Pharmacotherapy for acute pouchitis

Medical treatment of pouchitis: a guide for the clinician

Pouchitis is the most common complication in patients who have undergone restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Up to 81% of IPAA patients experience pouchitis, with 40% of patients presenting within the first year of surgery. Common risk factors include genetic mutations, extensive colitis, rheumatologic disorders, and primary sclerosing cholangitis. Currently, there are no medications with approved indications for pouchitis. As such, the conventional treatment of pouchitis is entirely off-label. This paper is intended to be a practical and up-to-date review of available therapies used for the management of pouchitis. The mainstay of treatment for acute pouchitis remains antibiotics, but newer therapeutics have also shown promise in the treatment of chronic pouchitis. Common lifestyle considerations that may play a role in pouchitis are also reviewed.

PLAIN LANGUAGE SUMMARY

Medical treatment of pouchitis: a guide for the clinician The ileal pouch-anal anastomosis ("pouch") is the most common way patients who require surgery to remove their colon are able to avoid a permanent ileostomy ("ostomy"). This pouch, created from the small intestines, serves as a reservoir to hold stool. The most common complication after pouch surgery is pouchitis. Pouchitis symptoms include more frequent bowel movements, urgency to defecate, blood in the stool, incontinence, and abdominal pain. This paper is intended to be a practical review of available therapies including medications and lifestyle changes that can be considered for the management of acute pouchitis, chronic pouchitis, and cuffitis.

Prevention and Medical Treatment of Pouchitis In Ulcerative Colitis

Approximately 50% of patients who have undergone IPAA surgery for Ulcerative Colitis (UC) develop at least 1 episode of pouchitis. Patients with pouchitis have a wide range of symptoms, endoscopic and histologic features, disease course, and prognosis. To date, there are no universally accepted diagnostic criteria in terms of endoscopy and histology; though, semi-objective assessments to diagnose pouchitis in patients with ileal pouch- anal anastomosis (IPAA) have been proposed using composite scores such as the Pouchitis Triad, Heidelberg Pouchitis Activity Score and Pouchitis Disease Activity Index (PDAI). In a systematic review that included four randomized trials evaluating five agents for the treatment of acute pouchitis, ciprofloxacin was more effective at inducing remission as compared with metronidazole. Rifaximin was not more effective than placebo, while budesonide enemas and metronidazole were similarly effective for inducing remission of acute pouchitis. Patients with pouchitis relapsing more than three times per year are advised maintenance therapy, and guidelines recommend ciprofloxacin or the probiotic VSL#3. In patients with antibiotic-refractory pouchitis, secondary factors associated with an antibiotic-refractory course should be sought and treated. In this review, we will discuss the prevention and management of pouchitis in Ulcerative Colitis patients.

Probiotic mixture VSL#3: An overview of basic and clinical studies in chronic diseases

Probiotics are known as “live microorganisms” and have been proven to have a health effect on hosts at the proper dose. Recently, a kind of probiotic mixture including eight live bacterial strains, VSL#3, has attracted considerable attention for its combined effect. VSL#3 is the only probiotic considered as a kind of medical food; it mainly participates in the regulation of the intestinal barrier function, including improving tight junction protein function, balancing intestinal microbial composition, regulating immune-related cytokine expression and so on. The objective of this review is to discuss the treatment action and mechanism for the administration of VSL#3 in chronic diseases of animals and humans (including children). We found that VSL#3 has a therapeutic or preventive effect in various systemic diseases per a large number of studies, including digestive systemic diseases (gastrointestinal diseases and hepatic diseases), obesity and diabetes, allergic diseases, nervous systemic diseases, atherosclerosis, bone diseases, and female reproductive systemic diseases.

Outcomes and Management of the Ileal Pouch-Anal Anastomosis in the Elderly

PURPOSE OF REVIEW

Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients undergoing colectomy to maintain intestinal continuity. Earlier studies have suggested that outcomes are worse in elderly patients who underwent IPAA. However, more recent reports have shown that IPAA outcomes in the elderly are comparable to younger patients. We review the recent medical literature regarding outcomes and treatments for common complications in elderly IPAA patients.

