SIBO Treatment Options
Content
1. What is SIBO?
1.1 SIBO Diagnosis
1.2 SIBO Treatment
2. Treatment of Small Intestinal Bacterial Overgrowth
2.1 Antibiotic Therapy
2.1.1 Rifaximin
2.1.2 Other Antibiotics
2.2 Herbal Therapy
2.2.1 Oregano
2.2.2 Neem
2.2.3 Allicin
2.2.4 Berberine
2.2.5 Choosing Herbal Therapies
3. Strategies for Maintaining Wellbeing After SIBO Treatment
3.1 Nutrition
3.1.1 PHGG
3.2 Lifestyle
1. What is SIBO?
SIBO, or Small Intestinal Bacterial Overgrowth, refers to the overgrowth of bacteria in the small intestine, an area that typically has low levels of bacteria. This can lead to symptoms such as constipation, abdominal pain, bloating, and diarrhea. These SIBO symptoms occur due to an excessive bacterial presence in the small intestine, an area of the digestive system that is usually free from significant microbial growth. While the large intestine is naturally populated with a diverse microbiome, the small intestine cannot handle such bacterial abundance, leading to discomfort.
1.1 SIBO Diagnosis
SIBO is usually diagnosed with breath testing, which detects hydrogen and methane produced by bacteria. These gases are not produced by human cells, so their presence in the breath indicates bacterial overgrowth. Substances like lactulose, lactose, glucose, or fructose are used in the test. These substances are metabolized by bacteria, leading to gas production. The timing of gas production after ingestion reveals whether bacteria are present in the small intestine.
1.2 SIBO Treatment
Several treatment options exist for SIBO, including tailored diets, as well as the use of herbal or conventional antibiotics and probiotics. The choice of therapy depends on the type of bacteria involved and the predominant symptoms.
2. Treatment of Small Intestinal Bacterial Overgrowth
Once a positive SIBO test is confirmed, various treatment methods are available. The treatment depends on the type of SIBO, the bacteria involved, and the level of gas detected. Treatment options include specially designed SIBO diets and the use of herbal or conventional antibiotics. The main goal of therapy is to reduce problematic bacterial levels.
2.1 Antibiotic Therapy
2.1.1 Rifaximin
Among the conventional antibiotics, rifaximin is the most widely used in the treatment of SIBO (1). Rifaximin is a broad-spectrum antibiotic that acts specifically in the gastrointestinal tract and is not absorbed systemically. Thanks to its local mode of action, rifaximin is the first choice of antibiotic SIBO treatment. The antibiotic rifaximin is actually approved in Germany for the treatment of traveler’s diarrhea. Its use for SIBO treatment is therefore an off-label use and is usually not covered by statutory health insurance.
In a study from 2017, Gatta et al. demonstrated a SIBO eradication rate of around 71% for rifaximin (2). This efficacy claim relates to hydrogen SIBO. The effectiveness of methane SIBO or hydrogen sulphide SIBO is reported to be significantly lower.
A study from 2010 demonstrated an even better efficacy of rifaximin for SIBO eradication when combined with the prebiotic partially hydrolyzed guar gum (PHGG). The authors see the positive effect of PHGG on intestinal motility as the reason for this. (3)
2.1.2 Other Antibiotics
In addition to rifaximin, systemic antibiotics are also used to treat SIBO. These include, for example, metronidazole (4, 5) and neomycin (6). In practice, these two antibiotics are mainly used to treat methane SIBO.
Neomycin is currently not available in Germany. If too much of the active ingredient enters the bloodstream, it can lead to severe side effects such as a drop in blood pressure, tachycardia, anaphylactic shock or dizziness (7). The antibiotic metronidazole also has a broad spectrum of side effects.
2.2 Herbal Therapy
In addition to conventional antibiotics, there is growing research and application of herbal treatments for SIBO worldwide (8).
