Abstract
Irritable bowel syndrome (IBS) is the most common gastrointestinal condition effecting adults in developed countries worldwide. Over the last decade, evidence has emerged suggesting that gut bacteria play a role in the pathophysiology of IBS. While difficult to identify using noninvasive means, one of the most common attributable bacterial concepts in IBS is the small intestinal bacterial overgrowth hypothesis (SIBO). In this article, we review the different mechanisms by which gut flora and, specifically, SIBO may contribute to IBS and the evidence supporting the use of various antibiotic therapies in treating IBS.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance
Drossman DA, Sandler RS, McKee DC, et al. Bowel patterns among subjects not seeking health care. Use of a questionnaire to identify a population with bowel dysfunction. Gastroenterology. 1982;83(3):529–34.
Thompson WG, Heaton KW. Functional bowel disorders in apparently healthy people. Gastroenterology. 1980;79(2):283–8.
Thompson WG. The functional gastrointestinal bowel disorders. In: Drossman DA, editor. The functional gastrointestinal disorders. Boston: Little, Brown; 1994. p. 117–34.
Whitehead WE. Patient subgroups in irritable bowel syndrome that can be defined by symptom evaluation and physical examination. Am J Med. 1999;107(5A):33S–40S.
Thompson WG, Longstreth GF, Drossman DA, et al. Functional bowel disorders and functional abdominal pain. Gut. 1999;45 Suppl 2:II43–7.
Pimentel M, Hwang L, Melmed GY, et al. New clinical method for distinguishing D-IBS from other gastrointestinal conditions causing diarrhea: the LA/IBS diagnostic strategy. Dig Dis Sci. 2010;55(1):145–9.
Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterology. 2006;130(5):1480–91.
Drossman DA, Dumitrascu DL. Rome III: new standard for functional gastrointestinal disorders. J Gastrointestin Liver Dis. 2006;15(3):237–41.
Guidelines--Rome III diagnostic criteria for functional gastrointestinal disorders. J Gastrointestin Liver Dis. 2006;15(3):307–12
Kruis W, Thieme C, Weinzierl M, et al. A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease. Gastroenterology. 1984;87(1):1–7.
Mertz HR. Irritable bowel syndrome. N Engl J Med. 2003;349(22):2136–46.
Ringel Y, Williams RE, Kalilani L, et al. Prevalence, characteristics, and impact of bloating symptoms in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. 2009;7(1):68–72. quiz 3.
McKee DP, Quigley EM. Intestinal motility in irritable bowel syndrome: is IBS a motility disorder? Part 2. Motility of the small bowel, esophagus, stomach, and gall-bladder. Dig Dis Sci. 1993;38(10):1773–82.
McKee DP, Quigley EM. Intestinal motility in irritable bowel syndrome: is IBS a motility disorder? Part 1. Definition of IBS and colonic motility. Dig Dis Sci. 1993;38(10):1761–72.
Nieuwenhuijs VB, Verheem A, van Duijvenbode-Beumer H, et al. The role of interdigestive small bowel motility in the regulation of gut microflora, bacterial overgrowth, and bacterial translocation in rats. Ann Surg. 1998;228(2):188–93.
Pimentel M, Soffer EE, Chow EJ, et al. Lower frequency of MMC is found in IBS subjects with abnormal lactulose breath test, suggesting bacterial overgrowth. Dig Dis Sci. 2002;47(12):2639–43.
Mertz H, Morgan V, Tanner G, et al. Regional cerebral activation in irritable bowel syndrome and control subjects with painful and nonpainful rectal distention. Gastroenterology. 2000;118(5):842–8.
Manabe N, Tanaka T, Hata J, et al. Pathophysiology underlying irritable bowel syndrome–from the viewpoint of dysfunction of autonomic nervous system activity. J Smooth Muscle Res. 2009;45(1):15–23.
Whitehead WE, Crowell MD, Robinson JC, et al. Effects of stressful life events on bowel symptoms: subjects with irritable bowel syndrome compared with subjects without bowel dysfunction. Gut. 1992;33(6):825–30.
