How Long Does Sibo Die-Off Last?

If you’ve started your SIBO treatment, you might be feeling rough. While some people breeze through their SIBO treatment with barely any side effects, others get debilitating fatigue, IBS symptoms, rashes and mood changes. Everyone is different, because everyone’s bodies and microbiomes are different. If you’d like to explore your gut microbiome, we recommend taking a gut microbiome test, which will open a window not only on the types of bacteria in your gut, but a whole host of other gut health markers too, shining a light into the seat of your health and wellbeing.

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What is SIBO die-off and how long does it last?

It sounds a bit scary, but SIBO die-off is nothing to be alarmed about. In a nutshell, it’s the symptoms you feel when high numbers of bacteria are dying in your body. When bacteria die, they give off various chemicals known as ‘endotoxins’ that can affect the way your body functions.

Because SIBO die-off can be uncomfortable, you should only have SIBO treatment if you know you have SIBO. If you’re not sure, you can take our SIBO breath test at home. 

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When does SIBO die-off occur? 

Die-off symptoms can start almost immediately: sometimes the same day you begin your treatment. If you’re going to get them, they almost always start within a few days—and definitely within a week—of starting antimicrobial treatment, whether that’s herbal antimicrobials or pharmaceutical antibiotics.

If you start getting symptoms after a week of starting treatment, they’re unlikely to be happening as part of a die-off reaction. You’re much more likely to have caught a virus, be reacting to foods or going through stress, for example.

Can SIBO die-off happen after antibiotics? 

Antibiotics are designed to kill bacteria, so SIBO die-off can absolutely happen during a course of antibiotics.

If the question is can it happen after antibiotics, though, the answer is probably not. When you stop taking the antibiotics, you stop killing the bacteria. If you’ve finished your course of antibiotics, your symptoms are more likely to be happening because of the shift in the make-up of your microbiome. 

Research tells us that a single course of antibiotics can decimate your population of gut bacteria to one tenth of its previous level. Not by one tenth, to one tenth: that’s a 90 percent reduction. It depends on a few factors, like the type of antibiotic, your age and your health status, but we shouldn’t underestimate the power of antibiotics to shape our microbiomes and our health. 

Oregano oil SIBO die-off 

One of the most popular herbal antimicrobials used to treat SIBO is oregano oil. It’s important to remember that herbal antimicrobials are different to antibiotics, although they can have similar effects. Only a doctor can prescribe you antibiotics, and a UK doctor is very unlikely to give you herbal antimicrobials, unless they are working privately and have specialised in alternative health.

The die-off from oregano oil isn’t any different from the die-off from any other herbal antimicrobial. If your bacteria are dying, they’re giving off endotoxins which can make you feel ill: it doesn’t matter what the substance is that’s killing them. However, everyone has a different reaction to each herbal antimicrobial (and each antibiotic). Each one kills specific types and species of bacteria, so if oregano oil is killing a large amount of your gut bacteria, you’re likely to get a bigger die-off reaction. In that sense, a die-off reaction is sometimes a good sign.

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SIBO die-off experience 

If you’re worried about suffering from extreme die-off symptoms throughout your SIBO treatment, rest assured that it’s unlikely. While some people feel very unwell for the first week or so, it’s rare.

Die-off symptoms happen because your body needs to eliminate the endotoxins your dying bacteria produce. That burden is placed on your liver, spleen, and other organs, including your gut. If you have leaky gut, you might get symptoms outside of your GI tract. Often the toxins can cause your immune system to react, leading to a temporary increase in inflammation in different areas of your body.

Some common die-off symptoms are:

• Bloating
• Diarrhoea
• Gas
• Headaches
• Joint pain
• Nausea
• Rashes and hives

When do SIBO die-off symptoms start? 

SIBO die-off symptoms usually start shortly after starting treatment. As soon as your bacteria come into contact with the antimicrobials or antibiotics, they start dying and releasing endotoxins. We’ve noticed most people will start to feel unwell in one to two days, and continue for perhaps a few days after that.

However, some people have no symptoms at all. Some people can have a bad reaction to the antibiotic or antimicrobial, which isn’t linked to the bacteria dying at all: they’re simply sensitive to that particular antimicrobial or antibiotic.

