Medical management of acute idiopathic pouchitis

NSAIDs: nonsteroidal anti-inflammatory drugs; IBD: inflammatory bowel disease.
* Patients with acute idiopathic pouchitis have endoscopic evidence of active pouch inflammation without a clear cause identified on histology, stool studies, or blood tests. Refer to UpToDate content on the diagnosis of acute pouchitis.
¶ Ciprofloxacin is typically used for initial therapy, while metronidazole or tinidazole are reasonable alternatives.
Δ If susceptibility testing is not available, an alternative approach is an empiric dual antibiotic regimen (eg, ciprofloxacin plus metronidazole) for 4 weeks.
◊ Patients with <3 episodes of pouchitis per year are treated with a single antibiotic agent as needed. The antibiotic agent that was effective initially may be used again.
§ Laboratory testing including stool specimen for Clostridioides (formerly Clostridium) difficile is performed to confirm that secondary causes and coexisting conditions have been excluded.
¥ An alternative option for maintenance therapy is an antibiotic (eg, rifaximin).
‡ For patients who do not respond to topical and/or oral mesalamine, subsequent options include topical and/or oral glucocorticoids, or a biologic agent.