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Taking Antibiotics With Crohn’s Disease

Antibiotics: A Trigger For Inflammatory Bowel Disease

Crohn’s Disease and Antibiotic Use
  • AffiliationsSorbonne Université, Institut national de la santé et de la recherche médical, Centre de Recherche Saint-Antoine, Assistance publique Hôpitaux de Paris, Saint Antoine Hospital, Gastroenterology department, F-75012 Paris, FranceInstitut national de la recherche agronomique, UMR1319 Micalis and AgroParisTech, Jouy en Josas, FranceParis Centre for Microbiome Medicine, Fédération hospitalo-universitaires, Paris, France
  • Mogno I
  • et al.

Immunity.Lancet.Microbiome.

Antibiotics And Ibd: The Evidence

IBD is a diverse condition with response to treatment dependent on multiple interrelated variables. To assess antibiotics in IBD as a whole, or even overall in CD or UC independently, is overly simplistic and will not reflect the true effect in specific circumstances. Hence we have attempted to review the role of antibiotics in more specific scenarios.

Evidence relating to efficacy of therapeutic interventions generally depends on a number of large, high quality randomized controlled trials . Due to the relatively low number of high quality studies in antibiotics, and the high variability in antibiotics trialed, treatment course and outcome measures, drawing firm conclusions remains difficult.

Further complicating attempts at analysis of existent data is the potential diverse conclusions drawn from individual studies. For example, in the seminal Australian antibiotic RCT of anti-MAP combination therapy including over 200 patients followed for 3 years , the primary endpoint of prolonged relapse-free course out to 3 years was not met, however the antibiotic group had a higher 16-week remission rate , and a clear trend to lower 12 months and 24 months relapse rate . However, considering that the antibiotic course was specifically tailored to target MAP, concerns were raised regarding possible underdosing of antibiotics, lack of pre-treatment testing for MAP, and levels of antibiotic resistance, further casting a doubt on the applicability of the evidence .

Suppurative Complications: Abscesses And Fistulas

Treatment of abdominal and anorectal abscesses consists of surgical or percutaneous drainage combined with antibiotic therapy. Small abscesses can be treated with antibiotics alone, especially in cases without associated fistulas or in immunomodulator-naive patients. Antibiotics should cover gram negative bacteria and anaerobes. A combination of fluoroquinolones or cephalosporins and metronidazole is considered appropriate.

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Probiotics Bacteria And Gut Health

Often, bacteria are perceived as dangerous germs that lead to the development of disease. For instance, many people are familiar with strep throat a bacterial infection caused by the bacteria streptococcus. However, bacteria like probiotics can also be beneficial to your health, and many naturally live in the human body as part of the microbiome.

The microbiome and the bacteria in it are critical for proper digestion and overall health. The good bacteria within the microbiome are responsible for:

  • Producing certain vitamins and amino acids
  • Breaking down toxic food, complex carbohydrates, and sugars including lactose, which is broken down by the bacteria Lactobacillus rhamnosus
  • Forming short-chain fatty acids, which some clinical trials have demonstrated may help treat Crohns disease

The microbiome is responsible for many vital functions, so protecting and maintaining its health is important. Ingesting probiotics can help maintain and even boost the population of good bacteria in the gut. These good bacteria help preserve and thicken the barrier in the GI tract that blocks harmful bacteria from penetrating the lining of the GI tract . Probiotics may also help manage the health of the gastrointestinal immune system and reduce intestinal inflammation.

Unintended Consequences Of Microbiome Manipulation

10 Questions to Ask Your Doctor About Crohn

Due to the complexity and diversity of the microbiome, the effects of antibiotics are far reaching. Antibiotics are associated with increased dysbiosis with relatively higher fungal proportions in the microbiome under treatment . Long-term changes to microbiome continue well beyond cessation of therapy. For example, assessment of mucosal flora from IBD patients treated with a 2-week antibiotic course, demonstrate an initial suppression effect on mucosal flora followed by a massive rebound following cessation, with dramatically increased bacterial load out to 5 months . The long-term significance of this microbiome manipulation is not certain. There is compelling evidence that such influences on microbiome may be more pronounced, and more significant during early life when the microbiome is more malleable than in later childhood and adults .

