Alpha Normix

The development of pathogenic microorganisms in the intestines often leads to diarrhea, digestive disorders, and inflammatory processes. For treatment in these cases, the antibiotic “Alpha Normix” is used. This is a universal-purpose product, the components of which destroy pathogenic bacteria. The effect is noticeable after the first use.

Pharmacological properties of the drug Alpha Normix

Pharmacodynamics. Rifaximin is a broad-spectrum antibiotic and is a semi-synthetic derivative of rifamycin SV. Irreversibly binds the β-subunits of the bacterial enzyme, DNA-dependent RNA polymerase and, therefore, inhibits the synthesis of RNA and bacterial proteins. As a result of irreversible binding to the enzyme, rifaximin exhibits bactericidal properties against sensitive bacteria. The drug has a wide spectrum of antibacterial activity, including most gram-negative and gram-positive, aerobic and anaerobic bacteria that cause gastrointestinal infections, including traveler's diarrhea. Gram-negative Aerobes: Salmonella spp., Shigella spp., Escherichia coli, including enteropathogenic strains, Proteus spp., Campylobacter spp., Pseudomonas spp., Yersinia spp., Enterobacter spp., Klebsiella spp., Helicobacter pylori ; anaerobes: Bacteroides spp., including Bacteroides fragilis, Fusobacterium nucleatum ; Gram-positive aerobes: Streptococcus spp., Enterococcus spp. , including Enterococcus fecalis, Staphylococcus spp. ; anaerobes: Clostridium spp. , including Clostridium difficile and Clostridium perfrigens, Peptostreptococcus spp. . Absorption of rifaximin in the α polymorphic form in the gastrointestinal tract when taken orally is insignificant (≤1%). The antibiotic acts locally in the intestine, where its high concentration is achieved, significantly higher than the minimum inhibitory concentration for the tested enteropathogenic microbes (after 3 days of therapy, a fecal level of 4000–8000 mcg/g is achieved when taking a daily dose of 800 mg). Due to this, rifaximin has a pronounced antibacterial effect. The use of the drug helps to reduce pathogenic intestinal bacterial flora, which causes some pathological conditions or is involved in their pathogenesis. The drug reduces:

the formation by bacteria of ammonia and other toxic compounds, which in the case of severe liver disease, accompanied by a violation of the detoxification process, are involved in the pathogenesis of hepatic encephalopathy;
increased proliferation of bacteria in intestinal microbial overgrowth syndrome;
the presence of bacteria in the intestinal diverticulum, which may be involved in inflammation in and around the diverticulum and may play a key role in the development of symptoms and complications of diverticulosis;
antigenic stimuli that, in the presence of genetically determined defects in mucosal immunoregulation and/or protective function, can induce or permanently maintain chronic intestinal inflammation;
risk of infectious complications during colorectal surgery.

Due to the virtually absent absorption of rifaximin in the gastrointestinal tract, there is no risk of systemic side effects. In numerous clinical studies, rifaximin was always well tolerated by patients. Pharmacokinetics Rifaximin oral absorption is ≤1% based on pharmacokinetic studies in rats, dogs and humans. The drug is not detected in blood plasma after administration in therapeutic doses (detection limit ≤0.5–2 ng/ml) or is detected in very low concentrations (less than 10 ng/ml in almost all cases) both in healthy volunteers and in patients with damaged intestinal mucosa (as a result of ulcerative colitis or Crohn's disease). Rifaximin found in urine is no more than 0.5% of the dose taken orally. Almost all rifaximin taken orally is found in the gastrointestinal tract, where very high concentrations of the drug are achieved (concentrations in feces of 4000-8000 mcg/g are achieved after 3 days of taking the drug at a daily dose of 800 mg). Comparative pharmacokinetic studies have demonstrated that polymorphic forms of rifaximin are absorbed from the intestine in greater quantities than polymorphic form α.

Pharmacodynamics and pharmacokinetics

"Alpha Normix" belongs to the refampicin group of antibiotics. The active component binds parts of bacterial enzymes, inhibits RNA synthesis, which inevitably leads to mass death of pathogenic microorganisms of different groups. The drug allows you to successfully fight gram-positive and gram-negative bacteria.

