Gosselink Martijn P, Schouten W Rudolph, van Lieshout Leo M C, Hop Willem C J, Laman Jon D, Ruseler-van Embden Johanneke G H
Colorectal Research Group of the Department of Surgery, Erasmus MC, Rotterdam, The Netherlands.
Dis Colon Rectum. 2004 Sep;47(9):1519-25. doi: 10.1007/s10350-004-0623-y. Epub 2004 Jul 8.
Pouchitis is the major long-term complication after ileal pouch-anal anastomosis for ulcerative colitis. Metronidazole and ciprofloxacin are commonly used for treatment; however, nothing is known about the effects on the pouch flora during and after pouchitis episodes. This study was designed to evaluate the effect of both antibiotics on eradication of pathogens and the restoration of normal pouch flora.
The fecal flora obtained from 13 patients with ulcerative colitis was examined at the beginning of a pouchitis episode before treatment, during treatment with metronidazole or ciprofloxacin, and during pouchitis-free periods. Some patients experienced more than one pouchitis episode. Therefore, a total of 104 samples was obtained. Each sample was cultured under aerobic and anaerobic conditions and the isolated bacteria were identified. Furthermore, the clinical response to both antibiotics was compared using the Pouchitis Disease Activity Index score.
During pouchitis-free periods, the patients had a flora characterized by high numbers of anaerobes and no or low numbers of pathogens. This flora resembles normal colon flora. During pouchitis episodes, we found a significant decrease of anaerobes ( P = 0.01), a significant increase of aerobic bacteria ( P = 0.01), and significantly more numbers of pathogens, such as Clostridium perfringens (in 95 percent of the samples; P < 0.01) and hemolytic strains of Escherichia coli (in 57 percent of the samples; P = 0.05). Treatment with metronidazole resulted in a complete eradication of the anaerobic flora, including C. perfringens. However, no changes in the numbers of E. coli were found. In contrast, when the patient was treated with ciprofloxacin, not only C. perfringens, but also all coliforms including hemolytic strains of E. coli disappeared. The larger part of the anaerobic flora was left undisturbed during the administration of ciprofloxacin. Patients treated with ciprofloxacin experienced significant larger reductions in Pouchitis Disease Activity Index score compared with patients treated with metronidazole ( P = 0.04).
This study strongly suggests a role of pathogenic bacteria ( C. perfringens and/or hemolytic strains of E. coli) in pouchitis. From a microbiologic and a clinical point of view, ciprofloxacin is preferable to metronidazole, because treatment with ciprofloxacin eradicates both pathogens and results in an optimal restoration of normal pouch flora.
袋炎是溃疡性结肠炎行回肠储袋肛管吻合术后主要的长期并发症。甲硝唑和环丙沙星常用于治疗；然而，对于袋炎发作期间及之后对储袋菌群的影响却一无所知。本研究旨在评估这两种抗生素对病原体根除及正常储袋菌群恢复的作用。
在袋炎发作开始时、甲硝唑或环丙沙星治疗期间以及无袋炎发作期，对13例溃疡性结肠炎患者的粪便菌群进行检测。部分患者经历了不止一次袋炎发作。因此，共获得104份样本。每个样本在需氧和厌氧条件下培养，并对分离出的细菌进行鉴定。此外，使用袋炎疾病活动指数评分比较两种抗生素的临床反应。
在无袋炎发作期，患者的菌群以大量厌氧菌为特征，病原体数量无或较少。这种菌群类似于正常结肠菌群。在袋炎发作期间，我们发现厌氧菌显著减少（P = 0.01），需氧菌显著增加（P = 0.01），且产气荚膜梭菌（95%的样本中存在；P < 0.01）和溶血性大肠杆菌菌株（57%的样本中存在；P = 0.05）等病原体数量显著增多。甲硝唑治疗导致厌氧菌群完全根除，包括产气荚膜梭菌。然而，大肠杆菌数量未发现变化。相比之下，当患者接受环丙沙星治疗时，不仅产气荚膜梭菌，而且包括溶血性大肠杆菌菌株在内的所有大肠菌群均消失。在使用环丙沙星期间，大部分厌氧菌群未受干扰。与接受甲硝唑治疗的患者相比，接受环丙沙星治疗的患者袋炎疾病活动指数评分显著降低（P = 0.04）。
本研究强烈提示病原菌（产气荚膜梭菌和/或溶血性大肠杆菌菌株）在袋炎中起作用。从微生物学和临床角度来看，环丙沙星优于甲硝唑，因为环丙沙星治疗既能根除病原体，又能使正常储袋菌群得到最佳恢复。
