Antibiotics in pediatric inflammatory bowel diseases: a systematic review

Abstract

Introduction: Current therapies in pediatric Inflammatory Bowel Diseases (IBD) target the immune system and often fail to sustain long-term remission. There is a high need for development of alternative treatment strategies such as antibiotics in pediatric IBD.Areas covered: This study systematically assessed efficacy and safety of antibiotics in pediatric IBD. CENTRAL, EMBASE, and Medline were searched for Randomized Controlled Trials (RCTs). Quality assessment was conducted with the Cochrane risk-of-bias tool. Expert opinion: Two RCTs (n = 101, 4.4-18 years, 43% male) were included. Both studies had overall low risk of bias. In mild-to-moderate Crohn's disease, azithromycin+metronidazole (AZ+MET) (n = 35) compared to metronidazole (MET) alone (n = 38) did not induce a significantly different response (PCDAI drop ≥12.5 or remission) (p = 0.07). For induction of remission (PCDAI≤10), AZ+MET was more effective than MET (p = 0.025). In Acute Severe Colitis, mean 5-day-PUCAI was significantly lower in the antibiotic (vancomycin, amoxicillin, metronidazole, doxycycline)+intravenous-corticosteroids group (AB +IVCS) (n = 16) compared to IVCS alone (n=12) (p = 0.037), whereas remission (PUCAI<10) did not differ (p = 0.61). No significant drug-related adverse events were reported. Results of this systematic review of antibiotic use highlight the lack of evidence in pediatric IBD. More evidence is needed before widespread implementation in daily practice.

Medical management of pediatric inflammatory bowel disease in the Asia‐Pacific region: A position paper by the Asian Pan‐Pacific Society for Pediatric Gastroenterology, Hepatology, and Nutrition (APPSPGHAN) PIBD Working Group

“…4 It may however be used as short-term rescue therapy in selected cases of ASC. 117 The lack of robust data limits our recommendation in this area. 118 Oral antibiotics have been used as treatment of pouchitis after total colectomy with ileo-anal pouch surgery in UC patients.…”

“…Currently, oral antibiotics are not recommended for routine use as induction or maintenance therapy for pediatric UC 4 . It may however be used as short‐term rescue therapy in selected cases of ASC 117 . The lack of robust data limits our recommendation in this area 118 .…”

Personalised azithromycin+metronidazole (PAZAZ), in combination with standard induction therapy, to achieve a faecal microbiome community structure and metagenome changes associated with sustained remission in paediatric Crohn’s disease (CD): protocol of a pilot study

“…Antibiotics, which directly target bacteria in the GI tract, could therefore possibly obtain a more prominent role in CD therapy 21. However, while several meta-analyses support the use of antibiotics in controlling luminal inflammation, results of individual trials are heterogeneous and data in children are particularly sparse 22 23. Recently, a combination of azithromycin+metronidazole has been found to be superior to metronidazole alone for induction of remission in children with mild to moderate CD 24.…”