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

Treatment of Respiratory Syncytial Virus (RSV) Infection

Primary Treatment: Supportive Care Only

RSV treatment is entirely supportive—there is no antiviral therapy for routine use, and most interventions commonly attempted (bronchodilators, corticosteroids, antibiotics) provide no benefit and should be avoided. 1, 2, 3

Core Supportive Measures

• Hydration assessment and maintenance is essential for all RSV patients, with nasogastric or intravenous routes used if oral intake is inadequate 1, 2, 3
• Supplemental oxygen should be provided only if oxygen saturation falls persistently below 90% in previously healthy infants 1, 2
• Acetaminophen or ibuprofen can be used for fever or pain management 1, 2
• Nasal saline irrigation may provide symptomatic relief in adults with upper respiratory symptoms 1

What NOT to Use: Critical to Avoid Ineffective Therapies

The evidence strongly recommends against multiple therapies that are commonly misused:

• Do NOT use bronchodilators routinely—they should only be continued if there is documented clinical improvement after a trial dose 1, 2
• Do NOT use corticosteroids—they provide no benefit in RSV bronchiolitis 1, 2, 3
• Do NOT use antibiotics unless there are specific indications of bacterial co-infection (not just fever or elevated white count) 1, 2, 3
• Do NOT use ribavirin routinely—it is restricted to severely immunocompromised patients, hematopoietic stem cell transplant recipients, or mechanically ventilated infants with documented severe RSV infection 1, 2
• Do NOT use palivizumab for treatment—it has zero therapeutic benefit for established RSV infection and is only approved for prevention in high-risk infants 1, 2, 4

High-Risk and Immunocompromised Patients: When Antiviral Therapy May Be Considered

Indications for Ribavirin

Ribavirin is the only antiviral option, but its use is highly restricted 1:

• Hematopoietic stem cell transplant (HSCT) recipients with RSV lower respiratory tract infection 1
• Severely immunocompromised patients (profound lymphopenia <100 cells/mm³) with RSV lower respiratory tract disease 1
• Mechanically ventilated infants with documented severe RSV infection 1, 2
• Solid organ transplant recipients with severe RSV infection may benefit 1

Ribavirin Administration Options

• Aerosolized ribavirin is FDA-approved and the primary option for hospitalized patients with severe lower respiratory tract RSV infection 1
• Systemic ribavirin (oral or intravenous, 10-30 mg/kg/day in 3 divided doses) can be used for patients unable to take oral medication 1
• Dosing schedule for systemic ribavirin: 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 1
• Renal adjustment: For creatinine clearance 30-50 mL/min, maximum 200 mg every 8 hours 1

Combination Therapy for HSCT Patients

• Consider combining ribavirin with intravenous immunoglobulin (IVIG) or anti-RSV-enriched antibody preparations for allogeneic HSCT patients with RSV lower respiratory tract disease or at high risk for progression 1

Monitoring for Ribavirin Adverse Effects

• Aerosolized form: Monitor for claustrophobia, bronchospasm, nausea, conjunctivitis, and declining pulmonary function 1
• Systemic form: Monitor for hemolysis, abnormal liver function tests, and declining renal function 1
• Avoid environmental exposure in pregnant healthcare workers due to teratogenic effects 1

Respiratory Support Escalation

When to Escalate Care

• High-flow nasal oxygen (HFNO) may be considered in selected patients with hypoxemic respiratory failure, but only in a monitored setting with personnel capable of intubation 1, 5
• Non-invasive ventilation (NIV) is NOT recommended for RSV infection 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

ICU Transfer Criteria

Transfer to intensive care if 1, 2:

• Failure to maintain SaO2 >92% in FiO2 >60%
• Shock
• Severe respiratory distress with rising PaCO2 (>6.5 kPa)

Infection Control: Critical to Prevent Transmission

Hand hygiene is the single most important measure to prevent RSV transmission 1, 2:

• Hand decontamination before and after direct patient contact is mandatory 1, 2
• Alcohol-based rubs are preferred if hands are not visibly soiled 1, 2
• Wear gloves and gowns for direct contact with RSV patients 1
• Education of personnel and family members about hand sanitation is essential 1
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 1

Special Considerations for Timing of Treatment

• Defer conditioning therapy for patients with RSV respiratory tract infection planned for allogeneic HSCT 1
• Consider deferring chemotherapy for patients with RSV infection 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, as serum levels are decreased 4

Common Pitfalls to Avoid

• Overuse of antibiotics without evidence of bacterial co-infection contributes to antimicrobial resistance 1, 2
• Continuing bronchodilator therapy without documented clinical improvement wastes resources and may cause adverse effects 1, 2
• Inadequate infection control measures leading to nosocomial transmission—restrict healthcare workers with active upper respiratory symptoms from caring for high-risk infants 1, 2
• Using palivizumab as treatment—this is a prevention-only medication with no therapeutic benefit once infection is established 1, 2, 4