How should respiratory syncytial virus infection be managed and prevented in healthy children under two years, high‑risk infants (premature <29 weeks gestation, chronic lung disease, congenital heart disease, immunodeficiency), and high‑risk adults?

Management and Prevention of RSV Infection

Prevention in Healthy Children Under Two Years

All infants under 8 months entering their first RSV season should receive nirsevimab, a single-dose long-acting monoclonal antibody that represents a major advance over older monthly prophylaxis. 1

• Nirsevimab is administered as a one-time intramuscular injection before or during RSV season (typically October through March in most of the continental United States). 1
• This recommendation is based on high-certainty evidence from phase 2b and 3 trials showing significant reduction in medically attended RSV lower respiratory tract infections and hospitalizations. 1
• Approximately 79% of infants hospitalized with RSV have no underlying medical conditions, making universal prophylaxis for this age group critical. 1

Universal Prevention Measures for All Infants

• Avoid all tobacco smoke exposure, as this is a controllable risk factor that significantly increases RSV hospitalization risk. 2
• Encourage breastfeeding to potentially decrease the risk of severe lower respiratory tract disease. 2, 3
• Limit exposure to crowds and group childcare during RSV season, particularly from November through March. 2
• Keep infants away from sick contacts and situations where exposure to infected individuals cannot be controlled. 2
• Ensure rigorous hand hygiene by all caregivers and family members, as RSV can survive on countertops for ≥6 hours and on skin for up to 20 minutes. 2

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Prevention in High-Risk Infants

Infants Requiring Prophylaxis in Second RSV Season

Children aged 8-19 months who are at increased risk for severe RSV disease entering their second RSV season should receive nirsevimab. 1

High-risk criteria include:

• Premature infants born ≤29 weeks gestation (especially ≤28 weeks) who are younger than 12 months at the start of RSV season. 2, 3
• Chronic lung disease/bronchopulmonary dysplasia requiring medical treatment (supplemental oxygen, diuretic therapy, or chronic corticosteroid therapy) within 6 months of RSV season onset. 2, 3
• Hemodynamically significant congenital heart disease. 2, 3
• Severe combined immunodeficiency (SCID) or suspected SCID. 2
• Neuromuscular disorders impairing secretion clearance. 2

Alternative: Palivizumab

For infants who cannot receive nirsevimab or in settings where it is unavailable:

• Palivizumab dosing: 15 mg/kg intramuscularly monthly throughout RSV season, maximum of 5 doses per season. 2
• Palivizumab reduces RSV hospitalization by 45-55% in high-risk populations. 2
• Critical limitation: Palivizumab has NO therapeutic benefit for treating established RSV infection—it is only for prevention. 2, 4

Special Consideration: Premature Infants by Gestational Age

• Born ≤28 weeks gestation: Receive prophylaxis during their first RSV season, whenever that occurs during the first 12 months of life. 2
• Born 29-31 weeks gestation: May benefit from prophylaxis up to 6 months of age. 2
• The rate of RSV-associated hospitalization among infants born at ≤30 weeks' gestation is three times that of term infants. 1

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Management of Acute RSV Infection in Children

Core Treatment Principles

RSV treatment in children is purely supportive care—there is no effective antiviral therapy for routine use in otherwise healthy or immunocompetent children. 2, 4, 3

Oxygen Therapy

• Provide supplemental oxygen if saturation falls persistently below 90% in previously healthy infants. 2, 4
• Low-flow oxygen via nasal cannula or face mask is typically sufficient. 5
• Patients on oxygen therapy should have at least 4-hourly observations including oxygen saturation monitoring. 5

Hydration Support

• Ensure adequate hydration through oral fluids if tolerated, or via nasogastric or intravenous routes if the infant cannot maintain adequate oral intake. 2, 4

Symptomatic Relief

• Acetaminophen or ibuprofen for fever and pain management as needed. 2, 4
• Nasal saline irrigation for symptomatic relief of upper respiratory symptoms. 2, 4

What NOT to Use

• Corticosteroids: Not recommended routinely in bronchiolitis management. 2
• Bronchodilators: Should not be continued without documented clinical improvement. 2
• Ribavirin: Should NOT be used routinely in otherwise healthy children with RSV bronchiolitis. 2
• Antibiotics: Only use when specific indications of bacterial co-infection exist. 2, 5

Hospitalization Criteria

Hospitalize if the infant has:

• Hypoxemia (SpO2 persistently <90%). 2, 4
• Signs of severe respiratory distress (retractions, grunting, flaring). 2, 4
• Inability to maintain adequate oral intake. 2, 4
• Underlying high-risk conditions (prematurity, chronic lung disease, congenital heart disease, immunodeficiency). 2, 4
• Age under 3 months (highest risk for severe disease). 4

ICU Transfer Criteria

Escalate to intensive care if:

