Can auto‑brewery syndrome be treated with herbal antimicrobials?

Auto-Brewery Syndrome Treatment with Herbal Antimicrobials

Auto-brewery syndrome should NOT be treated with herbal antimicrobials; instead, use proven pharmaceutical antifungal agents (such as fluconazole or nystatin) combined with a low-carbohydrate diet, as these are the only evidence-based treatments that have successfully eradicated the causative organisms.

Evidence-Based Treatment Approach

Primary Treatment: Pharmaceutical Antifungals

The causative organisms in auto-brewery syndrome are predominantly fungal species including Candida albicans, C. glabrata, C. kefyr, C. parapsilosis, Saccharomyces cerevisiae, and occasionally bacteria like Klebsiella pneumoniae 1. Antifungal medications are the cornerstone of treatment, not herbal antimicrobials 2, 3, 4.

• Antifungal therapy should be initiated for 6 weeks as the standard treatment duration 4
• The specific antifungal agent should be selected based on fungal speciation and sensitivity testing obtained from upper and lower endoscopy samples 4
• Treatment success requires complete eradication of the fermenting organisms, which has only been documented with pharmaceutical antifungals 1, 2, 4

Essential Dietary Modification

• Carbohydrate-free diet must be maintained during the initial 6-week antifungal treatment period 4
• The association between carbohydrate-rich meals (particularly fruit drinks) and symptom occurrence is well-established 2
• Carbohydrates should only be reintroduced after confirming eradication through rechallenge testing 4

Role of Probiotics (Not Herbal Antimicrobials)

While probiotics have been used adjunctively, their role remains unproven:

• Single-strain probiotics for competitive inhibition of fungal growth have been attempted 4
• Multi-strain bacterial probiotics may theoretically inhibit fungi better than single-strain preparations 4
• The beneficial role of probiotics in this condition has not been formally studied 4

Why Herbal Antimicrobials Are Inappropriate

No Evidence Base

• Zero case reports or studies document successful treatment of auto-brewery syndrome with herbal antimicrobials 1, 2, 3, 4
• All 20 patients across 17 case reports were treated with pharmaceutical antifungals, antibiotics (when bacterial), or dietary modification—never herbal products 1

Severity of Condition Demands Proven Therapy

• Auto-brewery syndrome causes blood ethanol concentrations reaching 15 mmol/L (69 mg/dL), producing genuine intoxication 2
• Symptoms include staggering gait, slurred speech, confusion, and gastrointestinal distress with severe impact on wellbeing and potential social/legal consequences 1, 3
• This is not a condition for unproven therapies—patients require definitive eradication of fermenting organisms 1

Antibiotic Exposure as Risk Factor

• Many auto-brewery syndrome cases occur after prolonged antibiotic courses that alter gut microbiome and allow fungal overgrowth 1, 4
• Using unproven herbal antimicrobials delays appropriate antifungal therapy and risks treatment failure

Diagnostic Confirmation Required Before Treatment

• Glucose challenge test with measurement of blood or breath ethanol levels confirms endogenous alcohol production 3, 4
• Upper and lower endoscopy with culture of intestinal secretions identifies the specific causative organism 4
• Fungal speciation and antifungal sensitivity testing guide appropriate pharmaceutical selection 4

Common Pitfalls to Avoid

• Do not use herbal antimicrobials as primary or adjunctive therapy—no evidence supports this approach
• Do not use broad-spectrum antibiotics in confirmed fungal cases, as antibiotics may have precipitated the condition 5
• Do not reintroduce carbohydrates before confirming organism eradication through rechallenge testing 4
• Do not rely on symptom resolution alone—formal testing is required to confirm cure 4

Special Populations

In patients with short bowel syndrome who develop auto-brewery syndrome, the same treatment principles apply: antifungal medication and carbohydrate restriction 2. This diagnosis should be added to the differential for D-lactic acidosis in short bowel syndrome patients 2.