Treatment Protocols

Treatment

Combined Antibiotic Protocolsi [1]

Below are a number of different protocols as recommended by Drs Stratton, Sriram of Vanderbilt University and Dr Wheldon UK consultant microbiologist. These protocols are constantly being adjusted and you might find that some patients are following a different one from you. To a certain extent the protocol you follow depends on your Cpni [2] load, and because that is often an unknown in the beginning of treatment we recommend that you start with Dr Wheldon’s protocol (unless you or your physician have consulted a doctor familiar with the treatment of Cpn).

Wheldon Protocol

Antibiotic	Dosage	When taken	Notes
Doxycycline	100mg	Once a day	Take this alone until well tolerated.
Azithromycin or Roxithromycin	250mg 150mg	Mon, Wed, Fri Twice a day	Add either one or the other of these to the 100mg doxycycline you are already taking
Doxycycline	100mg	Twice a day	When both the above are well tolerated add another 100mg of doxycycline
Metronidazolei [3] pulse, also called Flagyl. An alternative is Tinidazole	400mg or 500mg depending on dose available in your country. 500mg	Three times a day Twice a day	When the first two antibiotics are well tolerated start pulsing the third. For one day every three to four weeks initially. Increase the number of days per pulse gradually to five days.

When the protocol is well tolerated Doxycycline and Azithromycin (or Roxithromycin) are taken continuously as outlined above. They prevent Cpn from replicating as well as killing it slowly (these antibiotics are called bacteriostatic antibiotics). After three or four months of these two antibiotics you can start pulsing the third antibiotic.

Definition of a pulse: Think of a cycle of treatment as a period of time. How long that period is depends on how well you are coping with the Combined Antibiotic Protocol (CAPi [4]), usually this cycle is three or four weeks long. Once during this period of time you take Metronidazole (or Tinidazole) for a period of up to 5 days at the full dose. In the beginning of your treatment the pulse may be only one day long, as you tolerate the CAP you can increase the number of days you take the Metronidazole. Well into the treatment you may want to increase the number of days you take Metronidazole (or Tinidazole) beyond the 5 days recommended.

The reason behind a pulse is that Metronidazole or Tinidazole are the killer antibiotics (called bactericides) and when Cpn dies it releases toxins into your blood that your body has to process. This pulsing allows your body to recover and makes the treatment more bearable. Too much bacterial kill at one time is overwhelming to the body. Dr Wheldon regularly revises his protocol and it is worth visiting his website [5] for the latest information.

Sriram Protocol

Antibiotic	Dosage	When taken	Notes
Rifampin	150mg	Twice a day	Take this on its own for two weeks or as tolerated
Azithromycin	250mg	Mon, Wed, Friday	Take this together with Rifampin for the duration of the treatment
Metronidazole	400mg or 500mg	Three times a day	Start taking this a month into the treatment and take it for 15 days on 15 days off for the duration of the treatment.
Sodium or Calcium Pyruvate	4 to 6g	about an hour before antibiotics (twice a day)	Start this 8 weeks into the treatment.

Rifampin is a very effective killer of RBs (Reticulating Bodies) and therefore it may take a while to feel comfortable taking it. It may take longer than the two weeks suggested in the chart. It is also worth noting that Rifampin can affect the efficacy of other drugs you may be taking such as Thyroxine for example. It may also cause your liver enzymes to become elevated and for that reason you should be closely monitored by a doctor.

In this protocol Metronidazole pulses are 15 days long. This may well be very difficult to sustain and in that case patients have been advised to reduce the pulse to 7 days in 21.

Stratton Protocol

The Stratton protocol starts off in the same way as the Wheldon Protocol. However the aim is to build up to a point where you are taking all three antibiotics (ABXi [6]) continuously. Once you have achieved that you add:

Antibiotic	Dosage	When taken	Notes
Rifampin	150mg	Twice a day	Build up as tolerated
INHi [7]	300mg	Once a day	Pulsed with metronidazole or daily