Rifaximin-ciprofloxacin combination therapy is effective in chronic active refractory pouchitis

Objective Treatment of chronic refractory pouchitis is often difficult and disappointing and some of the affected pouches subsequently fail. This study was conducted to evaluate the efficacy and tolerability of treatment wit rifaximin, a nonabsorbable oral antibiotic with immunomdulatory functions, in combination with ciprofloxacin for chronic active refractory pouchitis. Patients and methods Eight patients with chronic active refractory pouchitis were treated orally with a combination of rifaximin 1 g b.d and ciprofloxacin 500 mg b.d. for two weeks. Clinical assessment, endoscopic and histological evaluations were performed before and after therapy using the Pouchitis Disease Activity Index (PDAI) score. Improvement was defined as a decrease of at least three points in the PDAI score and remission as a PDAI score of 0. The Wilcoxon signed rank test was used to compare pre-and post-treatment PDAI scores. The long-term outcome of the treated patients was prospectively monitored. Results Seven of the eight patients either went into remission (n = 5) or improved (n = 2). The median (range) PDAI scores before and after therapy were 12 (918) and 0 (0-15), respectively, (P = 0.018). All patients were compliant and no side effects were reported. Pouchitis recurred in two of the seven responding patients but returned into remission after further courses of the same combination. After a median follow-up of 30 months, the seven responding patients still had satisfactory pouch function. Conclusion Rifaximin-ciprofloxacin combination therapy is safe and objectively effective in chronic active refractory pouchitis and may salvage a significant percentage of 'at risk pouches'.