Ventilator-associated pneumonia: mechanisms, an appraisal of current therapies and the role for inhaled antibiotics in prevention and treatment

Ventilator-associated pneumonia (VAP) is the most prevalent nosocomial infection in the intensive care unit (ICU), accounting for more than 30 % of the overall costs for all healthcare-associated infections. VAP leads to poor outcomes, such as increased duration of mechanical ventilation, prolonged length of ICU stay and increased mortality rates for up to five years after discharge. The pathophysiology of VAP is complex, attributable to the colonisation of abnormal microbiota and micro-aspiration risks associated with mechanical ventilation and critical illness, and thus its prevention and treatment is complex. With the rising prevalence of multidrug resistance infections and antibiotic prescription pressures, the management of VAP is becoming increasingly challenging. The traditional treatment of VAP with intravenous or oral antibiotics is effective; yet inhaled antibiotics may offer a targeted, synergistic and effective alternative. Empirical therapy with broad-spectrum antibiotics are associated with systemic complications and increased pathogenic strains, whilst inhaled antibiotics reduce bystander antimicrobial resistance with fewer systemic side effects. However, large-scale clinical trials have failed to cosnsitently demonstrate the clinical benefits of inhaled antibiotics and thus translation into practice remains controversial. In this review, we summarise the pathophysiology and diagnosis of VAP, underpin the mechanisms of currently available therapies and discuss the potential role of inhaled antibiotics for the prevention and treatment of VAP, with critical discussion of the available evidence.