What is the recommended management approach for pediatric patients or individuals with compromised immune systems diagnosed with Respiratory Syncytial Virus (RSV) infection?

RSV Management

RSV management is primarily supportive care focused on maintaining oxygenation and hydration, with no routine antiviral therapy recommended for most patients, while palivizumab prophylaxis is reserved for specific high-risk infants during RSV season. 1

Core Management Principles

Supportive Care (Mainstay of Treatment)

• Provide supplemental oxygen if SpO2 falls persistently below 90% in previously healthy infants, targeting SpO2 >92%. 1
• Standard low-flow oxygen delivery systems are appropriate for most patients. 1
• Ensure adequate hydration through oral, nasogastric, or intravenous routes as needed. 2, 3
• Monitor oxygen saturation, respiratory rate, work of breathing, hydration status, feeding ability, and mental status continuously. 1

High-Flow Nasal Cannula (HFNO) Considerations

• HFNO may be considered in selected patients with hypoxemic respiratory failure, but only in monitored settings with personnel experienced in intubation due to potential for rapid deterioration. 1
• Non-invasive ventilation (NIV) is generally NOT recommended due to high failure rates and risk of aerosol generation. 2

Therapies NOT Recommended

• Do NOT use bronchodilators, corticosteroids, nebulized hypertonic saline, or chest physiotherapy routinely. 2, 3
• Do NOT use antibiotics unless specific bacterial co-infection is documented. 2, 3
• Palivizumab has NO therapeutic benefit for treating established RSV infection—it is ONLY for prevention. 2

Infection Control (Critical Priority)

Hand Hygiene (Single Most Important Measure)

• Perform hand decontamination before and after direct patient contact, after contact with objects near the patient, and after removing gloves. 1
• Alcohol-based rubs are preferred if hands are not visibly soiled. 1
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50%. 2

Contact and Droplet Precautions

• Wear gowns for direct patient contact with RSV-infected patients. 2
• Use gloves with frequent changes to prevent organism spread. 2
• RSV can survive on counter tops for ≥6 hours, on gowns for 20-30 minutes, and on skin for up to 20 minutes. 4
• Restrict healthcare personnel with upper respiratory infections from caring for high-risk patients. 4
• Do not allow persons with respiratory infection symptoms to visit pediatric, immunosuppressed, or cardiac patients. 4

High-Risk and Immunocompromised Patients

Populations Requiring Aggressive Management

• Hematopoietic stem cell transplant (HSCT) recipients with RSV infection require more aggressive management, including consideration of ribavirin therapy. 1, 2
• Solid organ transplant recipients may require more intensive care with supplemental oxygen and close monitoring. 1, 2
• Patients with profound lymphopenia (<100 cells/mm³) are at high risk for progression to lower respiratory tract disease. 2
• Children receiving chemotherapy for malignancy require close monitoring for respiratory complications. 4

Ribavirin Therapy (Limited Indications)

• Ribavirin should NOT be used routinely in children with RSV bronchiolitis. 1, 2, 5
• Ribavirin is indicated ONLY for HSCT patients with RSV lower respiratory tract infection or those at high risk for progression. 1, 2, 5
• Aerosolized ribavirin is FDA-approved for hospitalized infants and young children with severe lower respiratory tract RSV infection, though use should be limited to truly severe cases. 1, 5

Ribavirin Administration Options

• Aerosolized form: Primary option for mechanically ventilated patients with documented severe RSV infection. 2
• Systemic ribavirin (oral or IV): 10-30 mg/kg/day in 3 divided doses for patients unable to take oral medication. 2
  • Day 1: 600 mg loading dose, then 200 mg every 8 hours 2
  • Day 2: 400 mg every 8 hours 2
  • Day 3 onward: Increase to maximum of 10 mg/kg every 8 hours 2
  • Renal adjustment: For CrCl 30-50 mL/min, maximum 200 mg every 8 hours 2

Monitoring for Ribavirin Adverse Effects

• Monitor for claustrophobia, bronchospasm, nausea, conjunctivitis, and declining pulmonary function with aerosolized form. 2
• Monitor for hemolysis, abnormal liver function tests, and declining renal function with systemic form. 2
• Avoid environmental exposure in pregnant healthcare workers due to teratogenic effects. 2

