Oral Bacteriotherapy as Maintenance Treatment in Patients With Chronic Pouchitis:A Double-Blind,Placebo-Controlled Trial
PAOLO GIONCHETTI,*FERNANDO RIZZELLO,*ALESSANDRO VENTURI,*PATRIZIA BRIGIDI,‡
DIEGO MATTEUZZI,‡GABRIELE BAZZOCCHI,*GILBERTO POGGIOLI,§MARIO MIGLIOLI,*
and MASSIMO CAMPIERI*
*Department of Internal Medicine and Gastroenterology,‡Department of Pharmaceutical Sciences,and§Department of Clinical Surgery, University of Bologna,Bologna,Italy
See editorial on page584. Background&Aims:Pouchitis is the major long-term complication after ileal pouch–anal anastomosis for ul-cerative colitis.Most patients have relapsing dia, and no maintenance treatment study has been per-formed.We evaluated the efficacy of a probiotic prepa-ration(VSL#3)containing5؋1011per gram of viable lyophilized bacteria of4strains of lactobacilli,3strains of bifidobacteria,and1strain of Streptococcus sali-varius subsp.thermophilus compared with placebo in maintenance of remission of chronic pouchitis. Methods:Forty patients in clinical and endoscopic re-mission were randomized to receive either VSL#3,6 g/day,or an identical placebo for9months.Patients
were assd clinically every month and endoscopically and histologically every2months or in the ca of a relap.Fecal samples were collected for stool culture before and after antibiotic treatment and each month during maintenance treatment.Results:Three patients (15%)in the VSL#3group had relaps within the 9-month follow-up period,compared with20(100%)in the placebo group(P<0.001).Fecal concentration of lactobacilli,bifidobacteria,and S.thermophilus in-cread significantly from baline levels only in the VSL#3-treated group(P<0.01).Conclusions:The results suggest that oral administration of this new pro-biotic preparation is effective in preventingflare-ups of chronic pouchitis.
P ouchitis,a nonspecific inflammation of the ileal res-ervoir,is the most common long-term complication after pouch surgery for ulcerative colitis.Its cumulative frequency depends largely on the duration of the fol-low-up and is approximately50%after10years at the major referral centers.1–4
Pouchitis is characterized clinically by incread stool frequency,urgency,abdominal cramping,and discom-fort.Bleeding,low-grade fever,and extraintestinal man-ifestations may also occur.5,6Endoscopicfindings of in-flammation in the pouch include edema,granularity,loss of vascular pattern,contact bleeding,erosions,and ul-cerations7;biopsies show an acute neutrophilic inflam-matory infiltrate with crypt abscess and ulceration in addition to the normal chronic inflamm
atory infiltrate, the latter of which is almost universal and probably reprents an unavoidable respon to fecal stasis.8,9 The cau of pouchitis is still unknown,but it ems that a history of ulcerative colitis and incread bacterial concentration are main factors.10–12The importance of bacteria is further emphasized by the evident efficacy of antibiotics.10
In most cas,patients have multiple attacks.3,13,14So far,no studies have focud on the maintenance of re-mission.
Probiotics are living microorganisms that belong to the naturalflora and are important to the health and well-being of the host.15Recent obrvations support their role in the treatment of inflammatory bowel dis-eas.The administration of Lactobacillus spp.prevented the development of spontaneous colitis in interleukin (IL)-10–deficient mice,and continuous feeding with Lactobacillus plantarum attenuated established colitis in the same knockout model.16,17
Pouchitis has recently been shown to be associated with reduced counts of lactobacilli and bifidobacteria, suggesting that this syndrome may be the result of an unstable microflora.18
The aim of this study was to evaluate the efficacy of a new oral probiotic preparation,containing very high bacterial concentrations of8different bacterial strains Abbreviations ud in this paper:GI,gastroi
ntestinal;IL,interleukin; PDAI,Pouchitis Dia Activity Index.
