JAC Advance Access originally published online on November 22, 2007
Journal of Antimicrobial Chemotherapy 2008 61(1):227-228; doi:10.1093/jac/dkm451
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Letters to the Editor |
The use of erythromycin as a gastrointestinal prokinetic agent in adult critical care: benefits versus risks—authors' response
Department of Medical Microbiology, Sunderland Royal Hospital, Sunderland SR4 7TP, UK
* Corresponding author. Tel: +44-191-5656256; Fax: +44-191-5410531; E-mail: roland.koerner{at}chs.northy.nhs.uk
Keywords: modular evolution , non-antimicrobial activities
Since the publication of our recent article reviewing the benefits versus the risks of using erythromycin as a gastric prokinetic1 agent, two more studies have been published. One study demonstrates a statistical advantage of erythromycin over metoclopramide and the other study reports superiority of the combination of erythromycin plus metoclopramide versus erythromycin monotherapy as gastric prokinetic agents. Reduction of the gastric residual volume (GRV) was taken as the endpoint in both studies. Systematic enhanced surveillance of emergence of resistance was not part of the investigations of the two studies.2,3
On the basis of these two recent reports, Deane and Young4 express the belief that in view of these new findings, the use of the combination of erythromycin and metoclopramide to reduce residual gastric volume outweighs the risks of the associated promotion of antimicrobial resistance. We remain to be convinced that their belief is sufficiently substantiated for reasons as follows.
First, no improved clinical outcome could be found in the study group, which was given the combination therapy, the ultimate goal of any intervention in intensive care. This is consistent with previous findings that increased gastric emptying does not correlate with improved outcome;5 second, both studies demonstrated that the most critically ill patients, i.e. patients with a high Acute Physiology and Chronic Health Evaluation II score (APACHE II), patients requiring sedation by either opiates or benzodiazepines, patients with hyperglycaemia requiring insulin therapy, or patients who were already malnourished as indicated by hypoalbuminaemia responded least to either erythromycin or the combination of erythromycin plus metoclopramide as gastric prokinetic agents;2,3 third, as with other studies, the weakness of these studies is that the GRV has been taken as the endpoint of successful treatment.
As members of our local intensive care team, we share the concerns about optimizing enteric feeding as expressed by Deane and Young.4 However, neither the studies by Nguyen et al.2,3 nor Deane and Young4 provide any epidemiological data supporting their belief that the accumulating amount of low doses of erythromycin given as prokinetic agent does not promote the emergence of antibiotic resistance, as discussed in our review article. Therefore, we are convinced that our cautious approach "... that the use of erythromycin A as a prokinetic agent in the critical care unit should be restricted to only those patients who have already failed all other treatments for impaired gastric motility and are intolerant of a first-line agent such as metoclopramide" is still justified.1 Failing other treatments would, of course, include failure to insert a jejunal feeding tube.
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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 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]
3 Nguyen NQ, Chapman M, Fraser RJ, et al. Prokinetic therapy for feed intolerance in critical illness: one drug or two? Crit Care Med (2007) in press.
4
Deane A, Young R. Comment on: The use of erythromycin as a gastrointestinal prokinetic agent in adult critical care: benefits versus risks. J Antimicrob Chemother (2008) 61:227.
5 Yavagal DR, Karnad DR, Oak JL. Metoclopramide for preventing pneumonia in critically ill patients receiving enteral tube feeding: a randomized controlled trial. Crit Care Med (2000) 28:1408–11.[CrossRef][Web of Science][Medline]
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