Abstract
PURPOSE: Ventilator-associated pneumonia (VAP) is a common ICU complication linked to high morbidity and mortality. Inhaled antibiotics may offer targeted prophylaxis, but their effectiveness has shown mixed results. This study aims to further evaluate whether inhaled antibiotics reduce VAP incidence and ICU mortality through a systematic review and meta-analysis of the most updated available evidence. METHODS: A systematic review was conducted following PRISMA 2020 guidelines. Multiple databases were searched for studies published up to November 14, 2024. Ten studies including 2876 patients (1485 intervention; 1391 control) met inclusion criteria. A random-effects meta-analysis was performed to estimate pooled risk ratios (RR) for VAP incidence and ICU mortality. Risk of bias was assessed using ROBINS-I and certainty of evidence via GRADE. RESULTS: Inhaled antibiotics significantly reduced the incidence of VAP compared to controls (RR = 0.67; 95% CI: 0.58-0.77; p < 0.001), but showed no significant effect on ICU mortality (RR = 0.92; 95% CI: 0.79-1.06; p = 0.25). Moderate heterogeneity was observed in VAP outcomes (I(2) = 46.8%), while mortality analysis showed no heterogeneity. Funnel plot analysis suggested minimal publication bias, and GRADE rated the evidence as moderate in certainty. CONCLUSION: Inhaled antibiotics significantly reduce VAP incidence but show no clear mortality benefit. While promising for prevention, their survival impact remains uncertain. Clinical use should consider patient context and microbial patterns for targeted approach. Future research should identify high-risk subgroups, assess long-term outcomes, and evaluate antibiotic resistance.