Issue 05

Clinical Question

Are antibiotics effective in treating refractory IBD?

Editor’s Bottom Line

Broad spectrum antibiotics warrant further study as rescue therapy for refractory pediatric inflammatory bowel disease. Both controlled trials and insight into potential mechanisms of action are needed.

Reference

Breton J, Kasti A, Hoffmann N, et al. Efficacy of Combination Antibiotic Therapy for Refractory Pediatric Inflammatory Bowel Disease. Inflamm Bowel Dis. E-pub ahead of print Feb 4, 2019; https://doi.org/10.1093/ibd/izz006

Synopsis

Several studies have suggested that antibiotics may be effective in inducing clinical and endoscopic remission in patients with ulcerative colitis. To examine the efficacy of such regimens in their pediatric IBD population, researchers at the Children’s Hospital of Philadelphia reviewed medical records from 63 patients with refractory ulcerative colitis, Crohn’s colitis, and unclassified IBD. Patients were a median 15.3 years of age and had disease for a median of 1.2 years. All patients had failed to respond, or lost initial response, to anti-tumor necrosis alpha (anti-TNF) agents. Over half were corticosteroid-dependent. Patients received regimens of 3–4 antibiotics, most commonly amoxicillin, metronidazole, and either doxycycline or ciprofloxacin. These were administered for a median of 29 days, with 58 days being the longest treatment period. Patients had moderate-to-severe disease at baseline, with median Pediatric Ulcerative Colitis Activity Index (PUCAI) scores of 55 (Range, 40–65).

The researchers found that, after an average of three weeks, 63.5% of patients experienced clinical response, defined as a reduction of at least 20 points on the PUCAI. Moreover, 40% of patients achieved clinical remission, which the investigators defined as a PUCAI score less than 10. C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) significantly decreased with treatment, and haemoglobin levels significantly improved. Modifying anti-TNF treatment did not impact the efficacy of oral antibiotics.

Among the 25 children who experienced clinical remission, only one required surgery at one-year follow-up, while 10 of those who did not respond to antibiotic treatment needed surgery at that time. Univariate analysis showed exposure to doxycycline and PUCAI >65 were associated with a 75% and 80% lower likelihood of response to combination treatment, respectively (P≤0.016 for both).

Details

Study Design: Retrospective cohort study
Funding: National Institutes of Health
Allocation: Not applicable
Setting: Single-center
Level of Evidence: 2b (Oxford Levels of Evidence)

The summary and conclusion in this issue of E-mentoring in IBD pertains to the manuscript(s) being reviewed, and should be considered in the context of what is already known surrounding the topic and incorporated into practice as deemed appropriate by the individual learner.