How Long Should You Treat SIBO?

SIBO (small intestinal bacterial overgrowth) is a common cause of gas, bloating, constipation, and diarrhea. It can be treated with antibiotics, herbal antimicrobials, or a liquid elemental diet. The SIBO antibiotic is often given for two weeks. However, a recent study has shown this may not be the ideal approach for most patients and that one’s SIBO lab values can help determine the ideal use.


Dr. Michael Ruscio: Hi, this is Dr. Ruscio. And if you’re a patient that’s been diagnosed with SIBO—small intestinal bacterial overgrowth—which can typically manifest as the symptoms of IBS, including but not limited to gas, bloating, and either constipation, diarrhea, or abdominal pain, then you may be wondering what the ideal treatment length is.

[Continue reading below]


DrMR: Now, there are different treatment options. Two of the most used, I guess you could say, would be pharmaceutical antibiotics or herbal antimicrobials. And a recent study actually gives us some very valuable information in guiding how long to use the antibiotic Rifaximin in the treatment of SIBO. And this was a study predominantly looking at those with SIBO that had an IBS-D or an IBS diarrheal type presentation.

So, in short, what this study showed was that the higher one’s labs values may predict the longer need for treatment duration on this antibiotic. Now, more specifically, these researchers tracked a large group of patients. And the patients ended up being on either four weeks, eight weeks, or twelve weeks of Rifaximin.

Now, typically, a Rifaximin prescription is written for a two-week duration. So this is definitely quite a bit longer than is typically recommended. However, this is also a drug being used in a new application. So I still think we have much to learn.

So instead of the typical two weeks, these researchers found that the higher level of severity of the SIBO test, the SIBO breath test, that predicted if one would need Rifaximin for four weeks, for eight weeks, or even as long as twelve weeks.

Now, this, I think, provides us a few important things. One is the personalization of the dose. And I think that’s probably the most practical here because what we want to try to do is use a duration of treatment that’s going to have the highest likelihood of success—not too much, not too little.

“What this study again showed was that a patient will start to respond symptomatically before their labs impr”

Now, there’s another interesting finding from the study, which was that patients’ symptoms tended to improve before the labs improved. And why I think this is important is because it points to something that I think is a very important part of the clinical process, which is sometimes left out of modern day medicine or modern day health care, which is really having a strong concern for the way a patient is responding to treatment.

What this study again showed was that a patient will start to respond symptomatically before their labs improve. And so this may suggest that using the patient response to dictate the length of treatment and the retesting interval may be important.

I should note that the most significant symptomatic response on the antibiotic was seen at four weeks. So again, this, at most conservative, supports that perhaps using Rifaximin for longer than two weeks, four weeks, would be an intelligent strategy because it did appear that the most significant benefit was achieved at four weeks.

And there’s one other interesting point from this study, which was that someone’s severity of symptoms did not correlate with the severity of the labs. And I think this is important to mention because people can have problems in the gut. Or I should maybe say it this way: a problem in the gut could manifest as many different types of problems for different people and also different severities of problems.

So it’s important, I think, to keep this in mind where my personal opinion is that a problem in the gut can manifest in many different ways. And this is why it’s an important thing to evaluate digestive health before other considerations. And what this study is showing is that the severity of SIBO may not always correlate with the symptom severity. So someone may have a very mild case of SIBO but very severe symptoms, or very severe SIBO but very mild symptoms.

So this study provides some very interesting information. I think the biggest takeaway is that we may want to rethink or at least consider a longer duration of Rifaximin use in the treatment of SIBO, especially if a patient has a very high gas level on breath testing.

So this is Dr. Ruscio. Hopefully, this information helps you get healthy and get back to your life. Thanks.

What do you think? I would like to hear your thoughts or experience with this.

Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.

Discussion

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316 thoughts on “How Long Should You Treat SIBO?

  1. This is soo true: “someone may have a very mild case of SIBO but very severe symptoms, or very severe SIBO but very mild symptoms”

    Doctors should really have more understanding that mild SIBO can have severe symptoms outside and inside the gut. Very important. I think this is where researchers often fall into trap. They usually only capture the patients who have quite high gas levels, since they want to be sure, but in the real world, much lower gas levels can be just as problematic or even more problematic for some. So you look into research and see that maybe 60% of people with IBS have abnormal breath test, when in reality it’s much more likely it could aproach 90%. And it really downplays the significance of all these gut problems, manifesting as abdominal symptoms not even talking about the symptoms that manifest outside the gut…

    Also, when researchers do interventions to eradicate SIBO, they may also miss the point that all bacteria have to be gone completely before symptoms improve or other functions recover, at least for some people.

      1. Dr Ruscio thank you for all the great information my main dr ordered the Sibo test but while I was waiting I hAd horrible bloating and pain , went to urgent care dr he gave me doxy and flagyl. 5 day course helped but didn’t cure now waited 2wks the clear system then take test but I heard the test can be a false negative ?? I’m hope just to get the rifaximin

      2. Dr.ive had my stomach bliat for15or more years everyday ijust got zyfaxin tried it twice also neomycin the second time i have six pills left. Not working im so tired of carrying someone else around my stomach is pass my toes and no onw can help me. Please help me. Desperate in spokane wa.509-701-3461. It did go down for4days the first time. I was so happy..it came back with a vengence. Plz help thank you

        1. Hi Mei-Ling,

          I’m so sorry you’ve been dealing with this for so long, I know it’s easy to get discouraged. I would recommend getting a copy of Dr Ruscio’s book, “Healthy Gut, Healthy You” (which you can find here: https://www.drruscio.com/getgutbook) because he walks you through a DIY protocol to help with most gut issues including SIBO. If you’d like to become a patient of the clinic, you can apply to do so here: https://www.drruscio.com/gethelp

          Good luck!

    1. I was recently diagnosed with hydrogen dominant SIBO, and was put on Xifaxan 550 mg 3x a day. I have since finished the antibiotics. And I feel worse than when I was taking the antibiotics. Is this normal?

      1. Hi Hannah,

        I’m so sorry you haven’t seen improvement. It’s not uncommon to relapse after antibiotics if the right steps aren’t followed to make sure you’ve built a healthy gut ecosystem. You may want to check out Dr Ruscio’s book “Healthy Gut, Healthy You” where he lays out a DIY protocol to improve gut health (it addresses SIBO as well) that has helped countless people overcome stubborn gut issues. You can find it here: https://www.drruscio.com/getgutbook

        Good luck!

  2. I have had SIBO issues for years. The problem I’m facing now is that my Blue Cross insurance will only cover a 14 day supply and no more than 3 x a year.
    My johns Hopkins doctor has prescribed 555mg, 3x a day for 30 days and I cant get it covered because it doesnt meet guidelines. How can a patient get around this issue?

      1. Excellent info Dr. Ruscio. Thank you very much. I’m suffering from SIBO past 3 years . Even slight bacterial contamination wteaks havoc in my stomach and intestines swells up. Do you think it’s normal for SIBO patient’s intestines to swell up? It goes away after short rifixine course

        1. Thanks Raj,
          Bloating is a common symptom of SIBO. If it abates from Rifaximin it suggests SIBO could be present. My book will offer options for SIBO that recurs, so it may help. Def keep your doctor looped in here.
          Hope this helps.

          1. Hi Dr,
            I’ve had bad stomach issues for 5 years.. went through a divorce, wasn’t eating, drinking a lot and when I did eat it was candy or sugar or carbs. Had a breath test 3 weeks ago in Boston and tested positive for SIBO I started taking antibiotics 7 days ago and the bloating is awful.. I have started to go to the bathroom on my own which was a huge problem prior to treatment. I have gained a ton of weight from having this due to things not moving along and low or no energy. Will I start to lose some of the weight after I finish treatment? I’ve had all sorts of issues with inflammation and skin issues etc.

    1. You can get rifaximin from via Canadian pharmaceutical companies for very cheap in comparison. You still need a prescription from your doctor… but I got 100 pills for $150!

      1. May I which Canadian Pharmaceutical company you used? hAlso a problem with how many times can fill, per year and cannot afford on own. Thanks!

    2. Blue cross wouldn’t cover any of my Xifaxan. I ordered through Canadian Pharmacy king. Generic came from India. Professional and only $80 for 50 units of Rifaximin. Very happy, give it a try!

    3. If you haven’t already try the FODMAP diet. It’s worked wonders for me as well as some antimocrobial herbal antibiotics. Good luck!

      1. Hi Liz
        I’m on the same path as you. Can I ask his long it took to see any improvement and also what you were taking?
        I’m taking Allimed, Berb-evail, grapefruit seed extract (I have Candida aswell) plus a probiotic before bed.
        x

        1. Hi Stacey,

          My naturopath started me on Biotics brand Dysbiocide and FC-Cidal, which can be found on Amazon. I take 2 of each about 30-60 min before breakfast and dinner. I’m on week 2 of the 4-8 weeks she’s recommended. I’m monitoring my symptoms and haven’t decided yet if I’ll stop after 4 weeks, or continue up to the 8-week mark.

          So far, so good. Before treatment, I was having extremely painful side cramps and bloating at least a couple times a week, which would sometimes last several hours. I’ve had only one very brief episode of this since starting the Biotics herbs.

        2. Have SIBO for 18 months. Took 2 rounds of Xifaxan, no better maybe even worse. Okay in morning till I start eating. Have bm after breakfast. After that make lots of bathroom trips to no avail. No bm or not able to pass gas. Just lots of pain mostly on left side. How can I get rid of the gas? Dr. Pimental and Dr. Siebecker suggest 14 days of Xifaxan and Neomycin. What do you suggest?

  3. FWIW – I have read several SIBO sufferers say that treating with Rifaxim did not resolve there GI problems and the SIBO would return. It was when they were treated for parasites that their GI and SIBO problems were finally resolved.

  4. Can you post “the study” link? You don’t cite the Xifaxan regimen: dose, 24-hour frequency, cost. Also, a patient can expect to pay around to $32 a pill.

    Best,
    Cary Gossett, MD

    1. Hi Cary,
      Link is posted and you can see dose there, 1200mg/day was the dose I believe. The cost is an issue here, absolutely. I hope insurance coverage here changes b/c the current coverage may not be enough for many.

          1. Which canadian pharmacy can one get them and how f=do you go about it? On medicare and the $2500 cost is prohibitive.

          2. Hi Mary,

            See below 🙂

            Please check with your doctor before purchasing any Rx.

