Re: Re: Thrush / Fungal infections

[Guest guest]

Hi Guys,

Maybe I can help. At some point in our lives, most of us women have had a yeast infection. This is caused by Candida Albicans, the most common fungus that also causes thrush. It happens often when women are given antibiotics and other medications that throw off the body's natural balance. These medications are designed to kill off bacteria to ward off infections. Unfortunately, they also kill off the good bacteria which helps keep things running smoothly. All of my OB/GYN docs have told me to eat LIVE CULTURE yogurt when on antibiotics to ward off yeast infections. My children's pediatricians have always recommended yogurt when they prescribed antibiotics. When my father had cancer, he developed thrush because of the chemo During his 2nd round of therapy, he tried to eat yogurt everyday (when he could stomach food) and never developed thrush. Believe me guys, it works. The yogurt replaces the good bacteria and helps keep things in balance. When my ID doc put me on Bactrim, she prescribed that I eat a container of yogurt at least every other day. The only problem I had was when I was on vacation and I did NOT eat yogurt - I started getting an infection. Fortunately it was the beginning stages so when I returned home I went back to my normal routine and I haven't had any problems since.

Now, I am not a doctor and would not presume to give medical advice. However, eating a small container of yogurt every day or every other day can't hurt and might help - as long as you are not allergic to dairy. If I can treat something naturally instead of popping another pill, I'm all for it.

By the way, it must be live culture yogurt so read the lable carefully. Dannon makes a good one.

Hope this helps.

Judi

Re: Thrush / Fungal infections

Hi ,

Welcome to the group!

I never had thrush during the whole time that my CD4 count was in the double digits and I was having serious bouts of PCP. Then, years later when my CD4 count went above 300, I suddenly developed thrush. My throat was a mess. My doctor determined that it was being caused by the Rhinocort nasal spray that I had started using a few months prior. So I think there is a very good possibility that your thrush could have something to do with the steroid inhaler you were using.

Glenn

Hi everyone! After some time trying to find a group like this I finally succeeded! I am a farily recent HIV + individual (a year) and the only problems I have developed is Thrush / Candidas. I have been battling through it for about four months and right now am just about symptom free. I went through my doc prescribing different meds specifically for it only to realie they work only while I'm on them. As soon as I was off an anti-fungal med the thrush was returning within days. Then I discovered the benefits of proper diet and cut out sugar, yeast breads, dairy, etc. I also tried different herbal remedies and stopped taking any prescribed anti-fungal meds. However, even though the oral thrush is gone I still had a case of jock itch that seemd to almost turn worse. Through the fungal battle I also developed an ear infection. The first battle in the Candidas war with an ear infection was won with ear drops that contained a fairly hefty steroid. Again, they worked, but within a couple months the ear infection returned. During this time is when, through my own research, I discovered that steroid content can actually trigger a fungal inbalance. (even in people with non-compromised immune systems). My doc suspects that the Advair medication I was on for Asthma MAY have done just that because it has a farily heavy steroid in it. My doc prescribed another ear drop WITHOUT a steroid and only an anti-biotic. He didn't seem to think the anti-biotic content of these would cause a problem even though my research has shown anti-biotics may trigger a fungal attack as well. He also prescribed a topical cream for my jock itch with an anti-fungal agent and a mild steroid. I have been on both for only two days and BOTH symptoms are almost gone already. My questions are : Has anyone had similar problems and if so how they resolved them? Also, what is the current situation with anti-biotics and HIV and/or Fungal infection recurrence? Will this new ear drop trigger a Thrush attack again? If anybody would like my personal experiences for getting rid of Thrush I would be more than happy to share them. I should mention the diet seemed to have a side benefit of clearing my Asthma! I have not had an attack in over two months and have not used ANY kind of inhaler. Even though I still carry the old elbuterol around with me. Thanks! This looks like a great group. I'm looking forward to beneficial exchanges.

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[Guest guest]

Judi wrote about yogurt which contains some acidophilus and bifidus

bacteria that can help repopulate the gut. Great idea! Try to get a good

variety. You can also consider supplements, which may help.

In addition, avoiding sugars (even fruit juices) for a week or two can

help slow things down. Fermented stuff, beer, yeast, all help the candida

survive. Others also tried tea tree oil--smells like turpentine. Put a

couple drops in a glass of water, gargle (don't swallow).

Lark Lands has a good (somewhat old) monograph on candidiasis that I

append below. See also

http://www.larrylands.com/lark/larktreatments.htm

M.

**

~ Treatments for Candida

~

Candida is the yeast-like fungus that causes most cases of thrush, esophagitis, anal itching, and vaginitis in HIV+'s. Although Candida albicans is the most common cause of such symptoms, other strains of Candida also occur. Candida overgrowth is a significant problem for a large percentage of those living with this disease. It is, in fact, the most common fungal infection in people living with HIV. Research has shown that long-term Candida overgrowth is a significant cause of intestinal damage and subsequent absorption uptake block in those living with HIV. This sort of damage is a major cause of nutrient deficiencies. The development of thrush is also thought to be an indication of declining immune function even when CD4 counts remain in higher ranges. Because controlling this infection is very important, and too often underemphasized by physicians, it is important to note that multiple approaches may be necessary for complete suppression of this overgrowth.

