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Homeopathy in the Age of Antimicrobial
Resistance: Is It a Viable Treatment for
Upper Respiratory Tract Infections?
Alison Fixsen1
1Department of Life Sciences, University of Westminster, London,
United Kingdom
Homeopathy
Address for correspondence Alison Fixsen, DProf, BA (Hons.), MA,
Department of Life Sciences, University of Westminster, 115 New
Cavendish Street, London W1W 6UW, United Kingdom
(e-mail: A.Fixsen@westminster.ac.uk).
Keywords
►homeopathy
►antimicrobial
resistance
►upper respiratory
tract infections
►clinical studies
►combination
remedies
Abstract Background Acute upper respiratory tract infections (URTIs) and their complications
are the most frequent cause of antibiotic prescribing in primary care. With multi-
resistant organisms proliferating, appropriate alternative treatments to these condi-
tions are urgently required. Homeopathy presents one solution; however, there are
many methods of homeopathic prescribing. This review of the literature considers
firstly whether homeopathy offers a viable alternative therapeutic solution for acute
URTIs and their complications, and secondly how such homeopathic intervention
might take place.
Method Critical review of post 1994 clinical studies featuring homeopathic treat-
ment of acute URTIs and their complications. Study design, treatment intervention,
cohort group, measurement and outcome were considered. Discussion focused on the
extent to which homeopathy is used to treat URTIs, rate of improvement and
tolerability of the treatment, complications of URTIs, prophylactic and long-term
effects, and the use of combination versus single homeopathic remedies.
Results Multiple peer-reviewed studies were found in which homeopathy had been
used to treat URTIs and associated symptoms (cough, pharyngitis, tonsillitis, otitis
media, acute sinusitis, etc.). Nine randomised controlled trials (RCTs) and 8 observa-
tional/cohort studies were analysed, 7 of which were paediatric studies. Seven RCTs
used combination remedies with multiple constituents. Results for homeopathy
treatment were positive overall, with faster resolution, reduced use of antibiotics
and possible prophylactic and longer-term benefits.
Conclusions Variations in size, location, cohort and outcome measures make com-
parisons and generalisations concerning homeopathic clinical trials for URTIs proble-
matic. Nevertheless, study findings suggest at least equivalence between homeopathy
and conventional treatment for uncomplicated URTI cases, with fewer adverse events
and potentially broader therapeutic outcomes. The use of non-individualised homeo-
pathic compounds tailored for the paediatric population merits further investigation,
including through cohort studies. In the light of antimicrobial resistance, homeopathy
offers alternative strategies for minor infections and possible prevention of recurring
URTIs.
received
August 16, 2017
accepted
December 8, 2017
Copyright © The Faculty of Homeopathy DOI https://doi.org/
10.1055/s-0037-1621745.
ISSN 1475-4916.
Review Article
Introduction
With the emergence and proliferation of multi-resistant
organisms, the prospect of an ‘antimicrobial perfect storm’1
in the approaching decades has become an urgent public
health concern.1The excessive and indiscriminate use of
these drugs in both human and veterinary practices has led
to the emergence and dissemination of resistant organisms
that endanger their efficacy.2–4Each year in the United
States, at least 2 million people become infected with bac-
teria that are resistant to antibiotics, and at least 23,000
people die as a direct result of these infections.5Warning of
an approaching era in which antibiotics will no longer be
effective, the World Health Organization (WHO) and other
agencies6,7 suggest alternative approaches, including the
development of novel therapies to treat both mild and
serious infections.7,8 With a growing body of clinical evi-
dence, a strong safety record and evidence of cost-effective-
ness,9–11 homeopathy represents one potential therapeutic
solution that could lead to a reduction in the use of anti-
biotics. Acute upper respiratory tract infections (URTIs)
account for 60% of antibiotic prescribing in primary care,12
yet they provide little benefit for the large proportion of
respiratory tract infections which are viral in origin. This
review of the literature asks, firstly, whether the peer-
reviewed literature on this topic is sufficiently robust for
homeopathy to be seriously considered as an alternative to
antibiotics for URTIs and their complications and, secondly,
how this homeopathic intervention might take place, for
example through more widespread use of particular homeo-
pathic preparations.
