What is the risk of severe Respiratory Syncytial Virus (RSV) infection for an individual with an underlying condition, such as autoimmune disease or Chronic Obstructive Pulmonary Disease (COPD), taking 15mg of prednisone, a corticosteroid?

RSV Risk in Patients Taking 15mg Prednisone

Patients taking 15mg of prednisone daily face significantly elevated risk for severe RSV infection, with immunosuppressed individuals showing hospitalization rates of 1,288-1,562 per 100,000 and 90-day mortality rates reaching 52.8% among those requiring ICU admission. 1

Understanding the Immunosuppressive Risk

Moderate immunosuppression from corticosteroids is explicitly recognized as a major risk factor for severe RSV disease. 1 The CDC's Advisory Committee on Immunization Practices specifically lists "moderate or severe immune compromise" as a high-risk category warranting RSV vaccination in adults aged 60-74 years. 1

Specific Evidence for Corticosteroid Users

• Patients on systemic corticosteroids represent the highest-risk group for RSV hospitalization compared to other underlying conditions. 2
• In a prospective ICU cohort study, 32.6% of severe RSV pneumonia patients were receiving immunosuppressants including corticosteroids, with immunocompromise significantly more common in the RSV group (57.6%) compared to influenza (34.4%). 1
• Glucocorticoids may delay viral clearance and increase the risk of secondary infection in respiratory viral infections including RSV. 2
• The American College of Rheumatology specifically notes that prednisone >10mg daily significantly increases hospitalization risk in patients with viral respiratory infections. 2

Clinical Outcomes and Mortality Risk

The mortality burden is substantial in immunocompromised patients with RSV:

• 90-day mortality among immunocompromised ICU patients with RSV reaches 52.8%. 1
• ICU admission rates are 36% among immunocompromised patients hospitalized with RSV. 1
• Hospitalization rates for immunosuppressed individuals range from 1,288 to 1,562 per 100,000. 1

In a recent study of patients with systemic autoimmune rheumatic diseases (many on corticosteroids), 51% required hospitalization for RSV, 56% of hospitalized patients required oxygen, and 12.5% of hospitalized patients died within 90 days. 3

Risk Stratification Algorithm

Your patient's risk level depends on several factors:

High-Risk Features (requiring immediate vaccination consideration):

• Age ≥60 years (especially ≥75 years) 1
• Underlying chronic lung disease (COPD, asthma, interstitial lung disease) 1
• Chronic cardiovascular disease (heart failure, coronary artery disease) 1
• Chronic kidney disease or end-stage renal disease 1
• Diabetes with complications 1
• Frailty or residence in nursing home 1

The 15mg Prednisone Dose Context

This dose places the patient in the moderate immunosuppression category. 2 While not as severely immunosuppressed as transplant recipients or those on high-dose chemotherapy, this level of corticosteroid therapy still confers substantial risk, particularly when combined with the underlying condition requiring prednisone (likely autoimmune disease or COPD). 1

Management Recommendations

Prevention Strategy

RSV vaccination is strongly recommended for this patient if they meet age or additional risk criteria:

• All adults ≥75 years on any immunosuppression should receive RSV vaccine. 1
• Adults aged 60-74 years with moderate immunosuppression (including chronic corticosteroid use) should receive RSV vaccine. 1
• Adults aged 50-59 years with immunosuppression can receive RSVPreF3 (Arexvy). 4

The vaccine should be administered preferably between September and November, before RSV season, and can be co-administered with influenza vaccine at different injection sites. 2, 4

If RSV Infection Occurs

Treatment is primarily supportive, as no FDA-approved antivirals exist for RSV in adults: 2

• Do NOT routinely add or increase corticosteroids for RSV infection itself - evidence shows no benefit and potential harm, with delayed viral clearance. 2, 5
• Continue the baseline 15mg prednisone dose to control the underlying disease and prevent adrenal crisis, as abrupt discontinuation poses significant risk. 2
• Consider stress-dose corticosteroids only if the patient develops severe illness requiring ICU admission. 2
• Aggressive supportive care with oxygen supplementation as needed. 2
• Monitor closely for progression to lower respiratory tract disease. 1

Critical Pitfalls to Avoid

Common mistakes in managing immunosuppressed patients with RSV:

• Do not increase corticosteroid doses thinking it will help respiratory symptoms - this delays viral clearance and worsens outcomes. 2, 5
• Do not abruptly stop the baseline prednisone - this risks adrenal crisis during acute illness. 2
• Do not underestimate severity - immunosuppressed patients can deteriorate rapidly, with 40-60% progressing from upper to lower respiratory tract infection. 1
• Do not delay hospitalization if respiratory distress develops - early intervention improves outcomes. 1

Bottom Line

A patient on 15mg prednisone faces 3-4 times higher risk of RSV hospitalization compared to the general population, with substantial mortality risk if severe disease develops. 1, 6 Prevention through vaccination (if age/risk-appropriate) is the most effective strategy, as treatment options remain limited to supportive care. 1, 2