Levy RL, Cain KC, Jarrett M, et al. The relationship between daily life stress and gastrointestinal symptoms in women with irritable bowel syndrome. J Behav Med. 1997;20(2):177–93.
Blanchard EB, Lackner JM, Jaccard J, et al. The role of stress in symptom exacerbation among IBS patients. J Psychosom Res. 2008;64(2):119–28.
Yamini D, Pimentel M. Irritable bowel syndrome and small intestinal bacterial overgrowth. J Clin Gastroenterol. 2010;44(10):672–5.
• Posserud I, Stotzer PO, Bjornsson ES, et al. Small intestinal bacterial overgrowth in patients with irritable bowel syndrome. Gut. 2007;56(6):802–8. Provided the first conclusive direct evidence for SIBO in IBS i.e. evidence based on culture of the small bowel rather than breath testing.
Pyleris E, Giamarellos-Bourboulis EJ, Tzivras D, et al. The prevalence of overgrowth by aerobic bacteria in the small intestine by small bowel culture: relationship with Irritable Bowel Syndrome. Dig Dis Sci. 2012
Ford AC, Spiegel BM, Talley NJ, et al. Small intestinal bacterial overgrowth in irritable bowel syndrome: systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2009;7(12):1279–86.
Shah ED, Basseri RJ, Chong K, et al. Abnormal breath testing in IBS: a meta-analysis. Dig Dis Sci. 2010;55(9):2441–9.
Quigley EM. New perspectives on the role of the intestinal flora in health and disease. J Gastrointestin Liver Dis. 2006;15(2):109–10.
Gill SR, Pop M, Deboy RT, et al. Metagenomic analysis of the human distal gut microbiome. Science. 2006;312(5778):1355–9.
Turnbaugh PJ, Ley RE, Hamady M, et al. The human microbiome project. Nature. 2007;449(7164):804–10.
Pimentel M, Chow EJ, Lin HC. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome. Am J Gastroenterol. 2000;95(12):3503–6.
Pimentel M, Chow EJ, Lin HC. Normalization of lactulose breath testing correlates with symptom improvement in irritable bowel syndrome. a double-blind, randomized, placebo-controlled study. Am J Gastroenterol. 2003;98(2):412–9.
Lupascu A, Gabrielli M, Lauritano EC, et al. Hydrogen glucose breath test to detect small intestinal bacterial overgrowth: a prevalence case-control study in irritable bowel syndrome. Aliment Pharmacol Ther. 2005;22(11–12):1157–60.
Cuoco L, Salvagnini M. Small intestine bacterial overgrowth in irritable bowel syndrome: a retrospective study with rifaximin. Minerva Gastroenterol Dietol. 2006;52(1):89–95.
• Majewski M, McCallum RW. Results of small intestinal bacterial overgrowth testing in irritable bowel syndrome patients: clinical profiles and effects of antibiotic trial. Adv Med Sci. 2007;52:139–42. Important early study demonstrating SIBO in IBS pa#ents and the efficacy of antibiotic (rifaximin) treatment in allevia#ng symptoms.
Sharara AI, Aoun E, Abdul-Baki H, et al. A randomized double-blind placebo-controlled trial of rifaximin in patients with abdominal bloating and flatulence. Am J Gastroenterol. 2006;101(2):326–33.
• Pimentel M, Lembo A, Chey WD, et al. Rifaximin therapy for patients with irritable bowel syndrome without constipation. N Engl J Med. 2011;364(1):22–32. Describes two large phase 3, double‐blind, placebo‐controlled trials (TARGET 1 and TARGET 2) which showed that treatment with rifaximin for 2 weeks provided significant relief of IBS symptoms in patients who had IBS without constipation.
Lin HC, Pimentel M. Bacterial concepts in irritable bowel syndrome. Rev Gastroenterol Disord. 2005;5 Suppl 3:S3–9.
Basseri RJ, Weitsman S, Barlow GM, et al. Antibiotics for the treatment of irritable bowel syndrome. Gastroenterol Hepatol (NY). 2011;7(7):455–93.
