New gut research further explores connection with immunity

Addressing patient issues that may surprisingly lead to the microbiome

THE INTESTINES ARE AN ECOSYSTEM. You have 2-6 pounds of microorganisms in your intestines (according to the National Institutes of Health). There are more bacterial cells in the colon than there are cells in your entire body (bacteria cells are much smaller than your other cells).

When describing this system, the word microbiome is frequently used. Chemical byproducts from intestinal bacteria have a powerful effect on health. Plus, over 70% of the immune system is associated with the GI tract.

Your patients’ chemical factory

Bacteria are like little chemical factories, with good flora producing vitamins, healing the intestinal lining, breaking down toxins and suppressing bad flora. Bad flora produce toxins, irritate the intestinal lining and suppress good flora.

But that is an oversimplification. We all have some bad flora, which is normal. It is offset by a large and diverse population of good flora. It isn’t always necessary to kill the bad flora (although in some cases of SIBO or IBS, that is a good strategy).

Leaky gut

The cells of the intestines are meant to be packed tightly together, forming a barrier that keeps bacteria and undigested food out of the blood stream. Drug therapies, poor digestion (e.g., inadequate stomach HCl or pancreatic enzymes), poor diet or the presence of the wrong kind of flora can break down this barrier. This is known as increased intestinal permeability or “leaky gut.”

Leaky gut allows things into the body that should be kept out. This material, which can include bacteria, partially digested protein and toxins, will interact with the immune system and begin to create chronic health problems. Treating imbalances in the bowel flora has been shown to improve leaky gut.⁹

Disease and the microbiome

The key to many chronic health problems is to address the microbiome and to improve the integrity of the intestinal lining (addressing “leaky gut”).

It is fairly obvious that GI symptoms would be caused by bowel flora imbalance. Studies have shown this to be true.^13,14,15 Addressing the microbiome can also be helpful in liver disease.^16,17

More than just GI symptoms

Bacterial byproducts are linked to toxicity, nutrient status, the immune system and general biochemistry. The makeup of the bowel flora can affect organs and systems beyond the GI tract. Also, the GI symptoms may not be severe or obvious in patients with bowel flora imbalance or leaky gut.

Type 2 diabetes, obesity and metabolic syndrome — Several studies link insulin insensitivity and diabetes to the makeup of the bowel flora.^1,2,3,4 It is also linked to obesity.^5,6 Overweight people generally have different bowel flora than skinny people.

Berberine and its benefit to insulin insensitivity and type 2 diabetes has been extensively studied. Berberine also kills certain microbes and affects the bowel flora. Studies have shown that this may be the reason berberine is beneficial to diabetics.^7,8

Cardiovascular — There are a few studies that show cardiovascular benefit by addressing the microbiome.^18,19 High cholesterol has been linked to an imbalance of the bowel flora.^47,48

The brain and nervous system — Research has shown that gut bacteria can affect the brain.²⁰ Bowel flora may also be involved with neurodegenerative diseases, like Parkinson’s.²¹

Depression — New research is showing a strong connection between bowel ecology and depression.^22,23,24,25 There is a lot of excitement about this; addressing the makeup of bowel flora and the accompanying inflammation may be the way to help severely depressed individuals.

Since so much of the immune system is associated with the GI tract, problems with bowel flora and leaky gut have a strong effect. The makeup of the microbiome has a profound effect on the immune system in general. There are also studies that show GI involvement with allergies and with autoimmune diseases.

General immunity — The makeup of the microbiome can affect your resistance to viral and bacterial infection. Several studies support this. Most of them show that probiotic supplementation (good flora) can support the immune system.^10,11,12

Allergies — Both leaky gut and bowel flora imbalance are linked to allergies.^{32,33,34,35,36} The microbiome is also an issue for these patients.³¹ One interesting way that allergy/microbiome connection has been tested is with fecal transplant. Fecal transplant, which is moving the bowel flora from one individual to another, is one way to see if bowel flora have an effect on allergies. There are a few studies where fecal transplant improved atopic dermatitis^37,38 (this is just research; I am not suggesting it as a treatment).

