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

RSV Treatment

For most children and adults with RSV infection, treatment is supportive care only—no antiviral therapy is indicated. 1, 2

General Management for All Patients

Supportive care is the mainstay of RSV treatment across all age groups. 1, 3, 2

• Hydration: Ensure adequate fluid intake; use nasogastric or intravenous routes if oral intake is insufficient 1, 2
• Oxygen therapy: Provide supplemental oxygen if SpO2 falls persistently below 90%, targeting SpO2 >92% 1, 4
• Fever/pain management: Acetaminophen or ibuprofen can be used as needed 1
• Nasal saline irrigation: May provide symptomatic relief in adults with upper respiratory symptoms 1

What NOT to Use (Critical)

• Bronchodilators: Not recommended routinely 1, 2
• Corticosteroids: Not recommended for bronchiolitis 1, 2
• Antibiotics: Only use when specific bacterial co-infection is documented 1, 2
• Chest physiotherapy: Not recommended 2
• Palivizumab: Has NO therapeutic benefit for treating established RSV infection—it is ONLY for prevention in high-risk infants 1, 4

High-Risk and Immunocompromised Patients

Ribavirin is the only antiviral option and should be reserved exclusively for severely immunocompromised patients, particularly hematopoietic stem cell transplant (HSCT) recipients with lower respiratory tract disease. 5, 1, 4, 6

Indications for Ribavirin

Ribavirin should be considered ONLY in:

• HSCT patients with RSV lower respiratory tract infectious disease (LRTID) 5, 1, 6
• Severely immunocompromised patients (solid organ transplant, active chemotherapy) with RSV LRTID 1, 4
• Mechanically ventilated infants with documented severe RSV infection 1, 6

Ribavirin Administration Options

Aerosolized ribavirin:

• Dose: 2 g over 2 hours every 8 hours OR 6 g over 18 hours daily for 7-10 days 5
• FDA-approved for hospitalized infants and young children with severe lower respiratory tract RSV infection 4, 6
• Requires appropriate precautions to avoid environmental exposure (teratogenic risk to pregnant healthcare workers) 5, 1
• Monitor for claustrophobia, bronchospasm, nausea, conjunctivitis, and declining pulmonary function 5, 1

Systemic ribavirin (oral or IV):

• Dosing schedule: 1
  • 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 10 mg/kg every 8 hours (or 10-30 mg/kg/day in 3 divided doses) 5, 1
• Renal adjustment: For CrCl 30-50 mL/min, maximum 200 mg every 8 hours 1
• Monitor for hemolysis, abnormal liver function tests, and declining renal function 5, 1

Combination Therapy for HSCT Patients

• For allogeneic HSCT patients with RSV LRTID or at high risk for progression, consider combining ribavirin (aerosolized or systemic) with IVIG or anti-RSV-enriched antibody preparations 5, 1

Timing Considerations

• Defer conditioning therapy for patients with RSV infection planned for allogeneic HSCT 5, 1, 4
• Defer chemotherapy for patients with RSV infection scheduled for hemato-oncological treatment 1

Respiratory Support Escalation

High-flow nasal oxygen (HFNO):

• May be considered in selected patients with hypoxemic respiratory failure 1, 4
• Only use in monitored settings with personnel experienced in intubation 1, 4

Non-invasive ventilation (NIV):

• Generally NOT recommended due to high failure rates and risk of aerosol generation 1

Mechanical ventilation:

• Consider early intubation if respiratory distress worsens or oxygen requirements cannot be met with standard supplementation 1
• Transfer to ICU if patient fails to maintain SaO2 >92% in FiO2 >60%, is in shock, or has severe respiratory distress with rising PaCO2 (>6.5 kPa) 1

Infection Control (Essential to Prevent Transmission)

Hand hygiene is the single most important measure to prevent RSV transmission. 1, 4

• Use alcohol-based rubs before and after patient contact 1, 4
• Wear gowns for direct patient contact 1
• Change gloves frequently to avoid spreading organisms 1
• Implement droplet precautions 4
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 1, 4

Prevention Strategies

• Palivizumab: May be administered for prophylaxis in high-risk infants (prematurity, congenital heart disease, chronic lung disease) 5, 1
• Nirsevimab: Long-acting monoclonal antibody for all infants <8 months entering their first RSV season 1
• RSV vaccine: Indicated for people aged ≥50 years with risk factors and all persons aged ≥60 years 1
• Breastfeeding: Recommended to decrease risk of lower respiratory tract disease 1
• Avoid passive smoking exposure 1

Hospitalization Criteria

Consider hospitalization for:

• Hypoxemia (SpO2 persistently <90%) 1, 4
• Signs of severe respiratory distress 1, 4
• Inability to maintain adequate oral intake 1, 4
• Infants <3 months old 4
• Premature infants 4
• Underlying cardiopulmonary disease or immunodeficiency 1, 4

Common Pitfalls to Avoid

• Do not use antibiotics without documented bacterial co-infection 1
• Do not continue bronchodilator therapy without documented clinical improvement 1
• Do not use palivizumab to treat active RSV infection 1, 4
• Do not use ribavirin routinely in otherwise healthy children with bronchiolitis 1, 4, 6
• Ensure adequate infection control measures to prevent nosocomial transmission 1