WO2008004224A2 - Synergistic compositions for crohn's disease and inflammatory gastrointestinal disorders - Google Patents

Abstract

The invention relates to methods and synergistic compositions comprising a nitroimidazole antibiotic and a macrolide antibiotic, optionally in combination with polyphenolic compounds naturally contained in plant or fruit, for treatment of chronic inflammatory gastrointestinal disorders including Crohn's disease.

Description

SYNERGISTIC COMPOSITIONS FOR CROHN'S DISEASE AND INFLAMMATORY GASTROINTESTINAL DISORDERS

FTELD OF THE INVENTION The invention relates to methods and synergistic compositions comprising a nitroimidazole antibiotic and a macrolide antibiotic, optionally in combination with polyphenolic compounds naturally contained in plant or fruit, for treatment of chronic inflammatory gastrointestinal disorders including Crohn's disease.

BACKGROUND OF THE INVENTION

Crohn's disease, ulcerative colitis, inflammatory bowel disease and other related conditions form a spectrum of chronic inflammatory diseases of the gastrointestinal tract having unclear etiology and pathogenesis. Crohn's disease is characterized by ulcerations of the small and/or large intestines, but can affect the digestive system anywhere from the mouth to the anus. Various terms are used to describe Crohn's disease, and tend to reflect the portion of the gastrointestinal tract affected. For example, involvement of the large intestine (colon) only has been termed Crohn's colitis or granulomatous colitis, while involvement of the small intestine only has been termed Crohn's enteritis. Disease in the terminal portion of the small intestine i.e. the ileum, has been termed Crohn's ileitis. When both the small intestine and the large intestine are involved, the condition has been termed Crohn's enterocolitis or ileocolitis. Ulcerative colitis is a condition related to Crohn's disease that involves only the colon, and collectively these diseases are frequently referred to as inflammatory bowel disease (IBD). Ulcerative colitis and Crohn's disease have no medical cure, and once the diseases are manifest, they tend to fluctuate between periods of remission and relapse. Together, these conditions affect approximately 500,000 to 2 million people in the United States. The toll on both patients and the medical system is high, since surgical correction is eventually required in 90% of Crohn's disease patients, with 50% undergoing colonic resection. The recurrence rate after surgery is high, with 50% requiring further surgery within five years.

The development of Crohn's disease is likely multi-factorial, but appears to involve a dysregulated immune response to pathogenic and/or resident normal bacteria in a genetically pre-disposed host. According to one hypothesis, failure of the intestinal mucosal barrier, due to genetic susceptibilities and/or environmental factors, exposes the immune system to antigens from the intestinal lumen, including bacterial and food antigens. Another hypothesis is that persistent intestinal infection by pathogens such as Mycobacterium paratuberculosis, Listeria monocytogenes, abnormal Escherichia coli, or paramyxovirus, stimulates the immune response. It has alternately been suggested that symptoms result from a dysregulated immune response to ubiquitous antigens, such as normal intestinal microflora and the metabolites and toxins they produce. In Crohn's disease, a dysregulated immune response is skewed toward cell-mediated immunopathology. Immunosuppressive drugs, such as cyclosporine, tacrolimus, and mesalamine have been used to treat corticosteroid-resistant cases of Crohn's disease, but with mixed success.

Genetic research has indicated that susceptibility to Crohn's disease is associated with inherited defects in innate luminal immunity, specifically in genes encoding pattern recognition receptors (PRRs) which function in detecting molecular motifs of bacterial products. These include the NOD2/CARD15 gene and the toll-like receptor 4 (TLR4) gene. NOD2/CARD15 is a cytosolic receptor expressed on monocytes, dendritic cells, epithelial cells and Paneth cells, and functions as an intracellular activator of NFKB in response to peptidoglycan muramyl dipeptide. Three mutations of the NOD2/CARD15 gene were identified as independent risk factors for development of Crohn's disease, at least one of which produces a functionally deficient truncated NOD2 protein. Furthermore, diminished levels of mucosal α-defensins HD-5 and HD-6 were found in Crohn's disease patients having NOD2/CARD15 mutations. HD-5 and HD-6 are antibiotic effector molecules normally predominating in Paneth cells of the ileum, and accordingly their decreased expression in Crohn's disease could be responsible for a breech in the mucosal antibacterial barrier.

TLR4 is an extracellular receptor, which normally functions in recognition of the bacterial products lipopolysaccharide and lipoteichoic acid. A polymorphism in the TLR4 gene has also been associated with development of Crohn's disease. Close association of bacteria with the intestinal epithelial surface and/or penetration of the mucosal barrier triggers a cascade of signaling events in Crohn's disease . This includes increased production of cytokines including TNFα, IL-8, GROα, MCP-I, cyclooxygenase, prostaglandins E2 and F2α, nitric oxide synthase and increased surface expression of the adhesion molecule ICAM-I. Up regulation of cytokine expression is mediated by a common signal transduction pathway involving NF-κB. Increased local concentrations of cytokines initiate the biochemical cascade which produces tissue injury. Bacterial invasion is associated with activation of host antigen-presenting cells, which are responsible for initiating the inflammatory reaction. Treatments that have been proposed for Crohn's disease include the use of various cytokine antagonists, cytokine inhibitors and anti-cytokine antibodies. In particular, monoclonal antibodies against TNF-α have been used with some success in the treatment of Crohn's disease.

Gastrointestinal tissue surgically excised from Crohn's disease patients is typically characterized by the presence of colonized bacteria. The organisms identified are usually species found in the healthy gastrointestinal tract, particularly E. coli, Proteus sp., Bacteroides sp. and Streptococcus sp. However, in Crohn's disease and in other intestinal disorders, at least some of these organisms have acquired virulence factors which confer pathogenicity. For example, an adherent-invasive strain of E. coli identified in the intestinal mucosa of Crohn's disease patients adheres to intestinal epithelial cells, invades epithelial cells via a mechanism involving actin polymerization and microtubules, and replicates within macrophages. Certain immune function disorders manifest inflammatory gastrointestinal conditions which are very similar to those seen in Crohn's disease. Such conditions are variously termed Crohn' s-like colitis, Crohn' s-like ileitis and Crohn' s-like ileocolitis, depending on the affected organ. The underlying diseases include inherited primary immune deficiency diseases such as chronic granulomatomous disease, hypogammaglobulinemia, agammaglobulinemia, leucocyte adhesion deficiency, cyclic neutropenia and glycogen storage disease Ib, and infectious immune disease, primarily acquired immunodeficiency syndrome (i.e. AIDS).

Due to the postulated role of bacterial infection in Crohn's disease and Crohn's disease-like conditions, one therapeutic strategy involves at least partial eradication of the existing bacterial flora, by means which include use of antibiotics and antimicrobial agents. U.S. 5,599,795 discloses a method for the prevention and treatment of Crohn's disease which includes sterilizing the intestinal tract with at least one antibiotic and at least one anti-fungal agent to kill off the existing flora, and replacing it with selected different and well-characterized bacteria taken from normal humans. U.S. 5,443,826 teaches a method of treating Crohn's disease by lavage removal of the existing intestinal microflora and replacing it with a new bacterial population introduced by inoculum from a disease-screened human donor or by a composition comprising Bacteroides and Escherichia coli species. U.S. 5,443,826 further teaches that in Crohn's disease, antituberculosis therapy may be required for six to twelve weeks before bowel clearing and exchange of flora.

The nitroimidazole antibiotic metronidazole has been widely used for Crohn's disease, but fails on its own to satisfactorily control the disease. The combination of metronidazole and ciprofloxacin is known (Hudson et al (1984) J Med Microbiol.

18(3):335-45), and induces remission in some patients (Ishikawa et al (2003) Intern.

Med. Apr; 42(4):318-21). Use of the steroid budesonide with the antibiotics metronidazole and ciprofloxacillin, versus budesonide alone, provided no difference in patient outcome, bringing into question the efficacy of the antibiotic combination

(Steinhart et al (2002) Gastroenterology Jul;123(l):33-40).

