​Interpretation is different for each gas.
Interpretation varies among practitioners, labs, countries and studies. What one calls negative, another calls positive. While a consensus of North American experts published their interpretation recommendations in 2017 [2], these are primarily meant for research studies. Some practitioners and labs use these guidelines for their patients, while others interpret differently. No matter the criteria used, an individual's history and symptoms must be taken into account when interpreting tests.
 
I interpret similarly to the consensus criteria [2] with minor differences which I find more accurate for clinical practice, helping me not to miss SIBO when it's truly there.
In general, I consider a positive test to be:

• Hydrogen ≥ 20 ppm within the first 2 hours excluding baseline, Methane ≥ 10 ppm within 3 hours including baseline, 3-9 ppm if constipation is present, Hydrogen sulfide ≥ 2-3 ppm within 3 hours including baseline. Or "Flat Line": hydrogen < 6 ppm within 3 hours with no rise in the third hour, methane <3 ppm within 3 hours (lactulose 3-hour only)
• If any one gas is positive the test is positive
• Patterns are an important part of interpretation - for more see my Testing Masterclass or Courses

Podcast: SIBO Breath Testing, Review of the North American Consensus with Dr. Siebecker - a discussion of the North American Breath Test Consensus Guide

• X
• X

SIBO Herbal Antibiotic Dosing

A standard treatment round of herbal antibiotics is 4 weeks. Most cases need 2-5 treatment rounds (antibiotics, herbal antibiotics or elemental diet) to clear SIBO. Retesting is used to determine if/when more rounds are needed. See Treatment Overview for more info.
See handout for pregnancy, lactation and pediatric doses.

These protocols are based on the clinical experience of SIBO specialists and reflect current best practice. See medical disclaimer below.

HYDROGEN SIBO Herbal Antibiotic Options:

• Berberine 1500 mg 3 x day + Neem 600 mg 3 x day x 4-6 weeks
• Berberine 1500 mg 3 x day + Oregano (dry) 100 mg 3 x day x 4-6 weeks
• Neem 600 mg 3 x day + Oregano (dry) 100 mg 3 x day x 4-6 weeks

Note: If 1500mg 3 x day Berberine isn't tolerated, 1000 mg 3 x day may be used.

METHANE and MIXED (Hydrogen and Methane) Herbal Antibiotic Options:

• Berberine 1500 mg 3 x day + Allicin 900 mg 3 x day x 4-6 weeks
• Berberine 1500 mg 3 x day + "Atrantil" 550 mg 3 x day x 4-6 weeks    
• Neem 600 mg 3 x day + Allicin 900 mg 3 x day x 4-6 weeks
• Neem 600 mg 3 x day + "Atrantil" 550 mg 3 x day x 4-6 weeks   
• Oregano (dry) 100 mg 3 x day + Allicin 900 mg 3 x day x 4-6 weeks
• Oregano (dry) 100 mg 3 x day + "Atrantil" 550 mg 3 x day x 4-6 weeks    
• "Atrantil" 550 mg 3 x day x 4-6 weeks, then 550-2200 mg/day ongoing

HYDROGEN SULFIDE Herbal Antibiotic Options:
"Rx" = prescription from compounding pharmacies. "OTC" = over the counter (commercially available).

• Bismuth or Bismuth-Thiol*
  -Bismuth Rx: 700 mg 3 x day, or OTC: 524 4 x day (~2000 mg/day) x 2-4 weeks  (Suarez)
  -Bismuth-Thiol Rx: 1-3 caps/day x 4 weeks, or OTC:  2-5/day (Say MG) x 4 weeks
• Bismuth/Bismuth-Thiol* (see dose above) x 2-4 weeks + High Dose Oregano (dry) 250 mg 3 x day x 1 week, then 150 mg 3 x day x 3 weeks
• High Dose Oregano (dry) 250 mg 3 x day x 1 week, then 150 mg 3 x day x 3 weeks
• High Dose Oregano (dry) 250 mg 3 x day x 1 week, then 150 mg 3 x day x 3 weeks + Uva Ursi 200 mg 3 x day
• Bismuth/Bismuth-Thiol* (see dose above) x 2-4 weeks + Uva Ursi 200 mg 3 x day

*formulated by Dr. Paul Anderson, see his full Bismuth-Thiol dosing info HERE (PDF)

SIBO Antibiotic Dosing

Duration
A standard treatment round of pharmaceutical antibiotics is 2 weeks. If hydrogen or methane gas is high (≥ 70 ppm) , a 3 week course is sometimes used.  

