Jessica Bonovich RN

The Role of Probiotics in Candida and Clostridia Treatment: What Does the Evidence Say?

Jessica Bonovich, RN, BSN

Trillions of friendly microbes are currently living symbiotically within each of us right now (give or take a few billion). In fact, there are more of “them” than there are of “us”. While this phenomenon has been known for quite some time, only recently has modern medicine starting to examine this relationship and how it affects human health. Studies on the use of probiotics have been performed on a wide range of populations. Despite the seemingly obvious importance of these microbes, there is still some confusion about the role of probiotics in reducing the colonization of opportunistic pathogens like Clostridia and Candida? For example, some people believe that probiotics alone can treat an infection. Others believe
that they “compete” for resources and “crowd out” the bad guys. So, what does the evidence say?

Promising data by several studies have demonstrated the use of probiotics is effective against numerous pathological conditions caused by Candida. In these studies, Lactobacillus GG, L. acidophilus, and Saccharomyces boulardi were the predominant probiotics shown to be effective, with L. GG demonstrating the ability to induce antibody formation against Candida (PMID 15932169). Supplementation with probiotics has been shown to accelerate the healing of various pathological conditions in the gastro‐intestinal tract when Candida is present (PMID 17242486, 17251510). The use of probiotics have also been shown to accelerate immune response to Candida in both human and murine model simulations (PMID 17242486, 15813696). Probiotics have shown to decrease occurrence of Candida overgrowth in the elderly population (PMID 17251510). In preterm infants, probiotics were shown to prevent colonization of Candida, a common problem in this patient population (PMID 16705580). According to these data, probiotics promote and stimulate the host immune response against intestinal Candida overgrowth and accelerate healing in the intestinal mucosa. In most of the studies, probiotics were used alongside antifungals not instead of. 

So can probiotics help reduce oxalates? Since Candida can produce oxalates (PMID 11452311) many people are interested in using probiotics therapeutically to minimize the oxalate load. Many studies have demonstrated that Oxalobacter formingenes bacteria can reduce oxalate stone formation (hence the name) (PMID 16284877). As of right now, testing for Oxalobacter formingenes is available primarily in research settings and supplements are not widely available to the public (though I expect that they will be soon). Fortunately, there are other beneficial bacteria species shown to reduce oxalic acid. Many of these are already available probiotic form. These include Lactobacillus acidophilus, Lactobacillus Casei, Bifidobacterium breve, and Bifidobacterium lactis all of which are available in Lactoprime probiotic formula (PMID 17953571, 19214493, 15345383, 20602988, 20601517).  

Studies on the use of probiotics in the prevention and treatment of C. difficile infections have been promising with many well‐respected institutions incorporating them into protocol, particularly for patients with reoccurring C. difficile infections. A meta‐analysis was recently conducted that reviewed several randomized controlled trials investigating the use of probiotics against C. difficile in human subjects. The results demonstrated a reduction in the reoccurrence of infection in patients with reoccurring C. difficile infection when probiotic strains of Lactobacillus or Saccharomyces boulardi were used in combination with antibiotic treatment (PMID 19324296). A separate study indicated that S. boulardi inhibits toxins associated with C. difficile and mitigates the inflammation associated with infection (PMID: 9864230). Restoration of the intestinal microbial balance is thought to be an important
aspect to preventing reoccurring infections (PMID 18199029). Patients receiving treatment with vancomycin have better outcomes when the treatment is combined with probiotic supplementation (PMID 11049785). Here probiotics can potentially prevent reoccurring infection associated with Clostridia species and reduce inflammation associated with the toxins produced by Clostridia. Here again, these are used in conjunction with antibiotic therapy, not alone to fight infection.

The majority of these studies look at the efficacy of specific strains. Doing so helps to control the variables of the study but ignores the more clinically relevant aspect of multiple species. The broader question still remains to be asked, what is the appropriate ratio of beneficial bacterium to prevent disease states and illicit an appropriate humoral immune response in vulnerable versus healthy populations? As challenging as this question is to answer, it is one worth pursuing. In the mean time, a healthy dose of probiotics is likely to be a good choice for individuals concerned with combating or preventing opportunistic pathogens.

Candida: A Factor in Depression and Mental Health

Jessica Bonovich, R.N.