The active substance of the antibiotic is not absorbed into the intestines and does not enter the blood. The components act only on the pathogenic intestinal microflora, which minimizes the likelihood of side effects. As a result of taking the drug, it is possible to reduce:

the level of ammonia and other compounds that are products of the vital activity of microorganisms;
the concentration of bacteria that are present and multiply in colonic diverticula;
intensity of inflammatory processes with all accompanying symptoms;
proliferation of pathogenic bacteria, if it is associated with the syndrome of rapid proliferation of intestinal microflora;
an antigenic stimulus that can cause chronic inflammatory processes in the intestines;
risk of infection complications during or after colorectal surgery.

The antibiotic acts primarily on the intestinal microflora. No more than 1% is absorbed through the intestinal mucosa. The active substance of the drug is present in the blood in small quantities after administration. The maximum concentration is reached 3 hours after administration. Reaction products are excreted in feces by 99% and in small quantities (up to 1%) in urine.

Use of the drug Alpha Normix

Suspension Adults and children over 12 years of age: 10 ml oral suspension 3 times daily to 20 ml oral suspension 2–3 times daily (600–1200 mg rifaximin). Children aged 6 to 12 years: 10 ml oral suspension 2–3 times daily to 20 ml oral suspension 2 times daily (400–800 mg rifaximin). Children aged 2 to 6 years: 5 ml oral suspension 2-3 times daily to 10 ml oral suspension 3 times daily (200-600 mg rifaximin). For the treatment of adults and children over 6 years of age, instead of an oral suspension, Alpha Normix can be used in the form of film-coated tablets, 200 mg each. Tablets Adults and children over 12 years of age: from 1 tablet 3 times a day to 2 tablets 2-3 times a day (600-1200 mg rifaximin). Children aged 6 to 12 years: from 1 tablet 2-3 times a day to 2 tablets 2 times a day (400-800 mg of rifaximin). The duration of treatment should not exceed 7 days and depends on the clinical effect in patients. If necessary, repeated courses of treatment can be carried out with a break of 20–40 days. The total duration of therapy depends on the adequacy of the clinical effect in patients. Doses and frequency of administration can be changed on the recommendation of a doctor. Preparation of the suspension The granules for the preparation of the oral suspension are in a hermetically sealed bottle. The bottle must be opened, water added to the mark and shaken well. Add water again until the slurry reaches the specified level. The concentration of rifaximin in the finished suspension is 100 mg per 5 ml. To measure 5, 10 or 15 ml of suspension, add a measuring cup. The suspension remains stable for 7 days at room temperature. Before taking the drug, the bottle must be shaken well.

Determination of the frequency of side effects that have at least a possible connection with taking rifaximin: very common (≥10%), common (>1% - <10%), uncommon (>0.1% - <1%), rare (> 0.01 - <0.1%), very rare (≤ 0.01%).

The following are side effects that were observed in double-blind, placebo-controlled clinical studies. Most side effects, especially gastrointestinal side effects, may be symptoms of the disease for which treatment was prescribed during clinical trials and are reported with similar frequency in patients receiving placebo.

From the cardiovascular system:

infrequently - palpitations, flushing of the face, increased blood pressure.

From the hematopoietic system:

uncommon - lymphocytosis, monocytosis, neutropenia.

From the side of the central nervous system:

often - dizziness, headache; uncommon - loss of taste, hypoesthesia, migraine, insomnia, pathological dreams.

From the senses:

infrequently - diplopia, systemic dizziness.

From the respiratory system:

Uncommon: shortness of breath, dry throat, nasal congestion, pain in the laryngopharyngeal area.

From the digestive system:

often - bloating, abdominal pain, constipation, diarrhea, flatulence, nausea, tenesmus, vomiting, urge to defecate;
uncommon - anorexia, ascites, dyspepsia, impaired gastrointestinal motility, secretion of mucus and blood in feces, dry lips, hard stools, increased AST activity .
From the urinary system:

infrequently - glucosuria, polyuria, pollakiuria, hematuria.

Dermatological reactions:

uncommon - rash (including macular), cold sweat.

From the musculoskeletal system:

uncommon - lower back pain, muscle spasm, muscle weakness, myalgia.

From the reproductive system:

infrequently - polymenorrhea.

Infections:

infrequently - candidiasis.

General reactions:

often - fever; uncommon - asthenia, chest pain, chest discomfort, chills, fatigue, flu-like symptoms, peripheral edema.

With marketing experience

adverse reactions were observed very rarely: diarrhea, abdominal pain, heartburn, nausea, facial swelling, laryngeal edema, angioedema, peripheral edema, neutropenia, fainting, hypersensitivity reactions, agitation, headache, purpura, generalized itching, genital itching, erythema , palmar erythema, exanthema, allergic dermatitis, erythematous rash, urticaria, measles-like rash.