Any discussion of prolonged antibiotic exposure must also include consideration of development of antibiotic resistance. Indeed there is data to suggest that the prevalence of Methicillin-resistant Staphylococcus aureus , Vancomycin-resistant Enterococcus and extended-spectrum beta-lactamases is significantly higher among IBD patients. Recent hospitalization and recent antibiotic use are particularly associated with the higher prevalence .

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Do Opposites Attract Or Cancel Each Other Out We Asked The Experts For The Bottom Line

by Health Writer

In short: Yes, you can take a probiotic while youre taking an antibioticits perfectly safe to do so. In fact, experts generally agree that probiotics may help ward off the gut reaction that comes from taking antibiotics , but the data is limited. On the other hand, to reap the maximum gut flora-restoring benefits that probiotics offer, it may be better to wait until the tail-end of your course of antibiotics before starting to take them, says Eric Goldberg, M.D., an internist and medical director of NYU Langone Internal Medicine Associates in New York City.

To understand how probiotics and antibiotics work together, lets first talk about the gut microbiome. The microbiome is where trillions of bacteria, fungi, and viruses live. We all have a balance of good and bad bacteria in our gut microbiome. When levels of the harmful bacteria get too high, you get sickin the form of stomach bugs, fungal infections, and a hit to your immune system, making you more vulnerable to future infection.

What Are The Most Commonly Used Antibiotics In The Treatment Of Inflammatory Bowel Disease

The antibiotics metronidazole and ciprofloxacin are the most commonly used antibiotics in persons with inflammatory bowel disease . According to a systemic review, antituberculosis therapy, macrolides, fluoroquinolones, 5-nitroimidazoles, and rifaximin have not consistently been shown to induce remission in selective active Crohn disease and have rarely been shown to induce remission in ulcerative colitis.

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The Role Of The Microbiome In Ibd

Gut flora comprises an enormously complex microenvironment, with the microbial genome outnumbering the human genome by at least an order of magnitude . The majority of gut microbiota has never been cultured, and the advancement in our understanding of its complex role has only begun to flourish with the development of newer culture-independent technologies. Adding to the complexity of this microenvironment is the uncertain role of other members of this microbial community including fungi and bacteriophages.

Indirect support for the role of gut flora in IBD pathogenesis is provided by fecal stream diversion improving disease activity in CD, with restoration of fecal stream inducing recurrence. This does not occur, however, when ileostomy effluent is filtered to remove bacteria prior to reintroduction . Ileal microflora undergoes significant expansion on restoration of contiguity with colonic remnant, however the microbial pattern in patients with CD varies significantly from that of patients without CD upon restoration of fecal flow, with significantly higher counts of E coli and bacteroides in patients with CD, as compared to higher counts of bifidobacteria and ruminococci amongst controls .

Antibiotics Kill ‘good’ Gut Bacteria

Treating IBD: Antibiotics

Antibiotics kill the bad bacteria that cause illness. But they also kill good bacteria in the body that help digestion.

IBD runs in families. Most experts believe that genes aren’t the only trigger for the disease.

The study adds to the evidence that antibiotic use is one of these triggers, says Ilseung Cho, MD, of NYU Langone Medical Center.

Cho says the possible link reinforces the importance of prescribing antibiotics only when they are likely to be useful.

“Both physicians and parents are at fault for the overuse of antibiotics,” he says. “Antibiotics are very beneficial drugs, but it is important to be prudent about how we use them.”

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Antibiotics Associated With Increased Risk Of Inflammatory Bowel Disease

Date:
Karolinska Institutet
Summary:
Antibiotics use, particularly antibiotics with greater spectrum of microbial coverage, may be associated with an increased risk of new-onset inflammatory bowel disease and its subtypes ulcerative colitis and Crohn’s disease, according to a new study.

Antibiotics use, particularly antibiotics with greater spectrum of microbial coverage, may be associated with an increased risk of new-onset inflammatory bowel disease and its subtypes ulcerative colitis and Crohn’s disease. That is according to a study by researchers at Karolinska Institutet in Sweden and Harvard Medical School in the U.S., published in the journal The Lancet Gastroenterology & Hepatology. The association remained when patients were compared with their siblings.

IBD is becoming more common, particularly in Europe, the U.S. and other parts of the world undergoing rapid economic development, increased sanitation, and more frequent use of antibiotics. With growing appreciation for the gut microbiome’s role in maintaining human health, concern has risen that antibiotics may perturb and permanently alter these fragile microbial communities. This could potential impact the risk of gastrointestinal disease.