Something as simple as taking probiotics has benefited allergy patients.³⁹ One study even found bifidobacterial supplementation for mothers and newborns reduced the incidence of allergy.⁵

There is other evidence that taking probiotics during pregnancy affects the microbiome of the newborn.⁴⁶ It may give us a way to prevent asthma. Infants with delayed development of the microbiome are prone to asthma, and that issue can be addressed with probiotic supplementation.⁴⁹

Autoimmune disease — Addressing the microbiome and leaky gut may be the best way to help patients with autoimmune diseases. According to studies, there is a connection between the severity of the disease and the makeup of the microbiome and the integrity of the intestinal lining.

Patients with psoriasis and psoriatic arthritis have a distinct bowel flora makeup, according to studies.^41,42 In rheumatoid arthritis, changes in the microbiome can reduce symptoms.^43,44 Interestingly, the changes in the microbiome and the symptomatic improvements were brought about by changes in the diet. There may be a link between inflammatory bowel disease and autoimmune disease.⁵⁰ Inflammatory bowel disease seems to have both immune and autoimmune components.⁵¹

SIBO and IBS — It is appropriate to discuss SIBO (small intestine bacterial overgrowth) and IBS (irritable bowel syndrome) at the same time. For one thing, SIBO is likely to be responsible for most cases of IBS.^51,52 Even if that is not the case, bacteria and the makeup of the microbiome is strongly linked to irritable bowel syndrome.^{53,54,55,56,57,58,59,60,61,62} Fecal transplant has been used to successfully treat IBS.⁵⁹ That, combined with the fact that many cases of IBS begin as a gastrointestinal infection,⁶⁰ indicate involvement of the microbiome with IBS.

IBD (inflammatory bowel disease) — IBD includes Crohn’s disease and ulcerative colitis. There is much evidence that the microbiota plays a role in these diseases. Fecal transplant has consistently helped ulcerative colitis patients to go into remission^63,64,65 (there are many more studies, we have just listed a few). One study even identified problem bacteria.⁶⁴

Fecal transplant in patients with Crohn’s disease has also been successful in some studies. Success is less pronounced than it is for ulcerative colitis. This makes sense because Crohn’s disease occurs mainly in the small intestine, and bacteria do not belong there. Specific bacteria have been identified and linked to symptoms of Crohn’s disease.

Saccharomyces boulardii is a yeast that displaces other flora. It is used to get rid of undesirable bowel flora. Studies have shown it to be an effective treatment for inflammatory bowel disease.^66,67 Once you stop taking Saccharomyces boulardii, it goes away.

The microbiome may play a role in Crohn’s disease. Enteral feeding will produce remission in 80-90% of patients. The authors of one study believe the improvement is due to changes in the microbiome⁶⁹ and a reduction in bacterial toxins. They state, “A significant change occurs in the production of microbial metabolites after enteral feeding in both healthy volunteers and patients with CD [Crohn’s disease]. Many of those detected in CD are toxic and may feasibly lead to the immunological attack on the gut microbiota, which is characteristic of inflammatory bowel disease. The reduction in the production of such metabolites after enteral feeding may be the reason for its effectiveness in CD.”

Proper diet and digestion

A specific carbohydrate diet was developed by Sidney Haas, MD, in the 1940s. It was made popular by Elaine Gottschall in her book, “Ending the Vicious Cycle.”

It presents a reasonable mechanism for at least some cases of Crohn’s disease and ulcerative colitis. Many practitioners have found that this approach helps with other digestive issues like IBS, SIBO, GERD, etc. The diet has been well-studied and found to be effective in many cases of inflammatory bowel disease,^70,71,72 as well as cases of IBS and SIBO.

The mechanism that leads to digestive problems that Gottschall suggests is as follows:

Incomplete digestion — Growth of improper GI flora — Irritation of the SI mucosa — Decreased production of enzymes from the SI (disaccharidases) — Incomplete digestion — More improper flora, etc.

Poor digestion can cause inappropriate bowel flora to grow. Complex carbohydrates, in general, seem to have the potential to disrupt the microbiome. This may explain the popularity of ketogenic and Paleo diets.

What disrupts the microbiome?

Drug therapy, especially acid-suppressing medications and antibiotics, can alter the microbiome.^{26,27,28,29,30} Diet, especially refined foods, and chemical additives can disrupt it as well.

There is some indication that gluten and dairy are often problematic. Eating food that is not well-digested grows inappropriate flora, which is why the specific carbohydrate diet is so effective. Food that is not digested rots and disrupts the ecology of the intestines.

