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.
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