Berg RD. The indigenous gastrointestinal microflora. Trends Microbiol. 1996;4(11):430–5.
Macfarlane S, Macfarlane GT. Bacterial diversity in the human gut. Adv Appl Microbiol. 2004;54:261–89.
Backhed F, Ley RE, Sonnenburg JL, et al. Host-bacterial mutualism in the human intestine. Science. 2005;307(5717):1915–20.
O’Hara AM, Shanahan F. The gut flora as a forgotten organ. EMBO Rep. 2006;7(7):688–93.
Frank DN, St Amand AL, Feldman RA, et al. Molecular-phylogenetic characterization of microbial community imbalances in human inflammatory bowel diseases. Proc Natl Acad Sci U S A. 2007;104(34):13780–5.
Swidsinski A, Loening-Baucke V, Lochs H, et al. Spatial organization of bacterial flora in normal and inflamed intestine: a fluorescence in situ hybridization study in mice. World J Gastroenterol. 2005;11(8):1131–40.
Gorbach SL, Plaut AG, Nahas L, et al. Studies of intestinal microflora. II. Microorganisms of the small intestine and their relations to oral and fecal flora. Gastroenterology. 1967;53(6):856–67.
Savage DC. Microbial ecology of the gastrointestinal tract. Annu Rev Microbiol. 1977;31:107–33.
Mackie RI, Sghir A, Gaskins HR. Developmental microbial ecology of the neonatal gastrointestinal tract. Am J Clin Nutr. 1999;69(5):1035S–45S.
Palmer C, Bik EM, DiGiulio DB, et al. Development of the human infant intestinal microbiota. PLoS Biol. 2007;5(7):e177.
Pimentel M, Chang C. Inflammation and microflora. Gastroenterol Clin North Am. 2011;40(1):69–85.
Sekirov I, Russell SL, Antunes LC, et al. Gut microbiota in health and disease. Physiol Rev. 2010;90(3):859–904.
Cani PD, Delzenne NM. The gut microbiome as therapeutic target. Pharmacol Ther. 2011;130(2):202–12.
Abu-Shanab A, Quigley EM. The role of the gut microbiota in nonalcoholic fatty liver disease. Nat Rev Gastroenterol Hepatol. 2010;7(12):691–701.
Kim JJ, Sears DD. TLR4 and insulin resistance. Gastroenterol Res Pract. 2010;2010.
Musso G, Gambino R, Cassader M. Interactions between gut microbiota and host metabolism predisposing to obesity and diabetes. Annu Rev Med. 2011;62:361–80.
Barbara G, De Giorgio R, Stanghellini V, et al. New pathophysiological mechanisms in irritable bowel syndrome. Aliment Pharmacol Ther. 2004;20 Suppl 2:1–9.
Barbara G, Wang B, Stanghellini V, et al. Mast cell-dependent excitation of visceral-nociceptive sensory neurons in irritable bowel syndrome. Gastroenterology. 2007;132(1):26–37.
McNeil NI. The contribution of the large intestine to energy supplies in man. Am J Clin Nutr. 1984;39(2):338–42.
Pimentel M. Evaluating a bacterial hypothesis in IBS using a modification of Koch’s postulates: part 1. Am J Gastroenterol. 2010;105(4):718–21.
Mitsuoka T. Recent trends in research on intestinal flora. Bifido Microflora. 1982;1:3–24.
Toskes PP. Bacterial overgrowth of the gastrointestinal tract. Adv Intern Med. 1993;38:387–407.
Ringel Y, Carroll IM. Alterations in the intestinal microbiota and functional bowel symptoms. Gastrointest Endosc Clin N Am. 2009;19(1):141–50. vii.
Kassinen A, Krogius-Kurikka L, Makivuokko H, et al. The fecal microbiota of irritable bowel syndrome patients differs significantly from that of healthy subjects. Gastroenterology. 2007;133(1):24–33.
