RSV 免疫球蛋白 (RSV-IGIV) 可让有风险的婴儿获得免疫力;但它有几个限制其使用的缺点。其主要缺点包括需要静脉通路、输注时间长(4-6 小时)以及输注量大。[46]Morris SK, Dzolganovski B, Beyene J, et al. A meta-analysis of the effect of antibody therapy for the prevention of severe respiratory syncytial virus infection. BMC Infect Dis. 2009 Jul 5;9:106.http://www.biomedcentral.com/1471-2334/9/106http://www.ncbi.nlm.nih.gov/pubmed/19575815?tool=bestpractice.com
对于高风险婴儿(例如早产儿[妊娠少于 29 周]、早产儿慢性肺病、早产儿复杂型先天性心脏病或免疫功能受损的婴儿),可使用帕利珠单抗进行免疫预防。[21]Committee on Infectious Diseases; American Academy of Pediatrics. Red book. 30th ed. Elk Grove Village, IL: AAP; 2015:667-76.http://redbook.solutions.aap.org/chapter.aspx?sectionid=56798348&bookid=886[47]American Academy of Pediatrics Committee on Infectious Diseases; American Academy of Pediatrics Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics. 2014 Aug;134(2):415-20.http://pediatrics.aappublications.org/content/134/2/415.longhttp://www.ncbi.nlm.nih.gov/pubmed/25070315?tool=bestpractice.com[48]Frogel MP, Stewart DL, Hoopes M, et al. A systematic review of compliance with palivizumab administration for RSV immunoprophylaxis. J Manag Care Pharm. 2010 Jan-Feb;16(1):46-58.http://www.amcp.org/data/jmcp/46-58.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/20131495?tool=bestpractice.com 该药可将这些风险人群的住院率降低 45% 至 55%。[49]The IMpact-RSV Study Group. Palivizumab, a humanized respiratory syncytial virus monoclonal antibody, reduces hospitalization from respiratory syncytial virus infection in high-risk infants. Pediatrics. 1998 Sep;102(3 Pt 1):531-7.http://www.ncbi.nlm.nih.gov/pubmed/9738173?tool=bestpractice.com[50]Feltes TF, Cabalka AK, Meissner HC, et al. Palivizumab prophylaxis reduces hospitalization due to respiratory syncytial virus in young children with hemodynamically significant congenital heart disease. J Pediatr. 2003 Oct;143(4):532-40.http://www.ncbi.nlm.nih.gov/pubmed/14571236?tool=bestpractice.com[51]Prescott WA Jr, Doloresco F, Brown J, et al. Cost effectiveness of respiratory syncytial virus prophylaxis: a critical and systematic review. Pharmacoeconomics. 2010;28(4):279-93.http://www.ncbi.nlm.nih.gov/pubmed/20131925?tool=bestpractice.com[52]Wang D, Cummins C, Bayliss S, et al. Immunoprophylaxis against respiratory syncytial virus (RSV) with palivizumab in children: a systematic review and economic evaluation. Health Technol Assess. 2008 Dec;12(36):iii, ix-x, 1-86.http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014928/http://www.ncbi.nlm.nih.gov/pubmed/19049692?tool=bestpractice.com[53]Checchia PA, Nalysnyk L, Fernandes AW, et al. Mortality and morbidity among infants at high risk for severe respiratory syncytial virus infection receiving prophylaxis with palivizumab: a systematic literature review and meta-analysis. Pediatr Crit Care Med. 2011 Sep;12(5):580-8.http://www.ncbi.nlm.nih.gov/pubmed/21200358?tool=bestpractice.com[54]Pons JM, Tebé C, Paladio N, et al. Meta-analysis of passive immunoprophylaxis in paediatric patients at risk of severe RSV infection. Acta Paediatr. 2011 Mar;100(3):324-9.http://www.ncbi.nlm.nih.gov/pubmed/20950412?tool=bestpractice.com[55]Wang D, Bayliss S, Meads C. Palivizumab for immunoprophylaxis of respiratory syncytial virus (RSV) bronchiolitis in high-risk infants and young children: a systematic review and additional economic modelling of subgroup analyses. Health Technol Assess. 