General control measures to prevent nosocomial RSV transmission:
Educate hospital staff about RSV epidemiology, modes of transmission, and means of prevention.
Use contact and droplet isolation for RSV-positive patients including gloves and gown. Maintain good handwashing procedures following any contact with RSV-infected patients or fomites, even if gloves are used.
Limit visitors. Do not allow visitors with who have symptoms of respiratory infection to visit uninfected pediatric, immunosuppressed, or cardiac patients.
Restrict staff with upper respiratory symptoms from patients at high risk for complications from RSV infection.
Control measures during RSV outbreaks:
Avoid elective admissions for high-risk patients.
Admit young children with symptoms of viral upper respiratory infections to single rooms.
Cohort patients with RSV infection. Cohort staff to infected or uninfected patients.
Data from refs. 53,58.
RSV appears to be an increasing cause of respiratory disease in this population, especially those in nursing care facilities. During outbreaks, the attack rate ranges from 10% to 40% and accounts for 5-27% of all respiratory tract infections in long-term care facilities. Individuals over the age of 60, typically, present with mild nasal congestion, but fever, anorexia, pneumonia, or bronchitis may develop (55-57).
The initial concern should be prevention. Interrupting transmission at healthcare facilities is necessary to prevent the spread of infection. Special precautions should be advocated in RSV infected patients during the peak RSV season and, especially, when a hospital outbreak develops. Table 8 lists infection control guidelines.
The mainstay of therapy consists of respiratory support, nutrition, and hydration. The use of antivirals in the treatment of RSV infections remains controversial. Ribavirin is the only antiviral agent licensed for the treatment of RSV infections. Patients undergoing therapy should be placed in negative pressure rooms with frequent air exchanges and scavenging systems to decrease exposure to healthcare providers and to minimize release into the surrounding environment. Ribavirin is dosed at 6 g/300 cc of water over 18 h or 6 g/100 cc of water over 2 h three times a day. Early clinical trials of aerosolized ribavirin therapy suggested some therapeutic benefit; however, interpretation of the results is complicated by the investigators' use of distilled water, a known bronchoconstrictor, as the placebo treatment. A similar study, when conducted using aerosolized saline as the placebo, found no clinical benefit from ribavirin therapy (59).
Cohort studies also failed to demonstrate an improved clinical outcome with ribavirin therapy (60,61). The Committee on Infectious Diseases of the American Academy of Pediatrics has changed its recommendations on the use of ribavirin to "may be considered" in selected infants and young children at high risk for serious RSV disease (62); however most clinicians do not use aerosolized ribavirin because of the limited clinical benefit, cost, and difficulty in administration. Other agents such as bronchodilators CP-agonists and epinephrine) and antiinflammatory agents (cromolyn sodium and budes-onide) have demonstrated some clinical improvement, but further studies are required to confirm these findings (52,53,58).
Palivizumab is an FDA-approved humanized monoclonal antibody directed against an RSV surface glycoprotein. The recommended dose of palivizumab is 15 mg/kg i.m. every month during the RSV season for those individuals at increased risk of severe RSV infections. Prophylaxis should be individualized based on risk of complications if RSV is acquired.
Initial studies of palivizumab dosed at 15 mg/kg i.m. every month for 5 mo during the peak RSV season demonstrated an overall reduction in RSV-related hospitalizations by 55% with significant reductions in premature infants with chronic lung disease (39%) and premature infants without chronic lung disease (78%). Other significant reductions included number of hospital days (42%), days of oxygen requirement (40%), and incidence of ICU care (57%) (63,64). Advantages to the use of palivizumab include intramuscular route of administration, a delay in dosing other vaccines is not required, and palivizumab is not a blood product, and thus carries no risk of transmitting blood-borne pathogens. Palivizumab are not FDA approved for infants with congenital heart disease because of concerns regarding the safety in these individuals.
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