Other therapeutic modalities and practices: implications for clinical trials of hospital-acquired or ventilator-associated pneumonia.

Direct delivery of antimicrobial agents to the site of infection via aerosolization may represent a valid option in patients with ventilator-associated pneumonia (VAP). Although promising and supported by the results of several recent investigations, antibiotic aerosolization to treat VAP has not yet entered the armamentarium for daily practice. Its potential efficacy should be first evaluated as an adjunctive therapy in a superiority trial in which all participants receive a standard-of-care intravenous regimen and then are randomized to receive additional antibiotics by aerosol or a placebo (eg, combination therapy trials). Inclusion criteria should specifically target patients with microbiologically proven VAP caused by potentially multidrug-resistant strains, because a clear benefit of aerosolized antibiotics is awaited in only this subpopulation. Until results of these trials are known, antibiotic aerosolization can be recommended only for treating patients with multidrug-resistant VAP, for which no effective intravenous regimen is available.