The nitroimidazole antibiotic ornidazole has been disclosed to be effective for the prevention of recurrence of Crohn's disease after ileocolonic resection (Rutgeerts et al (2005) Gastroenterology 128(4):856-61). US 6,861,053 discloses a method of treating various conditions (many of which are not known to be characterized by bowel or gastrointestinal involvement), including fibromyalgia, chronic fatigue syndrome, depression, attention deficit hyperactivity disorder, irritable bowel syndrome, systemic lupus erythematosis, multiple sclerosis and Crohn's disease, by detecting and eradicating small intestinal bacterial overgrowth, which is alleged to be an underlying cause for all of the aforementioned conditions. The disclosed method comprises at least partially eradicating the small intestinal bacterial overgrowth by administering any of an antibiotic agent, an antimicrobial chemotherapeutic agent, a probiotic agent, a prokinetic agent, or combinations thereof, and/or by using intestinal lavage or enema. Among many others, metronidazole is mentioned as a candidate antibiotic; and macrolide compounds and azithromycin are mentioned as candidate prokinetic agents.

US 5,674,858 relates to a method of treating gastrointestinal disorders caused by H. pylori infection, including gastritis, non-ulcer dyspepsia, esophagal reflux disease or gastric motility disorder, by co-administering ranitidine bismuth citrate in combination with one or more antibiotics. US 5,674,858 further discloses a pharmaceutical composition which comprises ranitidine bismuth citrate, one anti-bacterial agent, and one antibiotic. Among many others, metronidazole and azithromycin are mentioned as candidate antibiotics or anti-bacterial agents for the disclosed method and composition.

US 2004/0170617 relates to treatment of a disease associated with an abnormal gastrointestinal flora by administering an antimicrobial composition which is an antibacterial agent and/or a probiotic agent comprising at least one of the bacterial species that is a normal, benign inhabitant of a human gut. Among many others, metronidazole, macrolides and azithromycin are mentioned as candidate antibacterial agents. The gastrointestinal disorders can include inflammatory bowel diseases such as ulcerative colitis or Crohn's disease.

US 2005/0209295 relates to treatment of diseases mediated by cell adhesion, including Crohn's disease, using a pharmaceutical composition comprising a methimazole derivative or tautomeric cyclic thione.

Also known in the art is that plant and fruit extracts and/or derivatives thereof may be used for treatment of gastrointestinal disorders and/or prevention of bacterial adhesion to tissue and cell surfaces. US 5,858,371 relates to a composition comprising an Euphorbia prostrata extract in combination with an anti-microbial agent for treatment of colonic diseases. US 5,474,774 and US 5,525,341 relate to a cranberry extract enriched for an activity which inhibits bacterial adhesion to cell surfaces. US 6,613,362 relates to an intestinal bowel soother comprising cranberry fruit.

Effective treatment of chronic inflammatory gastrointestinal disorders, such as Crohn's disease, remains an unmet medical need for many patients whose clinical conditions have not improved using known therapeutic methods, including antibiotic therapy. Nowhere in the background art is it taught or suggested that specific combinations of a macrolide and a nitroimidazole are particularly effective in achieving a beneficial clinical outcome in Crohn's disease and other chronic inflammatory gastrointestinal disorders. The invention disclosed herein is not directed to methods of treatment of gastrointestinal disorders caused or mediated by Helicobacter pylori, and further is not intended for use with ranitidine bismuth citrate. SUMMARY OF THE INVENTION

The invention disclosed herein provides synergistic compositions and methods of treatment for chronic inflammatory gastrointestinal disorders. The inventors have surprisingly found that specific antibiotic combinations comprising a first antibiotic, which is a nitroimidazole, and a second antibiotic, which is a macrolide, provide prolonged disease remission subsequent to treatment with these combinations of antibiotics. In particular embodiments of the methods and synergistic compositions disclosed herein, the inflammatory gastrointestinal disorders include Crohn's disease, inflammatory bowel disease and ulcerative colitis. In other embodiments, the inflammatory gastrointestinal disorder is associated with an immune function disorder. Examples of such immune function disorders include acquired immunodeficiency syndrome, chronic granulomatomous disease, hypogammaglobulinemia, agammaglobulinemia, leucocyte adhesion deficiency, cyclic neutropenia, and glycogen storage disease Ib.

According to a first aspect, the present invention provides a method for treating an inflammatory gastrointestinal disorder wherein the method comprises administering to a patient in need thereof: (i) a first antibiotic, which is a nitroimidazole, in an amount effective to provide bactericidal activity against anaerobic bacteria; and (ii) a second antibiotic, which is a macrolide, in an amount effective to provide bactericidal activity against bacteria localized within cells of the intestinal lining, and the intestinal lumen.

In one embodiment, the nitroimidazole antibiotic is selected from metronidazole, ornidazole and tinidazole, and the macrolide antibiotic is selected from azithromycin, clarithromycin, dirithromycin and roxithromycin. In a particular embodiment, the nitroimidazole antibiotic and the macrolide antibiotic are each administered at a dosage of 100 to 2000 mg per day for three to seven days per week for a period of six to twelve weeks, hi a further embodiment, the nitroimidazole antibiotic is administered at a dosage of 15-50 mg per kg body weight per day, and the macrolide antibiotic is administered at a dosage 5-15 mg per kg body weight per day. In a currently preferred embodiment, the nitroimidazole antibiotic is metronidazole and the macrolide antibiotic is azithromycin. In another particular embodiment, the metronidazole is administered at a dosage of up to 1500 mg per day and the azithromycin is administered at a dosage of up to 600 mg per day. In a further embodiment, the metronidazole is administered seven days per week, and the azithromycin is administered five days per week, each for a period of eight weeks.

In other embodiments, the nitroimidazole antibiotic and the macrolide antibiotic are administered in a single dosage unit or in separate dosage units. In yet other embodiments, the nitroimidazole antibiotic and the macrolide antibiotic are administered concurrently, sequentially, alternately, intermittently, or any combination thereof.

In one embodiment, the intestinal bacteria are selected from the group consisting of Actinomyces sp., Bacteroides sp., Bifidobacterium sp., Bilophila sp., Butyrovibrio sp., Citrobacter sp., Clostridium sp., Coprococcus sp., Corynebacterium sp.,

Desulfomonas sp., Desulfovibrio sp., Enterobacter sp., Enterococcus sp., Escherichia sp., Eubacterium sp., Fusobacterium sp., Klebsiella sp., Lactobacillus sp., Micrococcus sp., Mycobacterium sp., Peptococcus sp., Peptostreptococcus sp, Proteus sp., Pseudomonas sp., Ruminococcus sp., Staphylococcus sp., Streptococcus sp. and

Veillonella sp.

In another embodiment, the method further comprises administering a nutritional supplement comprising polyphenolic compounds contained in a plant or fruit. In particular embodiments, the nutritional supplement is a capsule, a liquid, a suspension, a tincture, an extract or a pill. In a particular embodiment, the polyphenolic compounds are contained in a plant part selected from leaf, stem, flower, seed, root, bud, sprout or combinations thereof. In a particular embodiment, the polyphenolic compounds are naturally contained in a plant or fruit. In another embodiment, the polyphenolic compounds are contained in a plant or fruit following processing. In particular embodiments, the fruit is cranberry , and the nutritional supplement is cranberry juice. In another particular embodiment, the cranberry juice is administered at a dosage of 100 to 1000 ml per day, for a period of eight weeks.

According to another aspect, the present invention further provides a method of treating an inflammatory gastrointestinal disorder, selected from the group consisting of Crohn's disease, inflammatory bowel disease and ulcerative colitis, wherein the method comprises administrating to a patient in need thereof a synergistic therapeutic regimen, wherein the regimen comprises the components (i) azithromycin at a dosage of 100 to 600 mg per day; (ii) metronidazole at a dosage of 100 to 1500 mg per day; and optionally, (iii) cranberry juice at a dosage of 100 to 1000 ml per day. In a particular embodiment, the metronidazole is administered at a dosage of 15-50 mg per kg body weight per day, and the azithromycin is administered at a dosage 5-15 mg per kg body weight per day. In particular embodiments, the azithromycin and the metronidazole are administered in a single dosage unit or in separate dosage units. In yet other embodiments, the azithromycin and the metronidazole are administered concurrently, sequentially, alternately, intermittently, or any combination thereof.

