Aerosolized polymyxins for ventilator-associated pneumonia caused by extensive drug resistant Gram-negative bacteria: class, dose and manner should remain the trifecta

Excerpt

Improving the management of ventilator-associated pneumonia (VAP) represents an unmet clinical need, particularly when caused by carbapenem-resistant organisms, with need to optimize therapy to reduce adverse events, intubation period and length of ICU stay. Aerosolized antibiotics have been postulated as an opportunity to improve outcome, based on the large experience in chronic Pseudomonas aeruginosa bronchial infection in cystic fibrosis bronchiectasis. In contrast to non-ventilated patients, or with aerosolized steroids or brochodilators, aerosolized antibiotics among ventilated patients require a specific administration protocol [1] regarding devices and ventilator settings with need to minimize ventilator asynchronies for good patients’ tolerance. Interestingly, meta-analysis of randomized clinical trials [2], documented that replacement of the intravenous route by nebulization among ventilated patients reduce the risk of acute kidney injury; as a consequence, the European Society of Clinical Microbiology and Infectious Diseases endorsed in a position paper recommend this topic as an area of priority research [3]. …