One of the first psychiatrists to publish findings about the connection between Candida and depression is Dr. Orian Truss. His compelling work has been cited in numerous books and helped countless patients to date. Interestingly, his discovery in 1981 did not generate much interest from the psychiatric community who had just begun to see the effects of MAO inhibitors. While these and other modern antidepressants remain an important tool for treating psychiatric patients, studies have demonstrated that their efficacy rate is only about 20-30 percent (Kroenke, Hansen). Clearly, we do not have sufficient understanding of the complex spectrum of mental disorders that plague millions of individuals. To this end, we should leave no stone unturned. Especially if that stone has already shown to provide helpful information.

Dr. Truss hypothesized that where Candida is merely a nuisance for some, it causes chronic illness (including mental illness) in others. People with weakened immune systems are particularly at risk however they need not have HIV or leukemia to suffer. At the Huxley symposium (1981), he presented 6 case studies he believed to encompass the so-called Candida syndrome that he discovered. All individuals had been exposed to multiple rounds of antibiotics or other immune lowering agents. These individuals were often female. Depression was almost always one of many vague symptoms. Loss of memory, difficulty concentrating, sensitivity to chemicals and other symptoms were also noted. Dr. Truss began to incorporate treatment with antifungal therapy for patients with chronic mental illness. Interestingly, all of the individuals responded to the treatment and their symptoms of depression lifted.

More recently, a double blind placebo controlled study in 2001, under the direction of Heiko Santelmann found the antifungal drug nystatin to be significantly more effective at reducing symptoms of depression in polysymptomatic patients. In fact, the authors of the study noted that some of the most dramatic improvements reported were from individuals who had mental complaints. While nystatin is not specific to Candida, it is a compelling study that demonstrates yeast can affect mental health.

Dr. Truss noted the difficultly of testing for Candida since nearly everyone has had exposure to the organism. Determining the degree to which each individual suffers is based on a set of vague symptoms that often ends with the patient being labeled as psychosomatic or psychiatric. Fortunately, today we have more robust methods of detecting Candida and a better understanding of the mechanism which may be causing symptoms.

Genetic coding has helped determine the mechanisms that pathogens employ to help increase virulence. In the case of Candida albicans, a specific gene that codes for Immunogenic Alcohol Dehydrogenase was detailed in 1994 (Bertryam). This enzyme produces acetylaldehyde from glucose or ethanol (Gainza-Cirauqui). This acetylaldehyde creates an environment that is not conducive to most microbes which effectively decreases the competition. In humans, acetylaldehyde is a carcinogenic compound that easily passes the blood brain barrier where it interferes with neurotransmission (Correa). Depression and acetylaldehyde both cause a reduction in natural killer cell cytotoxicity (Irwin). Since nearly everyone has Candida in the body, it is plausible that a brief episode of depression may increase the possibility of developing a chronic condition.

For years, a yeast culture with sensitivity has been the mainstay of Candida testing. The benefit to this test is that it can determine the exact species of yeast so that appropriate treatment can be instituted. The problem with this method is that it is notorious for producing false negatives (Maaroufi). Metabolites of yeast detected in The Great Plains Laboratory Organic Acids Test are a very reliable method of detecting Candida overgrowth (Shaw). While this test cannot determine the exact organism, this is less important. Most prescriptive antifungal agents are effective at killing Candida albicans, which is the most common yeast species (Shaw).

Armed with correct information, the latest in diagnostic testing, and viable treatment options, psychiatric and primary care physicians can exercise multiple options for patients with symptoms of depression and other mental health disorders. As more and more physicians are looking outside the box to find solutions to psychiatric diseases as complex as the patients themselves, many are turning to comprehensive testing for yeast (and other pathogens) for answers. If a patient presents with a recent onset of chronic depression in the absence of major trauma, it makes sense to ask the question: Could this be related to Candida or another pathogen? Doing so may save your patient's life, or at least the life they once knew!

