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Nebulized Antibiotics for Ventilator-associated Pneumonia: Next Steps After the Meta-analyses

Zampieri, Fernando G. MD; Aguiar, Fernanda de J. MD; Nassar, Antonio Paulo Jr MD, PhD

doi: 10.1097/CPM.0000000000000152
Critical Care/Respiratory Care

Ventilator-associated pneumonia (VAP) represents a major clinical challenge for all physicians caring for critically ill patients. Important concerns regarding the optimum treatment regimen for the management of pulmonary infections—such as the choice of antibiotic, the dosing, the duration of therapy, and drug delivery to the infected tissue—play an even more prominent role in the management of VAP. Patients with VAP are usually severely ill and have already been exposed to prolonged periods of intensive care; therefore, the safety margin for error is narrowed. Nebulized antibiotics represent a promising way to deliver high doses to the lung tissue with fewer concerns regarding systemic toxicity. In the context of multidrug-resistant VAP, where therapeutic options may be reduced to more toxic drugs, nebulized antibiotics may be a reasonable and logical choice. While most studies focused on the adjunctive role (ie, complementary to intravenous infusion) of nebulized antibiotics, some reports have suggested that nebulization may be effective even as a single therapy. Nevertheless, important differences in nebulization techniques contribute to the difficulty in obtaining robust data regarding the efficacy of nebulized therapy. Two recent meta-analyses have evaluated the role of nebulized antibiotics for VAP, one of them focusing specifically on nebulized polymyxin and the other assessing the role of nebulization therapy regardless of the drug used. Although conceptually different, both studies concluded that nebulized therapy could indeed play a significant role in the management of VAP. In this review, we reassess the evidence for nebulized antibiotics and provide guidance for future studies in this field to fill the knowledge gaps.

*Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clínicas, Faculty of Medicine, University of São Paulo

Intensive Care Unit, Hospital Alemão Oswaldo Cruz

Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil

Disclosure: The authors declare that they have no conflicts of interest.

Address correspondence to: Fernando G. Zampieri, MD, Rua Dr. Enéas de Carvalho Aguiar, 255, Sixth Floor, Intensive Care Unit, São Paulo 05403–000, Brazil. E-mail:

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