The therapeutic potential of antibiotics and probiotics in the treatment of pouchitis

Abstract

Pouchitis is the most frequent long-term complication of pouch surgery for ulcerative colitis. There is consistent evidence on the implication of bacterial flora in the pathogenesis of pouchitis, and there is evidence for a therapeutic role of antibiotics and probiotics in therapy of this disease. Antibiotics, particularly ciprofloxacin and metronidazole, are the mainstay of treatment for acute pouchitis. In chronic refractory pouchitis, after having excluded other diagnoses (infections, Crohn’s disease of the pouch, ischemia and irritable pouch), antibiotic combination therapy is the treatment of choice. The highly concentrated probiotic mixture VSL#3 has been shown to be effective in prevention of pouchitis onset and in maintaining antibiotic-induced remission.

Keywords:

• chronic pouchitis
• ciprofloxacin
• Ileal-pouch anal anastomosis
• metronidazole
• pouchitis
• probiotics
• VSL#3

Financial & competing interests disclosure

P Gionchetti and F Rizzello have received grants for advisory board and speaking services from Abbvie, MSD, Takeda and Ferring. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Pouchitis is the most frequent long-term complication of IPAA for UC, and is more frequent within the first year after ileostomy closure.

• There is growing evidence of the involvement of bacterial flora in the pathogenesis of pouchitis.

• Antibiotics, even in absence of well-done trials, have become the treatment of choice for acute pouchitis. The most effective antibiotics are ciprofloxacin and metronidazole.

• Combined antibiotic therapy is the treatment of choice of chronic pouchitis. The best combination and duration of treatment are not still determined.

• VSL#3, highly concentrated probiotic mixture, is effective both in prevention of pouchitis onset and in maintaining antibiotic-induced remission.