Intravenous Erythromycin Research Articles

Application of Endoscopy in Improving Survival of Cirrhotic Patients with Acute Variceal Hemorrhage

Playing a central role in the modern multidisciplinary management of acute gastroesophageal variceal hemorrhage, endoscopy is essential to stratify patient at risk, control active hemorrhage, and prevent first as well as recurrent bleeding. Before endoscopic procedure, antibiotic prophylaxis along with vasoactive medication is now routine practice. Intravenous erythromycin effectively cleanses stomach and may improve the quality of endoscopy. The timing of endoscopy should be on an urgent basis as delay for more than 15 hours after presentation is associated with mortality. Active variceal bleeding on endoscopy in a patient with hepatic decompensation heralds poor prognosis and mandates consideration of aggressive strategy with early portosystemic shunting. Band ligation has become the preferred modality to control and prevent bleeding from esophageal varices, although occasionally sclerotherapy may still be used to achieve hemostasis. Addition of pharmacotherapy with nonselective beta blockade to endoscopic ligation has become the current standard of care in the setting of secondary prophylaxis but remains controversial with inconsistent data for the purpose of primary prophylaxis. Gastric varices extending from esophagus may be treated like esophageal varices, whereas variceal obliteration by tissue glue is the endoscopic therapy of choice to control and prevent bleeding from fundic and isolated gastric varices.

Pharmacotherapy for Gastroparesis: An Attempt to Evaluate a Safer Alternative

Pharmacotherapy for Gastroparesis: An Attempt to Evaluate a Safer Alternative

A summary of recent recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding

Recommendations in managing patients with nonvariceal upper gastrointestinal bleeding were recently updated, addressing resuscitation, risk assessment and pre-endoscopic care, endoscopy, pharmacotherapy, and secondary prophylaxis. Initial adequate resuscitation and risk stratification using validated scales remain critical. Intravenous erythromycin improves visualization when likely to find blood in the stomach. Pre-endoscopic proton pump inhibition (PPI) does not improve outcomes, but downstages high-risk endoscopic lesions and may be considered. In patients on anticoagulants, correction of a coagulopathy is recommended, but should not delay early endoscopy (within 24 h), as it improves clinical outcomes. In patients with high-risk endoscopic stigmata, although better than doing nothing, epinephrine injection alone provides suboptimal efficacy and should be combined with another modality such as clips, thermal or sclerosant injection, which are also efficacious alone. Following an attempt at dislodgment, adherent clots can be treated with high-dose intravenous PPI infusion alone (80 mg bolus and 8 mg/h for 3 days) or following endoscopic hemostasis. The combination is indicated for all other patients with high-risk stigmata as there is currently a lack of high-quality generalizable data supporting other intravenous or oral PPI regimens. A second-look endoscopy is recommended only selectively after endoscopic hemostasis. A negative Helicobacter pylori test requires confirmation in the acute setting. Following appropriate discussions, acetylsalicylic acid (ASA) can soon be restarted acutely after bleeding; long-term PPI co-therapy is imperative in patients having bled on nonsteroidal anti-inflammatory drugs if still needed (preferably with a cyclooxygenase-2, if appropriate) or ASA (not clopidogrel alone). Further work is needed to implement and disseminate these recommendations.

Effect of intravenous erythromycin on the colonic motility of children and young adults during colonic manometry

Purpose Erythromycin is successfully used as a gastroduodenal prokinetic agent. Given the limited available treatments for colonic dysmotility, further investigation into erythromycin's effect on colonic motility is warranted. We aimed to study the effect of erythromycin on colonic motility in pediatric patients with recalcitrant chronic constipation/encopresis and other suspected colonic motility disorders. Methods Patients referred for colonic manometry were eligible for enrollment. Fasting motility was recorded for 1 to 2 hours, then erythromycin lactobionate (EL), 3 mg/kg, was administered intravenously, and colonic motility was monitored for 1 to 2 hours after erythromycin. Manometry was then continued per routine. The motility index (MI) of pressure tracings at each pressure transducer was calculated for each patient for a period of 15 and 60 minutes before and after EL infusion. Change in MI was compared by Wilcoxon signed rank test. Results Twenty patients were enrolled. The most common indication was constipation with encopresis. Seventy percent of patients had normal colonic manometry, and 30% of patients demonstrated a neuropathy. Average MI for the 60-minute period before and after EL infusion were 254 ± 74 mm Hg/h and 253 ± 94 mm Hg/h, respectively ( P = .55). Average MI for the 15-minute period before and after EL infusion were 64 ± 23 mm Hg/15 min and 69 ± 32 mm Hg/15 min, respectively ( P = .45). Conclusions Administration of intravenous EL resulted in no changes in colonic MI in pediatric patients referred for colonic manometry. Further studies on potential colokinetic agents are warranted in this population of patients.

