Xifaxan alternatives: what to try when rifaximin isn’t an option

Rifaximin (Xifaxan) is useful for a few problems, but it’s not always the best choice. Maybe it’s not available, you’re pregnant, or your illness doesn’t respond. Here’s a clear look at real, practical alternatives and when to pick them.

Antibiotic alternatives — when infection needs treatment

For traveler’s diarrhea caused by invasive bugs, or when rifaximin isn’t suitable, common antibiotic choices are azithromycin and fluoroquinolones (ciprofloxacin, levofloxacin). Azithromycin is often preferred in many parts of the world because it works well against resistant strains and is safe in pregnancy. Fluoroquinolones can work fast but carry risks — tendon injury, nerve problems, and more antibiotic resistance in some regions. Never use rifaximin for bloody diarrhea or high fever; that usually means a different bug that needs systemic antibiotics like azithromycin.

For hepatic encephalopathy, lactulose is the frontline treatment. Rifaximin is commonly added later, but if rifaximin isn’t an option, older antibiotics such as neomycin or metronidazole have been used. They can help lower gut ammonia but come with more side effects and aren’t preferred long-term. Talk to your liver specialist before switching drugs.

Non‑antibiotic options and when to use them

If you’re dealing with IBS‑D (irritable bowel with diarrhea), antibiotics aren’t always the answer. Loperamide controls diarrhea quickly and works for many people. Bile acid binders like cholestyramine help when bile acid malabsorption causes diarrhea. Prescription drugs such as eluxadoline or alosetron may help certain patients with severe IBS‑D, but they have limits and safety rules — ask your doctor.

Diet changes matter. A low‑FODMAP approach often reduces IBS symptoms within a few weeks. Probiotics can help some people with mild diarrheal problems; strains like Saccharomyces boulardii or specific Lactobacillus blends show benefit in studies. For traveler’s diarrhea without fever or blood, staying hydrated, oral rehydration solutions, and loperamide plus a short antibiotic course (if needed) usually works.

Safety notes: antibiotics have side effects and may not be safe in pregnancy or if you have liver or kidney problems. Some non‑antibiotic meds interact with other prescriptions. If you have fever, bloody stools, severe dehydration, or symptoms lasting more than 48–72 hours, see a clinician. For chronic liver disease or recurrent encephalopathy, coordinate any change with your specialist.

Bottom line: there’s no single replacement for rifaximin — pick the option that matches your condition: azithromycin or fluoroquinolones for certain infections, lactulose (and sometimes neomycin) for encephalopathy, and loperamide, bile acid binders, diet, or prescription IBS drugs for IBS‑D. Ask your provider for tests and personalized advice before switching treatments.