In a particular embodiment, the metronidazole is administered at a dosage of up to 1500 mg per day, seven days per week, and the azithromycin is administered at a dosage of up to 600 mg per day, five days per week. In a further embodiment, each of the components is administered for a period of eight weeks.

According to yet another aspect, the present invention provides a synergistic composition having activity against an inflammatory gastrointestinal disorder, wherein the composition comprises (i) a nitroimidazole antibiotic selected from the group consisting of metronidazole, ornidazole and tinidazole; (ii) a macrolide antibiotic selected from the group consisting of azithromycin, clarithromycin, dirithromycin and roxithromycin; (iii) at least one pharmaceutically acceptable carrier or excipient, and optionally, (iv) polyphenolic compounds comprising those contained in a plant or fruit. According to yet another aspect, the present invention provides a use of (i) a nitroimidazole antibiotic selected from the group consisting of metronidazole, ornidazole and tinidazole, and (ii) a macrolide antibiotic selected from the group consisting of azithromycin, clarithromycin, dirithromycin and roxithromycin, and optionally, (iii) polyphenolic compounds comprising those contained in a plant or fruit, for the preparation of a medicament having activity against an inflammatory gastrointestinal disorder.

In some embodiments of the aforementioned composition and medicament, the nitroimidazole antibiotic and the macrolide antibiotic are each present in the composition or medicament at a concentration of 100 to 2000 mg per unit dose. In currently preferred embodiments, the nitroimidazole antibiotic is metronidazole and the macrolide antibiotic is azithromycin. In particular embodiments, the metronidazole is present in the composition or medicament at a concentration of 1500 mg per unit dose and the azithromycin is present in the composition or medicament at a concentration of 600 mg per unit dose. In particular embodiments, the polyphenolic compounds are contained in a plant part selected from leaf, stem, flower, seed, root, bud, sprout or combinations thereof. In particular embodiments, the polyphenolic compounds are naturally contained in a plant or fruit. In other embodiments, the polyphenolic compounds are contained in a plant or fruit following processing. In particular embodiments, the fruit is cranberry. In other embodiments, the polyphenolic compounds are present in the composition or medicament in an amount equivalent to that contained in 100 to 1000 ml of cranberry juice. In some embodiments, the composition or medicament is administered once daily for a period of six to twelve weeks. In particular embodiments, the composition or medicament is administered once daily for a period of eight weeks.

According to yet another aspect, the present invention provides a blister pack for pharmaceutical use, comprising (i) a first plurality of blisters, wherein each blister contains a solid dosage unit of metronidazole, or a pharmaceutically acceptable salt thereof, in association with at least one pharmaceutically acceptable carrier or excipient, and (ii) a second plurality of blisters, wherein each blister contains a solid dosage unit of azithromycin, or a pharmaceutically acceptable salt thereof, in association with at least one pharmaceutically acceptable carrier or excipient. In a particular embodiment, the solid dosage unit is selected from a tablet, a granulate powder, a lozenge, a cachet, a dry powder, a capsule and a wafer sheet. In another embodiment, the blisters are composed of a material selected from polyvinyl chloride, polyvinylidene chloride, a polyvinyl chloride/polyvinylidene chloride blend, polyethylene, polypropylene, polystyrene, polyester, paper, polyamide, polyethylene terephthalate, cyclic olefin copolymer, aluminium foil or a combination thereof. In another embodiment, the solid dosage unit of metronidazole comprises 100 to 2000 mg of metronidazole and the solid dosage unit of azithromycin comprises 100 to 2000 mg of azithromycin. In a particular embodiment, the first plurality of blisters is equal in number to the second plurality of blisters. In another embodiment, the first plurality of blisters is unequal in number to the second plurality of blisters.

Without wishing to be bound by any particular theory or mechanism of action, the therapeutic efficacy of the methods and compositions described herein may be attributed to the synergistic activity of (i) a nitroimidazole antibiotic in an amount effective to provide bactericidal activity against anaerobic bacteria; and (ii) a macrolide antibiotic in an amount effective to provide bactericidal activity against bacteria localized within cells of the intestinal lining, and within the intestinal lumen. The specific antibiotic combinations disclosed herein have not been previously taught for use in inflammatory gastrointestinal disease conditions, including Crohn's disease, and they are superior over previously known therapeutic strategies in providing symptomatic relief and in their ability to induce remission.

Other objects, features and advantages of the present invention will become clear from the following description.

DETAILED DESCRIPTION OF THE INVENTION

The invention relates to synergistic compositions and methods of treatment which provide symptomatic relief and/or induce remission in patients suffering from inflammatory gastrointestinal disorders. The gastrointestinal disorders may be of unclear etiology, such as Crohn's disease, inflammatory bowel disease and ulcerative colitis, or may be secondary to acquired or inherited immune function disorders, including acquired immunodeficiency syndrome, chronic granulatomous disease, hypogammaglobulinemia, agammaglobulinemia, leucocyte adhesion deficiency, cyclic neutropenia, and glycogen storage disease Ib.

The method of the invention comprises administering to a patient in need thereof a first antibiotic which is a nitroimidazole antibiotic, in an amount effective to provide bactericidal activity against anaerobic bacteria, and a second antibiotic which is a macrolide antibiotic, in an amount effective to provide bactericidal activity against bacteria localized within cells of the intestinal lining, and within the intestinal lumen. It has been found that the efficiency of each antibiotic is unexpectedly enhanced by the other, and that a course of treatment according to the invention results in symptomatic relief and clinical remission of Crohn's disease. The subject treatment method can result in recovery or remission in cases when recovery or remission could not be attained by the administration of the individual components or by other therapeutic methods.

Definitions

"Synergistic" as used herein denotes a clinical effect achieved by a combination of therapeutic agents, including antibiotics, wherein the effect is qualitatively and/or quantitatively greater than the effect achieved or expected using either agent on its own. Synergistic effects may be demonstrated by a combination of agents found together in a single pharmaceutical composition, or by a combination of agents present in distinct pharmaceutical compositions, which are administered together, for example in a therapeutic regimen.

"Amount effective" as used herein denotes a sufficient amount of a particular antibiotic which achieves clinical improvement in a patient's disease condition. Within the scope of sound medical judgment, the required dosage of an antibiotic or of the composition containing that antibiotic will vary with the severity of the condition, the duration of the treatment, the nature of adjunct treatment, the age and physical condition of the patient, the specific antibiotic employed, and like considerations.

"Bactericidal activity" as used herein denotes the ability of a therapeutic agent, including an antibiotic, to kill bacteria in vivo or in vitro. "Anaerobic bacteria" as used herein denotes bacteria which are obligate or facultative anaerobes with respect to metabolic function. They comprise species, subspecies and strains which are either part of the indigenous human flora, and/or are known pathogens or opportunistic pathogens.

"Localized within" as used herein denotes situated or located within a particular compartment, cell, cell type, organ, tissue, circulatory system, anatomical site or space or region thereof, but not necessarily confined or limited to that location. "Bacteria localized within" such a site or location pertains to those bacteria which have colonized the host in an infectious and/or pathogenic process and are accordingly the target of the antibiotics of the invention described herein. "Cells of the intestinal lining" as used herein denotes any of the cell types within either the small or large intestine which are situated between the lumen and the intestinal-associated lymphatic and capillary systems. Such cells include but are not limited to epithelial cells, immune system cells, stem cells, goblet cells, enterocytes, enteroendocrine cells, crypt cells, and Paneth cells. "Intestinal lumen" as used herein denotes the space enclosed and surrounded by the tissue layers of either or both of the small and large intestine. The intestinal lumen is the space occupied by ingesta and associated degradation products as they pass through the gastrointestinal tract.

"Pharmaceutically acceptable" as used herein denotes that the antibiotics and other ingredients including excipients and carriers used in the compositions and methods defined herein are suitable for use in contact with the tissues of humans without undue toxicity, irritation, allergic response, and the like, commensurate with a reasonable benefit/risk ratio.

"Administering" as used herein denotes that the antibiotics and synergistic compositions defined herein may be delivered by a variety of means and routes. It includes systemic use, as by injection (especially parenterally), intravenous infusion, suppositories, and oral administration thereof, as well as topical application of the compositions. Oral administration is particularly preferred in the present invention.