RECENT FINDINGS

Compared to younger patients, IPAA in the elderly is not associated with increased major surgical complications, but is associated with increased length of stay and re-admission rate for dehydration in older patients. Rates of fecal incontinence after IPAA were similar between younger and older patients. Sacral nerve stimulation has shown early promise as a possible treatment for fecal incontinence after IPAA, but more research is needed. Pouchitis is a common complication, and antibiotics remain first-line treatment options. Other treatment options include mesalamines, steroids, immunomodulators, and biologics. The efficacy of newer biologics such as vedolizumab and ustekinumab has been reported, but more data is needed. IPAA is safe in the elderly with high self-reported patient satisfaction. However, the elderly IPAA patient warrants special consideration regarding outcomes and management.

Use of design of experiments to optimize the production of microbial probiotic biofilms

Here, we describe the production of a probiotic biofilm through three intermediate steps: (1) measurement of the adhesion capacity of 15 probiotic strains to evaluate their tendency to form biofilm on different surfaces (stainless steel, glass, and polycarbonate); (2) evaluation of the effects of pH, temperature, cellular growth phase, agitation, and presence of surfactants on probiotic biofilm formation (BF) through the Design of Experiments (DoE) approach; (3) study of the effects of pH, temperature and surfactants concentration on probiotic BF using the Central Composite Design. Finally, we show that biofilms pre-formed by selected probiotics can delay the growth of pathogens, such as Listeria monocytogenes chosen as model organism. Among the tested strains, Bifidobacterium infantis DSM20088 and Lactobacillus reuteri DSM20016 were found to be as the probiotics able to ensure the greatest adhesion (over 6 Log CFU cm2) to the surfaces tested in a very short time (<24 h). Cellular growth phase and agitation of the medium were factors not affecting BF, pH exerted a very bland effect and a greater tendency to adhesion was observed when the temperature was about 30 °C. The results obtained in the last experimental phase suggest that our probiotic biofilms can be used as an efficient mean to delay the growth of L. monocytogenes: the λ phase length, in fact, was longer in samples containing probiotic biofilms (0.30-1.02 h) against 0.08 h observed in the control samples. A reduction of the maximum cell load was also observed (6.99-7.06 Log CFU mL-1 against about 8 Log CFU mL-1 observed in the control samples).

Cell free preparations of probiotics exerted antibacterial and antibiofilm activities against multidrug resistant E. coli

The sharp increase in antibiotic resistance imposes a global threat to human health and the discovery of effective antimicrobial alternatives is needed. The use of probiotics to combat bacterial pathogens has gained a rising interest. Pathogenic Escherichia coli is causative of multiple clinical syndromes such as diarrheal diseases, meningitis and urinary tract infections. In this work, we evaluated the efficacy of probiotics to control multidrug-resistant E. coli and reduce their ability to form biofilms. Six E. coli resistant to at least five antibiotics (Ceftazidime, Ampicillin, Clarithromycin, Amoxicillin + Clavulanic Acid and Ceftriaxone) were isolated in this work. Preparations of cell-free spent media (CFSM) of six probiotics belonging to the genus Bifidobacterium and Lactobacillus which were grown in Man-Rogosa-Sharpe (MRS) broth exhibited strong antibacterial activity (inhibition zones of 11.77-23.10 mm) against all E. coli isolates. Two E. coli isolates, namely E. coli WW1 and IC2, which were most resistant to all antibiotics were subjected to antibiofilm experiments. Interestingly, the CFSM of MRS fermented by all probiotics resulted in inhibition of biofilm formation while B. longum caused highest inhibition (57.94%) in case of E. coli IC2 biofilms and L. plantarum was responsible for 64.57% reduction of E. coli WW1 biofilms. On the other hand, CFSM of skim milk fermented by L. helveticus and L. rhamnosus exhibited a slight inhibitory activity against IC2 isolate (inhibition percentage of 31.52 and 17. 68, respectively) while WW1 isolate biofilms was reduced by CFSM of milk fermented by B. longum and L. helveticus (70.81 and 69.49 reduction percentage, respectively). These results support the effective use of probiotics as antimicrobial alternatives and to eradicate biofilms formed by multidrug-resistant E. coli.