©2000by the American Gastroenterological Association
0016-5085/00/$10.00
doi:10.1053/gast.2000.9370
GASTROENTEROLOGY2000;119:305–309
compared with placebo in the maintenance treatment of chronic relapsing pouchitis.
the artistPatients and Methods
Patients
The study was performed in accordance with the Dec-laration of Helsinki and was approved by the ethical commit-tee of our hospital;written,informed connt was obtained from the patients.Eligible patients were between18and65 years old and had chronic relapsing pouchitis,defined as at least3relaps per year.In addition,patients were in clinical and endoscopic remission,defined as sco
re0after1month of combined antibiotic treatment,in the clinical and endoscopic portion of the Pouchitis Dia Activity Index(PDAI)by Sandborn et al.,19which includes clinical,endoscopic,and acute histologic criteria(Table1).No concurrent treatments were allowed.Patients with perianal dia,including abscess,fistula,fissure,stricture,or anal sphincter weakness,were excluded.
Study Medication
VSL#3(Yovis;Sigma-Tau,Pomezia,Italy)consisted of 3-g bags each containing300billion viable lyophilized bac-teria per gram of4strains of Lactobacillus(L.cai,L.plantarum,L.acidophilus,and L.delbrueckii subsp.bulgaricus),3strains of Bifidobacterium(B.longum,B.breve,and B.infantis),and1strain of Streptococcus salivarius subsp.thermophilus.
The placebo consisted of identical bags each containing3g of maize starch.The VSL#3and placebo were administered orally twice a day.The taste and smell of the active drug were not readily identifiable.
Study Design
This was a randomized,double-blind,placebo-con-trolled study.
Patients,who conditions were in clinical and endoscopic remission(with a score of0in the clinical and endoscopic portion of PDAI)after1month of antibiotic treatment with 1g ciprofloxacin plus2g rifaximin daily(Alfa-Wasrman, Bologna,Italy),were randomized to receive VSL#3(6g/day)or placebo for9months.
Assignment to therapy or placebo was determined according to a computer-generated randomization scheme.20Randomiza-tion was done by the clinical trial’s pharmacist,who kept the codes until completion of the study.None of the staff or patients had access to the randomization codes during the study.The medications were dispend by the investigator at each visit;compliance was assd by counting returned bags and questioning the patients.
Evaluation and Scheduling
Symptoms were assd,medical histories were taken, and physical examinations were performed at baline and every month thereafter.Endoscopic examination of the ileal pouch and the ileum for a few centimeters proximal to the pouch,with mucosal biopsies,was performed at baline and every2months thereafter,and histologic asssment of biopsy specimens was performed at entry and every2months there-after.Laboratory studies,including a complete blood count and blood chemistry measurements,were performed at ba-line and at the end of treatment.
Relap was defined as an increa of at least2points in the clinical portion of PDAI,confirmed by endoscopy and histol-ogy.
日语初级单词表Microbiological Determinations
Stool cultures were performed before and after antibi-otic treatment and every month during maintenance treat-ment.Collection of specimens,anaerobic culture techniques, isolation procedures,and identification methods were per-formed according to the Wadsworth Anaerobic Bacteriology Man-ual(5th edition).21Fecal specimens were collected into sterile plastic containers and stored atϪ20°C until they were assayed (within7days).Fecal samples were homogenized and rially diluted in an anaerobic cabinet(Anaerobic System,model 2028;Forma Scientific Co,Marietta,OH)with half-strength Wilkins Chalgreen anaerobic broth(Oxoid,Basingstoke,En-gland).Plates were incubated in triplicate using the appropri-ate media for enumeration of total aerobes(nutrient agar; Oxoid),total anaerobes(Schaedler agar;Oxoid),enterococci
Table1.Pouchitis Dia Activity Index
Criteria Score
Clinical
Postoperative stool
frequency
Usual0
变量英语1–2stools/day more than
usual
1
3or more stools/day more
than usual
2
Rectal bleeding None or rare0
Prent daily1
Fecal urgency/abdominal
cramps
None0
Occasional1
Usual2
Fever(temperatureϾ
100°F)
Abnt0
Prent1
Endoscopic
Edema1
Granularity1
Friability1
Loss of vascular pattern1
Mucus exudate1
Ulcerations1
Acute histological
Polymorph infiltration Mild1
Moderateϩcrypt abscess2
Severeϩcrypt abscess3
Ulcerations per low-powerfield
(average)Ͻ25%
1
25%–50%2
Ͼ50%3
逃生技巧
306GIONCHETTI ET AL.GASTROENTEROLOGY Vol.119,No.2
(Azide malto agar;Biolife,Milan,Italy),coliforms(Mac-Konkey agar;Merck,Darmstadt,Germany),Bacteroides(Schaed-ler agar plus vancomycin and gentamycin;Oxoid),bifidobac-teria(PYG,plus polymyxin[50mg/mL]and kanamycin[50 mg/mL]),and Clostridium perfringens(O.P.S.P.;Oxoid).Plates were incubated aerobically or anaerobically as appropriate.The lower limit of detection was1000microorganisms per gram of feces.