Literature Search Strategy
The literaturereview focuses on peer-reviewedclinical studies
featuring homeopathic treatment of URTIs published after
1994. Due to the close association between URTIs and acute
rhinopharyngitis and tonsillitis and their frequent treatment
with antibiotics, several peer-reviewed studies in which
homeopathy was used to treat these conditions were also
reviewed. Although not rigorously following the format of a
systematic review, the PRISMA guidelines (http://www.
prisma-statement.org) and recommendations of PRISMA-P
checklist (http://www.prisma-statement.org/documents/
PRISMA-P-checklist.pdf) were utilised for the reporting of
data in ►Tables 1 and 2. Searches were conducted in two
phases. In phase one, the following electronic databases were
searched: AMED, Embase, Cochrane Library, PubMed, Scien-
ceDirect, Elsevier Health periodicals and CORE-Hom database.
In phase two, additional searches were performed through
Google Scholar, Mendeley literature search and the author’s
university library. Citation chaining was also utilised; how-
ever, studies for which the full article or key study details
could not be later established were excluded from the final
systematic analysis. Searches, although wide, were limited to
published, peer-reviewed human trials reported in English.
Key search terms were homeopathy, upper respiratory tract
infections, rhinopharyngitis and mild viral infections. Studies
which included related conditions, such as bronchitis,13 influ-
enza,14 otitis media and tonsillitis,15 were considered only if
URTI or viral infection involving the upper respiratory tract
(URT) was mentioned in the title or aims, and where relevant
to the study questions. Further exclusion criteria included
studies deemed to be of poor quality, published before 1994
and where more than one complementary and alternative
medicine (CAM) therapy was used. Case reports of homeo-
pathic treatments for URTIs from books and journals were
also not considered. To ensure that a broad body of evidence
was considered, peer-reviewed published studies, whether
randomised, controlled or cohort, were reviewed, but were
considered separately in terms of study aims and design
(see ►Table 1). Analysis of all studies focused on the following
elements: trial design; treatment intervention, with particu-
lar reference to single/complex homeopathic medicaments
(see ►Table 2); cohort group (paediatric/adult/both); mea-
surement criteria, and outcome, with particular reference to
reduction in antibiotic use.
URTIs and Antibiotics
The upper respiratory tract (URT) consists of the nose, mouth,
throat, larynx and trachea. URTI is the most common infectious
illness in most populations and the primary reason people miss
work or school.16 Although generally short lived, symptoms of
URTIs, such as fever, sore throat, headache and cough, are
sources of distress for both adults and children and are costly
in terms of time off work17,18 and school.18 The acute cough
following a URTI can continue for several weeks.13 Children are
especially susceptible and may have as many as eight or even
more episodes each year. Most URTIs are caused by a self-
limiting viral illness (such as influenza and rhinoviruses) with
symptoms lasting 7 to 10 days; however, complications such as
otitis media,19 pharyngitis,20 tonsillitis21 and sinusitis22 are
frequently treated with antibiotics.23–27 In the United States,
23% of paediatric medical visits from 2004 to 2008 resulted in
prescriptions for antibiotics9with otitis media, the most com-
mon reason for prescribing antibiotics in children. Other phar-
macological treatments include antipyretics,ant i-inflammatory
drugs, expectorants, decongestants, and cough suppressants,
either alone or in combination.28 Respiratory complaints are
also the most frequent reason for over-the-counter (OTC) pur-
chases of homeopathic medicines,29 suggesting a demand for
alternatives to pharmaceutical OTC products.