Combination Therapy for HSCT Patients

• Consider combining ribavirin with IVIG or anti-RSV-enriched antibody preparations for allogeneic HSCT patients with RSV lower respiratory tract disease or at high risk for progression. 2

Prevention Strategies

Palivizumab Prophylaxis (NOT Treatment)

Indications for Prophylaxis

• Infants born ≤28 weeks gestation who are <12 months old at the start of RSV season. 2
• Infants with chronic lung disease of prematurity requiring supplemental oxygen, diuretic therapy, or chronic corticosteroid therapy within 6 months of RSV season onset. 4
• Infants born 29-31 weeks gestation may benefit from prophylaxis up to 6 months of age. 2
• Children with hemodynamically significant congenital heart disease (acyanotic group showed 68 fewer RSV hospitalizations per 1000 prophylaxis recipients). 4

Dosing and Duration

• Administer 15 mg/kg intramuscularly monthly throughout RSV season, maximum of 5 doses per season. 2
• Initiate in November and continue for 5 doses to provide protection into April. 4
• If initiated in October, give fifth and final dose in February for protection into March. 4
• Palivizumab reduces RSV hospitalization by 45-55% in high-risk populations. 1, 2

Second Year of Life

• Palivizumab prophylaxis is NOT recommended for children in the second year of life except for those with chronic lung disease requiring supplemental oxygen, chronic corticosteroid therapy, or diuretic therapy within 6 months of the second RSV season onset. 4

Conditions NOT Requiring Routine Prophylaxis

• Down syndrome: Routine prophylaxis NOT recommended unless child qualifies due to cardiac disease or prematurity. 4
• Cystic fibrosis: Routine prophylaxis NOT recommended (randomized trial showed no clinically meaningful differences). 4
• Immunocompromised children: Insufficient data for routine use, but prophylaxis may be considered for HSCT recipients. 4
• Neuromuscular disease, pulmonary abnormality: Insufficient data for routine prophylaxis. 4

Universal Prevention Measures

• Avoid tobacco smoke exposure completely—it is a controllable risk factor that increases RSV hospitalization risk. 2
• Limit exposure to crowds and group childcare during RSV season (November through March). 2
• Keep infants away from sick contacts. 2
• Encourage breastfeeding to potentially decrease risk of lower respiratory tract disease. 4, 2
• Ensure influenza vaccination for infants starting at 6 months and all household contacts. 2

Criteria for ICU Transfer

• Failure to maintain SaO2 >92% in FiO2 >60%. 1, 2
• Shock or severe respiratory distress with rising PaCO2 (>6.5 kPa). 1, 2
• Development of apnea or persistent grunting. 1, 2

Discharge Criteria

• Oxygen saturation consistently >90% in room air for at least 12-24 hours. 2
• Clinical improvement including better activity level, improved appetite, and decreased or absent fever for 12-24 hours. 2
• Normal or baseline mental status. 2
• Absence of substantially increased work of breathing, sustained tachypnea, or tachycardia. 2

Isolation Precautions Duration

• Maintain contact and droplet precautions throughout hospitalization for all RSV-positive patients. 2
• RSV viral shedding typically continues throughout acute illness and can persist for 1-3 weeks in infants and young children. 2
• Do NOT discontinue isolation based on antibiotic treatment duration or clinical improvement alone—viral shedding persists even as symptoms improve. 2
• Isolation can be discontinued upon hospital discharge if patient is going home. 2

Common Pitfalls to Avoid

• Do NOT use palivizumab to treat active RSV infection—it has no therapeutic benefit. 2
• Do NOT continue palivizumab prophylaxis after breakthrough RSV hospitalization. 4
• Do NOT use palivizumab to prevent nosocomial RSV disease in NICU or hospital settings. 4
• Do NOT administer palivizumab to reduce recurrent wheezing in later years—no evidence supports cost-effectiveness for this indication. 4
• Avoid overuse of antibiotics when there is no evidence of bacterial co-infection. 2
• Do not continue bronchodilator therapy without documented clinical improvement. 2