Antibiotics ulcerative colitis

Minimal effects on intestinal flora were seen with rifaximin administration [9, 35]. In an early study, performed on healthy volunteers who received a short-term (5 days) rifaximin treatment, the observed changes in bowel flora returned to baseline levels within 1-2 weeks [9]. In a recent investigation fecal samples of patients with ulcerative colitis given three 10 day courses of the antibiotic were cultured and the different microbial species quantitated. Despite the high dose (i.e. 1800 mg daily) of rifaximin used there was only a minor change in bacterial counts which reverted back to pre-treatment values during the washout period [35]. It appears therefore that administration of this antibiotic does not disrupt intestinal microbial ecology. 

An increasing number of both clinical and laboratory-derived observations support the importance of luminal components in driving the inflammatory response in ulcerative colitis and Crohn s disease. Although its role is unclear, antibiotic therapy is commonly used in clinical practice for the treatment of moderately to severely active ulcerative colitis. Metronidazole and/or ciprofloxacin are currently employed in active Crohn s disease, particularly in patients with colonic involvement and with perianal disease. Rifaximin, a rifamycin-derived antibiotic, is characterized by a wide range of antibacterial activity and a very low systemic absorption. Some preliminary data show its efficacy in severe active ulcerative colitis, pouchitis and prevention of postoperative recurrence in Crohn s disease. 

Guslandi M, Giollo P, Testoni PA Corticosteroid-sparing effect of rifaximin, a nonabsorbable oral antibiotic in active ulcerative colitis Preliminary clinical experience. Curr Ther Res 2004 65 292-296. 

Parenteral Anticoagulant-induced prothrombin deficiency hypoprothrombinemia secondary to conditions limiting absorption or synthesis of vitamin K (eg, obstructive jaundice, biliary fistula, sprue, ulcerative colitis, celiac disease, intestinal resection, cystic fibrosis of the pancreas, regional enteritis) drug-induced hypoprothrombinemias due to interference with vitamin K metabolism (eg, antibiotics, salicylates) prophylaxis and therapy of hemorrhagic disease of the newborn. 

Speciai risk Use with caution in the following situations Nonspecific ulcerative colitis if there is a probability of impending perforation, abscess, or other pyogenic infection diverticulitis fresh intestinal anastomoses hypertension CHF thromboembolitic tendencies thrombophlebitis osteoporosis exanthema Cushing syndrome antibiotic-resistant infections convulsive disorders metastatic carcinoma myasthenia gravis vaccinia varicella diabetes mellitus hypothyroidism, cirrhosis (enhanced effect of corticosteroids). 

Diarrhea Diphenoxylate may prolong or aggravate diarrhea associated with organisms that penetrate intestinal mucosa (ie, toxigenic Escherichia coli, Salmonella, Shigella) or in pseudomembranous enterocolitis associated with broad-spectrum antibiotics. Do not use diphenoxylate in these conditions. In some patients with acute ulcerative colitis, diphenoxylate may induce toxic megacolon. Fluid/Electrolyte balance Dehydration, particularly in younger children, may... 

I Contraindications Acute ulcerative colitis (may produce toxic megacolon), diarrhea associated with pseudomembranous enterocolitis due to broad-spectrum antibiotics or to organisms that invade intestinal mucosa (such as Escherichia coli, shigella, and salmonella), patients who must avoid constipation... 

Therapeutic pyramid approach to inflammatory bowel diseases. Treatment choice is predicated on both the severity of the illness and the responsiveness to therapy. Agents at the bottom of the pyramid are less efficacious but carry a lower risk of serious adverse effects. Drugs may be used alone or in various combinations. Patients with mild disease may be treated with 5-aminosalicylates (with ulcerative colitis or Crohn s colitis), topical corticosteroids (ulcerative colitis), antibiotics (Crohn s colitis or Crohn s perianal disease), or budesonide (Crohn s ileitis). Patients with moderate disease or patients who fail initial therapy for mild disease may be treated with oral corticosteroids to promote disease remission immunomodulators (azathioprine, mercaptopurine, methotrexate) to promote or maintain disease remission or anti-TNF antibodies. Patients with moderate disease who fail other therapies or patients with severe disease may require intravenous corticosteroids, anti-TNF antibodies, or surgery. Natalizumab is reserved for patients with severe Crohn s disease who have failed immunomodulators and TNF antagonists. Cyclosporine is used primarily for patients with severe ulcerative colitis who have failed a course of intravenous corticosteroids. TNF, tumor necrosis factor. 

