What is the recommended management of respiratory syncytial virus infection, including supportive care, indications for ribavirin and palivizumab, and treatment considerations for high‑risk infants, adults, and immunocompromised patients?

RSV Management

Primary Management Approach

The cornerstone of RSV management is supportive care—adequate hydration, supplemental oxygen when SpO₂ falls persistently below 90%, and symptomatic relief with acetaminophen or ibuprofen for fever. 1 Most RSV infections are self-limited viral illnesses resolving within 10–14 days without specific antiviral therapy. 2

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Supportive Care Essentials

Oxygen and Respiratory Support

• Administer supplemental oxygen if SpO₂ persistently falls below 90% in previously healthy infants, targeting maintenance above 92%. 1, 3
• Deliver oxygen via nasal cannula, head box, or face mask as needed. 3
• High-flow nasal oxygen (HFNO) is the first-line escalation when standard oxygen supplementation fails, but only in monitored settings with personnel capable of intubation. 1, 3
• Early intubation and mechanical ventilation should be considered if respiratory distress worsens, oxygen requirements exceed FiO₂ >60%, or recurrent apnea develops. 1, 3

Hydration and Nutrition

• Assess and maintain adequate fluid intake; use nasogastric or intravenous routes if the child cannot maintain oral intake. 1, 3
• Monitor for signs of dehydration (decreased urine output, dry mucous membranes, lethargy). 2

Symptomatic Relief

• Use acetaminophen or ibuprofen for fever or discomfort. 2, 1, 3
• Nasal saline irrigation may provide symptomatic relief in adults and older children. 2, 1
• Perform gentle nasopharyngeal suctioning only when nasal secretions obstruct breathing—avoid routine aggressive suctioning. 3

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What NOT to Use

Ineffective Therapies

• Do NOT use bronchodilators routinely—they provide no consistent benefit in RSV bronchiolitis. 1, 3
• Do NOT use corticosteroids—they offer no benefit for mortality, morbidity, or quality of life. 1, 3
• Do NOT prescribe antibiotics unless there is documented bacterial co-infection (e.g., consolidation on chest X-ray, persistent high fever, elevated inflammatory markers). 2, 1, 3
• Steam inhalation is ineffective for RSV and should not be recommended. 2

Critical Misuse to Avoid

• Palivizumab has NO therapeutic benefit for treating established RSV infection—it is FDA-approved only for prevention in high-risk infants and must never be used as treatment. 1, 4

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Ribavirin: Indications and Administration

Who Should Receive Ribavirin

Ribavirin is reserved for severely immunocompromised patients, particularly hematopoietic stem cell transplant (HSCT) recipients with RSV lower respiratory tract infection or those at high risk for progression. 1, 5

Specific High-Risk Populations:

• HSCT recipients with RSV lower respiratory tract disease or at high risk for progression. 1
• Solid organ transplant recipients with severe RSV infection. 1
• Patients with profound lymphopenia (<100 cells/mm³)—strong predictor of progression to lower respiratory tract disease. 1
• Mechanically ventilated infants with documented severe RSV infection. 1, 5

Ribavirin Administration Routes

Aerosolized Ribavirin (Preferred for Mechanically Ventilated Patients)

• Dosing options: 2 g over 2 hours every 8 hours, or 6 g continuously over 18 hours per day for 7–10 days. 1
• Monitor for adverse events: claustrophobia, bronchospasm, nausea, conjunctivitis, declining pulmonary function. 1
• Safety precautions: Implement environmental controls and protect pregnant healthcare workers from teratogenic exposure. 1, 5

Systemic Ribavirin (Oral or Intravenous)

• Day 1: 600 mg loading dose, then 200 mg every 8 hours. 1
• Day 2: 400 mg every 8 hours. 1
• Day 3 onward: Increase to maximum 10 mg/kg every 8 hours. 1
• Renal adjustment: For creatinine clearance 30–50 mL/min, limit to 200 mg every 8 hours. 1
• Monitor for adverse events: hemolysis, abnormal liver function tests, declining renal function. 1

Combination Therapy for HSCT Patients

• Consider combining ribavirin with intravenous immunoglobulin (IVIG) or anti-RSV-enriched antibody preparations in allogeneic HSCT recipients with RSV lower respiratory tract disease or high risk of progression. 1

Timing Considerations

• Defer conditioning therapy for patients with RSV respiratory tract infection planned for allogeneic HSCT. 1
• Consider deferring chemotherapy for patients with RSV infection scheduled for hemato-oncological treatment. 1

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Palivizumab Prophylaxis (Prevention Only)

FDA-Approved Indications

Palivizumab is indicated ONLY for prevention of serious lower respiratory tract disease caused by RSV in specific high-risk pediatric populations. 4

Eligible Populations:

• Infants born ≤28 weeks gestation who are <12 months old at the start of RSV season. 1, 4
• Infants with bronchopulmonary dysplasia (BPD) requiring medical treatment (supplemental oxygen, diuretics, or chronic corticosteroids) within 6 months of RSV season onset, who are ≤24 months old. 1, 4
• Children ≤24 months old with hemodynamically significant congenital heart disease. 1, 4
• Patients with severe combined immunodeficiency (SCID) or suspected SCID during RSV season. 1

Dosing and Administration

• 15 mg/kg intramuscularly monthly throughout RSV season (typically November through April in the Northern Hemisphere), maximum 5 doses per season. 1, 4
• Administer preferably in the anterolateral aspect of the thigh; avoid the gluteal muscle due to risk of sciatic nerve damage. 4
• Children undergoing cardiopulmonary bypass should receive an additional dose as soon as possible after the procedure, then continue monthly dosing. 4

