High-Dose Probiotics for the Treatment of Active Pouchitis

High-Dose Probiotics for the Treatmentof Active PouchitisPaolo Gionchetti, M.D.,1 Fernando Rizzello, M.D.,1 Claudia Morselli, M.D.,1

Gilberto Poggioli, M.D.,2 Rosi Tambasco, M.D.,1 Carlo Calabrese, M.D.,1

Patrizia Brigidi, M.D.,3 Beatrice Vitali, M.D.,3 Giulia Straforini, M.D.,1

Massimo Campieri, M.D.1

1 Department of Internal Medicine and Gastroenterology, University of Bologna, Bologna, Italy2 Department of Clinical Surgery, University of Bologna, Bologna, Italy3 Department of Pharmaceutical Sciences, University of Bologna, Bologna, Italy

PURPOSE: Pouchitis is the major long-term complicationafter ileal-pouch anal anastomosis for ulcerative colitis.Broad-spectrum antibiotics are the mainstay of treatment inthis condition. Recently, we have shown the efficacy of ahighly concentrated probiotic preparation (VSL#3, 900billions/sachet lyophilized viable bacteria) in preventingrelapses of chronic pouchitis and in preventing pouchitisonset. This study was designed to evaluate the efficacy ofhigh-dose VSL#3 in the treatment of mildly active pouchitis.METHODS: Twenty-three consecutive patients with mildpouchitis, defined as a score of between 7 and 12 in thePouchitis Disease Activity Index, which includes clinical,endoscopic, and histological criteria, were treated withVSL#3, 2 sachets b.i.d. (3600 billion bacteria/day) forfour weeks. Symptomatic, endoscopic, and histologicevaluations were undertaken before and after treatmentaccording to Pouchitis Disease Activity Index. Remissionwas defined as a combination of a Pouchitis DiseaseActivity Index clinical score of e2, endoscopic score ofe1, and total Pouchitis Disease Activity Index score of e4.Patients in remission after treatment were treated withVSL#3, 1 sachet b.i.d. (1800 billion bacteria), as mainte-nance treatment for six months. The quality of life wasassessed with the Inflammatory Bowel Disease Question-naire. RESULTS: Sixteen of 23 patients (69 percent) were inremission after treatment. The median total PouchitisDisease Activity Index scores before and after therapywere 10 (range, 9–12) and 4 (range, 2–11), respectively

(P<0.01). The median Inflammatory Bowel Disease Ques-tionnaire score also significantly improved from 110(range, 90–140) to 200 (range, 95–220; P<0.001). All 16patients who went into remission maintained remissionduring maintenance treatment. Only one patient experi-enced a transient bloating at the beginning of treatment.CONCLUSIONS: High doses of the probiotic VSL#3 areeffective in the treatment of mild pouchitis. Furthercontrolled studies are warranted. [Key words: Ulcerativecolitis; Pouchitis; Probiotics]

T otal proctocolectomy with ileal pouch-anal

anastomosis (IPAA) has emerged during the

past 15 years as the surgical procedure of choice for

the management of ulcerative colitis (UC). Pouchitis,

a nonspecific idiopathic inflammation of the ileal

reservoir, has become the most frequent long-term

complication after pouch surgery for UC.1 The

reported incidence of pouchitis is variable, largely

because of differences in the type and duration of

follow-up and, particularly, because myriad diagnostic

criteria have been used to define this syndrome.2–7

Most patients who develop acute pouchitis do so

within the first year, but some may suffer their first

attack some years after surgery.4

The etiology is still unknown, but both a history of

UC and increased bacterial concentrations are the

main factors.1,8 The importance of bacteria is further

emphasized by the evident efficacy of antibiotics.9–11

This syndrome is clinically characterized by vari-

able symptoms, including increased stool frequency

and fluidity, rectal bleeding, abdominal cramping,

Correspondence to: Paolo Gionchetti, M.D., Department ofInternal Medicine and Gastroenterology, Policlinico S. Orsola, ViaMassarenti 9, Bologna 40138, Italy, e-mail: [email protected].

Dr. Pardi does consulting and research for Salix.

Dis Colon Rectum 2007; 50: 2075–2084DOI: 10.1007/s10350-007-9068-4* The American Society of Colon and Rectal SurgeonsPublished online: 13 October 2007

2075

urgency and tenesmus, incontinence, fever, and

extraintestinal manifestations.8 A clinical diagnosis

should be confirmed by endoscopy and histology.

