Skip to Content

Rifaximin

Pronunciation

Class: Rifamycins
VA Class: AM900
Chemical Name: [2S - (2R*,16Z,18E,20R*,21R*,22S*,23S*,24S*,25R*,26S*,27R*,22E)] - 25 - acetyloxy) - 5,6,21,23 - tetrahydroxy - 27 - methoxy - 2,4,11,16,20,22,24,26 - octamethyl - 2,7 - (epoxypentadeca[1,11,13]trienimino)benzofuro[4,5 - e]pyrido[1,2 - a]benzimidazole - 1,15(2H) - dione
Molecular Formula: C43H51N3O11
CAS Number: 80621-81-4
Brands: Xifaxan

Introduction

Rifamycin antibiotic;11 12 structural analog of rifampin.1 11 12

Uses for Rifaximin

Hepatic Encephalopathy

Reduction of risk of recurrence of overt hepatic encephalopathy in adults.1 20 21 36 Comparative efficacy of rifaximin used alone or in conjunction with lactulose for prevention of hepatic encephalopathy recurrence not established.1

Experts recommend rifaximin as an adjunct to lactulose for prevention of hepatic encephalopathy recurrence in patients who have had at least 1 episode of overt hepatic encephalopathy while receiving lactulose alone.36

Not evaluated for prevention of overt hepatic encephalopathy recurrence in patients with model for end-stage liver disease (MELD) scores >25.1 20 Rifaximin systemic exposure is increased in patients with a history of hepatic encephalopathy who have severe hepatic impairment.1

Has been used in the treatment of hepatic encephalopathy to reduce blood ammonia concentrations and decrease severity of neurologic manifestations;6 7 8 9 10 11 17 21 36 designated an orphan drug by FDA for treatment of this condition.5

Information from the American Association for the Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL) regarding the management of hepatic encephalopathy, including recommendations for treatment and prevention of recurrence, is available at .36

Irritable Bowel Syndrome with Diarrhea

Treatment of irritable bowel syndrome (IBS) with diarrhea in adults.1 22

Travelers’ Diarrhea

Treatment of travelers’ diarrhea caused by noninvasive strains of Escherichia coli in adults and adolescents ≥12 years of age.1 3 4 12 13 18 19

Not effective in and should not be used for treatment of diarrhea complicated by fever or bloody stools.1

Not effective in and should not be used for treatment of diarrhea known or suspected to be caused by pathogens other than E. coli (e.g., Campylobacter jejuni, Shigella, Salmonella).1

Travelers' diarrhea caused by bacteria may be self-limited and often resolves within 3–7 days without anti-infective treatment.18 19 CDC and others recommend fluoroquinolones (ciprofloxacin, levofloxacin) as drugs of choice when anti-infective treatment, including self-treatment, indicated.18 19 Rifaximin can be considered an alternative when causative organism is enterotoxigenic E. coli;3 4 12 13 18 19 however, usefulness for empiric self-treatment of travelers' diarrhea remains to be determined.19

Has been used for prevention of travelers’ diarrhea.2 14 15 16 18 19 CDC and others state that anti-infective prophylaxis for prevention of travelers' diarrhea not recommended for most travelers.18 19

Rifaximin Dosage and Administration

Administration

Oral Administration

Administer orally without regard to meals.1

Dosage

Pediatric Patients

Travelers’ Diarrhea Caused by Noninvasive Strains of E. coli
Treatment
Oral

Adolescents ≥12 years of age: 200 mg 3 times daily for 3 days.1

If diarrhea worsens or persists >24–48 hours after drug initiated, discontinue and consider alternative anti-infective.1

Adults

Hepatic Encephalopathy
Reduction of Risk of Recurrence of Overt Hepatic Encephalopathy
Oral

550 mg twice daily.1

Treatment of Hepatic Encephalopathy
Oral

600–1200 mg daily (usually in 3 divided doses) for 7–21 days has been used.2 6 7 8 9 10 17

Irritable Bowel Syndrome with Diarrhea
Oral

550 mg 3 times daily for 14 days.1

If symptoms recur, up to 2 additional courses may be given using the same 14-day regimen.1

Travelers’ Diarrhea Caused by Noninvasive Strains of E. coli
Treatment
Oral

200 mg 3 times daily for 3 days.1

If diarrhea worsens or persists >24–48 hours after drug initiated, discontinue and consider alternative anti-infective.1

Special Populations

Hepatic Impairment

Dosage adjustment not needed;1 use with caution in those with severe hepatic impairment (Child-Pugh class C).1 (See Hepatic Impairment under Cautions.)

