Cipro and Metronidazole are the two most popular antibiotics for pouchitis, Xifaxan is a distant third. Vancomycin is typically used for CDIff. At least that is how I understand it.

Xifaxan is what I like but expensive.  I agree with Doug cipro or flagyl.  Vanco is real good for c diff for us, you do not want to get used to that in case u need it for something like that.

Thank you both, Doug and Pals, for your input. My first thought was not to use Vancomycin for this so it could be effective with more serious infection. Thank you for confirming that! What an amazing community we have here to help us all navigate this journey! So thankful to have some place to turn!

I also called my old Gastro to see what he’d recommend for mild pouchitis and he recommended me use what helped in the past. Even though it’s been a while, it made it easier to request Cipro or Flagyl  from this gastro stating that I had good results with those in the past.

Cipro is cheap drug and if works why not!  Flagyl, will work too but u can’t even have a glass of wine with that.  I would not use vanco unless it a c diff case.  If you get used that drug and u need it. What then ?

@Pals posted:

Cipro is cheap drug and if works why not!  Flagyl, will work too but u can’t even have a glass of wine with that.  I would not use vanco unless it a c diff case.  If you get used that drug and u need it. What then ?

Cipro is black boxed so be mindful. It can cause tendon ruptures and neuropathy. Odd thing is that you could be fine on it for years and then out of the blue you take it and it messes you up. its always worked for me too but now hesitant taking it again. I now take Tindamax which is in same family as flagyl.

Thanks for the heads up! Still waiting to see if gastro willing to prescribe cipro or Flagyl vs Vanco. Will be aware if it’s Cipro.

Started Cipro so hoping things change in few days but Dr sent script for metronidazole and cipro? Confused. Pharmacist said can take both together as they are for different things. Said the metronidazole is for fungal infection, which I do not believe I have. Think Dr just ticked that I suggested these 2, saying I had used each in the past with success and preferred not the vancomycin.. Plan to not take the metronidazole. Also got compounded pharmacy cream with dilitiazen, hydrocortisone and lidocaine for ulcerations. Yikes, hard to use that stuff! So painful!

Some clarification: metronidazole is the drug name for flagyl. So you’d be taking both antibiotics for the same thing, haven’t  heard that as recommended from my docs.
I’ve taken cipro and flagyl in the past, but had allergic reaction to flagyl and Achilles tendinitis from cipro, which can cause tendon rupture, so as a tennis player I stopped that. Currently I’ve been taking cefdinir and it does the best at controlling mild pouchitis .  
For anal irritation, which I’ve had too, the best thing is a warm water bidet to wash your rear so you don’t have to wipe. Just use a towel to dry. The best ointment I’ve used in the past (don’t need it much with the bidet) is calmoseptine. You need a gauze pad or something like that to keep it off your underwear.

Thanhs for recommendation of Cefdinir! Will keep in mind, if as you and others mentioned cause tendon issue. I do know flagyl/ metronidazole same, but will hold off on taking that since taking cipro now. Can it even imagine how bad I’d be without my bidet! Was onjy relief I had for days! I didn’t like the menthol in calmoseptine years ago but may try again if this regimen fails. Thanks for your input!

Some docs like to prescribe both Cipro and Flagyl together for pouchitis under certain circumstances. It might be best to contact the doc if you think there’s been some confusion, or even if you just prefer to try the single antibiotic first.

For what it is worth, I used AI to research medications for treating pouchitis.  Not all physicians may know about these.  Here is what I found:

MEDICATIONS FOR POUCHITIS

Budesonide and Entyvio can be used to treat pouchitis, although their use is considered off-label for this condition.  Budesonide: This corticosteroid can be used for chronic antibiotic-refractory pouchitis, particularly in a controlled-ileal release form.   Entyvio: This medication, which is typically used for ulcerative colitis and Crohn’s disease, can also be used for treating chronic pouchitis.

Xifaxan (generic name: rifaximin) is an antibiotic primarily used to treat traveler’s diarrhea, irritable bowel syndrome with diarrhea (IBS-D), and to reduce the risk of hepatic encephalopathy in patients with liver disease. It works by inhibiting the growth of bacteria in the intestines.  Regarding pouchitis, Xifaxan can indeed be used, particularly for chronic antibiotic-dependent pouchitis. Studies have shown that rifaximin can help maintain remission in patients with this condition. It is often used in combination with other antibiotics, like ciprofloxacin, to improve treatment outcomes.

Rifaximin is a non-absorbable antibiotic that belongs to the rifamycin class. It is primarily used to treat gastrointestinal conditions such as traveler’s diarrhea, irritable bowel syndrome with diarrhea (IBS-D), and to reduce the risk of hepatic encephalopathy in patients with liver disease. Rifaximin works by inhibiting the growth of bacteria in the intestines.  Use in Pouchitis. Rifaximin can be used to treat pouchitis, particularly in cases where the condition is chronic and dependent on antibiotics. Although it is not specifically licensed for this use, it has been found effective in maintaining remission and managing symptoms of pouchitis. It is often used in combination with other antibiotics, such as ciprofloxacin, to enhance its effectiveness.

Remicade (generic name: infliximab) is a monoclonal antibody that targets and inhibits tumor necrosis factor-alpha (TNF-α), a protein involved in inflammation. It is used to treat various autoimmune diseases, including rheumatoid arthritis, Crohn’s disease, ulcerative colitis, ankylosing spondylitis, psoriatic arthritis, and plaque psoriasis.  Use in Pouchitis.  While Remicade is not specifically approved for pouchitis, it can be used off-label to treat chronic antibiotic-refractory pouchitis. This is particularly considered when other treatments have failed to control the inflammation and symptoms.

Visbiome is a high-potency probiotic. It contains a blend of beneficial bacteria designed to support gut health and manage conditions like irritable bowel syndrome (IBS) and antibiotic-associated diarrhea.  Visbiome is available over the counter and does not require a prescription. However, there is also a prescription-strength version called Visbiome Extra Strength, which is intended for more intensive medical applications.

https://www.gastrojournal.org/article/S0016-5085(23)05142-9/fulltext

AGA Guidelines are not the most exciting reading, but support Cipro and Flagyl as first choice antibiotics, including in combination  

Recommendation 3. In patients with UC who have undergone IPAA and experience infrequent symptoms of pouchitis, the AGA suggests using antibiotics for treatment of pouchitis. (Conditional recommendation, very low certainty of evidence)

Thank you all for sharing your research, info, expertise on recommended antibiotics for pouchitis! Much appreciated! I’m more than halfway thru my Cipro dosage and have managed to avoid getting sunburn even with holiday weekend. I believe it alone helped reduce my frequency, which is I guess the most obvious symptom of pouchitis I had. After I messaged Dr re. taking both, reply was yes she wanted me to take both so I am almost a week into dosage of the Metronidizole. Haven’t noticed any change since I started it. Taking probiotic with it as worried about it causing diarrhea. With reduced frequency my ulcerations are healing and I’m able to sit down more comfortably but still believe there is issue with anus restricting and therefore I have pain after straining, causing more problems to recur. Seeing 2 different surgeons this week, 1 at CC. Hoping  for answers and a remedy!