Statistical Analysis
Bad on their experience,clinical investigators thought it was reasonable to expect a25%respon in the placebo group and a75%respon in the therapy group,and such difference is relevant from a clinical point of view. Accordingly,for␣ϭ0.05(2-tailed test)andϭ0.20,a sample size of more than19patients per group was estimated. Baline characteristics of patients after randomization in t北京一对一外教
he2groups were compared using the2test or the Student t test for independent samples as appropriate.The primary study variable(number of patients who relapd)was tested using the2test with the Yates correction.
Survival analysis was ud to analyze the data t with respect to relap.The Kaplan–Meier method was ud to estimate the survivor function,and comparison of cumulative relap rates between treatment groups was tested by the log-rank test. The results of microbiological tests(condary study vari-able)have been submitted to comparative multivariate analy-s of variance.The significance of contrasts and multiple pairwi comparisons was tested using the2-tailed Student t test.The level of significance was adjusted using the Bonfer-roni correction for multiple comparisons.
Results
Patient Characteristics
Forty-three patients were screened,and40were eligible;20were randomly assigned to receive VSL#3 and20to receive placebo;and3patients were excluded becau they refud connt.Study groups were well matched with respect to age,x,duration of follow-up, duration of pouchitis,and number of
yearly relaps (Table2).
The basal median PDAI score was0(range,0–1)in both groups(median clinical portion score,0[range,0–0];median endoscopic portion score0[range,0–0]; and median histologic portion score,0[range,0–1]). Median stool frequency was10(range,8–13)before antibiotic treatment and4(range,3–7)after antibiotic treatment.
Clinical Results
Life-table analysis of the relaps in the2groups is shown in Figure1.
Of the20patients who received the placebo,all had relaps,8within2months,7within3months,and5 within4months.Of the20patients treated with VSL#3, 17(85%)were still in remission after9months(PϽ0.001)(Figure2);all17of the patients had relaps within the4months after the conclusion of active treat-ment,and the median duration of remission was2 months(range,1–4).
The median total PDAI score of the20relapd patients treated with placebo was12(range,8–18);this score was the result of a significant increa in clinical (median4[range,3–6]),endoscopic(median4[range, 3–6]),or histologic(median4[range,3–5])scores on the PDAI;median stool frequency was9(range,7–11).
In the group treated with VSL#3,the3patients who had relaps during the9months of follow-up had a median total PDAI score of11(range,9–17;median clinical portion score3[range,2–5];median endoscopic portion score4[range,3–5];and median histologic portion score4[range,3–5]).Median stool frequency in the patients was8(range,6–11)at the time of relap. The17patients who remained in remission had a median total PDAI score of0(range,0–1;median clinical por-tion score0[range,0–0];median endoscopic portion score0[range,0–0];and median histologic portion score0[range,0–1]).The median stool frequency in the patients did not increa significantly compared with that obtained after antibiotic treatment(4[range, 3–6]).Median stool frequency incread slightly within 15days after cessation of active treatment(5[range, 2–6])and was7(range,6–11)at the time of
relap. Figure1.Kaplan–Meier estimates of relap during treatment with VSL#3(A)or placebo(B).
