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Systematic review
Antimicrobial treatment for human intestinal spirochaetosis: a systematic review
  1. Jin Keng Stephen Lam1,
  2. Lucy Rabuszko2,
  3. Colin Fitzpatrick3,
  4. Deborah Williams1,
  5. Daniel Richardson1,2
  1. 1University Hospitals Sussex NHS Foundation Trust, Brighton, UK
  2. 2Brighton and Sussex Medical School, Brighton, UK
  3. 3Sexual Health & HIV, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
  1. Correspondence to Professor Daniel Richardson, University Hospitals Sussex NHS Foundation Trust, Brighton, UK; daniel.richardson7{at}


Introduction The antimicrobial treatment options for patients with intestinal spirochaetosis (caused by Brachyspira pilosicoli and Brachyspira aalborgi) are not well defined. We aimed to systematically review the literature to explore antimicrobial treatment options to inform future clinical guidelines.

Method We systematically searched three bibliographical databases (MEDLINE, EMBASE, SCOPUS and Web of Science) for manuscripts written in English up to January 2024. The primary author conducted an initial abstract screen and two authors conducted independent full-text reviews. We included manuscripts which included primary data for patients with intestinal spirochaetosis who had received antimicrobial treatment and had an outcome measured. Quality and risk of bias was assessed independently by two authors using the Joanna Briggs Institute critical appraisal tools. We used the nine-point synthesis method to synthesise narrative data.

Results There were 58 manuscripts included in this review published between 1977 and 2023 (42 case reports, 12 case series, 3 cross-sectional studies, and 1 prospective cohort). In total, there were 270 individuals with intestinal spirochaetosis: 225 patients received oral metronidazole monotherapy, 1 intravenous metronidazole, 2 rectal metronidazole, 5 metronidazole as part of a dual/triple regimen, 17 doxycycline monotherapy, 5 doxycycline (or tetracycline) dual therapy with either a beta-lactam, or neomycin, 4 benzathine penicillin, 1 procaine penicillin/steroids and 3 other antimicrobials including clarithromycin and vancomycin. 230 (85%) of patients in this review had an adequate clinical and or histological response to treatment with a median follow-up period of 30 days (IQR 14–90). The combined treatment response to all metronidazole-based treatment was 195/233 (84%).

Conclusion Metronidazole, doxycycline and parenteral penicillin are the most frequently used antimicrobials for the treatment of human intestinal spirochaetosis and treatment response is generally good. More work is needed to understand the pathophysiology and treatment outcomes in patients with symptomatic intestinal spirochaetosis including the development of non-invasive diagnostic tools.


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  • Contributors DR came up with the study concept, JKSL and DR designed the study protocol, JKSL conducted the data search, JKSL, LR independently reviewed the manuscript's eligibility, JKSL and LR independently conducted the risk of bias assessment, JKSL and DR conducted the data synthesis and JKJL, LR, CF, DW and DR all contributed to the final manuscript. DR is the study guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.