What is the treatment approach for a patient with Respiratory Syncytial Virus (RSV) infection, particularly in high-risk infants such as those born prematurely or with underlying health conditions?

RSV Treatment

Primary Treatment Approach

Treatment of RSV infection is primarily supportive care, as there is no effective antiviral therapy for routine use in most patients. 1, 2, 3, 4

Core Supportive Measures

• Ensure adequate hydration by assessing fluid intake regularly; provide nasogastric or intravenous fluids if the patient cannot maintain oral intake 1, 4
• Administer supplemental oxygen if oxygen saturation falls persistently below 90% in previously healthy infants 1, 4
• Use acetaminophen or ibuprofen for fever or pain management as needed 1
• Maintain hand hygiene before and after all patient contact to prevent nosocomial transmission—this is the single most important infection control measure 1, 5

What NOT to Use in Routine Cases

• Do NOT use bronchodilators routinely—they have not shown consistent benefit 4
• Do NOT use corticosteroids—they are not recommended for bronchiolitis management 1, 4
• Do NOT use antibiotics unless there is specific evidence of bacterial co-infection 1, 4
• Do NOT use ribavirin routinely in otherwise healthy children with bronchiolitis 1, 4
• Do NOT use palivizumab for treatment—it has no therapeutic benefit for established RSV infection and is only approved for prevention 1, 6

---

High-Risk Infants: Identification and Management

Who Are High-Risk Infants?

High-risk infants requiring closer monitoring and potentially more aggressive management include: 1, 2, 7

• Premature infants born at ≤35 weeks gestation, especially ≤28 weeks
• Infants with chronic lung disease/bronchopulmonary dysplasia (BPD) requiring medical treatment within the previous 6 months
• Children with hemodynamically significant congenital heart disease
• Immunocompromised patients, particularly those with profound lymphopenia (<100 cells/mm³), hematopoietic stem cell transplant (HSCT) recipients, or solid organ transplant recipients
• Children with neuromuscular disorders that impair secretion clearance

Enhanced Monitoring for High-Risk Patients

• Monitor oxygen saturation closely and provide supplemental oxygen to maintain SpO2 >90% 1
• Assess respiratory status frequently for signs of worsening distress (increased work of breathing, rising respiratory rate, accessory muscle use) 1
• Ensure adequate hydration with close monitoring of fluid balance 1
• Consider hospitalization if the infant has hypoxemia (SpO2 persistently <90%), severe respiratory distress, inability to maintain oral intake, or underlying high-risk conditions 1

---

Antiviral Therapy: Ribavirin for Severely Immunocompromised Patients Only

When to Consider Ribavirin

Ribavirin should be reserved exclusively for severely immunocompromised patients, particularly HSCT recipients with RSV lower respiratory tract infection. 1, 2, 3

Specific Indications for Ribavirin:

• HSCT patients with RSV lower respiratory tract infectious disease (LRTID) or at high risk for progression 1
• Mechanically ventilated infants with documented severe RSV infection 1
• Patients with profound lymphopenia (<100 cells/mm³) at high risk for progression to lower respiratory tract disease 1

Ribavirin Administration Options

Aerosolized Ribavirin:

• Primary option for HSCT patients and mechanically ventilated patients with severe RSV 1
• FDA-approved for hospitalized infants and young children with severe lower respiratory tract RSV infection 1

Systemic Ribavirin (Oral or IV):

• Dosing schedule: 1
  • 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 of 10 mg/kg body weight every 8 hours
  • Renal adjustment: For creatinine clearance 30-50 mL/min, maximum 200 mg every 8 hours

Combination Therapy for HSCT Patients:

• Consider combining ribavirin with intravenous immunoglobulin (IVIG) or anti-RSV-enriched antibody preparations for allogeneic HSCT patients with RSV LRTID 1

Monitoring for Ribavirin Adverse Effects

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

Timing Considerations for Immunocompromised Patients

• 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

---

Prevention: Palivizumab Prophylaxis (NOT Treatment)

Critical Distinction: Prevention vs. Treatment

Palivizumab is ONLY for prevention of RSV infection in high-risk infants—it has no therapeutic benefit for treating established RSV infection. 1, 6

Who Should Receive Palivizumab Prophylaxis?

