Probiotics for SIBO: Friend or Foe?

Every day I see probiotics touted as the cure for something new: acne, depression, and of course, SIBO and IBS. But how well founded is this belief in the healing power of probiotics for SIBO or IBS?

One of the problems with studying probiotics is that there are SO many strains of bacteria that exist in the human microbiome. Each person has between 300 to 1000 different types of bacteria in their digestive system! So, not only is it difficult to figure out which ones to study, but how do you also account for the interaction between all the different strains that one might have? As you can imagine, it’s very tricky to properly study the impact of introducing more bacteria to such a diverse environment.

There are two major questions to ask when it comes to SIBO and probiotics. First, are probiotics helpful, harmful, or neutral in treating SIBO? And second, in those cases where they might be helpful, which strains of probiotics are beneficial? It turns out both of these questions have complicated answers.

Will Probiotics Help With SIBO?

I see people ask this question ALL the time: should I take probiotics to help with my SIBO or IBS?

Frustratingly, no reputable source that I can find seems to have a definitive answer. However, from the sources I’ve read, the general answer seems to be: use caution, as they can end up causing more problems. However, there is some evidence that certain strains might be helpful.

Why You Want to Be Careful About Using Probiotics for SIBO

Here’s why you want to be careful with probiotics. SIBO occurs because bacteria builds up in the small intestine, due to some reduction in motility in the small intestine. Although many people think that SIBO occurs because the bacteria overpopulating the small intestine are toxic or harmful bacteria, this is incorrect.

The type of bacteria populating the small intestine is not the problem–it’s the overpopulation of bacteria of any kind in the small intestine, whether “bad” or “good” bacteria, that causes problems. In other words, bacteria that are totally harmless or even beneficial to humans in appropriate numbers in the large intestine, will cause SIBO symptoms when overpopulating the small intestine.

Therefore, be very careful about taking a probiotic in the hopes of it healing or helping with SIBO. Dr. Mark Pimentel, a SIBO expert at Cedars-Sinai hospital in Los Angeles, has said he doesn’t usually recommend probiotics for SIBO. As the protocol for Dr. Pimentel’s low fermentation diet explains:

“Probiotics are very complicated . . . the
simple message is all bacteria ferment. All bacteria produce gas and you have a hard
time clearing bacteria from your small bowel. The same is true for the bacteria in
probiotic products. We have occasional patient who say that they are better on
probiotics but for the most part people with SIBO either get worse or stay the same. “

Another study done on patients with SIBO, bloating, gas, and brain fog who were taking probiotics show that when the patients stopped taking probiotics and were treated with antibiotics, their symptoms improved. In fact, 70% of patients reported “significant improvement” when they stopped taking probiotics (as well as stopping eating probiotic foods like yogurt) and took antibiotics!

So, in short, there doesn’t seem to be a whole lot of evidence or experts recommending probiotics as a method for healing SIBO. And it makes sense! If the whole problem is an overpopulation of bacteria of all kinds, adding MORE bacteria to the overpopulation is the opposite of what you want to do.

So, Are Probiotics Ever Helpful for SIBO?

The majority of advice I’ve heard from reputable sources don’t suggest probiotics as a first or even second or third remedy to try for SIBO.

My feeling is, if you haven’t found anything else that’s worked, probiotics might be worth trying. Particularly if you aren’t actually sure if your digestive problems are caused by SIBO or another reason, it might also be worth trying a probiotic. However, that’s just my opinion, and I am not a doctor, so always listen to your doctor or other medical professional!

What Probiotics Have Shown A Potential Benefit for SIBO?

There are a few bacteria strains that have demonstrated at least some evidence suggesting they might help with SIBO or IBS.

Bacillus Coagulans

Bacillus Coagulans is a probiotic strain that in one study helped patients who had tested positive on a lactulose breath test. The patients were first treated with antibiotics, then half of the patients received a Bacillus Coagulans, along with prebiotics, for fifteen days, followed by 15 days of minocycline. The control group did not take any Bacillus Coagulans. The study then followed the patients for another six months to see how well they recovered and to re-test them.

Encouragingly, the patients who took Bacillus coagulans had significant reductions in pain, bloating, burping, and diarrhea when compared to the control group. All of the patients who took Bacillus coagulans had complete resolutions of their stomach pain. What’s more, 93.3% of the patients who took Bacillus coagulans had a negative breath test at the end of the six month follow-up period, while only 66.7% of patients who took antibiotics did. The patients who did not take Bacillus coagulans experienced significantly less symptom relief.

Unlike many probiotic strains which are difficult to find or difficult to find without being mixed with other strains, Bacillus coagulans is relatively easy to find as a single strain. You can find single-strain probiotic capsules of Bacillus coagulans on Amazon among other places.

Bacillus clausii

Bacillus clausii is another non-pathogenic bacteria that has been studied as a possible treatment for digestive symptoms. Interestingly, some evidence exists that Bacillus clausii has antimicrobial effects against harmful bacteria including Staphylococcus aureus, Enterococcus faecium, and Clostridium difficile.