            • Canada prescriptions plus
            ohttps://www.canadaprescriptionsplus.com/pricesearch/rifaximin
            oprice breakdown page –
            https://www.canadaprescriptionsplus.com/pricedetail/xifaxan
            ▪ 200mg, 117 tabs is $447 (8 tabs/day x 14 days= 112 tabs, so there
            are 5 extra)
            Another option is:
            • Pharmastore
            ohttps://www.pharmstore.com/drugs/xifaxan
            ▪ select Rifaximin (℞), 550mg Tablet
            ▪ Price
            • 100 of the 555mg tablets cost about $100.
            • 200 of the 550mg tables cost about $187
            oadditional info found here, https://en.wikipedia.org/wiki/Lupin_Limited

      1. This is 3 years that my mom has sibo and sutll have it keep eating medcine and doesnt fell any better is is their any medcine that cane help her always sick feel really bad.

  5. This is soo true: “someone may have a very mild case of SIBO but very severe symptoms, or very severe SIBO but very mild symptoms”

    Doctors should really have more understanding that mild SIBO can have severe symptoms outside and inside the gut. Very important. I think this is where researchers often fall into trap. They usually only capture the patients who have quite high gas levels, since they want to be sure, but in the real world, much lower gas levels can be just as problematic or even more problematic for some. So you look into research and see that maybe 60% of people with IBS have abnormal breath test, when in reality it’s much more likely it could aproach 90%. And it really downplays the significance of all these gut problems, manifesting as abdominal symptoms not even talking about the symptoms that manifest outside the gut…

    Also, when researchers do interventions to eradicate SIBO, they may also miss the point that all bacteria have to be gone completely before symptoms improve or other functions recover, at least for some people.

      1. Dr Ruscio thank you for all the great information my main dr ordered the Sibo test but while I was waiting I hAd horrible bloating and pain , went to urgent care dr he gave me doxy and flagyl. 5 day course helped but didn’t cure now waited 2wks the clear system then take test but I heard the test can be a false negative ?? I’m hope just to get the rifaximin

      2. Dr.ive had my stomach bliat for15or more years everyday ijust got zyfaxin tried it twice also neomycin the second time i have six pills left. Not working im so tired of carrying someone else around my stomach is pass my toes and no onw can help me. Please help me. Desperate in spokane wa.509-701-3461. It did go down for4days the first time. I was so happy..it came back with a vengence. Plz help thank you

        1. Hi Mei-Ling,

          I’m so sorry you’ve been dealing with this for so long, I know it’s easy to get discouraged. I would recommend getting a copy of Dr Ruscio’s book, “Healthy Gut, Healthy You” (which you can find here: https://www.drruscio.com/getgutbook) because he walks you through a DIY protocol to help with most gut issues including SIBO. If you’d like to become a patient of the clinic, you can apply to do so here: https://www.drruscio.com/gethelp

          Good luck!

    1. I was recently diagnosed with hydrogen dominant SIBO, and was put on Xifaxan 550 mg 3x a day. I have since finished the antibiotics. And I feel worse than when I was taking the antibiotics. Is this normal?

      1. Hi Hannah,

        I’m so sorry you haven’t seen improvement. It’s not uncommon to relapse after antibiotics if the right steps aren’t followed to make sure you’ve built a healthy gut ecosystem. You may want to check out Dr Ruscio’s book “Healthy Gut, Healthy You” where he lays out a DIY protocol to improve gut health (it addresses SIBO as well) that has helped countless people overcome stubborn gut issues. You can find it here: https://www.drruscio.com/getgutbook

        Good luck!

  6. I have had SIBO issues for years. The problem I’m facing now is that my Blue Cross insurance will only cover a 14 day supply and no more than 3 x a year.
    My johns Hopkins doctor has prescribed 555mg, 3x a day for 30 days and I cant get it covered because it doesnt meet guidelines. How can a patient get around this issue?

    1. I understand Linda. Your doctor can try to resubmit the claim but ultimately I think policy needs to change. Hopefully studies like this will help with this change.

      1. Excellent info Dr. Ruscio. Thank you very much. I’m suffering from SIBO past 3 years . Even slight bacterial contamination wteaks havoc in my stomach and intestines swells up. Do you think it’s normal for SIBO patient’s intestines to swell up? It goes away after short rifixine course

        1. Thanks Raj,
          Bloating is a common symptom of SIBO. If it abates from Rifaximin it suggests SIBO could be present. My book will offer options for SIBO that recurs, so it may help. Def keep your doctor looped in here.
          Hope this helps.

          1. Hi Dr,
            I’ve had bad stomach issues for 5 years.. went through a divorce, wasn’t eating, drinking a lot and when I did eat it was candy or sugar or carbs. Had a breath test 3 weeks ago in Boston and tested positive for SIBO I started taking antibiotics 7 days ago and the bloating is awful.. I have started to go to the bathroom on my own which was a huge problem prior to treatment. I have gained a ton of weight from having this due to things not moving along and low or no energy. Will I start to lose some of the weight after I finish treatment? I’ve had all sorts of issues with inflammation and skin issues etc.

    2. If you haven’t already try the FODMAP diet. It’s worked wonders for me as well as some antimocrobial herbal antibiotics. Good luck!

      1. Hi Liz
        I’m on the same path as you. Can I ask his long it took to see any improvement and also what you were taking?
        I’m taking Allimed, Berb-evail, grapefruit seed extract (I have Candida aswell) plus a probiotic before bed.
        x

      2. Hi there

        Would you be kind enough to share the name and brand of the antimicrobial herbal antibiotics you used? Need some relief
        Many thanks

        1. Hi Stacey,

          My naturopath started me on Biotics brand Dysbiocide and FC-Cidal, which can be found on Amazon. I take 2 of each about 30-60 min before breakfast and dinner. I’m on week 2 of the 4-8 weeks she’s recommended. I’m monitoring my symptoms and haven’t decided yet if I’ll stop after 4 weeks, or continue up to the 8-week mark.

          So far, so good. Before treatment, I was having extremely painful side cramps and bloating at least a couple times a week, which would sometimes last several hours. I’ve had only one very brief episode of this since starting the Biotics herbs.

        2. Have SIBO for 18 months. Took 2 rounds of Xifaxan, no better maybe even worse. Okay in morning till I start eating. Have bm after breakfast. After that make lots of bathroom trips to no avail. No bm or not able to pass gas. Just lots of pain mostly on left side. How can I get rid of the gas? Dr. Pimental and Dr. Siebecker suggest 14 days of Xifaxan and Neomycin. What do you suggest?

    3. You can get rifaximin from via Canadian pharmaceutical companies for very cheap in comparison. You still need a prescription from your doctor… but I got 100 pills for $150!

      1. May I which Canadian Pharmaceutical company you used? hAlso a problem with how many times can fill, per year and cannot afford on own. Thanks!

    4. Blue cross wouldn’t cover any of my Xifaxan. I ordered through Canadian Pharmacy king. Generic came from India. Professional and only $80 for 50 units of Rifaximin. Very happy, give it a try!

  7. In many ways, doing 4 weeks (or even 3 weeks) makes more sense. We’ve seen this with our dogs, that vets are now prescribing 3-4 weeks, rather than 2 because it’s better to kill the bad bugs once and for all, rather than have them keep coming back. Even in humans, I believe that part of the problem with antibiotics is that they are prescribed for too short a duration. I would rather take it longer than have to repeat the whole process!

    To the person complaining that insurance will only cover 2 weeks — consider yourself lucky. Most plans will not cover Rifaxamin at all, and if they do it’s for only 5 days and only if you have already taken several other nastier drugs that haven’t worked within a recent history. If I want to take Rifaximin, I have to pay retail for each and every pill!

  8. FWIW – I have read several SIBO sufferers say that treating with Rifaxim did not resolve there GI problems and the SIBO would return. It was when they were treated for parasites that their GI and SIBO problems were finally resolved.

  9. Can you post “the study” link? You don’t cite the Xifaxan regimen: dose, 24-hour frequency, cost. Also, a patient can expect to pay around to $32 a pill.

    Best,
    Cary Gossett, MD

    1. Hi Cary,
      Link is posted and you can see dose there, 1200mg/day was the dose I believe. The cost is an issue here, absolutely. I hope insurance coverage here changes b/c the current coverage may not be enough for many.

          1. Hi Mary,

            See below 🙂

            Please check with your doctor before purchasing any Rx.

            • Canada prescriptions plus
            ohttps://www.canadaprescriptionsplus.com/pricesearch/rifaximin
            oprice breakdown page –
            https://www.canadaprescriptionsplus.com/pricedetail/xifaxan
            ▪ 200mg, 117 tabs is $447 (8 tabs/day x 14 days= 112 tabs, so there
            are 5 extra)
            Another option is:
            • Pharmastore
            ohttps://www.pharmstore.com/drugs/xifaxan
            ▪ select Rifaximin (℞), 550mg Tablet
            ▪ Price
            • 100 of the 555mg tablets cost about $100.
            • 200 of the 550mg tables cost about $187
            oadditional info found here, https://en.wikipedia.org/wiki/Lupin_Limited

      1. This is 3 years that my mom has sibo and sutll have it keep eating medcine and doesnt fell any better is is their any medcine that cane help her always sick feel really bad.

  10. In many ways, doing 4 weeks (or even 3 weeks) makes more sense. We’ve seen this with our dogs, that vets are now prescribing 3-4 weeks, rather than 2 because it’s better to kill the bad bugs once and for all, rather than have them keep coming back. Even in humans, I believe that part of the problem with antibiotics is that they are prescribed for too short a duration. I would rather take it longer than have to repeat the whole process!

    To the person complaining that insurance will only cover 2 weeks — consider yourself lucky. Most plans will not cover Rifaxamin at all, and if they do it’s for only 5 days and only if you have already taken several other nastier drugs that haven’t worked within a recent history. If I want to take Rifaximin, I have to pay retail for each and every pill!

  11. I was treated for SIBO twice with Xiflaxan for two week periods. Obviously, the first time was a unsuccessful. The second was as well as my symptoms returned. I do not like antibiotics and was not tested the second time. I am now trying a low carb, low sugar, low fiber diet and am having more success. I am unhappy with the weight loss and still struggle with my GERD most days, but have had no major gut attacks since changing my diet.

    1. Dr Ruscio recently posted this podcast about the Fast Track Diet which may help with GERD.
      https://drruscio.com/reducing-fermentation-to-heal-your-gut-with-dr-norman-robillard-episode-61/

      I recently cut out all fruit and reduced my veggies to 2-3 cups a day max (I use the fast track diet guide for my veg choices),, I use lots of herbs with meals, and I eat only 2 meals a day (intermittent fasting works for me but if you have blood sugar imbalances you need to be careful with this). These things have helped a lot with very severe digestive issues. In addition I supported my methylation cycle with a quality B-vitamin complex and started taking glycine and iodine. My energy levels and overall well being have drastically improved. I have found supporting methylation (50% of people may be under-methylating) to be key for me in lowering digestive inflammation (it reduces histamine levels too), but it also has many other important health benefits. Dr Ben Lynch has lots of info on this if you are interested.

