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Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 21, 2016; 22(3): 1078-1087
Published online Jan 21, 2016. doi: 10.3748/wjg.v22.i3.1078
Role of antibiotics for treatment of inflammatory bowel disease
Orna Nitzan, Mazen Elias, Avi Peretz, Walid Saliba
Orna Nitzan, Infectious Disease Unit, Baruch-Padeh Medical Center, Poriya 15208, Israel
Mazen Elias, Department of Internal Medicine C, Ha’Emek Medical Center, Afula 18101, Israel
Mazen Elias, Walid Saliba, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 31096, Israel
Avi Peretz, Clinical Microbiology Laboratory, Baruch-Padeh Medical Center, Poriya 15208, Israel
Walid Saliba, Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa 34362, Israel
Author contributions: All authors contributed equally to this work.
Conflict-of-interest statement: No potential conflict of interest or disclosures declared.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Walid Saliba, MD, MPH, Department of Community Medicine and Epidemiology, Carmel Medical Center, 7 Michal St. Haifa 34362, Israel. saliba_wa@clalit.org.il
Telephone: +972-4-8250474 Fax: +972-4-834435
Received: March 17, 2015
Peer-review started: March 19, 2015
First decision: June 25, 2015
Revised: July 6, 2015
Accepted: November 13, 2015
Article in press: November 13, 2015
Published online: January 21, 2016
Processing time: 273 Days and 2.9 Hours
Abstract

Inflammatory bowel disease is thought to be caused by an aberrant immune response to gut bacteria in a genetically susceptible host. The gut microbiota plays an important role in the pathogenesis and complications of the two main inflammatory bowel diseases: Crohn’s disease (CD) and ulcerative colitis. Alterations in gut microbiota, and specifically reduced intestinal microbial diversity, have been found to be associated with chronic gut inflammation in these disorders. Specific bacterial pathogens, such as virulent Escherichia coli strains, Bacteroides spp, and Mycobacterium avium subspecies paratuberculosis, have been linked to the pathogenesis of inflammatory bowel disease. Antibiotics may influence the course of these diseases by decreasing concentrations of bacteria in the gut lumen and altering the composition of intestinal microbiota. Different antibiotics, including ciprofloxacin, metronidazole, the combination of both, rifaximin, and anti-tuberculous regimens have been evaluated in clinical trials for the treatment of inflammatory bowel disease. For the treatment of active luminal CD, antibiotics may have a modest effect in decreasing disease activity and achieving remission, and are more effective in patients with disease involving the colon. Rifamixin, a non absorbable rifamycin has shown promising results. Treatment of suppurative complications of CD such as abscesses and fistulas, includes drainage and antibiotic therapy, most often ciprofloxacin, metronidazole, or a combination of both. Antibiotics might also play a role in maintenance of remission and prevention of post operative recurrence of CD. Data is more sparse for ulcerative colitis, and mostly consists of small trials evaluating ciprofloxacin, metronidazole and rifaximin. Most trials did not show a benefit for the treatment of active ulcerative colitis with antibiotics, though 2 meta-analyses concluded that antibiotic therapy is associated with a modest improvement in clinical symptoms. Antibiotics show a clinical benefit when used for the treatment of pouchitis. The downsides of antibiotic treatment, especially with recurrent or prolonged courses such as used in inflammatory bowel disease, are significant side effects that often cause intolerance to treatment, Clostridium dificile infection, and increasing antibiotic resistance. More studies are needed to define the exact role of antibiotics in inflammatory bowel diseases.

Keywords: Antibiotic treatment; Inflammatory bowel disease; Ulcerative colitis; Crohn’s disease

Core tip: The gut microbiota plays an important role in the pathogenesis and complications of inflammatory bowel disease. Antibiotics may influence the course of inflammatory bowel disease by decreasing concentrations of bacteria in the gut lumen and altering the composition of intestinal microbiota. In Crohn’s disease, antibiotics may have a modest effect in decreasing disease activity and achieving remission, are more effective in patients with disease involving the colon, and are useful in the treatment of suppurative complications. Data is more sparse and less conclusive for the treatment of ulcerative colitis, though there might be some benefit in antibiotic treatment. Side effects, the risk of Clostridium dificile infection, and increasing antibiotic resistance should be considered. Further studies are needed to define the role of antibiotic treatment in inflammatory bowel diseases.