Nebulization of antimicrobial agents in mechanically ventilated adults in 2017: an international cross-sectional survey

Abstract

2017 ESCMID practice guidelines reported safety concerns and weak evidence of benefit supporting use of aerosolized antibiotics in mechanically ventilated patients. Our primary goal was to assess current patterns of aerosolized antibiotic prescription in mechanically ventilated patients. A sequential global survey was performed prior to the release of the ESCMID guidelines, from the 1st of February to the 30th of April 2017, using an electronic platform. Responses were analyzed comparing geographical regions. A total of 410 units responded, with 261 (177 from Europe) being eligible for the full survey. 26.8% of units reported not using aerosolized antibiotics. The two major indications amongst prescribing units were ventilator-associated pneumonia and ventilator-associated tracheobronchitis (74.3% and 49.4%, respectively). 63.6% of units indicated prescription solely in response to multi-drug resistant organisms. In comparison with a survey undertaken in 2014, there was a significant reduction in use of aerosolized antibiotics for prophylaxis (50.6% vs 7.7%, p < 0.05) and colonization (52.9% vs 25.3%, p < 0.05). The large majority of units (91.7%) reported only prescribing in patients with positive pulmonary cultures. Asia appeared to be an outlier, with 53.3% of units reporting empirical use. The most commonly used device was the jet nebulizer. The most commonly prescribed drugs were colistin methanesulfonate (57.6%), colistin base (41.9%) and amikacin (31.4%), although there was considerable heterogeneity across geographical areas. A significant gap exists between ESCMID clinical practice recommendations and the use of aerosolized antibiotics in clinical practice. Our findings indicate an urgent need for high-quality education to bring practice into line with evidence-based guidelines.

Heterogeneous approach to nebulization of antimicrobial agents in mechanically ventilated adults in a German tertiary care hospital: a cross-sectional survey

“…The high percentage of daily filter exchange in our hospital may contribute to the perception of all respondents that nebulization of antibiotics was safe as adverse events in the literature have been linked to obstruction of the expiratory filter [6]. However, respondents in the study by Alves et al commonly described bronchospasm, cough, and a moderate decrease in oxygen saturation [4]. All these adverse events may occur independently of frequent filter exchanges.…”

“…Nonetheless, protocols for filter exchange were in place on all wards and filters were exchanged at least daily in 10 out of 11 units. In the international survey by Alves et al, daily filter changes were carried out in 83 of 216 (38.4%) units [4]. The high percentage of daily filter exchange in our hospital may contribute to the perception of all respondents that nebulization of antibiotics was safe as adverse events in the literature have been linked to obstruction of the expiratory filter [6].…”

“…In this journal, Alves et al reported the results of an international cross-sectional survey on nebulization of antimicrobial agents in mechanically ventilated adults. They found considerable heterogeneity of practice among participating intensive care units (ICU) from different continents [4]. However, little is known about different practices within a single institution.…”

Precision medicine and aerosolization in mechanically ventilated adults

“…Another interesting observation is that two-thirds of patients used jet nebulizers and one-third mesh nebulizers, in accordance with general use in antimicrobial aerosolization (19)(20)(21). This is not a minor issue, because these devices deliver particles of different size.…”

Management of pneumonia in intensive care

“…Nebulised antibiotics are used in the management of MDR bacteria in several contexts, and is supported by the American guidelines on HAP and VAP (25), however this is based on weak evidence and many units do not use nebulised antibiotics at all (118). Where they are used, practice is variable and seldom in accordance with the advised best practice (118). Before this approach achieves widespread adoption, well conducted trials are needed.…”