Pigs as Source for ToxigenicCorynebacterium ulcerans

To the Editor: Toxigenic Corynebacterium ulcerans may cause a zoonotic infection similar to diphtheria caused by C. diphtheriae. Previously, dairy cattle were considered to be the main reservoir for C. ulcerans (1), but recent publications suggest pet dogs and pet cats as carriers (cats often show bilateral nasal discharge) (2). We report a case of severe C. ulcerans diphtheria-like disease in a person who had had contact with pigs. In December 2007, a previously healthy 56-year-old female farmer was admitted to the Ear, Nose and Throat Department of the University Hospital Erlangen with a 1-week history of sore throat and progressive dysphagia. She did not report fever and had not received prior treatment with antimicrobial drugs. She had thick, whitish pseudomembranes on her uvula, pharynx, and both tonsils. Endoscopic examination of her larynx and hypopharynx showed that both vocal cords were mobile and the mucosa was erythematous. Enlarged cervical lymph nodes were palpable on both sides of her neck. She had no signs of cranial nerve palsies. Her temperature was 36.5°C. Because of the extensive oropharyngeal pseudomembranes, diphtheria was suspected and diphtheria antitoxin (30,000 IU) was administered intramuscularly. The patient was isolated and received intravenous penicillin (5 million units 4×/day). A pharyngeal swab obtained from below the whitish pseudomembranes grew toxigenic C. ulcerans. Species identification was achieved by biochemical differentiation (API Coryne code 0111326), rpoB sequencing (3), and MALDI-TOF analysis (Microflex LT and Biotyper 2.0 Software; Bruker Daltonics, Bremen, Germany). Toxigenicity of the strain, named KL126, was verified by using a C. diphtheriae tox–PCR (4–6), a C. ulcerans tox–specific PCR (4), and the Elek test as described previously (4,5). The tox sequence (GenBank accession no. {type:entrez-nucleotide,attrs:{text:FJ858272,term_id:238817560,term_text:FJ858272}}FJ858272) differs from 2 other published C. ulcerans tox sequences ({type:entrez-nucleotide,attrs:{text:AB304279.1,term_id:167216113,term_text:AB304279.1}}AB304279.1 and {type:entrez-nucleotide,attrs:{text:AY703827.1,term_id:56694206,term_text:AY703827.1}}AY703827.1) at only 3 bp. The patient recovered quickly, and the pseudomembranes vanished within 2 days. However, because an allergic rash had developed after her third day of treatment with penicillin, antimicrobial drug treatment was switched to intravenous erythromycin (500 mg 4×/d). When 1 day later the standardized antibiogram showed resistance to erythromycin, the patient received intravenous ceftriaxone (2 g 1×/d) for 12 days. Seven days after initiation of antimicrobial drug therapy, pharyngeal swabs were taken on 3 consecutive days. Because C. ulcerans no longer grew on culture, the patient was discharged from the hospital. However, 2 days later she was readmitted to hospital for severe polyneuropathy with neuralgia and weakness of both arms, acute difficulty swallowing, and hoarseness. Signs of cardiomyopathy, including sinus bradycardia and grade I atrioventricular block, were present. The patient recovered after symptomatic treatment and returned home after 2 weeks. According to her records, the patient had received a basic vaccination against diphtheria in 1960 and a booster in 1998. The literature describes the classic animal sources for toxigenic C. ulcerans as dairy cattle with mastitis (1). Since 2005, toxigenic C. ulcerans carriage in companion animals, e.g., pet cats and dogs, has been reported (2). Two cases of transmission of a toxigenic C. ulcerans strain from pet dogs to their immunocompromised female owners have been documented in France (7,8). In 2008, toxigenic C. ulcerans in 2 dead killer whales from a Japanese zoo was reported (9). To determine the source of our patient’s illness, an outbreak investigation involving her family and their farm animals was conducted. Their medium-sized pig-breeding farm was located in a remote rural village surrounded by woods; they raised ≈500 pigs in a nonindustrialized manner, and no piglets were purchased from outside the farm. Pharyngeal swabs of 3 family members, 19 pigs, and the farm dog were analyzed for C. ulcerans. Although all family members and the dog were negative for C. ulcerans, 1 of the 19 asymptomatic pigs harbored a toxigenic strain of C. ulcerans. Sequencing of rpoB and tox showed 100% homology between the human and the pig strains. Ribotyping (10) confirmed this result, suggesting the identity of both strains; the obtained ribotype is similar to the reported U1 ribotype profile found in humans and cats (2). We report proven transmission of a toxigenic C. ulcerans strain between a livestock animal and a human, as well as harboring of toxigenic C. ulcerans in pigs. Introduction of C. ulcerans from wild animals seems unlikely because the barn doors were reportedly closed at all times. Because handling of C. ulcerans–infected pigs may lead to diphtheria-like illnesses, studies of toxigenic C. ulcerans carriage among pigs are needed. Similar to our case, diphtheria-like disease caused by an erythromycin- and clindamycin-resistant toxigenic C. ulcerans strain in a US patient has been recently (in 2008) reported (1). Because current recommendations based on C. diphtheriae–caused disease consider erythromycin as the second-line option for treatment or postexposure prophylaxis, these findings highlight the importance of antimicrobial-drug susceptibility testing of toxigenic C. ulcerans strains.

