Advice for rotating antibiotics

If you're lucky enough to find two or three antibiotics that work for you, antibiotic rotation should continue every 2-3 weeks as long as you need antibiotics.

Ceftin is probably not a good choice as it is one of those broad spectrum antibiotics that are associated with C. difficile outbreaks. 

I rotate ciprofloxacin, metronidazole, and rifaximin. Dr. Shen also prescribes tinidazole (same class as metronidazole) and levaquin (same class as ciprofloxacin). 

Other people have used a variety of other antibiotics, but mostly for short term use.

Jan

Thank you Scott and Jan, I wish I can have flagyl as part of the rotation, but I have too much nausea and cramping when I take it, unless there's something I can do for those side effects.  I guess I can take gravol, but not sure if I can handle it for long term.

The best first step for side effects is to take a lower dose (if it's effective at that dose). I don't know what dose of Flagyl you were on, but a lower dose may be worth a try.

For me, these are the top meds that have worked:  Cipro, Flagyl, Augmentin, Xifaxin (rifaxamin), and Pepto Bismol.  2-3 weeks on each is good for rotation.  I've had some success with oil of oregano.  My doctor has also written me scripts that I haven't needed to fill for Bactrim DS and doxycycline if/when the other antibiotics all stop working.

Regarding Flagyl dosage, I agree with Scott.  I take a very low dose that is extremely effective.  The higher mg tabs at 3x a day is overkill for me.  You could try that and see if it helps with the side effects.

Agree with clz81- that is my exact rotation and I have been on it for MANY years and rotating antibiotics for 20 years.  Now, I am also taking Remicade and doing well.

Thank you for your responses, when the rotation ends, do you all stay with one or combination of antibiotics or nothing at all?  I ask because I think I've become resistant to all antibiotics, so will I need to rotate always or should I eventually consider removing the pouch? ...which is my very last option....I tell my doctor that I'm basically stalling until there are more options out there or until a cure is found.

Tinat, when you write "resistant to all antibiotics" I'm not sure what you mean. If they simply don't work for you, then rotating them won't help. The rotation doesn't end: for someone who gets good results from three different antibiotics (and can't stop them entirely), rotation means they take antibiotic 1 for a few weeks, then antibiotic 2 for a few weeks, then antibiotic 3 for a few weeks, then back to antibiotic 1 for a few weeks, repeating the cycle more or less as long as it works.

Hi Scott, yes that's what I meant by resistant, I haven't been responding well to any single antibiotic, nor any combination.  I thought that rotating them was a way of confusing the body until one of them kicks in again and you continue with whichever one works.  I guess rotating them won't work for me, so now I'm hoping taking a break from them will help, but that's more wishful thinking on my part.

Unfortunately, antibiotic rotation is intended to *prevent* bacterial resistance (it''s the bacteria that become resistant, not you). Once the antibiotics stop working, rotation can't help, I think. I've had good results from combining Cipro and Flagyl, but you've already tried that strategy. Perhaps it's time to try a biologic?

Perhaps you have a type of pouchitis that does not respond to antibiotics, such as ischemic pouchitis. This can lead to pouch failure, I'm afriad. But before going there, be sure to be checked for C. difficile infection and CTM (cytomegalovirus) infection.

Yes, Scott is correct that resistance is in reference to the bacteria being resistant. If your pouchitis does not respond to antibiotics, it is antibiotic-refractory pouchitis. For treatment of chronic antibiotic-refractory pouchitis (CARP) check out this link and scroll down to that topic. http://www.usahealthsystem.com...icles/2014_01_16.pdf

Jan

Thank you Jan and Scott, I really hope it's not pouch failure, but I have contacted my doctors to see if we can do further testing to figure this all out.  And Scott, yes I am currently trying Entyvio, but so far haven't really noticed any improvements.  I know this is a question for the doctors, but is it possible to do another pouch surgery, getting rid of the old and creating a new one?  Am I reaching here??

Pouches can be remade, but that's done in cases of structural pouch defects. It wouldn't really fix CARP, as far as I know, though it could potentially fix ischemic pouchitis. And if it's infectious (C. diff or CMV)  an entirely different approach is needed.

Hi, a little general  advice please what is a "standard" dosage of Cipro (1500mg?)  and Flagyl (1000mg?) I chronic pouchitis 3/4 seriousne cases a year often these are accompanied by full blockages (may be a coincidence). I would like to discuss rotating antibiotics with my Family doctor, I live in the country so she has little experience with this condition.

I take 500mg Cipro twice a day. This is the typical dose.

Low dose Flagyl is 250mg 3 times a day. High dose is 500mg 3 times a day. I used to respond well to the low dose, but now I get by on 500mg twice a day. The lowest dose that does the job is best.

My GI also wants me to use rifaximin as much as possible in my rotation, because it acts only in the gut, and is not systemic.

So, I rotate two weeks each:

Rifaximin-Flagyl-Rifaximin-Cipro-Rifaximin-Flagyl- and so on. RIfaximin does not work as well for me, so I also take Pepto Bismol tablets with it.

Jan

Thanks I will look into the Rifaximin, had my surgery 18 years ago in New Zealand and have not been prescribed this drug

I am not sure if it is available in NZ. But it is worth a look. It's super expensive here in the US. For me it is a restricted drug, meaning I can get only a maximum of a 30 day supply and it cannot be mail ordered.

Jan

If your doctor is unfamiliar with Rifaxamin, make sure to get the higher strength tablets (550 mg) used for IBS and hepatic encephalopathy rather than the 200 mg tablets used for traveler's diarrhea. A common dose is 1100 mg daily.

I use a lower dose of Cipro and Flagyl than Jan describes , but I use them in combination and gradually decreased the doses until I found the lowest effective dose (for me). OTOH, I have to take them every day rather than a few times per year.

I've had my pouch now for 12 years and have had pouchitis for all 12 of those years!  I've found that I do OK on Augmentin and Cipro daily.  Every 8-10 days (or thereabouts), things go south and I have to add in some Flagyl for 2-3 days, which seems to reset the bacterial resistance.  I then go back to Augmentin and Cipro.

Thanks I am the same have had this since day one, surgery was still the right move ��

I've actually gotten to the point where i can't even think about taking Flagyl without gagging.  I start gagging when I pick up the bottle.  Funny, huh?  Sadly, it's the only thing that resets my system for another 8-10 days.   

FreeAtLast posted:

I've actually gotten to the point where i can't even think about taking Flagyl without gagging.  I start gagging when I pick up the bottle.  Funny, huh?  Sadly, it's the only thing that resets my system for another 8-10 days.   

Flagyl 500mg is without a doubt the worst tasting med on the face of the earth. However, it is the only broad spectrum antibiotic that continues to work for me. If I don't use Flagyl I start burning, it feels like a match was lit in my rectum and other symptoms surface. So for me it is  Flagyl. Good news it is cheap