We have read with some interest an article published recently in the journal, related to antibiotic prophylaxis against ventilator-associated pneumonia (VAP) in patients with coma.1

The randomized clinical trial (RCT) developed in 1997 by Dr. Sirvent and his group 2 showed the efficacy of antibiotic prophylaxis against VAP on intubated patients with structural coma. Other authors, with different methodologies (type of antibiotic, duration of therapy and design of the study) reached similar findings in favor of the utility of antibiotic prophylaxis after intubation as a preventative measure against VAP, setting a trend in the daily clinical practice of a large number of intensive care units (ICU) worldwide.

We share concerns about progressive resistance to cefuroxime and amoxicillin-clavulanate of germs that cause respiratory infection in this group of patients, which would make this protective measure against a potentially lethal complication obsolete.

The protocol of empirical antibiotic therapy for aspiration pneumonia in our hospital includes, as occurs in others, amoxicillin-clavulanate as first choice. Our group has recently performed a retrospective, observational study 3 trying to identify resistance patterns of the most common microorganisms isolated from bronchial aspirates in patients admitted to the ICU after resuscitated cardiac arrest. Patients admitted after resuscitated cardiac arrest during the years 2013–2015 were included. The inpatient cases included met a hospital stay <48h without prior antibiotic therapy. The patients who had had tracheobronchial secretion cultures in the first 72h after hospital admission were selected. A total of 62 patients were included. In most (87.1%), the cardiac arrest had an out-of-hospital origin. Therapeutic hypothermia was performed in 50.0% of the patients. The most commonly used empirical antibiotic was amoxicillin-clavulanate (54.8%), followed by piperacillin-tazobactam (6.5%) and levofloxacin (4.8%). Microbiological isolation in bronchial aspirates was obtained in 24 patients (38.7%). The most frequent were Staphylococcus aureus (22.2%), Escherichia coli (14.8%), Enterobacter cloacae (14.8%) Klebsiella pneumoniae (11.1%), Serratia marcescens (11.1%) and Haemophilus influenzae (7.4%). It was observed that 48.1% of the isolates were resistant to amoxicillin-clavulanate, 18.5% to piperacillin-tazobactam and 14.8% to third-generation cephalosporin. No microorganism was resistant to quinolones or carbapenems. The epidemiology of our healthcare environment is similar to that described in another recent study,4 which showed a high rate of resistance to amoxicillin-clavulanate (15.0%).

Due to the high prevalence of amoxicillin-clavulanate resistant microorganisms isolated in early respiratory infections in these patients, we agree with Dr. Sirvent that the use of more effective antibiotics should be assessed instead of cefuroxime or amoxicillin-clavulanate. However, it is crucial to take into account the local epidemiology and the individual characteristics of each patient, as well as to evaluate the risk of resistance development that this fact could entail. The design of new RCT's could clarify, in coming years, the best path to follow.