Clinical References

  • Hansen, R. et al. (2005). Efficacy and Safety of Second-Generation Antidepressants in the Treatment of Major Depressive Disorder. Annals of Internal Medicine, 143(6); 415-426.
  • Kroenke, K., et al. (2001). Similar Effectiveness of Paroxetine, Fluoetine, and Sertaline in Primary Care. JAMA, 286(23); 2947-2955
  • Truss, O. (1981). The Role of Candida in Human Illness. Presented that the Huxley symposium, September, Birmingham, AL.
  • Bertryam, G., et al. (1995). Structure and Regulation of the Candida albicans ADH1 Gene Encoding an Immunogenic Alcohol Dehydrogenase. Yeast, 12:115-127.
  • Santelmann, H et al. (2001). Effectiveness of nystatin in polysymptomatic patients. A randomized, double-blind trial with nystatin versus placebo in general practice. Family Practice, 18; 258-265.
  • Gainza-Cirauqui, ML., et al. (2013). Production of carcinogenic acetaldehyde by Candida albicans from patients with potentially malignant oral mucosal disorders. Journal of Oral Pathology and Medicine, 42(3); 243-9.
  • Correa, M., et al. (2011). Piecing together the puzzle of acetaldehyde as a neuroactive agent. Neuroscience and Biobehavioral Reviews, 36; 404-430.
  • Irwin, M., et al. (1990). Major Depressive Disorder, Alcoholism, and Reduced Natural Killer Cell Cytotoxicity: Role of Severity of Depressive Symptoms and Alcohol Consumption. JAMA Psychiatry, 47(8); 713-719.
  • Maaroufi, Y., Heymans, C., De Rune, J., Duchateau, H. (2003). Rapid Detection of Candida albicans in Clinical Blood Samples by Using a TaqMan-Based PCR Assay. Journal of Clinical Microbiology, 41; 3293-3298.
  • Shaw ,W., (2008) Biological Treatments for Autism and PDD. Publisher: Author.

A Primer on Natural Antifungal Agents: Evidence and Rationale for Their Use

Jessica Bonovich RN, BSN

Guidelines for the treatment of yeast have been documented in the literature for nearly every major organ system (Pappas). Yet, a standard of care for gastrointestinal yeast treatment is surprisingly absent despite the large body of work demonstrating that pathogenic yeast causes harm to various aspects of the gastrointestinal tract (Zwolinska, Brzozowski). Clinicians suspicious of GI yeast overgrowth typically perform a fecal analysis with culture and sensitivity. While this method is ideal for the effective treatment of yeast, it is poorly understood why patients with yeast overgrowth often test negative upon laboratory examination of stool (Maaroufi, Shaw). Up to 50% of stool analysis negative for yeast species returned positive on PCR (Maaroufi). Metabolites of yeast detected in The Great Plains Laboratory Organic Acids Test are a very reliable method of detecting yeast (Shaw). However, this test cannot determine the exact organism and therefore its susceptibility to antifungals (Shaw). It also cannot determine the exact location of the yeast overgrowth but clinical experience has shown that the majority of cases are in fact GI related. The documentation set forth is based broadly on in vivo and in vitro studies on the antifungal properties of the natural agents, documentation of yeast infections involving organ systems other than the GI tract, and yeast overgrowth in the GI of the irritable bowel patient population.

Probiotic Support

Evidence:

Candida: Promising data by several small studies has demonstrated the use of probiotics as effective against numerous pathological conditions caused by Candida. In these studies, Lactobacillus GG, L. acidophilus, and Saccharomyces boulardi were the predominant probiotics shown to be effective with L. GG demonstrating the ability to induce antibody formation against Candida in immune deficient mice. Probiotics have been shown to accelerate the healing of various pathological conditions in the gastro-intestinal tract when Candida is present (Zwolinska 2006 & 2009, Hatakka). Probiotics have also been shown to accelerate immune response to Candida in several murine simulations (Wagner, Zwolinska 2006 & 2009).

Aspergillus: Data on the effectiveness of probiotics against Aspergillus infection is not available. Aspergillus infections are thought to be rare in comparison to other yeast species such as Candida. However, a recent study indicated a high percentage of Aspergillus in stool samples of patients with Crohn's disease. (Li) Aspergillus infections are usually associated with pulmonary infection and or post-surgical complications that are often very acute. The severity of the Aspergillus complications and small numbers of infection are presumably responsible for the lack of research in this regard. The relative safety of Lactobacilli, bifidobacteria, and lactococci has been demonstrated extensively in the literature. Incorporation of these probiotics into a protocol for Aspergillus treatment may be considered appropriate in many cases.

