mdpi.com
In the high-stakes environment of intensive care, ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT) continue to pose serious challenges. These infections, frequently caused by multidrug-resistant Gram-negative organisms, demand aggressive treatment strategies. Emerging evidence now points to the value of nebulized antibiotics as a potent adjunct to traditional intravenous therapy—offering a targeted approach that may improve clinical and microbiological cure rates while reducing systemic drug exposure.
For pulmonologists and infectious disease specialists, this dual modality represents a promising shift in managing complex respiratory infections in ventilated patients. By delivering antibiotics directly to the lungs, nebulized therapy achieves high local concentrations at the site of infection, where systemic antibiotics may fall short. When paired with intravenous regimens, this approach has been shown to improve clinical outcomes significantly. Meta-analyses have reported an increase in clinical cure rates with risk ratios around 1.23 and even higher gains in microbiological eradication, with ratios nearing 1.64. These findings underscore the growing consensus that inhaled antibiotics have a meaningful role in critical care.
Importantly, this strategy isn’t solely about efficacy—it’s also about resistance. By concentrating antimicrobial activity where it’s needed most, nebulized delivery reduces systemic antibiotic exposure and, in turn, selection pressure on non-target flora. This localized therapy could help curb the development of resistant strains, an urgent goal in today’s antibiotic stewardship landscape.
Despite the clear advantages, safety remains a consideration. Certain agents, notably colistin and aminoglycosides, are associated with airway irritation and bronchospasm, particularly in spontaneously breathing patients. Adverse effects such as coughing and wheezing, while typically manageable, require vigilance. Studies suggest that precise dosing protocols, the use of vibrational mesh nebulizers, and careful patient selection can mitigate these risks effectively. As always, monitoring remains key—especially in critically ill patients with fluctuating respiratory dynamics.
In practice, the integration of nebulized antibiotics requires coordination across disciplines, from pharmacy to respiratory therapy to bedside clinicians. Success depends on tailoring therapy to the patient’s respiratory status, infection profile, and tolerance, as well as ensuring devices and delivery methods are optimized for ICU settings.
As resistant Gram-negative pathogens continue to rise, and as traditional therapies face growing limitations, nebulized antibiotics offer a strategic advantage. When implemented thoughtfully, they not only enhance treatment efficacy for VAP and VAT but also represent a step forward in balancing aggressive care with stewardship principles. For ICU teams confronting these infections daily, the message is clear: inhaled antibiotics are no longer a niche option—they are becoming a critical component of modern respiratory infection management.