Renal Impairment

Not specifically studied in renal impairment;1 clinically important changes in rifaximin elimination not expected.2 11 12

Geriatric Patients

Not specifically studied in patients ≥65 years of age.1

Cautions for Rifaximin

Contraindications

  • Known hypersensitivity to rifaximin, other rifamycin anti-infectives, or any ingredient in the formulation.1

Warnings/Precautions

Sensitivity Reactions

Hypersensitivity reactions, including exfoliative dermatitis, rash, angioedema (swelling of face and tongue and difficulty swallowing), urticaria, flushing, pruritus, and anaphylaxis, reported during postmarketing experience.1 Such reactions have occurred as soon as 15 minutes after a dose.1

Precautions Related to Treatment of Travelers’ Diarrhea

Do not use for treatment of diarrhea complicated by fever or bloody stools.1

Do not use for treatment of travelers’ diarrhea known or suspected to be caused by C. jejuni, Shigella, or Salmonella.1

If diarrhea worsens or persists >24–48 hours after initiating rifaximin, discontinue and consider use of another anti-infective.1

Interactions

Concomitant use of rifaximin with drugs that are P-glycoprotein (P-gp) transport inhibitors (e.g., cyclosporine) may substantially increase rifaximin systemic exposure.1 In patients with hepatic impairment, potential additive effect of reduced hepatic metabolism and concomitant use with P-gp inhibitors may further increase rifaximin systemic exposure.1 Use caution if concomitant use with a P-gp inhibitor necessary.1

Superinfection/Clostridium difficile-associated Diarrhea and Colitis (CDAD)

Treatment with anti-infectives alters normal colon flora and may permit overgrowth of Clostridium difficile.1 23 24 25 C. difficile infection (CDI) and C. difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis) reported with nearly all anti-infectives, including rifaximin, and may range in severity from mild diarrhea to fatal colitis.1 23 24 25 C. difficile produces toxins A and B which contribute to development of CDAD;1 23 hypertoxin-producing strains of C. difficile are associated with increased morbidity and mortality since they may be refractory to anti-infectives and colectomy may be required.1

Consider CDAD if diarrhea develops during or after therapy and manage accordingly.1 23 24 25 Obtain careful medical history since CDAD may occur as late as ≥2 months after anti-infective therapy is discontinued.1

If CDAD suspected or confirmed, discontinue anti-infectives not directed against C. difficile whenever possible.1 23 Initiate appropriate supportive therapy (e.g., fluid and electrolyte management, protein supplementation), anti-infective therapy directed against C. difficile (e.g., metronidazole, vancomycin), and surgical evaluation as clinically indicated.1 23 24 25

Selection and Use of Anti-infectives

Not suitable for treatment of systemic bacterial infections because rifaximin plasma concentrations are low and variable following oral administration.1 (See Pharmacokinetics.)

To reduce development of drug-resistant bacteria and maintain effectiveness of rifaximin and other antibacterials, use only for treatment of infections proven or strongly suspected to be caused by susceptible bacteria.1

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing.1 In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.1

Specific Populations

Pregnancy

Data not available regarding use in pregnant women.1 Teratogenic effects (e.g., ocular, oral and maxillofacial, cardiac, and lumbar spine malformations) observed in animal reproduction studies in rats and rabbits.1

Lactation

Not known whether distributed into human milk, affects human milk production, or affects breast-fed infant.1

Consider benefits of breast-feeding and importance of rifaximin to the woman;1 also consider potential adverse effects on the breast-fed child from the drug or from underlying maternal condition.1

Pediatric Use

Hepatic encephalopathy: Safety and efficacy not established in children and adolescents <18 years of age.1

IBS with diarrhea: Safety and efficacy not established in children and adolescents <18 years of age.1

Travelers' diarrhea: Safety and efficacy not established in children <12 years of age.1

Geriatric Use

Hepatic encephalopathy: No overall differences in safety or effectiveness observed between patients ≥65 years of age and younger adults.1

IBS with diarrhea: No overall differences in safety or effectiveness observed between patients ≥65 years of age and younger adults.1

Travelers' diarrhea: Experience in those ≥65 years of age insufficient to determine whether they respond differently than younger patients.1

Hepatic Impairment

Severe hepatic impairment (Child-Pugh class C): Use with caution.1

Although dosage adjustments not needed in patients with hepatic impairment, severe hepatic impairment results in increased rifaximin systemic exposure.1 (See Pharmacokinetics.)

