The prospective cohort and randomized, double-blind, placebo controlled study will be
conducted on the basis of Research Institute of Epidemiology, Microbiology and Infectious
Diseases and Coloproctology department of the Republic clinical hospital №1, Ministry of
Public Health of the Republic of Uzbekistan.
Participants Diagnosis of UC will be confirmed using standard clinical, endoscopic,
radiographic, and pathological criteria according to the Montreal classification of extent
and severity of ulcerative colitis (Silverberg MS et al. 2006). UC categories include
proctitis, left-sided colitis, and extensive colitis or pancolitis. Activity of the disease
will be measured by Mayo Clinic score that consists of 4 items: stool frequency, rectal
bleeding, findings of flexible proctosigmoidoscopy, and patient's functional assessment
(D'Haens G et al. 2007). The disease duration will be measured in years from the first time
of symptoms onset.
UC patients hospitalized in coloproctology department of Republic clinical hospital №1 will
be examined before surgery and receiving of medications. Additional cohort groups: the 1st
one will include UC patients infected with B. hominis which will be examined before and after
taking nitazoxanide (monotherapy), the 2nd group will include UC patients infected with B.
hominis before and after taking nitazoxanide and mesalazine (combination therapy) and 3rd one
- patients with UC infected with B. hominis before and after taking mesalazine (monotherapy).
The control group will include residents of Tashkent region without any complaints from the
gastrointestinal tract, who will apply to the clinic for planned medical examinations.
Suggested age of the population from 17 to 90 years
Exclusion criteria Patients with diagnosis of Crohn's disease will be excluded from the
analysis. Other exclusion criteria are toxic megacolon, abdominal abscess, symptomatic
colonic stricture, stoma, a history of colectomy, an increased risk of infectious
complications (e.g. as a result of recent pyogenic infection, enteric pathogens detected in
microbiological stool analysis, active or latent tuberculosis, immunodeficiency, hepatitis B
or C, or recent live vaccination), clinically meaningful laboratory abnormalities, pregnancy
or lactation, unstable or uncontrolled medical disorders, an anticipated requirements for
major surgery, colonic dysplasia or adenomas, and malignant neoplasms.
For additional groups except the above mentioned the followed patients will be excluded:
individuals who were operated, ever used immunosuppressants or biological drugs, infected
with intestinal pathologenic bacteria, including Clostridium difficile, Salmonella spp,
Shigella spp, Campylobacter spp, Yersinia spp, and Mycobacteria.
Parasitological method Collection of stool samples. Three stool samples for parasitological
examination will be taken from both control subjects and UC patients at 2 days interval
before therapy (all participants) and in the 2nd week of monotherapy therapy with
nitazoxanide, nitazoxanide in combination with mesalazine and monotherapy with mesalazine and
in 6th and 12th weeks from beginning of the therapy. Stool samples (1-2g.) will be collected
in individual containers, with 5 ml of Turdiev's preservative provided conservation and
staining of proozoa cysts and eggs of worms for a year. The Turdiev's preservative includes:
80 ml of 0.2% aqueous solution of sodium nitrite, 10 ml of formaldehyde, 2 ml of glycerin, 8
ml of Lugol's solution, 250 ml of distilled water.
Stool samples (1-2g.) for detection of C. parvum (Cryptosporidium parvum) will be collected
in individual empty containers no less 1 hour before parasitological examination.
Microscopy. Parasitological diagnosis will be performed by triple coproscopy using formalin -
ethyl acetate concentration technique [Truant AL, Elliott SH] and iodine stained smears [King
M.]. For preparations staining Lugol's solution will be used. The intensity of protozoa will
be estimated by the number of protozoa in the field of view (ocular x10, objective x40) in
iodine stained smears taken before application of formalin - ethyl acetate concentration
technique, the number of protozoa will be calculated at least in 10 fields of view. 1-2, 3-4
and 5-6 microorganisms in a field of view were considered as infection of low, mean and high
intensity respectively. For detection of C. parvum modified Ziehl - Neelsen method
[Henricksen SA, Pohlenz JF] will be used for staining the preparations. The stained smears
will be scanned with ×100 oil immersion lens for the presence of C. parvum.
Microbiological methods Microbiological methods wil be conducted for detection pathogenic
bacteria, including Clostridium difficile, Salmonella spp, Shigella spp, Campylobacter spp,
Yersinia spp, and Mycobacteria only from UC patients infected with B. hominis before therapy.
If intestinal pathogenic bacteria are detected participants will be excluded from further
investigation.
Collection of stool samples. Fecal samples will be collected from UC patients infected with
B. hominis before therapy in sterile, wide-mouth, screw capped containers and immediately
transferred to the laboratory, preferably within 2 h. Specimens will be processed for
microscopy, anaerobic and aerobic culture, and ELISA (only for Clostridium difficile).
Procedures Parasitological examination in UC patients and population will be provided.
Additional UC patients infected with B. hominis will be divided into 3 cohorts, in
double-blinded fashion, to receive 1 of the following treatments: (1) patients with UC
infected with B. hominis will be treated with nitazoxanide, 1.0 g/daily (two pills) twice
over orally for 14 consecutive days; (2) UC patients infected with B. hominis will be treated
with nitazoxanide by a 1.0 g/day (one pill - 500 mg) twice over orally and mesalazine 1.5
g/day (one pill - 500 mg) three times a day orally for 14 consecutive days; (3) patients with
UC infected B. hominis will be treated with mesalazine ≥3 g/day (one pill - 500 mg) three
times a day orally for 14 consecutive days. Except drugs patients of all three groups adhered
to the diet. The purpose of follow-up was to monitor compliance with medications and to
record response to therapy, adverse events, and recurrence of symptoms.
Other detected pathogenic protozoan and helminthes was treated by standard dosage of
antiparasitic drugs.
Follow-up The study was conducted in two stages. At the first stage parasitological
examination of patients with UC before treatment and population will be provided . At the
second stage of the study in patients with UC infected with B. hominis drugs with anti
Blastocystis activity will be applied as well as monitoring of therapy efficiency.
Parasitological, microbiological, clinical and endoscopic examination will be conducted
before therapy and at the 2nd, 6th and 12th weeks. At each visit, a Mayo Clinic score will be
calculated and intensity/elimination of B. hominis will be determined.
Outcome measures The outcome measures of therapy are : eradication/ reduction of intensity of
B. hominis infection and a clinical response of UC patients at the 2nd, 6th and 12th weeks
will be defined as a reduction in the Mayo Clinic score.