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Hospital Lariboisière Paris, France
Correspondence to: J. M. Guerin, MD, Hopital Lariboisière, 2 rue Ambroise Paré, 75010 Paris, France; e-mail jean-michael.guerin@lrb.ap-hop-paris.fr
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.
References
Northwestern University Medical School Chicago, IL Rush University Medical School Chicago, IL
Correspondence to: Phillip Factor, DO, FCCP, Pulmonary and Critical Care Medicine, Evanston-Northwestern Healthcare, 2650 Ridge Ave, Evanston, IL 60201; e-mail: pfactor{at}northwestern.edu 
To the Editor:
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 low-dose erythromycin.
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.
References
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