Inhaled antibiotics in critical care: State of the art and future perspectives

Administration of inhaled antibiotics in intensive care units (ICU) remains confidential compared to bronchodilators, not withstanding extensive pre-clinical and clinical research and potential indications associated with the emergence of bacterial antibiotic resistances. Inhaled antibiotic administration enables delivery of high doses of antibiotics directly to the lung. Local antibiotic concentrations are pronouncedly higher than the minimum inhibitory concentration of causative pathogens of lung infection, and also higher than the minimal concentrations preventing resistant emergence, with low systemic passage and resulting side effects. In the available armamentarium face to multidrug-resistant bacteria spread, inhaled antibiotics may have a role, insofar they remain effective and prevent further emergence of resistance. In critically ill patients, some studies have documented the benefits of aerosolized antibiotic therapy compared to intravenous treatment. Prophylactic administration of inhaled antibiotics to prevent ventilator-associated pneumonia has yielded encouraging results. In ICUs, nebulized antibiotics may be considered for treatment of ventilator-associated pneumonia caused by resistant pathogens in patients at high risk of therapeutic failure, or as a last resort in case of uncontrolled infection with intravenous antibiotics. In this review, we address the rationale for this treatment method and provide a short technical update, followed by a discussion of potential indications for inhaled antibiotics in critically ill patients. Lastly, we present the innovations and future developments of inhaled antimicrobial therapies that could benefit ICU patients.