"Unit dose" and "dosage unit" are used interchangeably herein to denote a physically discrete unit suitable as a single dosage for a human subject, each unit containing a predetermined quantity of active material calculated to produce the desired therapeutic effect, in association with one or more suitable pharmaceutical excipients or carriers.

Clinical efficacy of the synergistic compositions and methods of treatment

The efficacy of the treatment methods and synergistic compositions of the invention described herein is indicated by significant clinical improvement in treated patients, as assessed by qualified practioners using methods known in the art. Clinical improvement means that any of a range of patient symptoms, biochemical indicators and pathological signs are ameliorated, eliminated or reduced. Patient symptoms include abdominal pain, rectal pain, chronic or intermittent diarrhea, weight loss, fever, rectal bleeding, tissue swelling and tenderness in the rectal area. Biochemical indicators include white blood cell count, sedimentation rate, red blood cell count, enzyme levels, protein levels, including C reactive protein, and body mineral concentrations. Visualization techniques used to assess pathological severity of gastrointestinal ulcers, abscesses, fissures and fistulae include x-ray, colonoscopy, sigmoidoscopy, computerized axial topography and video capsule endoscopy. Clinical improvement in the patient's condition is indicative of the bactericidal activity of the antibiotics used in the compositions and methods of the invention described herein. Bactericidal activity can also be demonstrated in microbiological assays, as are known in the art. For example, clinical isolates of organisms can be used as test organisms for in vitro determinations of minimal bactericide concentrations of nitroimidazole and macrolide antibiotics according to the invention. The rate of bactericidal action of the antibiotic combinations can also be quantitatively assessed using methods known in the art. For example, cultures of various bacterial isolates are incubated with antibiotics added singly or in combination. Synergism is indicated if a combination of antibiotics is more rapidly bactericidal then either drug alone.

Bacteria against which the synergistic combinations are directed

According to the invention described herein, aerobic and anaerobic bacteria, bacteria localized within cells of the intestinal lining and bacteria localized within the intestinal lumen, may variously be Gram positive or Gram negative bacteria. Such bacteria may be of species which are normally found within the gastrointestinal flora in healthy individuals. In patients affected with Crohn's disease or other inflammatory gastrointestinal disorders, certain of such bacteria may however, be involved in an infectious and/or pathogenic process. Alternately, such bacteria may be pathogenic strains or subtypes of normally innocuous species which have developed or evolved in a susceptible host or become established in a susceptible host. Alternately, such bacteria may be pathogens or opportunistic pathogens which are typically quiescent in a normal host (i.e. having a healthy immune system), but in a susceptible host readily establish an infectious and/or pathogenic process. A susceptible host may be an individual having an underlying disease and/or having certain defects in the immune system, due either to genetic inheritance or acquired disease.

The normal bacterial flora of the small intestine include Lactobacillus sp, Bifidobacterium sp., gram-negative anaerobes, enterococci, and Enterobacteriaceae e.g. E. coli. The large intestine contains predominantly obligate anaerobes including Bacteroides sp., Bifidobacterium sp., Clostridium sp., Lactobacillus sp., enterococci, and various anaerobic methanogenic bacteria. Gram-positive bacteria, such as Streptococcus sp. and Lactobacillus sp., are thought to adhere to gastrointestinal epithelial cell receptors using polysaccharide capsules or wall lipoteichoic acids. Gram- negative bacteria such as the enterics may attach by means of specific fimbriae which bind to glycoproteins on the epithelial cell surface.

Anaerobic bacteria found within the gastrointestinal tract may be obligate anaerobes or facultative anaerobes. According to the invention described herein anaerobic bacteria include but are not limited to Actinomyces sp., Bacteroides sp., Bifidobacterium sp., Bilophila sp., Butyrovibrio sp., Citrobacter sp., Clostridium sp., Coprococcus sp., Coryne bacterium sp., Desulfomonas sp., Desulfovibrio sp., Enterobacter sp., Enterococcus sp., Escherichia sp., Eubacterium sp., Fusobacterium sp., Klebsiella sp., Lactobacillus sp., Micrococcus sp., Mycobacterium sp., Peptococcus sp., Peptostreptococcus sp., Proteus sp., Pseudomonas sp., Ruminococcus sp., Staphylococcus sp., Streptococcus sp. and Veillonella sp.

According to the invention described herein, bacteria localized within cells of the intestinal lining and bacteria localized within the intestinal lumen, are bacterial species which are involved in infectious and/or pathogenic processes in patients affected with inflammatory gastrointestinal disorders such as Crohn's disease. Such intestinal bacterial species include but are not limited to Actinomyces sp., Bacteroides sp., Bifidobacterium sp., Bilophila sp., Butyrovibrio sp., Citrobacter sp., Clostridium sp., Coprococcus sp., Corynebacterium sp., Desulfomonas sp., Desulfovibrio sp., Enterobacter sp., Enterococcus sp., Escherichia sp., Eubacterium sp., Fusobacterium sp., Klebsiella sp., Lactobacillus sp., Micrococcus sp., Mycobacterium sp., Peptococcus sp., Peptostreptococcus sp., Proteus sp., Pseudomonas sp., Ruminococcus sp., Staphlococcus sp., Streptococcus sp. and Veillonella sp. Ulceration processes in Crohn's disease and ulcerative colitis

One possible mechanism for the chronic infection pattern seen in Crohn's disease and ulcerative colitis is the associated ulceration process. In the early stages, Crohn's disease causes small, scattered, shallow, crater-like areas (erosions) on the inner surface of the intestine. These erosions are termed aphthous ulcers. With time, the erosions become deeper and larger, ultimately becoming true ulcers, which cause scarring and stiffness of the intestine. As the disease progresses, the intestine becomes increasingly narrowed, and ultimately can become obstructed. Deep ulcers can puncture holes in the wall of the intestine, and bacteria from within the intestine can spread to infect adjacent organs and the surrounding abdominal cavity. Ulcers can further create tunnels between the intestine and adjacent organs, often resulting in abdominal abscesses and fϊstulae. Patients with abdominal abscesses can exhibit tender abdominal masses, high fevers, and abdominal pain. Fistulae can variously be enteric-vesicular (between the small intestine and the bladder), enteric- cutaneous (between the small intestine and the skin), colonic-vaginal (between the large intestine and the vagina) or anal, and lead to associated infections and complications in the involved organs. The patterns of inflammation and ulceration in ulcerative colitis are generally less wide-spread and less severe than that of Crohn's disease. Except in the most severe cases, ulcerative colitis tends to involve the superficial layers of the inner lining of the intestine. The inflammation also tends to be diffuse and uniform, such that all of the lining in the affected segment of the intestine is inflamed. In contrast, the inflammation of Crohn's disease is concentrated in some areas more than others and involves layers of the intestine that are deeper than the superficial inner layers. Therefore, the affected segment(s) of intestine in Crohn's disease is often studded with deeper ulcers with normal lining between these ulcers.

Antibiotics used in the synergistic compositions and methods of treatment A nitroimidazole antibiotic is one component of the synergistic compositions and methods of treatment described herein, and its use advantageously provides bactericidal activity against anaerobic bacteria. Without wishing to be bound by any particular theory, this activity is essential in conditions such as Crohn's disease which are characterized by infectious and/or pathogenic processes associated with a variety of anaerobic organisms, including species which normally colonize the gastrointestinal tract in healthy individuals. According to the invention, the nitroimidazole antibiotic is preferably selected from metronidazole, omidazole and tinidazole, and is most preferably metronidazole, which is chemically 2-methyl-5-nitro-lH-imidazole-l- ethanol. Nitroimidazole antibiotics, and in particular metronidazole, are well known in the art for treating infections in humans caused by several important Gram positive and Gram negative anaerobic bacterial species. Nitroimidazole antibiotics, and in particular metronidazole, are selectively toxic for obligate anaerobic bacteria due to the ability of such bacteria to reduce these antibiotics to their active form intracellularly. Specifically, the nitro group of the nitrosohydroxyl amino moiety of metronidazole is reduced by bacterial pyruvate:ferredoxin oxidoreductase, an electron transport protein present only in the mitochondria of anaerobic bacteria. The reduced antibiotic intermediate and free radicals produced interact with bacterial cell DNA, resulting in DNA strand breakage and fatal destabilization of the DNA helix, eventually leading to bacterial cell death. Metronidazole is equally effective against dividing and nondividing cells. Metronidazole is also cytotoxic to facultative anaerobic bacteria and protozoans, including Helicobacter pylori and Gardnerella vaginalis, but the mechanism of this action is not well understood.

