Potential Role Of Aerosolized Antibiotics

Although of interest for over five decades, our understanding of the role of this therapeutic strategy improved significantly during the last 10 years. Evaluations have focused on patients with cystic fibrosis. Potential clinical applications include the use of these therapies as primary or adjunctive therapy during acute exacerbations of lung infection in patients with chronic disease; suppressive regimens designed to reduce the frequency and severity of exacerbations, as well as the associated decline in lung function due to recurrent infections; and to delay or prevent the onset of chronic infection.

Aminoglycosides are the most widely studied class of aerosolized antibiotic therapies. Since they retain bioactivity when aerosolized and are poorly absorbed across epithelium, they can achieve and maintain high concentrations in bronchial and alveolar fluids with minimal potential for toxicity.

Although most recent studies have evaluated aerosolized aminoglycosides, other antimicrobial therapies are used as aerosolized therapy in patients infected with multiresistant organisms. Polymyxin antimicrobials are polypeptides that are poorly absorbed across mucosal membranes. These agents are not absorbed to a clinically significant extent, which limits their application to intravenous use or decontamination of the gastrointestinal tract. When used systemically, these agents carry a significant risk of neurotoxicity and nephrotoxicity. These agents have retained good activity against gram-negative organisms; therefore, their use as aerosolized therapy has been explored.

A worldwide survey of cystic fibrosis centers, including four in the United States [13], indicated that the use of aerosolized antibiotics was being considered on an increasing basis. In the survey, suppressive therapy was more likely to be used in older age groups ($ 19 years), with half the centers surveyed indicating that they were prescribed in at least 50% of their patients. Although this survey is relatively recent, it is likely this trend has continued to increase and has extended to younger patients, and additional evidence has likely been reported.

Although not well studied, the use of aerosolized antibiotics may have additional applications in other clinical situations, including bronchiectasis, pneumonias, and management of patients following lung transplantation.

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