The particular types of Candida problems that occur tend to be a reflection of CD4 counts. The Candida problem that occurs at the highest level of CD4s is vaginal candidiasis, or as it is more commonly called, a yeast infection. This can cause raised gray and white patches on the vagina, as well as external itching and burning around the genital area, vaginal soreness, painful urination (itching or burning feelings during urination or a feeling that it is difficult to urinate), pain during intercourse, and a creamy white or yellow, cottage cheese-like discharge. These symptoms may sometimes be accompanied by anal itching when the Candida overgrowth is also present in the intestines.

Even if these symptoms are not present, Abner Korn, M.D., and Landers, M.D., of the University of California at San Francisco, have suggested treatment if there is a combination of a Pap smear that is positive for a yeast species with vaginal inflammation that can be seen with close observation. As reported by BETA, they feel that allowing the inflammation to continue could lead to mucosal breaks and increase the woman's susceptibility to many different pathogens (as well as increasing HIV shedding and increasing the risk of transmission). Many physicians treat recurrent vaginal yeast overgrowth with vaginal suppositories or creams only. Although the suppositories or creams often work to eliminate the vaginal overgrowth, when there is significant recurrence or treatment failure, it may be necessary to use a systemic agent such as fluconazole or itraconazole. However, due to the problems with development of resistance to these drugs, it is not recommended that they be used long-term or prophylactically.

I would strongly consider at least adding some of the non-pharmaceutical therapeutics (notably acidophilus) to suppress the overgrowth throughout the body and help to put the system back in balance, lessening the likelihood of recurrence. If there are signs of Candida overgrowth throughout the body, a short course of one of the systemic antifungals may be advisable to help the body get the Candida under control. For recurrent, severe vaginal candidiasis, the CDC currently recommends ketoconazole, 100 mg daily, for six months. The reasoning is that resistance to ketoconazole usually develops more slowly than is the case with the triazole drugs (fluconazole and itraconazole). However, it definitely does not work as well as the triazoles. Short courses of the triazoles have not generally been seen to be related to development of resistance and may be the better approach. In The Gynecological Care Manual for HIV Positive Women, Risa Denenberg, FNP, recommends using either ketoconazole, 200 mg per day, continued for two weeks, or fluconazole, 100 mg per day, continued for one to two weeks. The current FDA-approved oral therapy for vaginal candidiasis is a single dose of fluconazole, 200 mg. Another similar (but not FDA-approved) possibility is the use of itraconazole, 200 mg, once daily for three days. Although either of these may work in some HIV+ women, they may be insufficient for many, especially if they have recurrent or refractory problems. In some women, Candida infections may not be merely recurrent (occurring again within 8 weeks of treatment), but rather may become chronic (you just can't get rid of it). When this occurs, initial systemic treatment with one of the better drugs (fluconazole or itraconazole), followed by use of the non-pharmaceutical agents discussed below (oregano extract, grapefruit seed extract, garlic, acidophilus, etc.) for maintenance is advisable. [For additional information on these drugs, see the separate listings, below.]

Also, be aware that many factors can increase the likelihood of vaginal yeast infections occurring. Included are wearing pantyhose (if you must, stick with the kind that have the cotton crotch or cut the crotch out completely), wearing nylon underpants (stick with cotton), wearing tight pants (your body needs to breathe; don't bind it up), leaving a nylon or other synthetic swimsuit on for a length of time after swimming, using chemical douches or vaginal sprays ( " feminine hygiene, " indeed; women are just fine the way they are, thank you very much), or introducing fecal material into the vagina (either by sexual practices or improper wiping after using the bathroom; you should wipe from front to back). Last but definitely not least, taking broad-spectrum antibiotics will greatly increase the risk that a yeast infection will occur. Any time you must take antibiotics, make sure you're doing a number of the non-pharmaceutical approaches discussed below to try to prevent this problem. This includes eating yogurt, taking acidophilus, and using the oregano or grapefruit seed extracts, along with plenty of garlic in the diet. If these can prevent a yeast infection, then you won't have to go through another miserable treatment go-round.

The most easily observed manifestation of Candida is the thick white coating on the tongue called thrush. This is a fairly common condition in those with CD4 counts below 200 but may occur at higher counts. In those with lower CD4 counts, this often extends down into the esophagus, where it is called esophageal candidiasis. This can cause pain on swallowing or an uncomfortable feeling of choking. In some cases, esophageal candidiasis can result in constant hiccuping, a condition which can be devastating when it prevents eating or sleeping. Many physicians treat thrush or esophageal candidiasis locally with clotrimazole lozenges (Mycelex troches; a troche is a lozenge) or the use of " swish and swallow " suspensions of either ketoconazole or itraconazole. Although the lozenges or suspensions may work to temporarily eliminate the thrush from the mouth and esophagus, it frequently recurs. In many cases, the obvious symptoms are an indicator that there may be more widespread overgrowth throughout the digestive tract. In such cases, it may be preferable to treat with a systemic agent (fluconazole or itraconazole) first in order to really suppress candida overgrowth throughout the digestive tract. Then the local agents can be used, when necessary, for maintenance. When esophageal candidiasis is causing hiccuping or a feeling of choking during eating, it is very important to treat it aggressively, using a combination of a systemic drug with a " swish and swallow " suspension that is gargled and swallowed. Recipes for itraconazole and ketoconazole suspensions are given under those drug entries below.