  12. I was treated for SIBO twice with Xiflaxan for two week periods. Obviously, the first time was a unsuccessful. The second was as well as my symptoms returned. I do not like antibiotics and was not tested the second time. I am now trying a low carb, low sugar, low fiber diet and am having more success. I am unhappy with the weight loss and still struggle with my GERD most days, but have had no major gut attacks since changing my diet.

    1. Dr Ruscio recently posted this podcast about the Fast Track Diet which may help with GERD.
      https://drruscio.com/reducing-fermentation-to-heal-your-gut-with-dr-norman-robillard-episode-61/

      I recently cut out all fruit and reduced my veggies to 2-3 cups a day max (I use the fast track diet guide for my veg choices),, I use lots of herbs with meals, and I eat only 2 meals a day (intermittent fasting works for me but if you have blood sugar imbalances you need to be careful with this). These things have helped a lot with very severe digestive issues. In addition I supported my methylation cycle with a quality B-vitamin complex and started taking glycine and iodine. My energy levels and overall well being have drastically improved. I have found supporting methylation (50% of people may be under-methylating) to be key for me in lowering digestive inflammation (it reduces histamine levels too), but it also has many other important health benefits. Dr Ben Lynch has lots of info on this if you are interested.

  13. Hi Dr Ruscio,

    I have a number of severe health issues linked to poor digestive health. Currently I’m able to keep most of my symptoms in check with diet and lifestyle, but would like to heal my gut to a point where I don’t have to restrict so many healthy foods. My diet is very strict, AIP Paleo, no fruit and limited veg as I found even non starchy veg to be causing inflammation/body pain. I’ve had multiple rounds of antibiotics in the past to treat Blastocystis hominis (Flagyl plus others at high doses for 2 weeks) but the antibiotics made me much sicker, increased my digestive problems and did not permanently eradicate the parasite. In addition to fibromyalgia, chronic fatigue, reactive arthritis and myofacsial pain syndrome I have all the symptoms of ankylosing spondilitis (AS; which is the reason I tried the super low start diet that really helped). I am reluctant to try more antibiotics due to my previous experiences as I am worried it may cause even more gut dysbiosis.

    Considering my health history, do you think Rifaxim would benefit me to improve my overall gut health?
    How does Rifaxim effect the healthy gut microbes?
    Do you know if it specifically targets the microbes linked with AS or reactive arthritis such as Klebsiella or Proteus species?
    Does it eradicate Blastocystis hominis/antiparasitic?
    Are you aware of patients that have reacted badly to this antibiotic and developed worse symptoms?

    Thank you so much for all the information you provide, your website has been invaluable to me!

  14. Hi Dr Ruscio,

    I have a number of severe health issues linked to poor digestive health. Currently I’m able to keep most of my symptoms in check with diet and lifestyle, but would like to heal my gut to a point where I don’t have to restrict so many healthy foods. My diet is very strict, AIP Paleo, no fruit and limited veg as I found even non starchy veg to be causing inflammation/body pain. I’ve had multiple rounds of antibiotics in the past to treat Blastocystis hominis (Flagyl plus others at high doses for 2 weeks) but the antibiotics made me much sicker, increased my digestive problems and did not permanently eradicate the parasite. In addition to fibromyalgia, chronic fatigue, reactive arthritis and myofacsial pain syndrome I have all the symptoms of ankylosing spondilitis (AS; which is the reason I tried the super low start diet that really helped). I am reluctant to try more antibiotics due to my previous experiences as I am worried it may cause even more gut dysbiosis.

    Considering my health history, do you think Rifaxim would benefit me to improve my overall gut health?
    How does Rifaxim effect the healthy gut microbes?
    Do you know if it specifically targets the microbes linked with AS or reactive arthritis such as Klebsiella or Proteus species?
    Does it eradicate Blastocystis hominis/antiparasitic?
    Are you aware of patients that have reacted badly to this antibiotic and developed worse symptoms?

    Thank you so much for all the information you provide, your website has been invaluable to me!

  15. Hi Dr. Ruscio,
    Thanks so much for the helpful article and study,
    As you mentioned, this study was done for SIBO-D patients who produced excess Hydrogen.
    Has there been any new studies done for SIBO-C (Methane producing bacteria)?
    The old way of treating Methane as I understood it is to combine rifaximan and neomycin for 10 – 14 days and then low dose naltresone(LDN) for a few months. Has there been any new break through on that front?
    Thanks so much,

    1. Hi Peyman,
      My pleasure. No published breakthroughs with IBS-D/methane SIBO, but I would assume the same would apply; the higher the gas the longer the treatment needed. This is supported by many clinicians observations.

      1. My ND prescribed the rifaximin but the insurance changed it to a generic called xifaximin. They covered it 100%though so I tried it. Worked great but she also put me in low dose erythromycin as well to keep,the bowels moving. Have very sluggish bowels. It worked well but every time I was off. 2 weeks on 2 weeks off I got worse again. Should I be on this for longer? I’ve done 3 rounds but unsure if I should do again or jump to the herbals. I’m better but I’d like to have better withstanding results.

        1. Have SIBO for 18 months. Took 2 rounds of Xifaxan, no better maybe even worse. Okay in morning till I start eating. Have bm after breakfast. After that make lots of bathroom trips to no avail. No bm or not able to pass gas. Just lots of pain mostly on left side. How can I get rid of the gas? Dr. Pimental and Dr. Siebecker suggest 14 days of Xifaxan and Neomycin. What do you suggest?

  16. Hi Dr. Ruscio,
    Thanks so much for the helpful article and study,
    As you mentioned, this study was done for SIBO-D patients who produced excess Hydrogen.
    Has there been any new studies done for SIBO-C (Methane producing bacteria)?
    The old way of treating Methane as I understood it is to combine rifaximan and neomycin for 10 – 14 days and then low dose naltresone(LDN) for a few months. Has there been any new break through on that front?
    Thanks so much,

    1. Hi Peyman,
      My pleasure. No published breakthroughs with IBS-D/methane SIBO, but I would assume the same would apply; the higher the gas the longer the treatment needed. This is supported by many clinicians observations.

      1. My ND prescribed the rifaximin but the insurance changed it to a generic called xifaximin. They covered it 100%though so I tried it. Worked great but she also put me in low dose erythromycin as well to keep,the bowels moving. Have very sluggish bowels. It worked well but every time I was off. 2 weeks on 2 weeks off I got worse again. Should I be on this for longer? I’ve done 3 rounds but unsure if I should do again or jump to the herbals. I’m better but I’d like to have better withstanding results.

        1. Have SIBO for 18 months. Took 2 rounds of Xifaxan, no better maybe even worse. Okay in morning till I start eating. Have bm after breakfast. After that make lots of bathroom trips to no avail. No bm or not able to pass gas. Just lots of pain mostly on left side. How can I get rid of the gas? Dr. Pimental and Dr. Siebecker suggest 14 days of Xifaxan and Neomycin. What do you suggest?

  17. Hi Dr. Ruscio.

    Im right now into a rifaximin protocol on 5 weeks. I was scared of this long time treatment and reading this has calmed me. How about leaky gut, could this long term rifaximin use hurt the gut causing more grade of leaky gut?.

    Regards
    Mat

  18. Hi Dr. Ruscio.

    Im right now into a rifaximin protocol on 5 weeks. I was scared of this long time treatment and reading this has calmed me. How about leaky gut, could this long term rifaximin use hurt the gut causing more grade of leaky gut?.

    Regards
    Mat

    1. Hi Mat,
      SIBO can cause leaky gut so I would focus on addressing SIBO as the best method of fixing leaky gut, if you have documented SIBO that is.
      Hope this helps!

  19. I have had issues for about 20 years now. I recently began treatment for SIBO as my results for hydrogen were well over 200ppms via breath test (off the charts).

    I have been through 4 rounds of rifaximin with about a 1 week break in between rounds 3 and 4. It has now been about a week and a half since my last rifaximin treatment and my symptoms are worse than before.

    My Doc has recommended an additional round of rifaximin, but I’m curious if I should encourage a much longer treatment cycle….8 weeks? 12 weeks?

    Do you have any thoughts on this?

    1. Hey Derek,
      have you retested? If your breath test has improved and your symptoms have not then you might need to shift your focus. Things to consider; SIFO, elemental diets, IBD… just to name a few. If you need help contact my office for a phone consult.
      Hope this helps!

      1. Hi there,

        Yep – retested about a month ago and my hydrogen output decreased by about 50%. I am just now starting round 7 of Rifaximin and we’ll likely perform another breath test at the conclusion of this round.

        I’m sort of wondering at what point I need to stop with these antibiotics. I have been low FODMAP and Rifaximin for going on 6 months now. Hoping there is an end in sight.

  20. I have had issues for about 20 years now. I recently began treatment for SIBO as my results for hydrogen were well over 200ppms via breath test (off the charts).

    I have been through 4 rounds of rifaximin with about a 1 week break in between rounds 3 and 4. It has now been about a week and a half since my last rifaximin treatment and my symptoms are worse than before.

    My Doc has recommended an additional round of rifaximin, but I’m curious if I should encourage a much longer treatment cycle….8 weeks? 12 weeks?

    Do you have any thoughts on this?

    1. Hey Derek,
      have you retested? If your breath test has improved and your symptoms have not then you might need to shift your focus. Things to consider; SIFO, elemental diets, IBD… just to name a few. If you need help contact my office for a phone consult.
      Hope this helps!

      1. Hi there,

        Yep – retested about a month ago and my hydrogen output decreased by about 50%. I am just now starting round 7 of Rifaximin and we’ll likely perform another breath test at the conclusion of this round.

        I’m sort of wondering at what point I need to stop with these antibiotics. I have been low FODMAP and Rifaximin for going on 6 months now. Hoping there is an end in sight.

        1. Wrote a whole book on it 🙂 Healthy Gut, Healthy You. Your question indicates a flawed paradigm that the book will help correct, too long to answer that here.

  21. Does SIBO cause one to have very bad breath and body odor? My daughter cannot be in a car with me because she says my odor is actually from my skin??? Is that possible? thanks

    1. Hi Lynn,
      It could. As a general rule, imbalanced in gut bacteria and fungus can manifest as bad breath and body odor. I have seen a few cases where after treatment the improvements were dramatic.

  22. Hi Dr. Ruscio, This week I started taking a natural antimicrobial for SIBO – Olive Leaf extract. Do you know for how long should I take it to eradicate SIBO?? I started with 1 capsule and I’m having a mild die-off reaction. A good dose would be 3 to 4 caps a day??

    Please help me, thank you.

  23. Hi Dr. Ruscio, This week I started taking a natural antimicrobial for SIBO – Olive Leaf extract. Do you know for how long should I take it to eradicate SIBO?? I started with 1 capsule and I’m having a mild die-off reaction. A good dose would be 3 to 4 caps a day??

