What is the recommended treatment approach for an adult with Respiratory Syncytial Virus (RSV) pneumonia, particularly those with underlying health conditions or compromised immune systems?

Treatment of RSV Pneumonia in Adults

For immunocompetent adults with RSV pneumonia, treatment is entirely supportive care—there are no FDA-approved antivirals and ribavirin should NOT be used. 1, 2 However, for severely immunocompromised adults (particularly hematopoietic stem cell transplant recipients, solid organ transplant recipients, or those on active chemotherapy), ribavirin combined with IVIG should be strongly considered and initiated early. 1, 2

Primary Treatment Approach by Patient Population

Immunocompetent Adults: Supportive Care Only

Supportive care is the cornerstone of management for previously healthy adults and those with chronic conditions but intact immune systems. 1

Core supportive measures include:

• Oxygen supplementation to maintain SpO2 >90%, with escalation to high-flow nasal oxygen in monitored settings if standard supplementation fails 1
• Adequate hydration with careful fluid intake assessment 1, 3
• Acetaminophen or ibuprofen for fever and pain control 1, 3
• Nasal saline irrigation for symptomatic relief of upper respiratory symptoms 1, 3

Management of underlying disease exacerbations:

• For COPD or asthma exacerbations triggered by RSV, treat according to standard exacerbation protocols with bronchodilators and corticosteroids as indicated 1
• Monitor cardiovascular complications closely, as RSV increases risk of cardiac events in patients with heart failure or coronary artery disease 1
• Use antibiotics ONLY when specific bacterial co-infection is documented—not empirically 1, 3

Severely Immunocompromised Adults: Antiviral Therapy Indicated

For hematopoietic stem cell transplant recipients, solid organ transplant recipients, patients on active chemotherapy, or those with profound lymphopenia, ribavirin therapy should be strongly considered. 1, 2

Ribavirin administration options:

Aerosolized ribavirin (preferred for mechanically ventilated patients):

• 2 g for 2 hours every 8 hours OR 6 g over 18 hours daily for 7-10 days 2, 4
• Requires specialized equipment (SPAG-2 aerosol generator) and experienced personnel 4
• Monitor for claustrophobia, bronchospasm, nausea, conjunctivitis, and declining pulmonary function 2
• Implement strict precautions to avoid environmental exposure, particularly for pregnant healthcare workers due to teratogenic effects 2

Oral ribavirin (effective alternative, easier to administer):

• Day 1: 600 mg loading dose, then 200 mg every 8 hours 1, 2
• Day 2: 400 mg every 8 hours 1, 2
• Day 3 onward: Increase to maximum 10 mg/kg every 8 hours 1, 2
• Renal adjustment: Maximum 200 mg every 8 hours for creatinine clearance 30-50 mL/min 2
• Monitor for hemolytic anemia, abnormal liver function tests, and declining renal function 2

Combination therapy for allogeneic HSCT patients:

• Combine ribavirin with IVIG (500 mg/kg every other day) or anti-RSV-enriched antibody preparations 2
• Observational data shows improved survival with combination therapy 1, 2

Timing considerations:

• Defer conditioning therapy or chemotherapy until RSV infection resolves 2
• Early initiation of ribavirin is critical for reducing mortality 2

Diagnostic Approach

RT-PCR (nucleic acid-based testing) is the recommended diagnostic method for RSV in adults, particularly those at high risk for severe disease. 1

Testing is especially important in:

• Immunocompromised patients (solid organ or HSCT recipients, hematological malignancies, chronic immunosuppressive therapy, HIV infection) 1
• Patients with severe pneumonia requiring ICU admission 5
• Elderly patients ≥65 years with underlying cardiopulmonary disease 1

Do NOT use antigen detection tests in adults—they have poor sensitivity in this population. 5, 1

Respiratory Support Escalation

For hypoxemic respiratory failure:

• High-flow nasal oxygen (HFNO) may be considered in selected patients in monitored settings with personnel capable of intubation 1, 3
• Non-invasive ventilation (NIV) is NOT recommended due to high failure rates and risk of aerosol generation 1, 3
• Consider early intubation and mechanical ventilation if respiratory distress worsens or oxygen requirements exceed FiO2 >60% 1, 3

For mechanically ventilated patients:

• Use low-tidal-volume ventilation (6 mL/kg ideal body weight) if diffuse bilateral pneumonia or ARDS develops 5
• Aerosolized ribavirin is the primary antiviral option for documented severe RSV infection in immunocompromised patients 1, 2, 4

Empirical Antibiotic Coverage

If bacterial superinfection is suspected (new fever, leukocytosis, purulent sputum, focal consolidation), provide coverage for S. pneumoniae, S. aureus, and H. influenzae. 5

Antibiotic options for suspected bacterial superinfection:

• Amoxicillin-clavulanate, cefpodoxime, cefprozil, cefuroxime, or a respiratory fluoroquinolone 5
• For hospitalized patients not in ICU: respiratory fluoroquinolone OR β-lactam (cefotaxime, ceftriaxone, ampicillin) plus macrolide 5
• For ICU patients: β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus azithromycin or fluoroquinolone 5

Prevention: Vaccination Strategy

Two RSV vaccines (RSVPreF3/Arexvy and RSVpreF/Abrysvo) are now available and represent the most important preventive measure. 5, 1

Vaccination recommendations:

• All adults ≥75 years should receive RSV vaccination regardless of comorbidities 5, 1
• Adults aged 60-74 years with risk factors (chronic cardiopulmonary disease, diabetes, chronic kidney disease, immunocompromised status, nursing home residence) should receive vaccination 5, 1
• Administer between September and November, before or early in the RSV season 1
• Single dose recommended, can be co-administered with influenza vaccine at different injection sites 1

Infection Control Measures

Hand hygiene is the single most important measure to prevent transmission. 1, 3

Infection control practices:

• Alcohol-based hand rubs are preferred for hand decontamination 1, 3
• Gowns and gloves should be used for direct patient contact 1, 3
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 1, 3

Critical Pitfalls to Avoid

Do NOT use palivizumab for treatment of established RSV infection in adults—it has no therapeutic benefit and is only approved for prevention in high-risk infants. 1, 2, 3

Do NOT use ribavirin routinely in immunocompetent adults—there is no established efficacy (D-I recommendation) and it exposes patients to unnecessary risks including hemolytic anemia, teratogenicity, and significant cost. 5, 2

Do NOT use corticosteroids routinely for RSV pneumonia unless treating an underlying COPD or asthma exacerbation. 1, 3

Do NOT delay intubation in patients with severe hypoxemia (PaO2/FiO2 ratio <150) and bilateral infiltrates—NIV has high failure rates in this setting. 1, 3

Do NOT continue empirical antibiotics without evidence of bacterial co-infection—RSV pneumonia is viral and does not require antibacterial therapy. 1, 3

Clinical Outcomes and Prognosis

Mortality rates in hospitalized elderly patients range from 4.6% in those aged 60-74 years to 6.1% in those ≥75 years. 1 Functional decline following RSV infection can be prolonged, particularly in frail elderly patients from skilled nursing facilities. 1