A macrolide antibiotic is the other antibiotic component of the synergistic compositions and methods of treatment described herein, and it use advantageously provides bactericidal activity against bacteria localized within cells of the intestinal lining, and within the intestinal lumen. Without wishing to be bound by any particular theory, this activity is essential in conditions such as Crohn's diseasee which are characterized by infectious and/or pathogenic processes established both or alternately within cells of the intestinal lining, and within the intestinal lumen. According to the invention, the macrolide antibiotic is preferably selected from azithromycin, clarithromycin, dirithromycin and roxithromycin, and is most preferably azithromycin. Azithromycin comprises a lactone ring with 15 carbon atoms while the other mentioned macrolide antibiotics comprise a lactone ring with 14 carbon atoms. These synthetic antibiotics are broad spectrum antibiotics well known in the art. Azithromycin is chemically 9a-aza-9a-methyl-9-deoxo-9a-homoerythromycin A, and its structure and antibiotic activity have been disclosed, for example in U.S. 4,474,768 and U.S. 4,517,359. Azithromycin is particularly preferred in clinical practice for a wide range of infectious diseases and may be used for pediatric therapy. It is known to have a mechanism of action involving inhibition of the 50S ribosomal subunit, thus interfering with bacterial protein synthesis. Azithromycin is known in the art for its ability to penetrate intracellular spaces.

The synergistic compositions encompassed by the invention comprise a nitroimidazole antibiotic selected from the group consisting of metronidazole, ornidazole and tinidazole, and a macrolide antibiotic selected from azithromycin, clarithromycin, dirithromycin and roxithromycin. Preferably the nitroimidazole antibiotic and the macrolide antibiotic are each present in the composition at a concentration of 100 to 2000 mg per unit dose. In a preferred embodiment, the nitroimidazole antibiotic is metronidazole and the macrolide antibiotic is azithromycin.

In another preferred embodiment, the metronidazole is present at a concentration of 1500 mg per unit dose and the azithromycin is present at a concentration of 600 mg per unit dose.

In the methods of the invention, the nitroimidazole antibiotic may be administered at a dosage of 15-50 mg per kg body weight per day, and the macrolide antibiotic may be administered at a dosage 5-15 mg per kg body weight per day. Specific dosing methods within these ranges are envisioned, according to the specific clinical situation. For example, for pediatric use, metronidazole is generally recommended at a dosage of 20 mg per kg and azithromycin is generally recommended at a dosage of lOmg per kg. Similarly, the synergistic compositions according to the invention, may be prepared according to these ranges, both those suitable for pediatric use, and those suitable for adult use. One envisioned composition suitable for pediatric patients, contain metronidazole at a concentration of 500 mg per unit dose and azithromycin at a concentration of 250 mg per unit dose. Other dosage combinations can be prepared, for example in liquid form from stock solutions or suspensions, according to physician's prescription based on the body weight of the pediatric patient.

The nitroimidazole and macrolide antibiotics employed in the compositions and methods of treatment of this invention may be in the form of pharmaceutically acceptable salts, hydrates, solvates and anhydrous forms.

Polyphenols compounds The synergistic compositions and methods of treatment optionally comprise use of polyphenols compounds contained in a plant or fruit. The polyphenols compounds may be those found, in particular, in a plant part, including fruit, leaf, stem, flower, seed, root, bud, sprout or any combination thereof. The polyphenols compounds may be those naturally contained in a plant or fruit, or may be those which are formed upon processing thereof. Polyphenols compounds include but are not limited to compounds classified as anthocyanins, catechins, flavonoids, flavonols and proanthocyanidins. Proanthocyanidins are also known as leucoanthocyanins, leucodelphinins, leucocyanins, anthocyanogens, epicatechin-catechin polymers or procyanidins.

The polyphenols compounds preferably comprise those naturally contained in cranberry, preferably Vaccinum macrocarpon, the North American cranberry.

Polyphenols compounds naturally contained in cranberry are known in the art to have biological activity against pathogenic bacteria. In particular, such activities include prevention of bacterial adhesion and biofilm development.

Other sources of polyphenolic compounds according to the invention include but are not limited to bilberry, black currant, blueberry, bog whortleberry, cherry, chokeberry, crowberry, elderberry, grape, gooseberry, lingonberry, plum, raspberry, rowanberry, sea buckthorn berry, strawberry, sweet rowan and white currant.

Other sources of polyphenolic compounds include the tea plant Camellia sinesis and various processed tea forms produced therefrom. Processed teas include green tea, black tea, oolong tea and white tea, which are distinguished by different processing methods and, consequently, different concentrations of specific polyphenols. Green tea is produced by rapidly steaming or pan-frying freshly harvested leaves in order to inactivate enzymes, thereby preventing fermentation and producing a dry, stable product. Epicatechins are the main compounds in green tea, accounting for its characteristic color and flavor. White teas are unfermented teas made from very young tea leaves or buds that are steamed immediately after harvest to inactivate polyphenol oxidase and then dried. White teas usually contain higher concentrations of catechins than other teas. For the production of black and oolong teas, the fresh leaves are allowed to wither until their moisture content is reduced to about 55% of the original leaf weight, which results in the concentration of polyphenols. The withered leaves are then rolled and crushed, initiating fermentation of the polyphenols. During these processes, the catechins are converted to theaflavins and thearubigins. Oolong tea is prepared by firing the leaves shortly after rolling to terminate the oxidation and dry the leaves. Normal oolong tea is considered to be about half as fermented as black tea. The fermentation process results in oxidation of simple polyphenols to more complex condensed polyphenols to give black and oolong teas their characteristic colors and flavors.

According to the invention, polyphenolic compounds may optionally be administered in addition to the antibiotic combinations disclosed herein. The polyphenolic compounds may be administered in the form of a nutritional supplement, for example, in the form of a capsule, a liquid, a suspension, a tincture, an extract or a pill. In one embodiment, the polyphenolic compounds comprise those contained in cranberry. Accordingly, one convenient nutritional supplement is cranberry juice, administered for example, at a dosage of 100 to 1000 ml per day. Alternately, or in addition, the nutritional supplement may contain cranberry polyphenolic compounds in an amount equivalent to that contained in 100 to 1000 ml of cranberry juice. In another embodiment the polyphenolic compounds are present in the synergistic compositions of the invention in an amount equivalent to that contained in 100 to 1000 ml of cranberry juice.

The polyphenolic compounds may be obtained from plant tissue by chemical and food processing methods and techniques known in the art, including but not limited to phase extraction, chromatography and selective precipitation. The polyphenolic compounds may also be obtained by chemical synthesis or by fermentation. The polyphenolic compounds may be quantified by means known in the art.

Bacterial adhesion and biofilm development

Bacterial adhesion and biofilm development are significant determining factors in infectious and/or pathogenic processes. Adhesion enables a bacterial pathogen to become established at the port of entry i.e. the gastrointestinal tract. The involved bacteria usually possess tissue adherence mechanisms and ability to overcome or withstand the pressure of host defenses on the surface. For example, enteropathogenic E. coli have type-1 fimbriae which bind to distinct carbohydrate structures on intestinal epithelial tissues. Biofilms are dense microcolonies of bacteria entrapped within a polysaccharide matrix attached to a host surface. The 'biofilm concept' contradicts the assumption that infectious cells are evenly distributed and therefore equally vulnerable to immune responses or antibiotic therapies. The biofilm mode of growth is postulated to account for several problematic clinical aspects of Crohn's disease, including chronic inflammation, recurrent and persistent infections, and the spread of infectious emboli.

Without wishing to be bound by any particular theory, the polyphenolic compounds as disclosed herein may have activity against bacterial adhesion and/or biofilm development. Either or both of these phenomena may not necessarily be fully controlled by the antibiotic combinations of the invention. Accordingly, inclusion of polyphenolic compounds in the treatment methods or synergistic compositions can advantageously augment the anti-bacterial activity of the antibiotic combinations and/or provide additional synergistic activity against bacteria involved in infectious and/or pathogenic processes in Crohn's disease. Embodiments of the methods

The invention provides a method for treating an inflammatory gastrointestinal disorder, wherein the method comprises administrating to a patient in need thereof: (i) a first antibiotic, which is a nitroimidazole, in an amount effective to provide bactericidal activity against anaerobic bacteria; and (ii) a second antibiotic, which is a macrolide, in an amount effective to provide bactericidal activity against bacteria localized within cells of the intestinal lining, and within the intestinal lumen.