Efficacy

• Palivizumab reduces RSV hospitalization by 45–55% in high-risk populations. 1
• No randomized trial has shown statistically significant reduction in RSV-related mortality. 1

Limitations

• Palivizumab has minimal effect on overall RSV disease burden because most RSV hospitalizations occur in healthy term infants who are not eligible for prophylaxis. 1
• Prophylaxis is NOT recommended during the second year of life for most children—RSV hospitalization rates in the second year are less than half the rate in low-risk infants during the first five months of life. 1

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High-Risk Populations Requiring Vigilant Monitoring

Infants and Children

• Premature infants (≤35 weeks gestation, especially ≤28 weeks)—at highest risk for severe disease. 1, 3
• Chronic lung disease or bronchopulmonary dysplasia requiring medical treatment within the previous 6 months. 2, 1
• Hemodynamically significant congenital heart disease, especially conditions causing pulmonary hypertension. 2, 1
• Neuromuscular disorders impairing secretion clearance. 1

Immunocompromised Patients

• HSCT recipients—require aggressive management including consideration of ribavirin therapy. 1
• Solid organ transplant recipients—may require intensive care and ribavirin therapy. 1
• Patients with profound lymphopenia (<100 cells/mm³)—strong predictor of progression to lower respiratory tract disease. 1
• Active chemotherapy for malignancy—close monitoring for respiratory complications. 1
• HIV infection with significant immunosuppression—prompt treatment including consideration of antiviral therapy. 1
• Chronic immunosuppressive therapy (high-dose corticosteroids or biologics)—close monitoring for respiratory complications. 1

Adults

• Advanced age (≥75 years)—increased risk of severe disease. 2
• Chronic conditions including COPD, asthma, heart failure, diabetes, chronic kidney disease. 2

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Infection Control Measures

Hand Hygiene (Most Important Measure)

• Hand decontamination before and after patient contact is the single most important infection control measure. 1
• Use alcohol-based rubs when hands are not visibly soiled. 1
• Perform hand hygiene after contact with objects near the patient and after removing gloves. 1

Personal Protective Equipment

• Wear gowns for direct patient contact. 1
• Use gloves with frequent changes to prevent organism spread on contaminated gloves. 1

Isolation Precautions

• Maintain contact and droplet precautions throughout hospitalization for all RSV-positive patients. 1
• RSV can survive on countertops for ≥6 hours, on gowns for 20–30 minutes, and on skin for up to 20 minutes. 1
• Viral shedding typically continues for 1–3 weeks in infants and young children, even as symptoms improve. 1

Visitor Restrictions

• Restrict healthcare personnel with upper respiratory infections from caring for high-risk patients. 1
• Do not allow persons with respiratory symptoms to visit pediatric, immunosuppressed, or cardiac patients. 1

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When to Hospitalize

Hospitalization Criteria

• Hypoxemia (SpO₂ persistently <90%) in room air. 1
• Signs of severe respiratory distress (visible chest retractions, flaring nostrils, grunting). 1, 3
• Inability to maintain adequate oral intake or signs of dehydration. 2, 1
• Underlying high-risk conditions (prematurity, chronic lung disease, congenital heart disease, immunocompromised status). 1
• Recurrent apnea or altered mental status. 1, 3

ICU Transfer Criteria

• Failure to maintain SaO₂ >92% in FiO₂ ≥60%. 1
• Shock or severe respiratory distress with rising PaCO₂ (>6.5 kPa). 1
• Worsening respiratory distress despite supplemental oxygen. 1
• Development of apnea or persistent grunting. 1

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Discharge Criteria

Readiness for Discharge

• Oxygen saturation consistently >90% in room air for at least 12–24 hours. 1
• Clinical improvement: better activity level, improved appetite, decreased or absent fever for at least 12–24 hours. 1
• Normal or baseline mental status. 1
• Absence of substantially increased work of breathing, sustained tachypnea, or tachycardia. 1

Warning Signs for Return to Emergency Department

• SpO₂ falls below 90%. 1
• Increased work of breathing (visible chest retractions, flaring nostrils, grunting). 1
• Rapid breathing that doesn't improve with rest. 1
• Lethargy, difficulty waking, or altered mental status. 1

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Prevention Strategies

Universal Measures for All Infants

• Avoid tobacco smoke exposure completely—it is a controllable risk factor that increases RSV hospitalization risk. 1
• Encourage breastfeeding—may decrease the risk of lower respiratory tract disease. 2, 1
• Limit exposure to crowds and group childcare during RSV season (November through March in most regions). 1
• Keep infants away from sick contacts. 1
• Ensure influenza vaccination for the infant (starting at 6 months) and all household contacts. 1

Newer Prevention Options

• Nirsevimab (long-acting monoclonal antibody) is now recommended for all infants <8 months entering their first RSV season. 1
• RSV vaccination is recommended for adults ≥60 years, especially those with risk factors; priority should be given to individuals ≥75 years and those ≥50 years with risk factors if vaccine availability is limited. 1

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Common Pitfalls to Avoid

• Overuse of antibiotics when there is no evidence of bacterial co-infection. 1
• Continuing bronchodilator therapy without documented clinical improvement. 1
• Inadequate infection control measures leading to nosocomial transmission. 1
• Using palivizumab as treatment for established RSV infection—it has no therapeutic benefit. 1, 4
• Discontinuing isolation based on clinical improvement alone—viral shedding persists even as symptoms improve. 1