Hepatic encephalopathy: Clinical trials did not include patients with MELD scores >25.1

Renal Impairment

Not specifically studied in renal impairment.1 Clinically important changes in elimination not expected since the drug is poorly absorbed from GI tract and almost entirely excreted in feces.2 11 12

Common Adverse Effects

Hepatic encephalopathy: Peripheral edema, nausea, dizziness, fatigue, ascites, muscle spasms, pruritus, abdominal pain, anemia, depression, nasopharyngitis, upper abdominal pain, arthralgia, dyspnea, pyrexia, rash.1

IBS with diarrhea: Nausea, increased ALT concentrations.1

Travelers' diarrhea: Headache.1

Interactions for Rifaximin

Substrate of CYP3A4.1 Does not inhibit CYP1A2, 2A6, 2B6, 2C9, 2C19, 2D6, 2E1, or 3A4 in vitro.1 Has induced CYP3A4 in vitro, but clinically important effects on intestinal or hepatic CYP3A4 unlikely.1

Substrate of P-gp transport in vitro.1 Inhibits P-gp in vitro, but effect in vivo unknown.1

Substrate of organic anion transport polypeptides (OATP) 1A2, 1B1, and 1B3;1 not a substrate of OATP2B1.1 Inhibits OATP1B1, 1A2, and 1B3 in vitro, but effect in vivo unknown.1

Drugs Metabolized by Hepatic Microsomal Enzymes

CYP3A4 substrates: Pharmacokinetic interactions not expected in patients with normal hepatic function;1 not known whether interactions occur in those with hepatic impairment and increased rifaximin systemic exposure.1

CYP1A2, 2A6, 2B6, 2C9, 2C19, 2D6, and 2E1 substrates: Pharmacokinetic interactions not expected.1

Drugs Affecting or Affected by P-glycoprotein Transport

P-gp inhibitors: Substantially increased rifaximin exposures may occur.1

P-gp substrates: Possible effects in vivo unknown.1

Drugs Affecting or Affected by Organic Anion Transport Polypeptides

OATP1B1, 1A2, and 1B3 substrates: Possible effects in vivo unknown.1

Specific Drugs

Drug

Interaction

Comments

Cyclosporine

Substantially increased rifaximin concentrations and AUC1

Clinical importance unknown1

Hormonal contraceptives (ethinyl estradiol and norgestimate)

Decreased ethinyl estradiol and norgestimate concentrations1

Clinical importance unknown1

Midazolam

No substantial changes in pharmacokinetics of midazolam or its major metabolite (1′-hydroxymidazolam) 1 2

Dosage adjustment not needed2

Rifaximin Pharmacokinetics

Absorption

Bioavailability

Poorly absorbed from GI tract;1 11 12 <0.4% of an oral dose absorbed systemically.11 12

No evidence of accumulation following multiple doses.1

History of hepatic encephalopathy (550 mg twice daily): Mean AUC approximately 12-fold higher compared with healthy adults.1

IBS with diarrhea (rifaximin 550 mg 3 times daily for 14 days): AUC similar to healthy adults.1

Food

When administered 30 minutes after high-fat meal, time to peak plasma concentrations delayed from 0.75 hours to 1.5 hours after a dose,1 AUC increased twofold,1 peak plasma concentrations unchanged.1

Plasma Concentrations

Healthy individuals (single or multiple doses of 550 mg): Peak plasma concentrations attained about 1 hour after dosing;1 mean peak plasma concentrations range from 2.4–4 ng/mL.1

IBS with diarrhea (550 mg 3 times daily for 14 days): Peak plasma concentrations attained 1 hour after dosing;1 mean peak plasma concentrations similar to healthy individuals.1