Table2.Demographic and Clinical Characteristics
VSL#3 nϭ20Placebo nϭ20
Mean age(yr)32.834.2
Sex(M/F)11/912/8
Months of pouch function;median
(range)46(8–108)49(5–134)
Duration of dia(mo);median
(range)37(4–96)43(3–118)
No.of yearly relaps;mean 3.8 3.5
rious是什么意思August2000PROBIOTIC THERAPY IN POUCHITIS307
Microbiological Results
In patients treated with VSL#3,fecal concentra-tions of lactobacilli,bifidobacteria,and Streptococcus sali-varius incread significantly (P Ͻ0.001)compared with concentrations prent both before and after antibiotic treatment and remained stable throughout the study (Figure 3).No significant changes were registered for concentrations of Bacteroides ,coliforms,clostridia,entero-cocci,and total aerobes and anaerobes compared with basal levels.One month after discontinuation of VSL#3,fecal concentrations of lactobacilli,bifidobacteria,and Streptococcus salivarius subsp.thermophilus had reached lev-els similar to basal levels again.
In the group treated with placebo,fecal concentrations of all species evaluated remained similar at all intervals to tho measured before antibiotic treatment.
Safety
No side effects and no significant changes from baline values in any of the laboratory parameters ex-amined were registered in either group of patients.
Discussion
This is the first controlled trial of maintenance treatment of pouchitis.Oral administration of VSL#3was effective in the prevention of relaps in patients with chronic pouchitis;the efficacy of this new probiotic preparation may be related to the increa in concentra-tions of protective bacteria,as shown by the microbio-logical data,and in their metabolic activities.
sportsmeetingThe cumulative risk of developing pouchitis increas with time and,in ries from centers with the largest experience and the longest follow-up,approaches nearly 50%by 10years.3More than two thirds of patients experience multiple episodes,but most cas will re-
spond to oral antibiotics.The cau is still unknown and is likely to be multifactorial;however,the immediate respon to antibiotic treatment suggests a pathogenetic role for the microflora,and recently pouchitis was asso-ciated with a decread ratio of anaerobic to aerobic bacteria,reduced fecal concentrations of lactobacilli and bifidobacteria,and an increa in luminal pH.18Treat-ment of pouchitis is largely empiric,and only a few small placebo-controlled trials have been conducted.Antibiot-ics have become the mainstay of treatment;metronida-zole is the common initial therapeutic approach,and most patients have a dramatic respon within a few days,whereas treatment of chronic refractory pouchitis is often difficult and disappointing and may require a pro-longed cour of antibiotics.Other medical therapies reported to be of benefit in uncontrolled trials in
clude other antibacterial agents such as ciprofloxacin,amox-icillin/clavulanic acid,erythromycin and tetracycline,topical and oral mesalamine,conventional corticosteroid enemas,budesonide enemas,cyclosporine enemas,azathio-prine,bismuth carbomer enemas,bismuth subsalicylate tablets,and short-chain fatty acid enemas or suppositories.22
The probiotic preparation we ud has 2main inno-vative characteristics:a very high bacterial concentration (300billion viable bacteria per gram)and the prence of a mixture of different bacterial species with potential synergistic relationships to enhance suppression of po-tential pathogens.23
Various strains of probiotics can have very different and specialized metabolic activities,24such that claims made for one strain of an organism cannot necessarily be applied to another.Theoretically,a composite mixture of a large num-ber of probiotic strains should be most effective.Experi-ments using anaerobic continuous-flow chemostats that duplicate the normal gastrointestinal (GI)microecology have suggested that a single strain or even a few probiotic strains are unlikely to colonize the GI tract or determine important modifications in the GI microecology.
25
Figure 2.Clinical outcome of patients according to treatment re-
ceived.