Public health and medical stewardship programmes aim
to alter patients’perceptions and doctors’prescribing beha-
viour.1Yet in many clinical contexts, antibiotic prescribing
continues to elude best practice,1including in the treatment
of URTIs and URTI-related conditions.23,30,31 According to a
recent US clinical report, up to 10 million antibiotic pre-
scriptions per year directed towards respiratory conditions
were unlikely to provide any benefit.32 Fewer than 10% of
sore throats are caused by bacterial infections, yet in around
60% of cases, antibiotics were prescribed for them.33 In
recent Cochrane reviews, the short-term effects of antibio-
tics on acute otitis media (AOM)34 and URTIs35 were mod-
erate or negligible when compared with their potential risks.
Homeopathy
Homeopathy in the Age of Antimicrobial Resistance Fixsen
One Cochrane study found antibiotics to be ‘not very useful’
in the treatment of AOM, only marginally decreasing the
number of children with pain at 24 hours (when most
children were better), only slightly reducing those with
pain in the first few days following infection and having no
effect on reducing the number of children with subsequent
hearing loss.34 In some patients with acute bronchitis, anti-
biotics had a modest beneficial effect; however, these ben-
efits must be considered in the broader context of side
effects, the self-limiting nature of the condition, the costs
of antibiotic treatment and the increased resistance to
respiratory pathogens.35 Only in the case of pneumonia in
the elderly were the benefits of antibiotics seen as signifi-
cant;36 however, the authors of this study concluded that the
use of antibiotics for prophylaxis was still not justifiable.
Another US study estimated the number of annual antibiotic
prescriptions for acute respiratory conditions (including
sinusitis, otitis media, and pharyngitis) as 221 per 1,000
people, yet only half of these prescriptions were considered
appropriate for these conditions.37 Understanding differen-
tial diagnosis is also important, as is ruling out more serious
illness. For instance, while most cases of acute pharyngitis in
children have a viral origin, are benign and self-limiting
(and for which antibiotics are often unnecessarily pre-
scribed), untreated streptococcal tonsillopharyngitis can
result in serious complications, such as rheumatic fever
and related cardiovascular disorders or post-streptococcal
glomerulonephritis.38,39
In addition to efficacy, the immunological effects and
safety of antibiotics are a concern. Studies confirm that
pervasive changes occur within the human microbiome
after antibiotic treatment and that resistant strains of
bacteria can persist for years.40 Individuals prescribed
antibiotics in primary care for a respiratory infection
develop bacterial resistance to that antibiotic, which not
only increases the population carriage of organisms resis-
tant to first-line antibiotics, but also leads to increased use
of second-line antibiotics in the community.41 According to
one meta-analysis, the risk of acquiring methicillin-resis-
tant Staphylococcus aureus increased by 1.8-fold in patients
who had taken antibiotics.42 Nevertheless, public aware-
ness concerning the appropriate use and safety of antibio-
tics still appears to be lacking. In one Australian consumer
study, over one-third of the 252 participants thought that
taking antibiotics when suffering from a cold or fluwould
lead to more rapid recovery, while nearly one-fifth consid-
ered antibiotics as a cure for viral infections.43 Links have
been established between antibiotic use and paediatric
asthma44,45 and eczema46 and less common but grave
physical and psychoactive side effects associated with par-
ticular antibiotics. The class of antibiotics fluoroquinolones
is known to cause tendonitis, central nervous system (CNS)
effects, peripheral neuropathy,47 and juvenile fluoroquino-
lone-induced joint/cartilage toxicity.48 Severe side effects
of the broad spectrum antibiotic clarithromycin include
liver and renal failure49,50 and psycho-neurological effects
including hallucinations, depersonalisation, depression,
insomnia and psychosis.51
The Homeopathic Approach
As a CAM therapy, homeopathy has been subject to criticism
for its use of infinitesimal doses to treat different aliments,
with insufficient proof that such doses can have an effect.52
Yet, despite a long history of scientific controversy, homeop-
athy has proved resilient, is geographically widespread,53
and is an accepted part of the medical system in countries
such as India,54 France55 and Switzerland.56 Advantages of
homeopathy include ease of application and safety, with few
contraindications existing in the treatment of the very
young9and old, beside the careful selection of remedy and
dosage. Whereas using ant ibiotics and OTC medications does
little to improve the body’s future response to infection,
homeopathy purports to do so.
