Treating Gastrointestinal Candida Colonisation
Passé? Or Something to Consider?
Nowadays, with any mention of digestive symptoms of constipation, diarrhoea, gas, or bloating, and a history of antibiotic or proton-pump inhibitor use, one of the first things most integrative healthcare practitioners will consider in the differential diagnosis list is gastrointestinal dysbiosis with testing for small intestinal bacterial overgrowth (SIBO). SIBO has a lot of hype—and how can it not, with so many conferences, practitioners, and clinics focused on its treatment? Given that the lactulose breath test (LBT), commonly used for the diagnosis of SIBO, has a low sensitivity and frequently gives false-positive results (although sensitivity can be improved via three-hour methane and hydrogen testing), it can be overused for the ease of diagnosing, well, something.,
Fortunately, for many diagnosed with SIBO, symptoms do improve with a combination of dietary modification, digestive support (supplemental hydrochloric acid, enzymes, and/or ox bile), and antibiotics and/or herbal antimicrobials—and, in those with constipation, support for normal motility. However, in some patients, SIBO is seemingly resistant to treatment, even after many cycles of otherwise effective therapies. In this population, it is imperative that we consider other factors that may coexist leading to the symptomology that we often ascribe to SIBO.
Many of the factors that contribute to SIBO are also well-documented to contribute to candida colonization. Although we medically recognize an overgrowth of candida on the skin, vulvovaginal tissues, oral cavity, and numerous other locations as an indication for treatment, medical guidelines state that the presence of Candida spp. is normal in the gastrointestinal (GI) tract, and does not warrant treatment, even though multiple studies have shown higher faecal levels of candida in conditions such as antibiotic-associated diarrhea., In the gut, candida colonisation also is associated with constipation, Increased faecal candida counts have been shown in patients with inflammatory bowel disease,8 and, in individuals with ulcerative colitis, the lack of treating these patients with an antifungal has been shown to be associated with an increased level of disease activity.
Given this knowledge, is it really appropriate for us to neglect considering GI candida colonisation (and its treatment) completely, particularly in the presence of these often-chronic conditions? Much like the LBT for SIBO, testing is plagued by the lack of an absolute threshold at which treatment is indicated; however, there are tests that indicate the magnitude of overgrowth and candida viability (as indicated by culture), as well as sensitivity to different antifungal agents (both natural and pharmaceutical). Such tests give us a starting point for addressing candida colonisation—though, much like SIBO, many factors are necessary to consider for its successful resolution.
Taming Candida Overgrowth
Because the presence of candida is normal, we must consider the factors that lead to its overgrowth when addressing treatment. If we only use hard-hitting antifungals to eradicate candida, it will likely return in full force because we haven’t addressed the terrain that leads to colonisation to begin with. Immune system function. Below is a list of considerations for candida overgrowth and data supporting its use as a therapy:
- Saccharomyces boulardii: A probiotic yeast, boulardii has been shown to decrease candida colonisation and related inflammation. S. boulardii inhibits candida filamentation, adhesion, and biofilm formation, and also supports mucosal production of secretory IgA, a factor that helps protect against candida and other infections.
- Certain Lactobacillus: L. acidophilus, L. casei, and L. rhamnosus GG have been shown to reduce the formation of candida-related biofilms and candida colonisation via mechanisms similar to S. boulardii, also improving tissue healing and resolution of inflammation.11
Colostrum and lactoferrin: Colostrum provides immunoglobulins, proline-rich peptides, and a small amount of lactoferrin, each factors that support a normal immune response and help protect against infection. Colostrum also provides growth factors that support mucosal healing and repair, while lactoferrin exerts broad antimicrobial effects, with numerous studies showing its effectivity against candida in vitro and in vivo.,,, Colostrum can be a particularly effective treatment for GI pathogens and dysbiosis in settings of immunodeficiency.,
- Oregano (Origanum vulgare): The essential oil of oregano has broad-spectrum antimicrobial properties, inhibiting candida growth and diminishing its virulence., Carvacrol, one of the primary antimicrobial constituents found in oregano, has been demonstrated to dramatically reduce candida colonisation in animal models of an immunocompromised host., Oregano also may help reduce colonisation of methanogenic bacteria, commonly associated with constipation-type SIBO, and Blastocystis hominis, a parasite that can lead to GI symptoms.
- Black walnut (Juglans nigra): Tannins and juglone are among the antimicrobial constituents of black walnut hulls,, which have a history of traditional use for the treatment of fungal and parasitic infections. Clinical research has shown us that juglone and extracts from the walnut plant have antifungal properties, including activity against numerous strains of albicans., In animals, treatment of C. albicans with a product containing a black walnut husk extract was shown to be similarly effective to the standard antifungal treatment. The extract of black walnut husk was also shown to be effective against C. tropicalis and C. krusei, which have both been implicated in recurrent or chronic vulvovaginal candidiasis (VVC).
