What are the treatment options for a patient with Respiratory Syncytial Virus (RSV) infection, particularly for high-risk individuals such as premature infants or those with underlying health conditions?

RSV Treatment

For most infants and children with RSV infection, treatment is purely supportive care—no antiviral therapy is routinely recommended, and management focuses on hydration, oxygen supplementation when SpO2 falls below 90%, and monitoring until the infection resolves. 1, 2

General Management for All Patients

Supportive care is the cornerstone of RSV management and includes the following interventions:

• Ensure adequate hydration and assess fluid intake in all patients with RSV infection 1
• Provide supplemental oxygen if oxygen saturation falls persistently below 90% in previously healthy infants 1
• Use acetaminophen or ibuprofen for fever or pain management as needed 1
• Consider nasal saline irrigation for symptomatic relief in adults with upper respiratory symptoms 1

What NOT to Use

Several therapies have been proven ineffective and should be avoided:

• Do not use corticosteroids routinely in the management of bronchiolitis 1
• Do not use bronchodilators unless there is documented clinical improvement after trial 1
• Do not use antibacterial medications unless specific indications of bacterial co-infection exist 1
• 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, 3

High-Risk Populations Requiring Special Consideration

Certain patient populations warrant more aggressive monitoring and potential antiviral therapy:

Immunocompromised Patients (Highest Priority)

For hematopoietic stem cell transplant (HSCT) recipients and severely immunocompromised patients with RSV lower respiratory tract infection, ribavirin is the primary antiviral option, though evidence is based mainly on observational data 1, 2:

• Aerosolized ribavirin is FDA-approved for hospitalized infants and young children with severe lower respiratory tract RSV infection 2
• Systemic ribavirin (oral or intravenous) can be administered at 10-30 mg/kg/day in 3 divided doses 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 of 10 mg/kg body weight every 8 hours 1
• Consider combination therapy with intravenous immunoglobulin (IVIG) or anti-RSV-enriched antibody preparations for allogeneic HSCT patients with RSV lower respiratory tract disease 1

Monitor for ribavirin adverse events: claustrophobia, bronchospasm, nausea, conjunctivitis, declining pulmonary function (aerosolized form); hemolysis, abnormal liver function tests, declining renal function (systemic form) 1

Other High-Risk Groups

The following populations require close monitoring and lower threshold for hospitalization:

• Premature infants (≤35 weeks gestation, especially ≤28 weeks) 1
• Infants with bronchopulmonary dysplasia or chronic lung disease requiring medical treatment within the previous 6 months 1
• Children with hemodynamically significant congenital heart disease 1
• Patients with profound lymphopenia (<100 cells/mm³) who are at high risk for progression to lower respiratory tract disease 1
• Children with neuromuscular disorders impairing secretion clearance 1

Hospitalization and ICU Criteria

Hospitalize if the patient has:

• Hypoxemia (SpO2 persistently <90%) 1
• Signs of severe respiratory distress 1
• Inability to maintain adequate oral intake 1
• Underlying high-risk conditions (immunocompromised status, significant cardiopulmonary disease) 1

Escalate to intensive care if:

• Patient fails to maintain SaO2 >92% in FiO2 >60% 1
• Patient is in shock 1
• Severe respiratory distress with rising PaCO2 (>6.5 kPa) 1
• Development of apnea or persistent grunting 1

Respiratory Support Strategies

When standard oxygen supplementation is insufficient:

• High-flow nasal oxygen (HFNO) may be considered in selected patients with hypoxemic respiratory failure, though patients should be in a monitored setting with experienced 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

Infection Control Measures

Hand hygiene is the single most important measure to prevent transmission to others and nosocomial spread 1:

• Perform hand decontamination before and after direct patient contact, after contact with objects near the patient, and after removing gloves 1
• Use alcohol-based rubs if hands are not visibly soiled 1
• Wear gloves with frequent changes to avoid spreading organisms 1
• Wear gowns for direct contact with the patient 4
• Restrict healthcare personnel in the acute stages of an upper respiratory tract infection from caring for infants and other high-risk patients 4
• Do not allow persons with symptoms of respiratory infection to visit pediatric, immunosuppressed, or cardiac patients 4

Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 1

Prevention Strategies (Not Treatment)

While not treatment for active infection, prevention is critical for high-risk populations:

• Palivizumab prophylaxis reduces RSV hospitalization by 45-55% in high-risk populations, including infants born ≤28 weeks gestation who are <12 months old at the start of RSV season, and infants with bronchopulmonary dysplasia requiring medical treatment within the previous 6 months 1, 3
• Dosing is 15 mg/kg intramuscularly monthly throughout RSV season, with a maximum of 5 doses per season 3
• Avoid tobacco smoke exposure completely, as it is a controllable risk factor that increases RSV hospitalization risk 1
• Limit exposure to crowds and group childcare during RSV season 1
• Encourage breastfeeding to potentially decrease the risk of lower respiratory tract disease 1

Common Pitfalls to Avoid

• Do not continue palivizumab if an infant experiences a breakthrough RSV hospitalization, as there is extremely low likelihood of second RSV hospitalization in the same season 3
• Do not use ribavirin routinely in children with RSV bronchiolitis—its use is restricted to severely immunocompromised patients, HSCT patients, and mechanically ventilated infants with documented severe RSV infection 1
• Avoid environmental exposure to ribavirin in pregnant healthcare workers due to teratogenic effects 1
• Do not defer RSV testing in febrile infants ≤60 days old being evaluated for serious bacterial infection, as a positive result reduces (but does not eliminate) the risk of concurrent bacterial infection 1