Probiotics to counteract biofilm-associated infections: promising and conflicting data

Altered bowel flora is currently thought to play a role in a variety of disease conditions, and the use of Bifidobacterium spp. and Lactobacillus spp. as probiotics has been demonstrated to be health-promoting, even if the success of their administration depends on the applied bacterial strain(s) and the targeted disease. In the last few decades, specific probiotics have been shown to be effective in the treatment or the prevention of acute viral gastroenteritis, pediatric post-antibiotic-associated diarrhea, some pediatric allergic disorders, necrotizing enterocolitis in preterm infants, inflammatory bowel diseases and postsurgical pouchitis. The potential application of probiotics is continuously widening, with new evidence accumulating to support their effect on the prevention and treatment of other disease conditions, including several oral diseases, such as dental caries, periodontal diseases and oral malodor, as well as genitourinary and wound infections. Considering the increasingly widespread ability of pathogens to generate persistent biofilm-related infections, an even more attractive proposal is to administer probiotics to prevent or counteract biofilm development. The response of biofilm-based oral, intestinal, vaginal and wound infections to probiotics treatment will be reviewed here in light of the most recent results obtained in this field.

Long-term use of probiotics Lactobacillus and Bifidobacterium has a prophylactic effect on the occurrence and severity of pouchitis: a randomized prospective study

AIM

The aim of the study was to assess the impact of the long-term use of the composite probiotics in patients after restorative proctocolectomy.

METHOD

Forty-three patients (20 females and 23 males, aged 21 to 68 years) after restorative proctocolectomy were included in the study. After randomization patients were divided into placebo group and treatment group with oral intake of probiotic containing Lactobacillus acidophilus, Lactobacillus delbrueckii subsp. bulgaricus, and Bifidobacterium bifidus. Patients were investigated during initial visit and during final visit after 9 months. All patients were subjected to standard clinical and endoscopic examination with microscopic study of the specimens. Concentrations of calprotectin and pyruvate kinase isoenzyme M2-PK were determined in all cases.

RESULTS

The average severity of pouchitis and the number of patients with pouchitis significantly decrease after 9 months of the probiotic taking. The concentrations of calprotectin and pyruvate kinase isoenzyme M2-PK significantly decreased after the therapy.

CONCLUSIONS

Nine months of the probiotic treatment (Lactobacillus acidophilus, Lactobacillus delbrueckii subsp. bulgaricus, and Bifidobacterium bifidus) reduced the number of patients with pouchitis, decreased the PDAI score, and also decreased the fecal pyruvate kinase and calprotectin. The long-term probiotics use is safe and well accepted and can be an effective method of the pouchitis prevention.

The role of probiotics and prebiotics in inducing gut immunity

The gut immune system is influenced by many factors, including dietary components and commensal bacteria. Nutrients that affect gut immunity and strategies that restore a healthy gut microbial community by affecting the microbial composition are being developed as new therapeutic approaches to treat several inflammatory diseases. Although probiotics (live microorganisms) and prebiotics (food components) have shown promise as treatments for several diseases in both clinical and animal studies, an understanding of the molecular mechanisms behind the direct and indirect effects on the gut immune response will facilitate better and possibly more efficient therapy for diseases. In this review, we will first describe the concept of prebiotics, probiotics, and symbiotics and cover the most recently well-established scientific findings regarding the direct and indirect mechanisms by which these dietary approaches can influence gut immunity. Emphasis will be placed on the relationship of diet, the microbiota, and the gut immune system. Second, we will highlight recent results from our group, which suggest a new dietary manipulation that includes the use of nutrient products (organic selenium and Lithothamnium muelleri) and probiotics (Saccharomyces boulardii UFMG 905 and Bifidobacterium sp.) that can stimulate and manipulate the gut immune response, inducing intestinal homeostasis. Furthermore, the purpose of this review is to discuss and translate all of this knowledge into therapeutic strategies and into treatment for extra-intestinal compartment pathologies. We will conclude by discussing perspectives and molecular advances regarding the use of prebiotics or probiotics as new therapeutic strategies that manipulate the microbial composition and the gut immune responses of the host.