The endoscopic features of pouchitis include muco-

sal erythema, edema, friability, petechiae, granulari-

ty, loss of vascular pattern, erosions, and superficial

ulceration. Histologic examination shows an acute

inflammatory infiltrate with crypt abscesses and

ulceration in addition to chronic inflammation,

including villous atrophy, and crypt hyperplasia,

which is almost universal and probably represents

an adaptive response of the pouch mucosa to fecal

stasis.12 The absence of clear and universally accept-

ed criteria for the diagnosis, classification, and

definition of activity has created variability in the

reported incidence of pouchitis and in the assess-

ment of therapy. To overcome this problem, Sand-

born and colleagues developed the Pouchitis Disease

Activity Index (PDAI).13 This 18-point index is based

on clinical symptoms and endoscopic appearance, as

well as acute histologic findings, and represents an

objective and reproducible scoring system for

pouchitis. Active pouchitis is defined as a score Q7,

and remission is defined as a score <7.

Probiotics are defined as living microorganisms,

which on ingestion in adequate amounts, exert

health effects beyond inherent basic nutrition.14

Bacteria associated with probiotic activity are most

commonly lactobacilli, bifidobacteria, and strepto-

cocci, but other nonpathogenic bacteria, such as

some strains of Escherichia coli, and nonbacterial

organisms, such as the yeast Saccharomyces boular-

dii, have been used. The rationale for using pro-

biotics in inflammatory bowel disease is based on

convincing evidence implicating intestinal bacteria in

the pathogenesis of the disease.15,16

Good results have been obtained with probiotic

therapy in experimental colitis. Administration of

Lactobacillus reuteri reduced inflammation signifi-

cantly in acetic acid- and methotrexate induced-

colitis in rats.17,18 More recently, Lactobacillus sp.

was shown to prevent the development of sponta-

neous colitis in interleukin (IL)-10–deficient mice 19;

continuous feeding with Lactobacillus plantarum

could attenuate an established colitis in the same

knockout model.20 In IL-10–deficient mice, Lactoba-

cillus salivarius subsp. salivarius reduced the rate

of inflammation progression through dysplasia and

colonic cancer.21 Bifidobacterium infantis and

Lactobacillus salivarius attenuated inflammation,

reducing the production of Th1-type cytokines in

the IL-10 knockout model.22 Probiotics were shown

to be effective in maintenance therapy of UC.23–25

We have used a probiotic preparation (VSL#3)

with a high bacterial concentration and a cocktail

of eight different bacterial species. It has been

shown to be effective in maintenance therapy of

chronic pouchitis,26,27 in prevention of the onset of

pouchitis,28 in maintenance therapy of UC,29 and in

treatment of active mild-to-moderate UC.30 This

study was designed to evaluate the efficacy of

VSL#3 in the treatment of mildly active pouchitis.

PATIENTS AND METHODS

The study was performed in accordance with the

Declaration of Helsinki and was approved by the

ethical committee of our hospital; written, informed

consent was obtained from the patients. Patients

were included if they had current active mild

pouchitis, defined as a score between 7 and 12,

using the 18-point PDAI.13 All patients had J-shaped

constructed pouches; three-stage IPAA was per-

formed in 18 patients and two-stage IPAA in 5

patients.

Patients were excluded from entry if they 1) had

chronic pouchitis; 2) had received any treatment for

pouchitis, including antibiotics, steroids or immuno-

suppressants, within two weeks before participation;

3) had taken nonsteroidal anti-inflammatory drugs;

4) had previously taken VSL#3; 5) had a history of

epilepsy or convulsions; 6) had perianal disease

(including abscess, fissure, stricture, or anal sphincter

weakness); 7) had severe cardiovascular, respiratory,

hepatic (including primary sclerosing cholangitis) or

renal conditions; or 8) were pregnant or breast feeding.

Concurrent use of antidiarrheals, probiotics, or

narcotic drugs also excluded them from the study.

Study Medication

VSL#3 (VSL#3 Pharmaceuticals, Inc, Ft. Lauderdale,

FL) consisted of packets containing 900 billion viable

lyophilized bacteria of 4 strains of Lactobacillus (L. casei,

L. plantarum, L. acidophilus, and L. delbrueckii subsp.

bulgaricus), 3 strains of Bifidobacterium (B. longum,

L. breve, and B. infantis), and 1 strain of Streptococcus

salivarius subsp. thermophilus, designated as S. ther-

mophilus throughout this article.

Patients received VSL#3 2 packets b.i.d. for four

weeks. Patients who obtained remission were treated

with VSL#3 one sachet b.i.d. (1800 billion bacteria

2076 GIONCHETTI ET AL Dis Colon Rectum, December 2007

per day) for six months as maintenance treatment.

