
==== Front
Indian J Crit Care Med
Indian J Crit Care Med
IJCCM
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
0972-5229
1998-359X
Jaypee Brothers Medical Publishers

10.5005/jp-journals-10071-24736
Letter to the Editor
Contradictory Recommendation in the Guideline for Antibiotic Prescription
Das Praveen K 1https://orcid.org/0000-0001-8441-8401

Nath Soumya S 2https://orcid.org/0000-0002-5981-5437

Parashar Samiksha 3https://orcid.org/0000-0001-8130-5874

1–3 Department of Anaesthesiology and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences (Dr. RMLIMS), Lucknow, Uttar Pradesh, India
Samiksha Parashar, Department of Anaesthesiology and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences (Dr. RMLIMS), Lucknow, Uttar Pradesh, India, Phone: +91 7042345280, e-mail: samikshaparashar@gmail.com
7 2024
29 6 2024
28 7 713714
Copyright © 2024; The Author(s).
2024
https://creativecommons.org/licenses/by-nc/4.0/ © The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
How to cite this article: Das PK, Nath SS, Parashar S. Contradictory Recommendation in the Guideline for Antibiotic Prescription. Indian J Crit Care Med 2024;28(7):713–714.

Keywords

Antibiotic
Intra-abdominal infection
Peritonitis
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pmcDear Editor,

We have read with interest the detailed and exhaustive guidelines for antibiotic prescription prepared by Khilnani G et al.1 We want to congratulate the authors for the arduous task.

However, we have certain issues regarding the guidelines' contents. A minor issue is that while listing the most common organisms that cause peritonitis in intensive care unit (ICU), the authors mentioned E. coli, Klebsiella, and Enterobacteriaceae, which implies that Klebsiella is different from Enterobacteriaceae, whereas, in reality, Klebsiella is a member of the latter.

The major issue is that Khilnani G et al. forwarded the recommendation that in secondary peritonitis, beta-lactam/beta-lactamase inhibitor (BL-BLI) or carbapenems with an anerobic cover (using metronidazole) be used for treatment. We are interested in knowing the basis for such a recommendation. Even in the evidence statement, there is no mention of metronidazole, which was limited to the fact that organisms responsible for secondary peritonitis are susceptible to BL/BLIs or carbapenems. The authors quoted three studies in the preceding discussion.

The first was a more than two-decades-old narrative review of ICU management of intra-abdominal infections (peritonitis). The authors recommended that antimicrobial regimens for high-risk patients with intra-abdominal infections be either carbapenem (imipenem-cilastatin or meropenem) or piperacillin-tazobactam as a single agent. Anti-anerobic agents like metronidazole or clindamycin could be combined with aminoglycosides, aztreonam, or third/fourth-generation cephalosporin.2 The next one, a more than three decades old study, in which the authors compared piperacillin-tazobactam and imipenem-cilastatin for treating intra-abdominal infections. The authors mentioned that imipenem-cilastatin, like metronidazole, is effective against the most important anaerobic species of Bacteroides fragilis.3 The third study was also a more than one-and-a-half-decade-old French study, which explored the clinical and microbiological profiles of community-acquired and nosocomial intra-abdominal infections. They found that against anaerobic bacteria, metronidazole and carbapenems (imipenem and ertapenem) had comparable efficacy.4 Thus, none of these studies quoted by Khilnani G et al. mentioned adding an anerobic cover to BL-BLI or carbapenem for managing secondary peritonitis.

Moreover, in the same guideline for antibiotic prescription of critically ill patients by Khilnani G et al., on several earlier occasions, while discussing the management of anerobic infections, it has been mentioned that carbapenems and piperacillin-tazobactam have sufficient anti-anaerobic activity, and so do not warrant the addition of an agent with activity against anaerobes, (e.g., anerobic cover for VAP, antibiotic regimen for cholangitis).1 Thus, while recommending an anerobic cover (using metronidazole) with BL-BLI or carbapenems in secondary peritonitis, the authors not only contradicted their earlier statements in the same guideline but also did so without any credible scientific evidence.

A recent editorial, while reiterating that carbapenems and BL-BLI (piperacillin-tazobactam) had a satisfactory anaerobic cover, also reported that double anaerobic cover for intra-abdominal infections was associated with a longer length of hospital stay and higher in-hospital postoperative complications (septic shock, postoperative infections and surgical site infections), higher mortality and higher incidence of C difficile infections compared to carbapenems or BL-BLI alone.5

We look forward to the authors revisiting the guidelines and addressing our concerns.

Orcid

Praveen K Das https://orcid.org/0000-0001-8441-8401

Soumya S Nath https://orcid.org/0000-0002-5981-5437

Samiksha Parashar https://orcid.org/0000-0001-8130-5874

Source of support: Nil

Conflict of interest: None
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References

1. Khilnani GC Tiwari P Mittal S Kulkarni AP Chaudhry D Zirpe KG et al. Guidelines for antibiotics prescription in critically-ill patients Indian J Crit Care Med 2024 In press 10.5005/jp-journals-10071-24677
2. Marshall JC Innes M Intensive care unit management of intra-abdominal infection Crit Care Med 2003 31 8 2228 2237 10.1097/01.CCM.0000087326.59341.51 12973184
3. Brismar B Malmborg AS Tunevall G Wretlind B Bergman L Mentzing LO et al. Piperacillin-tazobactam versus imipenem-cilastatin for treatment of intra-abdominal infections Antimicrobial agents and chemotherapy 1992 36 12 2766 2773 10.1128/aac.36.12.2766 1336347
4. Montravers P Lepape A Dubreuil L Gauzit R Pean Y Benchimol D et al. Clinical and microbiological profiles of community-acquired and nosocomial intra-abdominal infections: Results of the French prospective, observational EBIIA study Journal of Antimicrobial Chemotherapy 2009 63 4 785 794 10.1093/jac/dkp005 19196742
5. Trienski TL Bhanot N Double anaerobic coverage—A call for antimicrobial stewardship Infectious Diseases in Clinical Practice 2022 30 6 e1244 10.1097/IPC.0000000000001244