- Pau d’arco (common name referring to various Tabebuia): Pau d’arco is a tree that is native to tropical regions of South and Central America, used traditionally for a variety of bacterial and fungal infections as well as malaria and trypanosomiasis. Although limited data exists with human trials, the two main bioactive components of pau d’arco (lapachol and beta-lapachone, extracted from the inner bark) have demonstrated considerable anti-inflammatory and antifungal effects in vitro. Extracts of pau d’arco or these isolates have been shown to effectively inhibit multiple species of candida including C. albicans, C. parapsilosis, and C. tropicalis.,
Caprylic acid: Caprylic acid is a medium-chain fatty acid, also known as octanoic acid, found at high levels in virgin coconut oil. Both coconut oil and caprylic acid have been shown to strongly inhibit candida in vitro., Caprylic acid and other similar fatty acids exert antifungal effects by disrupting cellular membranes and impeding critical metabolic processes, as well as reducing albicans biofilm formation and inhibiting the yeast-to-hyphae transition., The observed anti-Candida action of S. boulardii may be largely due to its secretion of caprylic, capric, and other fatty acids with antifungal effects.
- Biotin: Biotin, a B vitamin often recognised for its importance for skin, hair, and nail health, also may be important in difficult-to-resolve Candida infections. In individuals with biotin deficiency, a chronic scaly, erythematous dermatitis around orifices may exist, from which C. albicans has often been cultured. Biotin deficiency, in the absence of gross malnutrition or gastrointestinal disorders, is often attributable to biotinidase deficiency, an inborn error of metabolism present in approximately 1 of 123 individuals. Although the number of individuals experiencing a profound deficiency of this enzyme is low (and often is evident in infancy), a larger proportion of the population may have a partial deficiency, which leads to 10 to 30% of normal biotinidase function. A case report discusses the resolution of a chronic, 14-month case of VVC (and prevention of its recurrence) in a woman with biotinidase deficiency after being treated with 20 mg of biotin daily. Studies have shown that up to half of pregnant women in the U.S. are marginally biotin deficient (particularly by later stages of pregnancy), despite normal intake,, which may contribute to the increased rate of VVC during pregnancy.
Clearly, a wide array of nutritional tools exist that may help to reduce candida colonisation and improve the body’s resistance to recurrent infection. Although not clinically “diagnosable,” gastrointestinal candida overgrowth, much like other states of dysbiosis, can be a factor in many chronic conditions and may be improved with natural treatments.
 Miazga A, et al. Current views on the etiopathogenesis, clinical manifestation, diagnostics, treatment and correlation with other nosological entities of SIBO. Adv Med Sci. 2015 Mar;60(1):118-24.
 Rezaie A, et al. Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. Am J Gastroenterol. 2017 May;112(5):775-84.
 Ghoshal UC. How to interpret hydrogen breath tests. J Neurogastroenterol Motil. 2011 Jul;17(3):312-7.
 Kauffman CA. Overview of Candida infections. UpToDate. Updated May 31, 2019. Accessed November 6, 2019.
 Krause R, et al. Elevated fecal Candida counts in patients with antibiotic-associated diarrhea: role of soluble fecal substances. Clin Diagn Lab Immunol. 2003 Jan;10(1):167-8.
 Vaishnavi C, et al. Speciation of fecal Candida isolates in antibiotic-associated diarrhea in non-HIV patients. Jpn J Infect Dis. 2008 Jan;61(1):1-4.
 Khalif IL, et al. Alterations in the colonic flora and intestinal permeability and evidence of immune activation in chronic constipation. Dig Liver Dis. 2005 Nov;37(11):838-49.
 Kumamoto CA. Inflammation and gastrointestinal Candida colonization. Curr Opin Microbiol. 2011 Aug;14(4):386-91.
 Zwolińska-Wcisło M, et al. [Studies on the influence of Candida fungal colonization on the healing process of inflammatory lesions in the colon in rat animal model]. Przegl Lek. 2007;64(3):124-9.
 Yamaguchi N, et al. Gastrointestinal Candida colonisation promotes sensitisation against food antigens by affecting the mucosal barrier in mice. Gut. 2006 Jul;55(7):954-60.
 Zwolińska-Wcisło M, et al. [The influence of Candida albicans on the course of ulcerative colitis]. Przegl Lek. 2006;63(7):533-8.
 Golecka M, et al. Candida-associated denture stomatitis in patients after immunosuppression therapy. Transplant Proc. 2006 Jan-Feb;38(1):155-6.
