What is the recommended treatment for an adult patient with Respiratory Syncytial Virus (RSV) infection?

Treatment of RSV Infection in Adults

For acute RSV infection in adults, treatment remains entirely supportive—there are no FDA-approved antivirals or specific therapies for immunocompetent adults, and management focuses on oxygen supplementation, hydration, and symptom control. 1, 2

Supportive Care (Standard of Care for All Adults)

The cornerstone of RSV treatment in adults consists of:

• Oxygen therapy should be provided to maintain adequate oxygen saturation in patients with respiratory compromise 1, 3
• Intravenous or oral fluids should be administered to maintain hydration 1
• Antipyretics (acetaminophen or NSAIDs) should be used for fever management 1
• Bronchodilators may provide symptomatic relief for wheezing, though evidence is limited 2

Hospitalization Considerations

Adults with RSV infection frequently require extended hospital stays:

• Median hospital length of stay is 6 days (range 3-9 days), with disease severity being the primary determinant of duration 4, 3
• 15% of hospitalized adults require ICU care and 9% require mechanical ventilation 4
• Mortality during hospitalization is approximately 6%, with ICU admission and mechanical ventilation being associated with increased mortality risk 4

Common Pitfalls in Clinical Practice

Antibiotics are frequently overused in RSV infection—despite being a viral illness, 51-61% of hospitalized adults receive antibiotics, likely due to difficulty distinguishing RSV from bacterial pneumonia and concern for co-infection 3. However, antibiotics should only be used when bacterial co-infection is documented or strongly suspected 3.

Anti-influenza therapy is often inappropriately prescribed—36% of RSV-infected adults receive anti-influenza medications, highlighting the diagnostic challenge and need for specific RSV testing 4.

Special Population: Immunocompromised Adults

For immunocompromised patients (transplant recipients, cancer patients, those on immunosuppressive therapy), treatment options are more aggressive but remain controversial:

• Aerosolized ribavirin is the most studied treatment option and should be considered the backbone of therapy in high-risk immunocompromised adults, particularly those with lower respiratory tract involvement 5
• Addition of immunomodulators (intravenous immunoglobulin or palivizumab) to ribavirin may provide survival benefit over ribavirin alone in hematopoietic stem cell transplant patients with lower respiratory tract RSV infection 5
• Early bronchoscopy is valuable for diagnosis in immunosuppressed patients, as nasal swab testing is often falsely negative due to low viral titers 2
• Early therapy initiation (before progression to pneumonia) is associated with improved survival in immunocompromised persons 2

Prevention Through Vaccination (The Most Important Intervention)

Since treatment options are limited, prevention through vaccination is the primary strategy to reduce RSV morbidity and mortality in adults:

• All adults ≥75 years should receive a single lifetime dose of RSV vaccine regardless of comorbidities 6, 7
• Adults aged 60-74 years with chronic conditions (COPD, asthma, heart failure, diabetes, chronic kidney disease, immunocompromise) should receive RSV vaccination 6, 7
• Adults aged 50-59 years with risk factors should receive RSVPreF3 (Arexvy), the only vaccine approved for this age group 6, 7
• Optimal timing is September-November before RSV season begins 6, 7
• Only one lifetime dose is currently recommended—no booster doses are indicated at this time 6, 8

Clinical Algorithm for RSV Management

For suspected RSV in adults:

1. Confirm diagnosis with RT-PCR testing of nasopharyngeal swab (culture and antigen tests are insensitive in adults) 2
2. Assess severity and need for hospitalization based on oxygen saturation, respiratory rate, and underlying comorbidities 4, 3
3. Initiate supportive care with oxygen, fluids, and antipyretics as needed 1
4. Avoid routine antibiotics unless bacterial co-infection is documented 3
5. For immunocompromised patients with lower respiratory tract involvement, consider early consultation with infectious disease specialists for potential ribavirin therapy 5
6. Plan for discharge with recognition that 10-16% may require skilled nursing care and approximately 25% may need social work assistance 3