Efficacy of inhaled antibiotics in children with ventilator-associated pneumonia: A systematic review and meta-analysis

Introduction

The nebulization of antibiotics allows the delivery of high concentration of medication to the lungs without the systemic side-effects.

Aims

We performed a systematic review and meta-analysis to determine the efficacy and safety of inhaled antibiotics in children with ventilator-associated pneumonia (VAP).

Data sources

We searched Web of Science, SCOPUS, MEDLINE Complete, CINAHL and ClinicalTrials.gov trials registry until June 2025. This study was registered (CRD42024504982).

Study selection

We included studies published in the last ten years that recruited children under 18 years old with VAP and treated with inhaled antibiotics. We excluded studies of children with tracheostomy and bronchiectasis.

Data extraction

Type of intervention (inhaled ± intravenous (IV) antibiotics), clinical improvement, duration of mechanical ventilation (MV) and hospitalization, bacterial eradication, and adverse events were recorded.

Results

Seven articles (346 patients) reported the use of inhaled antibiotics in VAP, of which four were randomized controlled trials. These studies included premature infants, neonates and children. The commonest inhaled antibiotic used was colistin (six studies). Meta-analysis revealed that inhaled antibiotics + IV antibiotics versus IV antibiotics +/− inhaled normal saline(placebo) resulted in no significant reduction in duration of MV (MD 0.88 days, 95% CI −2.72, 4.49; p=0.63, I² = 85%) and ICU stay (MD 0.34[−2.79,3.40]; p=0.83, I² = 80%). Clinical success (RR 0.68, 95% CI 0.39, 1.21; p=0.19, I² =24%), microbiological eradication (RR 1.93, 95%CI 0.97,3.78; p=0.06, I² = 2%) and mortality (RR 0.91, 95% CI 0.67, 1.24; p=0.54, I² =0%) were also not significantly different. Inhaled antibiotics were not associated with increased nephrotoxicity (RR 0.91, 95% CI 0.18, 4.61; p=0.91, I² = 30%).

Conclusion

More robust studies are required to confirm the clinical efficacy of inhaled antibiotics in the treatment of VAP. Nonetheless, adjunctive inhaled antibiotics may be safe in children, although close monitoring is still required.