RSV Treatment: Evidence-Based Management
Primary Treatment Approach
RSV treatment is primarily supportive care—there is no routine antiviral therapy for most patients, and management focuses on maintaining oxygenation, hydration, and monitoring for respiratory deterioration. 1, 2
Supportive Care Measures
Oxygen Therapy
- Provide supplemental oxygen if SpO2 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 due to potential for rapid deterioration. 1, 3
- 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
Hydration and Nutrition
- Assess and maintain adequate fluid intake in all patients with RSV infection. 1
- Use nasogastric or intravenous routes for hydration and nutrition if the patient cannot maintain adequate oral intake. 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
Ineffective Interventions to Avoid
- Bronchodilators should NOT be used routinely—continue only if documented clinical improvement occurs. 1, 2
- Corticosteroids should NOT be used routinely in the management of bronchiolitis. 1, 2
- Antibacterial medications should only be used when specific indications of bacterial co-infection exist, not routinely. 1, 2
- Chest physiotherapy is not recommended. 2
- Nebulized hypertonic saline is not recommended. 2
- Epinephrine is not recommended for routine use. 2
Critical Distinction: Palivizumab is NOT Treatment
- Palivizumab 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, 4
Antiviral Therapy: Ribavirin (Highly Restricted Use)
When to Consider Ribavirin
Ribavirin should NOT be used routinely in children with RSV bronchiolitis. 1, 3 Its use is restricted to:
- Hematopoietic stem cell transplant (HSCT) recipients with RSV lower respiratory tract infection or those at high risk for progression. 1, 3
- Severely immunocompromised patients (e.g., profound lymphopenia <100 cells/mm³). 1
- Solid organ transplant recipients with severe RSV infection. 1
- Mechanically ventilated infants with documented severe RSV infection. 1
Ribavirin Administration Options
- Aerosolized ribavirin is FDA-approved for hospitalized infants and young children with severe lower respiratory tract RSV infection, though use should be limited to truly severe cases. 1
- Oral or intravenous ribavirin (10-30 mg/kg/day in 3 divided doses) can be administered for patients unable to take oral medication. 1
Ribavirin Dosing Schedule (Systemic)
- 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
- Renal adjustment: For creatinine clearance 30-50 mL/min, maximum 200 mg every 8 hours 1
Monitoring for Ribavirin Adverse Events
- 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
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
Infection Control: Critical for Preventing Transmission
Hand Hygiene (Most Important Measure)
- Hand decontamination before and after direct patient contact, after contact with objects near the patient, and after removing gloves is the single most important measure to prevent transmission. 5, 1, 3
- Alcohol-based rubs are preferred for hand decontamination if hands are not visibly soiled. 5, 1, 3
- Alternative is hand-washing with antimicrobial soap. 5
Droplet and Contact Precautions
- Ensure patients do not touch other persons' hands or environmental surfaces with hands contaminated with respiratory secretions. 5
- Wear gowns for direct contact with the patient. 5, 1
- Use gloves with frequent changes to avoid spreading organisms on gloves. 5, 1
- Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50%. 1, 3
Education
Special Population Considerations
High-Risk Patients Requiring Hospitalization
- Infants <3 months old 3
- Premature infants 3
- Those with cardiopulmonary disease 3
- Immunodeficiency 3
- Oxygen saturation persistently <90% 3
Immunocompromised Patients
- HSCT recipients with RSV infection require more aggressive management, including consideration of ribavirin therapy. 1
- Solid organ transplant recipients with RSV infection may require more intensive care, including supplemental oxygen and close monitoring of respiratory status. 1
- Patients with active chemotherapy for malignancy and RSV infection should be closely monitored for respiratory complications and considered for ribavirin therapy. 1
- Defer conditioning therapy for patients with RSV infection planned for allogeneic HSCT. 1, 3
- Consider deferring chemotherapy for patients with RSV infection scheduled for hemato-oncological treatment. 1
Infants with Cardiac Disease
- Infants with hemodynamically significant heart disease require close monitoring as oxygen is being weaned. 1
- Children undergoing cardio-pulmonary bypass should receive an additional dose of palivizumab (if on prophylaxis) as soon as possible after the procedure, as serum levels are decreased after bypass. 4
Monitoring and Escalation of Care
Routine Monitoring
- Assess oxygen saturation, respiratory rate, work of breathing, hydration status, and ability to feed. 3
- Monitor mental status as part of vital signs. 1
- As the child's clinical course improves, continuous measurement of SpO2 is not routinely needed. 1
Criteria for ICU Transfer
- Consider transfer to high dependency or intensive care if patient:
Prevention Strategies (Not Treatment)
Palivizumab Prophylaxis (Prevention Only)
Palivizumab is indicated for PREVENTION, not treatment, in specific high-risk pediatric populations: 1, 4
- Infants born ≤35 weeks gestational age who are ≤6 months at the beginning of RSV season 4
- Infants ≤24 months with bronchopulmonary dysplasia (BPD) requiring medical treatment within the previous 6 months 4
- Infants ≤24 months with hemodynamically significant congenital heart disease (CHD) 4
- Palivizumab reduces RSV hospitalization by 45-55% in high-risk populations. 1
Universal Prevention Measures
- Avoid tobacco smoke exposure completely. 1
- Limit exposure to crowds and group childcare during RSV season (November through March in most regions). 1
- Keep infants away from sick contacts. 1
- Encourage breastfeeding to potentially decrease the risk of lower respiratory tract disease. 5, 1
- Ensure influenza vaccination for the infant (starting at 6 months) and all household contacts. 1
Common Pitfalls to Avoid
- Overuse of antibiotics when there is no evidence of bacterial co-infection 1
- Continuing bronchodilator therapy without documented clinical improvement 1
- Inadequate infection control measures leading to nosocomial transmission 1
- Using palivizumab to treat active RSV infection (it has no therapeutic benefit) 1, 4
- Routine viral testing in outpatient bronchiolitis cases where management will be supportive regardless 1