Probiotics — Taking the right kind of bacteria has become a way to improve the intestinal ecology. As more research is being done, we are finding the importance of specific strains. Biffidobacterium, for example, is often beneficial to allergy patients. Increasing floral diversity has been one way to improve the health of IBD patients, and is another example of the use of probiotics for health.

The environment is more important — Many who take probiotic supplements find that they have to keep taking them. The good bacteria do not colonize because of poor living conditions. It is a lot like dropping polar bears off in the jungle or leaving tropical birds in Antarctica. They do not survive. You need to create an environment that is friendly to the new bacteria. Diet, chewing your food thoroughly and addressing the initial phase of digestion need to be addressed if you want the desirable bowel flora to survive.

You want diversity in the microbiome, and the way to get there is with diet. It makes sense. If you eat a lot of grease and fat, you grow bacteria that feed on it. If you eat a lot of sugar and starch, you get bacteria that feed on sugar and starch. Fiber and polyphenols (translation: vegetables) feed healthy flora. Fermented foods also help with diversity.

When addressing the microbiome, it is important to think about the computer term GIGO (garbage in, garbage out). You can take all the probiotics and gut-healing herbs you want, but if you do not address diet, you will not be very successful.

PAUL VARNAS, DC, DACBN, is a graduate of the National College of Chiropractic and has had a functional medicine practice for 34 years. He is the author of several books and has taught nutrition at the National University of Health Sciences. For a free PDF of “Instantly Have a Functional Medicine Practice” or a patient handout on the anti-inflammatory diet, email him at paulgvarnas@gmail.com.