Studies on the use of probiotics for gastrointestinal healing have been aimed at a wide range of populations. To date, the most promising studies have been in the treatment and prevention of acute infectious diarrhea, viral gastroenteritis, antibiotic associated diarrhea, ulcerative colitis, and necrotizing enterocolitis in preterm infants (Manzoni, Zwolinska, Szajewska). In all of these conditions, inflammation is of a primary concern.

Risks: Reports of bacteremia and even a few isolated cases of sepsis have been documented in the literature from the Lactobacillus genera including L. rhamnosis, L. plantarum, L. casei, L. paracasei, L. salivarius, L. acidophilus (Snydman, Borriello). Cases of sepsis have also been documented for the usually beneficial yeast Saccharomyces boulardi. In some cases, the cultures were linked to a probiotic supplement, in others, the bacteria were found to be intrinsic to the patient's own microflora (Snydman, Borriello). In all of the cases, the patients were severely immunocompromised and often had feeding tubes, short gut syndrome, and/or a central line (Snydman, Borriello, Munoz, Herbrecht). The cases of sepsis have most commonly been associated with S. boulardi (Munoz, Herbrecht). However, fungemia from S. boulardi infection is rare in comparison to the population believed to be taking the supplement (Herbrecht, Munoz). In one study, increase in bacteremia from Lactobacillus did not increase over a decade, despite the 6 fold increase in probiotic use (Borriello). These data indicate that individuals taking probiotics are not at any greater risk than the general population for bacteremia associated with Lactobacillus. Regardless, the practitioner should exercise caution in severely immunocompromised patient populations to reduce any risk to the patient.

Rationale:

Promote the immune response against intestinal yeast overgrowth. To promote healing and reduce inflammation in the intestinal mucosa during yeast overgrowth.

Dosing:

The strain most commonly championed in the literature is that of Lactobacillus GG in doses of 10 billion colony forming units (CFU's) taken early in treatment. Saccharomyces thermophilus and S. boulardi were found to be effective in some studies and less effective in others. A daily intake of 10^6 to 10^9 CFUs is reportedly the minimum effective dose for therapeutic purposes.

Allicin

Evidence:

Allicin is the active ingredient found in garlic. The most commonly understood mode of action for allicin is linked to its ability to cross cell membranes and combine with sulfur-containing molecular groups in amino acids and proteins, thus interfering with cell metabolism (Davis, Singla). The antimicrobial properties of allicin have been demonstrated in numerous in vitro and in vivo murine models (Davis, Guo, Shadkchan). The antifungal properties of allicin have been shown to potentiate the effectiveness of fluconazole, the synergistic combination being the most effective at killing Candida species in kidney cells (Guo). Human studies have been targeted largely toward cardiovascular and antihypertensive effects and little has been done to demonstrate the antimicrobial properties (Fugh-Berman, NACAM). However, a study in China reports successful use of intravenous allicin against invasive fungal infections (Davis).

The strength of the supplement is affected by the preparation of garlic. Studies have shown that water, oil, and high temperatures can degrade allicin content (Singla). Interestingly powdered garlic is found to be the highest in allicin (Singla). Interestingly, powdered preparations of garlic for cooking were found to have a greater allicin content than nine supplement tablets studied (PDR). There are also pure allicin extracts available on the market for use.

Risks: Studies have demonstrated that allicin can inhibit platelet aggregation in blood and several cases of bleeding complications have been documented. All of which were following an invasive procedure (Fugh-Berman). Allicin may also increase production of insulin by pancreatic cells causing the potential for hypoglycemia in some patient populations. Allicin may also inhibit cholesterol synthesis in the liver causing exacerbation of developmental delay in children with low cholesterol levels. Physicians should use caution in patients with bleeding conditions, on blood thinners, with hypoglycemia, or diabetics who are insulin dependent. Cholesterol testing is advised for children with developmental disorders prior to supplementation with allicin.

Rationale:

Mild antifungal therapy when prescriptive agents are unavailable or contraindicated and where dosing by weight is required (such as for children). Promote the synergistic modulation of antifungal therapy with fluconazole.

