Efficacy of Rifaximin and Probiotics in the Treatment of Small Intestinal Bacterial Overgrowth When Used Concomitantly or Sequentially

Background: With the prevalence of small intestinal bacterial overgrowth (SIBO) on the rise, treatment has become of paramount importance for patients suffering from this disease. Antibiotics used to treat SIBO include rifaximin, ciprofloxacin, metronidazole, and neomycin. Probiotics reinforce the small intestine's internal microbiota and help cure many diseases.   Aim: In this study, we aimed to evaluate the efficacy of rifaximin together with a multi-strain probiotic in patients with SIBO. In a multi-center open-labeled prospective study, recruited patients were randomized into two groups treated with rifaximin as a base and probiotics that varied in the timing of initiation (concomitantly; group A or sequentially; group B) for treating the clinical manifestations of the disease. The primary endpoint evaluated the clinical response to treatment, and the secondary endpoint evaluated the eradication rates.   Results: Eradication rates revealed that 69.8% of the patients in group A and 74.8% of the patients in group B were successfully treated and returned with negative lactulose hydrogen breath test results. Clinical response rates were divided into partial and complete responders; partial responders were reported in 23.3% and 26.6% of patients in groups A and B, respectively, and complete responders were reported in 62.7% and 59.5% of patients in groups A and B, respectively. Overall, partial or complete responders' combined rate comprised 86% and 86.2% in groups A and B, respectively. There were no reported side effects by patients treated with rifaximin and the multi-strain probiotic for both protocols.   Conclusion: The addition of probiotics, both concomitantly or sequentially, to the treatment regimen acts synergistically with rifaximin to improve outcomes. According to our study, there were no statistical differences between the two regimens. In conclusion, the extension of probiotics in the sequential regimen provided a more prolonged clinical response rate.