Respiratory Syncytial Virus (RSV) INFECTION

Respiratory Syncytial Virus (RSV) INFECTION is a topic covered in the 5-Minute Clinical Consult.

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Basics

Respiratory syncytial virus (RSV) is a medium-sized, membrane-bound RNA virus that causes acute respiratory tract illness in patients of all ages.

Description

  • In adults, RSV causes upper respiratory tract infection (URTI).
  • In infants and children, RSV commonly presents as lower respiratory tract infection (LRTI) that manifests as bronchiolitis and rarely pneumonia, respiratory failure, and death.

Pediatric Considerations

  • 90–95% of children are infected by 24 months.
  • Leading cause of pediatric bronchiolitis (50–90%)
  • Premature infants are at increased risk.

Epidemiology

  • Seasonality:
    • Outbreaks of RSV disease occur each winter (November to January).
  • Morbidity and mortality:
    • RSV infection leads to >100,000 annual hospitalizations. In the U.S., 2.1 million outpatient visits for RSV in children <5 years.

Incidence
  • Worldwide, RSV is responsible for approximately 33 million LRTI/year and up to 199,000 childhood deaths.
  • RSV is the cause of radiographically diagnosed pneumonia in the U.S.
  • RSV is the most common etiology of pneumonia in children (29%).
  • 177,000 hospitalizations. 14,000 annual deaths are attributable to RSV in the elderly.

Prevalence
Difficult to conclude accurately.

Etiology and Pathophysiology

  • RSV is a single-stranded, negative-strand, RNA virus belonging to the Paramyxoviridae family.
  • There is one serotype of RSV, classified into two strains, “A” and “B.”
  • RSV is spread from person to person via airborne droplet and personal contact. Incubation period ranges from 2 to 8 days, mean (4 to 6).
  • Natural RSV infections result in incomplete immunity, recurrent infections are common
    • RSV causes a neutrophil-intensive inflammation of the airway.
    • RSV develops in the cytoplasm of infected cells and matures by budding from the plasma membrane.
    • RSV is a major cause of exacerbation of asthma and chronic obstructive pulmonary disease (COPD).

Genetics
  • Severe RSV infections may be associated with polymorphisms in cytokine-related genes, including CCR5; IL4; IL8, IL10, and IL13.
  • RSV replicates in apical ciliated bronchial epithelial cells. The airway epithelium produces chemokines, which recruit neutrophils.

Risk Factors

Significant association with RSV-associated acute LRTI

  • Prematurity, age <12 weeks
  • Low birth weight, male gender
  • Underlying cardiopulmonary disease
  • Immunodeficiency
  • Siblings, maternal smoking
  • History of atopy, no breastfeeding
  • Crowding ≥7 persons in household
  • Other risk factors
    • Low parental education and socioeconomic status
    • Passive smoking, HIV
    • Daycare center attendance
    • Exposure to indoor and environmental air pollutants
    • Multiple births, malnutrition, higher altitude

General Prevention

  • Hand hygiene is the most important step to prevent the spread of RSV (1)[B].
    • Use alcohol-based rubs for hand decontamination when caring for children with bronchiolitis. When alcohol-based rubs are not available, wash hands with soap and water (1)[B].
  • Avoid passive smoke exposure (1)[B].
  • Isolate patients with proven or suspected RSV.
  • Palivizumab is a humanized monoclonal antibody for the prevention of severe RSV in high-risk children (2)[A]:
    • Children born at <35 wGA and <6 months
    • Children <2 years requiring treatment for bronchopulmonary dysplasia within the last 6 months
    • Children <2 years of age with hemodynamically significant congenital heart disease (HS-CHD)
  • Prophylactic use is indicated for infants and children <24 months of age with:
    • Chronic lung disease (CLD) of prematurity
    • Hemodynamically significant congenital heart disease
    • Congenital abnormalities of the airway or neuromuscular disease
  • AAP guidelines (2)[A]:
    • Preterm infants born <29 weeks’ gestational age (wGA) and <1 year at the RSV season start date; maintain through the end of RSV season.
    • Infants in the first year of life with CLD of prematurity
    • Infants with HS-CHD <1 year at season start
  • Dosage: maximum of 5 monthly doses beginning in November or December at 15 mg/kg per dose IM
  • Breastfeeding can significantly reduce hospitalizations due to respiratory infections (3)[A].

Commonly Associated Conditions

In hospitalized infants:

  • Pulmonary infiltrates/atelectasis (42.8%)
  • Otitis media (25.3%)
  • Hyperinflation (20.8%), respiratory failure (14%)
  • Hyperkalemia (10.1%, defined as K+ >6.0)
  • Apnea (8.8%), bacterial pneumonia (7.6%)

-- To view the remaining sections of this topic, please or --

Basics

Respiratory syncytial virus (RSV) is a medium-sized, membrane-bound RNA virus that causes acute respiratory tract illness in patients of all ages.