Distribution

Plasma Protein Binding

Healthy individuals: 67.5%.1

Hepatic impairment: 62%.1

Elimination

Metabolism

Systemically absorbed drug metabolized principally by CYP3A4.1

Elimination Route

Approximately 97% of an oral dose excreted in feces (mostly as unchanged drug);1 11 12 0.3% eliminated in urine (mostly as metabolites).1 11 12

Half-life

Healthy individuals: 5.6 hours.1

IBS with diarrhea: 6 hours.1

Special Populations

Pediatric patients: Pharmacokinetics not studied.1

Geriatric patients: Pharmacokinetics not studied.1

History of hepatic encephalopathy and with mild, moderate, or severe hepatic impairment: Systemic exposures approximately 10-, 14-, or 21-fold higher, respectively, compared with healthy individuals.1

Renal impairment: Pharmacokinetics not studied.1

Stability

Storage

Oral

Tablets

20–25°C (may be exposed to 15–30°C).1

Actions and Spectrum

  • Like other rifamycins, rifaximin inhibits RNA synthesis in susceptible bacteria by binding to the β subunit of bacterial DNA-dependent RNA polymerase.1 11

  • Escherichia coli: Active in vitro and in clinical infections (i.e., infectious diarrhea) against enterotoxigenic E. coli (ETEC) and enteroaggregative E. coli (EAEC).1 11 26 31 33 Although clinical importance unknown, also active in vitro against other E. coli strains, including enterohemorrhagic, enteroinvasive, enteropathogenic, and Hep-2 adherent strains.2 11 33

  • Other bacteria: Although clinical importance unknown, has some in vitro activity against Aeromonas,2 11 26 31 Bacillus,2 11 Bacteroides,2 11 Bifidobacterium,2 11 Campylobacter jejuni,2 11 26 Enterobacter cloacae,2 11 Fusobacterium,2 11 Helicobacter,2 11 Klebsiella pneumoniae,2 11 Plesiomonas shigelloides,2 11 26 31 Peptostreptococcus,2 11 Prevotella,2 11 Salmonella,2 11 26 Shigella (including S. dysenteriae, S. flexneri, S. sonnei),2 11 26 33 Vibrio,2 11 31 32 and Yersinia enterocolitica.2 11

  • Resistance to rifaximin has been produced in vitro in E. coli (ETEC and EAEC strains).29 Rifaximin resistance also reported in various clinical isolates of E. coli from patients with travelers' diarrhea or inflammatory bowel disease,26 27 28 30 including some patients who previously received the drug.27 Clinical isolates of Campylobacter,26 28 Salmonella,31 and Shigella28 31 with in vitro resistance to rifaximin also reported. Although some strains of Clostridium difficile susceptible to rifaximin in vitro, clinical isolates resistant to rifaximin (some with high-level resistance) reported.34 35

  • Resistance generally is associated with mutations in the rpoB gene1 27 34 that change the binding site on DNA-dependent RNA polymerase and decrease rifaximin binding affinity.1 Presence of efflux pumps also appears to cause or contribute to development of rifaximin resistance in some organisms.27

  • Cross-resistance between rifaximin and other classes of anti-infectives not observed.1

Advice to Patients

  • Advise patients that antibacterials (including rifaximin) should only be used to treat bacterial infections and not used to treat viral infections (e.g., the common cold).1

  • Importance of completing full course of therapy, even if feeling better after a few days.1

  • Advise patients that skipping doses or not completing the full course of therapy may decrease effectiveness and increase the likelihood that bacteria will develop resistance and will not be treatable with rifaximin or other antibacterials in the future.1

  • Advise patients and/or their caregivers that rifaximin may be taken with or without food.1

  • If used for treatment of travelers' diarrhea, advise patients of the importance of discontinuing rifaximin and seeking medical care if diarrhea worsens or persists for >24–48 hours after the drug is initiated or if fever and/or bloody diarrhea develop.1

  • If used in patients with severe hepatic impairment (Child-Pugh class C), advise patients that rifaximin systemic exposure is increased.1 (See Hepatic Impairment under Cautions.)

