Medication Summary
Medications to treat respiratory syncytial virus (RSV) infection include the antiviral drug ribavirin, which can be used in severe high-risk cases, and bronchodilators. The efficacy of bronchodilators or racemic epinephrine in treating RSV disease remains unproved. If these agents are given, attempts to measure response to therapy should be documented. If these treatments have no demonstrable benefit, they should be discontinued.
Nirsevimab is a long-acting monoclonal antibody administered as a single IM injection. Results from the MELODY study of nearly 1500 infants showed a 74.5% reduced incidence of medically attended LRTIs associated with RSV in those who received nirsevimab compared with those who received placebo. [23]
Palivizumab may be given for prophylaxis. A study evaluated the effectiveness of current regimens for palivizumab injections across different cities in order to design an optimized regimen. The study found that a 5-injection regimen using city-specific initiation dates would reduce the risk of RSV hospitalization by a median of 6.8%. [35, 30] A study by Lavoie et al found that abbreviated three-and four dose regimens had comparable outcomes to infants treated with the five-dose regimen. [36]
Respiratory syncytial virus vaccine (Abrysvo) was approved in August 2023 for active immunization of pregnant individuals at 32 through 36 weeks' gestation for the prevention of lower respiratory tract disease (LRTD) and severe LRTD caused by RSV in infants from birth through 6 months of age. [31]
Antiviral agents
Class Summary
Antiviral therapy for severe RSV disease may be indicated in high-risk patients. For effective inhibition of the replicating virus, treatment must be promptly initiated at the onset of the infection.
Ribavirin (Virazole)
Ribavirin is an analogue of the nucleic acid guanosine. It inhibits viral replication through an unknown mechanism.
Beta2 Agonists
Class Summary
Bronchodilators act to decrease muscle tone in the small and large airways in the lungs, thereby increasing ventilation. Beta2 -adrenergic and alpha-adrenergic agents are frequently administered (via inhalation) in an attempt to treat the bronchospasm observed in bronchiolitis.
Albuterol (AccuNeb, Proventil, ProAir HFA)
As a selective beta2-agonist, albuterol produces bronchial smooth muscle relaxation. Its efficacy in older children with reactive airway disease is well established, but its benefits in children with acute bronchiolitis are less well established. It is available in inhaled and oral preparations.
Epinephrine racemic
Racemic epinephrine consists of 1-1.125% of epinephrine base solution given by aerosol. It may be superior to beta2-adrenergic agents for treating RSV lower respiratory tract infection.
Monoclonal Antibodies
Class Summary
Humanized monoclonal antibody directed against the F (fusion) protein of RSV are indicated for prophylaxis of newborns and young infants during or entering RSV season.
Nirsevimab (Beyfortus)
Administered as a single IM dose per season. It is indicated for prevention of respiratory syncytial virus (RSV) lower respiratory tract disease in neonates and infants born during or entering their first RSV season, and in children up to 24 months of age who remain vulnerable to severe RSV disease through their second RSV season.
Palivizumab (Synagis)
Administered as a monthly IM injection through the RSV season, it has been demonstrated to decrease the chances of RSV hospitalization in premature babies who are at increased risk for severe RSV-related illness. Owing to the shift in RSV seasonality noted in spring 2021 and the surge of RSV cases in fall 2022, the American Academy of Pediatrics supports providing more than 5 consecutive doses of palivizumab to eligible children in regions with disease activity lasting more than the typical 6-month duration.
Vaccines
Class Summary
Active immunization for infants via maternal vaccination has been approved by the FDA.
Respiratory syncytial virus (RSV) vaccine (Abrysvo)
Indicated for active immunization of pregnant individuals at 32 through 36 weeks gestation for the prevention of lower respiratory tract disease (LRTD) and severe LRTD caused by RSV in infants from birth through 6 months of age.
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Respiratory syncytial virus infection season, United States, by region and Florida. Image courtesy of Centers for Disease Control and Prevention.
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Electron micrograph of respiratory syncytial virus (RSV). RSV is most common cause of bronchiolitis and pneumonia in children younger than 1 year. Image courtesy of Centers for Disease Control and Prevention.