Simon GL, Gorbach SL. Intestinal flora in health and disease. Gastroenterology. 1984;86(1):174–93.
Ley RE, Turnbaugh PJ, Klein S, et al. Microbial ecology: human gut microbes associated with obesity. Nature. 2006;444(7122):1022–3.
Pimentel M, Lezcano S. Irritable bowel syndrome: bacterial overgrowth–what’s known and what to do. Curr Treat Options Gastroenterol. 2007;10(4):328–37.
Pimentel M. The prevalence of small intestinal bacterial overgrowth in irritable bowel syndrome: IBS vs healthy controls (not historical definitions). Gut. 2008;57(9):1334–5. author reply 5.
King CE, Toskes PP. Small intestine bacterial overgrowth. Gastroenterology. 1979;76(5 Pt 1):1035–55.
Vantrappen G, Janssens J, Hellemans J, et al. The interdigestive motor complex of normal subjects and patients with bacterial overgrowth of the small intestine. J Clin Invest. 1977;59(6):1158–66.
Jee SR, Morales W, Low K, et al. ICC density predicts bacterial overgrowth in a rat model of post-infectious IBS. World J Gastroenterol. 2010;16(29):3680–6.
Khoshini R, Dai SC, Lezcano S, et al. A systematic review of diagnostic tests for small intestinal bacterial overgrowth. Dig Dis Sci. 2008;53(6):1443–54.
Sahakian AB, Jee SR, Pimentel M. Methane and the gastrointestinal tract. Dig Dis Sci. 2010;55(8):2135–43.
Kunkel D, Makhani MD, Chong K, et al. Methane on breath testing is associated with constipation: a systematic review and meta-analysis. Gastroenterology. 2010;138:S629.
Simren M, Stotzer PO. Use and abuse of hydrogen breath tests. Gut. 2006;55(3):297–303.
Bratten JR, Spanier J, Jones MP. Lactulose breath testing does not discriminate patients with irritable bowel syndrome from healthy controls. Am J Gastroenterol. 2008;103(4):958–63.
Corazza GR, Menozzi MG, Strocchi A, et al. The diagnosis of small bowel bacterial overgrowth. Reliability of jejunal culture and inadequacy of breath hydrogen testing. Gastroenterology. 1990;98(2):302–9.
Youn YH, Park JS, Jahng JH, et al. Relationships among the lactulose breath test, intestinal gas volume, and gastrointestinal symptoms in patients with irritable bowel syndrome. Dig Dis Sci. 2011;56(7):2059–66.
Bauer TM, Steinbruckner B, Brinkmann FE, et al. Small intestinal bacterial overgrowth in patients with cirrhosis: prevalence and relation with spontaneous bacterial peritonitis. Am J Gastroenterol. 2001;96(10):2962–7.
Pimentel M, Chatterjee S, Chang C, et al. A new rat model links two contemporary theories in irritable bowel syndrome. Dig Dis Sci. 2008;53(4):982–9.
Tack J, Fried M, Houghton LA, et al. Systematic review: the efficacy of treatments for irritable bowel syndrome-a European perspective. Aliment Pharmacol Ther. 2006;24(2):183–205.
Bearcroft CP, Perrett D, Farthing MJ. Postprandial plasma 5-hydroxytryptamine in diarrhoea predominant irritable bowel syndrome: a pilot study. Gut. 1998;42(1):42–6.
Camilleri M, Chey WY, Mayer EA, et al. A randomized controlled clinical trial of the serotonin type 3 receptor antagonist alosetron in women with diarrhea-predominant irritable bowel syndrome. Arch Intern Med. 2001;161(14):1733–40.
Cash BD, Chey WD. Advances in the management of irritable bowel syndrome. Curr Gastroenterol Rep. 2003;5(6):468–75.
Muller-Lissner SA, Fumagalli I, Bardhan KD, et al. Tegaserod, a 5-HT(4) receptor partial agonist, relieves symptoms in irritable bowel syndrome patients with abdominal pain, bloating and constipation. Aliment Pharmacol Ther. 2001;15(10):1655–66.
