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Review
. 2021 Apr;9(7):598.
doi: 10.21037/atm-20-3686.

Inhaled antibiotics during mechanical ventilation-why it will work

Maxime Desgrouas  1   2   3 , Stephan Ehrmann  1   3
Affiliations
Review

Inhaled antibiotics during mechanical ventilation-why it will work

Maxime Desgrouas et al. Ann Transl Med. 2021 Apr.

Abstract

Inhaled antibiotics are a common therapy among patients suffering recurrent or chronic pulmonary infections. Their use is less frequent in acutely ill patients despite a strong theoretical rationale and growing evidence of their efficiency, safety and beneficial effect on reducing bacterial resistance emergence. Clinical trials of inhaled antibiotics have shown contradictory results among mechanically ventilated patients. The optimal nebulization setup, not always implemented in all trials, the difficulty to identify the population most likely to benefit and the testing of various therapeutic strategies such as adjunctive versus alternative to systemic antibiotics may explain the disparity in trial results. The present review first presents the reasons why inhaled antibiotics have to be developed and the benefits to be expected of inhaled anti-infectious therapy among mechanically ventilated patients. A second part develops the constraints of aerosolized therapies that one has to be aware of and the simple actions required during nebulization to ensure optimal delivery to the distal lung parenchyma. Positive and negative studies concerning inhaled antibiotics are compared to understand the discrepancies of their findings and conclusions. The last part presents current developments and perspective which will likely turn it into a fully successful therapeutic modality, and makes the link between inhaled antibiotics and inhaled anti-infectious therapy.

Keywords: Anti-bacterial agents; critical care; inhalation; intensive care units; respiration, artificial; ventilator associated pneumonia (VAP).

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Conflict of interest statement

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-3686). The series “Medical Aerosol in Acute and Critical Care” was commissioned by the editorial office without any funding or sponsorship. SE reports grants, personal fees and non-financial support from Aerogen Ltd, grants, personal fees and non-financial support from Fisher and Paykel healthcare, grants from Hamilton medical, personal fees from La Diffusion Technique Française, during the conduct of the study. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
Influence of the nebulizer position on aerosol loss during expiration. With permission (19).
Figure 2
Figure 2
Differences of efficacy, resistance emergence and systemic toxicity between inhaled and intravenous antibiotics for pulmonary infections. Antibiotics administered by nebulization reach tissue concentrations above the minimal inhibitory concentration (MIC) of most bacteria, or even over the concentration preventing resistance emergence, and systemic toxicity is low. Systemic antibiotics can induce systemic toxicity before reaching MIC due to poor lung diffusion.
See this image and copyright information in PMC

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