Gastric Lavages Versus Intravenous Erythromycin Prior to Urgent Endoscopy for Acute Upper Gastrointestinal Bleeding: A Randomized Trial-Preliminary Results

Introduction: The diagnostic and therapeutic capacity of the endoscopy in patients with acute upper gastrointestinal bleeding (UGB) is limited by the presence of clots. Different suggesting studies have published that the previous administration of a bolus of intravenous erythromycin improves stomach cleansing before endoscopy. There is not any work that compares the nasogastric tube lavages with the infusion of erythromycin prior to the endoscopy. Aim: determining if the quality of vision of the urgent endoscopy in patients with UGB after administering intravenous erythromycin is comparable to the one obtained with gastric lavages by nasogastric tube.

Strain measurement during antral contractions by ultrasound strain rate imaging: influence of erythromycin

Strain rate imaging (SRI) is a non-invasive ultrasound (US) modality that enables the study of mechanical deformation (strain) with high spatial and temporal resolution. A total of 244 contractions in seven healthy volunteers were studied by SRI on two separate days to characterize radial strain of antral contractions in the fasting and fed states and to assess the influence of intravenous erythromycin. Gastric accommodation and emptying were assessed by 2D ultrasonography. The perception of hunger was registered by the participants. The strain increased from early to late phase II and phase III activity by (median) 18%, 58% and 82%, respectively, P < 0.05. Erythromycin infusion in phase I induced contractions with median strain of 35%, but did not increase postprandial strain. Both fasting and postprandially, lumen-occlusive contractions with erythromycin were more frequent than in naturally occurring contractions, 69%vs 48%, P = 0.036 and 40%vs 5%, P < 0.001 respectively. All subjects had rumbling in their abdomens when intraluminal air was detected sonographically (85% of all phase III contractions) and that rumbling was perceived by the participant as maximal awareness of hunger. SRI enabled detailed strain measurement of individual antral contractions. Erythromycin initiated fasting antral contractions and increased the number of lumen-occlusive contractions.

Prokinetic Therapy for Feed Intolerance in Critical Illness: One Drug or Two?