    Please help me, thank you.

  24. Hi doc, nice article, very informative. I have been suffering from digestive issues since 2011. Got my endoscopy done twice, recent in January 2017. H pylori and gastroduodinitis come positive every time. My Gastro gave me a course of Antibiotics twice.. had relief for some months but relapse again. I am an Indian staying in India.. since 2 months I am avoiding gluten, milk, fried foods, alcohol etc.. doing exercise regularly.. started drinking Kefir twice daily.. reflux is better.. but abdominal pain and bloating is still there with gas and inability to pass stool easily.
    What will help me? I am fed up of taking Nexium now.. please help me resolve this issue

  25. Hi doc, nice article, very informative. I have been suffering from digestive issues since 2011. Got my endoscopy done twice, recent in January 2017. H pylori and gastroduodinitis come positive every time. My Gastro gave me a course of Antibiotics twice.. had relief for some months but relapse again. I am an Indian staying in India.. since 2 months I am avoiding gluten, milk, fried foods, alcohol etc.. doing exercise regularly.. started drinking Kefir twice daily.. reflux is better.. but abdominal pain and bloating is still there with gas and inability to pass stool easily.
    What will help me? I am fed up of taking Nexium now.. please help me resolve this issue

  26. Thanks so much for all this great info. I had diverticulitis in July. I had to take 3 antibiotics. My stomach has been so messed up since then. (I used probiotics, but they didn’t help). I had the lactulose breath test last week and it came back positive for sibo. I just started xiflaxin last night. My gas has increased and I’m going to the bathroom more. Is that a side effect of the ziflaxin? Also, could the sibo have been caused by the antibiotics? Thanks so much!!

    1. Hi Joan,
      Give it time, sometimes there can be ups and down on Xifaxin. Make sure to discuss with your doctor also. It’s possible but not very likely, in my opinion. Book will be out Feb. 15th so if you still need help there will be help on the way. Or you can contact my office.

  27. Hi
    I I’m sure EBV cause of all that bacteria .H.pylory and SIBO . But unfortunately there is many doctors won’t talk about that .even they know 90%of the adults have that past infection .but always saying that is post .but im sure is not ,and will reactive stage by stage . The best things I think there is book call medium medical by Anthony Williams can hell you a lot to control that virus . And also help you to rid of that bacteria from your body . I already one of his patients .

    1. It’s exoensive to test for reactivated EBV… but I also feel there could be a link there..?” What are you doing to treat the virus?

  28. Please advise on reoccurring SIBO condition.
    I am doing my 3d round of antibiotics, but afraid it would come back like it happened after my second course.
    It’s just impossible to take antibiotics forever and it’s very depressing to leave with SIBO symptoms for the rest of your life.
    Any suggestions about natural supplements or remedies that really Work?
    Thank you for your help and great blog .
    Looking forward to read your book.

  29. I was dignosed with barrett’s esophagus and hiatus hernia. Then after i was treated for it, SIBO came in,was treated for the same about 3-4 times, nothing seems to work. Doctors just keep on prescribing the same medicines with no clue on whats actually going on.
    Should i try taking a course of rifaxamin for 8 weeks, 3 times a day? If not what else should i do

    1. Hi Patient101,
      Treating SIBO may help, I would speak with your doctor about this. A low FODMAP diet may help also, as may Iberogast, among other things. There are options. Find a good clinician to work with for help here.

  30. Dear Dr. Ruscio
    I am currently on my first round of Rifaximin, after taking a SIBO breath test and scoring 97 ppm (hydrogren gas). What do you recommend as the ideal interval between the last day of taking the antibiotic and a re-test? Personally, I don’t want to go for long without continued TX, and I wouldn’t want to treat the SIBO with anti-microbials while I wait to re-test, would I? Wouldn’t it defeat the purpose of determining if the Rifaximin was working?

    Many, many thanks!

    1. Hi Kathaleen,
      It’s really hard to say. If this if your first time being treated I wouldn’t worry too much. I usually have patients retest within 1 week of ending Rifaximin. Bottom line it comes down to one of two options after your Rifaximin; treat again or start into SIBO prevention.
      Hope this helps!

      1. Would the same go for the 1 week recommended interval between finishing an herbal antimicrobial (oregano oil) as for antibiotic? If I tested immediately after finishing the oregano oil would it make a difference?

        I guess I’m trying to determine if it’s better to retest immediately after to see if the treatment was effective or wait a week or 2 to see if it’s been treated and staying down.

        I did a 14 day course of Rifaximin which doesn’t seem to have helped much and after giving my body a 2 week rest while sticking to SCD/LowFODMAP diet am about to start the oregano oil.

  31. I was diagnosed with sibo about two weeks ago. I’m on grapefruit seed extract and we are trying to get up to 500mg per day but I’m also taking flucanazole because I developed candida. I’m on a probiotic. My question is how much of a probiotic should I take? Should I take one to coincide with each?
    I’m only taking 250mg of the grapefruit seed extract because I’m on the flucanazole and I’ve been severely fatigued. Do you recommended starting in smaller doses then working your way up or have a heavy dose to kill it off quickly? I was suffering last month from extreme die off symptoms, now I I don’t really notice much of these symptoms but continue to malabsorb fat and have diarrhea. I’m wondering if my dosage is not enough or I’m just not giving it enough time. I just feel so awful though.

    1. Hi Vicki,
      I like having people take probiotics along with antimicrobial therapy. Working in slowly is a good idea if you are sensitive. It’s very hard to make specific recommendations because there is so much I don’t know here. My book will lay out a comprehensive self-help plan. Or, you can contact my office to become a patient (we offer distance visits also). http://Www.drruscio.com/resources.
      Hope this helps!

  32. Hi,

    I have been diagnosed with SIBO and yeast overgrowth. I also have celiac disease. As one of the bacteria found was Klebsiella, I am on a treatment with herbs (berberine, esentric oils, kaprylic acid, oregano- to mane a few), that are are also meant to target biofilms. Do you have any experiece regarding the effect of natural herbs vs. antibioticis when treating SIBO? Thanks!

  33. Hi,

    I have been diagnosed with SIBO and yeast overgrowth. I also have celiac disease. As one of the bacteria found was Klebsiella, I am on a treatment with herbs (berberine, esentric oils, kaprylic acid, oregano- to mane a few), that are are also meant to target biofilms. Do you have any experiece regarding the effect of natural herbs vs. antibioticis when treating SIBO? Thanks!

  34. It’s unclear to me that the data supports Rifaximin as the drug of choice for SIBO, especially given it’s high cost. In fact, a study that you quote in the January 2017 newsletter says that ciprofloxacin was better than the combination of Rifaximin and neomycin. Other studies show only a marginal superiority of Riflaximin over other much cheaper antibiotics. Yes, I know that Riflaximin is supposed to stay in the gut and have no systemic effects but does this make it worth the price for most people?

    1. Hi Greg,

      Insurance companies are starting to cover it more and it’s available at a much lower cost to purchase from Canadian Pharmacies that ship to the U.S.

      Cipro can have potentially dangerous side effects, and the safety profile of Rifaximin is quite good.

      Hope this helps!

  35. Hi Dr. Ruscio,

    What diet is best to implement during the intake of rifaximin? After finishing the rifaximin doses, do I have to continue the same diet for prevention?

    Thank you,

    Alexa

  36. I’m so surprised! you are not up to date with “methane produced” SIBO?
    Neomyacin + Xifaxan =85%cure rate vs 36% for either alone. 10-14 days for each is the normal protocol.

  37. In your opinion/ experience- which is safer SIBO treatment for patient with recurrent C Diff history- Rifaximin or herbal antimicrobials? I developed SIBO a few months after successful FMT a year ago. Took 8 months to get a diagnosis! One doc said Rifaximin, one herbals. I went with herbals and started a few days ago. Thanks

    1. I don’t this we have data to answer this question, but that said I would assume they would both work and with that in mind why not start with herbals. An elemental diet might be my first suggestion for how to address this.

  38. In your opinion/ experience- which is safer SIBO treatment for patient with recurrent C Diff history- Rifaximin or herbal antimicrobials? I developed SIBO a few months after successful FMT a year ago. Took 8 months to get a diagnosis! One doc said Rifaximin, one herbals. I went with herbals and started a few days ago. Thanks

    1. I don’t this we have data to answer this question, but that said I would assume they would both work and with that in mind why not start with herbals. An elemental diet might be my first suggestion for how to address this.

  39. I just got diagnosed with sibo second time my insurance won’t give me rifaxmin so on keflex and Flagyl. Not feeling very good still have a lot of pain.Are these they only choices if you can’t get rifaxmin?

    1. You could try to herbal protocol laid out in my book which works very well for SIBO, and provides additional tactics for stubborn cases, https://drruscio.com/getgutbook/

      There are way to obtain Rifaximin at more reasonable prices. Check this with your doctor

      Canada prescriptions plus
      ohttps://www.canadaprescriptionsplus.com/pricesearch/rifaximin
      oprice breakdown page –
      https://www.canadaprescriptionsplus.com/pricedetail/xifaxan
      ▪ 200mg, 117 tabs is $447 (8 tabs/day x 14 days= 112 tabs, so there
      are 5 extra)
      Another option is:
      • Pharmastore
      ohttps://www.pharmstore.com/drugs/xifaxan
      ▪ select Rifaximin (℞), 550mg Tablet
      ▪ Price
      • 100 of the 555mg tablets cost about $100.
      • 200 of the 550mg tables cost about $187
      oadditional info found here, https://en.wikipedia.org/wiki/Lupin_Limited

  40. Hi, recently got dignosed w SIBO and have been proscribed Xifaxan. My question is- how long after taking the drug can I try to conceive? There is not a lot of information out there….

  41. I am currently trying a Keto diet for a month to get rid of my SIBO. After the first day, the inflammation of my small intestine was way, way down. After all of my previous food had passed out of me in a day or two, my gut distention (pregnant look and feel) was virtually gone. I felt so much better.
    Now, this isn’t to say that my SIBO was fixed in just a couple days, I’m sure the bacteria are still there, they’re just not getting what they want and not causing havoc because they’re getting almost 0 carbs. I am currently a full week into Keto and feel great, as far as SIBO is concerned. I have the normal side effects of starting Keto as my body adapts, but I’ll take that any day over this SIBO garbage.

  42. Hi, recently got dignosed w SIBO and have been proscribed Xifaxan. My question is- how long after taking the drug can I try to conceive? There is not a lot of information out there….

