The efficacy and safety of inhaled antibiotics in the treatment of lower respiratory tract infection: An updated meta-analysis and evidence map of systematic reviews.

OBJECTIVE

To synthesize evidence on the effectiveness and safety of different inhaled antibiotic regimens for treating LRTIs.

METHOD: RCTs-based systematic reviews on inhaled antibiotics treating LRTIs were identified from electronic databases. Methodological quality was assessed using the ROBIS tool. Meta-analysis estimated effects on microbiological eradication, lung function, clinical response, exacerbations, adverse events, mortality and antibiotic resistance. Subgroup analysis was conducted by antibiotic type, nebulizer and primary pathogen. Evidence maps visualised outcomes and certainty.

RESULT: A total of 21 systematic reviews and 69 RCTs (52 conducted in adults) were included, covering cystic fibrosis (CF), non-cystic fibrosis bronchiectasis (NCFB) and ventilator-associated pneumonia (VAP). Regarding effectiveness, inhaled antibiotics may improve lung function in CF and likely reduce exacerbation frequency in NCFB (RR 0.86, 0.78-0.96), while they may enhance microbiological eradication in CF (2.06, 1.19-3.57) and likely improve it in NCFB (2.16, 1.21-3.86). For VAP, adjunctive therapy may improve clinical response (1.22, 1.09-1.37) and pathogen clearance (1.38, 1.23-1.56). No significant decreases in mortality were observed. Regarding safety, inhaled antibiotics likely induce bronchospasm in NCFB (1.43, 1.05-1.96), and it may increase antibiotic resistance in both CF (RR 1.82, 1.06-3.11) and NCFB (RR 1.97, 1.55-2.49). Adjunctive therapy in VAP may induce bronchospasm (RR 2.53, 1.49-4.31) and reduce antibiotic resistance (RR 0.18, 0.05-0.64). Efficacy and safety outcomes varied across antibiotic types, nebulizers and target pathogens.

CONCLUSION

Inhaled antibiotics may be beneficial in CF and NCFB, and may have value as adjunctive therapy in VAP. Prospective studies, especially in pediatric populations and comparing inhaled versus systemic antibiotics, remain needed.