 Zhang X, et al. Estrogen effects on Candida albicans: a potential virulence-regulating mechanism. J Infect Dis. 2000 Apr;181(4):1441-6.
 Kim KY, et al. Acid suppression therapy as a risk factor for Candida esophagitis. Dig Dis Sci. 2013 May;58(5):1282-6.
 Rodrigues CF, et al. Candida sp. Infections in Patients with Diabetes Mellitus. J Clin Med. 2019 Jan 10;8(1).
 Mishra AA, Koh AY. Adaptation of Candida albicans during gastrointestinal tract colonization. Curr Clin Microbiol Rep. 2018 Sep;5(3):165-72.
 Prieto D, et al. Adaptation of Candida albicans to commensalism in the gut. Future Microbiol. 2016;11(4):567-83.
 Matsuo K, et al. Fecal microbiota transplantation prevents Candida albicans from colonizing the gastrointestinal tract. Microbiol Immunol. 2019 May;63(5):155-63.
 Jawhara S, Poulain D. Saccharomyces boulardii decreases inflammation and intestinal colonization by Candida albicans in a mouse model of chemically-induced colitis. Med Mycol. 2007 Dec;45(8):691-700.
 Krasowska A, et al. The antagonistic effect of Saccharomyces boulardii on Candida albicans filamentation, adhesion and biofilm formation. FEMS Yeast Res. 2009 Dec;9(8):1312-21.
 Rodrigues AC, et al. Saccharomyces boulardii stimulates sIgA production and the phagocytic system of gnotobiotic mice. J Appl Microbiol. 2000 Sep;89(3):404-14.
 Corthésy B. Role of secretory IgA in infection and maintenance of homeostasis. Autoimmun Rev. 2013 Apr;12(6):661-5.
 Zwolińska-Wcisło M, et al. Are probiotics effective in the treatment of fungal colonization of the gastrointestinal tract? Experimental and clinical studies. J Physiol Pharmacol. 2006 Nov;57 Suppl 9:35-49.
 Manzoni P. Use of Lactobacillus casei subspecies Rhamnosus GG and gastrointestinal colonization by Candida species in preterm neonates. J Pediatr Gastroenterol Nutr. 2007 Dec;45 Suppl 3:S190-4.
 Matsubara VH, et al. Probiotic lactobacilli inhibit early stages of Candida albicans biofilm development by reducing their growth, cell adhesion, and filamentation. Appl Microbiol Biotechnol. 2016 Jul;100(14):6415-26.
 Allergy Research Group. Colostrum and PRPs – First Immunity, Master Regulators. FOCUS Newsletter. May 2014:2-6.
 Soukka T, et al. Fungicidal effect of human lactoferrin against Candida albicans. FEMS Microbiol Lett. 1992 Jan 15;69(3):223-8.
 Samaranayake YH, et al. Antifungal effects of lysozyme and lactoferrin against genetically similar, sequential Candida albicans isolates from a human immunodeficiency virus-infected southern Chinese cohort. J Clin Microbiol. 2001 Sep;39(9):3296-302.
 Takakura N, et al. Oral lactoferrin treatment of experimental oral candidiasis in mice. Antimicrob Agents Chemother. 2003 Aug;47(8):2619-23.
 Velliyagounder K, et al. Oral lactoferrin protects against experimental candidiasis in mice. J Appl Microbiol. 2015 Jan;118(1):212-21.
 Rump JA, et al. Treatment of diarrhoea in human immunodeficiency virus-infected patients with immunoglobulins from bovine colostrum. Clin Investig. 1992 Jul;70(7):588-94.
 Ungar BL, et al. Cessation of Cryptosporidium-associated diarrhea in an acquired immunodeficiency syndrome patient after treatment with hyperimmune bovine colostrum. Gastroenterology. 1990 Feb;98(2):486-9.
 Puškárová A, et al. The antibacterial and antifungal activity of six essential oils and their cyto/genotoxicity to human HEL 12469 cells. Sci Rep. 2017 Aug 15;7(1):8211.
 Karaman M, et al. Origanum vulgare essential oil affects pathogens causing vaginal infections. J Appl Microbiol. 2017 May;122(5):1177-85.
 Pradebon Brondani L, et al. Evaluation of anti-enzyme properties of Origanum vulgare essential oil against oral Candida albicans. J Mycol Med. 2018 Mar;28(1):94-100.
 Chami F, et al. Evaluation of carvacrol and eugenol as prophylaxis and treatment of vaginal candidiasis in an immunosuppressed rat model. J Antimicrob Chemother. 2004 Nov;54(5):909-14.
 Chami N, et al. Antifungal treatment with carvacrol and eugenol of oral candidiasis in immunosuppressed rats. Braz J Infect Dis. 2004 Jun;8(3):217-26.
