Ileal pouch-anal anastomosis (IPAA) after restorative proctocolectomy is the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or familial adenomatous polyposis. The clinical implication of pathogenic bacteria beside Clostridium difficile infection (CDI) in patients with IPAA has not been well studied. This case series was designed to investigate the cumulative incidence, risk factors, and outcome of pathogenic bacteria beside CDI in patients with ileal pouches.Methods:
Consecutive IPAA patients (n = 2283) from 2002 to 2016 at our subspecialty Pouchitis Clinic with an increase of at least 3 stools per day more from the postoperative baseline for more than 4 weeks were included. Diagnosis was based on the presence of symptoms and positive stool cultures. Patients with positive stool cultures were treated with antibiotics for average of 2 weeks. Resolution of symptoms at one month, recurrence rate and rate of hospitalization at one and 3 months were assessed.Results:
Twenty-eight percent (643/2283) of the patients with Pouchitis symptoms had stool cultures done. Only 0.017% (11/643) had positive stool cultures. Campylobacter (45%) was the most common pathogen followed by Aeromonas (36%). Eighteen percent (2/11) of patients were febrile and 27%(3/11) had leukocytosis. Positive stool cultures were more prevalent in females (7/11), patients with h/o UC (10/11), with J-pouch who had 2 stage surgery (10/11) and h/o immunosuppression (8/9). After 2 weeks of antibiotic treatment there were no significant difference in Pouchitis Disease Activity Index (PDAI) with an average pre and post treatment values of 4 and 2 respectively, but only 2/6 patients had biopsies done on follow-up pouchoscopy. After treatment 71% were symptom free at 1 month. Symptom recurrence occurred in 90% and 40% required repeat antibiotic treatment. Fifty-five percent were hospitalized with a sepsis and mortality rate of 18% each. At 3 months, 35% of patients were hospitalized after initial infection. Thirty-six percent (4/11) required repeat pouch surgery.Conclusions:
All patients with pouchitis symptoms especially with fever and leukocytosis should get stool cultures done, as these pathogens can have high morbidity and mortality and can lead to pouch failure. Larger studies with higher number of patients with positive stool cultures need to be done to confirm these findings.