The effect of probiotics and gut microbiota on Th17 cells

Probiotics and gut microbiota have a significant impact on gut homeostasis in the host. Recent clinical studies demonstrated the ameliorative features of several kinds of probiotics in intestinal disorders, such as inflammatory bowel diseases (IBDs). Interleukin (IL)-17 is a potent inflammatory cytokine, and T-helper (Th)17 cells and other IL-17-producing cells are involved in the pathogenesis of IBD. Multiple mechanisms of action have been suggested to explain the protective anti-inflammatory effects of probiotics in intestinal inflammation, including the immunoregulation and suppression of Th17 activity and IL-17 production in part by signaling through pattern-recognition receptors such as Toll-like receptor family. However, steady-state Th17 cells have an important role in host defense against fungi and bacteria. Interestingly, recent studies revealed that specific commensal bacterial species such as segmented filamentous bacteria (SFB) induce the accumulation of Th17 cells in the small intestine in many species, including mice. It is important to determine the mechanisms by which intestinal Th17 cells are induced by SFB and whether these or other bacteria with similar properties are present in the human intestine. This brief review focuses on the interaction between probiotics/microbiota and Th17 cells during inflammation (war) and during steady-state homeostatic regulation (peace).

Are probiotics more efficacious than placebo at preventing radiotherapy-induced diarrhoea in adults with cancer

Background

Patients with cancer undergoing radiotherapy often develop diarrhoea, causing distress and hindering treatment. As probiotics have favourable effects on the gut flora, they are potentially good candidates in the prevention of radiotherapy-induced diarrhoea (RID).

Purpose

The outcome of interest of this systematic review was the efficacy of probiotics in preventing RID.

Materials and methods

Medline and Embase databases were systematically searched. Four randomised controlled trials (RCTs) were finally selected.

Results

Three RCTs showed beneficial results, which were statistically significant. One RCT showed non-beneficial results, which were not statistically significant. The quality of the studies was mixed, and serious limitations were found.

Conclusion

While the indications are towards a benefit of the use of probiotics in preventing RID, more robust evidence is required in the form of well-designed RCTs.

Probiotics VSL#3 protect against development of visceral pain in murine model of irritable bowel syndrome

BACKGROUND AND AIMS

Irritable bowel syndrome (IBS) is linked to post-inflammatory and stress-correlated factors that cause changes in the perception of visceral events. Probiotic bacteria may be effective in treating IBS symptoms. Here, we have investigated whether early life administration of VSL#3, a mixture of 8 probiotic bacteria strains, protects against development of visceral hypersensitivity driven by neonatal maternal separation (NMS), a rat model of IBS.

METHODS

Male NMS pups were treated orally with placebo or VSL#3 from days 3 to 60, while normal, not separated rats were used as controls. After 60 days from birth, perception of painful sensation induced by colorectal distension (CRD) was measured by assessing the abdominal withdrawal reflex (score 0-4). The colonic gene expression was assessed by using the Agilent Whole Rat Genome Oligo Microarrays platform and confirmed by real time PCR.

RESULTS

NMS rats exhibited both hyperalgesia and allodynia when compared to control rats. VSL#3 had a potent analgesic effect on CRD-induced pain without changing the colorectal compliance. The microarray analysis demonstrated that NMS induces a robust change in the expression of subsets of genes (CCL2, NOS3, THP1, NTRK1, CCR2, BDRKRB1, IL-10, TNFRSF1B, TRPV4, CNR1 and OPRL1) involved in pain transmission and inflammation. TPH1, tryptophan hydroxylase 1, a validated target gene in IBS treatment, was markedly upregulated by NMS and this effect was reversed by VSL#3 intervention.

CONCLUSIONS

Early life administration of VSL#3 reduces visceral pain perception in a model of IBS and resets colonic expression of subsets of genes mediating pain and inflammation.

TRANSCRIPT PROFILING

Accession number of repository for expression microarray data is GSE38942 (http://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE38942).

Treatment of chronic diarrhoea

The treatment of chronic diarrhoea can be challenging. While Oral Rehydration Solution is an important step in treating diarrhoeal illnesses, various medications can be used to alleviate the symptoms while the patient is undergoing diagnostic work up or to target the underlying mechanism responsible for their diarrhoea. Medications are also being prescribed in cases when there is a strong suspicious about a diagnosis or when there is no specific treatment for an underlying aetiology. This chapter discusses the treatment options for diarrhoeal disorders.