Inhaled tobramycin for chronic pseudomonas aeruginosa infection in non-cystic fibrosis bronchiectasis: an updated systematic review and meta-analysis

OBJECTIVE: To evaluate the efficacy and safety of inhaled tobramycin for the treatment of chronic Pseudomonas aeruginosa infection in adult patients with non-cystic fibrosis (NCF) bronchiectasis. METHOD: A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. PubMed, EMBASE, Web of Science, and the Cochrane Library were searched up to January 18, 2026. The search strategy incorporated Medical Subject Headings (MeSH) terms and free-text synonyms combined with Boolean operators. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Parallel-group RCTs comparing inhaled tobramycin with placebo or no treatment in adults with NCF bronchiectasis and chronic P. aeruginosa infection were included. RESULTS: Ten RCTs were included. Inhaled tobramycin was associated with a significantly higher rate of P. aeruginosa eradication (Odds Ratio [OR] 5.04, 95% CI 1.80–14.09) and a greater reduction in sputum bacterial density (Weighted Mean Difference [WMD] -2.87 log₁₀ CFU/g, 95% CI -4.21 to -1.52). Treatment with tobramycin significantly reduced the number of hospital admissions (WMD − 0.45, 95% CI -0.68 to -0.22) and the total days of hospital admission (WMD − 11.73, 95% CI -18.81 to -4.65). No significant improvement in FEV₁% predicted or the overall frequency of exacerbations was found. The incidence of non-fatal adverse events was similar between groups, with a non-significant trend towards increased tobramycin resistance. Sensitivity analyses, including leave-one-out analysis and exclusion of older studies, were performed to explore sources of heterogeneity. The GRADE assessment indicated that the certainty of evidence ranged from very low to moderate across outcomes. CONCLUSION: In patients with NCF bronchiectasis and chronic P. aeruginosa infection, inhaled tobramycin effectively improves microbiological outcomes and appears to reduce the frequency and duration of hospitalizations, although the latter finding is based on limited data (three studies, n = 90) and should be interpreted with caution. While it does not improve lung function or overall exacerbation rates, its safety profile is acceptable. The overall certainty of evidence, as assessed by the GRADE framework, ranges from very low to moderate, underscoring the need for large-scale, long-term RCTs to confirm these findings. TRIAL REGISTRATION: PROSPERO(CRD420261294797).