This article explains the options you and your healthcare provider can discuss for treating SIBO including taking antibiotics and adjusting how you eat.
Antibiotic Therapy
For now, the “gold standard” treatment for SIBO is using antibiotics to reduce bacterial overgrowth in the small intestine. These medications are also thought to ease inflammation in the small intestine lining, which could cause malabsorption.
SIBO can be categorized in two ways:
Methane-dominant SIBO usually results in constipation. Hydrogen-dominant SIBO causes diarrhea.
Antibiotics are used to treat both types of the disease, but along with antibiotics, methane-dominant SIBO may require you to take fiber.
Unfortunately, there are no clear SIBO treatment guidelines, and more research on the use of antibiotics for SIBO is still needed. Several types of antibiotics are used to treat SIBO, but which is best for a specific individual and at what dosage is still not clearly understood.
Xifaxan: First Course of Treatment
For now, the primary antibiotic used to treat SIBO is Xifaxan (rifaximin) since most patients seem to benefit from it. Research indicates that Xifaxan, a brand name for the generic drug rifaximin, kills various strains of bacteria, improving symptoms.
Flagyl (metronidazole) Cipro (ciprofloxacin) Tetracycline Amoxicillin-clavulanate Neomycin Norfloxacin Xifaxan (rifaximin)
In the body, Xifaxan is not absorbed into the bloodstream. This reduces side effects and improves the drug’s ability to act directly on the bacteria in the small intestine.
Another benefit is that Xifaxan has little impact on bacteria in the large intestine. This lowers the risk of gastrointestinal symptoms and yeast infections, which are common with other antibiotics.
Despite the promising research, Xifaxan has not been approved by the FDA for the treatment of SIBO (although it is approved for treating diarrhea-predominant IBS and travelers’ diarrhea). Therefore, prescribing Xifaxan for SIBO is considered “off-label” use.
With incomplete research, there’s no definitive consensus regarding the proper dosing and duration for using Xifaxan for SIBO. In most clinical trials, higher dosages are more effective than lower doses. In clinical practice, Xifaxan is most often prescribed in courses of two weeks. Other antibiotics may be prescribed simultaneously or in tandem with repeated courses prescribed as needed.
Dietary Interventions
In addition to using antibiotics to regulate intestinal bacteria, you may be able to manage SIBO symptoms by addressing nutritional deficiencies or avoiding foods that cause symptoms.
Nutritional Deficiencies
If you are diagnosed with SIBO, you should work with your healthcare provider to identify and address any possible nutritional deficiencies. Supplements should be taken for any or all of the following vitamins and minerals if a deficiency is found:
Vitamin AVitamin B12Vitamin DVitamin ECalciumMagnesium
If your healthcare provider believes that steatorrhea and/or another type of fat malabsorption is present, they may recommend that you take a pancreatic enzyme supplement.
Elemental Diet
The elemental diet is a diet restricted to medically formulated liquids. Nutrients are consumed in their most elemental form so it’s easy to digest and absorb them.
Some health practitioners recommend an elemental diet along with antibiotics to help people with SIBO because it reduces the amount of food that bacteria can work on. It also may lower your overall gut bacteria, which will improve symptoms.
More research is needed to understand the benefits of this hard-to-follow dietary plan. Meanwhile, it’s recommended that you do not try this at home with homemade formulas because there’s a risk of nutritional deficiency.
The Low-FODMAP Diet
The low-FODMAP diet was designed to reduce the symptoms of IBS. The idea is to temporarily restrict your intake of carbohydrates, or high FODMAPs, that contribute to IBS symptoms.
With SIBO, two of the five FODMAP types, lactose, and fructose, may be poorly absorbed due to inflammation along the lining of the small intestine. In addition to these two, other non-absorbed FODMAPs may be fermented by the bacteria residing inappropriately in the small intestine, leading to bloating and other digestive symptoms.
Therefore, the low-FODMAP diet may be helpful for SIBO because eating fewer carbohydrates might “starve” the bacteria in the small intestine. However, as of yet, there are no clinical studies on the subject.
