What are the management and prevention strategies for Respiratory Syncytial Virus (RSV) infection in elderly individuals, particularly those with underlying health conditions such as heart disease, lung disease, or immunocompromised states?

RSV Management and Prevention in Elderly Patients

All adults aged ≥75 years should receive a single lifetime dose of RSV vaccine, and adults aged 60-74 years with any chronic medical condition (heart disease, lung disease, diabetes, kidney disease) or immunocompromise should also be vaccinated, preferably between September and November before RSV season begins. 1, 2

Vaccination Strategy: The Primary Prevention Tool

Age-Based Recommendations

• Universal vaccination is indicated for all adults ≥75 years regardless of health status, as this age group faces hospitalization rates of 210-343 per 100,000 and mortality rates of 6.1% when hospitalized 3, 1
• Adults aged 60-74 years require vaccination if they have any of the following risk factors: 1, 2
  • Chronic lung disease (COPD, asthma, bronchiectasis, interstitial lung disease)
  • Cardiovascular disease (heart failure, coronary artery disease)
  • Diabetes mellitus
  • Chronic kidney disease
  • Chronic liver disease
  • Immunocompromise (including chronic corticosteroid use)
  • Residence in nursing homes or long-term care facilities
  • Frailty or dementia

Practical Vaccination Details

• Only one lifetime dose is currently recommended—no annual boosters are needed, as protection lasts at least 2-3 RSV seasons 2, 4
• Administer between September and November (or August-October) to maximize protection during peak RSV season 1, 2
• Can be co-administered with influenza vaccine at different injection sites on the same visit 1, 2
• Patient attestation alone is sufficient evidence of risk factors—do not delay vaccination waiting for medical documentation 2, 4

Available Vaccines

• RSVPreF3 (Arexvy): Approved for adults ≥50 years with risk factors and all adults ≥60 years 2, 4
• RSVpreF (Abrysvo): Approved for adults ≥60 years 2, 4
• mRNA-1345: Approved in some regions for adults ≥60 years 1

High-Risk Populations Requiring Urgent Attention

Immunocompromised Elderly: The Highest Risk Group

Immunocompromised patients face dramatically elevated risks: hospitalization rates of 1,288-1,562 per 100,000, ICU admission rates of 36%, and 90-day mortality of 52.8% among those requiring ICU care 3, 1

Specific high-risk immunocompromised categories include: 3, 1

• Hematopoietic stem cell transplant recipients (40-60% progress to lower respiratory tract infection with up to 80% mortality)
• Solid organ transplant recipients (especially lung transplant patients)
• Patients with hematological malignancies or solid tumors
• Patients on chronic immunosuppressive therapy (including corticosteroids ≥10-15mg prednisone daily)
• HIV-positive individuals, particularly those with CD4+ counts <200 cells/mm³

Patients on Chronic Corticosteroids: A Critical Caveat

• Patients taking prednisone ≥10-20mg daily represent the highest risk group for RSV hospitalization among all comorbid conditions 1
• Continue baseline corticosteroid dose during acute RSV infection to prevent adrenal crisis—do not abruptly discontinue 1
• Glucocorticoids may delay viral clearance, but stopping them abruptly poses greater immediate danger 1
• These patients should have been vaccinated preventively; if not yet vaccinated, prioritize vaccination once acute infection resolves 1

Treatment Approach: Primarily Supportive

Standard Management for Most Elderly Patients

There are no FDA-approved antiviral treatments for RSV in adults—treatment is supportive care focused on: 1

• Oxygen supplementation as needed to maintain adequate saturation
• Management of underlying disease exacerbations (COPD, asthma, heart failure) according to standard protocols 1
• Monitoring for progression to lower respiratory tract disease, especially in first 3-7 days 1
• Functional status assessment, as RSV causes significant functional decline particularly in frail elderly 1

Limited Role for Ribavirin in Severely Immunocompromised

• Off-label ribavirin (aerosolized or oral) combined with intravenous immunoglobulin has been used in severely immunocompromised adults based on observational data showing improved survival 1, 5, 6
• This is not FDA-approved for adults and evidence is limited to observational studies 1, 7
• Consider only in severely immunocompromised patients (HSCT recipients, lung transplant patients) with documented RSV lower respiratory tract infection 1, 5
• Early therapy (within first 3 days) is associated with better outcomes in immunocompromised patients 5, 6

Diagnostic Considerations

When and How to Test

• RT-PCR is the reference standard for RSV diagnosis in elderly patients, particularly those at high risk 1, 8
• Testing is especially important in: 1
  • Immunocompromised elderly patients
  • Those with severe lower respiratory tract symptoms
  • Nursing home residents during outbreaks
• Point-of-care antigen tests perform less well with lower viral loads typical in adults 8
• Clinical diagnosis alone is insufficient—RSV cannot be reliably distinguished from influenza or other respiratory viruses based on symptoms 8, 6

Clinical Outcomes and Prognosis

Mortality and Morbidity Data

• Overall mortality in hospitalized elderly: 4.6% (ages 60-74) and 6.1% (≥75 years) 1
• Patients with dementia have 86% higher mid- to long-term mortality (aHR=1.86) 1
• RSV accounts for 10.6% of pneumonia hospitalizations and 11.4% of COPD exacerbations in older adults 2, 4
• Functional decline following RSV can be prolonged, particularly in frail elderly from skilled nursing facilities 1

Common Pitfalls to Avoid

• Do not withhold vaccination from adults ≥75 years while waiting for documentation of comorbidities—age alone is sufficient indication 2
• Do not assume previous RSV infection provides lasting immunity—reinfections are common and prior infection does not contraindicate vaccination 2, 4
• Do not delay testing in immunocompromised patients—early diagnosis enables consideration of ribavirin therapy if severe disease develops 1, 6
• Do not abruptly stop chronic corticosteroids during acute RSV infection—maintain baseline dose to prevent adrenal crisis 1

Priority Algorithm for Limited Vaccine Supply

If vaccine availability is constrained, prioritize in this order: 2, 4

1. All adults ≥75 years
2. Adults aged 60-74 years with multiple comorbidities
3. Residents of nursing homes or long-term care facilities
4. Adults aged 50-59 years with significant immunocompromise or severe chronic lung/heart disease