In a particular embodiment, the nitroimidazole antibiotic is selected from metronidazole, ornidazole and tinidazole, and the macrolide antibiotic is selected from azithromycin, clarithromycin, dirithromycin and roxithromycin. In a further embodiment, the nitroimidazole antibiotic and the macrolide antibiotic are each administered at a dosage of 100 to 2000 mg per day for three to seven days per week for a period of six to twelve weeks. In a currently preferred embodiment, the nitroimidazole antibiotic is metronidazole and the macrolide antibiotic is azithromycin In further embodiments, the nitroimidazole antibiotic is administered at a dosage of 15- 50 mg per kg body weight per day, and the macrolide antibiotic is administered at a dosage 5-15 mg per kg body weight per day. In another embodiment, the metronidazole is administered at a dosage of up to 1500 mg per day and the azithromycin is administered at a dosage of up to 600 mg per day. The metronidazole may be administered seven days per week, and the azithromycin may be administered five days per week, each for a period of eight weeks.

Other antibiotic dosages are also envisioned, for example for pediatric use. It is within the ability of the skilled practitioner to adapt the dosages of the therapeutic regimen to the patient population being treated. For example, metronidazole is generally recommended for children at a dosage of 20 mg/ kg and azithromycin is generally recommended for children at a dosage of 10 mg/ kg. Thus, the theraeputic regimen will comprise dosages based on the body weight of the patient and the recommended dosing schedules of the specific antibiotics.

A nutritional supplement comprising polyphenols compounds contained in a plant or fruit may be optionally administered in addition to the antibiotic combinations.

The nutritional supplement can be a capsule, a liquid, a suspension, a tincture, an extract or a pill. The nutritional supplement can also be a syrup, elixir, microbead, granule, powder, sachet, pastille, sweet, bar or other administration form. The polyphenols compounds may be derived from a plant part including fruit, flower leaf, stem, seed, root, bud and sprout tissues or a combination thereof, or may comprise those naturally occurring in such tissues. The polyphenolic compounds may be those produced upon processing of plants, fruits or parts thereof. The polyphenolic compounds preferably comprise those naturally contained in cranberry, but may comprise, in addition or alternately, those found in other fruits, including but not limited to bilberry, black currant, blueberry, bog whortleberry, cherry, chokeberry, crowberry, elderberry, grape, gooseberry, lingonberry, plum, raspberry, rowanberry, sea buckthorn berry, strawberry, sweet rowan and white currant. According to the invention, the nutritional supplement is preferably cranberry juice and the cranberry juice is admim^'stered at a dosage of 100 to 1000 ml per day, for a period of eight weeks. In another embodiments, the polyphenolic compounds comprise those contained in tea, including green tea, white tea, black tea and oolong tea. Accordingly, the nutritional supplement may be any of these teas, administered at a dosage of 100 to 1000 ml per day.

According to the methods of the invention, the nitroimidazole antibiotic and the macrolide antibiotic may be administered in a single dosage unit or in separate dosage units, as is known in the art. Further, the nitroimidazole antibiotic and the macrolide antibiotic may be administered concurrently, sequentially, alternately, intermittently, or in any combination thereof. Concurrent administration means that the two antibiotics are administered simultaneously, or within a specified period of time of each other, for example within five minutes to one hour, or up to 24 hours of each other. Concurrent administration may be achieved by either a single dosage unit or by separate dosage units. A single dosage unit is provided, for example, by the synergistic compositions also described herein. Sequential administration means that the two antibiotics are administered one after the other in a prescribed manner, for example to avoid undesirable interactions. Sequential administration encompasses administration with a specified waiting period after administration of the first antibiotic and before administration of the second antibiotic, or vice versa. Alternating administration means that the two antibiotics are administered in an alternating fashion, for example, the first antibiotic on the first day and the second antibiotic on the second day, and so on. Intermittent administration means that administration of one or both antibiotics is periodically ceased and begun again. For example, the first antibiotic is administered daily, while the second antibiotic is administered every second day, or in any other intermittant manner determined by the prescribing clinician. For example, in one embodiment of the invention described herein, metronidazole is administered seven days per week, and azithromycin is administered five days per week, which is a form of intermittent administration. Intermittent adminstration also encompasses administration of only one of the antibiotics, prior to or following the administration of the combination of antibiotics. For example, the combination of a nitroimidazole and a macrolide may be administered for a period of eight weeks, and then a macrolide may be administered on its own for a further period of four weeks. The dosing schedule may also include combinations of concurrent, sequential, alternating and intermittent administration, and is readily determined by one skilled in the art, according to the specific clinical situation. Sequential, alternating and intermittant administration are achieved by separate dosage units. The dosing schedules disclosed herein may further include administration of a nutritional supplement, either as part of a dosage unit containing one or both of the antibiotics, or as a separate entity, for example a fruit extract or a capsule comprising polyphenolic compounds extracted from plant material.

The invention further provides a method which comprises administering to a patient in need thereof a synergistic therapeutic regimen, wherein the regimen comprises the components: (i) azithromycin at a dosage of 100 to 600 mg per day; (ii) metronidazole at a dosage of 100 to 1500 mg per day; and (iii) cranberry juice at a dosage of 100 to 1000 ml per day. In one embodiment, the metronidazole is administered at a dosage of 1500 mg per day, seven days per week, and the azithromycin is administered at a dosage of 600 mg per day, five days per week, and each of the components is administered for a period of eight weeks. In another embodiment, the metronidazole is administered at a dosage of 15-50 mg per kg body weight per day, and the azithromycin is administered at a dosage 5-15 mg per kg body weight per day.

Embodiments of the synergistic compositions

Synergistic compositions of the invention comprise (i) a nitroimidazole antibiotic selected from the group consisting of metronidazole, ornidazole and tinidazole; (ii) a macrolide antibiotic selected from the group consisting of azithromycin, clarithromycin, dirithromycin and roxithromycin; (iii) at least one pharmaceutically acceptable carrier or excipient, and optionally, (iv) polyphenols compounds comprising those naturally contained in plant or fruit. The nitroimidazole antibiotic and the macrolide antibiotic may each be present at a concentration of 100 to 2000 mg per unit dose. In a preferred embodiment, the nitroimidazole antibiotic is metronidazole and the macrolide antibiotic is azithromycin. In one preferred embodiment, the metronidazole is present in the composition at a concentration of 1500 mg per unit dose and the azithromycin is present in the composition at a concentration of 600 mg per unit dose.

In a more particular embodiment, the synergistic compositions comprise (i) azithromycin at a concentration of 100 to 600 mg per unit dose; (ii) metronidazole at a concentration of 100 to 1500 mg per unit dose; (iii) polyphenols compounds comprising those naturally contained in cranberry, present in the composition in an amount equivalent to that contained in 100 to 1000 ml of cranberry juice; and (iv) at least one pharmaceutically acceptable carrier or excipient.

The synergistic compositions described herein may be used in methods for treating inflammatory gastrointestinal disorders selected from Crohn's disease, inflammatory bowel disease and ulcerative colitis. In one embodiment, the synergistic composition is administered once daily for a period of six to twelve weeks. In a more particular embodiment, the synergistic composition is administered once daily for a period of eight weeks. Blister packs

The invention further provides a blister pack for pharmaceutical use, comprising (i) a first plurality of blisters, wherein each blister contains a solid dosage unit of metronidazole, or a pharmaceutically acceptable salt thereof, in association with at least one pharmaceutically acceptable carrier or excipient, and (ii) a second plurality of blisters, wherein each blister contains a solid dosage unit of azithromycin, or a pharmaceutically acceptable salt thereof, in association with at least one pharmaceutically acceptable carrier or excipient.

