What is the appropriate management for an 89‑year‑old woman who tests positive for respiratory syncytial virus?

Management of RSV-Positive 89-Year-Old Woman

Provide supportive care as the primary treatment, ensure close monitoring for respiratory deterioration, and plan for RSV vaccination once the acute infection resolves. 1, 2

Immediate Management: Supportive Care

The cornerstone of treatment for RSV in elderly patients is supportive care, as there are no FDA-approved antiviral treatments for RSV in adults. 1

Respiratory Support

• Administer supplemental oxygen to maintain adequate oxygen saturation, which is critical given the patient's advanced age and high risk for respiratory compromise. 2
• Monitor closely for progression to lower respiratory tract disease, as mortality rates reach 6.1% in hospitalized patients ≥75 years. 1
• Be prepared for potential mechanical ventilation needs, as 12.3% of hospitalized RSV patients require mechanical ventilation and 26.9% require ICU-level care. 3

General Supportive Measures

• Ensure adequate hydration support and monitor for signs of respiratory deterioration. 2
• Consider bronchodilators if bronchospasm develops or if the patient has underlying reactive airway disease. 2
• Maintain standard infection control practices including hand hygiene and isolation precautions. 4, 5

Critical Monitoring Parameters

Watch for Cardiovascular Complications

At 89 years old, this patient faces substantial cardiovascular risk:

• Acute cardiac events occur in 22.4% of hospitalized RSV patients, rising to 33% in those with pre-existing cardiovascular disease. 6
• Monitor for heart failure exacerbation, which independently increases mid- to long-term mortality (adjusted HR 1.86). 6
• Watch for atrial fibrillation, which increases short-term mortality (adjusted HR 1.66). 6

Age-Specific Risk Stratification

• Patients ≥75 years have a 30-day mortality hazard ratio of 2.85 compared to younger adults. 1, 6
• The overall mortality rate is 6.1% in those ≥75 years who require hospitalization. 1

Antibiotic Stewardship

When to Initiate Antibiotics

Do NOT routinely prescribe antibiotics for RSV infection alone, as this is a viral illness. 1

Antibiotics are indicated ONLY when:

• Documented bacterial co-infection is confirmed by positive blood, sputum, or bronchoscopy cultures. 1
• Strong clinical evidence of secondary bacterial pneumonia exists (new infiltrate on chest X-ray plus purulent sputum). 1
• Clinical deterioration after initial improvement suggests superimposed bacterial infection. 1

Diagnostic Steps Before Antibiotics

• Obtain two sets of blood cultures before starting antibiotics. 1
• Perform sputum Gram stain and culture when purulent sputum is available. 1
• Acquire a chest X-ray to evaluate for new infiltrates. 1

Important Caveat

Re-evaluate antibiotic necessity within 48-72 hours after RSV confirmation and culture results; discontinue if no bacterial infection is identified. 1 Despite this guidance, antibiotics are inappropriately used in 76.3% of RSV inpatients, highlighting a common pitfall to avoid. 3

Special Considerations for Immunocompromised Patients

If this patient is on immunosuppressive medications (e.g., corticosteroids ≥10mg prednisone daily):

• She faces significantly elevated risk with hospitalization rates of 1,288-1,562 per 100,000 and 90-day mortality rates reaching 52.8% among those requiring ICU admission. 1
• For severely immunocompromised adults, off-label ribavirin (aerosolized or oral) combined with intravenous immunoglobulin has been used based on observational data showing improved survival, though it is not FDA-approved for this indication. 1, 4, 5

Prevention for Future Episodes

RSV Vaccination Recommendation

Once the acute infection resolves, administer a single lifetime dose of RSV vaccine. 2

At 89 years old, this patient meets universal vaccination criteria regardless of comorbidities:

• All adults ≥75 years should receive RSV vaccination due to significantly elevated rates of hospitalization, severe disease, and mortality. 1, 6
• Available vaccines include RSVPreF3 (Arexvy) or RSVpreF (Abrysvo), both administered as a single intramuscular dose. 7, 1

Optimal Timing

• Administer vaccination in late summer or early fall (August-October), just before RSV season begins. 1, 6
• The vaccine can be co-administered with seasonal influenza vaccine at different injection sites. 1, 6

Vaccine Efficacy

• RSVPreF3 demonstrates 82.6% efficacy against RSV-associated lower respiratory tract disease and 94.1% efficacy against severe disease in the first season. 7, 6
• Protection is sustained for at least two consecutive RSV seasons with a single dose. 6

Common Pitfalls to Avoid

1. Do not prescribe antibiotics empirically without evidence of bacterial co-infection—this is a viral illness. 1, 3
2. Do not delay vaccination once acute infection resolves; previous RSV infection does not confer long-lasting immunity. 6
3. Do not underestimate cardiovascular risk—monitor closely for cardiac complications given the 22.4% incidence of acute cardiac events. 6
4. Do not assume mild disease—at 89 years, this patient has a 2.85-fold increased mortality risk compared to younger adults. 1, 6