Intratracheal Administration of Antimicrobial Agents in Mechanically Ventilated Adults: An International Survey on Delivery Practices and Safety

Abstract

BACKGROUND: Intratracheal antibiotic administration is increasingly used for treating respiratory infections. Limited information is available on delivery devices, techniques, and safety. METHODS: An online survey on intratracheal administration of anti-infective agents in mechanically ventilated adults was answered by health-care workers from 192 ICUs to assess the most commonly used devices, current delivery practices, and safety issues. We investigated whether ICU usage experience (>3 y) impacted its performance. RESULTS: Intratracheal antibiotic administration was a current practice in 87 ICUs (45.3%), with 40 (46%) having experience with the technique (>3 y). Sixty-six (78.6%) of 84 health-care workers reported avoiding intratracheal antibiotic administration due to an absence of evidence-based guidelines (78.6%). Jet nebulizers were the most commonly used devices for delivery, in 24 less experienced ICUs (27.6%) and in 18 (20.7%) experienced ICUs. Direct tracheal instillation (6; 6.9%) was still considered for drug prescription in 12 ICUs (6.9%). More experience resulted in neither greater adherence to measures improving the drug's delivery efficiency (93 measures in the experienced group; 27.9%) nor a greater adoption of measures to increase safety. Indeed, the expiratory filter was changed after each nebulization in only 2 experienced ICUs (6.9%), whereas 15 (51.7%) changed it daily instead. CONCLUSIONS: Intratracheal antibiotic administration is a common therapeutic modality in ICUs, but inadequate practices were widely encountered, independent of the level of experience with the technique. This suggests a need to develop standardization to reduce variability and improve safety and efficacy.

Use of nebulized antimicrobials for the treatment of respiratory infections in invasively mechanically ventilated adults: a position paper from the European Society of Clinical Microbiology and Infectious Diseases

“…Nebulization of antibiotics in mechanically ventilated adults with respiratory infections is a practice that is increasingly used, despite a lack of standardization and limited evidence on the associated efficacy and safety [2,3]. Based on a previous systematic review and meta-analysis [7], this ESCMID panel does not support the use of nebulization of antibiotics in any of the scenarios assessed because the available evidence is weak and heterogeneous (and in some scenarios entirely absent).…”

“…However, the clinical challenges posed by extremely-or pan-drug-resistant Gram-negative pathogens are causing significant concern for clinicians, creating situations reminiscent of the pre-antibiotic era. Therefore, despite lacking high-quality efficacy and safety data, clinicians worldwide are increasingly using antibiotic nebulization to optimize the treatment of respiratory infections in critically ill invasively mechanically ventilated adult patients [2,3].…”

Current options in aerosolised drug therapy for children receiving respiratory support

“…There are some informative reviews available covering the history and methodology associated with aerosol delivery to intubated and ventilated adult patients , and aerosol delivery in the ventilated paediatric population . Despite these reviews, a wide variety of differing drug delivery practices have been reported , indicating a disconnection between those working in aerosol research and those working in clinical areas. In this article, we review the available literature in order to provide suggestions as to how best to treat individuals requiring a variety of respiratory support.…”

Recommendations for aerosolized antibiotics in ventilator-associated pneumonia and ventilator-associated tracheobronchitis: too little and too late?

“…Owing to the weak evidence in support of these indications, primarily due to the limited number of prospective randomized trials, the panel recommended against the routine use of aerosolized antibiotics for the treatment of VAT and VAP. Unfortunately, several recent surveys suggest that clinicians in many parts of the world are already employing aerosolized antibiotics in their daily practices, potentially making the current recommendations of Rello et al too little and too late [17,18].…”