Two-times increased risk

Nearly 1 percent affected in Sweden

IBD affects nearly 1 percent of the Swedish population and can have a substantial effect on patients’ life. It has been linked to an increased risk of both death and cancer.

Story Source:

Asc And Chronic Refractory Colitis

Given the inconsistent data and the high-risk nature of ASC, antibiotics are not currently routinely recommended in UC. However it is reasonable to consider an oral antibiotic cocktail of amoxicillin, metronidazole, doxycycline and vancomycin if standard therapies have failed. In ASC this is usually considered if refractory to IV steroids, however salvage therapy or colectomy should never be delayed while trialing this approach.

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Moderate To Severe Disease

Patients with Crohn’s disease that is classified as moderate to severe should be treated with steroids until symptoms resolve and weight loss is reversed. The immunomodulators azathioprine and mercaptopurine may be used, but full response may not be achieved for several months. Infliximab may be an alternative if corticosteroids are ineffective or contraindicated.

Oral corticosteroids have been the mainstay for treating moderate to severe active Crohn’s disease. Their effectiveness in inducing remission has long been known, and their onset of action is more rapid than that of salicylates. While studies have not revealed a generally accepted dosage schedule, 50 to 70 percent of patients receiving the equivalent of prednisone 40 mg daily over eight to 12 weeks have been shown to achieve a clinical response.9

After clinical response, dosage is tapered according to rapidity and completeness of response, often requiring months to discontinue.14 Dosages can be tapered by 5 to 10 mg weekly until 20 mg, and by 2.5 to 5 mg weekly thereafter.14 Steroids have no role in maintaining remission. In addition, concerns regarding the long-term side effects of steroid use, including diabetes mellitus, osteoporosis, and adrenal suppression, limit their long-term use. Prednisone enemas may be helpful in proctosigmoid disease but are not as effective as salicylate preparations.

Surgery For Severe Crohn’s

Mercaptopurine for Crohn

You may need an operation if medications don’t help, or if you have other complications. Some fistulas, abscesses, or bowel obstructions may require one. During the procedure, your doctor will remove damaged parts of your intestines. But theyâll try to preserve as much as they can to keep your digestion normal.

American Academy of Family Physicians.

Crohn’s & Colitis Foundation of America.

Hanauer, S. Digestive Diseases, 2009.

National Digestive Diseases Information Clearinghouse.

National Institute of Diabetes and Digestive and Kidney Diseases.

U.S. Department of Agriculture.

This tool does not provide medical advice. See additional information.

THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for general informational purposes only and does not address individual circumstances. It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health. Never ignore professional medical advice in seeking treatment because of something you have read on the WebMD Site. If you think you may have a medical emergency, immediately call your doctor or dial 911.

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Evidence For Antibiotics In Perianal Cd

Antibiotics have long been used in clinical practice for active perianal CD however the evidence remains relatively limited. Three randomized placebo controlled trial have been performed, two of which assessed antibiotics in combination with biological therapy . One small RCT comparing metronidazole, ciprofloxacin and placebo was too underpowered to detect any statistically significant effect . Ciprofloxacin as an adjunct to infliximab had a higher response than infliximab alone , and was also found to be significantly better as adjunct to adalimumab .

A large open label trial assessed response of perianal disease to ciprofloxacin or metronidazole in addition to azathioprine at 8 weeks, prior to expected azathioprine efficacy. Half of patients had a significant improvement in perianal disease scores .

Topical metronidazole ointment was assessed in an RCT and while both groups had the same mean reduction in perianal CD activity index scores, more patients applying metronidazole ointment had at least 5 point reduction in the score , significantly reduced perianal discharge and a trend to less perianal pain .

Pooled analysis of ciprofloxacin in perianal CD demonstrates efficacy in reducing fistula drainage but not for fistula healing . These results suggest that antibiotics should be used as adjunctive therapy for perianal CD, but not as sole therapy .

Evidence For Antibiotics In Crohns Disease

Induction of remission in active CD

Diverse RCTs have been performed utilizing different antibiotic combinations, varying treatment periods and with differing end-points. Studies have primarily assessed either specific anti-MAP therapy or non-specific broad spectrum antibiotics or antibiotic combinations. Overall the strongest signal by antibiotic type appears to be with clofazimine and rifamycins with macrolides failing to achieve convincing induction of remission .

