Probiotics are living organisms, including lactic acid bacteria and nonpathogenic yeasts, that provide health benefits to the host 4. Furthermore, long-term treatment with most of the aforementioned broad-spectrum antibiotics may be complicated by poor patient tolerance (and, therefore, compliance issues), disruption of the commensal microbiota, antibiotic-associated diarrhoea (including the risk of Clostridium difficile-associated disease), the development of antibiotic resistance, and the potential for rebound colonization once the antibiotic is stopped 1, 4.įor all of these reasons and given their ability to repopulate the microbiota, it should come as no surprise that there has been considerable recent interest in the use of probiotics and prebiotics in SIBO. Not surprisingly, due to the lack of an adequate evidence base, the choice of antibiotic(s), their dose and schedule of administration, as well as the duration of therapy, all lack standardization. While more recent studies involving the poorly absorbed antibiotic rifaximin have provided more guidance on optimal dosage and treatment duration 2, 3, empirical trials of broad-spectrum antibiotics remain the norm in the treatment of SIBO. It must be conceded that antibiotic strategies in SIBO, be it a once-off course, a rotating schedule or continuous therapy, owe more to empiricism than to an evidence base as there have been a few high quality trials of any regimen in this condition. Traditionally, the latter approach has been based on the use of various, typically broad-spectrum, antibiotic regimens with norfloxacin, tetracycline, ciprofloxacin, metronidazole and doxycycline being popular choices 3. In many situations, unfortunately, an underlying cause cannot either be found or, if present, reversed for many patients, therefore, therapy focuses on the suppression of SIBO per se. In managing the patient with SIBO attention should first be directed towards the detection and elimination, where feasible, of any underlying cause and, secondly, to the correction of any resultant nutritional deficiencies. The lack of an accepted “gold standard” for the clinical definition of SIBO, especially, in a non-classical clinical scenario, represents a major challenge for the clinician.
#TREATMENT FOR SMALL INTESTINAL BACTERIAL OVERGROWTH HOW TO#
Currently, there is a lack of consensus on how to define an abnormal breath test with no agreement on either the optimal duration of sampling or the best cut-off level to define a positive test 3. Despite their ease of performance and acceptability to patients, HBTs have been criticized on the basis of considerable variability in sensitivity and specificity, as well as their inability to detect bacterial overgrowth in the more distant reaches of the small intestine and their failure to detect overgrowth by non-H 2-producing bacteria 2, 3. This approach, due to its invasive nature and resultant costs has fallen into abeyance and, in clinical practice, has been replaced either by cultures of duodenal aspirates obtained via an endoscope or, more commonly, by hydrogen breath tests (HBTs) performed using substrates such as lactulose or glucose. Traditionally, SIBO was clinically defined on the basis of quantitative cultures of jejunal aspirates with the presence of more than 10 5 colony forming unit (cfu)/ml of proximal jejunal aspirate being regarded as diagnostic 1.
Classically, SIBO was recognized as an important cause of maldigestion and malabsorption more recently, SIBO has been implicated in a variety of clinical scenarios ranging from non-alcoholic fatty liver disease to unexplained diarrhoea and the irritable bowel syndrome (IBS). Disruption of homeostasis in the small intestinal microbial community can lead to significant clinical consequences, most notably small intestinal bacterial overgrowth (SIBO) a situation where bacteria are present, not only in greater numbers, but also in a distribution more commonly associated with the colon. The human intestinal microbiota is a complex community comprised a myriad of bacterial species.
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