Description

  • In adults, RSV causes upper respiratory tract infection (URTI).
  • In infants and children, RSV commonly presents as lower respiratory tract infection (LRTI) that manifests as bronchiolitis and rarely pneumonia, respiratory failure, and death.

Pediatric Considerations

  • 90–95% of children are infected by 24 months.
  • Leading cause of pediatric bronchiolitis (50–90%)
  • Premature infants are at increased risk.

Epidemiology

  • Seasonality:
    • Outbreaks of RSV disease occur each winter (November to January).
  • Morbidity and mortality:
    • RSV infection leads to >100,000 annual hospitalizations. In the U.S., 2.1 million outpatient visits for RSV in children <5 years.

Incidence
  • Worldwide, RSV is responsible for approximately 33 million LRTI/year and up to 199,000 childhood deaths.
  • RSV is the cause of radiographically diagnosed pneumonia in the U.S.
  • RSV is the most common etiology of pneumonia in children (29%).
  • 177,000 hospitalizations. 14,000 annual deaths are attributable to RSV in the elderly.

Prevalence
Difficult to conclude accurately.

Etiology and Pathophysiology

  • RSV is a single-stranded, negative-strand, RNA virus belonging to the Paramyxoviridae family.
  • There is one serotype of RSV, classified into two strains, “A” and “B.”
  • RSV is spread from person to person via airborne droplet and personal contact. Incubation period ranges from 2 to 8 days, mean (4 to 6).
  • Natural RSV infections result in incomplete immunity, recurrent infections are common
    • RSV causes a neutrophil-intensive inflammation of the airway.
    • RSV develops in the cytoplasm of infected cells and matures by budding from the plasma membrane.
    • RSV is a major cause of exacerbation of asthma and chronic obstructive pulmonary disease (COPD).

Genetics
  • Severe RSV infections may be associated with polymorphisms in cytokine-related genes, including CCR5; IL4; IL8, IL10, and IL13.
  • RSV replicates in apical ciliated bronchial epithelial cells. The airway epithelium produces chemokines, which recruit neutrophils.

Risk Factors

Significant association with RSV-associated acute LRTI

  • Prematurity, age <12 weeks
  • Low birth weight, male gender
  • Underlying cardiopulmonary disease
  • Immunodeficiency
  • Siblings, maternal smoking
  • History of atopy, no breastfeeding
  • Crowding ≥7 persons in household
  • Other risk factors
    • Low parental education and socioeconomic status
    • Passive smoking, HIV
    • Daycare center attendance
    • Exposure to indoor and environmental air pollutants
    • Multiple births, malnutrition, higher altitude

General Prevention

  • Hand hygiene is the most important step to prevent the spread of RSV (1)[B].
    • Use alcohol-based rubs for hand decontamination when caring for children with bronchiolitis. When alcohol-based rubs are not available, wash hands with soap and water (1)[B].
  • Avoid passive smoke exposure (1)[B].
  • Isolate patients with proven or suspected RSV.
  • Palivizumab is a humanized monoclonal antibody for the prevention of severe RSV in high-risk children (2)[A]:
    • Children born at <35 wGA and <6 months
    • Children <2 years requiring treatment for bronchopulmonary dysplasia within the last 6 months
    • Children <2 years of age with hemodynamically significant congenital heart disease (HS-CHD)
  • Prophylactic use is indicated for infants and children <24 months of age with:
    • Chronic lung disease (CLD) of prematurity
    • Hemodynamically significant congenital heart disease
    • Congenital abnormalities of the airway or neuromuscular disease
  • AAP guidelines (2)[A]:
    • Preterm infants born <29 weeks’ gestational age (wGA) and <1 year at the RSV season start date; maintain through the end of RSV season.
    • Infants in the first year of life with CLD of prematurity
    • Infants with HS-CHD <1 year at season start
  • Dosage: maximum of 5 monthly doses beginning in November or December at 15 mg/kg per dose IM
  • Breastfeeding can significantly reduce hospitalizations due to respiratory infections (3)[A].

Commonly Associated Conditions

In hospitalized infants:

  • Pulmonary infiltrates/atelectasis (42.8%)
  • Otitis media (25.3%)
  • Hyperinflation (20.8%), respiratory failure (14%)
  • Hyperkalemia (10.1%, defined as K+ >6.0)
  • Apnea (8.8%), bacterial pneumonia (7.6%)

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