What is the recommended treatment for Respiratory Syncytial Virus (RSV) infection in adults, particularly those with underlying health conditions or compromised immune systems?

RSV Treatment in Adults

Treatment for RSV infection in adults is primarily supportive care, as there are no FDA-approved antiviral medications for this indication, with the critical exception of severely immunocompromised patients (particularly transplant recipients) who may benefit from off-label ribavirin therapy. 1, 2

Supportive Care: The Standard Approach

For the vast majority of adult RSV patients, management focuses on symptomatic relief:

• Oxygen supplementation as needed to maintain adequate saturation 2
• Antipyretics for fever control 3
• Hydration (oral or intravenous fluids) 3
• Management of underlying conditions such as COPD or asthma exacerbations according to standard protocols 2

The American Thoracic Society emphasizes that most adult RSV infections are self-limited and resolve within 1-2 weeks with supportive care alone. 1

Antiviral Therapy: Limited Role

FDA-Approved Options

No antiviral medications have FDA approval for RSV treatment in adults. 1 The FDA has only approved ribavirin for inhalation (Virazole) for hospitalized infants and young children with severe RSV lower respiratory tract infections—not for adults. 4

Off-Label Ribavirin Use in High-Risk Patients

For severely immunocompromised adults only, off-label ribavirin may be considered:

• Hematopoietic stem cell transplant (HSCT) recipients 1, 2
• Lung transplant recipients 1, 2
• Patients with hematological malignancies 2
• Solid organ transplant recipients 2

The American Thoracic Society notes that ribavirin use is based primarily on observational data showing potential survival benefit in these populations, though evidence quality remains limited. 1 Both aerosolized and oral formulations have been used, with oral ribavirin being significantly less expensive and easier to administer. 1

Important caveat: The decision to use ribavirin in immunocompromised patients should be made early in the disease course, ideally before progression to severe lower respiratory tract disease, as efficacy diminishes with delayed treatment. 1, 2

Combination Therapy

Some centers combine ribavirin with intravenous immunoglobulin (IVIG) in severely immunocompromised patients, based on observational data suggesting improved survival, though this remains off-label and lacks randomized controlled trial support. 2, 5

High-Risk Populations Requiring Aggressive Monitoring

Even with supportive care only, these patients warrant close observation:

• Adults ≥75 years (mortality rates 6.1% when hospitalized) 2
• Chronic cardiopulmonary disease (COPD, asthma, heart failure) 2, 6
• Patients on systemic corticosteroids (highest hospitalization risk) 2
• Chronic kidney disease 2
• Diabetes with complications 2
• Frail elderly or nursing home residents 2, 5

Cardiovascular Complications: A Critical Pitfall

Acute cardiac events occur in 22.4% of hospitalized RSV patients, rising to 33% in those with pre-existing cardiovascular disease. 2 Monitor closely for:

• Heart failure exacerbation (increases mid-to-long-term mortality, adjusted HR 1.86) 2
• Atrial fibrillation (increases short-term mortality, adjusted HR 1.66) 2
• Acute coronary syndrome 2

Antibiotics: Avoid Unnecessary Use

Antibiotics should not be routinely prescribed for RSV infection. 6 However, 78% of hospitalized RSV patients receive antibiotics in practice, often because:

• Presenting symptoms are nonspecific and overlap with bacterial pneumonia 6
• Co-infections occur in approximately 13% of cases 6
• Bacterial cultures have low diagnostic yield 1

Use antibiotics only when:

• Clear evidence of bacterial co-infection exists 6
• Patient deteriorates despite supportive care 6
• High clinical suspicion for secondary bacterial pneumonia 6

Corticosteroids: Generally Contraindicated

Do not use corticosteroids for RSV treatment. 2 The American Academy of Pediatrics explicitly recommends against routine corticosteroid use, and adult data show no benefit with potential harm including delayed viral clearance. 2

Exception: Patients already on chronic corticosteroids should continue their baseline dose to prevent adrenal crisis, and may require stress-dose steroids if critically ill. 2

Diagnostic Testing

Nucleic acid-based testing (RT-PCR) is recommended for diagnosis in:

• High-risk adults (elderly, immunocompromised, chronic cardiopulmonary disease) 1, 2
• Hospitalized patients with suspected RSV 1
• Immunocompromised patients where antiviral therapy might be considered 1

Viral culture and antigen detection are insensitive in adults due to low viral titers and should not be relied upon. 5

Prevention: The Most Effective Strategy

RSV vaccination is now the primary preventive approach and should be prioritized over treatment:

• All adults ≥75 years: Single lifetime dose recommended 2, 7
• Adults 60-74 years with risk factors: Single lifetime dose recommended 2, 7
• Adults 50-59 years with risk factors: RSVPreF3 (Arexvy) only 2, 7

Administer preferably September-November before RSV season. 2, 7, 8 This represents the most significant advance in RSV management for adults, with vaccine efficacy of 82.6% against lower respiratory tract disease in the first season. 8

Clinical Outcomes Without Specific Treatment

Understanding natural history helps set expectations:

• Median hospital length of stay: 6 days (mean 10.8 days) 6
• ICU admission rate: 15% of hospitalized patients 6
• Mechanical ventilation: 9% of hospitalized patients 6
• In-hospital mortality: 6% overall 6
• 90-day mortality in immunocompromised ICU patients: 52.8% 2

These sobering statistics underscore why prevention through vaccination is paramount, and why early recognition and aggressive supportive care in high-risk patients is essential even without specific antivirals.