Not much is known about the appropriateness of the low-FODMAP diet for a person taking antibiotics for SIBO. Some experts think the diet may reduce the effectiveness of the antibiotic treatment because it makes bacteria dormant. Instead, it’s recommended that you eat a normal diet while on antibiotics. After the course of antibiotics, you can follow the low-FODMAP diet to prevent future SIBO recurrences.
Address Underlying Issues
Before prescribing antibiotics, your doctor will do a complete physical exam and medical history to see if your SIBO symptoms could be due to an underlying condition.
Diseases that Affect the Small Intestines
Certain diseases can contribute to the onset of SIBO and may impair digestion in the stomach or small intestine. These include:
Gastroparesis, which affects the nerves in the stomach, causes a slow down in the digestive process. It’s often related to diabetes, and if blood sugar is regulated it may go away. Celiac disease, an autoimmune disease that affects the small intestines, causes problems with absorption in the digestive tract. People with celiac disease are at higher risk for SIBO. For these individuals, strict adherence to a gluten-free diet is essential for improving symptoms and overall health.
Structural Problems
In addition to disease, abnormalities in the digestive system’s structure can lead to the development of SIBO. Some of these defects may be correctable through surgery. They include:
Blind loops Bowel obstruction Diverticula present in the small intestine Fistulas Crohn’s disease of the small bowel Strictures
SIBO may also be experienced by those who have undergone a partial colectomy (removal of the colon), which can result in colonic bacteria flowing backward into the small intestine.
Medication Side Effects
Sometimes, a medication used to treat a different health problem may cause conditions that foster SIBO. These medications include:
Opiate medications typically prescribed for pain Proton pump inhibitors (PPIs) typically prescribed for GERD
Discontinuing these drugs may help to reduce SIBO symptoms.
The Future of SIBO Treatment
As more research is done on SIBO, more treatments are likely to emerge. A particularly exciting avenue of research is the development of advanced technology which will accurately identify the presence and type of bacteria present in a person’s small intestine. In the meantime, other possible options are being explored as possible safe, effective treatments for SIBO.
Herbal Formulations
In one published study, the herbal formulation was found to be at least as effective as Xifaxan for treating SIBO.
Herbal formulations also promise to avoid the side effects of antibiotic medication and treat those for whom antibiotics are not working. They may also prevent the recurrence of SIBO.
Prokinetic Medications
Prokinetic medications are used to treat gastrointestinal disorders and acid reflux. They may also help with SIBO. Preliminary research suggests that these medications may be especially helpful for those with SIBO and scleroderma.
Prokinetic medications may be helpful because they potentially enhance the power of the small intestine’s own “cleansing wave” to wash bacteria out.
Probiotics
In theory, probiotic supplements may be helpful for treating SIBO because they have been shown to have a positive effect on bacterial makeup, to improve the health of the gut lining, and to reduce inflammation. However, there is a lack of significant research on the effectiveness of probiotics in treating SIBO.
Preventing Relapse
Despite success in treating SIBO with medication, relapses are common. Not much is known about the best way to prevent SIBO symptoms from returning. The recommended course of action is to prescribe a course of antibiotics rather than have people modify their diet. If necessary another course of antibiotics is prescribed.
It can be difficult to understand what those diet modifications would look like. It may be helpful to follow the low-FODMAP diet for a short time. It may also be helpful to avoid foods containing artificial sweeteners such as aspartame, saccharin, and sorbitol, which hold the potential for interacting with bacteria present within the small intestine.
Summary
SIBO can be extremely painful and reduce your quality of life, but it doesn’t have to be that way. Antibiotics are often completely effective at treating SIBO. However, it may take multiple antibiotics, or you may need repeat treatments if SIBO recurs.
Along with taking medication, it’s recommended that you modify your diet to ensure you are getting adequate nutrients and to prevent inflammation.
SIBO can be complicated by other medical conditions that affect digestion. Taking care of these diseases and conditions can reduce the amount of bacteria in your intestines and stop inflammation.
Researchers continue to look for treatments that help with easing SIBO symptoms. The hope is to reduce side effects and lower the risk of SIBO returning after antibiotics clear up the bacteria.