  43. I am currently trying a Keto diet for a month to get rid of my SIBO. After the first day, the inflammation of my small intestine was way, way down. After all of my previous food had passed out of me in a day or two, my gut distention (pregnant look and feel) was virtually gone. I felt so much better.
    Now, this isn’t to say that my SIBO was fixed in just a couple days, I’m sure the bacteria are still there, they’re just not getting what they want and not causing havoc because they’re getting almost 0 carbs. I am currently a full week into Keto and feel great, as far as SIBO is concerned. I have the normal side effects of starting Keto as my body adapts, but I’ll take that any day over this SIBO garbage.

  44. Hello Dr. Ruscio. I have SIBO and it has been stubborn. It is a disorder (or whatever category it falls under) that is isolating and causes me to feel depressed because my honest efforts have failed. I believe I have had it for years but did not know. I have off the charts hydrogen and low methane, but still above normal. Constipation is normally associated with methane I think, yet I have it with high hydrogen. My ND prescribed me a second 2 week round of Zaxine and Metronidazole after the first round only lowered the methane. So I did the 2 weeks of antibiotics and then immediately, on my own, I did 2 weeks of Physician’s Elemental Diet. The Zaxine is not really expensive here in Canada but the Elemental Diet Powder was around $350 for 2 weeks and not covered by medical. I am also taking low dose Naltrexone for helping to heal my Migrating Motor Complex. I just retested 1.5 weeks after finishing the Elemental diet and literally nothing has changed! My ND thinks I should try seeing someone with more experience. Why do you think the Zaxine, Metronidazole and Elemental Diet combo did not work and would you suggest trying 4-8 weeks of Zaxine now? Should I ask for the Neomycin instead of Metronidalze? I am really down now 🙁

    1. I would start with the Healthy Gut, Health You book’s protocol. If this does not provide relief I would work with a knowledgeable provider or contact my office – SIBO might be barking up the wrong tree and a good doc could determine this. Hang in there! 🙂

  45. Hello Dr. Ruscio. I have SIBO and it has been stubborn. It is a disorder (or whatever category it falls under) that is isolating and causes me to feel depressed because my honest efforts have failed. I believe I have had it for years but did not know. I have off the charts hydrogen and low methane, but still above normal. Constipation is normally associated with methane I think, yet I have it with high hydrogen. My ND prescribed me a second 2 week round of Zaxine and Metronidazole after the first round only lowered the methane. So I did the 2 weeks of antibiotics and then immediately, on my own, I did 2 weeks of Physician’s Elemental Diet. The Zaxine is not really expensive here in Canada but the Elemental Diet Powder was around $350 for 2 weeks and not covered by medical. I am also taking low dose Naltrexone for helping to heal my Migrating Motor Complex. I just retested 1.5 weeks after finishing the Elemental diet and literally nothing has changed! My ND thinks I should try seeing someone with more experience. Why do you think the Zaxine, Metronidazole and Elemental Diet combo did not work and would you suggest trying 4-8 weeks of Zaxine now? Should I ask for the Neomycin instead of Metronidalze? I am really down now 🙁

    1. I would start with the Healthy Gut, Health You book’s protocol. If this does not provide relief I would work with a knowledgeable provider or contact my office – SIBO might be barking up the wrong tree and a good doc could determine this. Hang in there! 🙂

  46. What is considered high hydrogen? I tested positive for hydrogen at a peak of 84ppm at 180 minutes and baseline was 4ppm. Methane was baseline 1ppm and peak at 5ppm at 180 minutes. Interestingly I had more slow motility than diarrhea. Also tested positive for fungal overgrowth (not Candida). 2 weeks of rifaximin improved me but didn’t cure. Not starting a protocol with a naturopath on Berberine and Neem plus antifungal and herbals for MMC and intestinal inflammation. Feeling discouraged though.

  47. What is considered high hydrogen? I tested positive for hydrogen at a peak of 84ppm at 180 minutes and baseline was 4ppm. Methane was baseline 1ppm and peak at 5ppm at 180 minutes. Interestingly I had more slow motility than diarrhea. Also tested positive for fungal overgrowth (not Candida). 2 weeks of rifaximin improved me but didn’t cure. Not starting a protocol with a naturopath on Berberine and Neem plus antifungal and herbals for MMC and intestinal inflammation. Feeling discouraged though.

  48. Hi, Is generic Rifaximin worth buying, Is quality good enough since I think I have SIBO for more than 20 years, and my Hydrogen test went up 35 ppm rapidly. Is it still going to be poorly absorbed antibiotic. I can’t find any review on generic Rifaximin. Please advise.

        1. There is a generic? I was under the impression there was no generic equivalent. I’ve been paying $600+ for Xifaxan…3rd time now yikes! What is the generic called and how do you get it? Thanks! 🙂

  49. Hi, Is generic Rifaximin worth buying, Is quality good enough since I think I have SIBO for more than 20 years, and my Hydrogen test went up 35 ppm rapidly. Is it still going to be poorly absorbed antibiotic. I can’t find any review on generic Rifaximin. Please advise.

        1. There is a generic? I was under the impression there was no generic equivalent. I’ve been paying $600+ for Xifaxan…3rd time now yikes! What is the generic called and how do you get it? Thanks! 🙂

  50. Dr. Ruscio,

    If I did a consultation with you, are you able prescriptions for Rifaximin or do I have to go to a GI doctor for that?

    Thanks,
    Ray

  51. Dr. Ruscio,

    If I did a consultation with you, are you able prescriptions for Rifaximin or do I have to go to a GI doctor for that?

    Thanks,
    Ray

  52. As far as the body odor… can anything help besides the treatment? Probiotics? And if so, does that aggravate the sibo? Thanks

  53. So glad I found this article… I was diagnosed with sibo with both methane and hydrogen levels around 60. After one 2 week courses of rifaximin and neomycin my methane levels went down to 10, but my hydrogen levels went up. My doctor said she has seen this before, and it’s just because the methane needs the hydrogen and without it those levels can go up. She started me on another round of the antibiotics and I retest tomorrow. If the hydrogen doesn’t go down she is starting me on herbals. She has reassured me that most people with high levels need 2 or more rounds of treatment. I’m also following a sibo diet and working on my anxiety. My question is if you think my hydrogen levels going up after the first treatment isn’t cause for concern, and if there’s hope for me to beat this. I bought your book and it’s been invaluable. Just need a little reassurance! Thank you!

  54. So glad I found this article… I was diagnosed with sibo with both methane and hydrogen levels around 60. After one 2 week courses of rifaximin and neomycin my methane levels went down to 10, but my hydrogen levels went up. My doctor said she has seen this before, and it’s just because the methane needs the hydrogen and without it those levels can go up. She started me on another round of the antibiotics and I retest tomorrow. If the hydrogen doesn’t go down she is starting me on herbals. She has reassured me that most people with high levels need 2 or more rounds of treatment. I’m also following a sibo diet and working on my anxiety. My question is if you think my hydrogen levels going up after the first treatment isn’t cause for concern, and if there’s hope for me to beat this. I bought your book and it’s been invaluable. Just need a little reassurance! Thank you!

  55. Dr. Ruscio, have you heard of an antibiotic called Alinia (500 mg twice daily,) rather than Rifaximin? My doctor prefers it, I guess, if it is insured, as it was for me (very expensive!). I have been on it for 5 weeks with some improvement but would not say I am symptom-free yet. My symptoms are not gastrointestinal like most people but months of severe, chronic hives that do not respond to even strong, antihistamines. My integrated health doctor believes it stems from food that has escaped into my blood system and my immune system overreacting with histamines. From this article I guess it is safe to remain on these antibiotics for several weeks . .or do you think Rifaximin would be better?
    My Hydrogen was 21 and my Methane was 16

    Thank you SO much for your articles on SIBO and hives.!! I have been to MANY doctors, (including large University medical centers) that have been of no help till my SIBI test and recent meds.

    1. Hi Lynne,
      I have and am open to it. If you get stuck, go through the protocol in Healthy Gut, Healthy You. It is the most comprehensive gut healing plan I could point you toward. My pleasure.

  56. My 14 y/o daughter is being treated for SIBO with rifaximin only. Her dr didn’t want to add neomycin and she had a bad reaction to flatly. Can it be combined with allicin to attack the allicin,

    1. Hi Helen,
      These are questions for your doctor, but theoretical I suppose so. I would offer you the protocol in Healthy Gut, Health You. It was a 3 year labor of love to provide the most comprehensive, self-help plan I could erect.

  57. My 14 y/o daughter is being treated for SIBO with rifaximin only. Her dr didn’t want to add neomycin and she had a bad reaction to flatly. Can it be combined with allicin to attack the allicin,

    1. Hi Helen,
      These are questions for your doctor, but theoretical I suppose so. I would offer you the protocol in Healthy Gut, Health You. It was a 3 year labor of love to provide the most comprehensive, self-help plan I could erect.

  58. Dr Ruscio,
    Do you think HCL plays a role here in that low levels allow bacteria to get through to the small intestine?
    Thanks

  59. Dr Ruscio,
    Do you think HCL plays a role here in that low levels allow bacteria to get through to the small intestine?
    Thanks

  60. My son is taking Xifaxan 200mg three times a day and weighs about 160lbs. I’ve only read people taking 550mg three times a day. Is this too low of a dose for to treat SIBO? Done week one and no change.

  61. hi I have methane sibo with bloating as my only symptom. Constant intesne severe methane or bacteria in my small intestine no matter if I eat o not.
    Just started protocol of candibactin ar and br 2 capsules 2X a day pus allicin 4 capsues a day. I feel significanty more bloated! Is this normal and what can I expect? I do not want to do ABX and I HAVE to get rid of this bloat I have had for two years!

  62. hi I have methane sibo with bloating as my only symptom. Constant intesne severe methane or bacteria in my small intestine no matter if I eat o not.
    Just started protocol of candibactin ar and br 2 capsules 2X a day pus allicin 4 capsues a day. I feel significanty more bloated! Is this normal and what can I expect? I do not want to do ABX and I HAVE to get rid of this bloat I have had for two years!

  63. Hi! I’m on my second round of Rifaximin/Neomycin and will be finished with my second round in 6 days. I have felt NO improvement. I’ve been tested for everything else under the sun, so know I don’t have any other GI manifestations. My doctor is very renowned and definitely knows his stuff so I’m not questioning him at all. I’m just wondering if it’s common to repeat 3-4 times to feel any relief.

    1. p.s. I should Say I have methane SIBO and bloating is my main symptom. My hormones (specifically progesterone) is also extremely low and I am treating.

  64. I found the study results very interesting: “severity of symptoms did not correlate with the severity of the labs.” My 3-hour breath test showed flatline methane >81 (highest amount reported by Genova). After taking Atrantil for 4 weeks, my test results were similar (48/65/76 and rest >81). I then took Allimed/Neem for 3 weeks. I still had constipation (no bloating) and extensive burping and a few weeks later had severe pain in my middle back and left arm (alleviated with 9 acupuncture treatments). Taking magnesium, Xymogen ProbioMax DF, and an alkaline diet has alleviated the constipation but I still have excessive burping.