REFERENCES

Cell Metab. 2020 Jan 7;31(1):77-91.e5 Gut Microbiome Fermentation Determines the Efficacy of Exercise for Diabetes Prevention
Diabetologia. 2018 Apr;61(4):810-820 Aberrant intestinal microbiota in individuals with prediabetes
Orv Hetil. 2016 Jan 3;157(1):13-22 [Physiological patterns of intestinal microbiota. The role of dysbacteriosis in obesity, insulin resistance, diabetes and metabolic syndrome]
Physiol Genomics. 2018 Apr 1;50(4):244-254 Gut microbiome may contribute to insulin resistance and systemic inflammation in obese rodents: a meta-analysis
mBio. 2016 Aug 23;7(4):e01018-16. Looking for a Signal in the Noise: Revisiting Obesity and the Microbiome
Gut. 2016 Mar;65(3):426-36 Akkermansia muciniphila and improved metabolic health during a dietary intervention in obesity: relationship with gut microbiome richness and ecology
Nat Commun. 2020 Oct 6;11(1):5015 Gut microbiome-related effects of berberine and probiotics on type 2 diabetes (the PREMOTE study)
Biomed Pharmacother. 2020 Nov;131:110669 Berberine alleviates type 2 diabetic symptoms by altering gut microbiota and reducing aromatic amino acids
Clin Infect Dis. 2014 Apr;58(8):1107-15 Immune response and intestinal permeability in children with acute gastroenteritis treated with Lactobacillus rhamnosus GG: a randomized, double-blind, placebo-controlled trial
JPEN J Parenter Enteral Nutr. 2013 Mar;37(2):243-53. A meta-analysis of probiotic and synbiotic use in elective surgery: does nutrition modulation of the gut microbiome improve clinical outcome?
World J Pediatr. 2019 Jun;15(3):255-261 Alterations of intestinal flora and the effects of probiotics in children with recurrent respiratory tract infection
Nutr Res. 2019 Apr;64:1-8 Short-term probiotic supplementation enhances cellular immune function in healthy elderly: systematic review and meta-analysis of controlled studies
Aliment Pharmacol Ther. 2021 Feb;53(4):499-509. Fructan-sensitive children with irritable bowel syndrome have distinct gut microbiome signatures
Inflamm Bowel Dis. 2014 Jun;20(6):978-86. Alterations in the intestinal microbiome (dysbiosis) as a predictor of relapse after infliximab withdrawal in Crohn’s disease
Gastroenterology. 2015 Oct;149(4):883-5.e9. Proton Pump Inhibitors Alter Specific Taxa in the Human Gastrointestinal Microbiome: A Crossover Trial
Inflamm Bowel Dis. 2010 Aug;16(8):1286-98. Immunosuppressive effects via human intestinal dendritic cells of probiotic bacteria and steroids in the treatment of acute ulcerative colitis
Nurs Res. 2010 Nov-Dec;59(6):426-32 Probiotic yogurt effects on intestinal flora of patients with chronic liver disease
Aliment Pharmacol Ther. 2011 Mar;33(6):662-71 Meta-analysis: the effects of gut flora modulation using prebiotics, probiotics and synbiotics on minimal hepatic encephalopathy
Biomed Res Int. 2017;2017:3796359. Association Study of Gut Flora in Coronary Heart Disease through High-Throughput Sequencing
Br J Nutr. 2014 Oct 28;112(8):1341-52 Patterns of dietary intake and serum c Gut Microbes. 2018 Nov 2;9(6):486-496. Probiotics drive gut microbiome triggering emotional brain signatures
Cells. 2020 Feb 6;9(2):376 Interventional Influence of the Intestinal Microbiome Through Dietary Intervention and Bowel Cleansing Might Improve Motor Symptoms in Parkinson’s Disease
Nutrients. 2020 Jun 18;12(6):1815. Flavonoid-Rich Orange Juice Intake and Altered Gut Microbiome in Young Adults with Depressive Symptom: A Randomized Controlled Study
Psychoneuroendocrinology. 2018 Dec;98:52-60 Marital distress, depression, and a leaky gut: Translocation of bacterial endotoxin as a pathway to inflammation
Sci Rep. 2020 Feb 28;10(1):3680 Disturbance in human gut microbiota networks by parasites and its implications in the incidence of depression
Neuro Endocrinol Lett. 2008 Feb;29(1):117-24. The gut-brain barrier in major depression: intestinal mucosal dysfunction with an increased translocation of LPS from gram negative enterobacteria (leaky gut) plays a role in the inflammatory pathophysiology of depression
Cell. 2019 Sep 5;178(6):1313-1328.e13 Antibiotics-Driven Gut Microbiome Perturbation Alters Immunity to Vaccines in Humans
BMC Biol. 2019 Sep 18;17(1):76. Distinct impact of antibiotics on the gut microbiome and resistome: a longitudinal multicenter cohort study
Nat Med. 2020 Apr;26(4):589-598 Effects of underfeeding and oral vancomycin on gut microbiome and nutrient absorption in humans
Sci Rep. 2020 Mar 25;10(1):5397 Rosuvastatin alters the genetic composition of the human gut microbiome
Medicine (Baltimore). 2020 Aug 28;99(35):e21488 Celiac disease serology and gut microbiome following proton pump inhibitor treatment