To compare the efficacy of combination therapy, with erythromycin and metoclopramide, to erythromycin alone in the treatment of feed intolerance in critically ill patients. Randomized, controlled, double-blind trial. Mixed medical and surgical intensive care unit. Seventy-five mechanically ventilated, medical patients with feed intolerance (gastric residual volume ≥250 mL). Patients received either combination therapy (n = 37; 200 mg of intravenous erythromycin twice daily + 10 mg of intravenous metoclopramide four times daily) or erythromycin alone (n = 38; 200 mg of intravenous erythromycin twice daily) in a prospective, randomized fashion. Gastric feeding was re-commenced and 6-hourly gastric aspirates performed. Patients were studied for 7 days. Successful feeding was defined as a gastric residual volume <250 mL with the feeding rate ≥40 mL/hr, over 7 days. Secondary outcomes included daily caloric intake, vomiting, postpyloric feeding, length of stay, and mortality. Demographic data; use of inotropes, opioids, or benzodiazepines; and pretreatment gastric residual volume were similar between the two groups. The gastric residual volume was significantly lower after 24 hrs of treatment with combination therapy, compared with erythromycin alone (136 ± 23 mL vs. 293 ± 45 mL, p = .04). Over the 7 days, patients treated with combination therapy had greater feeding success, received more daily calories, and had a lower requirement for postpyloric feeding, compared with erythromycin alone. Tachyphylaxis occurred in both groups but was less with combination therapy. Sedation, higher pretreatment gastric residual volume, and hypoalbuminemia were significantly associated with a poor response. There was no difference in the length of hospital stay or mortality rate between the groups. Watery diarrhea was more common with combination therapy (20 of 37 vs. 10 of 38, p = .01) but was not associated with enteric infections, including Clostridium difficile. In critically ill patients with feed intolerance, combination therapy with erythromycin and metoclopramide is more effective than erythromycin alone in improving the delivery of nasogastric nutrition and should be considered as the first-line treatment. ( Crit Care Med. 2007;35:2561-2567.) NQ Nguyen, M Chapman, RJ Fraser, LK Bryant, C Burgstad, RH Holloway.

Gastrointestinal Bleeding &amp; Gastroparesis Secondary to Amyloidosis

Purpose: Amyloidosis is common in multiple myeloma; however, extensive gastrointestinal tract involvement without involvement of other organ systems is extremely rare. We are describing a case of gastroparesis and gastrointestinal bleeding associated with kappa light chain multiple myeloma. A 55 year old female with kappa light chain multiple myeloma and a fourteen month history of chemotherapy, was admitted with complaints of nausea, vomiting, and rectal bleeding of five days duration. Five months prior to admission, patient had a gastrointestinal work-up because of recurrent vomiting and guaiac positive stool, which revealed gastritis and internal hemorrhoids. The patient had type II diabetes mellitus, without diabetic triopathy and hemoglobin A1c was less than 6. Patient did not have a history of renal failure or thyroid disease. Echocardiography was negative for any signs of cardiac amyloidosis. On physical examination, she was lethargic and appeared cachectic. She had bibasilar crackles and diminished breath sounds in right lower lobe. The patient had 2 + pitting edema in the lower extremities. Laboratory data were within normal range except for hemoglobin of 7.8, with a drop from 8.8 one week prior to admission. Gastroparesis was confirmed on gastric scintigraphy (nuclear gastric emptying study). Friable gastric mucosa with active oozing of blood was noted on upper endoscopy. Bleeding was controlled with injection of submucosal epinephrine and gold probe therapy. Due to persistent nausea and vomiting, a second upper endoscopy was done and revealed edematous mucosa of pylorus and several regions of submucosal bleeding. There was no evidence of gastric outlet obstruction. Antral and pyloric biopsies revealed active gastritis with submucosal pink material and special stains for amyloid were positive. Patient was treated with metoclopramide and intravenous erythromycin and was discharged home on regular diet. Conclusion: Amyloid is a fibrous protein with local extracellular deposition that can involve any organ system and present with or without clinical manifestations. Our patient's chronic anemia is multifactorial including components of multiple myeloma and chronic gastrointestinal bleeding secondary to amyloidosis. Gastroparesis is common in familial amyloidotic polyneuropathy but infrequent in patients with kappa light chain multiple myeloma.