Most cases need 2-5 treatment rounds of antibiotics or herbal antibiotics to clear SIBO. Retesting is used to determine if/when more rounds are needed, based on gas ppm levels.

See Treatment Overview for more info. 
​
Protocols and Doses
These protocols are based on published research as well as the clinical experience of SIBO specialists and reflect current best practice. See medical disclaimer below.

Probiotics are often taken with antibiotics to prevent yeast overgrowth and microbiome disruption. Probiotic and microbiome expert Dr. Jason Hawrelak's recommended protocol for this is:

• Both Culturelle Health and Wellness and Florastor - taken during antibiotics (1 hour away from the antibiotic) and for 6 weeks after. 

HYDROGEN SIBO Antibiotic Options:

• Rifaximin 550 mg 3 x day x 2-3 weeks [1] [2] [3] [4]
• Rifaximin 550 mg 3 x day +  5 grams Partially Hydrolyzed Guar Gum/day x 2 weeks [5 Furnari]
• Rifaximin 550 mg 3 x day + Nitazoxanide 500 mg 3 x day x 2-3 weeks [paper Doug sent me in Simplero]
• Nitazoxanide 500 mg 3 x day x 2-3 weeks (less effective when used alone) [find Ref that doesn't work on E coli - ask Doug rep]

See Additional Rifaximin Dosing below.

METHANE / HYDROGEN + METHANE Antibiotic Options:

• Rifaximin 550 mg 3 x day + Neomycin 500 mg 2 x day x 2-3 weeks [1] [2] [3]
• Rifaximin 550 mg 3 x day + Metronidazole 250 mg 3 x day x 2-3 weeks
• Rifaximin 550 mg 3 x day + Nitazoxanide 250 mg 3 x day x 2-3 weeks
• Nitazoxanide 500 mg 3 x day x 2-3 weeks (less effective when used alone)
• Rifaximin 550 mg 3 x day x 2-3 weeks + "Allimed"/"Allimax Pro" 900 mg 3 x day (6 caps/d) x 4-6 weeks (Allimed/Allimax Pro is taken alone at some point during this protocol)

HYDROGEN SULFIDE Antibiotic Options:

• Bismuth/Bismuth-Thiol (see Bismuth details below)  
  • ​Bismuth: 524 mg 4 x day, or ~2000 mg/day 
  • Bismuth-Thiol: Rx: 1-3 caps/d, or "Biofilm Phase 2 Advanced": 2-5 caps/day
  • Can be added to any other SIBO protocol for Hydrogen Sulfide
• Bismuth/Bismuth-Thiol + Rifaximin 550 mg 3 x day x 2-3 weeks (if diarrhea is present)
• Bismuth/Bismuth-Thiol (see dose above) + Nitazoxanide 500 mg 3 x day x 2-3 weeks
• Bismuth/Bismuth-Thiol (see dose above) + Rifaximin 550 mg 3 x day + Neomycin 500 mg 2 x day x 2-3 weeks (if constipation is present).
• Bismuth/Bismuth-Thiol (see dose above) + Rifaximin 550 mg 3 x day + Metronidazole 250 mg 3 x day x 2-3 weeks (if constipation is present)

Note: if bismuth is not tolerated, it may be omitted or Herbal Antibiotics or Elemental Diet may be used.
​

Additional Rifaximin Dosing
Rifaximin is available in both 200 mg and 550 mg.

Alternative Rifaximin Dosing options:
Old Dose

• 1200 mg/day x 10 days
  - 87-91% success normalizing breath test, 90-94% symptom improvement [Lombardo]

High Dose

• 2400 mg/day x 14 days
  - Used for repeat therapy [Jolley]

With Fiber

• Rifaximin + 5 grams/day Partially Hydrolyzed Guar Gum (PHGG)
  - 87% success normalizing breath test, 91% symptom improvement [Furnari]
• PHGG Sources: Nestle “Nutrisource”, Healthy Origins “Healthy Fiber”, Tomorrow's Nutrition "SunFiber" (exclusive pricing at Fullscript) 

Rifaximin Pediatric Dosing options:

•  600 mg per day x 7-14 days
  • 64% success normalizing breath test [Scarpellini]
• 10-30 mg/kg body weight per day x 14 days
  • 61% of IBD cases had symptom relief. Higher dose had better pain relief [Muniyappa] and gives best clinical results.

