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Effect of Antibiotics Administered via the Respiratory Tract in the Prevention of Ventilator- Associated Pneumonia: A Systematic Review and Meta- Analysis
Povoa FCC, Cardinal-Fernandez P, Maia IS, et al. J Crit Care. 2018; 43: 240- 45.
Study Question: What is the effect of antibiotics given by the respiratory tract when used for the prevention of ventilator- associated pneumonia (VAP) in mechanically ventilated patients?
Study Description: This systematic review and meta-analysis included randomized trials and observational studies with matched groups comparing placebo to antibiotics administered by the respiratory tract (i.e. nebulization or intratracheal administration) in mechanically ventilated patients.
Results: A total of 6 studies (N=1158) were included. Three studies performed intratracheal installation and three utilized nebulization. Antibiotics used were cefepime, colistin, and gentamicin. When comparing mechanically ventilated patients who received antibiotics vs. control, the pooled odds ratio of developing VAP was 0.53 (95% CI 0.34-0.84). Prophylactic antibiotics were only found to protect against VAP when administered via nebulization (OR 0.46, 95% 022-0.97). There was no difference in mortality between those who received antibiotic prophylaxis and those who did not (OR 0.89, 95% CI 0.64-1.25). Two studies evaluated the incidence of VAP due to multidrug resistant (MDR) pathogens. There was no difference in VAP due to MDR pathogens (OR 0.67, 95% CI 0.17-2.62).
Conclusion(s): Antibiotics given via nebulization for VAP prophylaxis reduce the occurrence of VAP and do not increase the risk of VAP due to MDR pathogens.
Perspective: Current Infectious Disease Society of America (IDSA) and Society for Healthcare and Epidemiology of America guidelines do not recommend prophylactic antibiotics for VAP due to the risk of MDR infections. While this meta-analysis showed a reduction in the recurrence of VAP and no increase in MDR pathogens, there was also no difference in mortality. This study does not provide enough evidence to contradict current guidelines. Prophylactic antibiotics still cannot be routinely recommended.