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Rationale: Extracorporeal membrane oxygenation (ECMO) treatment is widely used worldwide, and many hospitals consider using antibiotics to prevent nosocomial infection in patients receiving ECMO treatment. However, the efficacy of antimicrobial prophylaxis for patients receiving ECMO treatment remains unclear. Objectives: To evaluate the efficacy of prophylactic antibiotics for patients receiving ECMO treatment. Methods: This retrospective cohort study was performed using data recorded in the Japanese Diagnosis Procedure Combination database from July 1, 2010, to March 31, 2017. We compared in-hospital mortality, nosocomial pneumonia, acute kidney injury, and diarrhea between patients receiving prophylactic antibiotics (prophylaxis group) and those not receiving antibiotics (control group) using propensity score matching. For in-hospital mortality and nosocomial pneumonia, multivariable logistic regression models fitted using a generalized estimating equation, stabilized inverse probability of treatment weighting, and instrumental variable analysis were performed. Results: We identified 9,615 eligible patients and classified them into the prophylaxis (n = 5,552) and control (n = 4,063) groups. In the propensity score-matched analysis, 3,650 pairs were generated. Significant differences between the prophylaxis group and the control group were detected in the in-hospital mortality (56.4% vs. 59.8%; risk difference, -3.7%; 95% confidence interval [CI], -6.0 to -1.3) and nosocomial pneumonia (12.9% vs. 15.3%; risk difference, -2.4%; 95% CI: -4.3 to -0.6). In the multivariable logistic regression models fitted using a generalized estimating equation, stabilized inverse probability of treatment weighting, and instrumental variable analysis, the point estimates suggested a direction similar to that found in the propensity score analysis. The proportions of patients with acute kidney injury or diarrhea did not significantly increase with the use of prophylactic antibiotics. Conclusions: Using prophylactic antibiotics during ECMO treatment was associated with reduced in-hospital mortality and lower proportions of patients with nosocomial pneumonia. Future prospective studies are needed to validate these results. [ABSTRACT FROM AUTHOR]