Left unchecked, candida overgrowth can become systemic and could be fatal, although this is rare. Nonetheless, any indication of candida should be taken very seriously and treated comprehensively. Besides the white coating on the tongue, pain on swallowing or choking feeling, or vaginal itching and white discharge, other symptoms include excessive gas or belching after sugars or starches are eaten (including sweets and fruits or fruit juices). This is because simple sugars are a source of food for the yeast and stimulate their activity and growth, resulting in the excess gas formation. Alternating constipation and diarrhea can also be symptoms, as can diarrhea alone. A bloated feeling after eating carbohydrates is also indicative, as is anal itching. Candida can also cause sinus problems and constant runny nose, skin rashes, body aches and pains, headaches, and emotional problems (due to its effects on the nervous system). A sample of the vaginal discharge or mouth coating can be taken for laboratory analysis with a microscope. With vaginal discharges, it is important that other causes also be considered, including chlamydia.

A basic step that may help eliminate a yeast infection is to quit feeding the yeast as much as possible. Research has shown that sugar stimulates the growth of yeast in the body, from the mouth to the intestines. In a study with yeast-infected mice, it was shown that those fed water containing sugar had greatly increased amounts of yeast in their stools compared to mice fed either water containing a sugar substitute (xylitol) or water with no sweetener at all. When the mice were given chemotherapy to suppress their immune systems, the amount of yeast in the stool samples of the mice fed the sugar water dramatically escalated. The level of yeast from the other groups of non-sugar-fed mice remained stable. Eighty percent of the mice who had been fed the sugar water had detectable yeast in the intestines, whereas 90% of the mice fed either the sugar substitute or no sweetener at all had either no detectable yeast or only minor amounts. The difference between the sugar-fed group and the other groups was highly statistically significant. The researchers also showed that the intestines of the mice who had been fed the sugar had yeast that was able to penetrate the intestines and enter their bodies. This can hardly be considered unimportant. Regularly taking in a substance that encourages the growth of these fungal organisms is certainly not conducive to eliminating fungal overgrowth problems. Eliminating sugar from the diet, along with all the countless foods that contain it, may be one of the most important measures that people with candida overgrowth problems should adopt.

This means temporarily eliminating all simple sugars from the diet, including all foods made with sugar and even natural sweeteners, fruit, and fruit juice. The diet should emphasize vegetables and protein with moderate amounts of fat and a sufficient amount of complex carbohydrates (such as brown rice or whole grains) to avoid weight loss. The idea is to starve the yeast as much as possible while at the same time you take the substances that will help to destroy them. Yeasts' favorite food is simple sugar. In fact, if you want to culture it in the lab (or the brewery), that's what you give it. By taking this food away from it, you help to slow its growth while you also take the therapeutics that destroy it. And, yes, complex carbohydrates do eventually break down into simple sugars but they do so farther down in the digestive tract where the body has better controls against candida growth. By avoiding the simple sugars you definitely avoid feeding the yeast in the mouth and esophageal area where it so often grows. And, apparently, based on the mouse study, you also discourage yeast growth in the intestines. It is, thus, very useful to make these dietary changes while you take the antifungals or other therapeutic agents. However, it is very important to only use this suggested diet for a relatively short period (no more than 2-3 weeks) during the beginning of your yeast therapy program. Withholding fruits and fruit juices long-term is not healthful and not necessary, although abstaining from sugar and foods made with it is an excellent long-term suggestion. [For a discussion of all the adverse consequences of sugar use, see Chapter Three.]

It is also a very good idea to make sure that your transit time (the time it takes your food to be digested and eliminated) is normal. A too-slow transit time, and the intestinal conditions that result from that, can encourage yeast overgrowth. Ideally, transit time should be 1218 hours. You can test this by swallowing charcoal tablets (20 or so), available at most pharmacies as a treatment for intestinal gas, and counting how many hours it takes for them to appear in your stool (trust me; you'll notice this black mass; just don't scare yourself by forgetting you took the charcoal). If the total transit time is over 18 hours, you probably need to look at the fiber content of your diet (from whole grains, fruits, and vegetables) to see if it needs to be increased and/or consider the possibility of a magnesium deficiency which also causes slowed transit time and constipation.

