What is the appropriate management for an otherwise healthy adult with respiratory syncytial virus infection?

Management of RSV in Otherwise Healthy Adults

For an otherwise healthy adult with RSV infection, treatment is entirely supportive with no specific antiviral therapy indicated, focusing on adequate hydration, supplemental oxygen if SpO2 falls below 90%, acetaminophen or ibuprofen for symptom relief, and nasal saline irrigation for upper respiratory symptoms. 1

Why No Specific Treatment Exists

There is no antiviral agent with established efficacy for treating RSV in immunocompetent adults 2. Unlike influenza, where neuraminidase inhibitors have proven benefit, RSV lacks effective pharmacologic interventions once infection is established 1. This makes prevention through vaccination the cornerstone of RSV management rather than treatment of active infection 1.

Supportive Care Measures

Symptomatic Management

• Hydration assessment and adequate fluid intake are essential components of supportive care 1
• Acetaminophen or ibuprofen should be used for fever and pain management 1
• Nasal saline irrigation provides symptomatic relief of upper respiratory symptoms 1

Respiratory Support

• Standard supplemental oxygen should be administered if SpO2 persistently falls below 90% 1
• High-flow nasal oxygen may be considered in selected patients with hypoxemic respiratory failure, but only in monitored settings 1
• Non-invasive ventilation in patients with severe RVI causing acute hypoxemic respiratory failure is associated with high likelihood of transition to invasive ventilation, so careful patient selection is critical 3

When to Consider More Aggressive Management

Immunocompromised Patients (NOT Your Question, But Important Context)

The management paradigm changes dramatically for immunocompromised patients. In this population:

• Ribavirin is the only antiviral option, reserved exclusively for severely immunocompromised patients with lower respiratory tract involvement 1
• Aerosolized ribavirin is the primary option for hematopoietic stem cell transplant patients with RSV lower respiratory tract disease 1
• Early therapy with ribavirin and intravenous gamma-globulin improves survival in immunocompromised persons 4, 5

However, for your otherwise healthy adult patient, ribavirin is NOT indicated 1.

Infection Control to Prevent Transmission

• Hand hygiene is the single most important measure to prevent RSV transmission, with alcohol-based hand rubs used before and after patient contact 1
• Droplet precautions can reduce nosocomial transmission by 39-50% 1
• Gowns should be used for direct patient contact 1
• Education about hand sanitation is crucial for personnel and family members 1

Clinical Monitoring

Patients should be monitored for:

• Worsening dyspnea or hypoxemia requiring escalation of respiratory support 1
• Signs of bacterial superinfection, which would warrant empiric antibiotics covering S. pneumoniae, S. aureus, and H. influenzae (similar to influenza management) 2
• Exacerbations of underlying chronic conditions if present, as RSV commonly triggers decompensation of cardiopulmonary disease 2

Prevention: The Real Strategy

Since no effective treatment exists for established RSV infection in adults, vaccination represents the primary management strategy 1. Current guidelines recommend:

• All adults ≥60 years should receive RSV vaccination 1, 6
• Adults aged 50-59 years with risk factors (COPD, asthma, heart failure, diabetes, chronic kidney disease, immunocompromise) should receive RSV vaccination 1, 6
• Single lifetime dose administered preferably between September and November 1, 6
• Can be co-administered with influenza vaccine at different injection sites 1, 6

Common Pitfalls to Avoid

• Do not prescribe antivirals like oseltamivir (used for influenza) as they have no activity against RSV 2
• Do not routinely use corticosteroids unless indicated for another condition, as their use in viral pneumonia may be harmful 2
• Do not use RSV antigen detection tests in adults as they are insensitive for detecting infections in this population 2
• Do not delay supportive care while waiting for viral testing confirmation, as clinical diagnosis is often sufficient 2