The medications were dispensed by the investigator

at the initial visit; compliance was assessed by

counting returned bags and questioning the patients.

Evaluation and Scheduling

Demographics and pouchitis risk factors (recent

tobacco cessation, sclerosing cholangitis, extraintesti-

nal manifestation, pancolitis) were assessed at baseline.

Symptom assessment (stool frequency, rectal bleeding,

fecal urgency, abdominal cramps, fever) and endo-

scopic examination of the ileal pouch and the ileum for

several centimeters proximal to the pouch, with

mucosal biopsies and histologic assessment of biopsy

specimens were performed at baseline and after four

weeks and six months according to the PDAI.

Mild pouchitis was defined as a total PDAI score of

Q7 and e12. Remission was defined as a clinical score

of e2 (total possible range, 0–6), endoscopic PDAI

score of e1 (total possible range, 0–6), and total PDAI

of e4.

Patients were assessed according to whether they

had achieved remission. Health-related quality of life

was assessed at baseline and after four weeks, by

using the Inflammatory Bowel Disease Questionnaire

(IBDQ),31 which considers bowel, systemic, and

emotional symptoms as well as social function. The

IBDQ ranges from 32 (worst quality of life) to 224

(best quality of life).

Safety Assessment

All unfavorable, unexpected symptoms were

recorded in the diary kept by patients during the

study. Laboratory studies, including a complete

blood count and blood chemistry measurements,

were performed at baseline and at the end of

treatment.

Microbiologic Determinations

Fecal sample collection. Fecal samples of patients

were examined before starting treatment (T0) and

after one month of treatment (T1). The specimens

were collected with sterile plastic containers,

immediately stored at j20-C, and analyzed within

ten days for evaluating their bacterial microflora

composition.

Isolation and enumeration of fecal bacterial

groups. Anaerobic culture techniques, isolation

procedures, and identification methods were

performed following the Wadsworth Anaerobic

Bacteriology Manual 5th edition.32 One gram of each

fecal sample was homogenized in 99 ml of prereduced

half-strength Wilkins Chalgreen Anaerobic Broth

(Oxoid, Basingstoke, UK) and serially diluted in an

anaerobic cabinet (Anaerobic System, Mod. 2028,

Forma Scientific Co, Marietta, OH). The dilutions

were spread onto plates containing the following

agar media: LAMVAB33 for Lactobacillus; RB34 for

Bifidobacterium; Schaedler anaerobe (Oxoid,

Basingstoke, UK) plus defibrinated horse blood

(50 g/l), menadione (5 mg/l), vancomycin (28 mg/l),

and kanamycin (100 mg/l) for Bacteroides; and Oxoid

Perfringens Agar (Oxoid, Basingstoke, UK) for

Clostridium perfringens. Plates were anaerobically

incubated in triplicate at 37-C for 24 to 48 hours. The

same dilutions were removed from the anaerobic

glove box and used to inoculate the following media:

Azide Maltose (Biolife, Milan, Italy) for enterococci;

MacConkey (Merck, Darmstadt, Germany) for

coliforms; and ST agar,35 slightly modified by adding

bromocresole purple (30 mg/l), bromocresole green

(100 mg/l), and nalidixic acid (30 mg/l) for S.

thermophilus. Plates were aerobically incubated in

triplicate at 37-C for 24 to 36 hours. The lower limit

of detection was 1,000 microorganisms/g feces, and

bacterial concentrations were expressed as colony-

forming units (CFU) per gram of dry feces. Represen-

tative colonies of each selective medium were

identified to genus level by standard bacteriological

procedures, such as Gram_s stain reaction, colonial and

cellular morphology, and biochemical reactions.

PCR detec t ion of S . thermophi lus and

Bifidobacterium. Amplification reactions were

carried out in a Biometra Thermal Cycler II

(Biometra, Gottingen, Germany). Dynazyme II

(Celbio, Milan, Italy) was used as a thermostable

polymerase as suggested by the supplier. The total

volume of each reaction mixture was 25 ml, and cells

from plate colonies were used directly as template,

wi thout i so la t ion of chromosomal DNA.

Amplification of S. thermophilus was obtained using

the species-specific primer set ThI/ThII, based on

the 16S–23S rDNA internal transcribed region.36 The

expected size of the PCR product was 250 bp. The

reaction mixture consisted of 200 mM each dNTP, 1

mM of ThI and ThII primer, and 1 U of Dynazyme II.

