First-Line Treatment for Auto-Brewery Syndrome
The first-line treatment for Auto-Brewery Syndrome (ABS) is antifungal medication combined with a low-carbohydrate diet to eliminate the microorganisms causing endogenous alcohol production. 1, 2
Diagnostic Confirmation
Before initiating treatment, confirm the diagnosis with:
- Glucose challenge test showing elevated blood/breath ethanol levels without alcohol consumption 3
- Upper and lower endoscopy to obtain intestinal secretions for fungal culture and speciation 2
- Monitored carbohydrate challenge in a controlled setting 4
Treatment Algorithm
Step 1: Antifungal Therapy
- Primary treatment: Systemic antifungal medication targeting identified fungi
- Common causative organisms include Candida species (C. albicans, C. glabrata, C. intermedia, C. parapsilosis, C. kefyr) and Saccharomyces cerevisiae 1
- In some cases, bacterial species like Klebsiella pneumoniae may be involved 1
- Antifungal selection should be based on culture and sensitivity results 2
- Treatment duration: Initial 6-week course 2
Step 2: Dietary Modification
- Implement strict carbohydrate-free or low-carbohydrate diet during initial treatment phase 2
- Gradually reintroduce carbohydrates after successful antifungal treatment 2, 4
Step 3: Probiotic Supplementation
- Add probiotics to restore normal gut microbiome:
- Begin with single-strain probiotics
- Progress to multi-strain bacterial probiotics for better competitive inhibition of fungal growth 2
Monitoring and Follow-up
- Rechallenge with carbohydrates under supervision before fully reintroducing them to diet 2
- Monitor for recurrence of symptoms after treatment
- Consider repeat testing of blood alcohol levels after carbohydrate consumption to confirm resolution
Risk Factors to Address
- Recent antibiotic use (disrupts normal gut flora) 1, 5
- Gastrointestinal abnormalities or prior surgeries 5
- Impaired liver function (may contribute to reduced alcohol metabolism) 5
Treatment Pitfalls to Avoid
- Failure to identify the specific causative organism before starting treatment
- Premature reintroduction of carbohydrates before adequate treatment
- Overlooking the condition as simple alcohol intoxication, leading to social and legal consequences 3, 5
- Neglecting to monitor liver function tests, which may be elevated in ABS patients 5
Special Considerations
- Patients may present with symptoms resembling alcohol intoxication (staggering gait, slurred speech, confusion) without alcohol consumption 3
- The condition can have serious medicolegal implications, particularly for driving-related incidents 5
- Patients often report symptom correlation with carbohydrate intake 4
This rare but likely underdiagnosed condition requires a high index of suspicion and targeted treatment approach to effectively manage symptoms and prevent serious social and legal consequences for affected individuals.