Treatment with antifungal agents combined with repopulation of the intestines with acidophilus and other needed microorganisms is the most effective way to suppress candida overgrowth and prevent the damage it can cause. Candida is present in many HIV+'s in whom the problem remains unrecognized. Because it can present such a danger, especially if undiagnosed over a long period of time, I would recommend that all HIV+'s consider the possibilities for overgrowth and, if discovered, use appropriate measures to counter the problem. Regardless of the therapy used, it is important to know that what is called a Herxheimer reaction may occur during the first few days of treatment when the candida begin to die off in large quantities and start releasing into the body their toxins. The result can be unpleasant symptoms of nausea, fatigue, headaches, fever, diarrhea, and a general feeling of illness. Some people mistake such symptoms for signs of drug toxicity and abandon the treatment when this is really just a sign that it is working. This is obviously a mistake so forewarned is forearmed. Understand that this may happen and don't panic. There are several things that may help reduce the symptoms. Pantetheine, the active coenzyme form of pantothenic acid, a B vitamin, can help the body to deal with these reactions. Pantetheine induces the production of aldehyde dehydrogenase which, in turn, breaks down acetaldehyde and formaldehyde. It works very well in alleviating such Herxheimer reactions. Vitamin C can also help the body to deal with this toxins and, thus, lessen symptoms. Drinking large quantities of water will also help the body flush out the toxins more quickly. Generally, symptoms caused by a Herxheimer reaction will fade away within a few days, in any case, but doing these things may help prevent what is often otherwise an unpleasant period.

Of the pharmaceutical agents discussed below, fluconazole and itraconazole are clearly the most effective agents for suppression of Candida overgrowth and would be considered the first-line therapy by most. However, be cautious about long-term use of any of the azoles (fluconazole, itraconazole, or ketoconazole) because of the danger of developing resistance (discussed below). Longterm daily usage of nontoxic substances like grapefruit seed extract, oregano extract, acidophilus, garlic, and the others discussed below are preferable for prevention, if satisfactory results can be obtained with them. Long-term use of acidophilus is particularly important. The pharmaceutical agents are discussed first here; the biological agents are in the second section.

~ Topical Treatments ~

Clotrimazole and miconazole are both azole drugs belonging to the imidazole class. Clotrimazole is found in the lozenges used for thrush (Mycelex troches), in several different kinds of antifungal lotions and creams (Lotrimin, Mycelex), and in vaginal tablets and creams used to treat vaginal yeast infections (Mycelex and Gyne-Lotrimin). Miconazole is found in vaginal suppositories used to treat vaginal yeast and in antifungal cream (both under the brand name of Monistat). As discussed above, although effective against yeast overgrowth in the oral cavity, using the Mycelex troches alone may not suffice as a treatment for either thrush or esophageal candidiasis. The occurrence of these conditions is often an indicator of widespread candida overgrowth that should be more aggressively addressed. At least, the addition of acidophilus supplements and, perhaps, some combination of garlic, oregano extract, and grapefruit seed extract (or the other non-pharmaceutical agents discussed below) to an antifungal program should be automatic. In addition, it may be wise to treat such overgrowth with a short-term course of fluconazole or itraconazole to help fully suppress the overgrowth and, thus, help prevent recurrence.

For women with vaginal yeast problems, it has been shown that clotrimazole or miconazole vaginal suppositories or creams or tablets are very effective at eliminating the yeast infections, but the effect is often temporary. There is a high rate of recurrence of yeast overgrowth in the vagina in HIV+ women. Thus, again, combining use of the vaginal treatment with, in serious cases, a short course of systemic treatment with either fluconazole or itraconazole and, of course, long-term use of acidophilus supplements and the other non-pharmaceutical agents may substantially improve the chances of long-term yeast overgrowth suppression. The usual treatment is nightly use of the regular-strength antifungal intravaginal creams or suppositories for seven consecutive nights.

With any use of the vaginal creams or suppositories, the complete course of treatment recommended should be carried out, regardless of whether symptoms have already subsided. In other words, if the directions say to use one dose every night for seven nights, do that even if the itching and discharge have already ended by the third or fourth day. This will help prevent recurrence. Also note that for women with more suppressed immune function, it may be necessary to extend the course of treatment beyond the time period suggested in the standard instructions on the product label. If you don't get results with the standard course of treatment, consult your physician for advice on continuing for a lengthier period. Also consider the use of one of the systemic drugs to help ensure success. Most insurance will not cover these over-the-counter agents. If this is a problem, there are three prescription drugs that can be used instead: butoconazole (Femstat), terconazole (Terazol), and a prescription version of Monistat called Monistat DS. The latter is a double-strength formula usually only used once nightly for three consecutive nights.

~ D0870 ~

D0870 is a new oral drug being investigated in Europe as a treatment for fluconazole-resistant candidiasis. In the small study initially done, approximately one-half of those with fluconazole-resistant candida problems did get some improvement from the drug. However, the only two people who had complete disappearance of signs and symptoms of candidiasis turned out to have organisms that were not resistant to fluconazole. Thus, the drug may provide some benefit but is probably not going to be a big breakthrough. Side effects were minimal, with only a few cases of headaches and dizziness in study participants.

