Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep Network, CHRU Tours, Tours France and Centre d'étude des Pathologies Respiratoires INSERM U1100, Université de Tours, Tours.
Médecine Intensive Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris.
Curr Opin Infect Dis. 2020 Apr;33(2):197-204. doi: 10.1097/QCO.0000000000000633.
The aim of the article is to review the evidence to select ventilated patients most likely to benefit from inhaled antibiotic therapy and summarize the optimal implementation setup to favor clinical success.
Although a large body of literature describes the optimal ventilator circuit and settings to implement to favor a high amount of inhaled antibiotic delivery to ventilated patients, recent clinical trials failed to show a significant benefit on patient-centered outcomes. Currently, inhaled antibiotic therapy can only be recommended as a therapeutic modality of last resort after case-by-case discussion among specific patients or settings with high antimicrobial resistances.
Currently, inhaled antibiotic therapy may only be recommended to treat ventilator-associated pneumonia caused by extensively resistant bacteria only susceptible to colistin, and should be used either after documentation of such an infection or empirically in settings with a high probability of such an infection. A similar approach may be considered for aminoglycoside-only-susceptible pneumonia. In these cases, inhaled antibiotics should be ideally delivered as a complement to intravenous therapy placing a vibrating mesh nebulizer upstream in the inspiratory limb, reducing inspiratory flow and increasing inspiratory time, avoiding gas humidification under close clinical and pharmacological monitoring.
本文旨在回顾证据，以选择最有可能从吸入性抗生素治疗中获益的机械通气患者，并总结最佳实施方案以促进临床成功。
尽管大量文献描述了为了使更多的抗生素能够输送到机械通气患者而实施的最佳呼吸机回路和设置，但最近的临床试验未能显示出对患者为中心结局的显著获益。目前，吸入性抗生素治疗仅可作为一种治疗方法，仅在特定患者或存在高耐药率的情况下，经逐例讨论后才可应用。
目前，吸入性抗生素治疗可能仅推荐用于治疗对多黏菌素敏感的广泛耐药菌引起的呼吸机相关性肺炎，并且应在已证实存在这种感染或在存在这种感染高概率的情况下经验性使用。对于仅氨基糖苷类敏感的肺炎也可考虑类似的方法。在这些情况下，吸入性抗生素应作为静脉治疗的补充，在吸气支上游放置一个振动网式雾化器，降低吸气流量，增加吸气时间，在密切的临床和药理学监测下避免气体湿化。
