I was offered Rifaximin for Bacterial Ovegrowth and although I did not find it very successful, it has worked for a high percentage with SIBO and is known not to be both effective and safe ( Rifaximin Meta-analysis below). I have since found better antibiotics for recurrence of symptoms and Metronidazole is also known to be fast acting in D-La. I had become unresponsive to a number of antibiotics at the point that I was diagnosed with D-La, that it why I was given the exclusion diet which can work just as well as antibiotics and is used as an alternative.
All Bacterial Overgrowth produce unwanted metabolites (D-La is only one form of Metabolite) and needs to be controlled. There are unknown affects upon Gut Bacteria from Antibiotics and Metronidazole is also known to suppress the immune system but is widely used for infections. It is better to use an Exclusion Diet alone if your symptoms can be controlled by not feeding the Bacteria rather than using Antibiotics.
I have mixed feeling about using Antibiotics but have been forced to when I have failed to maintain my diet which has happened for a number of reasons. But if symptoms cannot be controlled and are severe then antibiotics have to be used. Overuse of Antibiotics could paradoxically be implicated in Bacterial Overgrowth and this is why we need urgent research. It feels like trying to crack a walnut with a sledgehammer, but if you only have a sledgehammer.....
You can reduce the Bacteria using antibiotics to destroy them or starve them and not to supply what is being converted to D-Lactic acid or other Metabolites produced by Bacterial Overgrowth. Dr. Myhill also uses dietary means to control SIBO symptoms but also uses antibacterials such as Neem (Some Gastroenterologists will also used antibacterials with antibiotics to eradicate Helico-Bacter which is another Bacteria affecting the Stomach and Duodenum).
I feel sorry for those in the Netherlands, because SIBO alone can clearly cause a number of problems including fatigue and muscle pain and Leaky Gut comes with SIBO due to damage from Bacterial Overgrowth and Metabolites produced on the Mucosal Lining causing Immune Dysfuntion due to Bacteria/Metabolites crossing the Mucosal barrier and activating an immune response (but there are drugs such as NSAID's which will also cause similar Mucosal damage).
Perhaps someone should start with a survey of as many ME/CFS as possible to find out what drugs, antibiotics and problems sufferers had before falling ill. What treatments have been tried and with what success. Whether all or only some ME/CFS have some form of Gastrointestinal problems or SIBO and what they can remember may be significant prior to falling ill eg. Pesticide Contact or Infections. Whether anyone has had treatment for Helico-Bacter such as Omeprazole or Antibiotics, whether they used NSAID analgesics. Acid lowering drugs such as Omeprazole are contraindicated for SIBO because they lower acidity at the gateway to the Gastrointesinal System allowing increased Bacteria access. Did symptoms start with Blood Sugar problems or other illness such as Diabetes? I think that this is going to be incredibly complex and there may be a number of subtypes. But a wide statistical analysis might provide some insight. We must hold the key.
I was given NSAIDs for a number of years before falling unwell (Non Steroidal Anti-Inflammatorie's) which also cause damage to the Mucosal Lining. Leaky Gut could possibly then result in a chain of problems that feed back in a negative chain of events. I also had Helico-Bacter and used frequent Proton Pump Inhibitors and also Zantac and a number of Antibiotics over a period of years.
Professor Hooper had some tests performed for me on two occasions confirming high IAG believed resulting from Leaky Gut. I was also diagnosed with Immune Dysfunction, Hypogammaglobulinaemia IgM.
But if anyone has the symptoms of SIBO, it needs to be controlled and underlying causation identified as a starting point.
If a number of Bacteria are implicated in different forms of Bacterial Overgrowth then there may be a number of Metabolites involved in different combinations (Sheedy et al have stated in 2017 that it is not only the production of D-Lactic acid, but other metabolites may be involved in D-La.). How many forms of combination of Overgrowth are there and what toxic affects?
I have so many unanswered questions and have to admit that I am fascinated, still experimenting and hoping to find a cure, not just treatment.
Systematic review with meta‐analysis: rifaximin is effective and safe for the treatment of small intestine bacterial overgrowth
1 , 2 and C. Scarpignato
L. Gatta, Email: moc.liamg@glattag
, L. Lombardo
, M. Pimentel
, R. D'Incà
, A. Gasbarrini
, A. De Stefano
, and E. Cerda
1Clinical Pharmacology and Digestive Pathophysiology Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
2Gastroenterology and Endoscopy Unit, Versilia Hospital, Azienda USL Toscana Nord‐Ovest, Lido di Camaiore, Italy
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Small intestinal bacterial overgrowth (SIBO) is a heterogeneous syndrome, characterised by an increased number and/or abnormal type of bacteria in the small bowel. Over the past decades, rifaximin has gained popularity for this indication despite its use is not evidence based.
