title: The use of inhaled antibiotic therapy in the treatment of ventilator-associated pneumonia and tracheobronchitis: a systematic review.
abstract: BACKGROUND
  Ventilator-associated respiratory infections (tracheobronchitis, pneumonia) contribute significant morbidity and mortality to adults receiving care in intensive care units (ICU). Administration of broad-spectrum intravenous antibiotics, the current standard of care, may have systemic adverse effects. The efficacy of aerosolized antibiotics for treatment of ventilator-associated respiratory infections remains unclear. Our objective was to conduct a systematic review of the efficacy of aerosolized antibiotics in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT), using the Cochrane Collaboration guidelines.
  
  
  METHODS
  We conducted a search of three databases (PubMed, Web of Knowledge and the Cochrane Collaboration) for randomized, controlled trials studying the use of nebulized antibiotics in VAP and VAT that measured clinical cure (e.g., change in Clinical Pulmonary Infection Score) as an outcome measurement. We augmented the electronic searches with hand searches of the references for any narrative review articles as well as any article included in the systematic review. Included studies were examined for risk of bias using the Cochrane Handbook's "Risk of Bias" assessment tool.
  
  
  RESULTS
  Six studies met full inclusion criteria. For the systemic review's primary outcome (clinical cure), two studies found clinically and statistically significant improvements in measures of VAP cure while four found no statistically significant difference in measurements of cure. No studies found inferiority of aerosolized antibiotics. The included studies had various degrees of biases, particularly in the performance and detection bias domains. Given that outcome measures of clinical cure were not uniform, we were unable to conduct a meta-analysis.
  
  
  CONCLUSIONS
  There is insufficient evidence for the use of inhaled antibiotic therapy as primary or adjuvant treatment of VAP or VAT. Additional, better-powered randomized-controlled trials are needed to assess the efficacy of inhaled antibiotic therapy for VAP and VAT.
authors.affiliation: Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #94, Los Angeles, California, 90027, USA. crussell@chla.usc.edu.|Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. crussell@chla.usc.edu.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Russell
authors.affiliation: Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. Mark.Shiroishi@med.usc.edu.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Shiroishi
authors.affiliation: School of Social Work, University of Southern California, Los Angeles, California, USA. siantz@usc.edu.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Siantz
authors.affiliation: MD-PhD Program, Keck School of Medicine, University of Southern California, Los Angeles, Calfornia, USA. brianwwu@usc.edu.
authors.forename: Brian W
authors.initials: BW
authors.lastname: Wu
authors.affiliation: Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. patinosu@med.usc.edu.
authors.forename: Cecilia M
authors.initials: CM
authors.lastname: Patino
mesh_terms: D000280:Administration, Inhalation; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D001991:Bronchitis / Q000188:drug therapy* / Q000209:etiology; D003428:Cross Infection / Q000188:drug therapy / Q000209:etiology; D006801:Humans; D053717:Pneumonia, Ventilator-Associated / Q000188:drug therapy*; D012121:Respiration, Artificial / Q000009:adverse effects; D012141:Respiratory Tract Infections / Q000188:drug therapy / Q000209:etiology; D014136:Tracheitis / Q000188:drug therapy* / Q000209:etiology; D012122:Ventilators, Mechanical / Q000009:adverse effects
chemical_list: D000900:Anti-Bacterial Agents