What influences how long SIBO die-off lasts? 

There are various ways your body deals with the toxins dying bacteria give off. The ‘better’ your body is at those processes, the sooner you’ll feel better.

There are three variables that govern how severe your die-off symptoms will be:

• How many bacteria are dying: The more bacteria, the bigger the burden your body has to manage.
• How active your immune system is: the more active, the more inflammation your body will create and the sicker you’ll feel.
• How well your detox mechanisms are working: if you’re clearing the toxins from your body fast, you’ll feel better fast.

Can SIBO symptoms get worse during die-off? 

While everyone is different, as a rule SIBO symptoms either get steadily better over the course of treatment, or get worse for a short time before getting better.

It’s quite common for SIBO symptoms like diarrhoea, bloating or constipation to get temporarily worse as a result of your die-off reaction. That’s because large amounts of bacteria dying can trigger an immune response in your body that can flare your symptoms.

What are the symptoms of bacteria die-off? 

When bacteria die, they give off large amounts of the substances they release when they’re alive. Die-off symptoms can be a more intense version of an infection like a cold or other virus. Rest assured that it’s normal to feel worse before feeling better. 

The most common SIBO die-off symptoms are:

• Body aches and pains
• Fatigue
• Flu-like symptoms 
• Headaches
• Gastrointestinal upset like diarrhoea or constipation
• Mood symptoms like anxiety and depression
• Respiratory problems like a stuffy or runny nose
• Skin rashes or hives

Body aches

Body aches and pains are a typical inflammatory reaction to die-off. With die-off. Your immune system is trying to protect you from the release of toxins from the dying bacteria, which can lead to sore muscles and aching joints.

Fatigue

Fatigue is the number one die-off symptom we hear from our clients. Healing is hard on your body and uses a lot of energy, depleting your tank. It’s important to rest throughout SIBO treatment if you need to, giving your body as much energy as possible to fight and eliminate the toxins from the dying bacteria.

Flu-like symptoms

When researchers first observed die-off symptoms over a hundred years ago, a fever was one of the first they noticed. While they were looking at syphilis infections treated with heavy doses of antibiotics, similar symptoms seem to happen in less serious infections with gentler antibiotics or antimicrobials. A fever is one of the ways your body tries to kill infections. However, because herbal antimicrobials have longer timeframes and are generally more gentle, flu-like symptoms are less common than in antibiotic treatment.

Headaches

Headaches are a very common reaction to detoxification. While dying bacteria can certainly take some of the blame, if you’ve also started a typical SIBO diet and removed things like caffeine or sugar, your body could be temporarily struggling to adjust. 

Gastrointestinal upset

Diarrhoea, constipation, bloating, gas and abdominal pain can make you feel miserable as pathogens die and release toxins into your gut. However, GI symptoms are also common with reactions to new foods and supplements, which are likely to be a part of your SIBO treatment plan. Working with a practitioner can be helpful to work out what’s causing what.

Mood changes

Your gut and your mood are inextricably linked. Most of your neurotransmitters (chemicals that influence and drive your moods) are actually in your gut. As can be expected, killing off a lot of bacteria in your gut can flare anxiety and depression. A lot of our clients report feeling anxious at the beginning of treatment—despite not consciously worrying about what was going to happen—but feeling better after a few days.

Respiratory problems like a stuffy or runny nose

Mucus captures and eliminates toxins: that’s why your body produces it when you have a cold. An increase in mucus production can signal bacterial die-off while your body does all it can to flush out excess toxins.

Skin rashes or hives

Your body will eliminate toxins through your skin if your other elimination pathways—like your liver, for instance—are overworked. If you’re prone to skin issues, you could see a flare in them at the beginning of your SIBO treatment. These flares don’t usually last longer than a week or so.

SIBO die-off stools 

If you suffer from IBS symptoms like diarrhoea or constipation, you could go through a temporary flare when you start taking herbal antimicrobials. As we explained before, killing off large amounts of bacteria can provoke an immune reaction in your gut or elsewhere in your body. The resulting inflammation can worsen IBS symptoms, especially if inflammation usually contributes to your symptoms.