Primary Indications: 8, 6

• Infants born before 29 weeks gestation who are younger than 12 months at the start of RSV season
• Infants and children <12 months old with chronic lung disease/BPD requiring medical treatment within the previous 6 months
• Children ≤12 months old with hemodynamically significant congenital heart disease

May Be Considered In: 8

• Profoundly immunocompromised children <24 months during RSV season
• Children <2 years undergoing cardiac transplantation during RSV season
• Infants with cystic fibrosis with clinical evidence of chronic lung disease AND/OR nutritional compromise in the first year of life

Palivizumab Dosing and Administration

• Dose: 15 mg/kg intramuscularly monthly throughout RSV season 8, 6
• Maximum doses: 5 monthly doses for most infants in the continental United States 8
• Timing: Initiate in November and continue through March (adjust based on local RSV season) 8
• First dose: Should be administered BEFORE RSV season starts; if season has already started, give as soon as possible 6

Special Circumstances for Palivizumab

• Children undergoing cardiopulmonary bypass: Administer an additional dose as soon as possible after the procedure (even if sooner than a month from the previous dose), then resume monthly dosing 6
• Children who develop RSV infection: Continue scheduled monthly palivizumab injections to help prevent severe disease from new RSV infections 6

What NOT to Do with Palivizumab

• Do NOT use palivizumab to treat established RSV infection 1, 8, 6
• Do NOT continue prophylaxis in the second year of life unless the child has chronic lung disease requiring ongoing medical support 8
• Do NOT use palivizumab to prevent recurrent wheezing—there is no evidence supporting cost-effectiveness for this indication 8
• Do NOT use palivizumab for nosocomial RSV prevention in NICU or hospital settings 8

---

Infection Control: Critical for Preventing Nosocomial Spread

Hand Hygiene: The Most Important Measure

• Perform hand decontamination before and after all direct patient contact, after contact with objects near the patient, and after removing gloves 1, 5
• Use alcohol-based hand rubs if hands are not visibly soiled; otherwise, wash with antimicrobial soap 1, 5
• Educate all personnel and family members about proper hand hygiene techniques 1, 5

Contact and Droplet Precautions

• Wear gloves when handling patients with respiratory symptoms or touching potentially contaminated surfaces; change gloves between patients 5
• Wear gowns if clothing could be soiled by respiratory secretions, particularly when handling infants or young children; change gowns after contact and before caring for another patient 5
• Cohort patients with confirmed RSV infection when possible during outbreaks 5
• Admit young children with viral respiratory symptoms to single rooms when possible 5

Visitor and Staff Restrictions

• Do NOT allow persons with respiratory infection symptoms to visit pediatric, immunosuppressed, or cardiac patients 5
• Restrict healthcare personnel with acute upper respiratory infections from caring for high-risk patients (infants, immunocompromised individuals, children with severe cardiopulmonary conditions, premature infants, those receiving chemotherapy) 5

---

Respiratory Support and Escalation of Care

Oxygen Therapy

• Provide supplemental oxygen if SpO2 falls persistently below 90% 1, 4
• Wean oxygen as clinical course improves; continuous SpO2 monitoring is not routinely needed once the child is improving 1
• Monitor closely in infants with hemodynamically significant heart or lung disease and premature infants as oxygen is being weaned 1

Advanced Respiratory Support

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

Criteria for ICU Transfer

Consider transfer to high dependency or intensive care if: 1

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

---

Common Pitfalls to Avoid

• Overusing antibiotics when there is no evidence of bacterial co-infection 1, 4
• Continuing bronchodilator therapy without documented clinical improvement 1
• Using palivizumab to treat established RSV infection rather than for prevention only 1, 8, 6
• Inadequate infection control measures leading to nosocomial transmission 1, 5
• Routine use of chest radiography or viral testing when diagnosis is clinical and management will not change 4
• Using ribavirin in otherwise healthy children—reserve for severely immunocompromised patients only 1, 4