A review of the RCTs performed for induction of remission in CD reveals a significant confounding factor. All of these trials utilized clinical indices with clinical remission and relapse being the primary outcome measures . It is well established that a large component of clinical activity in CD is not necessarily related to inflammation, with irritable bowel syndrome , bacterial overgrowth and chronic pain syndromes all occurring with greater frequency than the general population. The role of antibiotics in treating IBS and bacterial overgrowth is also well supported . Hence it is unclear whether clinical outcomes reflects a direct effect on mucosal inflammation and disease progress, or treatment of secondary clinical manifestations of arguable importance to true mucosal response.

Table 1

Maintenance of remission

Post-operative prophylaxis

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Talk With Others Who Understand

MyCrohnsAndColitisTeam is the social network for people with Crohns disease and ulcerative colitis, and their loved ones. More than 140,000 members come together to ask questions, give advice, and share their stories with others who understand life with IBD.

Have you taken probiotics for Crohns disease? Share your experience in the comments below, or start a conversation by posting on MyCrohnsAndColitisTeam.

Antibiotics May Raise Bowel Disease Risk In Kids

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Sept. 24, 2012 — Overuse of antibiotics may help explain why more children are being diagnosed with inflammatory bowel disease .

In a new study, getting antibiotics, especially very early in childhood, was linked to a raised risk for IBD.

IBD is a catch-all term for a group of serious intestinal conditions that include Crohn’s disease and ulcerative colitis.

The symptoms typically include diarrhea, rectal bleeding, and abdominal cramping.

The rate of IBD among children has doubled over the last decade. The study is the largest yet to suggest that the increased use of antibiotics may be at least partially to blame.

“We need to be judicious in our use of antibiotics,” says researcher Matthew P. Kronman, MD, of Seattle Children’s Hospital’s division of infectious diseases. “Antibiotics should be used when needed. But too many children are still getting them for conditions like the common cold, where they do no good.”

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Gut Microbiota And Ibd

The adult gut ecosystem contains trillions of organisms from over 1000 species, with the most abundant species being from the Firmicutes and Bacteroidetes phyla. Changes in gut bacterial population occur over time, and depend on age, diet, hygiene, climate, geography and ethnicity. Nowadays over 25 diseases or syndromes have been linked to an altered intestinal microbiome. There is abundant data confirming the importance of gut microbiota in the inflammatory process that exists in IBD. For example, genetically engineered mice deficient in the cytokines IL-2 and IL-10 or rats containing the HLA-B27 transgene are protected from colitis in the germ-free state, but develop IBD upon reconstitution of normal gut flora, thus implying that colitis depends on the presence of gut bacteria.

There is also ongoing debate whether mucosa attached bacteria play a more important role than luminal bacteria in the propagation of IBD. Mucosal surfaces of IBD patients were found to be densely colonized with Bacteroides fragilis.

Management Of Crohn’s Disease

The medical management of Crohn’s disease is based on the location and severity of disease and extra-intestinal complications .5 Therapy has two goalsto treat the acute disease flare-ups and to maintain remission. Because no gold standard exists to define disease severity, working definitions of disease activity have been established to help guide therapy. These definitions are listed and defined in Table 3,5 while the various treatment options for Crohn’s disease are provided in Table 4.5

Extra-intestinal Manifestations of Crohn’s Disease

Joint manifestations

Aphthous ulcers of the mouth

Ocular manifestations

Uveitis

Recurrent iritis

Information from Hanauer SB, Sanborn W. The management of Crohn’s disease in adults. Am J Gastroenterol 2001 96:63543.

Extra-intestinal Manifestations of Crohn’s Disease

Joint manifestations

Aphthous ulcers of the mouth

Ocular manifestations

Uveitis

Recurrent iritis

Information from Hanauer SB, Sanborn W. The management of Crohn’s disease in adults. Am J Gastroenterol 2001 96:63543.

Working Definitions of Crohn’s Disease Activity

Mild to moderate disease

Information from Hanauer SB, Sanborn W. The management of Crohn’s disease in adults. Am J Gastroenterol 2001 96:63543.

Working Definitions of Crohn’s Disease Activity

Mild to moderate disease

Information from Hanauer SB, Sanborn W. The management of Crohn’s disease in adults. Am J Gastroenterol 2001 96:63543.

Treatment Options in Crohn’s Disease

FIGURE 1.

FIGURE 1.

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