Submitted by Michèle on Sat, 2008-04-26 03:59


Combined Antibiotic Protocols

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 to you.   To a certain extent the protocol you follow depends on your Cpn 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.  

With all the protocols it is important to take note of your reactions and tailor the treatment to suit your condition.   It is recommended that before you start you should ask your doctor for a liver enzyme test and a standard blood test to provide a bench mark for future comparison.

Wheldon Protocol

Doxycycline       100mg                   x2 a day or x1 a day, to start.          

Take this alone until well tolerated  (You will take 200mg/daily, once you're on the full protocol)

Azithromycin     250mg                   Mon, Wed, Fri   


Roxithromycin 150mg                   x2 a day               

Add one OR the other to the 100mg Doxycycline


Metronidazole also called Flagyl Pulse

When the first two antibiotics are well tolerated, probably after three months, start pulsing the third.  For one day, every three to four weeks initially.  Increase the number of days per pulse gradually to five days.

Metronidazole 400mg                   x3 a day               

                                or 500mg             x3 a day               

Dosage varies from country to country


Tinidazole           500mg                   x2 a day               

This is an alternative to Metronidazol/Flagyl


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 (CAP), 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, this is what we call a pulse.   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.

Dr Wheldon regularly revises his protocol and it is worth visiting his website for the latest information.  

 Sriram Protocol

Rifampin                             300mg                   x2 a day               

Take this on its own for 2 weeks.

Azithromycin                     250mg                   Mon, Wed, Fri 

Take this with above for duration

Metronidazole                 400 or 500mg     x3 a day               

Start taking this a month into the treatment and take it 15 days on and 15 days off for the duration of the treatment

Sodium or Calcium Pyruvate      Up to 4g              

through the day: start this 8 weeks into the treatment.


Rifampin is a very effective killer of RBs 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

Dr Stratton recommends that you start by taking 600mg of N-Acetyl Cysteine (NAC) a day; this is a supplement which you can buy over the counter.   Taking NAC may reveal the extent of the Cpn load.   You may get the flu like symptoms described here.  If the reactions are severe you may need to take 5mg of prednisone a day for the first few weeks of therapy.   If there are no reactions increase the dose of NAC to 1200mg a day and continue to take this for the duration of the treatment and beyond.

Clarithromycin                  500mg                   x2 a day


Roxithromycin                  150mg                   x2 a day


Azithromycin                     250mg                   1 on MWF

Take one or the other of these antibiotics for two weeks. 1 hour before taking antibiotics, take 6gm pyruvate.   More pyruvate may be taken during the day to alleviate reactions to antibiotics.

400 mg of Ibuprofen twice a day 1,200 mg of NAC twice a day if needed to moderate reactions


If you get major reactions continue on the antibiotic alone, leaving out the pyruvate until the reactions subside. If you don’t get severe reactions continue as follows:

Doxycycline                       100mg                   x1 a day               

One hour after 6gm pyruvate.

When well tolerated add another dose of pyruvate and doxycycline daily.

When the two antibiotics and the pyruvate are well tolerated start pulsing Metronidazole building up to 7 days in every month at the same time as the other antibiotics and pyruvate.  


Metronidazole                 400mg or 500mg               x3 a day               

Depending on the dosage available


1st pulse 1 day, 2nd pulse 2 days, 3rd pulse 3 days etc

When reactions are acceptable you may want to reduce the time between pulses so you are doing a pulse once every 3 weeks.   Here are further details on this protocol and how you can progress from a different protocol to this one.