Original article by: Bincy Abraham and Eamonn M M Quigley

We have all been there haven’t we? A patient with IBD, a crp that is through the roof with evidence of co-existing sepsis. To give steroids? To give antibiotics? I have been involved in many cases where antibiotics and steroids combined have been used in this situation to control disease. But is this best practice? What is the evidence behind this? Where exactly do antibiotics and even probiotics fit in with our treatment algorithms for IBD, if at all?

Probably the original mantra for using antibiotics in IBD was the thought that the aetiology had something to do with an infective nature. Through our further understanding of the diseases it has become much more widely accepted that probably it is the gut microbiota that in some way at least contribute to IBD. This has led many investigators to look into the altering the gut microbiota in an attempt to change the disease course in IBD. It is well documented that both antibiotics and probiotics can alter the gut microbiota and therefore this approach has been seen as a potential therapeutic option for IBD.

This review summarises really well the recommendations about the use of antibiotics in IBD. I think it lends itself to some really neat and useful messages.

For Crohn’s disease they recommend:

• Rifaximin and ciprofloxacin may have some benefit in induction of remission.
• Antimycobacterial therapies may reduce the risk of relapse in quiescent disease
• The combination of metronidazole and ciprofloxacin can help treat perianal fistulae but likely need to be combined with other therapies.
• Short-term use of rifaximin or nitroimidazole antibiotics may help reduce the risk of postoperative recurrence of CD
• No evidence for probiotics in CD

For ulcerative colitis they recommend:

• That antibiotics strongest evidence is in the acute situation.

The review highlighted that probiotics have a limited evidence base. The strongest evidence suggesting that VSL#3 can be used in both the primary prevention of pouchitis after and maintenance of remission. Whilst also limited data suggesting they could be used in mild UC.

With the explosion of studies looking at the microbiota in IBD I am sure some of these treatments may find their way back into clinical practice with a few further tweaks. Furthermore, I wonder if I am alone in thinking that probiotics despite limited evidence are a useful adjunct in patients with IBD and IBS overlap? Read the full review here

https://fg.bmj.com/content/early/2019/03/21/flgastro-2018-101057