Oral antibiotic therapy for small intestinal bacterial overgrowth (SIBO)

Antibiotic	Adult dose^[1]	Pediatric dose*^[2,3]	Notes
Rifaximin^¶	550 mg three times daily	Children and adolescents ≥12 years: Refer to adult dosing Children 3 to 11 years: 200 mg three times daily^[4]	Preferred by UpToDate author Efficacy 61 to 78% Low systemic absorption High cost relative to other options
Alternative antibiotics
Trimethoprim-sulfamethoxazole (TMP-SMX)	160/800 mg twice daily	4 to 5 mg/kg of trimethoprim component per dose twice daily^[5]
Ciprofloxacin	500 mg twice daily	10 to 20 mg/kg per dose twice daily	Routine use in children avoided due to potential risk of musculoskeletal toxicity (usually mild)
Amoxicillin-clavulanate	875 mg twice per day	25 to 30 mg/kg per day (amoxicillin component) in two or three divided doses
Metronidazole	250 mg three times per day	10 mg/kg per dose twice daily
Doxycycline	100 mg once daily to twice per day	Children ≥8 years and >45 kg: Refer to adult dosing Children <8 years: Not recommended	Less risk of dental staining in children with short course Use and dosing extrapolated from data with tetracycline
Tetracycline	250 mg four times per day	Children ≥8 years: 10 to 15 mg/kg per dose three times daily Children <8 years: Not recommended	Use in children <8 years old avoided due to risk of permanent tooth discoloration

Suggested antibiotic regimens for reduction of gut flora overgrowth and symptomatic improvement. The author usually treats for 10 days per course with the exception of rifaximin a 14-day course is given. Doses listed are for patients with normal renal function. For indications and administration of antibiotic therapy in SIBO, refer to the UpToDate clinical topic review.

* Optimal antibiotic regimen(s) in children have not been established. Antimicrobial choices and doses shown are those used by the UpToDate author and some other experts when antibiotic therapy of SIBO is indicated in children^[2,3]. The pediatric daily dose should not exceed the usual daily dose for adult patients. Pediatric doses listed in this table are for children ≥6 years except as noted.
¶ In patients with intestinal methane overgrowth (IMO) the author uses a combination regimen of oral rifaximin 550 mg three times daily with oral neomycin 500 mg twice daily for 14 days.

References:

Pimentel M, Saad R, Long M, et al. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol 2020; 115:165.
Malik BA, Yuan XY, Wine E, Huynh HQ. Diagnosis and pharmacological management of small intestinal bacterial overgrowth in children with intestinal failure. Can J Gastroenterol 2011; 25:41.
Avelar Rodriguez D, Ryan PM, Ramirez Mayans JA, Quigley EM. Small Intestinal Bacterial Overgrowth in Children: A State-Of-The-Art Review. Frontiers in Pediatrics 2019; 7:363.
Scarpellini E, Giorgio V, Gabrielli M, et al. Rifaximin treatment for small intestinal bacterial overgrowth in children with irritable bowel syndrome. Eur Rev Med Pharmacol Sci 2013; 17:1314.
Kimberlin DW, Brady MT, Jackson MA, Long SS. Dose based on usual range recommended for children. In: Red Book, 31st ed, Committee on Infectious Diseases (Ed); American Academy of Pediatrics, Itasca 2018.

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Oral antibiotic therapy for small intestinal bacterial overgrowth (SIBO)