Other Classes

GI HEALTH FOUNDATION WEBCASTS

FREE CME for physicians, with the more recent videos (listed first).  
  Click the CME Offerings tab at the GI Health Foundation site for many other CME topics by expert physicians. 

By Dr. Pimentel (SIBO is discussed in all of Dr Pimentel's webcasts)
  Improving Patient Outcomes in IBS-D, Jun 12, 2017
  An Evidence-Based Approach to IBS and Chronic Idiopathic Constipation, Nov 17, 2016

  Novel Strategies for IBS-C, July 18, 2016
  Beyond Gut Instinct- Applying the Latest IBS Advances to Practice, May 22, 2016 (no CE)
  New IBS Biomarker, Jan 20, 2016
  Xpert Perspectives: New Insights into the Recognition and Management of FGIMDs 2015, Nov 15, 2015
  Gi News Tonight: Case Discussions on Functional GI and Motility Disorders, Oct 2014
  IBS: An Infectious Disease? June 2013 (no CE- from GALA 2013 conference)
  Expert Perspectives on Digestive Disease Week- Reporting on Functional GI Diseases, June 28, 2013
  Drug Harm in IBS Studies, August 22, 2012
  Gut Microbes and Irritable Bowel Syndrome, July 20, 2012
  Antibiotic Treatment and Retreatment in IBS, February 20, 2012
  Irritable Bowel Syndrome - The Effect of Antibiotics, June 16, 2011
  Irritable Bowel Syndrome - A Bacterial Hypothesis, June 16, 2011
  The Clinical Implications of IBS, 2010  (Dr. Pimentel plays electric guitar in this talk-show style, 3 part video)

By other Doctors
  SIBO and SIFO, June 2017
 IBS Prime, Dec 2017
 An Evidence Based Approach to Managing IBS-Diarrhea & Constipation and Chronic Constipation, Nov 17, 2016
Disaccharidase Deficiency & IBS- Integrating Novel Diagnostic Strategies into Practice: Key Points, July 19, 2016
Diagnosis and Treatment of SIBO, Feb 8, 2016
Rifaximin for IBS-D, Feb 8, 2016

Bone Broth

How to make it, how to use it and why it's good for us. Excerpted from my 2005 article Traditional Bone Broth in Health and Disease.

Dr Siebecker's Class Videos (Recorded Video Webinars)

CE available.  Classes are in recorded webinar format, with video of both the powerpoint and Dr Siebecker as a picture-in-picture.  PDF handouts of the presentation slides as well as other handouts are included.

1. Small Intestine Bacterial Overgrowth: Clinical Strategies 2011, 7 hours
In depth coverage of what it is, how we get it, how to test for it and what to do about it.  Topics include: symptoms, disease associations, pathophysiology, etiology, diagnostic criteria, testing with interpretation examples, treatment algorithm, antibiotic treatment, herbal antibiotic treatment, elemental diet, specific carbohydrate diet, gaps diet, prevention and more.
      Although this class was presented to physicians, it is intended for anyone who wishes to learn more about SIBO.

You Tube Clip

Recorded at the National College of Natural Medicine September 17 2011. 
Continuing Education: 7 hrs (1 Pharmacy)
Cost: $150

2.  SIBO Overview 2012, 2 hours
This class covers symptoms, causes, pathophysiology, testing with examples of interpretation, treatment, and prevention- as it follows a detailed treatment protocol algorithm. 
     Although this class was presented to physicians, it is open for anyone who wishes to learn more about SIBO.

You Tube Clip

Recorded at the National College of Natural Medicine January 21 2012, as part of the Naturopathic Gastroenterology Conference.  Continuing Education: 2 hrs
Cost: $60.00

3.  Leaky Gut Syndrome: Physician's Panel 2012, 1 hour
As part of the Naturopathic Gastroenterology Conference, this panel begins with Dr Siebecker's presentation on the structure of tight junctions and the zonulin pathway of leaky small intestine (leaky gut).