Dosing:

Insufficient evidence exists in US literature for dosing recommendations, especially for children. However, there are several governing bodies outside of the US that regulate supplementation and provide a guideline for dosing. According to the National Center for Complementary and Alternative Medicine in the US, allicin is considered safe for most adults. Use of allicin for antifungal treatment may be appropriate in doses as high as one milligram per kilogram of body weight. Human studies have demonstrated that doses of allicin effectively potentiated the effects of antifungal treatment in doses of 7.8 - 27 mg per dose. The European Scientific Cooperative on Phytotherapy (ESCOP) recommends 3 to 5 milligrams allicin daily (1 clove or 0.5 to 1.0 gram dried powder) for the prevention of atherosclerosis. The World Health Organization (WHO) recommends 2 to 5 grams fresh garlic, 0.4 to 1.2 grams of dried powder, 2 to 5 milligrams oil, 300 to 1,000 milligrams of extract, or other formulations that are equal to 2 to 5 milligrams of allicin daily. The European Scientific Cooperative on Phytotherapy (ESCOP) recommends 2 to 4 grams of dried bulb or 2 to 4 milliliters of tincture (1:5 dilution in 45% ethanol), by mouth three times a day for upper respiratory tract infections.

MCT Oil/ Caprylic Acid/Monolauren/Coconut Oil

Evidence:

There are numerous in vitro and in vivo animal studies that demonstrate the effectiveness of coconut oil and/or its medium chain fatty acid constituents (Caprylic Acid, Capric Acid, and Lauric Acid) against Candida and other pathogens (Bergsson, Batovska, Huang, Dayrit). Human trials are much more limited. Therefore the evidence for treating yeast with this substance is based on the clinical observation of physicians who commonly treat yeast conditions. Physicians who routinely treat patients for Candida report very good success with using MCT oil/Caprylic acid. In his book, The Yeast Connection, Dr. Crook sites numerous examples of physicians who have reported this supplement as clinically useful (Crook).

Immunomodulating Properties: Like Omega-3 fatty acids, MCT's produce fewer inflammatory eicosanoids of the two- and four-series (Wan). Several in vivo studies have demonstrated anti-inflammatory properties of MCT oil and antipyretic and analgesic properties have also been documented (Canela, Intahphuak). In vivo MCTs may reduce intestinal injury and protect from hepatotoxicity which is a concern in patients taking fluconazole and itraconazole antifungal therapy (Berit, Kono). Human studies are few but promising as many of the studies are on severely immunocompromised patients who require total parernteral nutrition (TPN) and the HIV/AIDS patient population (Wanke, Dayrit, Craig, Wolfram, Chen). This patient population has responded well to the addition of MCT's. The degree to which these results apply to the general population is unclear. However, the safety of this supplement can be inferred given its effective use in severely immune compromised patient populations.

Risks: Acute toxicity tests conducted in several species of animal demonstrate that MCTs are essentially non-toxic. Ninety-day toxicity tests did not result in notable toxicity, whether the product was administered in the diet up to 9375mg/kg body weight/day or by intramuscular injection (up to 0. 5ml/kg/day, rabbits). Levels of up to 1g/kg/day have been confirmed safe in several clinical human trials (Traul). The use of MCT is only contraindicated in patients with impaired states of fat metabolism such as ketosis, acidosis, and cirrhosis (Bach).

Rationale:

Mild antifungal therapy when prescriptive agents are unavailable or contraindicated and where dosing by weight is required (such as for children).

Dosing:

Caprylic acid: PDR for nutritional supplements indicate dose as 300-1200 mg daily
Monolauren: 240 – 720 mg three times daily (adults)
Virgin coconut Oil: 2 ml/kg/day of virgin coconut oil in children
MCT: levels of up to 1g/kg/day have been confirmed safe in several clinical human trials.