Side effects of the drug Alpha Normix

Analysis of safety data showed that the risk of side effects when using Alpha Normix is very low. These effects are limited primarily to gastrointestinal disturbances (nausea, dyspepsia, vomiting, abdominal pain and cramps), are mild to moderate and usually self-limit without the need for dose changes or interruption of therapy. The drug is practically not absorbed from the gastrointestinal tract, which eliminates the risk of developing systemic side effects. In rare cases, skin reactions such as urticaria may occur, which are likely due to individual intolerance to treatment. The risk of side effects is 0.7–2% of all cases of drug use. Post-marketing surveillance data confirm the above risk assessment and the nature of the observed events.

Contraindications and side effects

The drug is indicated for patients with various diseases, with the exception of:

all types of intestinal obstruction;
ulcerative intestinal lesions;
individual intolerance to the active or auxiliary components of the tablets;
the appearance of allergic reactions;
Also, the drug should not be given to children under 12 years of age (by agreement with the doctor, the suspension can be given to children from 2 years of age).

One of the advantages of Alpha Normix antibiotics is the absence or extremely rare occurrence of side effects. However, in rare cases, the following consequences may occur:

nausea;
vomit;
pain in the epigastric region;
headaches;
dizziness;
loss or disturbance of taste;
increased blood pressure;
dyspnea;
weakness, cold sweat;
Quincke's edema;
rash;
diarrhea;
heartburn.

In most cases, symptoms disappear without additional medications within the first hours after administration. If they persist for several days, the Alpha Normix tablets and suspension are discontinued. Symptomatic treatment and change of course are indicated. To do this, you must consult a doctor.

Special instructions for the use of Alpha Normix

During prolonged treatment with high doses or when the intestinal mucosa is damaged, a small amount of the drug (≤1%) may be absorbed, which can cause urine to turn reddish. This is due to the active substance, which, like most antibiotics of this series (rifamycins), has a red-orange color. Use during pregnancy and lactation. Rifaximin did not cause teratogenic effects in rats and rabbits. Adequate data and well-controlled studies in pregnant women are lacking. Since reproductive toxicity studies in animals do not allow assessment of the possibility of a toxic effect in humans, during pregnancy the drug should be taken only in cases of urgent need and under the direct supervision of a physician. The penetration of rifaximin into breast milk has not been studied, but is expected to be negligible due to very low absorption into the systemic circulation. Therefore, the use of Alpha Normix by women who are breastfeeding is permitted with appropriate medical supervision. The ability to influence the reaction rate when driving vehicles or other mechanisms. Not installed.

Indications for use of "Alpha Normix"

Tablets and suspension are taken in case of acute conditions and chronic intestinal diseases:

microflora overgrowth syndrome;
diverticular pathology of the colon;
traveler's diarrhea;
acute infectious processes in the intestines;
chronic intestinal inflammation;
prevention of possible complications after colorectal surgery;
hepatic encephalopathy.

Alpha Normix: possibilities for use in gastroenterological practice

As part of the IX Congress of the Scientific Society of Gastroenterologists of Russia, held at the Central House of Scientists of the Russian Academy of Sciences, on March 3, 2009, a scientific symposium was held with the support of Solvay Pharma “Alpha Normix. Possible applications in gastroenterological practice.” The symposium was chaired by Professor L.B. Lazebnik, chief therapist of Moscow, director of the Central Research Institute of Gastroenterology. The basis of the scientific program was the reports of professors S.N. Mehdieva, E.A. Belousova, A.A. Ilchenko, who presented the specialists with the modern selective intestinal antibiotic Alpha Normix (rifaximin).

S.N. Mehdiev, Doctor of Medical Sciences, Professor

A.A. Ilchenko, Doctor of Medical Sciences, Professor of the Central Research Institute of Gastroenterology

E.A. Belousova, Doctor of Medical Sciences, Professor of MONIKI named after. M.F. Vladimirsky

Scope of application of Alpha Normix for gastrointestinal diseases caused by bacterial flora

Two main questions that we want to consider at the start of our symposium are what is the place of antibacterial therapy and the characteristics of the so-called ideal antibiotic in gastroenterology.