~ Fluconazole (Diflucan) ~

Fluconazole is probably the most effective antifungal available today and has been specifically shown to be effective against the five most common strains of candida, including two that in the past were considered treatment-resistant. A study that compared the effectiveness of ketoconazole to fluconazole showed significantly better results with fluconazole. All studies done to date have shown very high levels of effectiveness using fluconazole against candida overgrowth. This drug can be taken orally and is easily absorbed. Side effects can include nausea, vomiting, bloating, headaches, abdominal pain, diarrhea, liver dysfunction, and skin rash, but these appear in only a small percentage of users. With higher dosages (400 mg/day) which are continued for three or more months, hair loss is not uncommon. Hair loss from the scalp is most common but may also occur on the legs, face, and pubic area. The hair will usually re-grow when the drug is either discontinued or the dosage is decreased by at least half. Fluconazole is very expensive but is available by prescription and should be covered by insurance or other drug assistance programs. If you are taking fluconazole, you are warned not to use any other azoles, including ketoconazole, itraconazole, or clotrimazole (Mycelex troches). The combination could increase the chances of liver toxicity.

With long-term use, resistance to fluconazole can develop, most often in those with CD4s below 50. Studies have shown that in those receiving intermittent treatment, fungi tend to remain fluconazole-sensitive, whereas in those with a past history of long-term continuous treatment, a large percentage of fungal organisms may become fluconazole-resistant. Thus, it is desirable to treat overgrowth for a relatively brief period of time, only until symptoms are gone. Then attempt to repopulate the intestines with acidophilus and the other " good " bacteria that will block candida overgrowth in the future. This is far safer than long-term use of any of the triazoles because of the danger of resistance developing and making these drugs un-usable for some future serious infection. Note that cimetidine and rifampin can both lower fluconazole levels in the bloodstream so use of these is inadvisable during treatment with it. If there is a necessity for the use of either of these drugs, higher doses of fluconazole may be required. For candida overgrowth, a loading dose of 200 mg/day of fluconazole is generally given the first day, followed by use of 100 mg/day for 2-3 weeks. There are occasions when higher doses, up to 200 mg, twice per day, are required to fully eliminate candida overgrowth. When even the higher doses are ineffective, resistance should be presumed and other approaches tried (See Itraconazole, below). With some cases of vaginal yeast infections, it is possible to use a single dose of fluconazole, followed by the other supportive, non-drug therapies discussed here. However, for many women living with HIV a longer course of therapy will be required.

An oral suspension of fluconazole is also available. A comparison study has shown that it is far superior to mycostatin (Nystatin) oral liquid for oral or pharyngeal candidiasis. The dosage is 100 mg daily for 14 days.

~ Itraconazole (Sporanox) ~

Itraconazole is similar to fluconazole but may be an effective alternative with fluconazole-resistant organisms. It has a broader spectrum of effectiveness but has several drawbacks. It must be taken with food or acidic drinks because it requires an acidic environment for absorption. It has been shown to be absorbed far less well in HIV+'s than in the HIV-negative, most likely because of the decrease in hydrochloric acid production that is common to this population. Absorption is also adversely affected by antacids, anticonvulsants, and rifampin. There is potential cardiac toxicity if itraconazole is combined with either Hismanal or Seldane, common antihistamines, so these, too, should be avoided during treatment. It can also cause nausea, vomiting, diarrhea, rashes, itchiness, headaches, hypertension, edema, fever, and fatigue. The usual dosage is 100 mg, twice per day, continued until signs of overgrowth disappear. If this dosage is not effective, it may be increased to doses as high as 300 mg, twice per day. This high-end dosage should not be used for more than a week.

For those with esophageal candidiasis or thrush, itraconazole can be mixed into a suspension and then used as a " swish and swallow " solution. Any pharmacist can prepare this solution, the recipe for which is as follows:

To make 480 ml (one pint) of 100 mg/15 ml suspension, dissolve 32 itraconazole capsules in 5-10 ml of 1.0N HCl; add 1.0 gm of methylcellulose, 0.5 gm of Nutrasweet, 0.5 gm of citric acid, 14 ml of tutti fruiti flavoring, and enough preserved water to increase to a total amount of 480 ml. The solution must be refrigerated and will have a 3-month expiration. To use, shake well and then gargle one tablespoon for several minutes, swallowing the liquid at the end. Repeat four times each day.

A new cyclodextrin oral solution formulation of itraconazole (ITRA-OS) has been shown to be effective in two-thirds of those with either oral or esophageal candida that had been refractory to treatment with the standard oral forms of itraconazole, fluconazole, or ketoconazole. In those who have not developed fluconazole resistance, it works as well as or better than fluconazole. The recommended dosage is 100-200 mg, given once daily for 14 days.

~ Ketoconazole (Nizoral) ~

Ketoconazole is an older drug that was once used more widely for nystatin-resistant candida problems but is now generally considered more toxic and less effective than either fluconazole or itraconazole. For those with limited incomes or no health coverage, ketoconazole has the advantage of being significantly less expensive. The usual dosage is 200-400 mg/day. Because of the potential for developing resistance, usage should generally be short-term. However, resistance usually develops more slowly to ketoconazole than to fluconazole or itraconazole.

