Optimal Antibiotic Selection for the Treatment of Pouchitis After Ileal Pouch-Anal Anastomosis

Pouchitis is the most common complication following ileal pouch-anal anastomosis for ulcerative colitis. Antibiotics remain the cornerstone of therapy for acute and chronic antibiotic dependent pouchitis, though evidence guiding their optimal use is limited.

A comprehensive literature search of PubMed, MEDLINE, Embase, and Google Scholar was conducted from database inception through October 2025 to identify studies evaluating antibiotic therapy for acute pouchitis. Eligible studies included randomized controlled trials, cohort studies, and observational series reporting clinical, endoscopic, or histologic outcomes. Data were extracted from 10 studies on study design, antibiotic regimen, efficacy, safety, and recurrence.

Data on the optimal selection of antibiotics for pouchitis is limited. Ciprofloxacin and metronidazole are the most extensively studied and commonly prescribed antibiotics. In a randomized clinical trial, ciprofloxacin demonstrated superior efficacy and tolerability compared with metronidazole. Rifaximin and vancomycin show potential benefit in selected cases.

Antibiotic therapy provides rapid and effective symptom control in most patients with acute pouchitis. Ciprofloxacin should be considered first-line, with metronidazole or combination therapy reserved for non-responders.