Why Don't We have more inhaled antibiotics to treat ventilator-associated pneumonia?
Clin Microbiol Infect. 2019 Apr 26;:
Authors: Sweeney DA, Kalil AC
BACKGROUND: The increasing prevalence of ventilator-associated pneumonia (VAP) due to either multidrug resistant (MDR) organisms or infections with limited treatment options (i.e., susceptible to only aminoglycosides or colisitin) coupled with a dearth of new antimicrobials has led clinicians to pursue alternative management strategies including the use of inhaled antibiotics (IA).
OBJECTIVES: To review the evidence surrounding the use of IA in the treatment of VAP with a focus on establishing a path whereby adjunctive IA could become a standard therapy for the treatment of specific VAP patient populations.
SOURCES: A meta-analysis performed by the 2016 IDSA/ATS Hospital-acquired Pneumonia Guideline Committee; a PubMed and clinicaltrials.gov search for subsequent trials of IA for the treatment of VAP.
CONTENT: Based on a meta-analysis of nine studies (RR, 1.29; 95% CI, 1.13-1.47), the 2016 IDSA/ATS Hospital-acquired Pneumonia Guideline Committee recommended adjunctive IA be used to treat VAP due to Gram-negative bacilli that are susceptible to only aminoglycosides or polymyxins. Two subsequent randomized trials of adjunctive IA for the treatment of mechanically ventilated patients with pneumonia failed to demonstrate a benefit. Despite these results, an updated meta-analysis (n=11) including these two recent trials suggests a benefit of adjunctive IA for the treatment of VAP due to MDR and difficult-to-treat infections (RR, 1.2; 95% CI, 1.05-1.57).
IMPLICATIONS: Patients with VAP and limited intravenous antibiotic options are the individuals most likely to benefit from adjunctive IA and should be the focus of future investigative studies. And while vibrating mesh nebulizers predominate in pharmaceutical-sponsored trials, these devices have not been directly compared to the traditional jet nebulizers in terms of efficacy or safety.
PMID: 31035015 [PubMed - as supplied by publisher]