Erythromycin lacks colon prokinetic effect in children with functional gastrointestinal disorders: a retrospective study

BackgroundMotilin, a peptide hormone has a direct excitatory effect on circular smooth muscle strips derived from the human colon. Reduced plasma motilin concentration has been reported in adults with chronic constipation. Erythromycin, a non-peptide motilin receptor agonist, induces phase 3 of the migrating motor complex (MMC) in the antro-duodenum and also reduces oro-cecal transit time. A pediatric study has reported an improvement in clinical symptoms of constipation following erythromycin administration, but the effect on colon motility in children has not been formally evaluated. We used colon manometry to study the effect of intravenous erythromycin lactobionate at 1 mg/kg on colon motiltiy in ten children.MethodsWe selected patients with normal antroduodenal and colon manometry studies that were performed simultaneously. All studies were performed for clinically indicated reasons. We quantified the effect of erythromycin on colon contraction by calculating the area under the curve (AUC).ResultsThe mean (SE of mean) AUC in the colon during the fasting, post-erythromycin and postprandial phases of the study was 2.1 mmHg/sec (0.35), 0.99 mmHg/sec (0.17) and 3.05 mmHg/sec (0.70) respectively. The AUC following erythromycin was significantly less compared to the fasting phase of the study (p < 0.01).ConclusionErythromycin lacks colon prokinetic effect in children with chronic constipation evaluated by colon manometry.

Avoiding errors with intravenous erythromycin administration

Erythromycin is a macrolide antibiotic often used in cases of penicillin allergy. When used intravenously, adverse effects ranging from discomfort at the injection site to severe cardiac arrhythmias are described [1]. Such reactions are most commonly associated with bolus injections or rapid infusion rates. The manufacturers recommend a continuous slow intravenous infusion to avoid such side effects [2]. We report three cases where erythromycin was wrongly administered as an intravenous bolus injection. All cases were reported to the Irish Medicines Board.

Use of Erythromycin in Prevention or Treatment of Postoperative Ileus

It is with great interest that we read the article by Lightfoot et al.,1 on the lack of the salutary effects of low-dose intravenous erythromycin in patients with postoperative ileus after surgery for bladder cancer. This observation remains in concert with previously published data in humans and practically excludes the possibility of erythromycin being used in the prevention or treatment of postoperative ileus.2 However, we would like to comment on the presented data, taking into account some basic pharmacokinetic data.

Severe Legionnaires' Disease Successfully Treated Using a Combination of Fluoroquinolone, Erythromycin, Corticosteroid, and Sivelestat

The patient was a 67-year-old man with diabetes mellitus who had been to a hot spring spa a few days before his admission. The diagnosis of Legionella pneumonia was made using a urinary antigen assay. Intravenous pazufloxacin and oral clarithromycin were started. However, despite these treatments, he developed acute respiratory distress syndrome (ARDS). He was administered the combination of intravenous pazufloxacin and erythromycin, corticosteroid, and sivelestat for two weeks. Then he was successfully recovered. The outcome suggests that treatment with corticosteroid and sivelestat, in addition to a combination of appropriate anti-Legionella antibiotics, should be considered for patients with severe Legionella pneumonia with ARDS.

Prokinetic therapy for feed intolerance in critical illness: One drug or two?

