Auto-Brewery Syndrome Treatment
The treatment of Auto-Brewery Syndrome (ABS) requires antifungal therapy combined with strict carbohydrate restriction, as the condition results from fungal overgrowth in the gastrointestinal tract that ferments dietary carbohydrates into endogenous ethanol. 1, 2
Diagnostic Confirmation Before Treatment
- Confirm the diagnosis with a carbohydrate challenge test showing elevated blood or breath ethanol levels in a monitored setting 3, 1, 4
- Perform upper and lower endoscopy to obtain intestinal secretions for fungal culture, speciation, and antifungal sensitivity testing to guide targeted therapy 1
- Rule out exogenous alcohol consumption and other causes of altered mental status before diagnosing ABS 3
Primary Treatment Strategy
Antifungal Therapy
- Initiate antifungal agents based on fungal sensitivity testing from endoscopic samples 1
- Micafungin has been successfully used in documented cases, with resolution of symptoms 4
- Continue antifungal therapy for at least 6 weeks during the initial treatment phase 1
Dietary Management
- Implement a strict carbohydrate-free diet during the initial 6-week antifungal treatment period 1, 2
- After completing antifungal therapy and confirming negative rechallenge testing, gradually reintroduce carbohydrates while monitoring for symptom recurrence 1
- Long-term carbohydrate restriction may be necessary to prevent relapse 3, 2
Adjunctive Therapies
Probiotic Support
- Consider single-strain probiotics initially for competitive inhibition of fungal growth 1
- Transition to multi-strain bacterial probiotics, as multiple bacterial species may provide superior fungal inhibition compared to single-strain formulations 1
- Note that the beneficial role of probiotics in ABS has not been formally studied in controlled trials 1
Treatment Monitoring and Follow-Up
- Perform carbohydrate rechallenge testing before reintroducing carbohydrates into the diet to confirm eradication of endogenous alcohol production 1
- Monitor blood alcohol levels after controlled carbohydrate intake to verify treatment success 4
- Educate patients on medication adherence, dietary modifications, and lifestyle adjustments necessary for long-term management 2
Critical Clinical Pitfalls
- Do not dismiss patients who present with signs of intoxication but deny alcohol consumption—maintain a high index of suspicion for ABS, particularly in patients with recent prolonged antibiotic exposure that may have altered gut microbiome 1, 4
- Recognize that undiagnosed ABS can lead to severe physical, social, psychological, and legal consequences including arrests for driving under the influence 2, 4
- Avoid premature carbohydrate reintroduction before completing the full antifungal course and confirming negative rechallenge testing 1
Underlying Pathophysiology to Address
- ABS typically develops after prolonged antibiotic courses that disrupt normal gut microbiome and allow pathologic fungal overgrowth 1
- The fermenting organisms (primarily fungal yeasts, though bacteria have been recently recognized) convert ingested carbohydrates into ethanol within the gastrointestinal tract 3, 2