 Kolling GJ, et al. Performance and methane emissions in dairy cows fed oregano and green tea extracts as feed additives. J Dairy Sci. 2018 May;101(5):4221-34.
 Force M, et al. Inhibition of enteric parasites by emulsified oil of oregano in vivo. Phytother Res. 2000 May;14(3):213-4.
 Coyle CM, et al. Blastocystis: to treat or not to treat… Clin Infect Dis. 2012 Jan 1;54(1):105-10.
 Amarowicz R, et al. Antibacterial activity of tannin constituents from Phaseolus vulgaris, Fagoypyrum esculentum, Corylus avellana and Juglans nigra. Fitoterapia. 2008 Apr;79(3):217-9.
 Sharma N, et al. Microwave-assisted efficient extraction and stability of juglone in different solvents from Juglans regia: Quantification of six phenolic constituents by validated RP-HPLC and evaluation of antimicrobial activity. Analytical Letters. 2009 Oct 30;42(16):2592-609.
 Strugstad M, Despotovski S. A summary of extraction, synthesis, properties, and potential uses of juglone: A literature review. J Ecosystems Management. 2013 Jan 8;13(3).
 Clark AM, et al. Antimicrobial activity of juglone. Phytotherapy Research. 1990 Feb;4(1):11-4.
 Sytykiewicz H, et al. Antifungal Activity of Juglans regia (L.) Leaf Extracts Against Candida albicans Isolates. Polish J Enviro Studies. 2015 May 1;24(3):1339-48.
 Noumi E, et al. Antifungal properties of Salvadora persica and Juglans regia L. extracts against oral Candida strains. Eur J Clin Microbiol Infect Dis. 2010 Jan;29(1):81-8.
 Abedi P, et al. Comparison of the Effects of Juglans nigra Green Husk and Clotrimazole on Candida albicans in Rats. Jundishapur J Microbiol. 2018;11(2).
 Rodrigues L, et al. Antifungal activity in Juglans nigra green husks. Planta Medica. 2010 Aug;76(12):P444.
 Makanjuola O, et al. An Update on the Roles of Non-albicans Candida Species in Vulvovaginitis. J Fungi (Basel). 2018 Oct 31;4(4).
 Gomez Castellanos J, et al. Red Lapacho (Tabebuia impetiginosa)-a global ethnopharmacological commodity? J Ethnopharmacol. 2009 Jan 12;121(1):1-13.
 Guiraud P, et al. Comparison of antibacterial and antifungal activities of lapachol and B-lapachone. Planta Med. 1994 Aug;60(4):373-4.
 Martins N, et al. Plants used in folk medicine: The potential of their hydromethanolic extracts against Candida species. Industrial Crops Products. 2015 Apr 1;66:62-7.
 Ogbolu DO, et al. In vitro antimicrobial properties of coconut oil on Candida species in Ibadan, Nigeria. J Med Food. 2007 Jun;10(2):384-7.
 Huang CB, et al. Short- and medium-chain fatty acids exhibit antimicrobial activity for oral microorganisms. Arch Oral Biol. 2011 Jul;56(7):650-4.
 Pohl CH, et al. Antifungal free fatty acids: a review. Science against microbial pathogens: communicating current research and technological advances. 2011;3:61-71.
 Rosenblatt J, et al. Caprylic acid and glyceryl trinitrate combination for eradication of biofilm. Antimicrob Agents Chemother. 2015;59(3):1786-88.
 Jadhav A, et al. The dietary food components capric acid and caprylic acid inhibit virulence factors in Candida albicans through multitargeting. J Medicinal Food. 2017 Nov;20(11):1083-90.
 Murzyn A, et al. Capric acid secreted by S. boulardii inhibits C. albicans filamentous growth, adhesion and biofilm formation. PLoS One. 2010 Aug 10;5(8):e12050.
 Trüeb RM. Serum Biotin Levels in Women Complaining of Hair Loss. Int J Trichology. 2016 Apr-Jun;8(2):73-7.
 Mock DM. Skin manifestations of biotin deficiency. Semin Dermatol. 1991 Dec;10(4):296-302.
 Zempleni J, et al. Biotin. Biofactors. 2009 Jan-Feb;35(1):36-46.
 Strom CM, Levine EM. Chronic vaginal candidiasis responsive to biotin therapy in a carrier of biotinidase deficiency. Obstet Gynecol. 1998 Oct;92(4 Pt 2):644-6.
 Mock DM, et al. Marginal biotin deficiency during normal pregnancy. Am J Clin Nutr. 2002 Feb;75(2):295-9.
 Mock DM, et al. Biotin status assessed longitudinally in pregnant women. J Nutr. 1997 May;127(5):710-6.
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