2011 Jan;15(5):iii-iv, 1-124.http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014983/http://www.ncbi.nlm.nih.gov/pubmed/21281564?tool=bestpractice.com证据 B通过帕利珠单抗减少入院人数:中等质量证据表明,在降低因细支气管炎而入院的支气管肺发育不良儿童、早产婴儿及先天性心脏病婴儿的数量方面,帕利珠单抗有效。[49]The IMpact-RSV Study Group. Palivizumab, a humanized respiratory syncytial virus monoclonal antibody, reduces hospitalization from respiratory syncytial virus infection in high-risk infants. Pediatrics. 1998 Sep;102(3 Pt 1):531-7.http://www.ncbi.nlm.nih.gov/pubmed/9738173?tool=bestpractice.com[50]Feltes TF, Cabalka AK, Meissner HC, et al. Palivizumab prophylaxis reduces hospitalization due to respiratory syncytial virus in young children with hemodynamically significant congenital heart disease. J Pediatr. 2003 Oct;143(4):532-40.http://www.ncbi.nlm.nih.gov/pubmed/14571236?tool=bestpractice.com 美国儿科学会 (American Academy of Pediatrics) 建议在经选择的患者中使用这种药物。[47]American Academy of Pediatrics Committee on Infectious Diseases; American Academy of Pediatrics Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics. 2014 Aug;134(2):415-20.http://pediatrics.aappublications.org/content/134/2/415.longhttp://www.ncbi.nlm.nih.gov/pubmed/25070315?tool=bestpractice.com受试者<200名的随机对照临床试验(RCT)、受试者>200名且方法学存在缺陷的随机对照临床试验(RCT)、方法学存在缺陷的系统评价或者高质量的观察性(队列)研究。 帕利珠单抗预防还可降低这些患者在 RSV 季节的全因死亡率。[53]Checchia PA, Nalysnyk L, Fernandes AW, et al. Mortality and morbidity among infants at high risk for severe respiratory syncytial virus infection receiving prophylaxis with palivizumab: a systematic literature review and meta-analysis. Pediatr Crit Care Med. 2011 Sep;12(5):580-8.http://www.ncbi.nlm.nih.gov/pubmed/21200358?tool=bestpractice.com[56]Caballero MT, Polack FP, Stein RT. Viral bronchiolitis in young infants: new perspectives for management and treatment. J Pediatr (Rio J). 2017 Nov - Dec;93(suppl 1):75-83.https://www.sciencedirect.com/science/article/pii/S0021755717306587http://www.ncbi.nlm.nih.gov/pubmed/28859915?tool=bestpractice.com具有以下特征的婴儿,因 RSV 住院的发生率较高:孕 33 至 35 周的早产、男性、在 RSV 季节前半部分时间出生、多名兄弟姐妹或托儿所暴露。[4]Bont L, Checchia PA, Fauroux B, et al. Defining the epidemiology and burden of severe respiratory syncytial virus infection among infants and children in western countries. Infect Dis Ther. 2016 Sep;5(3):271-98.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5019979/http://www.ncbi.nlm.nih.gov/pubmed/27480325?tool=bestpractice.com[57]Anderson EJ, Carbonell-Estrany X, Blanken M, et al. Burden of severe respiratory syncytial virus disease among 33-35 weeks' gestational age infants born during multiple respiratory syncytial virus seasons. Pediatr Infect Dis J. 2017 Feb;36(2):160-7.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5242218/http://www.ncbi.nlm.nih.gov/pubmed/27755464?tool=bestpractice.com[58]Carbonell-Estrany X, Fullarton JR, Gooch KL, et al. The influence of birth weight amongst 33-35 weeks gestational age (wGA) infants on the risk of respiratory syncytial virus (RSV) hospitalisation: a pooled analysis. J Matern Fetal Neonatal Med. 2017 Jan;30(2):134-40.http://www.ncbi.nlm.nih.gov/pubmed/26965584?tool=bestpractice.com[59]Mauskopf J, Margulis AV, Samuel M, et al. Respiratory syncytial virus hospitalizations in healthy preterm infants: systematic review. Pediatr Infect Dis J. 2016 Jul;35(7):e229-38.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4927309/http://www.ncbi.nlm.nih.gov/pubmed/27093166?tool=bestpractice.com 在 RSV 季节,肌肉注射帕利珠单抗,每月一次。[47]American Academy of Pediatrics Committee on Infectious Diseases; American Academy of Pediatrics Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics. 2014 Aug;134(2):415-20.http://pediatrics.aappublications.org/content/134/2/415.longhttp://www.ncbi.nlm.nih.gov/pubmed/25070315?tool=bestpractice.com
