Therapeutic targeting of Respiratory Syncytial Virus: Current pharmacological options and future directions in antiviral development.

Respiratory syncytial virus (RSV) remains a major cause of severe acute respiratory infections across the life course, particularly in infants, older adults, and immunocompromised individuals. For decades, clinical management relied almost exclusively on supportive care, while ribavirin, the only licensed antiviral, offered limited therapeutic benefit. The recent introduction of prefusion F (pre-F)-based vaccines and long-acting monoclonal antibodies has reshaped RSV prevention and represents the most significant advance since the discovery of the virus. Nevertheless, effective pharmacological treatment of established infection continues to be an unmet need, and the burden of RSV-associated hospitalizations and mortality persists worldwide. This review critically synthesizes current and emerging RSV therapeutic strategies from a pharmacological and translational perspective, integrating approved interventions with emerging antiviral pipelines. Licensed vaccines and monoclonal antibodies have demonstrated high efficacy in preventing lower respiratory tract disease; however, their impact is constrained by limited access and uptake, as well as the absence of complementary direct-acting antivirals (DAAs). Investigational agents targeting the fusion protein and the N/L replication complex have shown potent antiviral activity, but clinical trials have highlighted challenges related to the timing of administration, host immunity, and resistance selection. Advances in structural biology, air-liquid interface models, high-throughput screening, and artificial intelligence are accelerating the identification of new molecular targets and host-directed strategies. Overall, RSV control will require an integrated therapeutic framework in which vaccines and monoclonal antibodies prevent severe disease, while early-administered DAAs and resistance-aware combination strategies treat established infection and reduce breakthrough disease in high-risk populations.