Clinical References:

  • Bach, AC., Babayan, VK. (1982). Medium Chain Triglycerides: un update. American Journal of Clinical Nutrition, 36(5); 950-962
  • Batovska, D., et al. (2009). Antibacterial study of the medium chain fatty acids and their 1-monoglycerides: individual and synergistic relationships. Polish journal of Microbiology, 58(1); 43-7.
  • Bergsson, G., et al. (2001). In vitro killing of Candida albicans by fatty acids and monoglycerides. Antimicrobial Agents and Chemotherapy, 45(11); 3209-12.
  • Berit, M., Pfeuffer, M., Schrezenmeir, J., (2006). Medium Chain triglicerides. International Dairy Journal, 16(11) 1378-1382.
  • Borriello, S., et al. (2003). Saftey of Probiotics that Contain Lactobacilli or Bifidobacteria. Clinical Infectious Disease, 36(6); 775-780. Doi 10.1086/368080
  • Brzozowski, T., et al (2005). Influence of gastric colonization with Candida albicans on ulcer healing in rats: Effect of ranitidine, asprin and probiotic therapy. American Journal of Gastroenterology, 40(3); 286-296.
  • Canani, R., et al. (2007). Probiotics for treatment of acute diarrhea in children: randomized clinical trial of five different preparations. BMJ, 335-340. Doi 10.1136/bmj.39272.581736.55
  • Canela, GO., (2007). Anti-inflammatory activity of virgin coconut oil. The Philippine Journal of Internal Medicine, 45(2) 85-88.
  • Craig, GB., et al. (1997). Decreased fat and nitrogen losses in patients with AIDS receiving medium chain triglyceride-enriched formula vs those receiving long-chain-triglyceride containing formula. Journal of the American Dietetic Association, 97(6); 605-11.
  • Chen, FM., et al. (2005). Efficacy of medium-chain triglycerides compared with long-chain triglycerides in total parenteral nutrition in patients with digestive tract cancer undergoing surgery. The Kaohsiung Journal of Medical Sciences, 21(11); 487-94.
  • Crook, W. (2000). The Yeast Connection Handbook. Jackson, TN: Woman's Health Connection.
  • Davis, S. (2005). An overview of the antifungal properties of allicin and its breakdown products-the possibility of a safe and effective antifungal prophylactic. Mycoses, 48(2); 95-100. DOI: 10.1111/j.1439-0507.2004.01076.
  • Dayrit, C. (2000). Coconut oil in Health and Disease: Its and Monolauren's potential as cure for HIV/AIDS. Read at the XXXVII Cocotech Metting Chennai, India July 25, 2000. http://coconutresearchcenter.org/article10526.pdf
  • Fugh-Berman, A., (2000). Herbs and Dietary Supplements in the Prevention and Treatment of Cardiovascular Disease. Preventive Cardiology, 3(1); 24-32. Doi:10.1111/j.1520-037X.2000.80355.
  • Guo, N., Wu, X.,, et al. (2010). In vitro and in vivo interactions between fluconazole and allicin against clinical isolates of fluconazole-resistant Candida albicans determined by alternative methods. FEMS Immunology and Medical Microbiology, 58(2); 193-201. Doi: 10.1111/j.1574-695X.2009.00620.
  • Hatakka, K., et al. (2007). Probiotics Reduced the Prevalence of Oral Candida in the Elderly – a Randomized Controlled Trial. Journal of Dental Research, 86 (2); 125-130. doi: 10.1177/154405910708600204
  • Herbrecht, R., Nivoix, Y., (2005). Saccharomyces cervisiae Fungemia: an adverse effect of Saccharomyces boulardi probiotic Administration. Clinical Infectious Disease, 40(11); 1635-1637. Doi 10.1086/429926
  • Huang, CB., Alimova, Y., Myers, TM., Ebersole, JL. (2011). Short and medium chain fatty acids exhibit antimicrobial activity for oral microorganisms. Archives of Oral Biology, 56(7); 650-4.
  • Intahphuak, S. et al. (2010). Anti-inflammatory, analgesic, and antipyretic activities of virgin coconut oil. Pharmaceutical Biology, 48(2); 151-7.
  • Khodavandi, A., Alizadeh, F., et al. (2011). Comparison between efficacy of allicin and fluconazole against Candida albicans in vitro and in a systemic candidiasis mouse model. FEMS Microbiology Letters, 315. Kono, H., et al. (2003). Protective effects of medium-chain triglycerides on the liver and gut in rats administered endotoxin. Annals of Surgery, 237(2); 246-55.