2.2.1 Oregano
Oregano oil is frequently used as a natural treatment for SIBO. Oregano has antibacterial (9) and antimicrobial (10) properties, attributed mainly to compounds like carvacrol and thymol. These substances help reduce harmful bacteria in the small intestine, thereby restoring bacterial balance and alleviating symptoms like bloating, pain, and digestive issues. However, oregano oil should be used under medical supervision and in carefully measured amounts, as excessive use can irritate the intestinal lining and affect beneficial bacteria.
2.2.2 Neem
Neem, an extract from the leaves and seeds of the neem tree, is also used as a natural option for treating SIBO. It has antibacterial properties (11) that can help combat harmful bacteria in the small intestine. Neem may help relieve symptoms such as bloating and digestive discomfort. However, like other herbal antimicrobials, Neem should be used only under medical supervision, as an overdose could irritate the gut lining or disrupt the natural gut flora.
Since late summer 2024, the sale and distribution of Neem in the EU have been halted due to an EU regulation classifying it as a “novel food.” This means it has not been consumed in significant amounts in the EU before 1997 and is considered potentially harmful until proven otherwise. (14) (RASFF Window – Notification detail (europe.eu), latest check 14.09.2024)
2.2.3 Allicin
Allicin, found in garlic, is used in SIBO treatment due to its strong antimicrobial properties (11,12). It effectively combats harmful bacteria in the small intestine and can help restore bacterial balance and alleviate symptoms like bloating and abdominal pain. Allicin in tablet form targets harmful microorganisms without burdening the gut with additional substances. Because Allicin is potent, it should only be used in precisely dosed forms under medical supervision to avoid side effects such as stomach irritation.
2.2.4 Berberine
Berberine, a plant compound derived from several medicinal plants like the barberry, is another natural remedy used in SIBO treatment. Due to its strong antimicrobial effect, Berberine inhibits the growth of harmful bacteria in the small intestine and supports gut health by restoring the microbial balance. Additionally, Berberine has anti-inflammatory (13) and antioxidant properties, which can protect the intestinal lining and promote healing. However, Berberine is potent and should be taken under medical supervision to avoid potential side effects and interactions with other medications.
2.2.5 Choosing Herbal Therapies
The choice of herbs depends on the type of SIBO. For hydrogen-dominant SIBO, plants like Neem or those containing Berberine are used. For methane-dominant SIBO, Allicin or Oregano may be more effective.
3. Strategies for Maintaining Wellbeing After SIBO Treatment
To ensure long-term success, maintain general wellbeing, and prevent relapses, it’s important to develop personalized strategies after treatment.
3.1 Nutrition
Nutrition plays a key role in maintaining gut health after SIBO treatment. Once the gut environment stabilizes, it should be carefully maintained. Dietary fiber and fermentable carbohydrates like PHGG and FODMAPs are crucial, as they feed beneficial gut bacteria. It’s also advisable to avoid heavily processed foods, sugar, and alcohol, as they can promote the growth of harmful bacteria.
3.1.1 PHGG
Partially hydrolyzed guar gum (PHGG) is a prebiotic fiber that has been shown to support SIBO treatment. Unlike many other fibers, PHGG ferments slowly in the small intestine, which reduces gas production and minimizes discomfort like bloating and abdominal pain. It serves as nourishment for beneficial bacteria in the large intestine, promoting a healthy gut microbiome and long-term gut health. PHGG can help regulate digestion and improve bowel movements. It is well tolerated and often used alongside other SIBO therapies but should be introduced gradually to ensure tolerance.
3.2 Lifestyle
Regular physical activity, stress management techniques such as meditation or yoga, and adequate sleep also play a crucial role in gut health. Additionally, if symptoms persist or recur, it is advisable to consider regular medical check-ups to intervene early. In general, ongoing medical supervision throughout the SIBO treatment process is strongly recommended.
References
- Rao SSC, Bhagatwala J. Small Intestinal Bacterial Overgrowth: Clinical Features and Therapeutic Management. Clin Transl Gastroenterol. 2019 Oct;10(10):e00078. doi: 10.14309/ctg.0000000000000078. PMID: 31584459; PMCID: PMC6884350.
