Respiratory syncytial virus infection: Treatment in infants and children

INTRODUCTION — Respiratory syncytial virus (RSV) causes acute respiratory tract illness in persons of all ages. Almost all children are infected by two years of age, and reinfection is common [1]. The clinical manifestations vary with age, health status, and whether the infection is primary or secondary.

The treatment of RSV in infants, children, and adults will be discussed here. The discussion assumes that the patient's illness is severe enough to require hospital admission and/or to pursue an etiologic diagnosis since specific etiologic diagnosis is usually not sought in otherwise healthy patients with mild respiratory tract infections who are treated symptomatically as outpatients. (See "Respiratory syncytial virus infection: Clinical features and diagnosis in infants and children", section on 'Diagnosis'.)

Related topics include:

●(See "Respiratory syncytial virus infection: Clinical features and diagnosis in infants and children" and "Respiratory syncytial virus infection: Prevention in infants and children".)

●(See "Bronchiolitis in infants and children: Clinical features and diagnosis" and "Bronchiolitis in infants and children: Treatment, outcome, and prevention".)

●(See "The common cold in children: Management and prevention" and "The common cold in adults: Treatment and prevention".)

SUPPORTIVE CARE — Therapy for RSV infection of the lower respiratory tract is primarily supportive [2,3]. Supportive care for patients with RSV lower respiratory tract infection includes frequent monitoring of clinical status and provision of fluid and respiratory support as necessary. The supportive care and inpatient treatment for bronchiolitis and pneumonia are discussed in detail separately. (See "Bronchiolitis in infants and children: Treatment, outcome, and prevention", section on 'Moderate to severe bronchiolitis (inpatient management)' and "Pneumonia in children: Inpatient treatment", section on 'Supportive care'.)

Mechanical ventilation may be required in patients with severe respiratory symptoms and/or apnea due to RSV. The frequency of mechanical ventilation varies according to age and underlying health status from approximately 5 percent in infants hospitalized with RSV to up to 50 percent of adults with leukemia and myelosuppression [4-8].

INDIVIDUALIZED MANAGEMENT

RSV bronchiolitis — Infants and young children with RSV bronchiolitis are treated in the same manner as children with bronchiolitis caused by other pathogens. Supportive care is the mainstay of management. Management of bronchiolitis is discussed in detail separately. (See "Bronchiolitis in infants and children: Treatment, outcome, and prevention".)

RSV-associated bronchial reactivity — Glucocorticoids and bronchodilators may be beneficial in the management of RSV-associated bronchial reactivity in older children, particularly those with asthma, in whom RSV-reinfection may have triggered an exacerbation. (See "Treatment of recurrent virus-induced wheezing in young children" and "Acute asthma exacerbations in children younger than 12 years: Inpatient management", section on 'Elements of treatment' and "Acute exacerbations of asthma in adults: Emergency department and inpatient management".)

Immunocompromised patients — Decisions regarding treatment of RSV infection in immunocompromised patients should be individualized. Treatment of RSV infection in immune-compromised patients has not been well studied and the optimal treatment is uncertain [9,10].

Interventions that have been associated with benefit (eg, reduced rates of progression from upper to LRTI, decreased mortality) in observational studies include single agent or combination therapy with ribavirin, intravenous immune globulin, palivizumab, and/or glucocorticoids [9,10]. Although combination therapy with intravenous immune globulin and ribavirin or palivizumab has not been supported by a randomized trial, these combinations are sometimes used in severely ill immunocompromised patients.

Data describing the efficacy of RSV treatment in adult hematopoietic cell transplant and lung transplant recipients is presented separately. (See "Respiratory syncytial virus infection in adults", section on 'Immunocompromised patients' and "Viral infections following lung transplantation", section on 'Respiratory syncytial virus'.)

PHARMACOTHERAPEUTIC AGENTS

Ribavirin — Ribavirin is a nucleoside analog with good in vitro activity against RSV. Ribavirin is approved by the US Food and Drug Administration for the treatment of RSV infection.

●Potential indications – Nebulized or oral ribavirin, alone or in combination with other interventions, may be warranted for the treatment of documented RSV infection in immunocompromised patients. (See 'Immunocompromised patients' above and "Respiratory syncytial virus infection in adults", section on 'Immunocompromised patients'.)

Ribavirin is not routinely recommended for the treatment of RSV bronchiolitis in infants and children. (See 'RSV bronchiolitis' above.)

●Contraindications and precautions – Ribavirin is contraindicated in pregnant females, and a negative pregnancy test should precede its use in persons of child-bearing age.