  • Advise patients that diarrhea is a common problem caused by anti-infectives and usually ends when the drug is discontinued.1 Importance of contacting a clinician if watery and bloody stools (with or without stomach cramps and fever) occur during or as late as 2 months or longer after the last dose.1

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and any concomitant illnesses.1

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1

  • Importance of informing patients of other important precautionary information.1 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Rifaximin

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets

200 mg

Xifaxan

Salix

550 mg

Xifaxan

Salix

AHFS DI Essentials. © Copyright 2017, Selected Revisions October 6, 2016. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

1. Salix Pharmaceuticals, Inc. Xifaxan tablets prescribing information. Raleigh, NC; 2015 Nov.

2. Salix Pharmaceuticals, Inc., Raleigh, NC: Personal communication.

3. Steffen R, Sack DA, Riopel L, et al. Therapy of traveler’s diarrhea with rifaximin on various continents. Am J Gastroenterol. 2003; 98:1073-8. [IDIS 502876] [PubMed 12809830]

4. Infante RM, Ericsson CD, Jiang Z, et al. Enteroaggregative Escherichia coli diarrhea in travelers: response to rifaximin therapy. Clin Gastroenterol Hepatol. 2003; 2:136-8.

5. Food and Drug Administration. FDA Application: Search Orphan Drug Designations and Approvals. Rockville, MD. From FDA website. Accessed 2016 Jun 27.

6. Riordan SM, Williams R. Treatment of hepatic encephalopathy. N Engl J Med. 1997;337:473-9.

7. Williams R, James OF, Warnes TW et al. Evaluation of the efficacy and safety of rifaximin in the treatment of hepatic encephalopathy: a double-blind, randomized, dose-finding multi-centre study. Eur J Gastroenterol Hepatol. 2000;12:203-8.

8. Puxeddu A, Quartini M, Massimetti A et al. Rifaximin in the treatment of chronic hepatic encephalopathy. Curr Med Res Opin. 1995;13:274-81.

9. Pedretti G, Calzetti C, Missale G et al. Rifaximin versus neomycin on hyperammoniemia in chronic portal systemic encephalopathy of cirrhotics. A double-blind, randomized trial. Ital J Gastroenterol. 1991;23:175-8.

10. Bucci L, Palmieri GC. Double-blind, double-dummy comparison between treatment with rifaximin and lactulose in patients with medium to severe degree hepatic encephalopathy. Curr Med Res Opin. 1993;13:109-18.

11. Gillis JC, Brogden RN.. Rifaximin. A review of its antibacterial activity, pharmacokinetic properties and therapeutic potential in conditions mediated by gastrointestinal bacteria. Drugs 1995;49:467-84.

12. Steffen R. Rifaximin: a nonabsorbed antimicrobial as a new tool for treatment of travelers’ diarrhea. J Travel Med. 2001;8:34-9.

13. DuPont HL, Ericsson CD, Mathewson JJ, et al. Rifaximin: a nonabsorbed antimicrobial in the therapy of travelers’ diarrhea. Digestion. 1998;59:708-14.

14. Flores J, Dupont HL, Jiang ZD et al. A randomized, double-blind, pilot study of rifaximin 550 mg versus placebo in the prevention of travelers' diarrhea in Mexico during the dry season. J Travel Med. 2011 Sep-Oct; 18:333-6. [PubMed 21896097]

15. Armstrong AW, Ulukan S, Weiner M et al. A randomized, double-blind, placebo-controlled study evaluating the efficacy and safety of rifaximin for the prevention of travelers' diarrhea in US military personnel deployed to Incirlik Air Base, Incirlik, Turkey. J Travel Med. 2010 Nov-Dec; 17:392-4. [PubMed 21050319]

16. Hu Y, Ren J, Zhan M et al. Efficacy of rifaximin in prevention of travelers' diarrhea: a meta-analysis of randomized, double-blind, placebo-controlled trials. J Travel Med. 2012; 19:352-6. [PubMed 23379704]

17. Miglio F, Valpiani D, Rossellini SR, et al. Rifaximin, a non-absorbable rifamycin, for the treatment of hepatic encephalopathy. A double-blind, randomised trial. Curr Med Res Opin. 1997;13:593-601.

18. . Advice for travelers. Med Lett Drugs Ther. 2015; 57:52-8. [PubMed 25853663]

19. Centers for Disease Control and Prevention. CDC health information for international travel, 2016. Atlanta, GA: US Department of Health and Human Services. Updates may be available at CDC website.