Clin Exp Allergy. 2015 Sep;45(9):1419-29 Gut microbiome and innate immune response patterns in IgE-associated eczema
West Indian Med J. 1994 Sep;43(3):87-8. The intestinal permeability test applied to the diagnosis of food allergy in paediatrics
Orv Hetil. 1996 Jan 14;137(2):65-9 [Relationship between intestinal permeability and antibodies against food antigens in IgA nephropathy]
Scand J Rheumatol. 1982;11(1):33-8. Intestinal permeability in dermatitis herpetiformis
Pediatr Med Chir. 1991 Mar-Apr;13(2):169-72. Intestinal permeability, atopic eczema and oral disodium cromoglycate
Scand J Rheumatol. 1982;11(1):33-8. Intestinal permeability in dermatitis herpetiformis
JCI Insight. 2018 May 3;3(9):e120608 First-in-human topical microbiome transplantation with Roseomonas mucosa for atopic dermatitis
J Clin Gastroenterol. 2012 Oct;46 Suppl:S56-63 Changing of fecal flora and clinical effect of L. salivarius LS01 in adults with atopic dermatitis
Benef Microbes. 2019 Feb 8;10(1):5-17 Eczema-protective probiotic alters infant gut microbiome functional capacity but not composition: sub-sample analysis from a RCT
Sci Rep. 2020 Jul 29;10(1):12754. Metagenomic analysis of gut microbiota in non-treated plaque psoriasis patients stratified by disease severity: development of a new Psoriasis-Microbiome Index
Exp Dermatol. 2018 Dec;27(12):1336-1343. Intestinal microbiota profiling and predicted metabolic dysregulation in psoriasis patients
Sci China Life Sci. 2019 Jun;62(6):807-815. Dysbiosis of gut microbiota was closely associated with psoriasis
Br J Rheumatol. 1997 Jan;36(1):64-8. Faecal microbial flora and disease activity in rheumatoid arthritis during a vegan diet
Cell Metab. 2018 Jun 5;27(6):1222-1235.e6 Intermittent Fasting Confers Protection in CNS Autoimmunity by Altering the Gut Microbiota
Allergol Int. 2014 Dec;63(4):575-85. Effects of bifidobacterial supplementation to pregnant women and infants in the prevention of allergy development in infants and on fecal microbiota
J Pediatr Gastroenterol Nutr. 2015 Aug;61(2):200-7 Does Maternal Perinatal Probiotic Supplementation Alter the Intestinal Microbiota of Mother and Child?
Eur J Nutr. 2019 Oct;58(7):2713-2729. Effects of products designed to modulate the gut microbiota on hyperlipidaemia
Biomed Res Int. 2017;2017:8127814. Bacterial Community Profile of the Gut Microbiota Differs between Hypercholesterolemic Subjects and Controls
Nat Commun. 2018 Feb 16;9(1):707. Delayed gut microbiota development in high-risk for asthma infants is temporarily modifiable by Lactobacillus supplementationClinical Experimental Rheumatology (2006 Jan-Feb;24(1):25-30)
Inflamm Bowel Dis. 2012 Oct;18(10):1809-17 Pediatric ulcerative colitis associated with autoimmune diseases: a distinct form of inflammatory bowel disease?
Scand J Gastroenterol. 2015;50(9):1076-87 Molecular assessment of differences in the duodenal microbiome in subjects with irritable bowel
J Gastroenterol Hepatol. 2011 Apr;26 Suppl 3:135-8 Small intestinal bacterial overgrowth (SIBO) in irritable bowel syndrome: frequency and predictors
Dig Dis Sci. 2009 Jan;54(1):132-5 Incidence of predominant methanogenic flora in irritable bowel syndrome patients and apparently healthy controls from North India
J Ethnopharmacol. 2019 Jun 12;237:182-191 Effect of water extract from Berberis heteropoda Schrenk roots on diarrhea-predominant irritable bowel syndrome by adjusting intestinal flora
Dig Liver Dis. 2017 Apr;49(4):331-337 Altered molecular signature of intestinal microbiota in irritable bowel syndrome patients compared with healthy controls: A systematic review and meta-analysis
Zhong Xi Yi Jie He Xue Bao. 2004 Sep;2(5):340-2 [Observation on intestinal flora in patients of irritable bowel syndrome after treatment of Chinese integrative medicine]
Zhongguo Zhong Xi Yi Jie He Za Zhi. 2006 Mar;26(3):218-20 [Preliminary study on intestinal flora in diarrhea type irritable bowel syndrome with pi-wei dampness-heat syndrome]
World J Gastroenterol. 2014 Mar 14;20(10):2449-55 Overgrowth of the indigenous gut microbiome and irritable bowel syndrome
Expert Rev Gastroenterol Hepatol. 2018 May;12(5):439-445. Fecal microbiota transplantation for managing irritable bowel syndrome
J Clin Gastroenterol. 2017 Nov/Dec;51(10):869-877 Postinfection Irritable Bowel Syndrome: The Links Between Gastroenteritis, Inflammation, the Microbiome, and Functional Disease
Curr Opin Endocrinol Diabetes Obes. 2014 Feb;21(1):15-21 Irritable bowel syndrome, inflammatory bowel disease and the microbiome