Diseases of the upper, middle, and lower parts of the gastrointestinal tract (GIT) are combined in terms of the choice of antibacterial agents and disturbances of the intestinal microflora. Dysbiosis is a violation of the quantitative and qualitative composition of microflora. Bacterial overgrowth syndrome, as a special case of many intestinal diseases (inflammatory bowel diseases, IBS included), has a clear clinical correlation - an increase in the number of microbes and pronounced clinical manifestations. Bacterial overgrowth syndrome leads to a number of pathological conditions - nutritional deficiency, endogenous intoxication, local inflammation, etc. Each of these conditions can be a separate direction of therapy, but the general approach to the entire pathogenetic list is decontamination.

How do we traditionally decontaminate the intestines? What do we consider so-called intestinal antibiotics? How to choose the optimal intestinal antibiotic? Neither tetracyclines, nor fluoroquinolones, nor nitrofurans, due to their limitations on drug and food interactions, the possibility of the formation of resistant strains and contraindications, are ideal drugs. What are the features of the ideal antibiotic, or decontaminant, that we would like to use in clinical practice?

These include a wide range of activities, e.g. the drug should act on both Gram+ and Gram–, both aerobes and anaerobes; rapid creation of high concentrations with low resistance and minimal side effects.

So, Alpha Normix. What is significant about this drug? First of all, it has a wide spectrum of antimicrobial action: it is active against most gram-positive and gram-negative, aerobic and anaerobic bacteria that cause gastrointestinal infections.

Almost 100% of the drug is present directly in the gastrointestinal tract, which is what creates high concentrations of the antibiotic, which are significantly higher than the MIC for enteropathogenic microorganisms. Alpha Normix does not have a systemic effect, but is local in nature. Rifaximin is poorly absorbed from the gastrointestinal tract when taken orally (less than 1%), so drug interactions are unlikely. A special feature of the drug is that we can absolutely safely combine it with other drugs, both for enteral and parenteral administration.

The issue of resistance is extremely relevant today. Very interesting data confirm that resistance does not increase in conditionally pathogenic and pathogenic bacteria, and the normal flora becomes protected from the action of the drug, i.e. high selectivity of exposure is observed. At the same time, we can absolutely safely repeat the administration of the drug Alpha Normix.

The dose and duration can be selected depending on the severity of clinical manifestations. Dose 1200 mg/day. Today it is accepted as optimal for the treatment of bacterial overgrowth syndrome. You can increase the dose, against the background of IBS, at 1600 mg - 80% achieved an effect, at 1200 - almost 60%. Today we can manipulate only one drug, only changing its dose depending on the clinical situation.

As for the duration of use of the drug, they tried to increase the duration from 7 to 10 weeks in patients with IBS. After 10 weeks, patients with IBS remain symptom-free (36% vs. 21% placebo).

Similarly, a clear demonstration of the safety and effectiveness of the drug is the category of patients with inflammatory bowel diseases. We state that it is not the antibacterial drug that regulates the dose and duration of use, but we, having a highly safe drug, select its dose and duration that we need. This leads to a wide variety of schemes for its use.

If there is a risk, for example, of reinfection, with diverticular disease, when inflammation occurs both inside and outside the diverticulum, a dose of 800 mg 2 times a day for 7 days every month for 1 or 2 years is proposed - highly effective prevention. And we see that all the main symptoms (flatulence) are significantly lower compared to dietary fiber, and the risk of complications is reduced by 8 times.

For liver pathology (hepatic encephalopathy), in comparison with other antibacterial agents, a dose of Alpha Normix of 1200 mg does not produce any undesirable side effects and is highly effective.

Regarding the issue of price/quality, in comparison with the original fluoroquinolones the figures are absolutely comparable. Yes, we are not talking about generics.

It is impossible to find any other antibacterial agent other than Alpha Normix, where the frequency of flatulence would be half as frequent as with placebo.

So, who is currently the ideal intestinal antibiotic that has a wide range of action with the ability to create high concentrations, with very low resistance, the ability to modify the dose and duration of use of the drug - this is Alpha Normix. Alpha Normix is a non-systemic, broad-spectrum antibiotic for the treatment of acute gastrointestinal infections and is indicated for use in travelers' diarrhea, intestinal overgrowth syndrome, hepatic encephalopathy, symptomatic uncomplicated diverticular disease of the colon and chronic inflammatory bowel disease, as well as for the prevention of infectious complications during colorectal surgical interventions.

PCES: do we always diagnose it and provide adequate therapy?

