Respiratory therapies in the critical care setting. Should aerosolized antibiotics be administered to prevent or treat ventilator-associated pneumonia in patients who do not have cystic fibrosis?

Ventilator-associated pneumonia (VAP) significantly increases intensive care unit morbidity, mortality, and costs. VAP is thought to be caused by bacterial entry into injured airways, which produces tracheobronchitis that evolves into diffuse pneumonia. The use of aerosolized antibiotics is conceptually attractive, especially when the infection is early and limited to the airway epithelium. Data show that aerosolized antibiotics kill airway bacteria and improve outcomes in cystic fibrosis. The clinical evidence for aerosolized antibiotics to prevent VAP is weak but suggestive. Concerns about the high cost, possible development of antibiotic resistance, and other potential risks of aerosolized antibiotics led several evidence-based consensus groups to recommend against routine use of aerosolized antibiotics for VAP prevention until better data are available. Importantly, the clinical evidence that aerosolized antibiotics can treat established VAP is negative, and multiple consensus groups recommend against treating established VAP with aerosolized antibiotics.