicated - for influenza, treatment must begin within 48 hours of symptom onset for maximum benefit 3. Similarly, early application of antivirals like lopinavir/ritonavir may be more effective than late application 4.

Establish a treatment escalation plan immediately as viral infections can deteriorate rapidly, particularly respiratory viruses 1. Patients should seek immediate medical attention if they develop worsening breathlessness, persistent chest pain, confusion, inability to stay awake, or oxygen saturation <94% on room air 1.

Monitoring Requirements

Regular monitoring should include:

• Blood routine, CRP, PCT, and organ function tests (liver enzymes, bilirubin, myocardial enzymes, creatinine, urea nitrogen) 4
• Coagulation function and arterial blood gas analysis in severe cases 4
• Chest imaging as clinically indicated 4
• Viral load monitoring (CMV DNA copies, EBV DNA copies) in immunocompromised patients when reactivation is suspected 4

Advanced Respiratory Support

For severe respiratory viral infections with hypoxemia:

• High flow nasal oxygen therapy (HFNO) or non-invasive ventilation (NIV) should be considered before invasive mechanical ventilation 4
• Extracorporeal Membrane Oxygenation (ECMO) should be considered for refractory hypoxemia difficult to correct with protective lung ventilation 4

Corticosteroid Use

Systemic glucocorticoids need to be used cautiously in viral infections 4. For severe ARDS with rapid disease progression, methylprednisolone 40-80 mg per day can be considered, with total daily dose not exceeding 2 mg/kg 4.