How should Respiratory Syncytial Virus (RSV) infection be managed in different patient populations?

Management of Respiratory Syncytial Virus (RSV) Infection

Immediate Treatment: Supportive Care Only

Treatment for RSV infection is exclusively supportive care, as there are no FDA-approved antiviral medications for RSV in adults, with management focused on oxygen support, hydration, and symptom control. 1

Core Supportive Measures

• Oxygen supplementation should be provided to maintain saturation above 90%, particularly in patients with hypoxemic respiratory failure 1
• Hydration must be maintained through oral intake when possible, or via nasogastric/intravenous routes if the patient cannot maintain adequate fluid intake 1, 2
• Analgesics (acetaminophen or ibuprofen) can be used for fever and pain management 1
• Nasal saline irrigation may provide symptomatic relief in patients with upper respiratory symptoms 1

Respiratory Support Escalation Strategy

• High-flow nasal oxygen (HFNO) may be considered in selected patients with hypoxemic respiratory failure in monitored settings with personnel capable of intubation 1
• Non-invasive ventilation (NIV) is NOT recommended due to high failure rates and risk of aerosol generation 1
• Early intubation and mechanical ventilation should be considered if respiratory distress worsens or oxygen requirements cannot be met with standard supplementation 1

Management of Underlying Conditions

• For COPD or asthma exacerbations: Manage according to standard exacerbation protocols, as RSV commonly triggers disease exacerbation in these populations 1, 3
• Cardiovascular complications should be monitored closely, as RSV infection increases risk of cardiac events in patients with heart failure or coronary artery disease 1
• Antibiotics should only be used when specific indications of bacterial co-infection exist, not empirically 1

Critical Pitfall: Corticosteroids

• Avoid routine use of corticosteroids in RSV management unless treating underlying COPD or asthma exacerbation 1, 3
• Glucocorticoids may delay viral clearance in RSV and other respiratory viral infections 3

Diagnostic Approach

• Nucleic acid-based testing (RT-PCR) is the recommended diagnostic method for RSV in adults, particularly those at high risk for severe disease 1, 3
• Antigen detection tests are NOT recommended for adults due to poor sensitivity in this population 1
• Testing is especially important in immunocompromised patients, including those with solid organ or hematopoietic stem cell transplants, hematological malignancies, chronic immunosuppressive therapy, or HIV infection 1, 3

Special Population: Immunocompromised Adults

For severely immunocompromised adults, off-label ribavirin combined with intravenous immunoglobulin may be considered based on observational data showing improved survival. 1, 3

Ribavirin Dosing Protocol (Off-Label Use)

• Aerosolized ribavirin is the primary option for mechanically ventilated patients with documented severe RSV infection 1
• Oral or intravenous ribavirin (10-30 mg/kg/day in 3 divided doses) can be used for patients unable to take oral medication 1
• Dosing schedule for systemic ribavirin: 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 every 8 hours
• Combination therapy with IVIG or anti-RSV-enriched antibody preparations may be considered for allogeneic HSCT patients with lower respiratory tract disease 1

Critical Pitfall: Palivizumab

Do NOT use palivizumab for treatment of established RSV infection in adults—it has no therapeutic benefit and is only FDA-approved for prevention in high-risk infants. 1, 4

Prevention: Vaccination Strategy

All adults aged ≥75 years should receive RSV vaccination regardless of comorbidities. 5, 1

Vaccination Recommendations by Age and Risk

• Adults ≥75 years: Universal vaccination recommended 5, 1, 3
• Adults 60-74 years with risk factors: Vaccination recommended if they have chronic cardiovascular disease, chronic lung/respiratory disease, end-stage renal disease, diabetes, neurologic/neuromuscular conditions, chronic liver disease, chronic hematologic conditions, severe obesity (BMI ≥30), moderate/severe immunocompromise, or residence in a nursing home 5, 1
• Adults 50-59 years at increased risk: May be considered for vaccination 5

Available Vaccines

• Two RSV vaccines are available: RSVPreF3 (Arexvy from GSK) and RSVpreF (Abrysvo from Pfizer) 5, 1, 3
• Single dose administered intramuscularly 5
• Optimal timing: Between September and November, before or early in the RSV season 1, 3
• Can be co-administered with seasonal influenza vaccine at different injection sites 1, 3

Vaccine Efficacy Data

• RSVPreF3 efficacy in Season 1 (adults ≥60 years): 5
  • RSV-associated lower respiratory tract disease: 82.6% (96.95% CI: 57.9,94.1)
  • Severe RSV-associated lower respiratory tract disease: 94.1% (95% CI: 62.4,99.9)
  • In participants with ≥1 pre-existing comorbidity: 94.6% (96.95% CI: 65.9,99.9)
• Cumulative efficacy over 2 seasons: 67.2% (97.5% CI: 48.2,80.0) for RSV-associated lower respiratory tract disease 5

Infection Control Measures

• Hand hygiene is the single most important measure to prevent transmission and nosocomial spread 1
• Alcohol-based hand rubs are preferred for hand decontamination 1
• Gowns and gloves should be used for direct patient contact 1
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 1
• Restrict healthcare personnel with upper respiratory tract infections from caring for high-risk patients 5
• Do not allow persons with respiratory infection symptoms to visit pediatric, immunosuppressed, or cardiac patients 5

Clinical Outcomes and Prognosis

• Mortality rates in hospitalized elderly patients: 4.6% in those aged 60-74 years and 6.1% in those ≥75 years 1, 3, 6
• Functional decline following RSV infection can be prolonged, particularly in frail elderly patients from skilled nursing facilities 1, 3, 6
• Patients on systemic corticosteroids are at highest risk for hospitalization due to RSV compared to other patients with underlying conditions 3
• 90-day mortality among immunocompromised ICU patients with RSV reaches 52.8% 3

Special Considerations for Pediatric Populations

Ribavirin is FDA-approved only for hospitalized infants and young children with severe lower respiratory tract infections due to RSV. 7

• Treatment should be initiated early in the course of severe lower respiratory tract infection 7
• RSV infection should be documented by rapid diagnostic method before or during the first 24 hours of treatment 7
• Palivizumab is indicated for prevention (not treatment) in high-risk pediatric patients: those with premature birth (≤35 weeks gestational age) who are ≤6 months old, those with bronchopulmonary dysplasia requiring medical treatment within previous 6 months who are ≤24 months old, or those with hemodynamically significant congenital heart disease who are ≤24 months old 4