You Tube Clip

Recorded at the National College of Natural Medicine January 21 2012. 
Continuing Education: 1 hrs
Cost: $30.00
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SIBO RECOVERY ROADMAP COURSE

For Patients and their loved ones

A Complete Guide to Treating & Beating SIBO:

• 36 video lessons
• Handouts and guides
• Bonus classes from Dr. Siebecker
• Guest lectures
• Cooking classes

The entire course costs less than 1 visit with a SIBO specialist!

Patient Course - Full Info HERE

SIBO PRO COURSE

For Professionals, all practitioners welcome

A Complete Practitioners Guide to SIBO!

• 22 Hours of video lessons (20 CME available)
• Pathophysiology, Etiology, Diagnosis and Treatment
• Treatment options for Hydrogen, Methane,  Hydrogen Sulfide
• Desk Reference Booklet, Slides, Handouts
• Certificate
• Office hours with Dr. Siebecker (Interactive option)
• Guest lectures (Interactive version) and more

Practitioner Course - Full INFO HERE

The Dietary History

Elaine Gottschall's daughter, Judy, had been successfully treated in the 1950's for Ulcerative Colitis by Dr Sidney Haas (full story).  Dr Haas was a highly successful pediatrician who cured Celiac Disease and other gastrointestinal disorders with the diet he developed- the Specific Carbohydrate Diet (SCD).  It was in 1951, after 25 years of clinical success, that he published The Management of Celiac Disease, describing his use of the SCD.
 
After Judy's miraculous improvement, Elaine found herself motivated to return to school to study the science of how and why the diet worked.  Her book Breaking the Vicious Cycle (BTVC) is the result of her research.  If it wasn't for her, the SCD might have been forgotten.  Although during the late 1940s, Dr Haas and his dietary treatment were famous, just one year after his book was published, the assertion that gluten was the dietary culprit in Celiac Disease took hold and the SCD fell out of favor (full story) as it eliminates all grains, not just gluten-containing grains.

Gottschall passed away in 2004.  But her work is continued with re-publishing of BTVC and by Dr Campbell-McBride (C-M), author of Gut and Psychology Syndrome.  Dr C-M's son suffered from Autism and was greatly helped by the SCD.  Since then Dr C-M devoted her practice to Autism and similar disorders.  Elaine discussed the gut-brain connection in BTVC but Dr C-M made it the focus of an entire book.  She alters the diet slightly, tailoring it to the sensitive Autistic patient and incorporates the dietary suggestions from the Weston Price Foundation, making it even more healthy and healing.  Her version of the SCD is called the Gaps diet.  Both SCD and Gaps have numerous websites, including their own yahoo support and recipe groups.

​Important: More than One Round of Antibiotic Treatment is Typically Needed for SIBO
In most SIBO cases, one 2-week round of antibiotics is not enough to clear SIBO. While some cases respond successfully to one round ("one and done"), most SIBO cases need 2-4 treatment rounds, or more, for success ("time and fine"). This is based on the type and levels of gas present. On average, antibiotics reduce gas by 30 ppm each round. When hydrogen is above 50 ppm, or methane is above 35-40 ppm, more than one 2-week round, is usually needed. Gas type and ppm levels can be found with SIBO breath testing.

The length of each antibiotic round can be extended from 2 weeks to 3 weeks to help in higher gas scenarios, but past 3 weeks of continuous use, antibiotics for SIBO may lose effectiveness. In this case, it is recommended to take a break from that antibiotic by using a different antibiotic or switching to herbal antibiotics or elemental diet, for subsequent rounds.

Rifaximin: Not A Typical Antibiotic
Rifaximin (Xifaxan in the U.S.) is not a typical antibiotic, in fact, it is called a eubiotic due to its many beneficial properties. While typical antibiotics harm the microbiome, rifaximin has been shown to restore the small intestine microbiome back to its healthy state when used for SIBO. It also has an anti-inflammatory effect, does not cause yeast overgrowth, and actually increases levels of the good bacteria lactobacillus, bifidus, and faecalibacterium. (XXXX)

Rifaximin is an ideal treatment for SIBO because it is almost completely non-absorbable and stays in the small intestine, having a local action. For the same reason, it also doesn't cause systemic side effects, such as urinary tract infections.

