Ciprofloxacin vs. Metronidazole for Acute Pouchitis

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Summary and Comment

Ciprofloxacin vs. Metronidazole for Acute Pouchitis

Metronidazole is effective for treating patients with acute pouchitis after total proctocolectomy for ulcerative colitis. Ciprofloxacin also is used with these patients, often as second-line therapy. To compare the 2 drugs, researchers randomized 16 patients with acute pouchitis to receive ciprofloxacin (1000 mg/day) or metronidazole (20 mg/kg/day) for 2 weeks. Acute pouchitis was defined as a score of 7 or higher on the 18-point Pouchitis Disease Activity Index (PDAI) and symptom duration of 4 weeks or less. Clinical symptoms, endoscopic findings, and histologic features were assessed before and after therapy.

Both antibiotics significantly reduced total PDAI scores, but the mean reduction was greater with ciprofloxacin than with metronidazole (6.9 vs. 3.8; P=0002). Ciprofloxacin was also associated with significantly greater reductions in symptom and endoscopic subscores. All 7 cases of pouchitis resolved (PDAI < 7) in the ciprofloxacin group versus only 6 of 9 (67 percent) in the metronidazole group (a nonsignificant difference). None of the ciprofloxacin recipients had side effects, whereas 3 metronidazole recipients experienced vomiting, dysgeusia, or transient peripheral neuropathy.

Comment: Although both ciprofloxacin and metronidazole should be included in the armamentaria of physicians treating pouchitis, the improved clinical outcome and better side-effect profile associated with ciprofloxacin suggest that it should be used before metronidazole for treating acute pouchitis.

— Douglas K. Rex, MD

Published in Journal Watch Gastroenterology December 26, 2001