Affiliations: Hospital Lariboisière
Northwestern University Medical School
Rush University Medical School
Correspondence to: J. M. Guerin, MD, Hopital Lariboisière, 2 rue Ambroise Paré, 75010 Paris, France; e-mail firstname.lastname@example.org
To the Editor:
In their excellent review of GI complications in patients
receiving mechanical ventilation, Mutlu and colleagues1
discuss the beneficial effects of erythromycin at a daily dose of 200
mg, plus metroclopramide and cisapride on GI motility.
Even if GI hypomotility is a serious problem in patients admitted to
the ICU, its clinical impact seems to be much less important than
nosocomial infections of the respiratory tract, which may develop in up
to 20% of patients who have received mechanical ventilation for a
period > 48 h.2
The use of erythromycin, at doses far below the concentrations
necessary for an inhibitory effect on susceptible bacteria, provides
close to ideal conditions for the induction of bacterial mutation and
selection. Since there are at least two other effective nonantibiotic
drugs to enhance GI motility, it seems reasonable to use one of these
in the first line of treatment rather than erythromycin, which has
prokinetic properties only as a side effect. To our knowledge, there is
no study addressing the question of the resistance of fecal bacteria
populations before and after the use of erythromycin at subinhibitory
concentrations. However, emergence of bacteria increasingly resistant
to macrolide antibiotics has recently been reported.3
In the absence of reliable data, the use of erythromycin
just for its prokinetic effects should thus be avoided, and
its prescription should be reserved for infections due to susceptible
bacteria. Only an approach toward the use of erythromycin as reasonable
as our approach toward other antibiotics may help to restrain
the emergence of resistant populations.
Guerin and Leibinger raise an insightful point about the use of
erythromycin for GI hypomotility in patients receiving mechanical
ventilation. Sublethal concentrations of antibiotics exert selective
pressure on bacteria and can contribute to the development of
resistance.1–2 While concerns regarding the development of
antimicrobial resistance are, in general, relevant, we are unaware, as
Drs. Guerin and Leibinger have also pointed out, of any data to support
the clinical relevance of this hypothesis regarding a short course of
GI hypomotility affects up to 50% of patients receiving mechanical
ventilation, it is associated with significant complications
(aspiration, esophagitis), and it impedes the delivery of enteral
nutrition. Furthermore, hypomotility may contribute to overgrowth and
translocation of bacteria across the bowel wall, which can be a cause
of spontaneous bacterial peritonitis and a contributor to multiorgan
system failure. Parenteral nutrition as an alternative for enteral
route in intractable cases of GI hypomotility is associated with myriad
complications (ie, catheter infections, deep venous
thrombosis). Therefore, GI hypomotility is a significant problem that
should be treated if possible. Unfortunately, treatment options are
limited; cisapride is no longer available in North America, and
metoclopramide does not always work. Thus, short-term use of low-dose
erythromycin is a reasonable approach to promote GI motility.
Until new enterokinetic drugs such as 5-HT4 receptor agonists
(ie, prucalopride)3–4 become available,
and given the ramifications of hypomotility in critically ill patients,
we believe that the benefits of a short-course treatment with once
daily low-dose erythromycin for intractable GI hypomotility outweigh
the unproven risk of erythromycin-induced bacterial resistance.
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