SIBO die-off gas 

Gas and bloating are probably the most common SIBO symptoms. Bacteria give off gases when they eat what you eat, and they can also secrete them when they die. However bloating and gas at the beginning of SIBO treatment can also be down to diet changes. If you start eating a lot of vegetables, for instance, that’s just as likely to result in gas as SIBO die-off.

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What helps with die-off symptoms? 

The good news is that there are alot of things you can do to help SIBO die-off symptoms.

They can all be broken down into one of these categories:

• Going slow with diet changes and new supplements
• Reducing inflammation
• Helping your body to clear out the toxins 

Going slow with diet changes and new supplements

Diet changes and new supplements can be a shock to the system for some people, while others appear to take them in their stride.

SIBO treatment can be a balancing act between minimising die-off symptoms and having an impact on the overgrowth. If we go too slowly, we won’t make a dent in your SIBO symptoms, but if we go too fast, you’ll feel unwell, overwhelmed and be unlikely to continue.

Going slowly includes the following strategies:

Using antimicrobial herbs instead of antibiotics 

Antimicrobial herbs like oregano are typically more gentle than antibiotics, however some people may have a powerful reaction to them and feel better on antibiotics.

Starting the diet before antimicrobial herbs or new supplements

We usually start clients on a SIBO diet right away while we wait for test results, to see how they react and what happens to their symptoms. If you struggle on your new diet, we can experiment to find the right approach before we give you your antimicrobial protocol. That way, you’ll know whether any new symptoms are down to your diet or your supplement plan.

Introducing one supplement at a time 

If you react to your antimicrobials or supplements, we go back to basics and introduce one at a time, starting with the lowest dose of each. That means we can monitor your reactions and separate them from any die-off symptoms you might be having. It also slows down the pace your microbes are dying at, making your treatment more gentle and less overwhelming.

Reducing inflammation

If your immune system is very active, you could get a big inflammatory reaction like extreme fatigue or flu-like symptoms.

You can ease inflammatory reactions in two main ways:

Reducing stress 

That means resting, avoiding excessive exercise and getting lots of sleep. 

Using anti-inflammatory foods and nutrients

• Omega-3 oils from oily fish 
• Vegan sources are flaxseed, chia seeds and walnuts 
• Spices like turmeric, ginger and cinnamon
• Antioxidants from green leafy vegetables, blackberries and blueberries
• Supplements like glutathione, quercetin and vitamin C 

Helping your body to clear out the toxins

You can help your body to clear excess toxins through your liver and gut with various nutrients and supplements.

Liver support

Your liver is your most important detox organ. You can support your liver with:

• N-Acetyl-Cysteine (NAC)
• St Mary’s Thistle
• Dandelion 

Gut support

Substances known as ‘binders’ mop up toxins and carry them out of your body, preventing them from getting into the bloodstream and causing further die-off symptoms.

• Activated charcoal can bind to microbes as well as minerals, vitamins and nutrients, so take it away from other foods and not long term.
• Bentonite clay is a gentler form of binder that can be taken longer term.
• Chlorella is an algae that you can take all throughout your SIBO treatment and beyond.

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Can SIBO die-off cause pain? 

SIBO die-off can cause headaches, joint pain or achy limbs, similar to the aches and pains you get with a heavy cold or flu. You could also get abdominal pain, especially if you usually suffer from IBS pain.
However, most people don’t get any pain.

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How long does it take to heal from SIBO? 

While there’s no timeline, most people start to notice their symptoms getting better a week or two into treatment. Some people feel better straight away, while for others it takes a bit longer. A few people need a longer course of antimicrobials to get on top of their symptoms.

Usually, a re-test after a six-week course of antimicrobials shows a big reduction in SIBO gases.

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How fast can SIBO come back? 

For some people, SIBO can come back almost immediately. An experienced practitioner will be able to explore the reasons why and address them.

Unfortunately, a fair amount of people find that if they go back to their ‘old ways’ of drinking a lot of alcohol or eating a lot of sugar, the SIBO comes back. If you’re one of these, you’ll need to keep an eye on your diet and lifestyle for good if you want to keep SIBO at bay.

