Effect of Additional Nebulized Amikacin in Ventilator-Associated Pneumonia Caused by Gram Negative Bacteria

After inclusion, the patients are randomized into two groups: nebulized amikacin plus intravenous antibiotic(s) or nebulized placebo plus intravenous antibiotic(s). The dose of nebulized amikacin is 400 mg every 12 hours for 10 days. The patients are followed up on day 3, 7, 10, and 28 for safety and efficacy. The estimate sample size is 84 subjects base on previous study of cure rate in VAP and the authors expected that nebulized amikacin can improve cure rate in VAP subjects for 30% when compared with intravenous antibiotic(s) alone with power of 80% at level of significance 0.05.

Inclusion criteria

• Age >/= 18 years
• On mechanical ventilator more than 7 days
• VAP diagnosis inclusion criteria:

• new/progressive infiltration of chest radiography
• 2/3 of the following: 1) fever 2) purulent sputum 3) Wbc > 12,000 cell/mm3 or < 4,000 cell/mm3
• Evidence of gram negative bacilli from sputum gram stain or previous sputum culture within 1 week

Exclusion criteria

• History of amikacin allergy
• GFR < 30 mL/min except dialytic patients
• Immunocompromised host: HIV CD4 < 200 cells/mm3, leukemia, lymphoma, received chemotherapy within 3 weeks, Absolute neutrophil count < 500/mm3
• Severe ARDS (P/F ratio < 100)
• Endobronchial obstruction:endobronchial mass, endobronchial stenosis
• Atelectasis
• Severe bronchospasm
• Lung abscess
• Complicated parapneumonic effusion/ Empyema
• Chest trauma
• Uncontrolled extrapulmonary infection(s)
• Received intravenous antibiotic(s) more than 48 hours
• Pregnancy/ Lactation