Novick J, Miner P, Krause R, et al. A randomized, double-blind, placebo-controlled trial of tegaserod in female patients suffering from irritable bowel syndrome with constipation. Aliment Pharmacol Ther. 2002;16(11):1877–88.
Drossman DA, Toner BB, Whitehead WE, et al. Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders. Gastroenterology. 2003;125(1):19–31.
Bardhan KD, Bodemar G, Geldof H, et al. A double-blind, randomized, placebo-controlled dose-ranging study to evaluate the efficacy of alosetron in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 2000;14(1):23–34.
Pimentel M, Park S, Mirocha J, et al. The effect of a nonabsorbed oral antibiotic (rifaximin) on the symptoms of the irritable bowel syndrome: a randomized trial. Ann Intern Med. 2006;145(8):557–63.
Lembo A, Zakko SF, Ferreira NL, et al. T1390 Rifaximin for the treatment of diarrhea-associated irritable bowel syndrome: short term treatment leading to long term sustained response. Gastroenterology. 2008;134(4, Supplement 1):A-545.
Van Citters GW, Lin HC. Management of small intestinal bacterial overgrowth. Curr Gastroenterol Rep. 2005;7(4):317–20.
Yang J, Lee HR, Low K, et al. Rifaximin versus other antibiotics in the primary treatment and retreatment of bacterial overgrowth in IBS. Dig Dis Sci. 2008;53(1):169–74.
Lamanna A, Orsi A. In vitro activity of rifaximin and rifampicin against some anaerobic bacteria. Chemioterapia. 1984;3(6):365–7.
Gerard L, Garey KW, DuPont HL. Rifaximin: a nonabsorbable rifamycin antibiotic for use in nonsystemic gastrointestinal infections. Expert Rev Anti Infect Ther. 2005;3(2):201–11.
Jiang ZD, DuPont HL. Rifaximin: in vitro and in vivo antibacterial activity–a review. Chemotherapy. 2005;51 Suppl 1:67–72.
Hoover WW, Gerlach EH, Hoban DJ, et al. Antimicrobial activity and spectrum of rifaximin, a new topical rifamycin derivative. Diagn Microbiol Infect Dis. 1993;16(2):111–8.
Ripa S, Mignini F, Prenna M, et al. In vitro antibacterial activity of rifaximin against Clostridium difficile, Campylobacter jejunii and Yersinia spp. Drugs Exp Clin Res. 1987;13(8):483–8.
Sierra JM, Navia MM, Vargas M, et al. In vitro activity of rifaximin against bacterial enteropathogens causing diarrhoea in children under 5 years of age in Ifakara, Tanzania. J Antimicrob Chemother. 2001;47(6):904–5.
Di Stefano M, Malservisi S, Veneto G, et al. Rifaximin versus chlortetracycline in the short-term treatment of small intestinal bacterial overgrowth. Aliment Pharmacol Ther. 2000;14(5):551–6.
Lauritano EC, Gabrielli M, Lupascu A, et al. Rifaximin dose-finding study for the treatment of small intestinal bacterial overgrowth. Aliment Pharmacol Ther. 2005;22(1):31–5.
Pimentel M, Park S, Kane SV, et al. Rifaximin, a non-absorbable antibiotic improves the symptoms of irritable bowel syndrome: a randomized, double-blind, placebo-controlled study. Ann Intern Med. 2006;145:557–63.
• Pimentel M, Morales W, Chua K, et al. Effects of rifaximin treatment and retreatment in nonconstipated IBS subjects. Dig Dis Sci. 2011;56(7):2067–72. Demonstrated that for subjects with nonconstipated IBS, retreatment with rifaximin was successful up to five times with no significant reduction in benefit, or of duration of benefit, for successive retreatments.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Sachdev, A.H., Pimentel, M. Antibiotics for Irritable Bowel Syndrome: Rationale and Current Evidence. Curr Gastroenterol Rep 14, 439–445 (2012). https://doi.org/10.1007/s11894-012-0284-2
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11894-012-0284-2