The amplification profile was at 95-C for 1 minute,

55-C for 30 seconds, and 72-C for 1 minute. This was

repeated for 40 cycles. The program also included

preincubation at 95-C for 5 minutes before the first

Vol. 50, No. 12 PROBIOTICS IN ACTIVE POUCHITIS 2077

cycle and a final incubation at 72-C for 5 minutes.

Bifidobacteria were amplified by using the 16S rDNA

genus-specific primer set Bif164/Bif662,37 obtaining

an amplicon of 523 bp. The VSL#3 strains B. infantis

and B. breve were detected specifically by the strain-

specific primer sets InfY-BV.L/R and BreY-BV.R/L

16S–23S rDNA,38 designed on the 16S–23S rDNA

sequences. The PCR product sizes were 330 and 340 bp

for B. infantis and B. breve strains, respectively. The

following experimental conditions were used: PCR

reaction mixture was composed of 200 mM each

dNTP, 0.5 mM of each primer, and 1 unit of

Dynazyme II. The thermocycle program consisted of

the following time and temperature profile: 1) 95-C for

5 minutes; 2) 40 cycles of 1 minute at 95-C, 30 seconds

at a specific annealing temperature, and 1 minute at

72-C; and 3) 5 minutes at 72-C. The annealing

temperature was 55-C for the primer sets Bif164/

Bif662 and InfY-BV.L/R and 64-C for the primer set

BreY-BV.R/L.

Enumeration of S. thermophilus and VSL#3 strains

B. infantis and B. breve was performed by direct

amplification of 30 to 50 colonies randomly selected

from the highest dilutions of ST modified and RB

agar plates. Aliquots (5–10 ml) of the amplified

products were subjected to gel electrophoresis in

2 percent agarose gels and were visualized by

ethidium bromide staining.

Statistical Analysis

Statistical analysis was performed with Prism Version

2.0 (GraphPad Inc., San Diego, CA). For descriptive

data, the median and range were calculated. The

Wilcoxon_s signed-rank test (paired, two-tailed) was

used to compare pretreatment and posttreatment

bowel frequency, PDAI scores, and IBDQ scores.

The primary measure of efficacy was the compar-

ison between the pretreatment and posttreatment

PDAI scores, with remission defined as a combination

of a clinical score of e2, endoscopic PDAI score of e1,

and total PDAI of e4. Comparison of fecal concentra-

tion of bacteria before treatment and after one month

was performed by using the Student_s t test.

RESULTS

Patient Characteristics

Twenty-three patients with mildly active pouchitis

participated in this trial. Characteristics of the patients are

shown in Table 1. Six patients had experienced their

first episode of pouchitis, whereas 17 had relapsing

pouchitis. No patients withdrew from the trial.

Clinical Results

Sixteen (69 percent) of 23 treated patients went

into remission, whereas 7 were unchanged. Four of

16 patients who went into remission had experienced

their first episode of pouchitis and 12 had relapsing

pouchitis. The median bowel frequency significantly

decreased from 10 (range, 8–15) to 6 (range, 3–12)

after probiotic treatment (P<0.001), as did the median

total PDAI score from 10 (range, 9–12) to 4 (range,

2–11; P<0.001); this significant decrease was the

result of a significant reduction in clinical, endoscop-

ic, and histologic scores of PDAI (Table 2). Figure 1

shows the changes in total PDAI scores in all patients.

All 16 patients who went into remission were still in

remission at the end of six months_ maintenance

therapy, with median bowel frequency of 4 (range,

2–8) and median PDAI scores of 3 (range, 2–4). The

median IBDQ score, at the end of the study, was

Table 1.Demographic and Clinical Characteristics

of Patients (N=23)

Male/Female ratio 13/10

Mean age (yr) 31.8Smoking habits

Smokers 5Ex-smokers 3Nonsmokers 15

Extension of colitisExtensive 20Distal 3

Extraintestinal manifestations 4Time since ileal-pouch anal

anastomosis (mo)43.5T26.3

Onset of pouchitis after surgery (mo) 21.3T13.5

Data are numbers or means T standard deviations.

Table 2.Median Total PDAI Score and Each Component

PDAI Score Variation

PDAI score Baseline Four Weeks Six Months

Total 10 (9–12) 4 (2–11). 3 (2–4).Clinical 3 (2–4) 1 (0–4)* 0 (0–2)*Endoscopic 4 (2–5) 1 (1–4)* 1 (0–1)*Histologic 3 (2–4) 1 (1–3)* 1 (0–2)*

PDAI = Pouchitis Disease Activity Index.Results are medians with ranges in parentheses.*P<0.002; .P<0.001 vs. baseline.Data at six months refer only to the 16 patients

who went into remission after four weeks


significantly improved compared with baseline (200

(range, 95–220) vs. 110 (range, 90–140), respectively;

P<0.001; Fig. 2).

