JAC Advance Access originally published online on November 2, 2007
Journal of Antimicrobial Chemotherapy 2008 61(1):227; doi:10.1093/jac/dkm419
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Letters to the Editor |
Comment on: The use of erythromycin as a gastrointestinal prokinetic agent in adult critical care: benefits versus risks
Department of Intensive Care, Royal Adelaide Hospital, Adelaide, Australia
* Corresponding author. Tel: +61-431-967-560; Fax: +61-882-222-367; E-mail: adam.deane{at}adelaide.edu.au
Keywords: delayed gastric emptying , critical illness , intensive care
Hawkyard and Koerner1 have valid concerns regarding the development of macrolide resistance exacerbated by the use of erythromycin as therapy for delayed gastric emptying in critical care. The enteral route remains the preferred mode of nutritional support in critical illness. However, up to 50% of critically ill patients suffer from delayed gastric emptying. Therefore, until a cheap, quick and minimally invasive method of post-pyloric tube placement becomes available, intensivists will require prokinetics to treat delayed emptying.
The pattern of motility seen in critically ill patients during enteral nutrition is virtual absence of antral motility with increased isolated pyloric pressure waves and retrograde duodenal activity.2 This motility pattern retards gastric emptying, and motilin agonists, which stimulate antral wave frequency and amplitude while suppressing pyloric activity, are an ideal prokinetic in critical illness. This was confirmed recently when erythromycin was demonstrated to be more effective than metoclopramide at treating delayed gastric emptying.3 There is also a benefit to using metoclopramide in combination with erythromycin,4 and our current regimen is to treat feed intolerance with a short course of combination therapy (erythromycin 200 mg twice a day and metoclopramide 10 mg four times a day). This approach improves feed tolerance while limiting tachyphylaxis and attempts to minimize pressure on macrolide resistance within the intensive care unit.
Other prokinetic options remain limited. Tegaserod, a selective serotonin type 4 receptor agonist, has been used successfully in critically ill patients to improve feed tolerance.5 However, we remain cautious of tegaserod because it has been associated with increased ischaemic cardiovascular events. Current FDA recommendations are that the use of tegaserod should be limited to patients who ‘meet strict criteria and have no known or pre-existing heart problems and be in critical need of this drug’.6 Opiate and cholecystokinin (CCK) antagonists, ghrelin agonists and motilin agonists without antibiotic activity are all appealing but require further trials before acceptance into critical care practice.
Nutritional support is standard care in critical illness. However, delivery of adequate enteral nutrition remains a problem because of delayed gastric emptying. In the absence of an alternative modality to enable more successful and safe delivery of nutrition, we believe that the benefits of short-course erythromycin outweigh the risks.
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1 Hawkyard CV, Koerner RJ. The use of erythromycin as a gastrointestinal prokinetic agent in adult critical care: benefits versus risks. J Antimicrob Chemother (2007) 59:347–58.
2
Chapman M, Fraser R, Vozzo R, et al. Antro-pyloro-duodenal motor responses to gastric duodenal nutrient in critically ill patients. Gut (2005) 54:1384–90.
3 Nguyen NQ, Chapman MJ, Fraser RJ, et al. Erythromycin is more effective than metoclopramide in the treatment of feed intolerance in critical illness. Crit Care Med (2007) 35:483–9.[CrossRef][Web of Science][Medline]
4 Nguyen NQ, Chapman M, Fraser RJ, et al. Prokinetic therapy for feed intolerance in critical illness: one drug or two? Crit Care Med (2007) [5 September 2007, Epub ahead of print].
5 Stephens DP, Thomas JH, Collins SJ, et al. A clinical audit of the efficacy of tegaserod as a prokinetic agent in the intensive care unit. Crit Care Resusc (2007) 9:148–50.[Medline]
6 U.S. Food and Drug Administration. Zelnorm (Tegaserod Maleate) Information. http://www.fda.gov/cder/drug/infopage/zelnorm/default.htm (21 October 2007, date last accessed).
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  C. V. Hawkyard and R. J. Koerner The use of erythromycin as a gastrointestinal prokinetic agent in adult critical care: benefits versus risks authors' response J. Antimicrob. Chemother., January 1, 2008; 61(1): 227 - 228. [Full Text] [PDF]
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