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

RSV Treatment

RSV treatment is primarily supportive care—there is no effective antiviral therapy for routine use, and management focuses on oxygen supplementation, hydration support, and monitoring until the infant's immune system controls the infection. 1, 2

Core Treatment Principles

Supportive care is the cornerstone of RSV management, with no pharmacologic interventions recommended for routine use as they show no meaningful impact on morbidity, mortality, or quality of life outcomes. 1, 2

Oxygen Therapy

• Provide supplemental oxygen if oxygen saturation falls persistently below 90% in previously healthy infants. 1, 2
• Continuous pulse oximetry is not routinely needed as the child's clinical course improves. 1
• Infants with hemodynamically significant heart or lung disease and premature infants require close monitoring as oxygen is being weaned. 1

Hydration Support

• Assess fluid intake adequacy and provide intravenous or nasogastric fluids for infants unable to maintain oral intake. 1, 2
• This is a critical intervention for infants with respiratory distress who cannot feed adequately. 1

Symptomatic Management

• Use acetaminophen or ibuprofen for fever and pain management as needed. 1, 2
• Nasal saline irrigation may provide symptomatic relief for upper respiratory symptoms. 1, 2

What NOT to Use

Palivizumab Has No Treatment Role

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. 3, 1, 2 This is a critical pitfall to avoid, as palivizumab is exclusively a prophylactic agent, not a therapeutic one.

Bronchodilators (Albuterol)

Do not use bronchodilators routinely in RSV bronchiolitis because randomized controlled trials have failed to demonstrate consistent benefit. 2 At most, only 1 in 4 children might have a transient improvement in clinical score of unclear clinical significance. 2

• A carefully monitored trial of albuterol is an option only if you can objectively measure response (improvement in respiratory rate, work of breathing, or oxygen saturation). 2
• If proceeding with a trial, administer 2-3 doses and assess for documented clinical improvement using objective criteria within 30-60 minutes. 2
• Discontinue immediately if there is no clear positive response, as continuing without benefit exposes the infant to potential adverse effects and costs without clinical gain. 2

Corticosteroids

Do not use corticosteroids routinely in the management of bronchiolitis. 1

Antibiotics

Use antibacterial medications only when specific indications of bacterial co-infection exist. 1 Overuse of antibiotics when there is no evidence of bacterial co-infection should be avoided. 1

Ribavirin for Routine Use

Ribavirin should not be used routinely in children with bronchiolitis. 1 Its use is restricted to specific high-risk populations (see below).

Treatment for High-Risk and Immunocompromised Patients

Ribavirin Indications

Ribavirin is the primary antiviral option for severely immunocompromised patients, particularly hematopoietic stem cell transplant (HSCT) recipients with RSV lower respiratory tract infection, though evidence is based mainly on observational data. 1, 4

Specific High-Risk Populations for Ribavirin:

• HSCT recipients with RSV lower respiratory tract infectious disease (LRTID) or those at high risk for progression. 1
• Mechanically ventilated infants with documented severe RSV infection. 1
• Solid organ transplant recipients with 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 is FDA-approved for hospitalized infants and young children with severe lower respiratory tract RSV infection. 1, 4 Treatment should be initiated early in the course of severe lower respiratory tract infection. 4

Systemic ribavirin can be administered orally or intravenously (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. 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:

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

Combination Therapy for HSCT Patients

Consider combining ribavirin with immunoglobulin therapy for allogeneic HSCT patients with RSV LRTID or at high risk for progression. 1 Aerosolized or systemic ribavirin may be combined with IVIG or anti-RSV-enriched antibody preparations. 1

Timing Considerations

• 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

Infection Control: Critical for Preventing Transmission

Hand hygiene is the single most important measure to prevent RSV transmission. 1, 2 Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50%. 2

Specific Infection Control Measures:

• Perform hand decontamination before and after direct patient contact, after contact with objects near the patient, and after removing gloves. 1, 2
• Use alcohol-based rubs if hands are not visibly soiled (preferred method). 1, 2
• Wear gowns for direct patient contact. 1, 2
• Ensure patients do not touch other persons' hands or environmental surfaces with hands contaminated with respiratory secretions. 5
• Educate personnel and family members on hand sanitation. 1, 2

Healthcare Personnel Restrictions:

• Restrict healthcare personnel in the acute stages of upper respiratory tract infection from caring for infants and other patients at high risk for complications. 5
• Do not allow persons with symptoms of respiratory infection to visit pediatric, immunosuppressed, or cardiac patients. 5

Hospitalization and ICU Criteria

Indications for Hospitalization:

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

ICU Transfer Criteria:

• Failure to maintain SaO2 >92% in FiO2 >60%. 1
• Shock. 1
• Severe respiratory distress with rising PaCO2 (>6.5 kPa). 1
• Development of apnea or persistent grunting. 1

Prevention Strategies for High-Risk Infants

Nirsevimab (Newest Recommendation)

ACIP recommends nirsevimab for infants aged <8 months who are born during or entering their first RSV season and for infants and children aged 8-19 months who are at increased risk for severe RSV disease and are entering their second RSV season. 5

Palivizumab (Alternative for Specific High-Risk Groups)

Palivizumab prophylaxis is recommended for infants born before 29 weeks, 0 days' gestation who are younger than 12 months at the start of RSV season, at a dose of 15 mg/kg intramuscularly every 30 days for a maximum of 5 monthly doses. 3, 2

Additional Palivizumab Eligibility:

• Infants with bronchopulmonary dysplasia requiring medical therapy within 6 months before RSV season start. 3
• Infants with hemodynamically significant congenital heart disease receiving medication to control congestive heart failure. 3
• Infants born 32-35 weeks gestation with at least 2 risk factors (child-care attendance, school-aged siblings, exposure to environmental pollutants, congenital abnormalities of airways, severe neuromuscular disease). 5

Important limitation: Palivizumab reduces RSV hospitalization by 45-55% but has no measurable effect on mortality and provides little benefit for reducing subsequent wheezing episodes. 3, 2

Discontinue prophylaxis if an infant experiences a breakthrough RSV hospitalization due to the extremely low likelihood of second RSV hospitalization in the same season. 3

Universal Prevention Measures for All Infants

• Avoid tobacco smoke exposure completely—this is a controllable risk factor that increases RSV hospitalization risk. 1, 2
• Limit exposure to crowds and group childcare during RSV season (November through March in most U.S. regions). 1, 2
• Keep infants away from sick contacts. 1, 2
• Encourage breastfeeding to potentially decrease the risk of lower respiratory tract disease. 1, 2
• Ensure influenza vaccination for the infant (starting at 6 months) and all household contacts. 1, 2