可以采用几种策略来限制 RSV 的传播。 洗手在临床及非临床环境中都很重要。[61]Ralston SL, Lieberthal AS, Meissner HC, et al; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502.http://pediatrics.aappublications.org/content/134/5/e1474.longhttp://www.ncbi.nlm.nih.gov/pubmed/25349312?tool=bestpractice.com证据 C通过护理干预减少院内感染:低质量数据表明,集中隔离、洗手、长袍、口罩、手套和护目镜可降低细支气管炎的传播。 另外,现有指南也建议使用这些措施(特别是洗手)。[61]Ralston SL, Lieberthal AS, Meissner HC, et al; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502.http://pediatrics.aappublications.org/content/134/5/e1474.longhttp://www.ncbi.nlm.nih.gov/pubmed/25349312?tool=bestpractice.com低质量的观察性(队列)研究或者受试者<200名且方法学存在缺陷的随机对照临床试验(RCT)。所有家庭成员和近距离接触者务必洗手并清洗共同使用的玩具,以限制 RSV 感染的蔓延。应对需要住院治疗的患者采取接触隔离措施。[21]Committee on Infectious Diseases; American Academy of Pediatrics. Red book. 30th ed. Elk Grove Village, IL: AAP; 2015:667-76.http://redbook.solutions.aap.org/chapter.aspx?sectionid=56798348&bookid=886 对存在较大的呼吸道飞沫,正确使用长袍、手套和口罩等可以起到隔离效果,在护理这些患者时,应佩戴这些防护用品。[149]Hall CB, Douglas RG Jr. Nosocomial respiratory syncytial viral infections: should gowns and masks be used? Am J Dis Child. 1981 Jun;135(6):512-5.http://www.ncbi.nlm.nih.gov/pubmed/7234784?tool=bestpractice.com[150]Gala CL, Hall CB, Schnabel KC, et al. The use of eye-nose goggles to control nosocomial respiratory syncytial virus infection. JAMA. 1986 Nov 21;256(19):2706-8.http://www.ncbi.nlm.nih.gov/pubmed/3773177?tool=bestpractice.com[151]Agah R, Cherry JD, Garakian AJ, et al. Respiratory syncytial virus (RSV) infection rate in personnel caring for children with RSV infections: routine isolation procedure vs routine procedure supplemented by use of masks and goggles. Am J Dis Child. 1987 Jun;141(6):695-7.http://www.ncbi.nlm.nih.gov/pubmed/3578197?tool=bestpractice.com[152]Leclair JM, Freeman J, Sullivan BF, et al. Prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions. N Engl J Med. 1987 Aug 6;317(6):329-34.http://www.ncbi.nlm.nih.gov/pubmed/3600729?tool=bestpractice.com 不需要 N95 呼吸面罩,它并不比简单的手术用口罩更有效。[20]Hall CB, Douglas RG Jr, Geiman JM. Respiratory syncytial virus infections in infants: quantitation and duration of shedding. J Pediatr. 1976 Jul;89(1):11-5.http://www.ncbi.nlm.nih.gov/pubmed/180274?tool=bestpractice.com[71]Krasinski K, LaCourture R, Holzman RS, et al. Screening for respiratory syncytial virus and assignment to a cohort at admission to reduce nosocomial transmission. J Pediatr. 1990 Jun;116(6):894-8.http://www.ncbi.nlm.nih.gov/pubmed/2348292?tool=bestpractice.com[153]Smith JD, MacDougall CC, Johnstone J, et al. Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis. CMAJ. 2016 May 17;188(8):567-74.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868605/http://www.ncbi.nlm.nih.gov/pubmed/26952529?tool=bestpractice.com 通过对可疑患者进行呼吸道合胞病毒 (RSV) 筛查,可以集中和隔离确诊的感染者,以限制病毒进一步传播。[71]Krasinski K, LaCourture R, Holzman RS, et al. Screening for respiratory syncytial virus and assignment to a cohort at admission to reduce nosocomial transmission. J Pediatr. 1990 Jun;116(6):894-8.http://www.ncbi.nlm.nih.gov/pubmed/2348292?tool=bestpractice.com
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