To compare the efficacy of combination therapy, with erythromycin and metoclopramide, to erythromycin alone in the treatment of feed intolerance in critically ill patients. Randomized, controlled, double-blind trial. Mixed medical and surgical intensive care unit. Seventy-five mechanically ventilated, medical patients with feed intolerance (gastric residual volume > or =250 mL). Patients received either combination therapy (n = 37; 200 mg of intravenous erythromycin twice daily + 10 mg of intravenous metoclopramide four times daily) or erythromycin alone (n = 38; 200 mg of intravenous erythromycin twice daily) in a prospective, randomized fashion. Gastric feeding was re-commenced and 6-hourly gastric aspirates performed. Patients were studied for 7 days. Successful feeding was defined as a gastric residual volume <250 mL with the feeding rate > or =40 mL/hr, over 7 days. Secondary outcomes included daily caloric intake, vomiting, postpyloric feeding, length of stay, and mortality. Demographic data; use of inotropes, opioids, or benzodiazepines; and pretreatment gastric residual volume were similar between the two groups. The gastric residual volume was significantly lower after 24 hrs of treatment with combination therapy, compared with erythromycin alone (136 +/- 23 mL vs. 293 +/- 45 mL, p = .04). Over the 7 days, patients treated with combination therapy had greater feeding success, received more daily calories, and had a lower requirement for postpyloric feeding, compared with erythromycin alone. Tachyphylaxis occurred in both groups but was less with combination therapy. Sedation, higher pretreatment gastric residual volume, and hypoalbuminemia were significantly associated with a poor response. There was no difference in the length of hospital stay or mortality rate between the groups. Watery diarrhea was more common with combination therapy (20 of 37 vs. 10 of 38, p = .01) but was not associated with enteric infections, including Clostridium difficile. In critically ill patients with feed intolerance, combination therapy with erythromycin and metoclopramide is more effective than erythromycin alone in improving the delivery of nasogastric nutrition and should be considered as the first-line treatment.

Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage: a cost‐effectiveness analysis

Erythromycin is a potent stimulator of gastrointestinal motility. Recent studies have examined the use of intravenous erythromycin to clear the stomach of blood before oesophago-gastroduodenoscopy (EGD) for acute upper gastrointestinal haemorrhage (UGIH). These studies have shown clinical effectiveness. To evaluate the cost-effectiveness of this intervention. We sought to determine the cost-effectiveness of erythromycin before EGD from the payer's perspective. We found three relevant studies of erythromycin and used these data for the analysis. We obtained costs for intravenous erythromycin and charges for peptic ulcer hospitalization, EGD, surgery, and angiographic embolization. Complication rates were also incorporated from the literature. We implemented a model of health-related quality of life to measure the impact of the intervention. We created a decision-analysis tree and performed a probabilistic sensitivity analysis. A strategy of erythromycin prior to EGD resulted in a cost-effective outcome in a majority of trials using willingness-to-pay figures of USD 0, USD 50,000 and USD 100,000 per quality-adjusted life-year (QALY). Because of the implications for cost saving and increase in QALY, we would recommend giving erythromycin prior to EGD for UGIH.

I Kr channel blockade to unmask occult congenital long QT syndrome

Patients with genetic evidence of long QT syndromes type 1 and 2 (LQT1, associated with impaired outward potassium current I(Ks); and LQT2, associated with impaired outward potassium current I(Kr)) may have normal baseline QT intervals (phenotype/genotype discordance) and elude clinical detection. Beta-adrenergic stimulation may unmask occult LQT1, but no maneuver has consistently unmasked the LQT2 phenotype. The purpose of this study was to test the repolarization reserve hypothesis (multiple challenges to repolarization are required to produce an abnormal phenotype), using subjects with LQT1 and LQT2 mutations but normal QT interval. We hypothesized that I(Kr) channel blockade would prolong the QT interval excessively in subjects with LQTS compared with controls and that I(Kr) channel blockade could unmask the abnormal LQTS phenotype in subjects with LQTS versus controls, as measured by the T peak-to-end interval (Tpe), a sensitive measure of abnormal repolarization. Subjects with known LQT1 (n = 5) and LQT2 (n = 6) mutations but baseline QTc < or = 450 ms and age- and gender-matched controls (n = 22) received intravenous erythromycin (an I(Kr) blocker). RR, QRS, QT, and Tpe intervals were measured at baseline and after drug infusion. Erythromycin caused only modest QT prolongation in all groups. In contrast, Tpe was specifically prolonged by I(Kr) channel blockade in LQT2 subjects but not in LQT1 subjects or controls. Short-acting I(Kr) channel blockade, together with the sensitive repolarization measure Tpe, can unmask abnormal repolarization in LQT2. Our finding of abnormal repolarization in LQT2 subjects exposed to I(Kr) channel blockade supports the repolarization reserve hypothesis.

