CHEST Guidelines--strong-COUNTERPOINT---strong--Should-Inhaled-Anti (2)

-strong-COUNTERPOINT---strong--Should-Inhaled-Anti (2)

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In the document, Dr. Marin H. Kollef argues against the routine use of inhaled antibiotic therapy for treating bacterial lower respiratory tract infections (BLRTI) in ICU settings. Kollef highlights the rapid emergence of antibiotic resistance due to increased antibiotic consumption, ultimately raising mortality risks and healthcare costs worldwide. By 2050, antimicrobial resistance is predicted to cause 10 million deaths annually, exceeding cancer fatalities.<br /><br />BLRTIs, including ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT), often require antibiotics. However, issues like inadequate antibiotic penetration into the lungs and subsequent resistance emergence have driven interests in aerosolized antibiotics. Despite improvements in nebulizer technology, reliable evidence supporting the efficacy of inhaled antibiotics for critical conditions like VAP and VAT is insufficient.<br /><br />Kollef notes that current studies and meta-analyses present mixed outcomes. While one analysis showed increased clinical cure and eradication rates with aerosolized colistin, overall mortality remained unchanged. The rise in inhaled antibiotic use, especially in countries like China and India to combat multidrug-resistant (MDR) bacteria, has also led to new resistant strains like plasmid-mediated colistin-resistant bacteria.<br /><br />The author stresses the lack of comprehensive clinical trial data supporting the safety and efficacy of these treatments to meet stringent FDA regulations. Kollef emphasizes that robust randomized controlled trials are necessary to address critical uncertainties, such as optimal dosing, duration of treatment, and effective delivery devices.<br /><br />Furthermore, inhaled antibiotics could potentially reduce BLRTI recovery time, treat MDR and extremely drug-resistant pathogens, and decrease resistance development. However, rushing their widespread use without substantial evidence could exacerbate antibiotic resistance issues, underlining the need for careful evaluation before routine adoption in ICUs.

Keywords

inhaled antibiotics

bacterial lower respiratory tract infections

ICU

antibiotic resistance

ventilator-associated pneumonia

ventilator-associated tracheobronchitis

aerosolized antibiotics

antimicrobial resistance

randomized controlled trials

multidrug-resistant bacteria