Ketoconazole's best remaining use may be as part of a " swish and swallow " solution for those with esophageal candidiasis or thrush. Any pharmacist can prepare this solution, the recipe for which is as follows:

To make 480 ml (one pint) of ketoconazole suspension, dissolve 24 ketoconazole tablets (4.8 gm) in propylene glycol; all 2.4 gm of methylcellulose, 1.0 gm of Nutrasweet, 0.48 gm of citric acid, 14.4 ml of tutti fruiti flavoring, and enough preserved water to make up a total of 480 ml. The solution should be refrigerated and has a 3-month expiration. To use, shake well and then gargle one tablespoon for several minutes, swallowing the liquid at the end. Repeat four times each day.

Ketoconazole is particularly toxic to the liver and any long-term use should be accompanied by monitoring of liver enzymes. It can also cause gynecomastia (increased breast size in men), decreased testosterone synthesis (which could cause decreased libido, lean tissue loss, fatigue, and depression in men and might also be problematic for women), decreased corticosteroid synthesis (which could cause reversible adrenal insufficiency), nausea, vomiting, abdominal pain, itching, headaches, dizziness, photophobia, and decreased sensation. Because of the frequency of adrenal insufficiency in later stages of HIV infection, ketoconazole is particularly problematic in this regard. (For physicians who doubt the importance of this, it should be noted that ketoconazole is actually prescribed to treat over-production of adrenal hormones.) It should also be noted that ketoconazole requires an acidic environment for absorption. Thus, the decrease in hydrochloric acid production that is common to this population can adversely affect absorption as can antacids, anticonvulsants, rifampin, and INH. There is potential cardiac toxicity if ketoconazole is combined with either Hismanal or Seldane, common antihistamines, so these, too, should be avoided during treatment.

~ Mycostatin (Nystatin) ~

Nystatin is an older drug that is often prescribed for candida overgrowth but because it has been so long in use, it is thought that much candida may be resistant to it. However, it is far less expensive than fluconazole and may be worth an initial try. It is also thought to be more effective in the lower intestine than the other antifungals so may be particularly useful for those with anal itching. Because candida has a tendency to mutate quickly into forms that are resistant to the drugs currently being used against it, there are increasing instances of resistance to fluconazole, the current drug of choice, and the other azoles. Interestingly, in some people in whom both fluconazole and itraconazole had been unable to suppress thrush, Nystatin has worked. One of my clients who is a television actor had been so worried about the thrush on his tongue becoming visible in closeups that he'd been bombarding his body with extremely high doses of first fluconazole and then itraconazole, all to no avail. Only when he switched to Nystatin did it finally vanish. He's generally able to prevent overgrowth now with the combination of several of the non-drug agents discussed below, along with plenty of acidophilus, but he keeps Nystatin on hand in case of any flareups. It may be that in some cases the candida is mutating into forms that are no longer susceptible to the azoles but are again susceptible to this older drug. In any case, it's worth a try if the others don't work.

In addition to all the pharmaceuticals now in use as antifungals, there are a number of natural products that also work effectively as anti-candida agents. Some of these, like the grapefruit seed and oregano extracts, are very powerful and may be able to serve as the major antifungal agent in some people's programs. Others, like garlic and ginger and various teas such as mathake and Pau D'Arco, are probably not powerful enough to serve as the major therapeutic agent, but may well help ensure the success of the total anti-candida approach. They may also work well as maintenance agents, which would be immensely helpful since resistance to the major antifungal drugs is known to develop rather quickly with long-term use. Most cutting-edge physicians now prefer avoiding such long-term use of the azole drugs (fluconazole, itraconazole, ketoconazole), as much as possible, reserving them as effective treatment agents, when necessary. Thus, using garlic in your food and frequent cups of ginger, mathake, or Pau D'arco tea, along with the acidophilus supplements, may help to prevent recurrence of problems after the more powerful agents used initially have wiped out the major overgrowth. In addition, for those in whom resistance to the major drugs such as fluconazole, itraconazole, clotrimazole, or Nystatin has already become a problem, these lesser used agents may provide an alternative to which candida is less likely to have developed resistance. The grapefruit seed, oregano, and caprylic acid products work throughout the intestinal tract and have provided relief to many. The sorbic acid products seem to have worked very well in many people with resistant thrush problems.

~ Acidophilus ~

Regardless of the antifungal therapy you use, taking acidophilus and other probiotic organisms is a cornerstone of any approach to keeping candida suppressed. The best probiotic supplements will supply a number of different microorganisms to repopulate the intestines with the good bacteria needed for health and, in particular, to keep candida in check. The naturally occurring intestinal microorganisms that normally suppress candida are often deficient in people living with HIV, particularly in those who have had repeated rounds of antibiotics or are using prophylactics. Supplements containing acidophilus and other microorganisms can help to prevent candida overgrowth and the digestive malfunction caused by it. We have long known that the good bacteria both directly attack yeast and produce chemicals such as lactic acid which suppress its growth. It now appears that these probiotic organisms also produce antifungal substances that actually help destroy candida. Two to four capsules or around 1/2 teaspoon of such supplements should be taken a half hour or so prior to meals for a period of a month or so to help re-establish a proper balance of flora in the intestines. Then 1-2 capsules should be taken before each meal long-term as maintenance. It is important to use brands from companies that guarantee the viability of their organisms. Because many people living with HIV are lactose-intolerant, it is probably wise to stick with the brands that are lactose-free. For a more complete discussion of probiotic organisms, see Chapter Six.