Chronic intestinal pseudoobstruction due to visceral myopathy

A case is reported of a chronic intestinal pseudoobstruction with lethal outcome in a 6-year-old boy. The clinical symptoms and radiology examination showed ileus without mechanical obstruction. During the observation the patient developed left sided mydriasis and grand mal seizures with lactacidosis. He was treated conservatively which included total parenteral nutrition, fluid-sodium supplements, intravenous erythromycin and somatostatin, correction of acidosis. On the 48th day he died suddenly of cardiac failure at the intensive care unit. The gastrointestinal and neurologic symptoms with lactacidosis suggested the possibility of mitochondrial myopathy. Postmortem histopathology showed visceral myopathy. Molecular genetic analysis could not confirm the presence of the mDNA mutation.

Prone Positioning for a Morbidly Obese Patient with Acute Respiratory Distress Syndrome: An Opportunity to Explore Intrinsic Positive End-expiratory Pressure–Lower Inflexion Point Interdependence

Prone Positioning for a Morbidly Obese Patient with Acute Respiratory Distress Syndrome: An Opportunity to Explore Intrinsic Positive End-expiratory Pressure–Lower Inflexion Point Interdependence

Treatment of Postoperative Ileus After Bowel Surgery with Low-Dose Intravenous Erythromycin

Treatment of postoperative ileus remains unsatisfactory. Erythromycin (EM), a macrolide antibiotic, has prokinetic effects on the gut. We investigated whether intravenous erythromycin decreases the time to the return of normal bowel function after bowel surgery in patients with bladder cancer and interstitial cystitis who have undergone cystectomy and urinary diversion. We conducted a double-blind, randomized, placebo-controlled study of 22 volunteers. On the first postoperative day, patients began receiving intravenous erythromycin (125 mg) or placebo every 8 hours (maximum of 21 doses). The patients' ability to tolerate a general diet and return of bowel function was monitored. A general diet was tolerated at a median of 9 days postoperatively for the EM arm and 8 for the placebo arm (P = 0.60). The first bowel sounds were detected at an average of 2 postoperative days for the EM arm and 3 for the placebo arm (P = 0.88). First flatus was present an average of 5 days postoperatively for both study arms (P = 0.35). The first bowel movement was present an average of 6 days postoperatively for the EM arm and 5 for the placebo arm (P = 0.98). No significant difference was found between EM and placebo with regard to the onset of bowel sounds, passage of flatus, passage of the first bowel movement, and the time to tolerate a general diet. These data indicate that erythromycin is not useful in improving postoperative bowel function.

High-Dose Oral Erythromycin Decreased the Incidence of Parenteral Nutrition-Associated Cholestasis in Preterm Infants

Background & Aims: Feeding intolerance because of functional gastrointestinal dysmotility and parenteral nutrition-associated cholestasis (PNAC) are common problems in preterm, very-low-birth-weight (VLBW) infants. This double-blind, randomized, placebo-controlled study aimed to assess the effectiveness of “high-dose” oral erythromycin as a prokinetic agent in decreasing the incidence of PNAC. Two secondary end points, including the time to achieve full enteral feeding and the duration of parenteral nutrition, were also evaluated. Methods: Infants consecutively admitted to the neonatal unit were randomized to receive erythromycin (12.5 mg/kg/dose every 6 hours for 14 days) or an equivalent volume of normal saline (placebo) if they attained less than half the total daily fluid intake (<75 mL/kg/day) as milk feeds on day 14 of life. Results: Of 182 VLBW infants enrolled, 91 received erythromycin. The incidence of PNAC was significantly lower in erythromycin-treated infants (18/91) compared with placebo infants (37/91; P = .003). Treated infants achieved full enteral nutrition significantly earlier (mean, 10.1; SE, 1.7 days; P < .001), and the duration of parenteral nutrition was also significantly decreased by 10 days (P < .001). Importantly, fewer infants receiving erythromycin had 2 or more episodes of septicemia (n = 4) compared with placebo patients (n = 13, P = .03). No serious adverse effect was associated with erythromycin treatment. Conclusions: High-dose oral erythromycin can be considered as a rescue measure for VLBW infants who fail to establish adequate enteral nutrition and in whom anatomically obstructive pathologies of the gastrointestinal tract have been excluded.