What is the recommended treatment for respiratory syncytial virus (RSV) infection in adults, including supportive care for healthy individuals and antiviral and adjunctive therapy for immunocompromised patients with lower respiratory tract infection?

RSV Treatment in Adults

For healthy adults with RSV infection, treatment is entirely supportive care with hydration, antipyretics, and oxygen supplementation as needed; there are no approved antivirals for routine use in immunocompetent adults. 1, 2

Treatment Approach by Patient Population

Healthy Immunocompetent Adults

Supportive care is the standard of care for RSV infection in healthy adults. 1, 2 This includes:

• Hydration (oral or intravenous depending on severity) 2
• Antipyretics for fever management 2
• Supplemental oxygen when hypoxemia is present 2
• Mechanical ventilation only in cases of severe respiratory distress requiring hospitalization 3

Most RSV cases in healthy adults can be managed as outpatients without specific antiviral therapy. 3

Immunocompromised Adults with Lower Respiratory Tract Infection

For immunocompromised patients with RSV lower respiratory tract disease, early combination therapy with ribavirin and intravenous immunoglobulin improves survival. 1

The treatment algorithm for high-risk immunocompromised patients should be:

• Initiate ribavirin (aerosolized formulation) early in the disease course 1
• Add intravenous immunoglobulin (hyperimmune or standard) concurrently 1
• Provide aggressive supportive care including oxygen support and monitoring for respiratory decompensation 1, 2

Critical caveat: Ribavirin use is limited by issues with efficacy, safety profile, and high cost, and it is not effective for routine use in immunocompetent patients. 4, 5 The evidence supporting ribavirin is primarily from older studies, and subsequent trials have shown conflicting results in non-immunocompromised populations. 5

Therapies NOT Recommended

Bronchodilators

Nebulized bronchodilators have no role in routine RSV treatment. 5 While individual patients may experience short-term symptom relief, there is insufficient evidence for standard use, and bronchodilators do not reduce hospitalization rates or duration of stay. 5

Corticosteroids

Corticosteroids are not effective for mild RSV infection and should not be used routinely. 5 There are limited indications that corticosteroids might benefit patients with more severe RSV lower respiratory tract infection, but the evidence remains insufficient for routine recommendation. 5

Ribavirin in Immunocompetent Adults

Ribavirin has not been proven effective in immunocompetent adults and should not be used outside of immunocompromised populations with severe disease. 4, 5

Immunoglobulins for Treatment

Immunoglobulins (including palivizumab) have no therapeutic role once RSV infection is established in adults; they are effective only for prophylaxis in high-risk pediatric populations. 4, 5

Prevention: The Most Effective Strategy

Prevention through vaccination is far more effective than treatment for RSV in adults. 6, 7

Vaccination Recommendations

All adults aged ≥75 years should receive a single lifetime dose of RSV vaccine regardless of comorbidities. 6, 7

Adults aged 60-74 years should receive RSV vaccination if they have any of the following risk factors: 6, 7

• Chronic cardiovascular disease (heart failure, coronary artery disease) 6
• Chronic lung disease (COPD, asthma, interstitial lung disease) 6
• End-stage renal disease or dialysis dependence 6
• Diabetes with complications (requiring insulin or with end-organ damage) 6
• Chronic liver disease (cirrhosis) 6
• Moderate or severe immunocompromise 6
• Severe obesity (BMI ≥40 kg/m²) 6
• Neurologic conditions causing impaired airway clearance 6
• Nursing home residence 6

Adults aged 50-59 years with risk factors should receive RSVPreF3 (Arexvy), the only vaccine approved for this age group. 7, 8

Vaccination Administration

• Single lifetime dose administered intramuscularly 7, 8
• Optimal timing: September through November before RSV season begins 7, 8
• Can be co-administered with influenza vaccine at different injection sites 7, 8
• No booster doses currently recommended as protection lasts at least two RSV seasons 7, 8

High-Risk Populations Requiring Close Monitoring

Elderly patients with pre-existing cardiovascular disease require vigilant monitoring for cardiac complications during RSV infection. 7 Acute cardiac events occur in 22.4% of hospitalized RSV patients, with rates reaching 33% in those with cardiovascular disease. 7

Patients aged ≥75 years have significantly worse outcomes with 30-day mortality hazard ratio of 2.85 compared to younger adults. 7

Key Clinical Pitfalls to Avoid

• Do not delay supportive care while awaiting viral confirmation – RSV diagnosis in adults is difficult due to low viral titers, and most cases go unrecognized 1
• Do not use ribavirin in immunocompetent patients – it is ineffective and costly outside of immunocompromised populations 4, 5
• Do not withhold vaccination from eligible patients due to lack of documentation – patient attestation of risk factors is sufficient 6, 7
• Do not assume prior RSV infection provides lasting immunity – reinfection is common and does not contraindicate vaccination 7, 8