Why is rifaximin (Rifaximin) stopped in almost all enterocutaneous fistula cases?

Management of Rifaximin in Enterocutaneous Fistula Cases

Rifaximin should be stopped in enterocutaneous fistula cases because it may increase the risk of intra-abdominal abscess formation and complicate fistula healing, particularly in patients receiving anti-TNF therapy. 1

Pathophysiology and Management Considerations

Enterocutaneous fistulae (ECF) represent abnormal connections between the gastrointestinal tract and skin, often occurring in the context of Crohn's disease with active inflammation, intra-abdominal abscesses, or as post-surgical complications. The management approach depends on several factors:

Fistula Assessment

• Location: Proximal vs distal fistulae require different management approaches
• Output volume: High vs low output determines nutritional support strategy
• Complexity: Multiple tracts and associated stenosis reduce healing rates with medical therapy

Why Rifaximin is Discontinued

1. Risk of Abscess Formation:

   • One-third of patients with enterocutaneous fistulae on anti-TNF therapy develop intra-abdominal abscesses 1
   • Adding rifaximin could potentially alter gut flora and increase infection risk

2. Limited Evidence for Benefit:

   • No prospective trial data supports rifaximin use in enterocutaneous fistulae 1
   • British Society of Gastroenterology guidelines do not recommend rifaximin for this indication

3. Nutritional Management Priority:

   • ESPEN guidelines emphasize that nutritional optimization is the cornerstone of fistula management rather than antimicrobial therapy 1
   • For proximal or high-output fistulae, partial or exclusive parenteral nutrition is recommended over medications like rifaximin 1

Evidence-Based Management Algorithm

Step 1: Initial Assessment and Stabilization

• Control sepsis and drain any abscesses before initiating any biological therapy 1
• Statement 61 from BSG guidelines: "Anti-TNF therapy should only be started after abscesses have been treated with antibiotics and, where possible, drainage" 1

Step 2: Nutritional Support Based on Fistula Type

• Low ileal/colonic fistula with low output: Enteral nutrition is usually sufficient 1
• Proximal fistula and/or high output: Require partial or exclusive parenteral nutrition 1

Step 3: Medical Management

• If fistula is associated with active inflammation, medical therapy with immunomodulators and biologics may be beneficial 1
• For low-volume fistulae: Consider immunomodulator and biological therapy 1
• For high-volume fistulae: Surgical intervention is typically required 1

Step 4: Surgical Intervention When Indicated

• Surgery required in approximately 54% of patients with enterocutaneous fistulae 1
• Surgical correction has better outcomes when nutritional status is optimized preoperatively 1

Clinical Pearls and Pitfalls

• Multidisciplinary Approach: All patients with enterocutaneous fistulae should be managed by a team including gastroenterologists, surgeons, and dietitians 1

• Predictors of Poor Healing with Medical Therapy:

  • Complex fistulae with multiple tracts
  • Associated stenosis
  • Malnutrition (BMI <20 kg/m²) is an independent risk factor for poor outcomes 1

• Timing of Intervention:

  • Allow sufficient time for nutritional optimization before surgical intervention
  • Delay surgical repair for at least 3 months when spontaneous closure doesn't occur 2

• Monitoring:

  • Regular assessment of nutritional status
  • Vigilance for refeeding syndrome in malnourished patients 1

By stopping rifaximin and focusing on proper nutritional support, drainage of collections, and appropriate timing of medical and surgical interventions, outcomes for patients with enterocutaneous fistulae can be optimized.