To perform a systematic review and meta‐analysis to summarise evidence about the efficacy and safety of rifaximin to eradicate SIBO in adult patients.
MEDLINE, EMBASE, CCRCT, Scopus and Web of Science were searched from inception to March 16, 2015 for RCTs and observational studies. Furthermore, abstract books of major European, American and Asian gastroenterological meetings were also examined.
Thirty‐two studies involving 1331 patients were included. The overall eradication rate according to intention‐to‐treat analysis was 70.8% (95% CI: 61.4–78.2; I
2 = 89.4%) and to per protocol analysis 72.9% (95% CI: 65.5–79.8; I
2 = 87.5%). Meta‐regression identified three covariates (drug dose, study design and co‐therapy) independently associated with an increased eradication rate. The overall rate of adverse events was 4.6% (95% CI: 2.3–7.5; I
2 = 63.6%). In the subset of studies (n= 10) allowing the analysis, improvement or resolution of symptoms in patients with eradicated SIBO was found to be 67.7% (95% CI: 44.7–86.9; I
2 = 91.3%).
Rifaximin treatment seems to be effective and safe for the treatment of SIBO. However, the quality of the available studies is generally poor. Well‐designed RCTs are needed to substantiate these findings and to establish the optimal regimen.
Small intestinal bacterial overgrowth (SIBO) is a heterogeneous syndrome characterised by an increased number and/or abnormal type of bacteria in the small bowel, and it is a well‐recognised cause of maldigestion and malabsorption.1
The recent discovery of an association between SIBO and functional gut symptoms, albeit controversial, has renewed interest in this mimicry. SIBO represents indeed an umbrella term, under which some different functional (e.g. irritable bowel syndrome, chronic constipation, diarrhoea) or organic (e.g. inflammatory bowel disease, coeliac disease, diverticular disease, etc.) conditions can be included, as – in each of them – bacterial proliferation (and consequent inflammation) may, at least in part, trigger similar abdominal symptoms.1
The overall, true prevalence of SIBO – which is usually under‐diagnosed – is unknown.2
Indeed, patients may not seek healthcare and SIBO may not be properly diagnosed by medical investigations. In addition, the diagnostic yield depends on the methodology adopted, so that results from different studies are difficult to compare.4
The mainstay of the SIBO treatment is based on the use of antimicrobial agents, whose aims should not be to eradicate the entire bacterial flora but rather to modify the intestinal microecology in order to get symptoms relief.1
Ideally, the choice of antimicrobials should reflect in vitro
susceptibility testing, but this is usually impractical because intestinal bacterial cultures need invasive methodology to collect samples under sterile conditions.6
Therefore, hydrogen breath test (HBT) is widely used as non‐invasive means to diagnose SIBO. As consequence, in clinical practice antibiotic treatment, which should cover both aerobic and anaerobic bacteria, remains primarily empiric.4
Several antibiotic regimens proved to be effective over the past 50 years, with treatment success ranging from 27% to 100%.7
Till the end of 90s, only systemic antimicrobials were used, whose adverse events (AEs) and detrimental effects on gut microbiota are today well known.8
Poorly absorbed antibiotics, unlike systemic ones, allow localised targeting of enteric pathogens and are associated with minimal risk of systemic toxicity or AEs. The restricted use of drugs only for enteric‐infections should also reduce the development of widespread resistance, especially of enterobacteria, a major limitation of current antibiotics.8
Rifaximin is a product of synthesis experiments designed to modify the parent compound, rifamycin, in order to achieve low gastrointestinal absorption while retaining good antibacterial activity.9
Both experimental and clinical pharmacology have clearly shown that this compound is a poorly absorbed antibiotic with a broad spectrum of antibacterial activity, covering Gram‐positive and Gram‐negative microorganism, both aerobes and anaerobes.10
Rifaximin fulfils all the characteristics set by DuPont and Ericsson14
for the ideal antimicrobial that should be used for the treatment of gastrointestinal infections (including dysbiosis and SIBO). As a consequence, over the past decades, rifaximin has been largely used to treat SIBO1
even if there is currently a lack of a critical summary of evidence. To bridge this gap, a systematic review and meta‐analysis of randomised and nonrandomised studies was performed to evaluate the clinical effectiveness of and safety rifaximin to eradicate SIBO in adult patients.