Abstract Background area under the curve AUC 0.74), whereas LBT had sensitivity 42.0%, specificity 70.6% and AUC 0.56, indicating clearly inferior performance. Lower hydrogen cut-offs (10–15 ppm) and post–gastrointestinal surgery cohorts improved GBT accuracy (AUC up to 0.86). Rifaximin achieved pooled intention-to-treat eradication of 70.8% and per-protocol eradication of 72.9%, with adverse events in 4–5%. Across six randomized trials ( n = 196), antibiotics increased global symptom response versus placebo (risk ratio 2.46; 95% CI 1.33–4.55). In methane-positive IMO, combination rifaximin–neomycin therapy yielded methane eradication rates of 87% and higher clinical response than either agent alone. Observational cohorts reported recurrence rates of approximately 40–45% within 9–12 months after successful eradication, with lower relapse when prokinetic maintenance was used. GRADE ratings were moderate for GBT accuracy and low for rifaximin eradication, symptom benefit, combination therapy in IMO and recurrence outcomes. Conclusions GBT, interpreted with contemporary cut-offs, offers moderate, clinically useful accuracy and outperforms LBT as a non-invasive diagnostic test for SIBO. Rifaximin provides substantial but not definitive microbiological eradication and symptom relief, while combination therapy appears necessary for optimal management of methane-dominant IMO. High recurrence rates and low-certainty treatment evidence support viewing SIBO/IMO as chronic relapsing conditions that require integrated strategies targeting motility, structural risk factors and diet, alongside judicious antimicrobial use. Large, well-designed randomized trials with standardized diagnostic and outcome criteria are urgently needed to refine these estimates and guide precision management.
Choudhary et al. (Mon,) studied this question.