Although there aren’t any large-scale clinical studies demonstrating efficacy of Bacillus clausii for SIBO, one study compared the effects of taking Bacillus clausii versus taking an antibiotic on SIBO patients.

The sixty patients in the study had been diagnosed with SIBO from a breath test. Half of these patients received Bacillus clausii for one month. The other half received 750mg of the antibiotic metronidazole (brand name Flagyl) for one week. After this regime, 56% of the group taking Bacillus clausii had a normal breath test, while 40% of the patients in the Flagyl group had a normal breath test. The group taking Bacillus clausii also reported fewer instances of diarrhea and nausea.

While this is a small study and not enough to convince me of anything definitive, I do like the fact that it compared taking a probiotic to taking an antibiotic. Many studies just compare whether patients do better with taking a probiotic versus taking nothing at all. So it’s very interesting to see that in this small example the probiotic actually fared slightly better than an antibiotic. One note of caution though is that Flagyl probably isn’t the best antibiotic to do a comparison against. Rifaximin, not Flagyl, appears to be the most effective antibiotic against SIBO. I’d rather see a study comparing Bacillus clausii to Rifaximin.

I found it a little challenging to find a probiotic that only contains Bacillus clausii without other strains. The best option I have found is a product called Enterogermina, which is actually liquid doses of the probiotic. Each dose has 2 billion spores in it, which is a very good amount.

Lactobacillus casei

Have you ever been at the grocery store and seen that little milk-looking drink with a red cap, called Yakult? It’s a Japanese probiotic drink that actually contains a strain of Lactobacillus casei, called Lactobacillus paracasei Shirota!

I’ve never tried Yakult, so I have no comment on how tasty (or not) it is. But the probiotic strain it contains does show some minor evidence that it may be helpful with SIBO.

In fact, one very small trial actually studied whether Yakult itself helped reduce SIBO patients’ hydrogen breath test scores and symptoms. Only 14 patients finished this study. Although the study concluded that Yakult did lower patients’ scores on a hydrogen breath test, which suggests that it at least helped reduce patients’ bacteria overgrowth,

Also, the same 12 person study I mentioned above that looked at Lactobacillus acidophilus also studied Lactobacillus casei. Lactobacillus casei assists the growth of acidophilus, so it makes sense to study the two strains together. As a reminder, that study found that the two strains taken together helped alleviate SIBO patients’ diarrhea.

If you’re looking for a source of Lactobacillus casei, I would not drink Yakult for that purpose. Yakult has 11 grams of sugar in it–quite a bit–and it’s unclear how much of the probiotic it contains. There are many probiotic blends that include Lactobacillus casei. If you are looking for a single strain capsule of Lactobacillus casei, I have only been able to find one. If anyone knows of another please let me know!

Lactobacillus Acidophilus

Lactobacillus Acidophilus might be one probiotic that you’ve heard of. It’s very well known and found in lots of dairy products, like yogurt. Scientists have even sequenced its genome!

There is some evidence suggesting Acidophilus might help with SIBO. In one small study of just 12 patients with SIBO that caused chronic diarrhea, the patients took a probiotic containing Lactobacillus Acidophilus and Lactobacillus Casei.

Patients in the study took the probiotics three weeks. These experienced a reduction in their diarrhea, and the hydrogen levels in their breath tests decreased. The study concluded that these probiotics, when taken consistently, were effective for treating diarrhea caused by SIBO. But, it’s important to note that this is a very small study. The study also did not note the number of CFUs or “colony forming units” (a measure of how much bacteria is present in a probiotic) the patients took each day.

If you want to try Lactobacillus Acidophilus, fortunately it is readily available and cheap. Just make sure you’re taking a high quality capsule with as high a dosage as possible, such as 10 billion CFUs (colony-forming units) or higher. Here is one good example of a Lactobacillus Acidophilus product, but there are many good Lactobacillus Acidophilus products available.

Remember, acidophilus can also be found naturally in a lot of fermented foods. If you look at the labels on products like yogurt and kefir the next time you’re at the grocery store, you’ll likely see strains of acidophilus in many of them. I don’t know of any studies showing that just eating acidophilus products help with IBS, SIBO, or other digestive problems, though. But hey, yogurt tastes good!

In conclusion….

Probably, it’s a bad idea to take probiotics if you’ve actually been diagnosed with SIBO. I personally haven’t taken one since being treated with antibiotics, and my doctor said he doesn’t recommend it.

I would consider taking one if I was on systemic antibiotics (the kind that wipe out all your bacteria and are not targeted to one specific strain or body part) for longer than a week or so, but ONLY if my SIBO continues to be under control and I’m also on a prokinetic. My thinking on this is that the only way I would introduce more bacteria is if I was fairly sure my migrating motor complex would properly be cleaning it out of my small intestine. If I felt like my migrating motor complex is keeping the SIBO at bay, then I might consider it.

Have any of you taken probiotics and had it help with SIBO? Was it before, during, or after antibiotics? Let me know in the comments!

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