What is the appropriate management of respiratory syncytial virus infection based on patient age and risk factors?

Management of Respiratory Syncytial Virus Infection

RSV management is primarily supportive care across all age groups, with prevention through vaccination now the cornerstone for adults ≥60 years and high-risk populations, while palivizumab prophylaxis remains indicated for specific high-risk infants and young children. 1, 2

Infants and Young Children

High-Risk Infants Requiring Palivizumab Prophylaxis

Palivizumab should be administered at 15 mg/kg intramuscularly monthly throughout RSV season for: 2

• Infants born ≤35 weeks gestational age who are ≤6 months old at RSV season onset 2
• Children ≤24 months with bronchopulmonary dysplasia requiring medical treatment within the previous 6 months 2
• Children ≤24 months with hemodynamically significant congenital heart disease 2
• Children with Down syndrome during their first 2 years of life, particularly those with concurrent cardiopulmonary disease (hospitalization rate 67/1000 child-years with risk factors vs 42/1000 without) 1

Important caveat: Children undergoing cardiopulmonary bypass require an additional dose immediately post-procedure, even if less than one month from the previous dose. 2

Immunocompromised Children

Profound lymphopenia (<100 cells/mm³) is the critical marker for progression to severe disease, not the degree of immunosuppression itself. 1

• HSCT recipients have 40-60% progression to lower respiratory tract infection with mortality up to 8.6% 1
• Children receiving chemotherapy for acute lymphoblastic leukemia have surprisingly low mortality despite severe immunosuppression 1
• Solid organ transplant recipients show variable outcomes but generally better than HSCT recipients 1

Acute Management in Children

Treatment is entirely supportive—there is no role for antivirals or corticosteroids in routine pediatric RSV management. 3, 4

• Hydration maintenance (oral or IV as needed) 4
• Supplemental oxygen for saturations <90-92% 5
• Mechanical ventilation only for respiratory failure 4

Recovery timeline counseling is critical to prevent unnecessary antibiotic use: 5

• Fever and systemic symptoms resolve within 5 days 5
• Cough and nasal congestion persist 2-3 weeks in most children—this is normal and does NOT indicate bacterial superinfection 5
• 7-13% of children have symptoms lasting >15 days, which remains consistent with uncomplicated RSV 5

Adults ≥60 Years and High-Risk Adults

Vaccination Strategy (Primary Prevention)

All adults ≥75 years should receive RSV vaccination regardless of comorbidities, and adults 60-74 years with any risk factor should be vaccinated. 1, 3

Risk factors mandating vaccination in adults 60-74 years include: 1, 3

• Chronic obstructive pulmonary disease or asthma 1
• Heart failure or coronary artery disease 1
• Diabetes mellitus 1
• Chronic kidney disease 1
• Chronic liver disease 1
• Immunocompromise (including chronic corticosteroids ≥10 mg prednisone daily) 1, 3
• Frailty or dementia 1
• Residence in nursing home or long-term care facility 1

Optimal timing: Administer between September and November, before RSV season onset. 1, 3

Co-administration: RSV vaccine can be given simultaneously with influenza vaccine at different injection sites. 1

Available vaccines: 1, 3

• RSVPreF3 (Arexvy, GSK): Approved for adults ≥50 years with risk factors and all adults ≥60 years, with efficacy maintained for at least 3 seasons 1
• RSVpreF (Abrysvo, Pfizer): Approved for adults ≥60 years, with efficacy maintained for at least 2 seasons 1

Acute Management in Adults

Treatment remains entirely supportive—no FDA-approved antivirals exist for RSV in adults. 3, 4

• Oxygen supplementation to maintain saturations ≥90% 3
• Aggressive management of underlying COPD or asthma exacerbations per standard protocols 3
• Hydration and antipyretics 6
• Mechanical ventilation for respiratory failure 4

Diagnostic testing with RT-PCR is recommended for: 3

• All immunocompromised adults with respiratory symptoms during RSV season 3
• Adults ≥75 years with lower respiratory tract symptoms 3
• Adults with multiple comorbidities requiring hospitalization 3

Special Consideration: Immunocompromised Adults

Immunocompromised adults face dramatically elevated mortality, with 90-day mortality reaching 52.8% among those requiring ICU admission. 1, 3

Highest risk immunocompromised populations: 1

• HSCT recipients (40-60% progression to lower respiratory tract disease, mortality up to 80%) 1
• Lung transplant recipients 1
• Patients with hematological malignancies (OR 5.17 for hospitalization) 1
• Patients with solid tumors (OR 5.2 for hospitalization) 1
• HIV-infected individuals with CD4 <200 cells/mm³ (18-fold increased hospitalization risk) 1
• Patients on chronic immunosuppressive therapy including corticosteroids ≥10 mg prednisone daily 1, 3

Management algorithm for immunocompromised adults: 3

1. Immediate vaccination if not previously vaccinated (all adults ≥75 years on any immunosuppression; adults 60-74 years with moderate immunosuppression) 3
2. If acute RSV infection occurs: Primarily supportive care with close monitoring for progression to lower respiratory tract disease 3
3. For patients on chronic corticosteroids: Continue baseline dose to prevent adrenal crisis; consider stress-dose corticosteroids only if severe illness requiring ICU admission develops 3
4. Off-label ribavirin consideration: For severely immunocompromised adults (particularly HSCT recipients), aerosolized or oral ribavirin combined with intravenous immunoglobulin has been used based on observational data, though evidence remains limited and it is not FDA-approved for this indication 3

Prognostic Factors in Older Adults

Age ≥75 years independently predicts worse outcomes: 1, 7

• Hospitalization rates: 210/100,000 for ages 75-84 years; 343/100,000 for ages ≥85 years 1, 7
• In-hospital mortality: 4.6% for ages 60-74 years; 6.1% for ages ≥75 years 1, 7
• 3.64-fold increased risk of serious outcomes (hospitalization, ED visit, pneumonia) in ages ≥75 vs 60-64 years 1, 7
• Longer hospitalization duration (aHR 0.74) and poorer 30-day survival (aHR 2.85) for age >75 years 1

Additional independent mortality predictors: 1

• Dementia (aHR 1.86 for mid- to long-term mortality) 1
• Lymphoma within 12 months (aHR 3.87 for short-term mortality; aHR 3.57 for mid- to long-term mortality) 1
• Residence in skilled nursing facility at admission (4.43-fold greater likelihood of severe infection) 1

Critical Pitfalls to Avoid

Do not prescribe antibiotics for persistent cough and congestion lasting 2-3 weeks in children—this is the normal RSV recovery course. 5

Do not use corticosteroids routinely in RSV management—they provide no benefit and may delay viral clearance, particularly in adults on chronic corticosteroids. 3

Do not assume degree of immunosuppression correlates with RSV severity—profound lymphopenia (<100 cells/mm³) is the key marker, not the underlying condition. 1

Do not withhold palivizumab from children with Down syndrome without cardiopulmonary disease—their hospitalization rate (42/1000 child-years) significantly exceeds the general population (12/1000 child-years). 1

Palivizumab is for prevention only, not treatment of active RSV infection. 2