What is the treatment, diet, and medication for small bowel bacterial overgrowth syndrome (SBBO) causing bloating?

From the Guidelines

The treatment for small bowel bacterial overgrowth syndrome (SBBO) causing bloating involves antibiotics, dietary modifications, and addressing underlying causes, with the primary antibiotic options including rifaximin (Xifaxan) 550 mg three times daily for 14 days, as recommended by the most recent and highest quality study 1.

Key Components of Treatment:

• Antibiotics: Rifaximin (Xifaxan) 550 mg three times daily for 14 days, or alternatives such as metronidazole 250 mg three times daily, ciprofloxacin 500 mg twice daily, or amoxicillin-clavulanate 875 mg twice daily for 7-14 days, as supported by 1 and 1.
• Dietary Changes: Focus on a low-FODMAP diet to reduce fermentable carbohydrates that feed bacteria, avoiding foods like onions, garlic, wheat, certain fruits, and dairy products, as suggested by 1.
• Prokinetic Medications: Low-dose erythromycin (50-100 mg at bedtime) or prucalopride may help improve intestinal motility, as mentioned in 1.
• Supplements: Probiotics (particularly Lactobacillus and Bifidobacterium strains), digestive enzymes with meals, and vitamin B12 supplementation if deficient, as recommended by 1 and 1.

Rationale:

The effectiveness of these approaches stems from directly reducing bacterial overgrowth with antibiotics while dietary changes starve the problematic bacteria of their preferred fuel sources. Prokinetics help by preventing stasis of intestinal contents, which can promote bacterial overgrowth. Treatment may need to be repeated in cases of recurrence, which is common, as noted in 1 and 1.

Additional Considerations:

• Patient Selection: Careful patient selection is needed when treating with antibiotics, considering the risk of resistant organisms and side effects, as warned by 1 and 1.
• Dietary Counseling: Dietary counseling should be guided by an experienced dietitian, focusing on maintaining compensatory hyperphagia and adjusting based on tolerance, as advised by 1.
• Monitoring and Follow-Up: Regular monitoring of symptoms, stool output, and weight trends is essential to track the development of symptoms and adjust treatment as needed, as recommended by 1 and 1.

From the Research

Treatment for Small Bowel Bacterial Overgrowth Syndrome (SBBO)

The treatment for SBBO typically involves a combination of dietary changes, medication, and other therapies.

• The primary goal of treatment is to reduce the symptoms of SBBO, such as bloating, pain, gas, and diarrhea.
• Treatment may involve the elimination or modification of underlying causes, induction of remission using antibiotics and elemental diet, and maintenance of remission through promotility drugs, dietary modifications, and repeat or cyclical antibiotics 2.

Diet for SBBO

• There is no specific diet recommended for SBBO, but certain foods may exacerbate symptoms and should be avoided.
• Foods that are high in fiber, sugar, and fat may contribute to bloating and gas.
• A low FODMAP (Fermentable Oligo-, Di-, Mono-saccharides, and Polyols) diet may be beneficial for some individuals with SBBO, as it can help reduce symptoms of bloating and gas.

Medication for SBBO

• Broad-spectrum antibiotics, such as rifaximin, amoxicillin, and ciprofloxacin, are commonly used to treat SBBO 2, 3, 4.
• Rifaximin has been shown to be effective in treating SBBO, with a higher decontamination rate and better tolerability compared to metronidazole 3, 4.
• The duration of antibiotic treatment typically ranges from 7 to 14 days, depending on the severity of symptoms and the response to treatment.

Course of Treatment

• The course of treatment for SBBO may involve a combination of antibiotics, dietary changes, and other therapies.
• Patients may need to undergo periodic treatment with antibiotics to maintain remission and prevent recurrence of symptoms.
• In some cases, additional medical or surgical measures may be necessary to control SBBO, such as intestinal lengthening procedures or probiotic therapy 5.
• Breath tests, such as the glucose breath test, may be used to diagnose and monitor SBBO, and to assess the effectiveness of treatment 2, 3, 4, 6.