  • Li, Qiurong., et al. (2014). Dysbiosis of Gut Fungal Microbiota is Associated with Mucosal Inflammation in chrohn's Disease. Journal of Clinical Gastrointerology, 48:513-523.
  • Maaroufi, Y., Heymans, C., De Rune, J., Duchateau, H. (2003). Rapid Detection of Candida albicans in Clinical Blood Samples by Using a TaqMan-Based PCR Assay. Journal of Clinical Microbiology, 41; 3293-3298.
  • Manzoni, P., et al. (2006). Oral Supplementation with Lactobacillus casei Subspecies rhamnosus Prevents Enteric Colonization by Candida Species in Preterm Neonates: a Randomized Study. Clinical Infectious Diseases, 42(12); 1735-1742. doi: 10.1086/504324
  • Munoz, P., et al. (2005). Saccharomyces cerevisiae fungemia: and emerging infectious disease. Clinical Infectious Disease, 40(11); 1625-34.
  • National Center for Complimentary and Alternative Medicine (NCCAM). Herbs at a Glance: Garlic. Retrieved on 3/3/2014 from http://nccam.nih.gov/health/garlic/ataglance.htm
  • Snydman, D. (2008). The Safety of Probiotics. Clinical Infectious Diseases, 46(2); S104-S111. Doi 10.1086/523331
  • Pappas, P., et al. (2004). Guidelines for Treatment of Candidiasis. Clinical Infectious Diseases. 38; 161-189
  • Shadkchan, Y., Shemesh, E., et al. (2004). Efficacy of allicin, the reactive molecule of garlic, in inhibiting Aspergillus spp. In vitro, and in a murine model of disseminated aspergillosis. Journal of Antimicrobial Chemotherapy, 53; 832-836. doi: 10.1093/jac/dkh174.
  • Shaw ,W., (2008) Biological Treatments for Autism and PDD. Publisher: Author.
  • Singla, V., Bhaskar, R, (2011). Garlic: a review. International Journal of Drug Formulation, 2. Retrieved from http://www.ordonearresearchlibrary.org/Data/pdfs/IJDFR80.pdf
  • Szajewska, H., Skorka, A., Dylag, M. (2006) Meta-analysis: Saccharomyces boulardii for treating acure diarrhea in children. Alimentary Pharmacology and Theraputics, 25(3); 257-264. Doi 10.1111/j.1365-2036.2006.03202.x
  • Szajewska, et al., (2006). Probiotics in Gastrointestinal Diseases in Children: Hard and Not-So-Hard Evidence of Efficacy. Journal of Pediatric Gastroenterology and Nutrition, 42(5); 454-475. Doi 10.1097/01.mpg.0000221913.88511.72
  • Wagner, D., et al. (2000). Effects of probiotic bacteria on humoral immunity to Candida albicans in immunodeficient bg/bg-nu/nu and bg/bg-nu/+ mice. Journal of Microbiology/Immunology, 17; 55-59. Pdf http://www.reviberoammicol.com/2000-17/055059.pdf
  • Traul, KA., Driedger A., Ingle DL., Nakhasi, D. (2000). Review of the toxicologic properties of medium-chain triglycerides. Food and Chemical Toxicology, 38(1), 79-98.
  • Wan, JM., TEO, TC., Babayan, VK., Blackburn GL. (1988). Invited Comment: lipids and the development of immune dysfunction and infection. Journal of Parenteral and Enteral Nutrition, 12(6 supplment); 43s-52s.
  • Wanke, CA., et al. (1996). A medium chain triglyceride-based diet in patients with HIV and chronic diarrhea reduces diarrhea and malabsorbtion: a prospective, controlled trial. Nutrition, 12(11-12); 766-71.
  • Wolfram, G., (1986). Medium Chain Triglicerides for Total Parenteral Nutrition. World Journal of Surgery, 10; 33-37.
  • Zwolinska, M., et al. (2009). Effect of Candida colonization on Human Ulcerative Colitis and the Healing of Inflammatory Changes of the Colon in the Experimental Model of Colitis Ulcerosa. Journal of Physiology and Pharmcology, 60(1); 107-108. Pdf http://jpp.krakow.pl/journal/archive/03_09/pdf/107_03_09_article.pdf
  • Zwolinska-Wcislo, M., et al. (2006). Are probiotics effective in the treatment of fungal colonization of the gastrointestinal tract? Eperimental and clinical studies. Journal of Physiology and Pharmcology, 57(9); 35-49. Pdf http://www.jpp.krakow.pl/journal/archive/11_06_s9/pdf/35_11_06_s9_article.pdf