What is the recommended management of respiratory syncytial virus infection, including supportive care, indications for palivizumab (monoclonal antibody) prophylaxis, and use of aerosolized ribavirin in high‑risk or severely ill patients?

RSV Treatment

RSV treatment is primarily supportive care for most patients, with antiviral therapy (ribavirin) reserved exclusively for severely immunocompromised patients such as hematopoietic stem cell transplant recipients with lower respiratory tract disease. 1, 2, 3

Supportive Care (Cornerstone for All Patients)

Oxygen therapy is the primary intervention when needed:

• Provide supplemental oxygen if SpO2 falls persistently below 90% in previously healthy infants, targeting SpO2 >92% 1, 2, 3
• Standard low-flow oxygen delivery systems are appropriate for most patients 1, 3
• High-flow nasal cannula 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, 2, 3

Hydration and monitoring are essential:

• Assess and maintain adequate fluid intake for all patients 2
• Monitor oxygen saturation, respiratory rate, work of breathing, hydration status, ability to feed, and mental status 2, 3

Symptomatic relief can be provided with:

• Acetaminophen or ibuprofen for pain or fever management 2
• Nasal saline irrigation may provide symptomatic relief in adults with upper respiratory symptoms 2

Antiviral Therapy: Ribavirin (Highly Restricted Use)

Ribavirin should NOT be used routinely in children with RSV bronchiolitis due to marginal benefit, cumbersome delivery, potential health risks to caregivers, and high cost 1, 2, 3

Specific Indications for Ribavirin

Consider ribavirin ONLY in these populations:

• Hematopoietic stem cell transplant (HSCT) recipients with RSV lower respiratory tract infection or at high risk for progression 4, 1, 2
• Severely immunocompromised patients (e.g., profound lymphopenia <100 cells/mm³) 2
• Mechanically ventilated infants with documented severe RSV infection 2

Ribavirin Administration Options

Aerosolized ribavirin (preferred for mechanically ventilated patients):

• 2 g for 2 hours every 8 hours OR 6 g over 18 hours/day for 7-10 days 4
• Monitor for adverse events: claustrophobia, bronchospasm, nausea, conjunctivitis, declining pulmonary function 4
• Apply appropriate precautions to avoid environmental exposure and teratogenic effects in pregnant healthcare workers 4

Systemic ribavirin (oral or intravenous):

• Day 1: 600 mg loading dose, then 200 mg every 8 hours 4, 2
• Day 2: 400 mg every 8 hours 4, 2
• Day 3 onward: Increase to maximum of 10 mg/kg body weight every 8 hours 4, 2
• For renal impairment (creatinine clearance 30-50 mL/min): Maximum 200 mg every 8 hours 4, 2
• Monitor for adverse events: hemolysis, abnormal liver function tests, declining renal function 4, 2

Combination therapy for HSCT patients:

• Aerosolized or systemic ribavirin may be combined with IVIG or anti-RSV-enriched antibody preparations for allogeneic HSCT patients with RSV lower respiratory tract disease or at high risk for progression 4, 2

Palivizumab: Prevention ONLY, Not Treatment

Palivizumab has NO therapeutic benefit for treating established RSV infection—it is ONLY approved for prevention in high-risk infants and should never be used as treatment 2, 5

Prophylaxis Indications (Prevention)

Palivizumab prophylaxis (15 mg/kg IM monthly throughout RSV season) is indicated for:

• Infants born ≤28 weeks gestation who are <12 months old at the start of RSV season 2
• Infants with bronchopulmonary dysplasia requiring medical treatment within the previous 6 months and who are ≤24 months old 2, 5
• Children with hemodynamically significant congenital heart disease who are ≤24 months old 2, 5
• Very young (<2 years) allogeneic HSCT patients with lower respiratory tract disease or at high risk for progression (weak recommendation, limited evidence) 4

Palivizumab reduces RSV hospitalization by 45-55% in high-risk populations 2, 5

Timing Considerations for Immunocompromised Patients

Defer conditioning therapy for patients with RSV respiratory tract infection planned for allogeneic HSCT 4, 2

Consider deferring chemotherapy for patients with RSV infection scheduled for hemato-oncological treatment 4, 2

Infection Control (Critical for All Settings)

Hand hygiene is the single most important measure to prevent RSV transmission:

• Perform hand decontamination before and after direct patient contact, after contact with objects near the patient, and after removing gloves 1, 2, 3
• Alcohol-based rubs are preferred if hands are not visibly soiled 2, 3
• Wear gowns for direct patient contact and use gloves with frequent changes 4, 2

Droplet precautions should be implemented:

• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 1, 2
• RSV can survive on counter tops for ≥6 hours, on gowns for 20-30 minutes, and on skin for up to 20 minutes 2

Visitor restrictions:

• Do not allow persons with respiratory infection symptoms to visit pediatric, immunosuppressed, or cardiac patients 4, 2

Therapies NOT Recommended

Do NOT use routinely:

• Corticosteroids for bronchiolitis 2
• Bronchodilators without documented clinical improvement 2
• Antibacterial medications unless specific indications of bacterial co-infection exist 2

Escalation of Care Criteria

Consider ICU transfer if:

• Failure to maintain SaO2 >92% in FiO2 >60% 2, 3
• Shock or severe respiratory distress with rising PaCO2 (>6.5 kPa) 2
• Development of apnea or persistent grunting 2

Common Pitfalls to Avoid

• Never use palivizumab for treatment—it is only for prevention 2, 5
• Avoid overuse of antibiotics when there is no evidence of bacterial co-infection 2
• Do not continue bronchodilator therapy without documented clinical improvement 2
• Ensure adequate infection control measures to prevent nosocomial transmission 1, 2
• Do not use ribavirin routinely—reserve for severely immunocompromised patients only 1, 2, 3, 6