When dealing with complex systems, a holistic medical
approach, such as is frequently used in homeo pathy, can offer
therapeutic advantages over no n-individualised reductionist
methods.57,58 In part, it is the person-focused approach of
traditional homeopathy that distinguishes it from conven-
tional approaches59 and contributes to its appeal to certain
population groups.60–62 Unlike mainstream medicine, where
treatment is based on the clinical diagnosis and the idiosyn-
cratic symptoms of the patient are given less importance, in
the ‘classical’homeopathic tradition the prescription of a
homeopathic medication or ‘remedy’is based on the totality
of symptoms and signs exhibited or expressed by an indivi-
dual patient.63 Thus, in homeopathic case-taking, the assess-
ment of the medical situation may not be the principal
reason for the choice of remedy,56 and a spectrum of
remedies based on different criteria may be considered.
There are, however, many variations to the homeopathic
method of prescribing, especially in the treatment of chronic
conditions. A particular distinction lies between individua-
lised and clinically based homeopathic treatment protocols,
the former being based on a ‘total system approach’as
described above and the latter on a more generic method, in
which ‘combination’or‘complex’homeopathic medicines may
be prescribed for a particular condition or disease.64 Another
method, ‘isopathy’, refers to the use of diseased by-products or
tissues, knownas ‘nosodes’, andhealthy animal tissue, referred
to as sarcodes,65 which may be prescribed individually or to a
population group for preventative purposes.66,67 All these
methodologies have been employed in clinical studies, includ-
ing for the treatment of URTIs. From the homeopathic per-
spective, patients with chronic conditions may require
‘constitutional’remedies, emphasising the suitability of the
in-depth individualised approach. Seeking a ‘totality’of symp-
toms in a holistic sense68 is resource and time consuming
however, as it requires a detailed chronological history of the
patient and their condition so that a single remedy can be
prescribed to treat a range of symptoms. In acute conditions,
the symptom picture is less complicated and the need to
prescribe more urgent, strengthening the case for non-indi-
vidualised prescribing.
Homeopathy and Research
With an empirical tradition going back more than 200 years
and homeopathic physicians trained in the scientific
Homeopathy
Homeopathy in the Age of Antimicrobial Resistance Fixsen
method, research has always been the backbone of homeop-
athy. Homeopathic literature includes a vast number of
published drug “provings’, case studies and practice reports;
however, substantial areas of practice have remained
uncharted. For instance, the treatment of large-scale epi-
demics has never been systematically and scientifically
researched.56 The problems of measuring the effects of
homeopathic treatment through randomised controlled
trials (RCTs) and other reductionist methods are consider-
able. A number of systematic r eviews of the homeopathy RCT
literature by Mathie et al64,69,70 found significant inadequa-
cies, with the majority of studies demon strating uncertain or
high risk of bias. Some studies were not properly rando-
mised, with most studies addressing a different aspect of
homeopathic care.71 Practical problems of RCTs include
selecting patients for participation, the insecurities caused
by blinding and variations in the level of training of indivi-
dual homeopathic physicians. Whereas conventional medi-
cine examines the specific effect of a pharmaceutical
substance, the effects of a homeopathic substance arise
from its complex individual interaction with the organism
and this limits the external validity and generalisability of
placebo-controlled, blinded homeopathy studies.56 As with
all clinical trials, there are variations in size and outcome
measures, with the limited number of homeopathic studies
making these types of anomalies more significant.
