trimethoprim--sulfamethoxazole-drug-combination and Colitis--Ulcerative

Cyclosporine is a fungal metabolite and a powerful immunosuppressant. While response to intravenous steroids in severe ulcerative colitis is in excess of 60%, the remainder of patients are left with the options of curative panproctocolectomy or administration of intravenous rescue therapy with cyclosporine. There have been conflicting reports on the efficacy of intravenous cyclosporine in acute ulcerative colitis, and there are serious concerns about potential toxicity and opportunistic infections such as Pneumocystis carnii pneumonia. There are also concerns about early relapse and colectomy following cyclosporine rescue. To date there has been a paucity of data available to help guide the gastroenterologist in the use of cyclosporine and the maintenance of remission once achieved.. Between 1994 and 2001, a total of sixteen patients who had received intravenous cyclosporine for acute exacerbation of their known UC (seven females, nine males, mean age 33 years) whose records were available for analysis. All patients were refractory to intravenous methylprednisolone (60 mg/24 h). Patients who responded to cyclosporine were discharged on a regimen of oral cyclosporine, oral steroids oral azathioprine and 5-aminosalicylate.. Median disease duration was 5.4 years (range 0.9-25 years). All sixteen patients were initially treated with cyclosporine at a dose of 4 mg/kg/day. Nine patients were started on oral azathioprine (median dose 1.8 mg/kg). Seven patients underwent surgery (panproctocolectomy), although none had surgery after 6 months. Comparisons were made between patients with <7 days and >7 days intravenous steroid. Other parameters analysed were stool frequency at 3 days and CRP at 3 days. There were no significant differences between these groups. Median bowel frequency at day 3 was higher in patients who finally underwent surgery. At 3 years follow-up, 56% of the sixteen patients had avoided surgery by using azathioprine immunosuppression.. The initial response rate to intravenous cyclosporine was high (69%). Side effects were documented in the majority of patients, but none of the patients had to discontinue treatment on account of these. Azathioprine has a useful role in maintaining the remission achieved by i.v. cyclosporine for acute ulcerative colitis patients. More than half the patients will avoid colectomy long-term when using triple immunosuppressive therapy including azathioprine adding support for its relative safety and another role for its use.

Topics: Administration, Oral; Adult; Anti-Infective Agents; Azathioprine; Colitis, Ulcerative; Cyclosporine; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Resistance; Drug Therapy, Combination; Female; Glucocorticoids; Humans; Immunosuppressive Agents; Infusions, Intravenous; Injections, Intravenous; Male; Methylprednisolone; Pneumocystis Infections; Prednisolone; Salvage Therapy; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

This study aimed to clarify the clinical characteristics of Pneumocystis jirovecii pneumonia (PJP) infection in patients with ulcerative colitis (UC) and to identify risk factors for PJP using a retrospective case-control study.. Of 4,525 patients with UC treated between 2007 and 2019, we identified those who satisfied the criteria for PJP. The Lichtiger clinical activity index (LCI) was compared between the initiation of immunosuppressive drug treatment and the onset of PJP. A retrospective case-control study was conducted using a PJP group and a non-PJP group.. Nine patients experienced PJP, of whom two died. Since October 2014, there were no cases of PJP among UC patients aged ≥50 years who were prescribed three or more immunosuppressive agents given prophylactic sulfamethoxazole-trimethoprim (TPM-SMX). The median LCI (range) was 13 (8-17) at the initiation of treatment versus 2 (1-8) at PJP onset (p = 0.016). The median time to PJP onset was 83 days after treatment initiation. In the PJP group the median age was significantly greater (p = 0.022), three immunosuppressants were used significantly more frequently (p = 0.004), and the lymphocyte counts during treatment were significantly lower (p < 0.01) than in the non-PJP group. The cut-off lymphocyte count that distinguished PJP patients from non-PJP patients was 570/μL according to a receiver-operating curve analysis.. Prophylactic administration of TPM-SMX prevented further cases of PJP. The onset of PJP occurred at the same time as the symptoms of UC were stabilizing and the immunosuppressive drugs were being reduced. Greater age, lower lymphocyte count, and treatment with three immunosuppressive drugs were risk factors for PJP.