Microbiologic Studies

For patients treated with VSL#3, no significant changes

were registered for concentrations of Bacteroides,

coliforms, clostridia, and enterococci compared with

their basal levels. On the contrary, fecal concentrations

of lactobacilli, bifidobacteria, and S. thermophilus were

significantly increased after treatment compared with

concentrations present at baseline (Table 3; P<0.001).

PCR analysis detected high levels of S. thermophilus

in all patients treated with VSL#3 (1.8�107 CFU/g),

whereas only 20 percent of patients harbored S.

thermophilus, before the probiotic treatment (1.5�103

CFU/g; P<0.001).

The VSL#3 bifidobacteria, B. infantis and B. breve,

were found only after treatment, and specific PCR

signals were detected in 50 and 70 percent of

patients at a mean concentration of 2.2�107 and

5.1�107 CFU/g feces, respectively. Both VSL#3

B. infantis and B. breve were observed transiently

in the feces of 20 percent of patients. VSL#3

bifidobacteria were found in 12 of 16 (75 percent)

patients who achieved remission and in 4 of 7 (57

percent) of those with unchanged disease (P value,

not significant).

DISCUSSION

In this open study, oral administration of high

doses of VSL#3 was effective in the treatment of

active mild pouchitis. Treatment with VSL#3

significantly improved clinical, endoscopic, and

histologic parameters on the PDAI, with complete

remission in almost 70 percent of patients. More-

over, treatment with this probiotic preparation

significantly improved quality of life. Patients

experiencing their first episode and patients with

relapsing pouchitis had the same chance of

achieving remission. Microbiologic study showed

that administration of VSL#3 significantly in-

creased fecal concentrations of bifidobacteria,

lactobacilli, and S. thermophilus, as previously

shown,26,29 not modifying the fecal concentration

of Bacteroides, clostridia, coliforms, and entero-

cocci, suggesting that the beneficial effect was not

mediated by the suppression of the endogenous

flora. Although a higher rate of specific bifidobac-

teria was found in the stools of patients who went

Figure 1. Changes in total pouchitis disease activity index(PDAI) score in all patients.

Figure 2. Changes in total inflammatory bowel diseasequestionnaire (IBDQ) score in all patients.

Table 3.Effect of VSL#3 on Intestinal Flora

Bacterial Counts(log10 CFU/g feces)

Time 0 Time 1 (1 mo)

Enterococci 6.8T0.9 7T0.6Coliforms 4.8T1.1 4.1T1.2C. perfrigens 3.8T0.8 4.3T0.9Bacteroides 5.7T1.2 4.9T0.8S. thermophilus <3 7.7T1.1*Lactobacilli 4.5T0.4 5.9T0.4*Bifidobacteria 7.1T0.5 8.2T0.6*VSL#3 B. infantis nd 5.1T0.5VSL#3 B. breve nd 6.1T0.4

nd = not detected; CFU = colony-forming units.Student_s t test baseline vs. 1 month, *P<0.001.


into remission, compared with patients who did

not respond to probiotic treatment, the difference

was not statistically significant, because of the

small sample size.

The use of a molecular method to distinguish

between endogenous and exogenous ingested bifi-

dobacteria confirmed that the bifidobacteria strains

administered with VSL#3 survived the gastric acid

and bile and influenced the gut flora composition.Furthermore, the specific detection of VSL#3

strains B. infantis and B. breve confirmed that the

increase of the total fecal bifidobacteria population

after probiotic consumption was caused by the

presence of VSL#3 bifidobacteria strains. The dif-

ferent colonization behavior in terms of size and

frequency of detection of the exogenous bifidobac-

terial strains in the patients treated with VSL#3

emphasizes the complexity of the relationships

between exogenous bacteria and the human host

and supports the importance of a mixture of pro-

biotic strains.The etiology of pouchitis is still unknown and is

likely to be multifactorial; however, the immediate

response to antibiotic treatment suggests a patho-

genic role of microflora, and recently pouchitis has

been associated with a decreased ratio of anaerobic

to aerobic bacteria, reduced fecal concentrations of

lactobacilli and bifidobacteria, and increased luminal

pH.39 Treatment of pouchitis is largely empiric and

only a few small placebo-controlled trials have been

conducted. Antibiotics are the mainstay of treatment,

and metronidazole and ciprofloxacin are most com-

monly used initially, with a rapid and dramatic

response. Small randomized trials have suggested

that antibiotic therapy with metronidazole and cipro-

floxacin may be effective in treating active pouchi-

tis.9–11 Both drugs significantly lowered PDAI scores,

but patients treated with ciprofloxacin experienced

significantly greater reductions in the PDAI scores

and fewer adverse effects than those treated with

metronidazole.11

Recent studies have supported the potential thera-

peutic role of probiotics in IBD. Encouraging results

have been obtained with probiotic therapy in experi-

mental colitis.17–22 In three controlled studies, capsules

containing a nonpathogenic strain of Escherichia coli,

the Nissle 1917, were shown to be as effective as

mesalamine in maintenance treatment of UC.23–25

In open studies, VSL#3 was shown to be effective

in preventing relapses in patients with UC, who were

intolerant or allergic to sulphasalazine or 5-amino-

salicylic acid.29 VSL#3 induced remission in 53

percent of patients with active mild-to-moderate

UC, with a further 24 percent improvement in a six-

week trial.30

In three double-blind studies, VSL#3 was shown to

be significantly superior to placebo in maintaining

remission in patients with chronic pouchitis and

preventing the onset of pouchitis.26–28

Regarding the mechanism of action, recent studies

have shown that treatment with VSL#3 significantly

increases tissue levels of the anti-inflammatory cyto-

kine IL-10, with a significant decrease of tissue levels

of proinflammatory cytokines IL-1, TNF-a, and IFN-g;

a reduction of matrix metalloproteinase activity; and

a modulation of dendritic cell function.40,41

CONCLUSIONS

The study results indicate that the use of a highly

concentrated mixture of probiotic bacterial strains is

effective in the treatment of active mild pouchitis, is

well tolerated, and improves significantly the quality

of life of patients with pouchitis. This treatment may

represent a possible alternative to antibiotics for

patients with mild pouchitis. Currently, the only

limiting factor for the expanded use of VSL#3 in

patients with pouchitis is the relatively high cost,

which is not covered by health insurance or govern-

ment agencies. The efficacy of this new probiotic

preparation may be related to the increase of

concentrations of protective bacteria, as demonstrat-

ed by the microbiologic data, and further support the

potential role for probiotics in IBD therapy.

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with cytokine balance. Gut 2003;52:975–80.

23. Kruis W, Schuts E, Fric P, Fixa B, Judmaier G, Stolte M.

Double-blind comparison of an oral Escherichia coli

preparation and Mesalazina in maintaining remission of

ulcerative colitis. Aliment Pharmacol Ther 1997;11:853–8.

24. Rembacken BJ, Snelling AM, Hawkey PM, Axon AT.

Non-pathogenic Escherichia coli versus mesalazine for

the treatment of ulcerative colitis: a randomized trial.

Lancet 1999;354:635–9.

25. Kruis W, Fric P, Pokrotnieks J, et al. Maintaining

remission of ulcerative colitis with Escherichia Coli

Nissle 1917 is as effective as with standard mesalazine.

Gut 2004;53:1617–23.

26. Gionchetti P, Rizzello F, Venturi A, et al. Oral

bacteriotherapy as maintenance treatment in patients

with chronic pouchitis: a double-blind, placebo-

controlled trial. Gastroenterology 2000;119:305–9.

27. Mimura T, Rizzello F, Helwig U, et al. Once daily high

dose probiotic therapy for maintaining remission in

recurrent or refractory pouchitis. Gut 2004;53:108–14.

28. Gionchetti P, Rizzello F, Helvig U, et al. Prophylaxis of

pouchitis onset with probiotic therapy: a double-blind

placebo controlled trial. Gastroenterology 2003;

124:1202–9.

29. Venturi A, Gionchetti P, Rizzello F, et al. Impact on the

faecal flora composition of a new probiotic prepara-

tion. Preliminary data on maintenance treatment of

patients with ulcerative colitis (UC) intolerant or

allergic to 5-aminosalicylic acid (5-ASA). Aliment

Pharmacol Ther 1999;13:1103–8.

30. Bibiloni R, Fedorak RN, Tannock GW, et al. VSL#3

probiotic mixture induces remission in patients with

active ulcerative colitis. Am J Gastroenterol 2005;100:

1539–46.

31. Guyatt G, Mitchell A, Irvine EJ, et al. A new measure of

health status for clinical trials in inflammatory bowel

disease. Gastroenterology 1989;96:804–10.

32. Summanen P, Baron EJ, eds. Wadswort anaerobic

bacteriology manual. 5th ed. Singapore: STAR Publishers

Co., 1993.

33. Hartemink R, Domenech VR, Rombouts FM. LAMVAB-

A new selective medium for the isolation of lactobacilli

from feces. J Microb Meth 1997;29:77–84.