~ Ascorbic Acid Therapy ~

Tissue saturation doses of ascorbic acid (vitamin C) can be very useful as part of a candida elimination program. Ascorbic acid both works as an antifungal and helps your intestines to repair themselves from the damage caused by the candida infection. Taking it in sufficient levels can definitely add to the overall success of any antifungal approach. [see Chapter Six for details.]

~ Beta-Carotene ~

A very interesting study carried out at the Albert Einstein College of Medicine in New York showed that the beta-carotene levels in the vaginal cells of 22 women with vaginal candidiasis were significantly reduced when compared to the cells of women not suffering from the candida overgrowth. It is theorized that reduced beta-carotene levels (perhaps along with lower levels of other antioxidants since diets low in beta-carotene would be likely to be low in other antioxidant nutrients also) may adversely effect the local immune response in the vagina, resulting in altered vaginal flora and candida overgrowth. It is, thus, possible that increased intake of carotenoid-rich foods (carrots, dark green leafy vegetables, squashes, apricots, peaches, and virtually any other orange, yellow, or dark green fruit or vegetable) might help prevent recurrent vaginal candidiasis, and possibly other kinds of candida overgrowth, as well.

~ Caprylic Acid ~

Caprylic acid products are derived from coconut oil. They have long been used successfully as natural anti-fungal agents and have no toxicity but, over time, they sometimes lose their effectiveness. They may be quite helpful, however, as part of a comprehensive program. In particular, with the growing presence of candida that has become resistant to commonly used therapeutic agents, adding another possible antifungal to the treatment repertoire is useful. The usual recommended dosage for caprylic acid is three capsules, taken three times per day on an empty stomach, until the overgrowth is eliminated.

~ Garlic ~

Garlic is another natural yeast suppressor. Even one high-garlic meal (6-8 whole cloves chopped into your pasta sauce) can dramatically reduce candida overgrowth in both the intestinal tract and vaginal area. Thus, adding a lot of fresh or sauteed garlic to salads or vegetables or grain dishes or soups or sauces can be both tasty and healing. Using a lot of garlic in at least one meal every day can do a lot to keep candida overgrowth suppressed and prevent flare-ups of vaginal or intestinal tract yeast. If you prefer to avoid the smell of the garlic, the deodorized encapsulated versions such as Kyolic may provide some benefit, although the concentrated amount of the healing ingredient in garlic is much lower in such preparations. [see Chapter Six for details on the use of garlic.]

~ Ginger Tea ~

Ginger tea can also be very helpful for candida and has the added bonus of being an immune system stimulant. Ginger is sold in powdered form in many health food stores but I think the best tea is made from fresh ginger root. You can just slice a tablespoon or two of the fresh ginger root into boiling water and them simmer it for a few minutes. It creates a hot, spicy tea so you may find that you will have to dilute it with a milder herbal tea, at least until you become accustomed to it. You can drink it warm or cold.

~ Grapefruit Seed Extract ~

Grapefruit seed extract, found in numerous over-the-counter products (Paracan144, Para-Myc, Nutri-Biotic, Citricidal, etc.) from a number of companies, is very effective against candida. It is a broadspectrum antimicrobial agent that has been used in the past as a preservative and antiseptic. It is not absorbed from the intestinal tract and has shown no toxicity except for a concentrationdependent local irritant effect. However, anyone allergic to citrus fruit may not be able to use it, for obvious reasons. It is usually best to use it in relatively large doses for a limited period of time (three capsules with each meal for 3-4 weeks), followed by smaller amounts for maintenance, if necessary to prevent recurrent candida. It also comes in liquid form with which the recommended dose is six drops in at least four ounces of water, swished around in the mouth for 3060 seconds and then swallowed, 23 times per day. It absolutely must be well diluted (using eight ounces of water may be advisable for some people) because the straight preparation is very irritating to the mucous membranes. It has a bitter taste which can be covered up by diluting it in vegetable juice. The liquid form may be more effective at eliminating thrush than the encapsulated form.

Leo Galland, M.D., a physician practicing in New York City, has reported excellent results using this product for both chronic candidiasis and parasite infestation. He says that it is just as effective as nystatin and the caprylic acid products. He believes that for many drugsensitive and chemically hypersensitive people it is the treatment of choice, being much better tolerated than other antifungal preparations in such individuals. He says that for severe candida infections it may be advisable to use it for several months. Some HIV+'s with recurring candida problems have used it for more than a year without any toxicity or development of any resistance. Dr. Galland believes that it works in an additive fashion with other antifungals. Because of the mounting evidence for development of azole-resistant organisms with long-term use of fluconazole, itraconazole, or ketoconazole, use of a non-toxic substance that works in a simpler way to suppress candida seems advisable, at least for maintenance. Many people have found that the combination of the grapefruit seed extract with daily use of acidophilus, as described below, is very effective in suppressing candida overgrowth and maintaining intestinal balance.

