Antibiotics and Probiotics in Inflammatory Bowel Disease: Why, When, and How

Cosimo Prantera; Maria Lia Scribano

Disclosures

Curr Opin Gastroenterol. 2009;25(4):329-333. 

In This Article

Abstract and Introduction

Abstract

Purpose of review To summarize recent evidence on the role of intestinal bacteria in inflammatory bowel diseases, and of antibiotics and probiotics in their treatment. The implications connected with the use of antibiotics are also examined.
Recent findings The hypothesis that Mycobacterium paratuberculosis could be a causative agent of Crohn's disease has not been confirmed by a large trial on symptomatic patients treated by a combination of antibiotics active against this bacterium. An increased number of adherent-invasive Escherichia coli have been found in the intestinal tissue of patients with Crohn's disease, but their role in the pathogenesis of this condition remains to be defined. The combination of metronidazole and azathioprine, associating the effects of a reduced bacterial load with immunosuppression, appears to be a therapeutic option to decrease the recurrence of postoperative Crohn's disease in high-risk patients. However, concerns are raised by the possibility that antibiotics may induce disease relapse due to Clostridium difficile infection.
Summary Recent literature provides increasing support for the use of antibiotics in Crohn's disease, although the side effects limit their long-term use. The efficacy of antibiotics in ulcerative colitis is not confirmed by the available literature, except in severe colitis. More trials are needed to support the use of probiotics as therapy in inflammatory bowel disease.

Introduction

The most widely accepted hypothesis on the cause of inflammatory bowel disease (IBD) is that it is caused by an excessively aggressive immune response to antigens in the gut of genetically susceptible individuals.[1] Intestinal bacteria are dominant antigens present in the gut and their role in IBD is supported by many experimental and clinical data. Nevertheless, whereas antibiotics are widely used in clinical practice for treating IBD's septic complications,[2] only few clinicians consider these drugs useful in the active noncomplicated stages of IBD to reduce a possible antigenic overload.[3] A number of randomized studies on antibiotic therapy have been carried out with varied results, mainly in Crohn's disease, but also in ulcerative colitis and pouchitis. The antibiotics used were those with antimycobacterial activity, metronidazole (Metro) active against anaerobic bacteria, ciprofloxacine (Cipro) active against Escherichia coli and, most recently, the nonabsorbable rifaximin.

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