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Prevention of ventilator-associated pneumonia: possible role of antimicrobials administered via the respiratory tract

¹ Alfa Institute of Biomedical Sciences, and ³ Dept of Medicine, Henry Dunant Hospital, Athens, Greece. ² Dept of Medicine, Tufts University School of Medicine, Boston, MA, USA.

To the Editors:

We read with interest the comprehensive and useful review of Lorente et al. 1 regarding the evidence concerning measures for prevention of ventilator-associated pneumonia (VAP). The authors did not comment on the prophylactic use of antimicrobial agents administered via the respiratory tract as a potential preventive strategy for VAP. Relevant guidelines of the Canadian Critical Care Trials Group and the Canadian Critical Care Society 2 recommend against the prophylactic use of oral or intratracheal antibiotics for this purpose. However, a recently published meta-analysis of randomised controlled trials (RCTs) revealed that prophylactic administration of antimicrobials (aerosolised or endotracheally instilled) via the respiratory tract, as opposed to control treatment, was associated with a reduced incidence of pneumonia (odds ratio (OR) 0.49; 95% confidence interval (CI) 0.32–0.76) in intensive care unit patients 3. In contrast, no difference was detected with regard to mortality between the groups compared (OR 0.86; 95% CI 0.55–1.32); the emergence of resistance associated with the implementation of this strategy was not examined due to insufficiency of the relevant available data 3.

After the publication of the aforementioned meta-analysis 3, one additional RCT on this topic has been published 4. By comparing a prophylactic course of aerosolised ceftazidime with placebo in intubated trauma patients, the authors of the RCT reported that the number of patients with VAP was 26 (49%) out of 53 and 26 (50%) out of 52 in the prophylaxis and placebo groups, respectively 4. We recalculated the pooled OR by adding this new information, in an attempt to update the previous meta-analysis 3. Again, a significant difference was revealed regarding the incidence of pneumonia in favour of the prophylactic as opposed to the nonprophylactic group (OR 0.47; 95% CI 0.24–0.91).

The potential usefulness of antimicrobials administered via the respiratory tract for the prevention of ventilator-associated pneumonia has been also commented upon by other experts in the field 5, 6. Thus, the present authors believe that the prophylactic administration of antimicrobials via the respiratory tract for ventilator-associated pneumonia deserves the attention of investigators. However, future studies should focus not only on the effectiveness of this strategy but also on safety and the issue of emergence of antimicrobial resistance.

Statement of interest

None declared.

REFERENCES

1. Lorente L, Blot S, Rello J. Evidence on measures for the prevention of ventilator-associated pneumonia. Eur Respir J 2007;30:1193–1207.[Abstract/Free Full Text]
2. Dodek P, Keenan S, Cook D, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 2004;141:305–313.[Abstract/Free Full Text]
3. Falagas ME, Siempos II, Bliziotis IA, Michalopoulos A. Administration of antibiotics via the respiratory tract for the prevention of ICU-acquired pneumonia: a meta-analysis of comparative trials. Crit Care 2006;10:R123[CrossRef][Medline] [Order article via Infotrieve]
4. Claridge JA, Edwards NM, Swanson J, et al. Aerosolized ceftazidime prophylaxis against ventilator-associated pneumonia in high-risk trauma patients: results of a double-blind randomized study. Surg Infect (Larchmt) 2007;8:83–90.[CrossRef][Medline] [Order article via Infotrieve]
5. MacIntyre NR, Rubin BK. 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?. Respir Care 2007;52:416–421.[Web of Science][Medline] [Order article via Infotrieve]
6. Dhand R. The role of aerosolized antimicrobials in the treatment of ventilator-associated pneumonia. Respir Care 2007;52:866–884.[Web of Science][Medline] [Order article via Infotrieve]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Permissions Request Permissions Services Email this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Falagas, M. E. Articles by Siempos, I. I. Search for Related Content PubMed PubMed Citation Articles by Falagas, M. E. Articles by Siempos, I. I.