It is safe [1], with equal side effects to placebo, and is effective for up to 7 repeat treatments in studies (although, clinically, a break is sometimes needed to refresh its effect).

For all these reasons, rifaximin has been the standard antibiotic for SIBO since the mid 2000's. It forms the backbone of treatment, since it is used for all SIBO gas types. However, it can be prohibitively expensive in branded form, such as Xifaxan in the U.S. (if insurance doesn't cover it). Thus, many turn to Canadian pharmacies or compounding pharmacies for generics, or work with company representatives for help. Rifaximin is available in both 200 mg and 550 mg. For a downloadable list of antibiotic alternatives to Rifaximin that have been studied for SIBO, see handout.

Abnormal migrating motor complex is the most common physiologic underlying cause of SIBO, most commonly caused by food poisoning.  Abnormal abdominal anatomy, specifically partial obstruction, is the second most common physiologic underlying cause of SIBO, most commonly caused by adhesions

Celiac disease is thought to be caused by an auto-immune response to gluten, but before the discovery of gluten in 1952, Dr Sidney V Haas proposed the theory of SIBO as the cause in his book The Management of Celiac Disease.  He was influenced by the complete cure of celiac children he treated with his Specific Carbohydrate Diet (SCD) which goes beyond gluten-free to a grain-free diet.  Elaine Gottschall discussed her support of Dr Haas's theory and her disagreement with the belief that gluten is the culprit in a chapter of her book, Breaking the Vicious Cycle.  Read her article Whatever Happened to the Cure for Celiac Disease.  Fascinating new information has been discovered relating to gluten and celiac disease in recent years, particularly the role of zonulin, discovered by Dr Fasano and team.  How all of this fits together is not clear. 

What is clear is that many Celiacs also have SIBO.  Studies show this is prevalent in those who still have persistent or partial symptoms after gluten avoidance.  Since bacteria eat the starch contained in all grains, SIBO offers an explanation why avoiding all grains, not just gluten grains, helps these patients.  SIBO has also been suggested as an alternative explanation for latent celiac, where gliadin antibodies are elevated but little to no change is observed in the small intestine.

SIBO has been linked in research with IBD (particularly Crohn's Disease- see below) but most notably, the predominant users of the Specific Carbohydrate Diet (SCD), a dietary treatment for SIBO are those with IBD.  Several of the authors of SCD cookbooks were Ulcerative Colitis patients who state they cured themselves using the SCD. See a study here.

Crohn's and SIBO
SIBO has been reported in 25% of Crohn's Disease patients.  Dr Shafran reported in 2005 that 78% of Crohn's Disease patients had a 70-point improvement and a 59% remission rate after treatment with Rifaximin, the antibiotic used to treat SIBO.  A 2010 study from Dr Shafran reported a 70% remission rate from Rifaximin therapy. 
See more Crohn's studies linked in above main list. 

She is the original force behind SIBO awareness and education in the Naturopathic profession. She is

Teaching Experience  Dr. Siebecker created and began teaching the first-ever SIBO curriculum at a medical university (Advanced Gastroenterology at NUNM) in 2013. She's been teaching physicians, medical students and patients internationally since 2010 - through conference lectures, online classes, podcasts and her free educational website siboinfo.com. She has taught over 6,000 students in continuing education conferences alone. Many of her students have gone on to become SIBO specialists and teachers, teaching alongside her at conferences and in their own SIBO courses, websites and books.
Clinical Experience  Dr. Siebecker has specialized in SIBO since 2011, treating only SIBO patients in her practice and serving as a second and third opinion referral doctor for patients who have failed previous treatments. This perspective has allowed her to identify pitfalls in SIBO care and how to overcome them to increase success. Many of her students have gone on to become SIBO specialists and teachers, teaching alongside her at conferences and in their own SIBO courses, websites and books.

---

The Primal Blueprint Cookbook by Mark Sisson

Make your transition to Primal eating easy and fun with this innovative cookbook.  Included are over 100 mouth-watering recipes with easy-to-follow instructions and nearly 400 brilliant, glossy, full-color photographs to guide and inspire you to cooking and eating Primally.