The solid dosage unit may be a tablet, a granulate powder, a lozenge, a cachet, a dry powder, a capsule or a wafer sheet. The blisters may be composed of a material selected from polyvinyl chloride, polyvinylidene chloride, a polyvinyl chloride/polyvinylidene chloride blend, polyethylene, polypropylene, polystyrene, polyester, paper, polyamide, polyethylene terephthalate, cyclic olefin copolymer, aluminium foil or a combination thereof. A blend also encompasses a layered composite. Blister pack manufacturing technology is conventional for a person skilled in the art. In one embodiment of the blister pack, the solid dosage unit of metronidazole comprises 100 to 2000 mg of metronidazole and the solid dosage unit of azithromycin comprises 100 to 2000 mg of azithromycin. In a particular embodiment, the first plurality of blisters is equal in number to the second plurality of blisters. In another embodiment, the first plurality of blisters is unequal in number to the second plurality of blisters.

Formulations and excipients The synergistic compositions of the present invention can be formulated for administration by a variety of routes including oral, rectal, transdermal, subcutaneous, intravenous, intramuscular, topical and intranasal. Such compositions are prepared in a manner well known in the art and comprise in addition to the antibiotics at least one pharmaceutically acceptable carrier or excipient. During the preparation of the synergistic compositions according to the present invention, the antibiotic(s), either singly or in combination, are usually mixed with an excipient, diluted by an excipient or enclosed within such a carrier which can be in the form of a capsule, sachet, paper or other container. When the excipient serves as a diluent, it can be a solid, semi-solid, or liquid material, which acts as a vehicle, carrier or medium for the antibiotics. Thus, the compositions can be in the form of tablets, pills, powders, lozenges, sachets, cachets, elixirs, suspensions, emulsions, solutions, syrups, aerosols (as a solid or in a liquid medium), ointments, soft and hard gelatin capsules, suppositories, sterile injectable solutions, and sterile packaged powders.

Some examples of suitable excipients include lactose, dextrose, sucrose, sorbitol, mannitol, starches, gum acacia, calcium phosphate, alginates, tragacanth, gelatin, calcium silicate, microcrystalline cellulose, polyvinylpyrrolidone, cellulose, water, syrup, and methylcellulose. The compositions can additionally include lubricating agents such as talc, magnesium stearate, and mineral oil; wetting agents; emulsifying and suspending agents; preserving agents such as methyl- and propylhydroxybenzoates; sweetening agents; and flavoring agents. The compositions of the invention can be formulated using procedures known in the art, so as to provide immediate, sustained, pulsatile or delayed release of the antibiotics following administration to the patient. For preparing solid compositions such as tablets, the principal active ingredient is mixed with a pharmaceutical excipient to form a solid homogeneous preformulation composition. By homogeneous, it is meant that the active ingredient is dispersed evenly throughout the composition so that the composition may be readily subdivided into equally effective unit dosage forms such as tablets, pills and capsules. This solid preformulation is then subdivided into unit dosage forms containing from, for example, 100 to 2000 mg of each antibiotic of the present invention. The tablets or pills of the present invention may be coated or otherwise compounded to provide a dosage form affording the advantage of prolonged action. For example, the tablet or pill can comprise an inner dosage and an outer dosage component, the latter being in the form of an envelope over the former. The two components can be separated by an enteric layer, which serves to resist disintegration in the stomach and permit the inner component to pass intact into the duodenum or to be delayed in release. A variety of materials can be used for such enteric layers or coatings, such materials including a number of polymeric acids and mixtures of polymeric acids with such materials as shellac, cetyl alcohol, and cellulose acetate. As used herein, tablets include compressed tablets, coated tablets, matrix tablets, osmotic tablets, and other forms known in the art

The liquid forms in which the compositions of the present invention may be incorporated, for administration orally or by injection, include aqueous solutions, suitably flavored syrups, aqueous or oil suspensions, and flavored emulsions with edible oils such as cottonseed oil, sesame oil, coconut oil, or peanut oil, as well as elixirs and similar pharmaceutical vehicles.

The following examples are presented in order to more fully illustrate certain embodiments of the invention. They should in no way, however, be construed as limiting the broad scope of the invention. One skilled in the art can readily devise many variations and modifications of the principles disclosed herein without departing from the scope of the invention.

EXAMPLES

Example 1

A 9 year old female with Crohn's colitis since age 1, had active disease with 10 bloody stools per day, anorexia and weight loss, despite treatment with azathioprine. A sigmoidoscopy revealed multiple ulcers and inflamed mucosa up to thirty centimeters, a pathology consistent with Crohn's disease. She received azithromycin (10 mg/kg, 5 days a week), in combination with metronidazole (20 mg/kg day, 7 days a week) and two glasses (approximately 100 to 250 ml each) of cranberry juice per day for 8 weeks followed by an additional two months with azithromycin 3 times a week. Diarrhea ceased, weight gain and clinical remission ensued. A repeat sigmoidoscopy three months after presentation revealed mucosal healing with only a single rectal apthous lesion. Example 2

A male child, aged 6 years seven months old with Crohn's disease involving ileum and colon since age 5, previously treated with azathioprine, presented with a complaint of diarrhea, anorexia, abdominal pain and low grade fever, for the past 3 weeks. The levl of C-reactive protein (CRP) was elevated (to levels 20 times that of normal). He did not improve with PENTAS A^® and nutritional support. He received azithromycin (10 mg/kg, 5 days a week), in combination with metronidazole (20 mg/kg day, 7 days a week) and two glasses (approximately 100 to 250 ml each) of cranberry juice per day for 8 weeks. After two weeks, diarrhea and fever ceased, CRP was reduced to only 3 times that of normal. After one month, the patient felt no abdominal pain, and albumin, CRP and sedimentation rate were normal, indicative of clinical remission. He was treated with azithromycin 10 mg/kg /day three times a week for an additional month.

Example 3

A 19 year old female with ileocecal Crohn's disease had new onset abdominal pain and elevation of CRP (18 times that of normal) after discontinuing azathioprine due to a period of quiescent disease. She received azithromycin (500 mg per day, 5 days per week) in combination with metronidazole (2 times 500 mg per day, 7 days per week) and two glasses (approximately 100 to 250 ml each) of cranberry juice for 8 weeks, with complete remission of clinical symptoms within a month.

Example 4 A 25 year old female with a three year history of colonic Crohn's disease was being treated with intramuscular injections of methotrexate 15 mg weekly. She had responded only to corticosteroids in the past, had constant diarrhea, abdominal pain and elevated sedimentation rate. She had not responded completely to 5-aminosalycilic acid or ciprofloxacillin in the past. She received azithromycin (500 mg/day, 5 days per week) in combination with metronidazole (2 times 500 mg per day, 7 days per week and two glasses (approximately 100 to 250 ml each) of cranberry juice for 8 weeks, with complete remission of clinical symptoms within a month.

Claims

1. A method for treating an imflammatory gastrointestinal disorder, wherein the method comprises administering to a patient in need thereof:

(i) a first antibiotic, which is a nitroimidazole, in an amount effective to provide bactericidal activity against anaerobic bacteria; and

(ii) a second antibiotic, which is a macrolide, in an amount effective to provide bactericidal activity against bacteria localized within cells of the intestinal lining, and the intestinal lumen.

2. The method of claim 1, wherein the nitroimidazole antibiotic is selected from the group consisting of metronidazole, ornidazole and tinidazole, and wherein the macrolide antibiotic is selected from the group consisting of azithromycin, clarithromycin, dirithromycin and roxithromycin.

3. The method of claim 1, wherein the nitroimidazole antibiotic and the macrolide antibiotic are each administered at a dosage of 100 to 2000 mg per day for three to seven days per week for a period of six to twelve weeks.

4. The method of claim 1, wherein the nitroimidazole antibiotic is administered at a dosage of 15-50 mg per kg body weight per day, and the macrolide antibiotic is administered at a dosage 5-15 mg per kg body weight per day.

5. The method of claim 2, wherein the nitroimidazole antibiotic is metronidazole and the macrolide antibiotic is azithromycin.

6. The method of claim 5, wherein the metronidazole is administered at a dosage of up to 1500 mg per day and the azithromycin is administered at a dosage of up to 600 mg per day.

7. The method of claim 6, wherein the metronidazole is administered seven days per week, and the azithromycin is administered five days per week, each for a period of eight weeks.

