Abstract

PHARMACOTHERAPEUTIC MANAGEMENT OF AUTO-BREWERY SYNDROME: A NARRATIVE REVIEW

Bhumika Shivangouda Patil, Pradeep Parashuram Patroti, Trupti Veerabhadrappa Baddi, Mallappa Shalavadi*

Abstract

Auto-brewery syndrome, also called gut fermentation syndrome, is a rare and underrecognized condition in which gastrointestinal or urinary microorganisms ferment ingested carbohydrates into ethanol, producing intoxication without alcohol consumption. Existing reviews describe its epidemiology, pathophysiology and clinical presentation, but none has been organized around medication management. This narrative review synthesizes published antifungal regimens, dietary adjuncts and emerging therapies for the condition and outlines the pharmacist’s role in its stewardship and long-term management. PubMed/MEDLINE, Scopus and Google Scholar were searched from inception to August 2026, and case reports, case series and reviews describing a treatment regimen and outcome were included. Fluconazole remains the empiric firstline antifungal, typically given at 100 to 200 mg daily for 2 to 3 weeks, with resolution reported in most susceptible cases; relapse or suspected azole resistance has prompted successful escalation to nystatin, micafungin, voriconazole or itraconazole in individual reports. A low-carbohydrate, sugar-restricted diet is a nearuniversal adjunct and, in several cases, was the main driver of relapse when discontinued. Fecal microbiota transplantation has emerged as a promising option in antifungal-refractory disease, with sustained remission reported at 34 months and 16 months of follow-up in separate cases. The evidence remains confined to case-level reports rather than controlled trials. A structured, pharmacist-informed approach to agent selection, susceptibility-guided escalation and dietary counselling may reduce relapse and support earlier recognition of treatment failure.

Keywords: Auto-brewery syndrome, gut fermentation syndrome, fluconazole, antifungal therapy, fecal microbiota transplantation, pharmacist.