We have read with interest the letter by Roldán-Reina et al.1 in relationship with our point of view published in this journal2 referring to the original article published 20 years ago.3 We fully agree with the authors on their concern for progressive resistance of micro-organisms that cause respiratory infection to cefuroxime and amoxicillin-clavulanic and consequently that they have become obsolete, these antibiotics should not be used for the prevention of ventilator-associated pneumonia in intubated coma patients.

The authors described the results of their recent retrospective and observational study4 to evaluate the resistance patterns of the common microorganisms isolated from bronchial aspirates in patients admitted to the ICU after resuscitated cardiac arrest. In the study 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%). They observed that 48.1% of the isolated microorganisms were resistant to amoxicillin-clavulanic, 18.5% to piperacillin-tazobactam and 14.8% to third-generation cephalosporin. They described no microorganism was resistant to quinolones or carbapenems.

Thus, the authors give us an approximate idea as to what might be an alternative to cefuroxime for prevention of ventilator-associated pneumonia in coma patients, and we believe is time to develop new RCT to study other antibiotics for prophylaxis with no effect on normal anaerobic microbiota and with a broad-spectrum to Gram-positive and enteric Gram-negative bacilli. A good alternative to cefuroxime might be levofloxacin, because the pharmacological properties are suitable and it is active against the causative micro-organisms.5 However, we should pay special attention to the development of local antibiotic resistance, and maintaining the antibiotic prophylaxis only 24h (one dose in case of levofloxacin).