In this episode, I’ll discuss inhaled antibiotics to prevent VAP.
The prevention of ventilator-associated pneumonia has been a focus of research for many decades. The peak incidence of VAP appears to occur after about 7 days of ventilator use and this has led researchers to focus on whether there is a point before this 7 day mark when progression to VAP can be hindered by antibiotics.
In episode 866 I discussed a study of nebulized amikacin given to critically ill adult patients who had been undergoing invasive mechanical ventilation for at least 72 hours at a dose of 20 mg/kg of ideal body weight once daily vs placebo for 3 days. The incidence of VAP dropped considerably in the amikacin group; however, the trial was not powered to assess differences in death or length of ICU and hospital stay.
Now, a group of researchers have conducted a systematic review and meta-analysis that combines the previous study with three others to examine the effect of nebulised inhalation of antibiotics on preventing ventilator-associated pneumonia in critically ill patients. Two of the other studies used inhaled ceftazidime and one used inhaled colistin.
The rate of VAP in patients who received antibiotics was 18.8% vs 27.1% in those who received placebo. This translated to a statistically significant risk ratio of 0.7 in favor of using antibiotics, and the I² statistic was 38%, which indicates only a moderate amount of heterogeneity influencing the results. While this would normally equate to a finding of moderate certainty of the evidence, the results did not hold up when individual studies were removed from the analysis. This inconsistency of results led to a downgrade from moderate to low-certainty of evidence due to critical susceptibility to study selection.
Unfortunately, this study did not find any statistically significant differences in ICU mortality or in-hospital mortality between antibiotics and placebo. Neither was there a difference between groups in adverse events, multidrug resistant VAP incidence, ICU length of stay, hospital length of stay, or duration of mechanical ventilation.
More trials will be needed before I would expect to see expert society recommendations from the likes of SCCM or IDSA calling for routine use of inhaled antibiotics for the purpose of preventing VAP in ICU patients.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
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