Chin Med J (Engl). 2019 Apr 20;132(8):889-904 Characteristic dysbiosis of gut microbiota of Chinese patients with diarrhea-predominant irritable bowel syndrome by an insight into the pan-microbiome
JAMA. 2019 Jan 15;321(2):156-164 Effect of Fecal Microbiota Transplantation on 8-Week Remission in Patients With Ulcerative Colitis: A Randomized Clinical Trial
Lancet. 2017 Mar 25;389(10075):1218-1228 Multidonor intensive faecal microbiota transplantation for active ulcerative colitis: a randomised placebo-controlled trial
Inflamm Bowel Dis. 2017 Oct;23(10):1702-1709 Systematic Review and Meta-analysis: Fecal Microbiota Transplantation for Treatment of Active Ulcerative Colitis
Immunopharmacol Immunotoxicol. 2018 Dec;40(6):465-475 Review of Saccharomyces boulardii as a treatment option in IBD
World J Gastroenterol. 2019 May 14;25(18):2188-2203 Diversity of Saccharomyces boulardii CNCM I-745 mechanisms of action against intestinal infections
Sci Rep. 2019 Sep 13;9(1):13263 Remission in Crohn’s disease is accompanied by alterations in the gut microbiota and mucins production
Eur J Clin Nutr. 2016 Sep;70(9):1052-6 Enteral feeding reduces metabolic activity of the intestinal microbiome in Crohn’s disease: an observational study
World J Gastroenter 2016 feb 14;22(6):2111-7 Response to strict and liberalized specific carbohydrate diet in pediatric Crohn’s disease
Cureus 2018 feb 9;10(2)e2177 Effect of the Specific Carbohydrate Diet on the Microbiome of a Primary Sclerosing Cholangitis and Ulcerative Colitis Patient
J Pediatr Gastroenterol Nutr 2014 Jan;58(1):87-91. Nutritional therapy in pediatric Crohn disease: the specific carbohydrate diet
Nat Commun. 2018 Nov 13;9(1):4630. A low-gluten diet induces changes in the intestinal microbiome of healthy Danish adults
Curr Pharm Des. 2017;23(16):2344-2351. Gut Microbiota Modulation and Anti-Inflammatory Properties of Dietary Polyphenols in IBD: New and Consolidated Perspectives
J Nutr Biochem. 2019 Feb;64:228-236. Impact of dietary fiber supplementation on modulating microbiota-host-metabolic axes in obesity
BMC Microbiol. 2016 Nov 3;16(1):255. Pectin enhances the effect of fecal microbiota transplantation in ulcerative colitis by delaying the loss of diversity of gut flora
Gut. 2020 Jul;69(7):1218-1228. Mediterranean diet intervention alters the gut microbiome in older people reducing frailty and improving health status: the NU-AGE 1-year dietary intervention across five European countries
Antioxidants (Basel). 2017 May 17;6(2):34 A Study of the Protective Properties of Iraqi Olive Leaves against Oxidation and Pathogenic Bacteria in Food Applications
Endocr Metab Immune Disord Drug Targets 2018;18(1):85-93 Olive Leaf Extracts Act as Modulators of the Human Immune Response
Biomed Pharmacother. 2019 Oct;118:109131 Effects of berberine and metformin on intestinal inflammation and gut microbiome composition in db/db mice
Appl Microbiol Biotechnol. 2020 Feb;104(4):1737-1749 Berberine ameliorates colonic damage accompanied with the modulation of dysfunctional bacteria and functions in ulcerative colitis rats
Acta Pharmacol Toxicol (Copenh) 1952;8(1):71-8 Toxicity of alkaloids to certain bacteria. II. Berberine, physostigmine, and sanguinarine
Front Pharmacol. 2018 May 31;9:571 Berberine Regulates Treg/Th17 Balance to Treat Ulcerative Colitis Through Modulating the Gut Microbiota in the Colon
Pak J Pharm Sci. 2009 Oct;22(4):421-4 Antibacterial activity of oregano (Origanum vulgare Linn.) against gram positive bacteria
Food Microbiol. 2015 May;47:69-73 Application of an oregano oil nanoemulsion to the control of foodborne bacteria on fresh lettuce
Curr Pharm Des. 2019;25(16):1809-1816 Essential Oil and Ethanol Extract of Oregano (Origanum vulgare L.) from Armenian Flora as a Natural Source of Terpenes, Flavonoids and other Phytochemicals with Antiradical, Antioxidant, Metal Chelating, Tyrosinase Inhibitory and Antibacterial Activity
Pak J Pharm Sci. 2009 Oct;22(4):421-4 Antibacterial activity of oregano (Origanum vulgare Linn.) against gram positive bacteria
J Oral Sci. 2017 Dec 27;59(4):597-601 The effects of essential oil, povidone-iodine, and chlorhexidine mouthwash on salivary nitrate/nitrite and nitrate-reducing bacteria
Zhonghua Yan Ke Za Zhi. 2008 Dec;44(12):1098-102 [Comparative study of gentamycin and povidone-iodine on eliminating the conjunctival bacteria]
Phys Chem Chem Phys. 2010 Oct 21;12(39):12653-7 The aluminium and iodine pentoxide reaction for the destruction of spore forming bacteria
J Cataract Refract Surg. 2012 Jan;38(1):92-6. Effect of povidone-iodine concentration and exposure time on bacteria isolated from endophthalmitis cases