How is dysbiosis treated?

Treatment of Dysbiosis

The treatment of dysbiosis should primarily focus on addressing the underlying cause, with antibiotics like rifaximin for bacterial overgrowth, probiotics to restore beneficial bacteria, and dietary modifications to support a healthy microbiome. 1, 2

Understanding Dysbiosis

Dysbiosis refers to an imbalance in the gut microbial community that can lead to various health issues. It is characterized by:

• Decreased diversity of gut microbiota species
• Altered metabolic activity of gut bacteria
• Potential overgrowth of pathogenic microorganisms
• Disruption of the normal gut-microbiota-brain relationship 3

Diagnostic Approach

Before initiating treatment, it's important to identify the type and cause of dysbiosis:

• Common symptoms: Abdominal distension, abdominal pain, diarrhea 4
• Associated conditions: Chronic pancreatitis, inflammatory bowel disease, irritable bowel syndrome, metabolic disorders 1, 4
• Diagnostic tests: Hydrogen/methane breath testing for SIBO (Small Intestinal Bacterial Overgrowth) 2

Treatment Algorithm

1. Address the Underlying Cause

• Antibiotic overuse: Discontinue unnecessary antibiotics 1
• Structural issues: Surgical consultation for anatomical abnormalities 2
• Motility disorders: Prokinetic agents (prucalopride, metoclopramide) 2
• Pancreatic insufficiency: Pancreatic enzyme replacement therapy 1, 2

2. Antimicrobial Therapy (for SIBO)

• First-line: Rifaximin (non-absorbable antibiotic) for 2 weeks 2
• For methane-predominant SIBO: Combination of rifaximin with neomycin 2
• Alternatives: Ciprofloxacin or amoxicillin 2
• For suspected fungal overgrowth: Fluconazole or nystatin 2

3. Probiotic Therapy

• Timing: Typically initiated after completing antibiotic course 2

• Effective strains:

  • Lactobacillus species (L. rhamnosus, L. reuteri)
  • Bifidobacterium species
  • Saccharomyces boulardii
  • Weizmannia coagulans (formerly B. coagulans)
  • Alkalihalobacillus clausii (formerly Bacillus clausii) 4

• Evidence: Multiple studies show probiotics can help restore beneficial bacteria, improve gut barrier function, reduce endotoxemia, and reduce TLR4 activation 1, 3

4. Dietary Modifications

• Low-FODMAP diet: Reduces fermentable substrates that feed bacterial overgrowth 2
• Avoid gas-producing foods: Limit cauliflower, legumes, and other foods that may exacerbate symptoms 2
• Consider polyphenol-rich foods: Fruits, vegetables, whole grains, and legumes can support healthy microbiome 1

5. Advanced Therapies for Refractory Cases

• Fecal Microbiota Transplantation (FMT):
  • Particularly effective for recurrent Clostridioides difficile infection (87% resolution rate)
  • May be considered for inflammatory bowel disease with dysbiosis that fails standard therapy 1
  • Routes include colonoscopy (93% success), enema (95% success), or naso-jejunal tube (76% success) 1

Special Considerations

Chronic Pancreatitis

• Small intestinal bacterial overgrowth (SIBO) may complicate up to 92% of patients with pancreatic exocrine insufficiency 1
• Consider SIBO in chronic pancreatitis patients where pancreatic enzyme replacement therapy (PERT) insufficiently treats gastrointestinal symptoms 1
• May require multiple courses of antibiotics as SIBO can recur 1

Inflammatory Bowel Disease

• Treat underlying inflammation first 2
• Consider FMT for refractory cases, with 45% clinical remission rate reported 1

Antibiotic-Induced Dysbiosis

• Beta-lactam, glycopeptide, and macrolide antibiotics are particularly associated with depletion of beneficial Bifidobacterium and Lactobacillus 5
• Probiotics should be considered during and after antibiotic therapy to mitigate dysbiosis 3, 5

Prevention of Recurrence

• Prokinetics: May prevent recurrence by improving intestinal motility 2
• Maintenance probiotics: Consider long-term use in high-risk patients 2
• Dietary vigilance: Continued adherence to microbiome-supporting diet 1
• Address modifiable risk factors: Reduce stress, improve sleep, avoid unnecessary medications that disrupt gut flora 6

Pitfalls and Caveats

• Antibiotics can paradoxically worsen dysbiosis if used inappropriately 1
• Probiotics are contraindicated in immunocompromised patients due to risk of bacteremia 1
• FMT carries risks including fever, chills, and gastrointestinal symptoms 1
• Treatment response should be monitored as recurrence is common, particularly with SIBO 1, 2

By following this structured approach to treating dysbiosis, clinicians can effectively address the underlying causes and restore a healthy gut microbiome, thereby improving patient outcomes related to morbidity, mortality, and quality of life.