20. Bass NM, Mullen KD, Sanyal A et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010; 362:1071-81. [PubMed 20335583]

21. Eltawil KM, Laryea M, Peltekian K et al. Rifaximin vs. conventional oral therapy for hepatic encephalopathy: a meta-analysis. World J Gastroenterol. 2012; 18:767-77. [PubMed 22371636]

22. Pimentel M, Lembo A, Chey WD et al. Rifaximin therapy for patients with irritable bowel syndrome without constipation. N Engl J Med. 2011; 364:22-32. [PubMed 21208106]

23. Cohen SH, Gerding DN, Johnson S et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010; 31:431-55. [PubMed 20307191]

24. Fekety R for the American College of Gastroenterology Practice Parameters Committee. Guidelines for the diagnosis and management of Clostridium difficile-associated diarrhea and colitis. Am J Gastroenterol. 1997; 92:739-50. [IDIS 386628] [PubMed 9149180]

25. American Society of Health-System Pharmacists Commission on Therapeutics. ASHP therapeutic position statement on the preferential use of metronidazole for the treatment of Clostridium difficile-associated disease. Am J Health-Syst Pharm. 1998; 55:1407-11. [IDIS 407213] [PubMed 9659970]

26. Ouyang-Latimer J, Jafri S, VanTassel A et al. In vitro antimicrobial susceptibility of bacterial enteropathogens isolated from international travelers to Mexico, Guatemala, and India from 2006 to 2008. Antimicrob Agents Chemother. 2011; 55:874-8. [PubMed 21115800]

27. Kothary V, Scherl EJ, Bosworth B et al. Rifaximin resistance in Escherichia coli associated with inflammatory bowel disease correlates with prior rifaximin use, mutations in rpoB, and activity of Phe-Arg-β-naphthylamide-inhibitable efflux pumps. Antimicrob Agents Chemother. 2013; 57:811-7. [PubMed 23183443]

28. Hopkins KL, Mushtaq S, Richardson JF et al. In vitro activity of rifaximin against clinical isolates of Escherichia coli and other enteropathogenic bacteria isolated from travellers returning to the UK. Int J Antimicrob Agents. 2014; 43:431-7. [PubMed 24661532]

29. Ruiz J, Mensa L, Pons MJ et al. Development of Escherichia coli rifaximin-resistant mutants: frequency of selection and stability. J Antimicrob Chemother. 2008; 61:1016-9. [PubMed 18325895]

30. Dogan B, Scherl E, Bosworth B et al. Multidrug resistance is common in Escherichia coli associated with ileal Crohn's disease. Inflamm Bowel Dis. 2013; 19:141-50. [PubMed 22508665]

31. Gomi H, Jiang ZD, Adachi JA et al. In vitro antimicrobial susceptibility testing of bacterial enteropathogens causing traveler's diarrhea in four geographic regions. Antimicrob Agents Chemother. 2001; 45:212-6. [PubMed 11120968]

32. Scrascia M, Forcillo M, Maimone F et al. Susceptibility to rifaximin of Vibrio cholerae strains from different geographical areas. J Antimicrob Chemother. 2003; 52:303-5. [PubMed 12837732]

33. Sierra JM, Navia MM, Vargas M et al. In vitro activity of rifaximin against bacterial enteropathogens causing diarrhoea in children under 5 years of age in Ifakara, Tanzania. J Antimicrob Chemother. 2001; 47:904-5. [PubMed 11389133]

34. O'Connor JR, Galang MA, Sambol SP et al. Rifampin and rifaximin resistance in clinical isolates of Clostridium difficile. Antimicrob Agents Chemother. 2008; 52:2813-7. [PubMed 18559647]

35. Carman RJ, Boone JH, Grover H et al. In vivo selection of rifamycin-resistant Clostridium difficile during rifaximin therapy. Antimicrob Agents Chemother. 2012; 56:6019-20. [PubMed 22908175]

36. American Association for the Study of Liver Diseases (AASLD). and European Association for the Study of the Liver (EASL). Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by AASLD and EASL. From the AASLD website. Accessed 2016 June 27.

Hide