    Does your comment about taking antibiotics for 4 weeks, 8 weeks or longer if a patient has a very high gas level on breath testing also apply to taking antimicrobials, such as Allimed and neem? Can these also be taken for a longer duration? If a month or more has passed since last treatment, do you recommend retesting before next treatment to determine length of treatment?

    Thanks for the terrific information!

    1. Hi Mary Ann,

      The answers to most of these questions can be found in Dr Ruscio’s book “Healthy Gut, Healthy You”, where he lays out the exact protocol he uses in his clinic. If you’d like to pick up a copy, you can find it here: https://www.drruscio.com/getgutbook

      Good luck!

      1. Thank you Drew. I already read the book. I can’t find anything about whether or not it is ok to take antimicrobials for longer than 4 weeks. Can you refer me to the chapter that answers this question?

        1. Hi Mary Ann,

          This is covered in chapter 26 (step 3: remove). The baseline protocol for antimicrobials that he recommends is 2 months (so yes, you can do them for longer than 4 weeks). Per the book, this can be repeated potentially 2-3x before checking in with a doctor, and if you relapse after treatment, one can potentially go on a low dose of antimicrobial for an even longer term. Hope this helps!

  65. I found the study results very interesting: “severity of symptoms did not correlate with the severity of the labs.” My 3-hour breath test showed flatline methane >81 (highest amount reported by Genova). After taking Atrantil for 4 weeks, my test results were similar (48/65/76 and rest >81). I then took Allimed/Neem for 3 weeks. I still had constipation (no bloating) and extensive burping and a few weeks later had severe pain in my middle back and left arm (alleviated with 9 acupuncture treatments). Taking magnesium, Xymogen ProbioMax DF, and an alkaline diet has alleviated the constipation but I still have excessive burping.

    Does your comment about taking antibiotics for 4 weeks, 8 weeks or longer if a patient has a very high gas level on breath testing also apply to taking antimicrobials, such as Allimed and neem? Can these also be taken for a longer duration? If a month or more has passed since last treatment, do you recommend retesting before next treatment to determine length of treatment?

    Thanks for the terrific information!

    1. Hi Mary Ann,

      The answers to most of these questions can be found in Dr Ruscio’s book “Healthy Gut, Healthy You”, where he lays out the exact protocol he uses in his clinic. If you’d like to pick up a copy, you can find it here: https://www.drruscio.com/getgutbook

      Good luck!

      1. Thank you Drew. I already read the book. I can’t find anything about whether or not it is ok to take antimicrobials for longer than 4 weeks. Can you refer me to the chapter that answers this question?

        1. Hi Mary Ann,

          This is covered in chapter 26 (step 3: remove). The baseline protocol for antimicrobials that he recommends is 2 months (so yes, you can do them for longer than 4 weeks). Per the book, this can be repeated potentially 2-3x before checking in with a doctor, and if you relapse after treatment, one can potentially go on a low dose of antimicrobial for an even longer term. Hope this helps!

  66. I feel my stomach very much bloated soon after food, i had the problems of belching flatulence constipation( the feeling that my bowel motion is incomplete), BRAIN FOG, lack of concentration. Is it because of SIBO

    1. Hi Akhil,

      I’m sorry to hear you’re not feeling well. I would definitely recommend picking up a copy of Dr Ruscio’s book “Healthy Gut, Healthy You” (https://www.drruscio.com/getgutbook) as he walks you through the exact protocol he uses in his clinic to help patients recover from gut issues. I hope this helps!

  67. I feel my stomach very much bloated soon after food, i had the problems of belching flatulence constipation( the feeling that my bowel motion is incomplete), BRAIN FOG, lack of concentration. Is it because of SIBO

    1. Hi Akhil,

      I’m sorry to hear you’re not feeling well. I would definitely recommend picking up a copy of Dr Ruscio’s book “Healthy Gut, Healthy You” (https://www.drruscio.com/getgutbook) as he walks you through the exact protocol he uses in his clinic to help patients recover from gut issues. I hope this helps!

  68. Have SIBO for 18 months. Took 2 rounds of Xifaxan, no better maybe even worse. Okay in morning till I start eating. Have bm after breakfast. After that make lots of bathroom trips to no avail. No bm or not able to pass gas. Just lots of pain mostly on left side. How can I get rid of the gas? Dr. Pimental and Dr. Siebecker suggest 14 days of Xifaxan and Neomycin. What do you suggest?

    1. Hi Shirley,

      I’m so sorry to hear you’ve been dealing with this for so long. I would definitely recommend picking up a copy of Dr. Ruscio’s book “Healthy Gut, Healthy You” because he walks you through the exact protocol that he uses with patients in his clinic to help them overcome gut issues (including persistent SIBO) and includes things like antimicrobial herbs as well as the elemental diet. You can find it here: https://www.drruscio.com/getgutbook

      Good luck!

  69. Hello I have been diagnosed with methane producing sibo. My functional medicine doctor prescribed rimaxin and neomycin for two weeks. I have one working kidney and one atrophied kidney- and the side effects of neomycin state you can experience kidney issues. This scares me. Is neomycin truly dangerous for kidneys?

    1. Hi Jennifer,

      This is definitely something to discuss with your doctor. Some clinicians use flagyl as an alternative to neomycin, but I’m not sure of the effect on the kidneys, so again, check in with your practitioner. Also, some people trying to avoid antibiotics have success with the elemental diet. Good luck!

  70. Hi, I have been sick for months, after all the testing, I tested positive for silo, I feel sick all the time more so if I try to eat almost anything besides fish ,chicken, rice and sweet potatoes, I’m so tired of being sick, my gastro dr. Put me on Flagyl for 2 weeks 2x a day 500mgs, I’m 5 days in and no change, I was told to call after 2 weeks, it feels like this will never end, I can’t live like this anymore, I work full time, I just can’t do much except wait and see I guess. Is this normal, people on here talk about having this for years, I can’t take that. I’m unhappy.

      1. Hi John,

        I’m so sorry you’re feeling like this – gut issues can be frustrating as it is, but to have them drag on can seem interminable. We can’t give direct medical advice here, but I will say that if going with traditional antibiotics, many clinicians prescribe a combination of rifaximin and flagyl together and find that to be effective. It could be worth asking your doctor about that. If you still don’t feel better, I would recommend picking up a copy of Dr Ruscio’s book, “Healthy Gut, Healthy You” as it walks through the exact protocol he uses with patients in his clinic to help them overcome frustrating digestive issues, including sibo. You can find it here: https://www.drruscio.com/getgutbook

        Good luck!

        1. Ok, fast forward to today, I’m now on my 2nd round of Xifaxan, 2 weeks each times ,550mgs 3x a day, I’m not feeling totally healed but some improvement , but I normally don’t while on the meds but don’t think I’m much better, my hydrogen was peaked at 68, if after this round 5 days of meds left, I’m considering natural stuff or element diet. My GI doctor said he has no experience with the natural stuff, I’m not sure what to do next. I’m 6 months into this and exhausted , I will do the element diet if this will clear me of this, I’ve been doing a lot of research on this and I have been taken PPI’s for reflux for 15 years and I’m convinced this is the reason this happened. I stopped my Omephazal and I’m now taken Zantac my doctor switched me, but I’m getting off this soon also, I believe these are the root of the problem. My doctor doesn’t seem to know enough about Sibo for my comfort, but I can’t seem to find a Sibo specialist in the Boston area. I don’t even know if there are specialists for Sibo. I’m concerned and unsure what to do next, get a second opinion, try to find a specialist, try natural next, retest after these meds wear off , I think I have to wait 2 weeks to retest, element diet? Any advice/ opinions would be appreciated, I’ve been sick to long, I feel like this will never go away.

          1. Hi John,

            I’m glad you’re feeling slightly improved. Like I said in my last comment, I suggest you pick up a copy of Dr Ruscio’s book. It will walk you through a DIY gut protocol using natural therapies. You can find it here: https://www.drruscio.com/getgutbook If you feel you need more personalized help, Dr Ruscio does see patients virtually and you can apply to meet with him here: https://www.drruscio.com/gethelp

  71. Hi, I have been sick for months, after all the testing, I tested positive for silo, I feel sick all the time more so if I try to eat almost anything besides fish ,chicken, rice and sweet potatoes, I’m so tired of being sick, my gastro dr. Put me on Flagyl for 2 weeks 2x a day 500mgs, I’m 5 days in and no change, I was told to call after 2 weeks, it feels like this will never end, I can’t live like this anymore, I work full time, I just can’t do much except wait and see I guess. Is this normal, people on here talk about having this for years, I can’t take that. I’m unhappy.

      1. Hi John,

        I’m so sorry you’re feeling like this – gut issues can be frustrating as it is, but to have them drag on can seem interminable. We can’t give direct medical advice here, but I will say that if going with traditional antibiotics, many clinicians prescribe a combination of rifaximin and flagyl together and find that to be effective. It could be worth asking your doctor about that. If you still don’t feel better, I would recommend picking up a copy of Dr Ruscio’s book, “Healthy Gut, Healthy You” as it walks through the exact protocol he uses with patients in his clinic to help them overcome frustrating digestive issues, including sibo. You can find it here: https://www.drruscio.com/getgutbook

        Good luck!

        1. Ok, fast forward to today, I’m now on my 2nd round of Xifaxan, 2 weeks each times ,550mgs 3x a day, I’m not feeling totally healed but some improvement , but I normally don’t while on the meds but don’t think I’m much better, my hydrogen was peaked at 68, if after this round 5 days of meds left, I’m considering natural stuff or element diet. My GI doctor said he has no experience with the natural stuff, I’m not sure what to do next. I’m 6 months into this and exhausted , I will do the element diet if this will clear me of this, I’ve been doing a lot of research on this and I have been taken PPI’s for reflux for 15 years and I’m convinced this is the reason this happened. I stopped my Omephazal and I’m now taken Zantac my doctor switched me, but I’m getting off this soon also, I believe these are the root of the problem. My doctor doesn’t seem to know enough about Sibo for my comfort, but I can’t seem to find a Sibo specialist in the Boston area. I don’t even know if there are specialists for Sibo. I’m concerned and unsure what to do next, get a second opinion, try to find a specialist, try natural next, retest after these meds wear off , I think I have to wait 2 weeks to retest, element diet? Any advice/ opinions would be appreciated, I’ve been sick to long, I feel like this will never go away.