I will try to clarify the concept of “postcholecystectomy syndrome” (PCES) and show its role in the formation of bacterial overgrowth syndrome (SIBO).

PHES is a symbol for various disorders, recurrent pain and dyspeptic symptoms that occur in patients after cholecystectomy. The modern definition of PCES interprets it as a set of functional or organic changes in various organs associated with the pathology of the gallbladder or ductal system, which is aggravated by cholecystectomy or develops independently as a result of technical errors in its implementation.

The causes of PCES can be grouped, which makes it possible to facilitate the diagnostic search for the pathology that is included in the concept of PCES: diagnostic errors made at the preoperative stage and during operations; technical errors and tactical errors during operations - the so-called pure PCES and functional disorders associated with removal of the gallbladder; as well as exacerbation and progression of diseases that existed before surgery and were provoked by cholecystectomy.

Diagnosing the presence of stones is currently not difficult. But what are the diagnostic errors at the preoperative stage? Secretory insufficiency of liver function is not assessed, and pathology of the biliary tract of a functional or organic nature is not detected. Diagnostic errors are also associated with the fact that the extrahepatic bile ducts are not fully examined. Stones can form a block at any level, which, of course, aggravates the course of the postoperative period. And the operation itself, of course, is also a diagnostic stage. Cholecystectomy should not be an end in itself, and this is also a diagnostic stage; if there are any doubts, then during the operation those instrumental diagnostic methods that allow the surgeon to calmly leave the abdominal cavity should be fully carried out and used, so that the therapist does not have to think about it later , why PHES arose in a given situation. Tactical and technical errors are a purely surgical problem, I will not dwell on this in detail, but I want to draw attention to the fact that the variability of the ductal system, various additional hepatic ducts and the connection of the cystic duct with the common duct is very great. Long stump syndrome is what, in particular, can await us if we do not take into account all these features.

The cause of PCES may be unreasonable removal of the gallbladder, expanding the indications for its removal. And, of course, the loss of the gallbladder, especially a functioning one, affects the work of other organs and systems, and functional restructuring occurs. A classic example of synchronous work is the work of the Lutkins sphincter with the sphincter of Oddi, when the bladder contracts, the Lutkins sphincter and the sphincter of Oddi open and the bladder is emptied, when there is no reflex effect of the bladder on the sphincter of Oddi, it is in a spastic state, this leads to biliary hypertension syndrome, and so on further, this is how all pathogenetic therapy is built.

Those organic diseases that accompanied cholelithiasis, because cholelithiasis does not develop in one day, its course continues for several years, and sometimes decades, and therefore other pathologies of the digestive organs have the right to join this pathology.

First of all, I would like to note that the course of cholelithiasis in almost all patients is accompanied by a decrease in the secretory function of the stomach with the development of atrophic processes in the antrum.

Due to the fact that the concentration function of the gallbladder is lost, because the concentration of bile acids, which have a bactericidal effect in the hepatic portion and the cystic portion, differ by an order of magnitude, which is an additional condition for the development of excessive bacterial growth in the very center of the duodenum, where crossover occurs all types of digestion. Thus, pathology of the biliary tract can cause structural and functional disorders of the liver, which are often not corrected by surgery, becoming the cause of PCES. The biliary tract is connected to the excretory ducts of the pancreas, and biliary pathology leads to the development of acute and chronic pancreatitis. The latter can also cause PCES. SIBO has now entered the clinical arena.

Diagnosis of PCES should adhere to two positions - this is the diagnosis of diseases that have worsened and developed after cholecystectomy, and the identification of technical errors of the operation or complications after the operation. Diagnostic methods of PCES are quite simple - clinical, laboratory and instrumental. These are available screening and clarifying methods, in which you can additionally see some kind of pathology that screening methods do not make it possible to identify. Spasm of the sphincter of Oddi, dyskinesia of the extrahepatic bile ducts, stomach and duodenum, microbial contamination, gastroduodenitis, long cystic duct after cholecystectomy may be the cause of some of the symptoms included in PCES, which should be deciphered based on the examination results. The formulation of the diagnosis should, of course, include the syndrome itself in the first place, information about the operation, and then functional disorders and some other concomitant pathology.