~ Mathake Tea ~

Another effective over-the-counter treatment is an herbal remedy called Mathake (Terminalia catappa). The bark and leaves of Mathake, when infused in hot water, make a hot tea that has proven to be effective against yeasts, molds, bacteria, and other microbes. It has been used as an antifungal agent in the South Seas for hundreds of years. It is effective in both oral and topical forms. It is not yet widely available but is being imported by Cardiovascular Research and so can be found wherever their products are sold. One tea bag will make three cups of tea and it is recommended that 2-3 cups per day be drunk for best effect.

~ Oregano Extract ~

An extract of oregano has been found to have both antibacterial and antifungal effects against a broad spectrum of pathogens. It appears to be particularly useful against Candida albicans. In addition, the oregano extract appears to have significant anti-inflammatory effects. In a clinical trial with HIV-negative people suffering from candida overgrowth (as evidenced by stool, vaginal, and throat cultures), oregano extract was shown to dramatically decrease the overgrowth. Prior to the treatment, all ten people had either moderate (2+), severe (3+), or maximal (4+) candida growth on cultures. Six out of ten had maximal (4+) growth on both stool and throat cultures. After only four weeks of treatment (one tablet given four times per day after meals, for the first week; followed by two tablets given four times per day after meals for the last three weeks), 6 people's lab cultures showed no remaining candida and three people had a 50% or greater reduction in their counts. Only one person showed no change. All those in the study reported symptomatic improvement, including improved energy, increased appetites, and lessened insomnia. One of the participants had had an eight-year history of well-documented chronic fatigue syndrome and was able to go back to work after a long absence.

The results were particularly impressive since the participants were asked to not use any other antifungals of any kind (including topical ones such as vaginal suppositories) and to make no dietary changes of the sort often used by those on anti-candida programs. Thus, it was clear that the results were solely based on the use of the oregano extract. There were no side effects reported of any kind. Interestingly, because oregano has been so long used in human populations as an herbal addition to food, it is thought that it will probably have little if any destructive effect on the probiotic intestinal organisms needed for health since they have probably long since adapted to it. In other words, the researchers think that, even with its apparently broad spectrum effects, it probably won't kill off the intestinal bacteria needed for the control of candida and other pathogens the way other broad-spectrum antimicrobial agents do. Nonetheless, until this is definitively shown, it would probably be wise to use acidophilus and other probiotics supplements during any use of this product. All in all, considering the widespread nature of candida overgrowth problems in so many people living with HIV, along with the bodywide inflammation that is commonly present, this product's antifungal and anti-inflammatory effectiveness combined with a complete lack of side effects make it a very promising addition to the treatment repertoire. It is also very inexpensive compared to the cost of triazole drugs like fluconazole and itraconazole. It also has the advantage that, at least to date, this concentrated form has had little use in either the general population or the HIV community and, thus, there will probably be little if any candida resistance to it for some time to come. The product used in the clinical trial was Biotics ADP, a non-prescription herbal formula available through health care practitioners or some AIDS buyers clubs.

[Guest guest]

john,

quick note b4 bed - i have been fighting candidiasis for 6 months+. it is concentrated in my esophagus and has been a most frustrating infection for my doctor and me. all i want to say now is that prolonged use of "-azole" drugs may lead to a resistance to them (as it did for me). second, i have had success with the costly IV drugs Ambisome and Cancidas. though my thrush comes back within a couple of days of ceasing the use of either.

the strongest caution i have for you is the ear infection (which i have not had) because thrush could spread to your nasal passages and from what i understand can be a real bear to manage. cancidas might be appropriate for your ear infection. ask your doc.

i, too, have changed my diet and eat tons of yogurt, but have still not resolved the thrush problem. but, many people i have consulted with do offer one consistent hope - it can just go away!

best, mitch

[Guest guest]

I've also had serious problems with esophageal candidiasis. For years I had swallowing problems from a bad overgrowth even with T-Cells over 300. My GI thinks that the thrush was secondary to a long-term reflux problem and scarring of the esophagus, and with control of that I've been free of the candida for a while. The suggestions about avoiding sugar (watch out for hard candy!) and getting acidophilus are good ones. Also, in the '80's when I had oral thrush a lot, I participated in a UCSF Oral Medicine study using Listerine to control it. It actually was effective for me (most store brands are the exact same formulation, too). If you're in recovery from alcohol use, this isn't a good option - I'm told. It also wouldn't do much beyond the mouth.

BG

john,quick note b4 bed - i have been fighting candidiasis for 6 months+. it is concentrated in my esophagus and has been a most frustrating infection for my doctor and me. all i want to say now is that prolonged use of "-azole" drugs may lead to a resistance to them (as it did for me). second, i have had success with the costly IV drugs Ambisome and Cancidas. though my thrush comes back within a couple of days of ceasing the use of either.