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Nevertheless, rifaximin has shown earlier improvement and fewer side effects.23,25,27 Likewise, the use of oral vancomycin was reported to reduce the diversity of the gut microbiota.28 In a Japanese study on 12 patients with lactulose-resistant HE, vancomycin was added to the management and the HE grade improved.29 The results of that small blind study suggest that vancomycin could be an option in patients that do not respond to treatment with lactulose, but that should be cautiously interpreted, given the design of that study and the fact that there is scant evidence on the use of said drug