I will talk about conservative treatment in connection with the question of whether this syndrome is treated correctly and fully. If we talk about the basic principles of drug treatment after PCES, they should include four provisions: ensuring the normal outflow of bile and pancreatic juice into the duodenum, normalizing the chemical composition of bile. The resolution of SIBO in the small intestine, due to both a decrease in the bactericidal properties of the bile itself and the bactericidal properties of pancreatic juice, because these two processes are interconnected, we see that there are prospects in terms of its treatment. And although there is currently no clinical material and experience regarding the treatment of patients with SIBO in the small intestine after cholecystectomy, we do have literature data. When the selective antibiotic Alpha Normix, which is not absorbed into the gastrointestinal tract, appeared, one can think that this drug brought quite a new milestone in the treatment of patients with PCES.

The therapeutic potential of this drug in patients with SIBO - there is a pronounced clinical effect of Alpha Normix, showing its advantage in the treatment of such patients compared to traditional tetracycline drugs. The drug reduces the formation of ammonia and other toxic compounds by bacteria, which, in the case of severe liver disease, accompanied by a violation of the detoxification process, are involved in the pathogenesis and sympathology of hepatic encephalopathy; increased proliferation of bacteria in intestinal microbial overgrowth syndrome; the presence of bacteria in the colonic diverticulum that may be involved in inflammation in and around the diverticular sac and may play a key role in the development of symptoms and complications of diverticular disease; an antigenic stimulus, which, in the presence of genetically determined defects in mucosal immunoregulation and/or protective function, can initiate or permanently maintain chronic intestinal inflammation; risk of infectious complications during colorectal surgery.

SIBO for pancreatic diseases

To understand what bacterial overgrowth syndrome (SIBO) is and whether it can be corrected at all, you need to know what the normal microflora of the gastrointestinal tract is, and remember that the population of the gastrointestinal tract is not the same. In the proximal small intestine there is a protective mechanism that allows a relative constant of 104-105 CFU/ml of intestinal contents to be maintained.

An increase in the content of microorganisms (over 105 CFU/ml) is SIBO, and I emphasize that this term, according to modern concepts, refers exclusively to the proximal parts of the small intestine. Both dysbiosis and SIBO are not a diagnosis, but a secondary syndrome, and the syndrome is microbiological. It does not always develop; one can even say that it can develop with a certain pathology. Treatment of both dysbiosis and SIBO is not an end in itself. First of all, you need to eliminate the cause, treat the underlying disease.

Pancreatic disease (most often chronic pancreatitis) is accompanied by three syndromes: impaired absorption processes, SIBO and impaired motor function of the gastrointestinal tract.

Toxins from opportunistic flora that colonize the small intestine in SIBO damage membrane enzymes and thus disrupt the part of digestion that occurs at the membrane of the small intestine. And therefore, we note violations of cavity, parietal, and membrane digestion, and all these components act interdependently and synergistically. But the main thing in the characteristics of these disorders is the deficiency of enzymes in the cavity of the duodenum and excessive colonization of the proximal parts of the small intestine by opportunistic pathogenic microorganisms.

The first syndromes that accompany pancreatic pathology are digestive disorders. In this case, we are talking about the fact that there must be adequate enzyme therapy - before correcting SIBO, you need to establish digestion, and with fairly high doses of enzyme preparations. In patients with chronic pancreatitis, SIBO occurs in 40% of cases. In chronic pancreatitis, SIBO is one of the most common causes that lead to insufficient effectiveness of enzyme preparations. The use of Creon in some cases may not be sufficient to eliminate SIBO. And then exposure to antibacterial drugs is necessary. In this case, decontamination of the small intestine is carried out. Let me emphasize that this should be selective decontamination, affecting primarily pathogenic and conditionally pathogenic flora and not affecting representatives of normal flora.

What should be the requirements for an optimal antibacterial drug? First, the drug should not be absorbed from the gastrointestinal tract. It should create a high concentration in the intestinal cavity and should not suppress normal flora. It should have a fairly wide spectrum of action against aerobes and anaerobes, a minimum of side effects and, of course, proven effectiveness.

To what extent can we say that rifaximin (Alpha Normix) meets these criteria? The drug is not absorbed or very little is absorbed from the gastrointestinal tract and therefore gives a high concentration both in the lumen and in the mucosa. Accordingly, since it is not absorbed, it has minimal side effects and is well tolerated. Has a wide spectrum of antibacterial action. When using rifaximin, the level of normal flora representatives drops by the first week, but by the second week their level returns to the original level, i.e. Rifaximin can be considered a selective drug that does not affect normal flora. And it does not cause resistance, i.e. essentially meets all the requirements that we would like to see in an antibiotic.