Antibiotic combination therapy in patients with chronic, treatment-resistant pouchitis

Background: Pouchitis is the major long-term complication after ileal pouch -anal anastomosis for ulcerative colitis. About 15% of patients have a chro nic, treatment-resistant disease. Aims: To evaluate the efficacy of an antibiotic combination for chronic act ive, treatment-resistant pouchitis. Patients and Methods: Eighteen patients were treated orally with rifaximin 1 g b.d. + ciprofloxacin 500 mg b.d. for 15 days. Symptoms assessment, endo scopic and histological evaluations were performed at screening and after 1 5 days using the Pouchitis Disease Activity Index (PDAI). Improvement was d efined as a decrease of at least 3 points in PDAI score, and remission as a PDAI score of 0. Systemic absorption of rifaximin was determined by high p erformance liquid chromatography. Faecal samples were collected before and after antibiotic treatment for stool culture. Results: Sixteen out of 18 patients (88.8%) either improved (n = 10) or wen t into remission (n = 6); the median PDAI scores before and after therapy w ere 11 (range 9-17) and 4 (range 0-16), respectively (P < 0.002). No side-e ffects were reported. Rifaximin plasma levels and urinary excretion were ne gligible, confirming its mainly topical activity. A significant decrease in total anaerobes and aerobes, enterococci, lactobacilli, bifidobacteria and bacteroides in faecal samples was observed, while the reduction in number of coliforms and Clostridium perfringens did not reach a statistical signif icance. Conclusions: A combination of rifaximin and ciprofloxacin was effective in patients with active chronic, treatment-resistant pouchitis, suggesting the need, in these patients, for treatment using antibiotic agents with wide a ntibacterial spectrum of activity.