34. Hartemink R, Kok BJ, Weenk GH, Rombouts FM.

Raffinose-Bifidobacterium (RB) agar, a new selective

medium for bifidobacteria. J Microb Meth 1996;27:33–43.

35. Dave RI, Shah NP. Evaluation of media for selective

enumeration of Streptococcus thermophilus, Lactobacil-

lus delbrueckii subsp. bulgaricus, Lactobacillus acid-

ophilus, and bifidobacteria. J Dairy Sci 1996;76:1529–36.

36. Timisjarvi AT, Alatossava T. Development of oligonu-

cleotide primers from the 16S23S rRNA intergenic

sequences for identifying different dairy and probiotic

lactic acid bacteria by PCR. Int J Food Microbiol

1997;35:49–56.

37. Kok RG, De Wall A, Schut F, Welling GW, Weenk G,

Hellingwerf KJ. Specific detection and analysis of a

probiotic Bifidobacterium strain in infant faeces. Appl

Environ Microbiol 1996;62:3668–72.

38. Brigidi P, Vitali B, Swennen E, Altomare L, Rossi M,

Matteuzzi D. Specific detection of Bifidobacterium

strains in a new probiotic preparation and in human

feces by polymerase chain reaction. Syst Appl Micro-

biol 2000;23:391–9.

39. Ruseler-van-Embden JG, Schouten WR, van Lieshout

LM. Pouchitis: result of microbial imbalance? Gut

114;35:658–64.

40. Ulisse S, Gionchetti P, D’Alo S, et al. Expression of

cytokines, inducible nitric oxide synthetase and matrix

metalloproteinases in pouchitis: effects of probiotic

treatment. Am J Gastroenterol 2001;96:2691–9.

41. Hart AL, Lammers K, Brigidi P, et al. Modulation of

human dendritic cell phenotype and function by pro-

biotic bacteria. Gut 2004;53:1602–9.

INVITED COMMENTARY

To the Editor—Total proctocolectomy with restorative

ileal pouch-anal anastomosis (IPAA) is the surgery of

choice for patients with medically refractory ulcerative

colitis or a complication, such as dysplasia.1 Approximately

30 percent of patients with ulcerative colitis eventually

require colectomy, and the majority will have an IPAA.

Pouchitis is an idiopathic inflammatory condition that

occurs in the ileal pouch in up to 60 percent of these

patients.2 In some reports, most pouchitis occurs within a

few years of the IPAA,3 whereas in others, the risk

continues to increase with longer follow-up.4 The

majority of patients have acute pouchitis that responds to

antibiotics, but approximately 60 percent have at least one

recurrence, 5 to 10 percent develop chronic pouchitis that

requires chronic medications, and a small subset has

refractory pouchitis that may require pouch excision or

exclusion.2

The pathophysiology of pouchitis is not known. The fact

that pouchitis occurs almost exclusively in patients who

had IPAA for ulcerative colitis and not for familial

adenomatous polyposis (FAP) suggests an underlying

immune dysregulation. Furthermore, the fact that

pouchitis typically does not occur until the diverting

ileostomy is closed, and that pouchitis typically responds

to antibiotic therapy, suggest that bacteria drive the

inflammatory process. However, it is not clear whether

pouchitis occurs because of overgrowth of normal bacteria

or the presence of abnormal bacteria (dysbiosis).5

Regarding the bacteriology of pouch effluent, levels of

various bacteria from pouches in ulcerative colitis patients

were similar to that in FAP in one study,6 and may

resemble normal colonic flora, 7 whereas other studies

have shown that the flora in pouch effluent has more

anaerobes,8 or an increase in strict anaerobes compared

with facultative anaerobes,9 or more bacteroides and

bifidobacteria, than from subjects with an end

ileostomy.3,10 Despite these findings, one study showed

that the increase in anaerobes did not correlate with

subsequent pouch mucosal inflammation.9 Finally, sulfate-

reducing bacteria, which produce the mucosal toxin

hydrogen sulfide, have been seen exclusively in pouches

of ulcerative colitis patients.6,9

In pouchitis, total aerobes and some pathogenic

bacteria, such as clostridia and sulfate-reducing bacteria,

may be increased, while total anaerobes and specific

bacteria, such as bacteroides, bifidobacteria, and

lactobacilli, may be decreased.7,11–15 Yet another study

showed that patients developing pouchitis had low

bacterial and high fungal diversity.16 However, the

differences in anaerobic bacteria were less pronounced in

one study that assessed mucosa-associated flora,17 and

three other studies have shown no significant changes in

effluent bacteriology in patients with pouchitis,3,18,19

although these studies have been criticized for

methodologic flaws.5

Antibiotic therapy decreases total bacterial counts and

may eradicate certain pathogens,7,19,20 although the effect

of ciprofloxacin may be different than metronidazole.7

Other investigators have shown no difference in the

bacterial milieu in those with or without pouchitis and

little change in the microflora after antibiotics.3,19 Given

this disparate data, the role of specific bacteria, or ratios of

different types of bacteria, in the pathogenesis of pouchitis

is not clear.