          1. Hi John,

            I’m glad you’re feeling slightly improved. Like I said in my last comment, I suggest you pick up a copy of Dr Ruscio’s book. It will walk you through a DIY gut protocol using natural therapies. You can find it here: https://www.drruscio.com/getgutbook If you feel you need more personalized help, Dr Ruscio does see patients virtually and you can apply to meet with him here: https://www.drruscio.com/gethelp

  72. I have been dealing with severe Mesenteric Adentits for 3 1/2 months now and I also have IBS and suddenly am sensitive to avocados and carbohydrates- food in general. I’ve been having more and more diarrhea. I’ve had an endoscopy, colonoscopy, ultra sounds and everyone is just telling me that adentits will go away on its own. I am now concerned that this could all be SIBO. What are your thoughts doctor?

    1. Hi Heather,

      I’m sorry you’ve been dealing with this. Unfortunately, we’re unable to give personalized medical advice on this forum. However, there are many resources on this site regarding SIBO if you type it into the search box, if you’d like to read more about it and see if you feel like it may apply to you. You can also work with a practitioner who will give you a breath test, or pick up a copy of Dr Ruscio’s book “Healthy Gut, Healthy You”, where he walks through the exact protocol he uses with clients in his clinic to help them overcome frustrating digestive issues. You can find that here: https://www.drruscio.com/getgutbook. Good luck!

  73. I have been dealing with severe Mesenteric Adentits for 3 1/2 months now and I also have IBS and suddenly am sensitive to avocados and carbohydrates- food in general. I’ve been having more and more diarrhea. I’ve had an endoscopy, colonoscopy, ultra sounds and everyone is just telling me that adentits will go away on its own. I am now concerned that this could all be SIBO. What are your thoughts doctor?

    1. Hi Heather,

      I’m sorry you’ve been dealing with this. Unfortunately, we’re unable to give personalized medical advice on this forum. However, there are many resources on this site regarding SIBO if you type it into the search box, if you’d like to read more about it and see if you feel like it may apply to you. You can also work with a practitioner who will give you a breath test, or pick up a copy of Dr Ruscio’s book “Healthy Gut, Healthy You”, where he walks through the exact protocol he uses with clients in his clinic to help them overcome frustrating digestive issues. You can find that here: https://www.drruscio.com/getgutbook. Good luck!

  74. Hello,
    Thank you so much for all of the advice you offer on your podcast, website, and now book! I’m eager to start reading mine after I post this. I’m currently struggling with starting Rifaximin or not. Hopefully you can help me, back in 2009 I was diagnosed with IBS, always sensitive to dairy, and eggs. Taking bentyl daily helped me a lot. After having my first child and not taking bentyl any more because I could not tolerate it, for 6 months I couldn’t eat, I went on a elimination diet, after cutting gluten, grains, eggs, and dairy out of my diet I was symptom free and didn’t need any medicine for 2 years! Then 3 months ago, I caught a virus, and everyday I had bloating, horrible pain, and diarrhea. I was tested for SIBO that came back negative. I had a colonoscopy 1 year ago as my grandma had colon cancer at 21, that was fine and my GI didn’t feel the need to retest yet. I’m catching every virus and always have a cold. My lymph nodes are swollen. And I never branch out away from my strict diet. So since every blood test, bacteria and parasite test came back normal he prescribed me Rifaximin. I was on board, until my sister spoke with her functional medicine doctor about me (unfortunately due to my insurance right now even if I paid out of pocket I can’t see one with the Clinic) and he recommended not eating animal protein for 3 weeks because I have major leaky gut, and taking a digestive enzyme. Once I started that for 6 days I found relief. I did have the original symptoms the other day but once I cut out the banana pancakes I eat daily, along with animal protein I felt fine again. So I’m not sure if I should take the Rifaximin, I feel like I’m literally living off sweet potatoes because I cut everything else out. Would taking Rifaximin mess with my gut if I don’t have a SIBO diagnosis, and if a elimination diet is helping? I guess I still don’t understand why the food I once could tolerate for 2 years with no problems would be a issue now still. I’m sure I’ll get a lot of information from your book too but I could really use your opinion too! Thank you in advance!

    1. Hi Amanda,

      I’m so sorry you’re not feeling well. Unfortunately we can’t give personalized medical advice on this forum and can’t tell you whether or not you should take it. I do, however, think the book will be very helpful for you. It does address herbal antimicrobials as well as more traditional antibiotics, so you’ll be able to make an informed choice with your doctor.

      Good luck!

  75. Hello,
    Thank you so much for all of the advice you offer on your podcast, website, and now book! I’m eager to start reading mine after I post this. I’m currently struggling with starting Rifaximin or not. Hopefully you can help me, back in 2009 I was diagnosed with IBS, always sensitive to dairy, and eggs. Taking bentyl daily helped me a lot. After having my first child and not taking bentyl any more because I could not tolerate it, for 6 months I couldn’t eat, I went on a elimination diet, after cutting gluten, grains, eggs, and dairy out of my diet I was symptom free and didn’t need any medicine for 2 years! Then 3 months ago, I caught a virus, and everyday I had bloating, horrible pain, and diarrhea. I was tested for SIBO that came back negative. I had a colonoscopy 1 year ago as my grandma had colon cancer at 21, that was fine and my GI didn’t feel the need to retest yet. I’m catching every virus and always have a cold. My lymph nodes are swollen. And I never branch out away from my strict diet. So since every blood test, bacteria and parasite test came back normal he prescribed me Rifaximin. I was on board, until my sister spoke with her functional medicine doctor about me (unfortunately due to my insurance right now even if I paid out of pocket I can’t see one with the Clinic) and he recommended not eating animal protein for 3 weeks because I have major leaky gut, and taking a digestive enzyme. Once I started that for 6 days I found relief. I did have the original symptoms the other day but once I cut out the banana pancakes I eat daily, along with animal protein I felt fine again. So I’m not sure if I should take the Rifaximin, I feel like I’m literally living off sweet potatoes because I cut everything else out. Would taking Rifaximin mess with my gut if I don’t have a SIBO diagnosis, and if a elimination diet is helping? I guess I still don’t understand why the food I once could tolerate for 2 years with no problems would be a issue now still. I’m sure I’ll get a lot of information from your book too but I could really use your opinion too! Thank you in advance!

    1. Hi Amanda,

      I’m so sorry you’re not feeling well. Unfortunately we can’t give personalized medical advice on this forum and can’t tell you whether or not you should take it. I do, however, think the book will be very helpful for you. It does address herbal antimicrobials as well as more traditional antibiotics, so you’ll be able to make an informed choice with your doctor.

      Good luck!

  76. In the study they note that they retested every 4 weeks but it does not say the exact time frame between ceasing antibiotics and the retest. I m assuming you would retest the following day or within days of completing the 4 week course to determine if continuation of treatment is required based on the breath test results/levels.

    1. Hi Hannah,

      Yeah I’m not sure either, but I would assume that yes, they’re re-testing immediately after.

  77. In the study they note that they retested every 4 weeks but it does not say the exact time frame between ceasing antibiotics and the retest. I m assuming you would retest the following day or within days of completing the 4 week course to determine if continuation of treatment is required based on the breath test results/levels.

    1. Hi Hannah,

      Yeah I’m not sure either, but I would assume that yes, they’re re-testing immediately after.

  78. Do you suggest taking an probiotic along with the Rifaximin for IBS D or wait until finished with antibiotic? If so which one do you reccomend?

    1. Hi Kathy,

      I recommend picking up a copy of Dr Ruscio’s book, “Healthy Gut, Healthy You”, as it lays out the exact protocol he uses in the clinic and recommends to patients in order to overcome tough gut issues including SIBO. It includes steps as well as specific supplement recommendations. You can find it here: https://www.drruscio.com/getgutbook

  79. Do you suggest taking an probiotic along with the Rifaximin for IBS D or wait until finished with antibiotic? If so which one do you reccomend?

    1. Hi Kathy,

      I recommend picking up a copy of Dr Ruscio’s book, “Healthy Gut, Healthy You”, as it lays out the exact protocol he uses in the clinic and recommends to patients in order to overcome tough gut issues including SIBO. It includes steps as well as specific supplement recommendations. You can find it here: https://www.drruscio.com/getgutbook

    1. Hi Anita,

      If you’re working with a doctor on this, you’ll want to proceed according to their guidance. You may also want to check out Dr Ruscio’s book “Healthy Gut, Healthy You”, as it outlines the protocol he uses in his clinic to help patients overcome stubborn gut issues (including SIBO and candida) in an easy-to-follow format. You can find it here: https://www.drruscio.com/getgutbook

      Good luck!

    1. Hi Anita,

      If you’re working with a doctor on this, you’ll want to proceed according to their guidance. You may also want to check out Dr Ruscio’s book “Healthy Gut, Healthy You”, as it outlines the protocol he uses in his clinic to help patients overcome stubborn gut issues (including SIBO and candida) in an easy-to-follow format. You can find it here: https://www.drruscio.com/getgutbook

      Good luck!

  80. May I ask if you have any idea what your SIBO patients histamine levels have been? And if any of them have had SIBO and candida overgrowth and how you might treat that?

  81. May I ask if you have any idea what your SIBO patients histamine levels have been? And if any of them have had SIBO and candida overgrowth and how you might treat that?

  82. I live in Portugal and im desesperat. One day my belly started to swell, I thought I was getting pregnant, and after a few weeks started diarrhea, nausea, headache, brain frog, digestion difficulties. I had colonoscopy and endoscopy and everything was fine just gastritis I was diagnosed with IBS, I took all the medicines and diets and it just got worse. After a few months I decided to look for a functional nutritionist who told me about Sibo. In my country no doctor recognizes this disease. I am desperate I lost a lot of weight and I have no strength to work. I’m 2 weeks taking oregano oil and arch stick passed by a nutritionist, at this time only eat protein (eggs, meat and fish) and rice, but so far the symptoms have not improved is normal?
    I’m well medicated?
    No longer know what to do to get my life back, in my country no doctor can help me.
    Thanks

    1. Hi Patricia,

      I’m so sorry you’re dealing with this, I know how frustrating it can be. If finding a doctor in your area who is experienced with SIBO isn’t possible, you may want to try and find someone who will treat you virtually. Dr Ruscio sees patients online who don’t live in California. If you’re interested in becoming a patient, you can apply to do so here: https://www.drruscio.com/gethelp

      In the meantime, I would also recommend picking up a copy of his book “Healthy Gut, Healthy You”, as it will give you a good place to start while you’re waiting for an appointment.

      Good luck!

