with ASUC, corticosteroid trials of 3–5 days are suggested; continued use of corticosteroids beyond 7 days has not been shown to be effective in nonresponding patients.33,34 Overall quality of evidence was rated as very low due to observational nature of evidence and indirectness in approach to comparing efficacy. 9. In hospitalized adult patients with acute severe ulcerative colitis without infections, the AGA suggests against adjunctive antibiotics. (Conditional recommendation, very low quality of evidence) The guideline panel suggests against the routine use of adjunctive antibiotics for the treatment of ASUC in patients without gastrointestinal or extra-intestinal infections. Four RCTs comparing antibiotics vs no antibiotics/placebo for the treatment of ASUC were identified.35–38 Different antibiotics were used, with durations ranging from 5 to 10 days. On meta-analysis, the addition of antibiotics was not superior to no antibiotics for decreasing short-term risk of colectomy in patients with ASUC (RR, 0.79; 95% CI, 0.46–1.35). After exclusion of 1 trial of oral vancomycin that was positive but used an insensitive test to exclude concomitant C difficile infection, overall summary estimate for adjunctive antibiotics was close to unity (RR, 0.95; 95% CI, 0.55–1.64). The quality of evidence was rated very low due to serious risk of bias, serious imprecision, and inconsistency, given the diverse group of antibiotics used in the studies. 10. In hospitalized adult patients with acute severe ulcerative colitis refractory to intravenous corticosteroids, the AGA suggests using infliximab or cyclosporine. (Conditional recommendation, low quality evidence) The guideline panel suggests using either infliximab or cyclosporine in hospitalized adult patients with ASUC refractory to a 3- to 5-day trial of intravenous corticosteroids. One RCT compared infliximab to placebo in 45 patients with ASUC refractory to intravenous corticosteroids.39 In this trial, infliximab was superior to placebo in decreasing the risk of colectomy within 90 days of hospitalization (RR, 0.44; 95% CI, 0.22–0.87). Patients were given a single dose of 5 mg/kg infliximab without further induction or maintenance doses. Likewise, intravenous cyclosporine (4 mg/ kg) was compared to placebo in a single small RCT in corticosteroid-refractory patients with ASUC.40 In this trial, there was a trend favoring cyclosporine over placebo (RR, 0.61; 95% CI, 0.18–2.01). In a subsequent RCT, cyclosporine dose 2 mg/kg/d was comparable to 4 mg/kg/d, with conceivably a superior safety profile with lower dose.41 In 2 head-to-head trials comparing infliximab vs cyclosporine, there was no significant difference in short-term risk of colectomy between standard-dose induction therapy with infliximab vs cyclosporine in hospitalized patients with corticosteroid-refractory ASUC (RR, 1.00; 95% CI, 0.72– 1.40).42,43 Long-term follow-up of these trials also suggest similar findings. Over a median follow-up of 4.5 years of participants in the CYSIF trial, 1- and 5- year colectomy-free survival rates were 70.9% and 61.5% in patients treated with cyclosporine initially and 69.1% and 65.1%, respectively, in patients randomized to infliximab (P ¼ .97). Importantly, in these trials, randomized treatment was offered for 12–14 weeks, after which treatment decisions were deferred to treating physicians. After the initial randomization period, 1- and 5-year cumulative use of infliximab in cyclosporine-treated patients was 45.7% and 57.1%, respectively; in contrast, only 4 infliximab-treated patients switched to cyclosporine.42,43 Overall quality of evidence supporting the use of infliximab or cyclosporine over placebo for ASUC refractory to intravenous corticosteroids was rated as moderate quality (imprecision) or low quality (very serious imprecision), respectively. Evidence supporting the comparability of infliximab and cyclosporine decreasing risk of short-term colectomy in hospitalized patients with corticosteroidrefractory ASUC was rated as low quality (open-label trials with high risk of bias, and imprecision). 11. In hospitalized adult patients with acute severe UC, refractory to intravenous corticosteroids, being treated with infliximab, the AGA makes no recommendation on routine use of