Open-label studies or case series suggest that most

patients with pouchitis respond promptly to antibiotic

therapy.2,3,21 Patients who fail to respond to a single

antibiotic may respond to combination antibiotics,20,22

and patients with relapsing or chronic pouchitis may

need continuous maintenance antibiotics. However, few

randomized, controlled, antibiotic trials have been

performed.23–25 Although clinical experience confirms that

antibiotics are effective in most patients with pouchitis,

adverse effects with even short-term use of metronidazole

occur in 33 to 57 percent of patients, including nausea,

vomiting, dysgeusia, abdominal discomfort, headache, and


skin rash.23–27 The incidence of these side effects and

others, such as peripheral neuropathy, increases with

chronic use. Thus, patients who require chronic antibiotic

therapy often are treated with ciprofloxacin. However,

even with this relatively safe and well-tolerated drug, there

is concern that chronic use of a single antibiotic may select

for resistant organisms and thus lead to more difficult to

treat pouchitis or other infections.

Recent reports have suggested that altering the pouch

flora with probiotic bacteria may be an alternative to

repeated or chronic antibiotic use. Several studies have

shown that a mixed-flora oral probiotic preparation (VSL

#3) can maintain remission in chronic pouchitis 26,27 or

prevent the development of pouchitis in the first place.28

This probiotic, which contains four strains of lactobacilli,

three strains of bifidobacteria, and a streptococcus, also has

shown promise in treatment and maintenance of remission

in ulcerative colitis.29 In the antibiotic withdrawal studies in

chronic pouchitis, remission was maintained in 85 percent

of patients treated with VSL #3 compared with 0 to 6

percent in those receiving placebo.26,27 In another

controlled trial, VSL #3 or placebo were given

prophylactically after IPAA.28 After one year of follow-up,

the incidence of pouchitis was 10 percent in the VSL #3

group and 40 percent in the placebo group. In this study,

VSL #3 also reduced the stool frequency of patients without

pouchitis. However, an open-label study of VSL #3 in

patients with antibiotic-dependent chronic pouchitis

treated at a referral center was less encouraging.30 In this

uncontrolled study, which did not assess for compliance

with probiotic treatment, <20 percent of patients were able

to maintain remission on VSL #3 during eight months of

follow-up.

The probiotic Lactobacillus rhamnosus GG also seems

to decrease the risk of developing pouchitis after IPAA

when given prophylactically,31 but was no better than

placebo for treatment of mild active pouchitis.32

In the current issue of Diseases of the Colon & Rectum,

the report by Gionchetti and colleagues extends the use of

VSL #3 from these prior studies of primary and secondary

prophylaxis to treatment. In this open-label study in 23

patients with mild pouchitis, four weeks of treatment with

high-dose VSL #3 was well tolerated and resulted in

remission in 69 percent, accompanied by significant

improvement in endoscopy, histology, and quality of life

scores. Response was seen in patients with their first

episode of pouchitis and in those with recurrent disease.

All patients who went into remission maintained remission

during six months of follow-up on a lower-dose VSL #3.

Given the results of this study, and the previous studies

using VSL #3, is it time to stop prescribing antibiotics for

patients with acute pouchitis? No. Although these results

are encouraging, the study was small and uncontrolled,

and the patients had mild pouchitis, which may be more

likely to experience random variation in symptom intensity

and a placebo response. This regimen or other probiotics

should be tested in well-designed, properly powered,

randomized, blinded, controlled trials. If the exciting

results reported in the Gionchetti article can be

confirmed, we may witness the end of the antibiotic era

for treatment of pouchitis, or at least a significant reduction

in the need for antibiotic therapy in this patient group in

lieu of probiotics. Furthermore, if the prophylactic efficacy

of VSL #3 or Lactobacillus GG are confirmed, we may

routinely place all of our colitis patients on probiotics after

IPAA, resulting in a significant reduction in the incidence of

pouchitis, and therefore the need for active treatment.

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Darrell S. Pardi, M.D.Rochester, Minnesota


High-Dose Probiotics for the Treatment of Active Pouchitis

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