  83. I live in Portugal and im desesperat. One day my belly started to swell, I thought I was getting pregnant, and after a few weeks started diarrhea, nausea, headache, brain frog, digestion difficulties. I had colonoscopy and endoscopy and everything was fine just gastritis I was diagnosed with IBS, I took all the medicines and diets and it just got worse. After a few months I decided to look for a functional nutritionist who told me about Sibo. In my country no doctor recognizes this disease. I am desperate I lost a lot of weight and I have no strength to work. I’m 2 weeks taking oregano oil and arch stick passed by a nutritionist, at this time only eat protein (eggs, meat and fish) and rice, but so far the symptoms have not improved is normal?
    I’m well medicated?
    No longer know what to do to get my life back, in my country no doctor can help me.
    Thanks

    1. Hi Patricia,

      I’m so sorry you’re dealing with this, I know how frustrating it can be. If finding a doctor in your area who is experienced with SIBO isn’t possible, you may want to try and find someone who will treat you virtually. Dr Ruscio sees patients online who don’t live in California. If you’re interested in becoming a patient, you can apply to do so here: https://www.drruscio.com/gethelp

      In the meantime, I would also recommend picking up a copy of his book “Healthy Gut, Healthy You”, as it will give you a good place to start while you’re waiting for an appointment.

      Good luck!

  84. Hi! I’m on my second round of Rifaximin/Neomycin and will be finished with my second round in 6 days. I have felt NO improvement. I’ve been tested for everything else under the sun, so know I don’t have any other GI manifestations. My doctor is very renowned and definitely knows his stuff so I’m not questioning him at all. I’m just wondering if it’s common to repeat 3-4 times to feel any relief.

    1. p.s. I should Say I have methane SIBO and bloating is my main symptom. My hormones (specifically progesterone) is also extremely low and I am treating.

  85. My son is taking Xifaxan 200mg three times a day and weighs about 160lbs. I’ve only read people taking 550mg three times a day. Is this too low of a dose for to treat SIBO? Done week one and no change.

  86. Dr. Ruscio, have you heard of an antibiotic called Alinia (500 mg twice daily,) rather than Rifaximin? My doctor prefers it, I guess, if it is insured, as it was for me (very expensive!). I have been on it for 5 weeks with some improvement but would not say I am symptom-free yet. My symptoms are not gastrointestinal like most people but months of severe, chronic hives that do not respond to even strong, antihistamines. My integrated health doctor believes it stems from food that has escaped into my blood system and my immune system overreacting with histamines. From this article I guess it is safe to remain on these antibiotics for several weeks . .or do you think Rifaximin would be better?
    My Hydrogen was 21 and my Methane was 16

    Thank you SO much for your articles on SIBO and hives.!! I have been to MANY doctors, (including large University medical centers) that have been of no help till my SIBI test and recent meds.

    1. Hi Lynne,
      I have and am open to it. If you get stuck, go through the protocol in Healthy Gut, Healthy You. It is the most comprehensive gut healing plan I could point you toward. My pleasure.

  87. Thanks so much for all this great info. I had diverticulitis in July. I had to take 3 antibiotics. My stomach has been so messed up since then. (I used probiotics, but they didn’t help). I had the lactulose breath test last week and it came back positive for sibo. I just started xiflaxin last night. My gas has increased and I’m going to the bathroom more. Is that a side effect of the ziflaxin? Also, could the sibo have been caused by the antibiotics? Thanks so much!!

    1. Hi Joan,
      Give it time, sometimes there can be ups and down on Xifaxin. Make sure to discuss with your doctor also. It’s possible but not very likely, in my opinion. Book will be out Feb. 15th so if you still need help there will be help on the way. Or you can contact my office.

  88. Does SIBO cause one to have very bad breath and body odor? My daughter cannot be in a car with me because she says my odor is actually from my skin??? Is that possible? thanks

    1. Hi Lynn,
      It could. As a general rule, imbalanced in gut bacteria and fungus can manifest as bad breath and body odor. I have seen a few cases where after treatment the improvements were dramatic.

  89. Hi
    I I’m sure EBV cause of all that bacteria .H.pylory and SIBO . But unfortunately there is many doctors won’t talk about that .even they know 90%of the adults have that past infection .but always saying that is post .but im sure is not ,and will reactive stage by stage . The best things I think there is book call medium medical by Anthony Williams can hell you a lot to control that virus . And also help you to rid of that bacteria from your body . I already one of his patients .

    1. It’s exoensive to test for reactivated EBV… but I also feel there could be a link there..?” What are you doing to treat the virus?

  90. Dear Dr. Ruscio
    I am currently on my first round of Rifaximin, after taking a SIBO breath test and scoring 97 ppm (hydrogren gas). What do you recommend as the ideal interval between the last day of taking the antibiotic and a re-test? Personally, I don’t want to go for long without continued TX, and I wouldn’t want to treat the SIBO with anti-microbials while I wait to re-test, would I? Wouldn’t it defeat the purpose of determining if the Rifaximin was working?

    Many, many thanks!

    1. Hi Kathaleen,
      It’s really hard to say. If this if your first time being treated I wouldn’t worry too much. I usually have patients retest within 1 week of ending Rifaximin. Bottom line it comes down to one of two options after your Rifaximin; treat again or start into SIBO prevention.
      Hope this helps!

      1. Would the same go for the 1 week recommended interval between finishing an herbal antimicrobial (oregano oil) as for antibiotic? If I tested immediately after finishing the oregano oil would it make a difference?

        I guess I’m trying to determine if it’s better to retest immediately after to see if the treatment was effective or wait a week or 2 to see if it’s been treated and staying down.

        I did a 14 day course of Rifaximin which doesn’t seem to have helped much and after giving my body a 2 week rest while sticking to SCD/LowFODMAP diet am about to start the oregano oil.

  91. Please advise on reoccurring SIBO condition.
    I am doing my 3d round of antibiotics, but afraid it would come back like it happened after my second course.
    It’s just impossible to take antibiotics forever and it’s very depressing to leave with SIBO symptoms for the rest of your life.
    Any suggestions about natural supplements or remedies that really Work?
    Thank you for your help and great blog .
    Looking forward to read your book.

  92. I was diagnosed with sibo about two weeks ago. I’m on grapefruit seed extract and we are trying to get up to 500mg per day but I’m also taking flucanazole because I developed candida. I’m on a probiotic. My question is how much of a probiotic should I take? Should I take one to coincide with each?
    I’m only taking 250mg of the grapefruit seed extract because I’m on the flucanazole and I’ve been severely fatigued. Do you recommended starting in smaller doses then working your way up or have a heavy dose to kill it off quickly? I was suffering last month from extreme die off symptoms, now I I don’t really notice much of these symptoms but continue to malabsorb fat and have diarrhea. I’m wondering if my dosage is not enough or I’m just not giving it enough time. I just feel so awful though.

    1. Hi Vicki,
      I like having people take probiotics along with antimicrobial therapy. Working in slowly is a good idea if you are sensitive. It’s very hard to make specific recommendations because there is so much I don’t know here. My book will lay out a comprehensive self-help plan. Or, you can contact my office to become a patient (we offer distance visits also). http://Www.drruscio.com/resources.
      Hope this helps!

  93. I was dignosed with barrett’s esophagus and hiatus hernia. Then after i was treated for it, SIBO came in,was treated for the same about 3-4 times, nothing seems to work. Doctors just keep on prescribing the same medicines with no clue on whats actually going on.
    Should i try taking a course of rifaxamin for 8 weeks, 3 times a day? If not what else should i do

    1. Hi Patient101,
      Treating SIBO may help, I would speak with your doctor about this. A low FODMAP diet may help also, as may Iberogast, among other things. There are options. Find a good clinician to work with for help here.

  94. It’s unclear to me that the data supports Rifaximin as the drug of choice for SIBO, especially given it’s high cost. In fact, a study that you quote in the January 2017 newsletter says that ciprofloxacin was better than the combination of Rifaximin and neomycin. Other studies show only a marginal superiority of Riflaximin over other much cheaper antibiotics. Yes, I know that Riflaximin is supposed to stay in the gut and have no systemic effects but does this make it worth the price for most people?

    1. Hi Greg,

      Insurance companies are starting to cover it more and it’s available at a much lower cost to purchase from Canadian Pharmacies that ship to the U.S.

      Cipro can have potentially dangerous side effects, and the safety profile of Rifaximin is quite good.

      Hope this helps!

  95. Hi Dr. Ruscio,

    What diet is best to implement during the intake of rifaximin? After finishing the rifaximin doses, do I have to continue the same diet for prevention?

    Thank you,

    Alexa

  96. I’m so surprised! you are not up to date with “methane produced” SIBO?
    Neomyacin + Xifaxan =85%cure rate vs 36% for either alone. 10-14 days for each is the normal protocol.

  97. I just got diagnosed with sibo second time my insurance won’t give me rifaxmin so on keflex and Flagyl. Not feeling very good still have a lot of pain.Are these they only choices if you can’t get rifaxmin?

    1. You could try to herbal protocol laid out in my book which works very well for SIBO, and provides additional tactics for stubborn cases, https://drruscio.com/getgutbook/

      There are way to obtain Rifaximin at more reasonable prices. Check this with your doctor

      Canada prescriptions plus
      ohttps://www.canadaprescriptionsplus.com/pricesearch/rifaximin
      oprice breakdown page –
      https://www.canadaprescriptionsplus.com/pricedetail/xifaxan
      ▪ 200mg, 117 tabs is $447 (8 tabs/day x 14 days= 112 tabs, so there
      are 5 extra)
      Another option is:
      • Pharmastore
      ohttps://www.pharmstore.com/drugs/xifaxan
      ▪ select Rifaximin (℞), 550mg Tablet
      ▪ Price
      • 100 of the 555mg tablets cost about $100.
      • 200 of the 550mg tables cost about $187
      oadditional info found here, https://en.wikipedia.org/wiki/Lupin_Limited

  98. Have SIBO for 18 months. Took 2 rounds of Xifaxan, no better maybe even worse. Okay in morning till I start eating. Have bm after breakfast. After that make lots of bathroom trips to no avail. No bm or not able to pass gas. Just lots of pain mostly on left side. How can I get rid of the gas? Dr. Pimental and Dr. Siebecker suggest 14 days of Xifaxan and Neomycin. What do you suggest?

    1. Hi Shirley,

      I’m so sorry to hear you’ve been dealing with this for so long. I would definitely recommend picking up a copy of Dr. Ruscio’s book “Healthy Gut, Healthy You” because he walks you through the exact protocol that he uses with patients in his clinic to help them overcome gut issues (including persistent SIBO) and includes things like antimicrobial herbs as well as the elemental diet. You can find it here: https://www.drruscio.com/getgutbook

      Good luck!

  99. Hello I have been diagnosed with methane producing sibo. My functional medicine doctor prescribed rimaxin and neomycin for two weeks. I have one working kidney and one atrophied kidney- and the side effects of neomycin state you can experience kidney issues. This scares me. Is neomycin truly dangerous for kidneys?

    1. Hi Jennifer,

      This is definitely something to discuss with your doctor. Some clinicians use flagyl as an alternative to neomycin, but I’m not sure of the effect on the kidneys, so again, check in with your practitioner. Also, some people trying to avoid antibiotics have success with the elemental diet. Good luck!

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