Global Survey Results: International Guidelines Lacking
Lung infections are common in the critically ill and parenteral treatment is the standard of care. Nebulisation of antimicrobials as monotherapy or combination therapy (with parenteral agents) is on the rise and there is little data regarding its use and outcomes. This is a prospective study assessing the indications, dosages and recent patterns of use for nebulised antimicrobial agents in mechanically ventilated (MV) patients. A survey was developed and distributed by the members ESCMID’s study group (ESGCIP). It was completed by 192 adult ICUs worldwide, experienced in administration of nebulised antimicrobials.
One professional per unit completed the questionnaire. 87 ICUs had completed all the information and were included: 42% from Asia, 37% from Europe and 21% from America/Australasia. Presence of multidrug-resistant Gram-negative bacilli (MDR-GNB) in a pulmonary specimen was the most frequent determinant factor for using nebulised antimicrobial (77%). The most common indications were: ventilator-associated pneumonia (VAP, 67%), ventilator-associated tracheobronchitis (VAT, 64%), airway colonisation by MDR-GNB (53%) and immunosuppression (26%). The most common prescribed nebulised agents were: colistin methanesulfonate/sulphate (CMS, 69%), tobramycin (37%) and amikacin (26%). Amongst antivirals only ribavirin was reported and amongst antifungals it was amphotericin B. Doses of all antibiotics were significantly higher for VAP than for VAT: 6 vs. 3 million IU/day for CMS, 600 vs. 300 mg/day for tobramycin and 30 vs. 15 mg/kg/day for amikacin. CMS dosing was variable.
Combination therapy was common and was more frequent in VAP (86%) than in VAT (64.2%).
Take home message
The use of nebulised antimicrobial agents in MV patients is very common, either as monotherapy or combination therapy; with great heterogeneity in clinical practice. MDR-GNB is the main determinant factor. CMS is the most frequently used antimicrobial. Higher doses of antimicrobials and combination therapy are more frequent in VAP. Randomized controlled clinical trials and guidelines are mandatory.
Article review for the ESICM Journal Review Club on behalf of the Pneumonia Working Group provided by Dr. Barbara Borgatta.
Solé-Lleonart C, Roberts JA, Chastre J, Poulakou G, Palmer LB, Blot S, Felton T, Bassetti M, Luyt CE, Pereira JM, Riera J, Welte T, Qiu H, Rouby JJ, Rello J; ESGCIP Investigators. Global survey on nebulisation of antimicrobial agents in mechanically ventilated patients: a call for international guidelines. Clin Microbiol Infect. 2016 Apr;22(4):359-64. doi: 10.1016/j.cmi.2015.12.016. Epub 2015 Dec 23.