C0281 - Symptomatic Response to Antibiotics in Patients With Small Intestine Bacterial Overgrowth: A Systematic Review and Meta-Analysis

Monday, October 24, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Has Audio

Presenting Author(s)

Will Takakura, MD

Cedars Sinai - Medically Associated Science and Technology
Los Angeles, California

Will Takakura, MD¹, Jiajing Wang, PhD², William D. Chey, MD³, Ali Rezaie, MD, MSc⁴, Mark Pimentel, MD¹
¹Cedars Sinai - Medically Associated Science and Technology, Los Angeles, CA; ²Cedars Sinai - Medically Associated Science and Technology Program, Los Angeles, CA; ³Michigan Medicine, Ann Arbor, MI; ⁴Cedars-Sinai Medical Center, Los Angeles, CA

Introduction: Small intestinal bacterial overgrowth (SIBO) is characterized by an increase in proteobacteria in the small intestine and is associated with gastrointestinal symptoms. Antibiotics are used to treat this condition and previous meta-analyses have shown that antibiotics can successfully eradicate SIBO. Currently, there have been no high-quality, multicenter trials evaluating the efficacy of antibiotics in improving symptoms. Here, we performed a systematic review and meta-analysis to assess the efficacy of antibiotics to relive symptoms in patients with SIBO.

Methods: Following the PRISMA protocol a systematic review and meta-analysis was conducted. From inception to March 2021, MEDLINE, EMBASE, Web of Science, and Cochrane database were searched. Randomized controlled trials and prospective studies were included. Studies were included if SIBO was diagnosed based on breath test or small bowel aspirate. The rate of no improvement in symptoms were compared between antibiotics and no antibiotics. To assess study bias, the Cochrane Risk of Bias Tool was used. Studies with all categories with low risk of bias were deemed good quality. If 1 category had high or unclear risk of bias, they were deemed fair, the rest were deemed as poor quality.

Results: Of 694 citations, 647 were excluded based on the title or abstract. After a full manuscript review, 6 studies met inclusion criteria and were included (Table 1). There was a total of 196 patients, out of which 101 received antibiotics and 95 received placebo or no antibiotics. Two studies compared rifaximin to placebo, 1 compared rifaximin with bran to placebo with bran, 1 compared norfloxacin to placebo, 1 compared neomycin to placebo, and another compared rifaximin to no antibiotics. Overall, the RR (95% CI) of no improvement was 0.63 (0.43-0.91) with antibiotics compared to no antibiotics or placebo (Figure 1). The NNT for antibiotics in relieving symptoms was 2.8. There was significant heterogeneity with I² = 69.3%. There was no publication bias based on Egger’s test (t = -1.5936, df = 4, p = 0.1863). Four studies were deemed to be of poor quality and 2 studies were deemed to be of fair quality.

Discussion: This is the first systemic review and meta-analysis to evaluate the efficacy of antibiotics in relieving symptoms in patients with SIBO. Our data suggests that antibiotics provide symptomatic relief for patients with SIBO. A large multicenter randomized control trial is needed to validate these findings.

Figure: Pooled analysis of the studies comparing the efficacy of antibiotics as compared to placebo or no antibiotics in SIBO. The RR of no improvement on antibiotics is 0.63.

Study	Country	Sample size (% female)	Disease	Method to diagnose SIBO	Criteria for symptomatic improvement	Antibiotic used	Duration of therapy	Duration of follow-up	Rate of no improvement on antibiotics	Rate of no improvement on placebo
Biancone 2000	Italy	14 (50%)	Crohn’s disease	Glucose breath test	Change in CDAI	Rifaximin 400 mg BID	7 days	7 days	7/7 (100%)	7/7 (100%)
Pimentel 2003	US	93 (62%)	Rome I IBS	Lactulose breath test	≥ 50% reduction in composite score of abdominal pain, diarrhea, and constipation	Neomycin 500 mg BID	10 days	7 days	25/46 (54.3%)	40/47 (85.1%)
D’inca 2007	Italy	22	Diverticular disease	Lactulose breath test	Global symptomatic improvement	Rifaximin 600 mg BID	14 days	End of treatment	4/12 (33.3%)	10/10 (100%)
Ghoshal 2016	India	34 (19%)	Rome III IBS	Duodenal aspirate 10³CFU	No longer meeting Rome III Criteria for IBS	Norfloxacin 400 mg BID	10 days	30 days	7/19 (36.8%)	15/15 (100%)
Ghoshal 2018	India	13 (54%)	Rome III IBS-C or FC	Lactulose breath test (methane)	BSS ≥ 3	Rifaximin 400 mg BID	14 days	7 days	1/6 (16.7%)	3/7 (42.9%)
Furnari 2019	Italy	20 (48%)	Cystic Fibrosis	Glucose breath test	≥ 50% reduction in composite GI score	Rifaximin 10 mg/kg TID (up to 400 mg TID)	14 days	21 days	7/11 (63.6%)	7/9 (77.8%)

Table: Study characteristics of studies evaluating symptomatic response for antibiotics in patients with SIBO

Disclosures:

Will Takakura indicated no relevant financial relationships.

Jiajing Wang indicated no relevant financial relationships.

William Chey: Abbvie – Consultant. Allakos – Consultant. Alnylam – Consultant. Arena – Consultant. Biomerica – Consultant. Commonwealth Diagnostics International – Consultant. Gemelli – Consultant. GI OnDEMAND – Stock Options. Ironwood – Consultant. Isothrive – Consultant. Isothrive – Stock Options. Modify Health – Stock Options. Nestle – Consultant. Phathom – Consultant. Progenity – Consultant. QOL Medical – Consultant, Grant/Research Support. Redhill – Consultant. Salix – Consultant, Grant/Research Support. Urovant – Consultant. Vibrant – Consultant.

Ali Rezaie: Gemelli Biotech – Equity. Salix Pharmaceuticals – Consultant, Grant/Research Support.

Mark Pimentel indicated no relevant financial relationships.

Will Takakura, MD¹, Jiajing Wang, PhD², William D. Chey, MD³, Ali Rezaie, MD, MSc⁴, Mark Pimentel, MD¹. C0281 - Symptomatic Response to Antibiotics in Patients With Small Intestine Bacterial Overgrowth: A Systematic Review and Meta-Analysis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.