The awareness of the crucial importance that faecal stasis and bacterial overgrowth may have in the pathogenesis of acute pouchitis has led clinicians to treat patients with antibiotics, which have become the mainstay of treatment, in absence of controlled trials. Usually metronidazole represents the most common first therapeutic approach, and most patients with acute pouchitis respond quickly to administration of 1-1.5 g/day [33-34]. A doubleblind, randomised, placebo-controlled, crossover trial was carried out in 1993 by Madden et al. [22] to assess the efficacy of 400 mg three times a day of metronidazole per os in 13 patients (11 completed both arms of the study) with chronic, unremitting pouchitis, defined by the presence of recurrent or persistent symptoms with almost six bowel movements a day and typical endoscopic findings. Patients were treated for 2 weeks, with a 7-day wash-out period before the crossover to the second treatment. Metronidazole was significantly more effective than placebo in reducing the stool frequency (73 vs. 9%), even without improvement of endoscopic appearance and histologic grade of activity. Some patients (55%) experienced side effects from metronidazole including nausea, vomiting, abdominal discomfort, headache, skin rash and metallic taste [35]. Dysgeu-sia and peripheral neuropathy may limit long-term administration of metronidazole, while patients drinking alcohol may have a disulfiram-like reaction. Recently Shen and colleagues have compared the effectiveness and side effects of ciprofloxacin and metronidazole in a randomised clinical trial regarding the treatment of acute pouchitis. Seven patients received ciprofloxacin 1 g/day and nine patients metronidazole 20 mg/kg/day for a period of 2 weeks. The results of this study have shown that both ciprofloxacin and metronidazole are efficacious in the treatment of acute pouchitis; they reduced the total PDAI scores and led to a significant improvement of symptoms and endoscopic and histologic scores. However, ciprofloxacin led to a greater degree of reduction in the total PDAI score and to a greater improvement in symptoms and endoscopic scores; furthermore ciprofloxacin was better tolerated than metronidazole (33% of metronidazole-treated patients reported adverse effects; none were reported in the ciprofloxacin-treated group). The authors have suggested that ciprofloxacin should be considered the first-line therapy for acute pouchitis [36].

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