Treatment of Auto-Brewery Syndrome
Auto-brewery syndrome should be treated with a combination of antifungal or antibiotic therapy targeting the causative organism (most commonly Candida species or Klebsiella species), strict carbohydrate restriction, and probiotic supplementation to restore normal gut microbiota.
Diagnostic Confirmation Before Treatment
- Confirm the diagnosis by measuring blood or breath ethanol levels after a standardized carbohydrate challenge test, which demonstrates endogenous alcohol production in the absence of alcohol ingestion 1, 2, 3.
- Obtain upper and lower endoscopy with intestinal secretions to identify and speciate the causative organisms, allowing targeted antimicrobial therapy based on sensitivity testing 2.
- Examine the oral cavity for significant tooth decay, periodontal disease, and fungal colonization, as these can also be sources of alcohol-producing microorganisms 4.
Antimicrobial Therapy
- Administer antifungal agents when Candida species (C. albicans, C. glabrata, C. kefyr, C. parapsilosis, C. intermedia) or Saccharomyces cerevisiae are identified as causative organisms 1, 2, 3.
- Use appropriate antibiotics when high-alcohol-producing Klebsiella species (K. pneumoniae) are identified, selecting agents based on sensitivity testing 1, 5.
- Continue antimicrobial therapy for at least 6 weeks during the initial treatment phase 2.
- For oral cavity sources, combine systemic antifungal therapy with topical miconazole oral gel and comprehensive dental treatment to address periodontal disease and tooth decay 4.
Dietary Modification
- Implement a strict carbohydrate-free or low-carbohydrate diet during the initial 6-week antimicrobial treatment period to eliminate substrate for microbial alcohol fermentation 2, 5.
- Monosaccharide content has been identified as a key food-related inducing factor for alcohol production and should be specifically restricted 5.
- Rechallenge the patient with carbohydrates only after completing antimicrobial therapy and confirming absence of endogenous alcohol production 2.
Probiotic Therapy
- Initiate probiotic supplementation for competitive inhibition of pathogenic fungal and bacterial growth 2, 5.
- Begin with a single-strain probiotic, then transition to a multi-strain bacterial probiotic preparation, as multiple bacterial strains may provide superior inhibition of alcohol-producing organisms 2.
- A complex probiotic preparation combined with antibiotics and dietary modification has been shown to alleviate symptoms and prevent relapse during long-term follow-up 5.
Microbiome Restoration
- Consider fecal microbiota transplantation as a potential treatment option for refractory cases, though evidence remains limited 1.
- Address any history of prolonged antibiotic exposure, which likely altered gut microbiome and allowed pathogenic fungal or bacterial overgrowth 1, 2.
Treatment Monitoring and Follow-Up
- Monitor blood alcohol levels and alcohol-degrading enzyme function throughout treatment, particularly in patients with unexplained liver dysfunction 4.
- Assess for improvement in associated conditions such as fatty liver disease, which may resolve with successful treatment 4, 5.
- Track the abundance of Proteobacteria (particularly Klebsiella genus) and restoration of Firmicutes in the gut microbiota, as these correlate with disease activity 5.
Common Pitfalls to Avoid
- Do not dismiss patients who present with signs of alcohol intoxication but deny alcohol consumption; always consider auto-brewery syndrome in the differential diagnosis 1, 2, 3.
- Avoid reintroducing carbohydrates before confirming eradication of alcohol-producing organisms through repeat challenge testing 2.
- Do not overlook the oral cavity as a potential source of alcohol-producing microorganisms; comprehensive dental evaluation and treatment are essential 4.
- Recognize that intestinal dysbiosis with decreased Firmicutes and increased Proteobacteria is strongly associated with the condition and requires targeted correction 5.