Topics: Age Factors; Anti-Bacterial Agents; Case-Control Studies; Chemoprevention; Colitis, Ulcerative; Female; Humans; Immunocompromised Host; Immunosuppressive Agents; Japan; Lymphocyte Count; Male; Middle Aged; Pneumocystis carinii; Pneumonia, Pneumocystis; Retrospective Studies; Risk Factors; ROC Curve; Trimethoprim, Sulfamethoxazole Drug Combination

The treatment of ulcerative colitis is based on systemic corticosteroids, immunomodulators such as cyclosporine and azathioprine and TNF-α antagonists. Patients undergoing such immunosuppressive treatment are more susceptible for infectious pathogens. Here, we report the case of a patient with a 13-year history of ulcerative colitis, treated initially with systemic corticosteroids in combination with immunomodulators, and subsequently with infliximab. The patient presented with severe watery diarrhoea, abdominal cramps, weight loss and low-grade fever. Stool examinations for cytomegalovirus, bacteria and parasites were negative. Following detection of numerous oocytes of Isospora belli (IB) in direct smear preparations of the diarrhoeic stool samples, the patient was successfully treated with trimethoprim-sulfamethoxazole (co-trimoxazole).

Topics: Antibodies, Monoclonal; Azathioprine; Colitis, Ulcerative; Drug Therapy, Combination; Humans; Immunosuppressive Agents; Infliximab; Isosporiasis; Male; Middle Aged; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Aged; Anti-Infective Agents; Anti-Inflammatory Agents; Colitis, Ulcerative; Contrast Media; Fever; Humans; Lung; Lung Diseases; Male; Nocardia asteroides; Nocardia Infections; Prednisolone; Radiography; Superinfection; Tomography, X-Ray Computed; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

We report the case of a 21-year-old man who was noted to have pneumomediastinum during an admission for an acute flare of ulcerative colitis. At that time, he was on maintenance treatment with azathioprine at a dose of 1.25 mg/kg per day, and had not received supplementary steroids for 9 mo. He had never received anti-tumor necrosis factor (TNF)alpha therapy. Shortly after apparently effective treatment with intravenous steroids and an increased dose of azathioprine, he developed worsening colitic and new respiratory symptoms, and was diagnosed with Pneumocystis jiroveci (carinii) pneumonia (PCP). Pneumomediastinum is rare in immunocompetent hosts, but is a recognized complication of PCP in human immunodeficiency virus (HIV) patients, although our patient's HIV test was negative. Treatment of PCP with co-trimoxazole resulted in resolution of both respiratory and gastrointestinal symptoms, without the need to increase the steroid dose. There is increasing vigilance for opportunistic infections in patients with inflammatory bowel disease following the advent of anti-TNFalpha therapy. This case emphasizes the importance of considering the possibility of such infections in all patients with inflammatory bowel disease, irrespective of the immunosuppressants they receive, and highlights the potential of steroid-responsive opportunistic infections to mimic worsening colitic symptoms in patients with ulcerative colitis.

Topics: Adolescent; Animals; Anti-Infective Agents; Colitis, Ulcerative; Humans; Immunosuppressive Agents; Male; Mediastinal Emphysema; Pneumocystis carinii; Pneumonia, Pneumocystis; Trimethoprim, Sulfamethoxazole Drug Combination; Tumor Necrosis Factor-alpha; Young Adult

Crohn's disease and colitis ulcerosa are marked by a high periintestinal infection rate as well as catabolism with negative protein balance. To eliminate these factors the principle of withdrawing the intestinal function has been applied. Patients are put on a completely absorbable diet (2,500-3,500 kcal/d) using a thin duodenal (or jejunal) tube for 4-6 weeks. Depending on the initial condition, assistant or total parenteral nutrition is performed. - 203 patients with Crohn's disease (n = 154) or colitis ulcerosa (n = 49) underwent elective surgery from January 1st, 1978 to April 30th, 1985. Using the preparation of withdrawing the intestinal function 85.7% of the patients have had an uncomplicated postoperative course. Septic complications were found in 12.8%, non-septic in 1.5%. The rate of mortality was 1.0%. In the case of Crohn's disease complications occurred in 10.4%, mortality was 0.6%.

Topics: Adolescent; Adult; Aged; Anti-Infective Agents; Child; Child, Preschool; Colitis, Ulcerative; Crohn Disease; Drug Combinations; Enteral Nutrition; Female; Food, Formulated; Humans; Intestine, Large; Intestine, Small; Male; Middle Aged; Postoperative Care; Premedication; Preoperative Care; Prognosis; Sulfamethoxazole; Surgical Wound Infection; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination