Urinary Tract Infection

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Urinary Tract Infection

Need to Know

Urinary Tract Infection
Urgency? Frequency? Could be a UTI. Triggered by bacteria, UTI, or urinary tract infection, can occur in the kidneys, bladder, or urethra. According to research or other evidence, the following self-care steps may be helpful.
  • Check out cranberry

    To treat and to prevent recurrences, drink 4 to 10 ounces (114 to 296 ml) of cranberry juice a day or take 400 mg of powdered cranberry concentrate twice a day

  • Try an enzyme preparation

    To enhance antibiotic effectiveness, take 400 mg a day of proteolytic enzymes, such as bromelain and trypsin

  • Aim for a strong immune system with a multivitamin

    Take one a day to avoid vitamin and mineral deficiencies and to better resist infections

  • If you have a UTI, see a healthcare provider Existing infections may require treatment with antibiotics

About

About This Condition

Urinary tract infections (UTIs) are infections of the kidney, bladder, and urethra.

UTIs are generally triggered by bacteria and are more common when there is partial blockage of the urinary tract. In some people, UTIs tend to recur.

Symptoms

Symptoms of a UTI usually begin suddenly and include frequent urination that is irritating or burning, a persistent urge to urinate even after the bladder has been emptied, and cramping or pressure in the lower abdomen. The urine often has a strong or unusual smell and may appear cloudy. In more serious infections, fever, chills, pain in the back below the ribs, nausea, vomiting, and diarrhea may also be present.

Holistic Options

Acupuncture might be of some benefit for women with recurrent UTIs. A controlled study compared acupuncture to sham (“fake”) acupuncture or no treatment in a group of women with recurrent UTIs. After six months, the women receiving real acupuncture had half as many UTI episodes as the sham group and only one-third as many as the untreated group, a significant difference.1

Eating Right

The right diet is the key to managing many diseases and to improving general quality of life. For this condition, scientific research has found benefit in the following healthy eating tips.

Recommendation Why Get started
Check out cranberry To treat and to prevent recurrences, drink 4 to 10 ounces (114 to 296 ml) of cranberry juice a day or take 400 mg of powdered cranberry concentrate twice a day

Check out cranberry

To treat and to prevent recurrences, drink 4 to 10 ounces (114 to 296 ml) of cranberry juice a day or take 400 mg of powdered cranberry concentrate twice a day
Watch your diet Cutting back on sugar, alcohol, and fat may support healing after infection and may help prevent recurrences.

Watch your diet

When healthy volunteers consumed a large amount (100 grams) of refined sugar, the ability of their white blood cells to destroy bacteria was impaired for at least five hours.2 Consumption of excessive amounts of alcohol has also been shown to suppress immune function.3 Reduced intake of dietary fat has been shown to stimulate immunity.4 For these reasons, many doctors recommend a reduced intake of sugar, alcohol, and fat during an acute infection and for prevention of recurrences.

Avoid allergenic foods Work with a knowledgeable health practitioner to find out if you have allergies to foods that increase your susceptibility to urinary tract infections.

Avoid allergenic foods

People who have recurrent or chronic infections should discuss the possible role of allergies with a doctor, since chronic infections have been linked to allergies in many reports.5 , 6 , 7 , 8 Identifying and eliminating foods that trigger problems may help reduce the number of infections.

Supplements

What Are "Star" Ratings?

a7_3star   Reliable and relatively consistent scientific data showing a substantial health benefit.

a7_2star   Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.

a7_1star   For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support.

Our proprietary “Star-Rating” system was developed to help you easily understand the amount of scientific support behind each supplement in relation to a specific health condition. While there is no way to predict whether a vitamin, mineral, or herb will successfully treat or prevent associated health conditions, our unique ratings tell you how well these supplements are understood by the medical community, and whether studies have found them to be effective for other people.

For over a decade, our team has combed through thousands of research articles published in reputable journals. To help you make educated decisions, and to better understand controversial or confusing supplements, our medical experts have digested the science into these three easy-to-follow ratings. We hope this provides you with a helpful resource to make informed decisions towards your health and well-being.


Supplement Amount Why
Bromelain
400 mg daily 2 stars   Taking bromelain during a UTI may enhance antibiotic effectiveness.


2 stars  Bromelain

400 mg daily

The proteolytic enzymes, bromelain (from pineapple) and trypsin may enhance the effectiveness of antibiotics in people with a UTI. In a double-blind trial, people with UTIs received antibiotics plus either bromelain/trypsin in combination (400 mg per day for two days) or a placebo. One hundred percent of those who received the enzymes had a resolution of their infection, compared with only 46% of those given the placebo.9 This study used enteric-coated tablets. Enteric-coating prevents stomach acid from partially destroying the bromelain. Most commercially available bromelain products today are not enteric-coated, and it is not known if non-enteric coated preparations would be as effective.


Supplement Amount Why
Cranberry
4 to 10 ounces (114 to 296 ml) of cranberry juice daily or 400 mg of powdered cranberry concentrate twice per day 2 stars   Supplementing with cranberry has been shown to help treat and prevent recurrences.


2 stars  Cranberry

4 to 10 ounces (114 to 296 ml) of cranberry juice daily or 400 mg of powdered cranberry concentrate twice per day

Modern research has suggested that cranberry may prevent urinary tract infections.10 In a double-blind trial, elderly women who drank 10 ounces (300 ml) of cranberry juice per day had a decrease in the amount of bacteria in their urine.11 In another study, elderly residents of a nursing home consumed either four ounces (120 ml) of cranberry juice or six capsules containing concentrated cranberry daily for 13 months. During that time, the number of UTIs decreased by 25%.12 A small preliminary trial found that supplementation with encapsulated cranberry concentrate (400 mg twice per day for three months) significantly reduced the recurrence of UTIs in women (aged 18–45) with a history of recurrent infections.13

Cranberry juice has also been found to be as effective as the antibiotic cefaclor for preventing UTIs in children who had recurrent UTIs because of a condition that causes urine to flow backwards from the bladder into the ureters (vesicoureteral reflux). In that study, the children received a cranberry juice concentrate that was equivalent to 200 ml of cranberry juice per day.14

Research has suggested cranberry may be effective against UTIs because it prevents E. coli, the bacteria that causes most urinary tract infections, from attaching to the walls of the bladder.15 Cranberry is not, however, a substitute for antibiotics in the treatment of acute UTIs. Moreover, in children whose UTIs are due to “neurogenic bladder” (a condition caused by spinal cord injury or myelomeningocele), cranberry juice supplementation did not reduce the rate of infection.16 Drinking 10–16 ounces (300–500 ml) of unsweetened or lightly sweetened cranberry juice is recommended by many doctors for prevention, and as part of the treatment of UTIs. Alternatively, 400 mg of concentrated cranberry extracts twice per day can be used.


Supplement Amount Why
Vitamin C
Refer to label instructions 2 stars   Supplementing with vitamin C may treat acute UTIs and help people who are prone to recurrent UTIs.


2 stars  Vitamin C

Many doctors recommend 5,000 mg or more of vitamin C per day for an acute UTI, as well as long-term supplementation for people who are prone to recurrent UTIs. Vitamin C has been shown to inhibit the growth of E. coli, the most common bacterial cause of UTIs.17 In addition, supplementation with 4,000 mg or more of vitamin C per day, results in a slight increase in the acidity of the urine,18 creating an “unfriendly” environment for some infection-causing bacteria. In one controlled trial, pregnant women who supplemented with 100 mg of vitamin C per day experienced 56% less UTI frequency, compared with a placebo.19


Supplement Amount Why
Asparagus
Refer to label instructions 1 star   Asparagus may relieve UTI symptoms by increasing urinary volume and helping to flush bacteria out of the urinary tract.


1 star  Asparagus

Asparagus (Asparagus officinalis), birch (Betula spp.), couch grass (Agropyron repens), goldenrod (Solidago virgaurea), horsetail, Java tea (Orthosiphon stamineus), lovage (Levisticum officinale), parsley (Petroselinum crispum), spiny restharrow (Ononis spinosa), and nettle are approved in Germany as part of the therapy of people with UTIs. These herbs appear to work by increasing urinary volume and supposedly helping to flush bacteria out of the urinary tract.20 Juniper is used in a similar fashion by many doctors. Generally, these plants are taken as tea.


Supplement Amount Why
Birch
Refer to label instructions 1 star   Birch may relieve UTI symptoms by increasing urinary volume and helping to flush bacteria out of the urinary tract.


1 star  Birch

Asparagus (Asparagus officinalis), birch (Betula spp.), couch grass (Agropyron repens), goldenrod (Solidago virgaurea), horsetail, Java tea (Orthosiphon stamineus), lovage (Levisticum officinale), parsley (Petroselinum crispum), spiny restharrow (Ononis spinosa), and nettle are approved in Germany as part of the therapy of people with UTIs. These herbs appear to work by increasing urinary volume and supposedly helping to flush bacteria out of the urinary tract.21 Juniper is used in a similar fashion by many doctors. Generally, these plants are taken as tea.


Supplement Amount Why
Blueberry
Refer to label instructions 1 star   Blueberry may help prevent and treat UTIs by keeping bacteria from attaching to the lining of the urinary tract.


1 star  Blueberry

Blueberry contains similar constituents as cranberry, and might also prevent bacteria from attaching to the lining of the urinary bladder.22 However, studies have not yet been done to determine if blueberry can help prevent bladder infections.

Asparagus (Asparagus officinalis), birch (Betula spp.), couch grass (Agropyron repens), goldenrod (Solidago virgaurea), horsetail, Java tea (Orthosiphon stamineus), lovage (Levisticum officinale), parsley (Petroselinum crispum), spiny restharrow (Ononis spinosa), and nettle are approved in Germany as part of the therapy of people with UTIs. These herbs appear to work by increasing urinary volume and supposedly helping to flush bacteria out of the urinary tract.23 Juniper is used in a similar fashion by many doctors. Generally, these plants are taken as tea.


Supplement Amount Why
Buchu
Refer to label instructions 1 star   Buchu leaf preparations have been historically used as a urinary tract disinfectant and diuretic.


1 star  Buchu

Buchu leaf preparations have a history of use in traditional herbal medicine as a urinary tract disinfectant and diuretic.24 However, the German Commission E monograph on buchu concludes that insufficient evidence supports the modern use of buchu for the treatment of UTIs or inflammation.25


Supplement Amount Why
Couch Grass
Refer to label instructions 1 star   Couch grass may relieve UTI symptoms by increasing urinary volume and helping to flush bacteria out of the urinary tract.


1 star  Couch Grass

Asparagus (Asparagus officinalis), birch (Betula spp.), couch grass (Agropyron repens), goldenrod (Solidago virgaurea), horsetail, Java tea (Orthosiphon stamineus), lovage (Levisticum officinale), parsley (Petroselinum crispum), spiny restharrow (Ononis spinosa), and nettle are approved in Germany as part of the therapy of people with UTIs. These herbs appear to work by increasing urinary volume and supposedly helping to flush bacteria out of the urinary tract.26 Juniper is used in a similar fashion by many doctors. Generally, these plants are taken as tea.


Supplement Amount Why
D-Mannose
Refer to label instructions 1 star   D-Mannose may help treat UTIs by binding to bacteria that would otherwise attach to the urinary tract lining.


1 star  D-Mannose

Some bacteria that typically cause urinary tract infections can attach themselves to the lining of the urinary tract by binding to molecules of mannose that naturally occur there.27 Theoretically, if enough D-mannose is present in the urine, it would bind to the bacteria and prevent them from attaching to the urinary tract lining.28 One animal study has demonstrated this protective effect,29 but whether it would occur in humans is unknown, and no human research has investigated the effectiveness of oral D-mannose for the prevention or treatment of urinary tract infections.


Supplement Amount Why
Goldenrod
Refer to label instructions 1 star   Goldenrod may relieve UTI symptoms by increasing urinary volume and helping to flush bacteria out of the urinary tract.


1 star  Goldenrod

Asparagus (Asparagus officinalis), birch (Betula spp.), couch grass (Agropyron repens), goldenrod (Solidago virgaurea), horsetail, Java tea (Orthosiphon stamineus), lovage (Levisticum officinale), parsley (Petroselinum crispum), spiny restharrow (Ononis spinosa), and nettle are approved in Germany as part of the therapy of people with UTIs. These herbs appear to work by increasing urinary volume and supposedly helping to flush bacteria out of the urinary tract.30 Juniper is used in a similar fashion by many doctors. Generally, these plants are taken as tea.


Supplement Amount Why
Goldenseal
Refer to label instructions 1 star   Goldenseal contains berberine, an alkaloid that may prevent UTIs by inhibiting bacteria from adhering to the wall of the urinary bladder


1 star  Goldenseal

Goldenseal is reputed to help treat many types of infections. It contains berberine, an alkaloid that may prevent UTIs by inhibiting bacteria from adhering to the wall of the urinary bladder.31 Goldenseal and other plants containing berberine (such as Oregon grape) may help in the treatment of UTIs. These herbs have not, however, been studied for the treatment of UTIs in humans.


Supplement Amount Why
Horseradish
Refer to label instructions 1 star   The volatile oil of horseradish has been shown to kill bacteria that can cause UTIs.


1 star  Horseradish

The volatile oil of horseradish has been shown to kill bacteria that can cause urinary tract infections.32 The concentration that is required to kill these bacteria can be attained in human urine after oral ingestion of the oil. One early study found that horseradish extract may help people with urinary tract infections.33 Further studies are necessary to confirm the safety and effectiveness of horseradish in treating urinary tract infections.


Supplement Amount Why
Horsetail
Refer to label instructions 1 star   Horsetail may relieve UTI symptoms by increasing urinary volume and helping to flush bacteria out of the urinary tract.


1 star  Horsetail

Asparagus (Asparagus officinalis), birch (Betula spp.), couch grass (Agropyron repens), goldenrod (Solidago virgaurea), horsetail, Java tea (Orthosiphon stamineus), lovage (Levisticum officinale), parsley (Petroselinum crispum), spiny restharrow (Ononis spinosa), and nettle are approved in Germany as part of the therapy of people with UTIs. These herbs appear to work by increasing urinary volume and supposedly helping to flush bacteria out of the urinary tract.34 Juniper is used in a similar fashion by many doctors. Generally, these plants are taken as tea.


Supplement Amount Why
Java Tea
Refer to label instructions 1 star   Java tea may relieve UTI symptoms by increasing urinary volume and helping to flush bacteria out of the urinary tract.


1 star  Java Tea

Asparagus (Asparagus officinalis), birch (Betula spp.), couch grass (Agropyron repens), goldenrod (Solidago virgaurea), horsetail, Java tea (Orthosiphon stamineus), lovage (Levisticum officinale), parsley (Petroselinum crispum), spiny restharrow (Ononis spinosa), and nettle are approved in Germany as part of the therapy of people with UTIs. These herbs appear to work by increasing urinary volume and supposedly helping to flush bacteria out of the urinary tract.35 Juniper is used in a similar fashion by many doctors. Generally, these plants are taken as tea.


Supplement Amount Why
Juniper
Refer to label instructions 1 star   Juniper may relieve UTI symptoms by increasing urinary volume and helping to flush bacteria out of the urinary tract.


1 star  Juniper

Asparagus (Asparagus officinalis), birch (Betula spp.), couch grass (Agropyron repens), goldenrod (Solidago virgaurea), horsetail, Java tea (Orthosiphon stamineus), lovage (Levisticum officinale), parsley (Petroselinum crispum), spiny restharrow (Ononis spinosa), and nettle are approved in Germany as part of the therapy of people with UTIs. These herbs appear to work by increasing urinary volume and supposedly helping to flush bacteria out of the urinary tract.36 Juniper is used in a similar fashion by many doctors. Generally, these plants are taken as tea.


Supplement Amount Why
Lovage
Refer to label instructions 1 star   Lovage may relieve UTI symptoms by increasing urinary volume and helping to flush bacteria out of the urinary tract.


1 star  Lovage

Asparagus (Asparagus officinalis), birch (Betula spp.), couch grass (Agropyron repens), goldenrod (Solidago virgaurea), horsetail, Java tea (Orthosiphon stamineus), lovage (Levisticum officinale), parsley (Petroselinum crispum), spiny restharrow (Ononis spinosa), and nettle are approved in Germany as part of the therapy of people with UTIs. These herbs appear to work by increasing urinary volume and supposedly helping to flush bacteria out of the urinary tract.37 Juniper is used in a similar fashion by many doctors. Generally, these plants are taken as tea.


Supplement Amount Why
Multivitamin
Refer to label instructions 1 star   Taking a multivitamin–mineral may help to avoid deficiencies and to better resist infections.


1 star  Multivitamin

Since the immune system requires many nutrients in order to function properly, many people take a multivitamin-mineral supplement for “insurance.” In one double-blind trial, healthy elderly people who used such a supplement for one year showed improvements in immune function, as well as a significant reduction in the total number of infections (including non-urinary-tract infections).38


Supplement Amount Why
Nettle
Refer to label instructions 1 star   Nettle may relieve UTI symptoms by increasing urinary volume and helping to flush bacteria out of the urinary tract.


1 star  Nettle

Asparagus (Asparagus officinalis), birch (Betula spp.), couch grass (Agropyron repens), goldenrod (Solidago virgaurea), horsetail, Java tea (Orthosiphon stamineus), lovage (Levisticum officinale), parsley (Petroselinum crispum), spiny restharrow (Ononis spinosa), and nettle are approved in Germany as part of the therapy of people with UTIs. These herbs appear to work by increasing urinary volume and supposedly helping to flush bacteria out of the urinary tract.39 Juniper is used in a similar fashion by many doctors. Generally, these plants are taken as tea.


Supplement Amount Why
Oregon Grape
Refer to label instructions 1 star   Oregon grape contains berberine, an alkaloid that may prevent UTIs by inhibiting bacteria from adhering to the wall of the urinary bladder.


1 star  Oregon Grape

Goldenseal is reputed to help treat many types of infections. It contains berberine, an alkaloid that may prevent UTIs by inhibiting bacteria from adhering to the wall of the urinary bladder.40 Goldenseal and other plants containing berberine (such as Oregon grape) may help in the treatment of UTIs. These herbs have not, however, been studied for the treatment of UTIs in humans.


Supplement Amount Why
Parsley
Refer to label instructions 1 star   Parsley may relieve UTI symptoms by increasing urinary volume and helping to flush bacteria out of the urinary tract.
Plantain
Refer to label instructions 1 star   Plantain has anti-inflammatory effects an may be beneficial in some people with UTIs.


1 star  Plantain

Because of the anti-inflammatory effects of plantain, it may be beneficial in some people with UTIs. However, human trials have not been done to confirm this possibility or to confirm the traditional belief that plantain is diuretic.41


Supplement Amount Why
Spiny Restharrow
Refer to label instructions 1 star   Spiny restharrow may relieve UTI symptoms by increasing urinary volume and helping to flush bacteria out of the urinary tract.


1 star  Spiny Restharrow

Asparagus (Asparagus officinalis), birch (Betula spp.), couch grass (Agropyron repens), goldenrod (Solidago virgaurea), horsetail, Java tea (Orthosiphon stamineus), lovage (Levisticum officinale), parsley (Petroselinum crispum), spiny restharrow (Ononis spinosa), and nettle are approved in Germany as part of the therapy of people with UTIs. These herbs appear to work by increasing urinary volume and supposedly helping to flush bacteria out of the urinary tract.42 Juniper is used in a similar fashion by many doctors. Generally, these plants are taken as tea.


Supplement Amount Why
Uva Ursi
Refer to label instructions 1 star   Uva ursi may help treat UTIs by killing bacteria in the bladder and urinary tract.


1 star  Uva Ursi

An extract of uva ursi is used in Europe and in traditional herbal medicine in North America, as a treatment for UTI.43 This herb is approved in Germany for treatment of bladder infections.44 The active constituent in uva ursi is arbutin. In the alkaline environment of the urine, arbutin is converted into another chemical, called hydroquinone, which kills bacteria. A generally useful amount of uva ursi tincture is 3–5 ml three times per day. Otherwise, 100–250 mg of arbutin in herbal extract capsules or tablets three times per day can be used. Uva ursi should only be used to treat a UTI under the close supervision of a physician.


Supplement Amount Why
Vitamin A
Refer to label instructions 1 star   Vitamin A deficiency increases the risk of many infection, supplementing with it may restore levels and help support the immune system.


1 star  Vitamin A

Vitamin A deficiency increases the risk of many infections. Although much of the promising research with vitamin A supplements and infections has focused on measles,45 vitamin A is also thought to be helpful in other infections. Some doctors recommend that people with urinary tract infections take vitamin A. A typical amount recommended to correct a deficiency is 10,000 to 25,000 IU per day.

References

1. Aune A, Alraek T, LiHua H, Baerheim A. Acupuncture in the prophylaxis of recurrent lower urinary tract infection in adult women. Scand J Prim Health Care 1998;16:37–9.

2. Sanchez A, Reeser JL, Lau HS, et al. Role of sugars in human neutrophilic phagocytosis. Am J Clin Nutr 1973;26:1180–4.

3. MacGregor RR. Alcohol and immune defense. JAMA 1986;256:1474.

4. Barone J, Herbert JR, Reddy MM. Dietary fat and natural-killer-cell activity. Am J Clin Nutr 1989;50:861–7.

5. Horesh AJ. Allergy and infection. Proof of infectious etiology. J Asthma Res 1967;4:269–82.

6. Rudolph JA. Allergy as a cause of frequent recurring colds and coughs in children. Dis Chest 1940;6:138.

7. Berman BA. Pseudomononucleosis of allergic origin: a new clinical entity. Ann Allergy 1964;22:403–9.

8. Randolph TG, Hettig RA. The coincidence of allergic disease, unexplained fatigue, and lymphadenopathy; possible diagnostic confusion with infectious mononucleosis. Am J Med Sci 1945;209:306–14.

9. Mori S, Ojima Y, Hirose T, et al. The clinical effect of proteolytic enzyme containing bromelain and trypsin on urinary tract infection evaluated by double blind method. Acta Obstet Gynaecol Jpn 1972;19:147–53.

10. Bailey DT, Dalton C, Joseph Daugherty FJ, Tempesta MS. Can a concentrated cranberry extract prevent recurrent urinary tract infections in women? A pilot study. Phytomedicine 2007;14:237–41.

11. Avorn J, Monane M, Gurwitz JH, et al. Reduction of bacteriuria and pyuria after ingestion of cranberry juice. JAMA 1994;271:751–4.

12. Dignam R, Ahmed M, Denman S, et al. The effect of cranberry juice on UTI rates in a long term care facility. J Am Geriatr Soc 1997;45:S53.

13. Walker EB, Barney DP, Mickelsen JN, et al. Cranberry concentrate: UTI prophylaxis. J Family Pract 1997;45:167–8 [letter].

14. Nishizaki N, Someya T, Hirano D, et al. Can cranberry juice be a substitute for cefaclor prophylaxis in children with vesicoureteral reflux? Pediatr Int 2009;51:433–4.

15. Sobota AE. Inhibition of bacterial adherence by cranberry juice: Potential use for the treatment of urinary tract infections. J Urol 1984;131:1013–6.

16. Schlager TA, Anderson S, Trudell J, Hendley JO. Effect of cranberry juice on bacteriuria in children with neurogenic bladder receiving intermittent catheterization. J Pediatr 1999;135:698–702.

17. Sirsi M. Antimicrobial action of vitamin C on M. tuberculosis and some other pathogenic organisms. Indian J Med Sci 1952;6:252–5.

18. Axelrod DR. Ascorbic acid and urinary pH. JAMA 1985;254:1310–1.

19. Ochoa-Brust GJ, Fernandez AR, Villanueva-Ruiz GJ, et al. Daily intake of 100 mg ascorbic acid as urinary tract infection prophylactic agent during pregnancy. Acta Obstet Gynecol Scand 2007;86:783–7.

20. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 428.

21. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 428.

22. Ofek I, Goldhar J, Zafriri D, et al. Anti-Escherichia coli adhesin activity of cranberry and blueberry juices. New Engl J Med 1991;324:1599 [letter].

23. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 428.

24. Leung AY, Foster S. Encyclopedia of Common Natural Ingredients Used in Food, Drugs and Cosmetics. New York: John Wiley and Sons, 1996, 104–5.

25. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 317.

26. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 428.

27. Ofek I, Goldhar J, Esltdat Y, Sharon N. The importance of mannose specific adhesins (lectins) in infections caused by Escherichia coli. Scand J Infect Dis Suppl 1982;33:61–7.

28. Toyota S, Fukushi Y, Katoh S, et al. Anti-bacterial defense mechanism of the urinary bladder. Role of mannose in urine. Nippon Hinyokika Gakkai Zasshi 1989;80:1816–23 [in Japanese].

29. Michaels EK, Chmiel JS, Plotkin BJ, Schaeffer AJ.Effect of D-mannose and D-glucose on Escherichia coli bacteriuria in rats. Urol Res 1983;11:97–102.

30. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 428.

31. Sun DX, Abraham SN, Beachey EH. Influence of berberine sulfate on synthesis and expression of pap fimbrial adhesin in uropathogenic Escherichia coli. Antimicrob Agents Chemother 1988;32:1274–7.

32. Kienholz VM, Kemkes B. The anti-bacterial action of ethereal oils obtained from horse radish root (Cochlearia armoracia L.). Arzneimittelforschung 1961;10:917–8 [in German].

33. Schindler VE, Zipp H, Marth I. Comparative clinical investigations of an enzyme glycoside mixture obtained from horse radish roots (Cochlearia armoracia L). Arzneimittelforschung 1961;10:919–21 [in German].

34. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 428.

35. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 428.

36. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 428.

37. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 428.

38. Chandra RK. Effect of vitamin and trace-element supplementation on immune responses and infection in elderly subjects. Lancet 1992;340:1124–7.

39. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 428.

40. Sun DX, Abraham SN, Beachey EH. Influence of berberine sulfate on synthesis and expression of pap fimbrial adhesin in uropathogenic Escherichia coli. Antimicrob Agents Chemother 1988;32:1274–7.

41. Doan DD, Nguyen NH, Doan HK, et al. Studies on the individual and combined diuretic effects of four Vietnamese traditional herbal remedies (Zea mays, Imperata cylindrica, Plantago major and Orthosiphon stamineus). J Ethnopharmacol 1992;36:225–31.

42. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 428.

43. European Scientific Cooperative for Phytotherapy. Proposal for European Monographs, Vol. 3. Bevrijdingslaan, Netherlands: ESCOP Secretariat, 1992.

44. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine Communications, 1998, 224–5.

45. Hussey GD, Klein M. A randomized, controlled trial of vitamin A in children with severe measles. N Engl J Med 1990;323:160–4.

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