Studies in rodents (rats, rabbits, hamsters) demonstrated teratogenicity and/or embryolethality [11]. The risk in human pregnancy is uncertain due to the small number of reported exposures, but preliminary findings from a ribavirin pregnancy registry have not suggested human teratogenicity [12]. Congenital anomalies occurred in 3 of 49 live births with direct maternal exposures and 3 of 69 live births following indirect exposure via the male sexual partner, with no consistent pattern of abnormality.

The prescribing information for oral ribavirin recommends that ribavirin be avoided in males whose partners are pregnant [13]. Given the long half-life of ribavirin, it is also recommended that female patients who receive ribavirin avoid pregnancy for nine months after completion of treatment and that the female partners of males who receive ribavirin avoid pregnancy for six months after completion of treatment.

Ribavirin has been associated with bronchoconstriction and should be used in caution in patients with asthma or chronic obstructive pulmonary disease [14].

●Adverse effects – Adverse effects of ribavirin include hemolytic anemia, leukopenia, cough, dyspnea, bronchospasm, deterioration in pulmonary function, rash, conjunctival irritation, and neuropsychologic symptoms [9,14-16].

Adverse effects related to occupational exposure to ribavirin have not been reported. However, the National Institute of Occupational Safety and Health has published recommendations to reduce the ambient air concentrations of ribavirin and limit occupational exposure to hospital personnel [17].

Immune globulin — Intravenous immune globulin (IVIG) alone or in combination with other agents (eg, ribavirin, palivizumab) has been tried in the treatment of RSV infection.

Although it is no longer available, IVIG with high neutralizing activity against RSV (RSV-IVIG) was shown to prevent RSV replication in lung tissues, reduce viral loads in pulmonary tissues, and prevent subsequent development of illness in immunocompetent and immunocompromised animal models [18,19].

IVIG may be warranted for the treatment of documented RSV infection in immunocompromised patients. (See 'Immunocompromised patients' above and "Respiratory syncytial virus infection in adults", section on 'Immunocompromised patients'.)

The clinical use and adverse effects of IVIG are discussed separately. (See "Overview of intravenous immune globulin (IVIG) therapy" and "Intravenous immune globulin: Adverse effects".)

Monoclonal antibodies

●Palivizumab – Palivizumab is an RSV-specific humanized monoclonal antibody. The typical intravenous dose (15 mg/kg) has a serum half-life of approximately 20 days in adult hematopoietic cell transplant (HCT) recipients without RSV and 11 days in HCT recipients with RSV infection [20].

Whether specific populations of immunocompromised patients benefit from palivizumab therapy for RSV infection is uncertain. It has not been evaluated in randomized trials. In observational studies, palivizumab has not been definitively associated with reduced severity of RSV infection or mortality, although it appears to be well tolerated [20-22]. Adverse reactions to palivizumab include fever, rash, and antibody development.

The role of palivizumab in the prevention of RSV infections, is discussed separately. (See "Respiratory syncytial virus infection: Prevention in infants and children", section on 'Immunoprophylaxis'.)

●Nirsevimab – Nirsevimab is a monoclonal antibody that targets the prefusion conformation of the RSV F glycoprotein. It has a long half-life and potent neutralizing activity. Nirsevimab has not been studied in the treatment of patients with documented RSV infection. It is used for prevention of RSV in infancy, as discussed separately. (See "Respiratory syncytial virus infection: Prevention in infants and children", section on 'Immunoprophylaxis'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Bronchiolitis in infants and children".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

●Beyond the Basics topic (see "Patient education: Bronchiolitis and RSV in infants and children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Supportive care – Therapy for respiratory syncytial virus (RSV) infection of the lower respiratory tract is primarily supportive. Supportive care includes frequent monitoring of clinical status and provision of fluid and respiratory support as necessary. (See 'Supportive care' above.)

Children with RSV bronchiolitis are treated in the same manner as children with bronchiolitis caused by other pathogens. Supportive care is the mainstay of management. Treatment of bronchiolitis is discussed separately. (See "Bronchiolitis in infants and children: Treatment, outcome, and prevention".)

Glucocorticoids and bronchodilators may be beneficial in the management of RSV-associated bronchial reactivity in older children and adults. (See 'RSV-associated bronchial reactivity' above.)

●Treatment of immunocompromised patients – Decisions regarding treatment of RSV infection in immunocompromised patients should be individualized. The optimal treatment is uncertain. Interventions that have been associated with reduced rates of progression from upper to lower respiratory tract infection or decreased mortality in observational studies include single agent or combination therapy with ribavirin, intravenous immune globulin, palivizumab, and/or glucocorticoids. (See 'Immunocompromised patients' above and "Respiratory syncytial virus infection in adults", section on 'Immunocompromised patients'.)