In an inpatient setting, what are the recommended respiratory syncytial virus (RSV) testing methods for a healthy 50‑year‑old woman?

RSV Testing in a Healthy 50-Year-Old Woman in an Inpatient Setting

RSV testing is generally not recommended for a healthy 50-year-old woman in an inpatient setting unless she presents with acute respiratory symptoms or has specific risk factors that would change clinical management or infection control practices. 1

Risk-Based Testing Algorithm

The decision to test should follow a risk-stratified approach based on clinical presentation, comorbidities, and institutional needs:

Do NOT test if:

• The patient is asymptomatic or admitted for non-respiratory reasons 1
• The patient has mild upper respiratory symptoms without comorbidities and testing will not change management 1
• Testing is requested solely for screening purposes in a healthy individual 1

Consider testing if:

• The patient develops new respiratory symptoms (cough, shortness of breath, wheezing, nasal congestion) during hospitalization 2
• Underlying chronic cardiac or pulmonary disease is present, even with mild symptoms 1, 2
• The patient is immunocompromised (transplant recipient, on immunosuppressive therapy, hematologic malignancy) 1, 2
• Infection control needs require cohorting patients with similar viral infections due to limited bed space 1
• The patient is critically ill in the ICU with respiratory symptoms 1

Recommended Testing Method (If Indicated)

Nucleic acid amplification testing (NAAT/RT-PCR) from a nasopharyngeal swab is the gold-standard diagnostic method and should be the first-line test. 2

Specific testing options include:

• Multiplex PCR panels that detect RSV along with influenza and other respiratory viruses (e.g., FilmArray Respiratory Panel, ePlex Respiratory Pathogen Panel) are preferred in hospital settings for comprehensive viral diagnosis 1, 2
• Targeted multiplex assays for influenza A/B plus RSV (e.g., Xpert Flu/RSV XC) offer a cost-effective alternative 1
• Sample-to-answer NAAT methods with turnaround times of approximately 1 hour are acceptable for hospitalized patients 1

Specimen collection:

• Nasopharyngeal swab or nasal aspirate is the standard specimen for immunocompetent adults 2
• Lower respiratory tract specimens (bronchoalveolar lavage fluid or endotracheal aspirate) should be obtained if the patient is immunocompromised or critically ill, as upper respiratory specimens have markedly lower sensitivity (nasal wash: 15% vs. BAL: 88.9%) 1, 2

Testing Methods to Avoid

Rapid antigen detection tests (RADTs) should not be used in adults due to suboptimal sensitivity (40-80%), which is significantly lower than in children. 1, 2

• Direct fluorescent antibody (DFA) testing has been largely replaced by more sensitive molecular methods 1
• Viral culture is time-consuming and has been supplanted by NAAT 2
• Serology is not useful for acute diagnosis and should not be used 2

Critical Pitfalls to Avoid

Do not order testing based solely on patient location (inpatient status) without considering clinical presentation and risk factors. 1

• Testing should be restricted based on patient location and clinical information to promote appropriate ordering habits 1
• Complex multiplex PCR assays should be reserved for the most ill patients with associated comorbidities, not healthy individuals 1
• In a healthy 50-year-old without respiratory symptoms or risk factors, testing represents low-value care and should not be performed 1
• If testing is performed in an immunocompromised patient, do not rely solely on upper respiratory specimens—obtain lower respiratory samples for higher diagnostic yield 1, 2

Institutional Considerations

Laboratories should work with clinical partners to establish risk-based algorithms using electronic medical record decision trees that incorporate patient location, clinical information, and demographic identifiers to streamline appropriate test selection. 1