Diagnosis and treatment of pouchitis.

Total proctocolectomy with ileal pouch-anal anastomosis is the surgical procedure of choice for the management of ulcerative colitis. Pouchitis, a non-specific inflammation of the ileal reservoir, is the most frequent complication that patients experience in the long-term. Diagnosis should be made on the basis of clinical, endoscopic and histological aspects. The Pouchitis Disease Activity Index (PDAI) represents an objective and reproducible scoring system for pouchitis: active pouchitis is defined as a score > or = 7 and remission as a score < 7. About 15% of patients develop a chronic disease. Treatment of pouchitis is empirical, and very few controlled studies have been carried out. antibiotics, particularly metronidazole and Ciprofloxacin (Cipro), are the treatment of choice. Chronic pouchitis may benefit from a prolonged course of a combination of antibiotics. Highly concentrated probiotics are effective for both prevention of relapses and prevention of pouchitis onset. There is no convincing evidence of the efficacy of other therapeutic agents.

Pseudomonas aeruginosa: resistance and therapy.

Pseudomonas aeruginosa resistance to antimicrobials is an important therapeutic consideration. Antibiotic resistance to P. aeruginosa may be chromosomally or plasmid mediated. Resistance to P. aeruginosa may also be affected by changes in the cellular membrane or intracellular environment. P. aeruginosa is primarily a nosocomial organism that most commonly colonizes respiratory secretions and urine. The selection of an antipseudomonal antibiotic depends on its inherent in vitro activity and its resistance potential. Anti-P. aeruginosa antibiotics with a high-resistance potential include gentamicin, tobramycin, Ciprofloxacin (Cipro), ceftazidime, and imipenem. Anti-P. aeruginosa antibiotics with a low-resistance potential include amikacin, piperacillin, cefoperazone, cefepime, meropenem, and polymyxin B. Copyright 2002, Elsevier Science (USA). All rights reserved.

Inflammatory bowel disease: management issues during pregnancy.

INTRODUCTION: Inflammatory bowel disease often affects women during their reproductive years, causing management concerns for obstetricians caring for these patients during pregnancy. TREATMENT: Apart from methotrexate, most drugs used regularly to treat ulcerative colitis and Crohn's disease can safely be used by pregnant women. No causal relationship has been established between exposure to sulfasalazine or other 5-aminosalicylic acid drugs and the development of congenital malformations and these drugs may be used with relative safety during pregnancy and lactation. Current evidence indicates that maternal use of azathioprine and mercaptopurine is not associated with an increased risk of congenital malformations, though impaired foetal immunity, intrauterine growth retardation and prematurity are occasionally observed. Cyclosporin is not teratogenic, but may be associated with growth retardation and prematurity. CONCLUSIONS: Pregnancy should be avoided in women treated with methotrexate because of its known abortifacient effects and risk of causing typical malformations. There is no actual evidence of adverse effect in pregnant women receiving Infliximab but the amount of clinical information is small. The treatment with metronidazole or Ciprofloxacin (Cipro) for short durations appear to be safe, but there is no data about the effects of increased length of treatment as required in Crohn's disease remains unknown. Control of disease activity before conception and during pregnancy is critical to optimise both maternal and foetal health. A multidisciplined approach involving both obstetrician and gastroenterologist and education about pregnancy are essential components of the treatment of any young women with IBD.

Objectives for antibiotic therapy in acute exacerbations of chronic bronchitis

ANTIBIOTIC EFFICACY: According to early studies, antibiotics have moderate efficacy in acute exacerbation of chronic bronchitis. The lack of efficacy is particularly clear for patent exacerbation with marked alteration of respiratory function. Recent studies have shown that newer compounds exhibit an efficacy similar (no proven superiority) to comparison compounds (75 to 95% favorable outcome with treatment). The recommendations of the IVth Consensus Conference on Anti-infectious Therapy thus propose first line antibiotic therapy for patients with a forced expiratory volume in 1 second (FEV1) between 80 and 35% and broader spectrum and new antibiotics in case of failure of the first line treatment for patients with severe obstruction or frequently recurrent exacerbation. EVALUATION CRITERIA: Using exacerbation-free interval, reduction in the number of exacerbations, duration of treatment and/or hospital stay as evaluation criteria, interesting results are obtained with amoxicillin/clavulanic acid, azithromycin, and Ciprofloxacin (Cipro). Independent factors predictive of therapeutic failure are, according to one study, FEV1 less than 35%, ambulatory administration of oxygen, more than 4 acute exacerbations within 24 months, history of pneumonia or sinusitis, and requirement for long-term corticosteroid therapy. Factors predictive of recurrence are, according to another study, dependence on oxygen therapy, prolonged corticosteroid therapy, smoking, and/or heart disease. Cost effectiveness is particularly interesting with Ciprofloxacin (Cipro), especially in more severe patients. PERSPECTIVES: It is important to target antibiotic therapy for acute exacerbation of chronic bronchitis specifically for patients who will truly benefit, adapting the prescribed compound to the bacterial target.