In our experience, most people do remain SIBO free after their treatment. It’s worth saying that these people are usually committed to a healthy diet and lifestyle, though. We usually recommend that you follow the 80/20 rule: Be disciplined 80 percent of the time, but relax the rules for the other 20 percent.

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How do I stop my SIBO from coming back after taking antibiotics? 

In our experience, there are three main ways to prevent SIBO from coming back:

• Minimise sugars and starches in your diet
• Address the use of some long-term medications 
• Identify and address any underlying conditions

Sugars and starches

Sugar means all sugars: whether that’s coconut sugar, honey, maple syrup or any of the latest alternative sugars that market themselves as healthy. Watch out for fruit because it’s high in natural sugars. Stick to low-sugar fruits like berries.

Alcohol is packed with sugar and it’s fermented too. It’s one of the worst things for SIBO and makes IBS symptoms such as bloating, gas, abdominal pain, constipation and diarrhea worse.

Your body immediately converts starches like bread, rice and pasta into sugar. Even vegetables like sweet potatoes and squash can be problematic.

There’s not much evidence to prove this, but it appears that once you’ve had SIBO, you’re more likely to get it again than if you’d never had it. You might need to keep an eye on your sugar, starch and alcohol intake for the rest of your life, filling up on vegetables like broccoli, cauliflower, cucumber, asparagus, and zucchini instead of potatoes and bread.

Long term medications

There are many medications that potentially worsen SIBO or leave you more vulnerable to developing it. The following are some of the most common:

Antibiotics

Although antibiotics kill bacteria, they can also lead to an overgrowth of bacteria. That’s because antibiotics do not ‘know’ the difference between the good bacteria and bad bacteria. If you have taken long courses of antibiotics, or take them often, you probably have an imbalance in the types, species and numbers of bacteria in your gut. A good microbiome is all about diversity, and when antibiotics wipe out whole sections, what grows in its place is often a much less diverse population of microbes, which is less able to maintain balance of your gut environment and fight off SIBO.

Antihistamines 

If you take antihistamines to suppress your runny nose, itchy eyes, or sinus headaches you’re blocking your body’s natural production of histamines. That sorts out your symptoms temporarily,  but over time, using antihistamines can provoke a histamine intolerance which in turn can allow certain types of bacteria to overgrow in your small intestine. 

NSAIDs

Non-steroidal antiinflammatories or NSAIDs, are used to reduce pain and lower fevers. They are one of the most popular drugs in the world, but they have been shown to increase your intestinal permeability (leaky gut) making SIBO more likely.

Underlying conditions

Here are the most common gut conditions that can lead to a SIBO relapse:

Crohn’s disease

People with Crohn’s disease are more likely to get SIBO because their gut environment is already disrupted. Medicines and invasive surgeries add to the burden. 

Celiac disease

Celiac disease is an autoimmune disease which if undetected or ignored can lead to SIBO because it triggers the release of chemicals into your gut lining, leading to inflammation and leaky gut. It also puts stress on your immune system.

Diabetes

Out of control blood glucose levels can damage nerves, resulting in uncoordinated gut movements and leftover bacteria in your small intestine. 

Leaky Gut

Leaky gut is a cause and a symptom of SIBO. When toxins, microbes, and undigested food particles escape through your gut and into your bloodstream, your immune system attacks them, allowing bacteria to overgrow in your small intestine. 

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Conclusion 

SIBO treatment kills off bacteria in your small intestine. As they die, they release toxins that cause inflammation, which in turn causes SIBO die-off symptoms. You might feel miserable with fever, joint pain, headaches fatigue or IBS symptoms, but they should only last a few days.

Resting, getting enough sleep and avoiding stress can make a big difference in your body’s ability to clear toxins. 

Eating food with lots of antioxidants and certain supplements that help your body’s detox processes and reduce inflammation can also help. 

Author 

Alexandra Falconer MA (Dist) DipCNM mBANT is a Nutritionist and Registered Nutritional Therapist. After graduating from Brighton’s College of Naturopathic Medicine in 2018, she set up her nutrition practice specialising in gut health, IBS, IBD and related conditions.

Before becoming a nutritionist, Alex was a journalist and copywriter. Now, she combines her two great loves—words and natural medicine—to help bring vibrant health to everyone who needs it.

Reviewed by: Tracey Randell