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

RSV Treatment

Primary Treatment Approach

Treatment of RSV infection is primarily supportive care, as there is no specific antiviral therapy recommended for routine use in otherwise healthy children and adults. 1, 2 The mainstay of management focuses on maintaining adequate oxygenation, hydration, and monitoring for respiratory deterioration.

Supportive Care Measures

Oxygen and Respiratory Support

• Provide supplemental oxygen if oxygen saturation falls persistently below 90% in previously healthy infants, targeting SpO2 >92%. 1, 3
• Standard low-flow oxygen delivery systems are appropriate for most patients 3
• High-flow nasal cannula (HFNO) may be considered in selected patients with hypoxemic respiratory failure, but only in monitored settings with personnel experienced in intubation 1, 3
• Non-invasive ventilation (NIV) is generally NOT recommended due to high failure rates and risk of aerosol generation 1
• Consider early intubation and invasive mechanical ventilation if respiratory distress worsens or oxygen requirements cannot be met with standard supplementation 1

Hydration and Nutrition

• Assess and maintain adequate hydration and fluid intake for all patients 1
• Use nasogastric or intravenous routes for hydration and nutrition if oral intake is inadequate 2

Symptomatic Management

• Acetaminophen or ibuprofen can be used for pain or fever management 1
• Nasal saline irrigation may provide symptomatic relief in adults with upper respiratory symptoms 1

Therapies NOT Recommended for Routine Use

The following interventions should be avoided in routine RSV management as they provide no clinical benefit:

• Bronchodilators should not be used routinely 1
• Corticosteroids are not recommended 1
• Ribavirin should NOT be used routinely in children with bronchiolitis 1, 3
• Antibacterial medications should only be used when specific indications of bacterial co-infection exist 1
• Epinephrine, nebulized hypertonic saline, and chest physiotherapy are not recommended 2

Treatment for High-Risk and Immunocompromised Patients

Indications for Ribavirin Therapy

Ribavirin is reserved exclusively for severely immunocompromised patients, particularly hematopoietic stem cell transplant (HSCT) recipients with RSV lower respiratory tract disease. 4, 1, 3

Specific high-risk populations who may benefit from ribavirin include:

• Allogeneic HSCT recipients with RSV lower respiratory tract infectious disease (LRTID) or at high risk for progression 4, 1
• Solid organ transplant recipients with severe RSV infection 1
• Patients with active chemotherapy for malignancy 1
• Mechanically ventilated infants with documented severe RSV infection 1

Ribavirin Administration Options

Aerosolized ribavirin:

• Administer 2 g for 2 hours every 8 hours, or 6 g over 18 hours daily for 7-10 days 4
• Monitor for adverse events including claustrophobia, bronchospasm, nausea, conjunctivitis, and declining pulmonary function 4, 1
• Apply appropriate precautions to avoid environmental exposure in pregnant healthcare workers due to teratogenic effects 4, 1

Systemic ribavirin (oral or intravenous):

• Dosing: 10-30 mg/kg body weight in 3 divided doses 4, 1
• Day 1: 600 mg loading dose, then 200 mg every 8 hours 1
• Day 2: 400 mg every 8 hours 1
• Day 3 onward: Increase to maximum of 10 mg/kg body weight every 8 hours 1
• Adjust for renal impairment: For creatinine clearance 30-50 mL/min, maximum 200 mg every 8 hours 1
• Monitor for hemolysis, abnormal liver function tests, and declining renal function 4, 1

Combination Therapy for HSCT Patients

For allogeneic HSCT patients with RSV LRTID or at high risk for progression, consider combining ribavirin with intravenous immunoglobulin (IVIG) or anti-RSV-enriched antibody preparations. 4, 1

Timing Considerations

• Defer conditioning therapy for patients with RSV infection planned for allogeneic HSCT 4, 1
• Consider deferring chemotherapy for patients scheduled for hemato-oncological treatment 1
• Children undergoing cardiopulmonary bypass should receive an additional dose of palivizumab (if on prophylaxis) as soon as possible after the procedure 5

Prevention vs. Treatment: Critical Distinction

Palivizumab (Synagis) has NO therapeutic benefit for treating established RSV infection—it is ONLY approved for prevention in high-risk infants and should NEVER be used as treatment. 1, 5

Palivizumab Prophylaxis Indications (Prevention Only)

Palivizumab is indicated for prevention in:

• Infants with history of premature birth (≤35 weeks gestational age) who are ≤6 months of age at beginning of RSV season 5
• Infants with bronchopulmonary dysplasia (BPD) requiring medical treatment within previous 6 months, who are ≤24 months of age 5
• Infants with hemodynamically significant congenital heart disease who are ≤24 months of age 5
• Patients with Severe Combined Immunodeficiency (SCID) or suspected SCID during RSV season 1

Dosing: 15 mg/kg intramuscularly monthly throughout RSV season (typically November through April) 5

Infection Control Measures

Hand hygiene is the single most important measure to prevent RSV transmission and nosocomial spread. 1, 3

• Perform hand decontamination before and after direct patient contact, after contact with objects near the patient, and after removing gloves 1
• Use alcohol-based rubs if hands are not visibly soiled 1
• Implement droplet precautions: wear gowns for direct contact with patients and change gloves frequently 1, 3
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 1
• Educate personnel and family members about hand sanitation 1
• Infants should not be exposed to passive smoking 1
• Encourage breastfeeding to decrease risk of lower respiratory tract disease 1

Hospitalization Criteria

Consider hospitalization for patients with:

• Hypoxemia (SpO2 persistently <90%) 1, 3
• Signs of severe respiratory distress 3
• Inability to maintain adequate oral intake 3
• Underlying high-risk conditions (age <3 months, prematurity, cardiopulmonary disease, immunodeficiency) 3

Escalate to intensive care if:

• Patient fails to maintain SaO2 >92% in FiO2 >60% 1
• Patient is in shock 1
• Severe respiratory distress with rising PaCO2 (>6.5 kPa) 1
• Development of apnea or persistent grunting 1

Common Pitfalls to Avoid

• Do not use antibiotics without evidence of bacterial co-infection 1
• Do not continue bronchodilator therapy without documented clinical improvement 1
• Do not use palivizumab to treat active RSV infection 1, 5
• Do not use ribavirin routinely in otherwise healthy children—reserve for severely immunocompromised patients only 1, 3
• Ensure adequate infection control measures to prevent nosocomial transmission 1