8. The method of claim 1, wherein the intestinal bacteria are selected from the group consisting of Actinomyces sp., Bacteroides sp., Bifidobacterium sp., Bilophila sp., Butyrovibrio sp., Citrobacter sp., Clostridium sp., Coprococcus sp., Corynebacterium sp., Desulfomonas sp., Desulfovibrio sp., Enterobacter sp., Enterococcus sp., Escherichia sp., Eubacterium sp., Fusobacterium sp., Klebsiella sp., Lactobacillus sp., Micrococcus sp., Mycobacterium sp., Peptococcus sp., Peptostreptococcus sp., Proteus sp., Pseudomonas sp., Ruminococcus sp., Staphylococcus sp., Streptococcus sp. and Veillonella sp.

9. The method of claim 1 , wherein the inflammatory gastrointestinal disorder is selected from the group consisting of Crohn's disease, inflammatory bowel disease and ulcerative colitis.

10. The method of claim 1, wherein the inflammatory gastrointestinal disorder is associated with an immune function disorder.

11. The method of claim 10, wherein the immune function disorder is selected from the group consisting of acquired immunodeficiency syndrome, chronic granulatomous disease, hypogammaglobulinemia, agammaglobulinemia, leucocyte adhesion deficiency, cyclic neutropenia, and glycogen storage disease Ib.

12. The method of claim 1, wherein the nitroimidazole antibiotic and the macrolide antibiotic are administered in a single dosage unit or in separate dosage units.

13. The method of claim 1, wherein the nitroimidazole antibiotic and the macrolide antibiotic are administered concurrently, sequentially, alternately, intermittently, or any combination thereof.

14. The method of claim 1, further comprising administering a nutritional supplement comprising polyphenolic compounds contained in a plant or fruit.

15. The method of claim 14, wherein the nutritional supplement is a capsule, a liquid, a suspension, a tincture, an extract or a pill.

16. The method of claim 14, wherein the fruit is cranberry.

17. The method of claim 14, wherein the nutritional supplement is cranberry juice.

18. The method of claim 17, wherein the cranberry juice is administered at a dosage of 100 to 1000 ml per day, for a period of eight weeks.

19. A method for treating an inflammatory gastrointestinal disorder selected from the group consisting of Crohn's disease, inflammatory bowel disease and ulcerative colitis, wherein the method comprises administrating to a patient in need thereof a synergistic therapeutic regimen, wherein the regimen comprises the components:

(i) azithromycin at a dosage of 100 to 600 mg per day;

(ii) metronidazole at a dosage of 100 to 1500 mg per day; and optionally,

(iii) cranberry juice at a dosage of 100 to 1000 ml per day.

20. The method of claim 19, wherein the metronidazole is administered at a dosage of 1500 mg per day, seven days per week, and the azithromycin is administered at a dosage of 600 mg per day, five days per week.

21. The method of claim 20, wherein each of the components is administered for a period of eight weeks.

22. The method of claim 19, wherein the metronidazole is administered at a dosage of 15-50 mg per kg body weight per day, and the azithromycin is administered at a dosage 5-15 mg per kg body weight per day.

23. A synergistic composition having activity against an inflammatory gastrointestinal disorder, wherein the composition comprises: (i) a nitroimidazole antibiotic selected from the group consisting of metronidazole, ornidazole and tinidazole;

(ii) a macrolide antibiotic selected from the group consisting of azithromycin, clarithromycin, dirithromycin and roxithromycin;

(iii) at least one pharmaceutically acceptable carrier or excipient, and optionally,

(iv) polyphenolic compounds comprising those contained in a plant or fruit.

24. The composition of claim 23, wherein the nitroimidazole antibiotic and the macrolide antibiotic are each present in the composition at a concentration of 100 to 2000 mg per unit dose.

25. The composition of claim 23, wherein the nitroimidazole antibiotic is metronidazole and the macrolide antibiotic is azithromycin.

26. The composition of claim 25, wherein the metronidazole is present in the composition at a concentration of 1500 mg per unit dose and the azithromycin is present in the composition at a concentration of 600 mg per unit dose.

27. The composition of claim 23, comprising polyphenolic compounds contained in cranberry.

28. The composition of claim 27, wherein the polyphenolic compounds are present in the composition in an amount equivalent to that contained in 100 to 1000 ml of cranberry juice.

29. The composition of claim 23, wherein the inflammatory gastrointestinal disorder is selected from the group consisting of Crohn's disease, inflammatory bowel disease and ulcerative colitis.

30. The composition of claim 22, wherein the inflammatory gastrointestinal disorder is associated with an immune function disorder.

31. The composition of claim 29, wherein the immune function disorder is selected from the group consisting of acquired immunodeficiency syndrome, chronic granulatomous disease, hypogammaglobulinemia, agammaglobulinemia, leucocyte adhesion deficiency, cyclic neutropenia, and glycogen storage disease

Ib.

32. A method for treating an inflammatory gastrointestinal disorder selected from the group consisting of Crohn's disease, inflammatory bowel disease and ulcerative colitis, wherein the method comprises administering to a patient in need thereof the composition of claim 23.

33. The method of claim 32, wherein the composition is administered once daily for a period of six to twelve weeks.

34. The method of claim 33, wherein the composition is administered once daily for a period of eight weeks.

35. Use of (i) a nitroimidazole antibiotic selected from the group consisting of metronidazole, ornidazole and tinidazole; (ii) a macrolide antibiotic selected from the group consisting of azithromycin, clarithromycin, dirithromycin and roxithromycin, and optionally, (iii) polyphenolic compounds comprising those contained in a plant or fruit, for the preparation of a medicament having activity against an inflammatory gastrointestinal disorder.

36. The use of claim 35, wherein the nitroimidazole antibiotic and the macrolide antibiotic are each present in the medicament at a concentration of 100 to 2000 mg per unit dose.

37. The use of claim 35, wherein the nitroimidazole antibiotic is metronidazole and the macrolide antibiotic is azithromycin.

38. The use of claim 37, wherein the metronidazole is present in the medicament at a concentration of 1500 mg per unit dose and the azithromycin is present in the medicament at a concentration of 600 mg per unit dose.

39. The use of claim 35, wherein the medicament comprises polyphenolic compounds contained in cranberry.

40. The use of claim 39, wherein the polyphenolic compounds are present in the medicament in an amount equivalent to that contained in 100 to 1000 ml of cranberry juice.

41. The use of claim 35, wherein the inflammatory gastrointestinal disorder is selected from the group consisting of Crohn's disease, inflammatory bowel disease and ulcerative colitis.

42. The use of claim 35, wherein the inflammatory gastrointestinal disorder is associated with an immune function disorder.

43. The use of claim 42, wherein the immune function disorder is selected from the group consisting of acquired immunodeficiency syndrome, chronic granulatomous disease, hypogammaglobulinemia, agammaglobulinemia, leucocyte adhesion deficiency, cyclic neutropenia, and glycogen storage disease Ib.

44. A blister pack for pharmaceutical use comprising (i) a first plurality of blisters, wherein each blister contains a solid dosage unit of metronidazole, or a pharmaceutically acceptable salt thereof, in association with at least one pharmaceutically acceptable carrier or excipient, and (ii) a second plurality of blisters, wherein each blister contains a solid dosage unit of azithromycin, or a pharmaceutically acceptable salt thereof, in association with at least one pharmaceutically acceptable carrier or excipient.

45. The blister pack of claim 44, wherein the solid dosage form is selected from the group consisting of a tablet, a granulate powder, a lozenge, a cachet, a dry powder, a capsule and a wafer sheet.

46. The blister pack of claim 44, wherein the blisters are composed of a material selected from the group consisting of polyvinyl chloride, polyvinylidene chloride, a polyvinyl chloride/polyvinylidene chloride blend, polyethylene, polypropylene, polystyrene, polyester, paper, polyamide, polyethylene terephthalate, cyclic olefin copolymer, aluminium foil or a combination thereof.

47. The blister pack of claim 44, wherein the solid dosage unit of metronidazole or pharmaceutically acceptable salt thereof comprises 100 to 2000 mg of metronidazole and the solid dosage unit of azithromycin or pharmaceutically acceptable salt thereof comprises 100 to 2000 mg of azithromycin.