Ulcerative colitis Action 5-ASA derivative, anti-inflammatory, 1 leukotiiene synth Dose 2.25 g (3 caps) tid x 8-12 wk Caution [B, ] Severe renal/hepatic failure Contra Mesalamine or salicylates hypersensitivity Disp Caps SE Dizziness, HA, N, agranulocytosis, pancytopenia, renal impair, allergic Rxns Interactions Oral antibiotics may interfere W/ mesalamine release in the colon EMS Allergic Rxn can occur if pt is allergic to ASA or other salicylates OD Not reported but may cause V, tinnitus, confusion and vertigo symptomatic and supportive... 

Diarrhoea is also part of some inflammatory disorders, such as irritable bowel syndrome, ulcerative colitis and Crohn s disease. These may best be relieved by treatment with corticosteroids and aminosalicylates. Diarrhoea is commonly associated with bacterial or other pathogenic infections (e.g. food poisoning) and these may require treatment with antibiotics or other antimicrobials. 

Sulfasalazine, a sulfonamide antibiotic (3 to 4 g p.o. daily in divided dosage), is indicated in the treatment of ulcerative colitis. 

Any form of colitis, such as pseudomembranous, acute ulcerative colitis or Crohn s colitis can also mimic diverticulitis. Usually, pseudomembranous colitis is associated with antibiotic therapy. In most cases a significant thickening of the colon is found. 

Infection risk Fatal Pneumocystis jirovecii pneumonia complicated immunosuppressive therapy in two patients with steroid-refractory ulcerative colitis taking steroids and tacrolimus [146" ]. Despite immediate therapy with high-dose co-trimoxazole and broad-spectrum antibiotics, both patients died with progressive respiratory failure. 

Immunologic A 64-year-old woman developed persistent fever with mucositis and submandibular phlegm, not responsive to antibiotics. She was on therapy with mesalazine for ulcerative colitis, which was currently in remission, and levothyroxine for hypothyroidism. Laboratory tests showed leukopenia with severe neutropenia, and blood culture positive for multi-resistant Streptococcus oralis. The syndrome was managed with antibiotics and filgrastim. The latter drug yielded a scarce benefit, with a modest neutrophil count recovery, which was lost after its discontinuation. Mesalazine was then discontinued, and the patient had a complete and stable normalisation of her neutrophil count within the following 20 days [86 ]. 

Bismuth salts are still in use. Tripotassium dicitrato-bismuthate and bicitropeptide (a bismuth-peptide complex) are used in the eradication of Helicobacter pylori in combination with antibiotics (SEDA-21,233) (1 ), and ranitidine bismuth citrate is used to treat peptic ulcer (5). Bismuth salicylates are used in other intestinal diseases, such as microscopic colitis (6,7) and collagenous colitis (8). Bismuth subnitrate plus iodoform is used to pack surgical cavities. Bismuth oxide and bismuth subgallate are found in some topical formulations that are used for treating hemorrhoids. Bismuth is also used topically as a bacteriostatic. 

The contribution of the gut flora to the available pantothenate for humans is unknown, but there is some evidence that bacterial synthesis of the vitamin may be important in animals, especially ruminants, since severe deficiency can only be achieved by using antibiotics or antagonists. Clinical conditions such as ulcers or colitis can adversely affect pantothenate status and excretion rates, and dietary fiber may affect its absorption. 

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