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

Treatment of Respiratory Syncytial Virus (RSV) Infection

RSV infection is treated with supportive care only—there is no antiviral therapy for otherwise healthy children, and palivizumab has absolutely no role in treating established RSV infection. 1, 2

Primary Treatment Approach: Supportive Care

For the vast majority of RSV cases, management focuses entirely on supportive measures:

• Maintain adequate hydration through oral intake when possible, or nasogastric/intravenous routes if the child cannot maintain oral intake 1, 3
• Provide supplemental oxygen only if oxygen saturation falls persistently below 90% in previously healthy infants 1, 3
• Use antipyretics (acetaminophen or ibuprofen) for fever control and pain management 1
• Consider nasal saline irrigation for symptomatic relief of upper respiratory symptoms 1

The American Academy of Pediatrics emphasizes that most RSV infections are self-limited and resolve with supportive care alone 4, 1.

What NOT to Do: Critical Pitfalls to Avoid

Do not use palivizumab to treat RSV infection—the FDA label explicitly states it has not been established as safe or effective for treatment of RSV disease and is only indicated for prevention 2. This is a common misconception that must be avoided 4, 1.

Do not routinely prescribe:

• Corticosteroids: No evidence of benefit for mortality, morbidity, or quality of life outcomes 1, 5
• Bronchodilators: Should not be continued without documented clinical improvement 1
• Antibiotics: Only use when specific bacterial co-infection is documented 1, 5
• Ribavirin: Not for routine use in otherwise healthy children with bronchiolitis 4, 1

High-Risk and Immunocompromised Patients: When to Consider Antiviral Therapy

For severely immunocompromised patients, treatment differs substantially:

Ribavirin is the only antiviral option and should be considered for 1:

• Hematopoietic stem cell transplant (HSCT) recipients with RSV lower respiratory tract infection
• Severely immunocompromised patients at high risk for progression
• Mechanically ventilated infants with documented severe RSV infection

Ribavirin administration options 1:

• Aerosolized form: Primary option for HSCT patients and mechanically ventilated patients
• Systemic (oral/IV): 10-30 mg/kg/day in 3 divided doses for those unable to take oral medication

Combination therapy may be considered for allogeneic HSCT patients: ribavirin plus intravenous immunoglobulin (IVIG) or anti-RSV-enriched antibody preparations 1.

Monitor for ribavirin adverse effects 1:

• Aerosolized: bronchospasm, nausea, conjunctivitis, declining pulmonary function
• Systemic: hemolysis, abnormal liver function, declining renal function
• Environmental: teratogenic—avoid exposure in pregnant healthcare workers

Hospitalization Criteria

Admit to hospital if 1, 6:

• Oxygen saturation persistently <90% despite supplemental oxygen
• Severe respiratory distress (tachypnea, retractions, accessory muscle use)
• Inability to maintain adequate oral hydration
• Underlying high-risk conditions (prematurity, chronic lung disease, congenital heart disease, immunocompromised status)
• Age <3 months with any lower respiratory tract involvement

Escalate to ICU if 1:

• Oxygen requirement FiO2 ≥0.50-0.60 with inability to maintain SpO2 >92%
• Development of shock
• Severe respiratory distress with rising PaCO2 (>6.5 kPa or ~49 mmHg)
• Apnea or persistent grunting

Respiratory Support Considerations

High-flow nasal oxygen (HFNO) may be considered in selected patients with hypoxemic respiratory failure, but only in monitored settings with personnel capable of intubation 1.

Non-invasive ventilation (NIV) is generally NOT recommended due to high failure rates and risk of aerosol generation 1.

Early intubation and invasive mechanical ventilation should be considered if respiratory distress worsens or oxygen requirements cannot be met with standard supplementation 1.

Infection Control: Essential for All Settings

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

• Decontaminate hands before and after direct patient contact
• Decontaminate after contact with objects near the patient
• Decontaminate after removing gloves
• Alcohol-based rubs are preferred unless hands are visibly soiled 4, 1

Additional infection control measures 1:

• Wear gowns for direct patient contact
• Implement droplet precautions
• Educate family members and personnel on hand sanitation
• Programs implementing strict protocols have decreased nosocomial RSV transmission by 39-50% 1

Prevention: Palivizumab Prophylaxis (NOT Treatment)

Palivizumab is only for prevention, not treatment, in specific high-risk groups 4, 2:

Indications for prophylaxis:

• Infants born <29 weeks gestation who are ≤12 months at RSV season start 4
• Infants with bronchopulmonary dysplasia requiring medical treatment within previous 6 months, ≤24 months at RSV season start 2
• Infants with hemodynamically significant congenital heart disease, ≤24 months at RSV season start 2

Dosing: 15 mg/kg intramuscularly monthly for 5 doses during RSV season (typically November through April) 4, 2

Discontinue palivizumab if the infant experiences breakthrough RSV hospitalization—the likelihood of a second RSV hospitalization in the same season is extremely low (<0.5%) 4.

Special Population Considerations

Do NOT routinely use palivizumab prophylaxis for 4:

• Children with cystic fibrosis (unless other qualifying indications present)
• Children with Down syndrome (unless qualifying heart disease, chronic lung disease, or prematurity <29 weeks present)
• Primary asthma prevention or to reduce subsequent wheezing episodes

Defer treatment timing for immunocompromised patients 1:

• Postpone conditioning therapy for allogeneic HSCT if RSV infection present
• Consider deferring chemotherapy for hemato-oncological patients with RSV infection