Figure 3.Fecal concentration of bifidobacteria,lactobacilli,and Streptococcus salivarius subsp.thermophilus before (Ϫ1)and after (0)antibiotic treatment and during maintenance treatment in the group treated with VSL#3.
308GIONCHETTI ET AL.GASTROENTEROLOGY Vol.119,No.2
Recent studies have supported the potential role of oral bacteriotherapy in inflammatory bowel dia (IBD).Lactobacillus spp.and Lactobacillus plantarum have been shown to be able to prevent the development of spontaneous colitis and to attenuate established colitis in IL-10knockout mice,respectively.16,17In2controlled studies,patients with ulcerative colitis were given oral mesalamine or capsules containing a nonpathogenic strain of Escherichia coli as a maintenance treatment;no significant difference in relap rates was obrved between the2 treatments.26,27Moreover,in an open study VSL#3was effective in the prevention of relaps in patients with ulcerative colitis who were intolerant or allergic to sulfasala-zine or mesalamine.28The mechanisms by which probiotics exert their beneficial effects in the host in vivo have not been fully defined;we showed recently that continuous treatment with VSL#3determines a significant increa of tissue levels of IL-10in patients with chronic pouchitis.29 In conclusion,the results of this study indicate that the u of a highly concentrated mixture of probiotic bacterial strains is effective in maintenance treatment of chronic relapsing pouchitis,further supporting the po-tential role of probiotics in IBD therapy.30
References
1.Svaninger G,Nordgren S,Oresland T,Hulten L.Incidence and
characteristics of pouchitis in the Koch continent ileostomy and the pelvic pouch.Scand J Gastroenterol1993;28:695–700. 2.Penna C,Dozois R,Tremaine W,Sandborn W,LaRusso N,
Schleck C,Ilstrup D.Pouchitis after ileal pouch–anal anastomo-sis for ulcerative colitis occurs with incread frequency in pa-tients with associated primary sclerosing cholangitis.Gut1996;
38:234–239.
3.Stahlberg D,Gullberg K,Liljeqvist L,Hellers G,Lo¨fberg R.Pou-
chitis following pelvic pouch operation for ulcerative colitis.Inci-dence,cumulative risk,and risk factors.Dis Colon Rectum1996;
39:1012–1018.
4.Meagher AP,Farouk R,Dozois RR,Kelly KA,Pemberton JH.J ileal
pouch–anal anastomosis for chronic ulcerative colitis:complica-tions and long-term outcome in1310patients.Br J Surg1998;
85:800–803.
5.Madden MV,Farthing MJ,Nicholls RJ.Inflammation in the ileal
rervoir:“pouchitis.”Gut1990;31:247–249.
6.Lohmuller JL,Pemberton JH,Dozois RR,Ilstrup DM,van Heerden
J.Pouchitis and extraintestinal manifestations of inflammatory bowel dia after ileal pouch–anal anastomosis.Ann Surg 1990;211:622–629.
7.Tytgat GN,van Deventer SJ.Pouchitis.Int J Colorectal Dis1988;
3:226–228.
8.Moskowitz RL,Sheperd NA,Nicholls RJ.An asssment of in-
flammation in the rervoir after restorative proctocolectomy with ileoanal ileal rervoir.Int J Colorectal Dis1986;1:167–174. 9.Sheperd NA,Jass JR,Duval I,Moskowitz RL,Nicholls RJ,Morson
BC.Restorative proctocolectomy with ileal rervoir:pathological and histochemical study of mucosal biopsy specimens.J Clin Pathol1987;40:601–607.
10.Sanborn WJ.Pouchitis following ileal pouch–anal anstomosis:
definition,pathogenesis,and treatment.Gastroenterology1994;
107:1856–1860.11.Keighley MRB.Review article:the management of pouchitis.
Aliment Pharmacol Ther1996;10:449–457.
12.Nicholls RJ,Banerjee AK.Pouchitis:risk factors,etiology,and
treatment.Word J Surg1998;22:347–351.
13.Hurst RD,Molinari M,Chung TP,Rubin M,Michelassi F.Prospec-
tive study of the incidence,timing and treatment of pouchitis in 104concutive patients after restorative proctocolectomy.Arch Surg1996;131:497–502.