• Worsening respiratory distress despite supplemental oxygen. 5
• Oxygen requirement of FiO2 ≥0.50 or inability to maintain SaO2 >92% in FiO2 >60%. 2
• Development of apnea or persistent grunting. 2, 5
• Altered mental status or lethargy. 2
• Rising PaCO2 (>6.5 kPa) or shock. 2

Discharge Criteria

Discharge when the patient meets ALL of the following:

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

Warning Signs for Return to Emergency Department

Parents should be instructed to return immediately if:

• Oxygen saturation falls below 90%. 2
• Increased work of breathing (visible chest retractions, flaring nostrils, grunting sounds). 2
• Rapid breathing that doesn't improve with rest. 2
• Difficulty breathing or appearing to struggle to breathe. 2
• Lethargy, difficulty waking, or altered mental status. 2

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Management in High-Risk Adults

RSV Vaccination

Adults aged ≥60 years should receive RSV vaccine, with priority given to those aged ≥75 years and those aged ≥50 years with risk factors if vaccine availability is limited. 2

Risk factors include:

• Chronic lung disease
• Chronic heart disease
• Immunocompromising conditions
• Diabetes mellitus
• Chronic kidney disease
• Chronic liver disease
• Nursing home residence

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Management in Immunocompromised Patients

Indications for Antiviral Therapy

Hematopoietic stem cell transplant (HSCT) recipients with RSV lower respiratory tract infection or at high risk for disease progression should receive ribavirin. 2, 4

Other high-risk immunocompromised groups who may benefit from ribavirin:

• Solid organ transplant recipients with severe RSV infection. 2
• Patients with profound lymphopenia (<100 cells/mm³). 2
• Patients receiving active chemotherapy for malignancy. 2
• Patients with HIV infection and significant immunosuppression. 2
• Patients on chronic high-dose corticosteroids or biologics. 2

Ribavirin Administration

Aerosolized Ribavirin (Preferred for Mechanically Ventilated Patients)

Dose options:

• 2 g administered over 2 hours every 8 hours, OR
• 6 g continuously over 18 hours per day for 7-10 days. 2

Adverse event monitoring:

• Watch for claustrophobia, bronchospasm, nausea, conjunctivitis, and declining pulmonary function. 2
• Implement environmental controls and protect pregnant healthcare workers from teratogenic exposure. 2

Systemic Ribavirin (Oral or Intravenous)

Dosing schedule:

• Day 1: 600 mg loading dose, then 200 mg every 8 hours. 2, 4
• Day 2: 400 mg every 8 hours. 2, 4
• Day 3 onward: Increase to maximum of 10 mg/kg every 8 hours. 2, 4
• Renal adjustment: For creatinine clearance 30-50 mL/min, maximum 200 mg every 8 hours. 2

Adverse event monitoring:

• Assess for hemolysis, abnormal liver function tests, and worsening renal function. 2

Combination Therapy for HSCT Patients

Consider combining ribavirin with intravenous immunoglobulin (IVIG) or anti-RSV-enriched antibody preparations for allogeneic HSCT recipients with RSV lower respiratory tract disease or at high risk for progression. 2

Timing Considerations

• Defer conditioning therapy for patients with RSV respiratory tract infection planned for allogeneic HSCT. 2
• Consider deferring chemotherapy for patients with RSV infection scheduled for hemato-oncological treatment. 2

Prophylaxis in Young HSCT Recipients

Monthly intramuscular palivizumab (15 mg/kg) throughout RSV season is recommended for very young (<2 years) allogeneic HSCT patients with lower respiratory tract disease or high risk of progression, though this recommendation is weak with limited supporting evidence. 2

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Infection Control Measures

Healthcare Settings

Hand hygiene is the single most important measure to prevent RSV transmission and nosocomial spread. 2, 4

• Hand decontamination before and after direct patient contact, after contact with objects near the patient, and after removing gloves. 2
• Alcohol-based rubs are preferred if hands are not visibly soiled. 2
• Wear gowns for direct contact with the patient. 2
• Use gloves with frequent changes to avoid spreading organisms on contaminated gloves. 2
• Implement droplet precautions for all children <2 years with respiratory symptoms during RSV season. 2, 4
• Restrict healthcare personnel with upper respiratory infections from caring for high-risk patients. 2
• Do not allow persons with respiratory infection symptoms to visit pediatric, immunosuppressed, or cardiac patients. 2

Isolation Duration

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

Environmental Considerations

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

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Common Pitfalls to Avoid

• Never use palivizumab or nirsevimab to treat active RSV infection—these are prophylactic agents only. 2, 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
• Do not use ribavirin routinely in otherwise healthy children with RSV bronchiolitis. 2
• Ensure adequate infection control measures to prevent nosocomial transmission. 2
• Do not discontinue isolation prematurely based on clinical improvement alone. 2