Mark Sisson is the founder & publisher of MarksDailyApple.com, and author of The Primal Blueprint. Mark is credited with spearheading the worldwide "Primal" health movement.
Jennifer Meier is a graduate of the prestigious California Culinary Academy in San Francisco.  She is a freelance food and wine writer.

Paleo diets are very similar, but not exactly the same as SIBO diets like SCD and Gaps diet.  They are not formulated for SIBO, and therefore some differences may occur.  For example some paleo diets use commercial yogurt but SIBO diets use only homemade 24-hour yogurt or commercial lactose free yogurt. 

Note:  Only use Paleo cookbooks/websites when familiar with the parameters of SCD/Gaps or the SIBO diet you're using, so that you can identify and substitute ingredients not recommended for SIBO.

SCD Recipes by Raman Prasad

Raman Prasad is the creator of www.scdrecipe.com, which includes over 500 SCD recipes and is also the author of the self-published memoir Colitis & Me: A Story of Recovery. www.scdrecipe.com

SCD Cookbooks by Jodi Bager and Jenny Lass

The Grain-Free Gourmet cookbook series helps people with limited food choices rediscover the joy of eating. Each book contains over 100 gluten-free, low-lactose, refined-sugar-free recipes that use only whole foods. The dishes in the Grain-Free Gourmet books are inspired by the Specific Carbohydrate Diet (SCD), which was made famous by Elaine Gottschall in her book Breaking the Vicious Cycle: Intestinal Health through Diet.

Jodi Bager owns and operates J. Gourmet, a company that supplies fresh almond-flour baked goods to a variety of retailers. She is also a baking services consultant for special dietary needs, such as diabetes and inflammatory bowel disease. Jenny Lass has taught grainfree cooking at a variety of cooking schools, and is an experienced medical writer. 
www.grainfreegourmet.com

SIBO Cookbooks by Rebecca Coomes 

After being diagnosed with SIBO in early 2015, Rebecca was surprised to find there were limited cookbooks available to those eating a SIBO diet.  Following the SIBO Bi-Phasic Diet Protocol, created by Australia's leading SIBO Specialist, Dr. Nirala Jacobi ND, and based on Dr. Siebecker's SIBO Specific Food Guide, Rebecca has now developed multiple cookbooks, a SIBO Meal Plan guide and mail order SIBO meals (pre-cooked, arrive frozen).
​
All recipes are 100% gluten-free, corn-free and soy-free.  The majority are dairy-free (with dairy alternatives listed), low FODMAP, low sugar, low carbohydrate and use minimal grains.

Rebecca Coomes is an author, SIBO coach and presenter.  She is the host of the SIBO Cooking Show and The Healthy Gut Podcast, and speaks regularly on SIBO. www.thehealthygut.com

Although Dr Haas was a Medical Doctor and thus his Specific Carbohydrate Diet is a Medical treatment, it is not commonly known of or prescribed by Gastroenterologist's today.  Somehow his dietary approach to SIBO has been separate from the world of information being discovered by the current medical researchers.  When I first focused my attention on SIBO several years ago, I was surprised to find that the SCD community (online support groups, websites and cookbooks) was unaware of the research on SIBO and visa versa.  My objective over the last few years has to integrate these two worlds of information.   

One missing piece in Breaking the Vicious Cycle and Dr Haas's work was an explanation for constipation.  It wasn't until 2004 that constipation's relationship to SIBO was discovered.  Dr Pimentel and his team at Cedars-Sinai found that one of the gases produced by bacteria- methane, alters the motility of the small intestine and is highly linked with constipation.  This is an astounding finding.  Chronic unremitting constipation can be due to bacterial infection.

In Gottschall's time, available antibiotics caused side effects such as diarrhea that made their use for SIBO unwise.   Recently a new antibiotic (Rifaximin) was developed that has a low incidence of this problem.  With an effective antibiotic available for SIBO, interest and research from the medical community increased.  This has allowed us to include diet, antibiotics and a spectrum in between, as ways to deal with this problem. 

These are just two examples that will be discussed in detail in my upcoming book on SIBO - stay tuned.

Integrating the Old and New Research