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Introduction

Patients too are changing and becoming better informed about their diseases and possible therapeutic strategies. More and more they are looking to providers of "alternative" therapies, either as adjunctive treatment or to replace conventional medical therapy.

There are several non-antibiotic approaches to the treatment and prevention of infection. Phytomedicines (plant-based remedies in the form of teas, extracts and oils) are a multimillion dollar industry worldwide,¹ and many are targeted towards infectious diseases. Some of these remedies have been, or are being, studied in controlled clinical trials, although few good data currently exist. Nevertheless, it behoves the informed practitioner to be aware of some of the possibilities and the current status of research with these compounds.  

Useful bacteria

Women suffering recurrences of urinary tract infection have a urogenital flora depleted of lactobacilli.^2,3 Treatment with oestrogen supplementation can replace the lactobacillus biofilm and reduce the incidence of urinary tract infection.⁴ A lack of lactobacilli and overgrowth of anaerobes is a necessary precondition of bacterial vaginosis.⁵ Candida vaginitis is also associated with a lack of lactobacilli, usually induced by antimicrobial therapy. Lactobacilli are also susceptible to spermicidal preparations containing nonoxynol-9, which explains, at least in part, the increased incidence of urogenital infections seen in women who use such contraceptives.⁶

Lactobacilli have been used, with varying degrees of success, to prevent urinary tract infection in women,⁷ vulvovaginal candidosis^8,9 and bacterial vaginosis.⁹ Unfortunately, all the studies, while showing at least some benefit, suffered from either a lack of adequate controls or low numbers of compliant patients.

Questions still to be answered are how best to deliver lactobacilli and which species is best to use. Lactobacilli taken orally do not persist in the gut, so continuous dosing is required.¹⁰ Commercial pasteurised yoghurts contain no useful viable bacteria. Direct high-concentration intravaginal delivery appears to be the most useful technique in the prevention of urogenital infections, as indicated by two recent publications employing vaginal pessaries containing 10⁹ viable cells of Lactobacillus casei.^11,12 Limited studies suggest that L. acidophilus or L. casei appear to be equally effective.^9,11,12

Diarrhoea associated with Clostridium difficile (CDAD) may be difficult and expensive to treat, and relapse rates approximate 25% with a variety of different treatment regimens. Oral Lactobacillus GG has been used with success in the therapy of relapsing CDAD,¹³ and rectal administration of faecal enemas¹⁴ or pure cultures of a non-toxigenic strain of C.difficile¹⁵ has also been used in the treatment of difficult cases.

Lately the results of several clinical trials of the yeast Saccharomyces boulardii for the treatment of CDAD have been published. When swallowed, S. boulardii survives gastric acid, establishes itself in the intestinal tract and multiplies to high numbers. It is not inhibited by antibiotics and does not affect the normal flora significantly.¹⁶ S. boulardii is effective in preventing CDAD and in treating various types of infectious diarrhoea.^17,18 It may be that S. boulardii therapy becomes an essential component of primary therapy for CDAD, particularly given concern about the use of oral vancomycin and the emergence of vancomycin-resistant enterococci.  

Other examples of "natural" therapies

"Natural" therapies are viewed favourably by many patients, chiefly because they believe, often correctly, that they are associated with fewer detrimental effects than most antibiotics. Unfortunately, the medical profession has been slow to embrace natural therapies and good scientific data are lacking. For the few situations discussed here there may be an important role for these agents and, while the results of further trials are awaited, we think that judicious use of adjunctive or replacement natural therapy is easy to justify.  

References

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