P308 Quadruple oral antibiotic treatment in refractory Paediatric Inflammatory Bowel Disease – incidence and analysis of responders from a 10 year cohort.
Meredith, J.J.(1,2);Armstrong, K.(1);Russell, R.K.(1,2);Henderson, P.(1,2);Wilson, D.C.(1,2);
(1)Royal Hospital for Children and Young People, Department of Paediatric Gastroenterology and Nutrition, Edinburgh, United Kingdom;(2)University of Edinburgh, Child Life and Health- College of Medicine and Veterinary Medicine, Edinburgh, United Kingdom;
Background
Recent, albeit limited, studies indicate that combination oral antibiotic therapy may be an efficacious, immunosuppressive-free, alternative strategy to achieve remission in a subset of medically refractory IBD patients. We sought to identify incidence data and provide cohort analysis of any refractory IBD patients who subsequently responded to combination oral antibiotic therapy from a large paediatric inflammatory bowel disease [PIBD] centre.
Methods
We identified a regional cohort of prospectively acquired incident cases of paediatric inflammatory bowel disease (CD, UC and IBD-U) diagnosed <16 years of age in South-East Scotland over a 10-year period (2009-2018) and conducted a retrospective review identifying all cases with treatment refractory disease who subsequently achieved remission with a quadruple oral antibiotic regimen (vancomycin/doxycycline/metronidazole/amoxicillin) as salvage therapy. We characterised demographic data, IBD disease type, classification, severity, duration, as well as prior treatment efficacy and duration. There was a minimum of 2 years of follow data available.
Results
In total, 4 cases of successful treatment with a quadruple oral antibiotic regimen in refractory patients were identified from our 10-year PIBD registry that included 222 new cases of PIBD (cumulative incidence 1.8%). Treatment was attempted in 9 refractory patients over the period. All responders were male, median age at diagnosis 13.1yrs (0.5, 11.3, 14.8, 15.7yrs), median disease duration was 1.3yrs. All responders had chronically active moderate-severe disease. 3 had ulcerative colitis (Paris classification E4), the remainder had Crohn’s disease (Montreal classification B1, L3/4). All responders had disease refractory to a least 2 biological therapies that were co-administered with either thiopurines or methotrexate. 3 of the 4 had failed at least one steroid induction course. 3 of the 4 maintained clinical remission at the minimum 2 year follow up on regular oral vancomycin therapy.
Conclusion
A subset of patients with PIBD that is highly refractory to conventional therapeutics, including to steroids and multiple biologics, may achieve remission with a quadruple combination oral antibiotic regimen. Those with active colitic phenotypes at intervention were more likely to respond and longer-term disease remission may be maintained with regular oral vancomycin.