Inhaled antibiotics for treatment and prevention of ventilator-associated pneumonia. Narrative review

Background Ventilator-associated pneumonia (VAP) remains a common and serious complication among patients receiving invasive mechanical ventilation. Inhaled antibiotics have been proposed as a strategy to either prevent or treat VAP by achieving high local concentrations in the lung with minimal systemic toxicity. However, their clinical benefit and optimal use remain uncertain. Objective This review aims to summarize current evidence on the use of inhaled antibiotics for both the prevention and treatment of VAP, identify existing knowledge gaps, and suggest directions for future research. Methods A narrative synthesis was conducted based on a comprehensive review of randomized controlled trials, meta-analyses, and observational studies published up to 2024. Particular attention is given to antibiotic class, delivery method, patient outcomes, safety, and microbial resistance. Findings Several high-quality studies suggest that prophylactic inhaled antibiotics, especially aminoglycosides such as amikacin, significantly reduce the incidence of VAP without increasing adverse events or multidrug resistance. Nonetheless, consistent improvements in mortality, ICU length of stay, or duration of mechanical ventilation have not been demonstrated. In the treatment context, inhaled antibiotics are frequently used as adjunctive therapy for multidrug-resistant Gram-negative pathogens, although robust RCT evidence remains limited. Key challenges include heterogeneity in study design, delivery devices, antibiotic regimens, and diagnostic definitions of VAP. Conclusions Inhaled antibiotics appear effective in preventing VAP, particularly when delivered via modern nebulization systems. However, their role in improving patient-centered outcomes and in the treatment of established VAP requires further clarification. Future research should focus on standardized protocols, long-term safety monitoring, and identifying patient subgroups most likely to benefit. Well-designed trials powered for clinical outcomes are essential to support the broader integration of inhaled antibiotics into VAP management strategies. Keywords: Ventilator associated pneumonia, inhaled antibiotics, mechanical ventilation