14.Sachar DB.How do you treat refractory pouchitis and when do
you decide to remove the pouch?Inflamm Bowel Dis1998;4: 165–166.
15.Fuller R.Probiotics in human medicine.Gut1991;32:439–442.
16.Madn KL,Doyle JSG,Jewell LD,Tavernini MM,Fedorak RN.
Lactobacillus species prevents colitis in interleukin-10gene–deficient mice.Gastroenterology1997;116:1107–1114.
17.Schultz M,Veltkamp C,Dieleman LA,Wyrick PB,Tonkonogy SL,
Sartor RB.Continuous feeding of Lactobacillus plantarum atten-uates established colitis in interleukin-10deficient mice(abstr).
Gastroenterology1998;114:A1081.
18.Ruler-van-Embden JGH,Schouten WR,van Lieshout LMC.Pou-
chitis:result of microbial imbalance?Gut1994;35:658–664.
19.Sandborn WJ,Tremaine WJ,Batts KP,Pemberton JH,Phillips SF.
Pouchitis after ileal pouch–anal anastomosis:a pouchitis dis-ea activity index.Mayo Clin Proc1994;69:409–415.
20.Tiplady B.A basic program for constructing a dispensing list for a
randomized clinical trial.Br J Clin Pharmacol1981;11:617–618.
21.Summanen P,Baron EJ,Citron DM,Strong C,Wexler HH,Fine-
gold SM,eds.Wadsworth anaerobic bacteriology manual.5th ed.
Singapore:Star,1993.
22.Sandborn WJ,McLeod R,Jewell DP.Medical therapy for induction
and maintenance of remission in pouchitis:a systematic review.
Inflamm Bowel Dis1999;5:33–39.
23.Mackowiak PA.The normal microbialflora.N Engl J Med1982;
307:83–93.
24.Bengmark S.Econutrition and health maintenance.A new con-
托福培训班
cept to prevent GI inflammation,ulceration and psis.Clin Nutr 1996;15:1–10.
25.Berg RD.Probiotics,prebiotics or“conbiotics”?Trends Microbiol
1998;6:89–92.
26.Kruis W,Schuts E,Fric P,Fixa B,Judmaier G,Stolte M.Double-
blind comparison of an oral Escherichia coli preparation and mesalazine in maintaining remission of ulcerative colitis.Aliment Pharmacol Ther1997;11:853–858.
27.Rembacken BJ,Snelling AM,Hawkey PM,Chalmers DM,Axon
ATR.Non pathogenic Escherichia coli versus mesalazine for the treatment of ulcerative colitis:a randomid trial.Lancet1999;
354:635–639.
28.Venturi A,Gionchetti P,Rizzello F,Johansson R,Zucconi E,Brigidi
P,Matteuzzi D,Campieri M.Impact on the fecalflora composition by a new probiotic preparation:prelim
f man
inary data on maintenance treatment of patients with ulcerative colitis.Aliment Pharmacol Ther1999;13:1103–1108.miry翻译
29.Gionchetti P,Rizzello F,Cifone G,Venturi A,D’Alo’S,Peruzzo S,
Bazzocchi G,Miglioli M,Campieri M.In vivo effect of a highly concentrated probiotic on IL-10pelvic pouch tissue levels(abstr).
Gastroenterology1999;116:A723.
30.Campieri M,Gionchetti P.Probiotics in inflammatory bowel dis-
ea:new insight to pathogenesis or a possible therapeutic alternative?Gastroenterology1999;116:1246–1249. Received November3,1999.Accepted March15,2000. Address requests for reprints to:Paolo Gionchetti,M.D.,Diparti-mento di Medicina Interna e Gastroenterologia,Policlinico S.Orsola, Via Massarenti9,40138Bologna,Italy.e-mail:paolo@med.unibo.it; fax:(39)51-392538.
August2000PROBIOTIC THERAPY IN POUCHITIS309
