TREATMENT OPTIONS (SIBO/IMO/DYSBIOSIS)

Before you read the information below; Prem Nand, Clinical Dietitian - Nutritionist strongly recommends that a patient with a positive hydrogen breath test result works with a Clinical Dietitian, Nutritionist or Naturopath who is specialised in SIBO treatment.

 
Do not use the information below to self treat.

Prem Nand recommends that a patient with a positive hydrogen breath test always works with his/her GP or Gastroenterologist if choosing the antibiotic option.
As a Clinical Dietitian – Nutritionist, Prem Nand can only provide a guideline from the various trainings she has attended and also through what is published in the literature.

 
Notes for those In NZ:
Rifaximin (brand name Xifaxan) is only prescribed for Hepatic encephalopathy: full subscription only through a gastroenterologist or hepatologist. It is available for $625 for 56 tablets. It also can be brought cheaper from overseas but for custom clearance, this process may require letter from a GP.

 
Neomycin is not available in New Zealand.

 
Metronidazole is available in New Zealand.

 
Suggested Dosage for Adults
Chronic Diarrhoea: Rifaximin 550mg three times a day for 14 days (Pimental et all, 2011).

Chronic Constipation (methane positive on lactulose breath test): Rifaximin 550mg three times day with Neomycin 500mg twice daily (Low et al 2010)

 
Chronic Diarrhoea: Rifaximin 550mg and Metronidazole 250mg three times a day

 
Note: success rate varies and may require multiple treatment.

 
SIBO Hydrogen sulfide: Rifaximin with Bismuth (presentation by Dr. Pimental 2022, dose not given). No published research found by Prem Nand using this combination as in March 2024.

 
Note that in Europe, there is a growing concern regarding development of bismuth encephalopathy in healthy people): refer Dupont 2008.

 
Suggested Dose for Children
Rifaximin 10mg to 30mg BW for 7 days (Muniyappa et al 2009)

There are multiple dietary interventions that are used in treatment of SIBO/IMO/Dysbiosis. They are:
a) Low FODMAP diet
b) Specific Carbohydrate Diet
c) GAPS (gut and psychology syndrome) Diet
d) Cedars-Sinai Diet
e) Fast Track Diet for IBS
f) SIBO Bi-Phasic Diet

Note to A Clinician: Choose a specific diet and develop your confidence using this in treatment, making adjustments with your patient as they progress with their treatment.
If there is leaky gut, it may take a while for the gut lining to heal before food can be digested properly again. Again, the clinician will need to monitor this and make appropriate adjustments to the treatment plan.

A study of one hundred and four persons that tested positive for SIBO by lactulose breath test were offered either 1200mg of rifaximin or herbal therapy for 4 weeks (Chedid V et a1 2012).

 
After 4 weeks of treatment, they were tested again for SIBO by lactulose breath test.
Of the 37 who received herbal therapy, 14 (46%) were negative to SIBO presence compared to 23 out of 67 (34%) of patients that received rifaximin.

Furthermore, 14 of the 44 (31.8%) non responders of rifaximin therapy tested negative to SIBO presence when after going through herbal therapy treatment.

 
The study concludes that herbal therapy is as effective a treatment as rifaximin for those with SIBO, especially given the safety of long term use of antibiotics. The study also recommends that more trials with greater number of participants is needed.

 
Note: herbal treatment is a slower in eliminating SIBO/IMO bugs and take longer time to work compared to rifaximin.

Recommendations for herbal treatment is using 1 to 3 herbs over 4 weeks period.  There may need to repeat after positive follow up breath test .

 
SIBO Hydrogen: Berberine Herbs, Neem, Oregano Oil
SIBO Methane: High Allicin Extract, Oregano Oil, Neem
SIBO Hydrogen Sulfide: Bismuth*, Oregano Oil
SIFO Candida: Oregano, Cinnamon, thyme or Horopito

Doses for these should be worked out in consultation with your Clinical Dietitian, Nutritionist or Naturopath who can adjust dose to patient’s symptoms.

* note comment on use of Bismuth under the section of antibiotics.

Note:
If after the first round of treatment and re-testing, the client remains positive for SIBO, another round of treatment can be done. With herbal treatment, a different combination of the above herbs can be used.

As the bacteria dies off as part of the treatment, they release a lot of toxins into the gut. These toxins can be harsh on gut lining and lead to an overload of the immune system.

 
Prem Nand had a patient that was given Floxacillin for yeast infection and had such a reaction on her gut and skin itchiness.

 
This reaction is known as “Herx or Herxheimer reactions”.

 
These are short term detoxification reactions in the body (from 24 hours to few weeks, especially after the use of antibiotics or herbal treatments.

The symptoms include flu-like symptoms, including headache, sore throat, body aches, muscle and joint pains, sweating, chills or nausea.

Usually with antibiotic treatment for SIBO/IMO/SIFO, patients can have a bad reaction for a few days to a week before the body settles down. If a HERX reaction occurs, stop treatment for a few days and allow symptoms to subside. Start treatment at a lower dose.

Have vitamin C: Esther C 1000mg three times a day with water if tolerated.
Increase water intake to 3 L a day.

Binders can be used 90 minutes after treatment to help bind the toxins from irritating the gut and the immune system. Bentonite clay (can be constipating) or zeolite are two of the binders that are used.

Pre-biotics and probiotics are also useful with treatment, usually a few weeks into the treatment. 

Pimental et all (2011): Rifaximin therapy for patients with irritable bowel syndrome without constipation

Clinical Trial N Engl J Med.: Jan 6;364(1):22-32. doi: 10.1056/NEJMoa1004409.

Low et al (2010): A combination of rifaximin and neomycin is most effective in treating irritable bowel syndrome patients with methane on lactulose breath test.  J Clin Gastroenterol Sep;44(8):547-50.  doi: 10.1097/MCG.0b013e3181c64c90.

Muniyappa et al (2009): Use and Safety of Rifaximin in Children With Inflammatory Bowel Disease. Gastroenterology 01 October 2009 https://doi.org/10.1097/MPG.0b013e3181a0d269

Chedid et al 2012: Herbal Therapy vs. Rifaximin for Treatment of Small Intestinal Bacterial Overgrowth (SIBO) American Journal of Gastroenterology 107():p S132-S133