- Gatta L, Scarpignato C. Systematic review with meta-analysis: rifaximin is effective and safe for the treatment of small intestine bacterial overgrowth. Aliment Pharmacol Ther. 2017 Mar;45(5):604-616. doi: 10.1111/apt.13928. Epub 2017 Jan 12. PMID: 28078798; PMCID: PMC5299503.
- Furnari M, Parodi A, Gemignani L, Giannini EG, Marenco S, Savarino E, Assandri L, Fazio V, Bonfanti D, Inferrera S, Savarino V. Clinical trial: the combination of rifaximin with partially hydrolysed guar gum is more effective than rifaximin alone in eradicating small intestinal bacterial overgrowth. Aliment Pharmacol Ther. 2010 Oct;32(8):1000-6. doi: 10.1111/j.1365-2036.2010.04436.x. Epub 2010 Aug 18. PMID: 20937045.
- Rao SSC, Bhagatwala J. Small Intestinal Bacterial Overgrowth: Clinical Features and Therapeutic Management. Clin Transl Gastroenterol. 2019 Oct;10(10):e00078. doi: 10.14309/ctg.0000000000000078. PMID: 31584459; PMCID: PMC6884350.
- Castiglione F, Rispo A, Di Girolamo E, Cozzolino A, Manguso F, Grassia R, Mazzacca G. Antibiotic treatment of small bowel bacterial overgrowth in patients with Crohn’s disease. Aliment Pharmacol Ther. 2003 Dec;18(11-12):1107-12. doi: 10.1046/j.1365-2036.2003.01800.x. PMID: 14653830.
- Thompson JR. Is irritable bowel syndrome an infectious disease? World J Gastroenterol. 2016 Jan 28;22(4):1331-4. doi: 10.3748/wjg.v22.i4.1331. PMID: 26819502; PMCID: PMC4721968.
- Neomycin – Anwendung, Wirkung, Nebenwirkungen | Gelbe Liste (gelbe-liste.de); latest check 18.02.2024
- Chedid V, Dhalla S, Clarke JO, Roland BC, Dunbar KB, Koh J, Justino E, Tomakin E, Mullin GE. Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Glob Adv Health Med. 2014 May;3(3):16-24. doi: 10.7453/gahmj.2014.019. PMID: 24891990; PMCID: PMC4030608.
- Liu Q, Meng X, Li Y, Zhao CN, Tang GY, Li HB. Antibacterial and Antifungal Activities of Spices. Int J Mol Sci. 2017 Jun 16;18(6):1283. doi: 10.3390/ijms18061283. PMID: 28621716; PMCID: PMC5486105.
- Mith H, Duré R, Delcenserie V, Zhiri A, Daube G, Clinquart A. Antimicrobial activities of commercial essential oils and their components against food-borne pathogens and food spoilage bacteria. Food Sci Nutr. 2014 Jul;2(4):403-16. doi: 10.1002/fsn3.116. Epub 2014 May 4. PMID: 25473498; PMCID: PMC4221839.
- Wylie MR, Merrell DS. The Antimicrobial Potential of the Neem Tree Azadirachta indica. Front Pharmacol. 2022 May 30;13:891535. doi: 10.3389/fphar.2022.891535. PMID: 35712721; PMCID: PMC9195866.
- Guo H, Lu S, Zhang J, Chen C, Du Y, Wang K, Duan L. Berberine and rifaximin effects on small intestinal bacterial overgrowth: Study protocol for an investigator-initiated, double-arm, open-label, randomized clinical trial (BRIEF-SIBO study). Front Pharmacol. 2023 Feb 15;14:1121435. doi: 10.3389/fphar.2023.1121435. PMID: 36873985; PMCID: PMC9974661.
- Jia Q, Zhang L, Zhang J, Pei F, Zhu S, Sun Q, Duan L. Fecal Microbiota of Diarrhea-Predominant Irritable Bowel Syndrome Patients Causes Hepatic Inflammation of Germ-Free Rats and Berberine Reverses It Partially. Biomed Res Int. 2019 Apr 3;2019:4530203. doi: 10.1155/2019/4530203. PMID: 31073525; PMCID: PMC6470425.