The absence of positive or any RCT results does not
necessarily mean that a t reatment is ineffective, and a danger
lies in eliminating treatments on the basis of no RCT proof of
their efficacy.56 Non-RCTs and patient reported surveys are
considered by some to be inferior for ms of research evidence,
but are important adjuncts to RCTs that can measure key
markers such as patient satisfaction, quality of life and
functional health. Observational studies such as clinical
outcome studies and case reports, monitoring the effects
of homeopathy in real-life clinical settings, are a helpful
adjunct to RCTs72 and more closely reflect real-life experi-
ences of patients and physicians than RCTs,73 and are there-
fore considered in this study.
Results
Searches of online libraries and bibliographical references
found multiple peer-reviewed studies (in English and non-
English) published between 1994 and 2017, in which
homeopathy had been used to treat URTIs and associated
symptoms (cough, pharyngitis, tonsillitis, otitis media, acute
sinusitis, etc.). Both RCTs and observational/cohort studies
were searched and screened to ensure that as many studies
as possible were included in the review and its discussion.
Non-English language studies, and those for which key study
details could not b e established, were later excluded from the
final review, as were those that did not directly refer to URTIs
in the title or content. For the final review, nine RCTs and
eight observational/cohort studies were analysed, of which
six of the RCTs and one observational/cohort trial were
paediatric studies. Seven RCTs used combination remedies
with multiple constituents. One of the RCTs in these tables is
featured twice as it measured treatment effects on two
different cohorts. The first article 74 reports the effects and
safety of standard treatment (ST) plus a homeopathic com-
pound (Influcid [IFC]), or ST only, on a mixed age cohort with
a URTI. The later article 28 reports the effects of ST plus IFC or
ST only, on a paediatric cohort. Both articles have been
included in the analysis. The two studies reported by Zanasi’s
team (RCT13 and observational75) bear similarities in that the
same homeopathic complex was used on both paediatric
arms; however, in the observational study one arm received
antibiotics in addition to the homeopathic cough medicine.
Full details of randomised and observational studies,
including trial design, mode of homeopathic treatment
(e.g. complex, individualised), cohort, outcome assessment,
results and conclusions, are given in ►Table 1.►Table 2
focuses on studies using complex homeopathic remedies,
and a breakdown of the homeopathic constituents where
this information was available.
The article’s discussion focuses on the following areas of
concern: extent to which homeopathy is used for URTIs,
tolerability and rate of improvement of homeopathic treat-
ment, complications of URTIs, prophylactic and long-term
effects, and the use of combination versus single homeo-
pathic remedies. As a literature review, rather than a sys-
tematic review, no attempt has been made to extract new
data from the primary articles, or to assess the intrinsic
quality of each study, including risk of bias.
Use of Homeopathy for URTIs
Respiratory infections are a common reason for seeking
homeopathic care.76,77 For example, out of 551 paediatric
patients treated at a homeopathic clinic in Rossi et al’s
observational study, 337 (61%) presented with respiratory
infections, making this the most frequently obser ved disease
in this population group.78 Of the various clinical trials
featuring the use of homeopathy for a specific condition,
those concerning infectious diseases of the URT,13,28,79,80
and complications such as AOM (ear infections)9,81 contain
some of the most positive evidence of the effectiveness of
homeopathic interventions.56 The evaluation of 27 studies
for a Health Technology Assessment report on effectiveness,
cost-effectiveness and appropriateness of homeopathy on
URTIs and allergic reactions showed a positive overall result
in favour of homeopathy, with six out of seven controlled
studies showing at least equivalence to conventional medical
interventions.56
Tolerability
In the treatment of self-limiting acute conditions such URTIs
and mild infections, both treatment tolerability and the rate
of improvement with a medical intervention are important,
and several studies suggest that homeopathic treatment can
fulfil both these prerequisites. Many participants in homeo-
pathic studies are children9,14,79,81–84 so it is significant that
the safety and tolerability of homeopathic treatment in the
trials reviewed was very good.28,74,79,85 A good rate of
improvement in the acute symptoms of URTIs in those
Homeopathy
Homeopathy in the Age of Antimicrobial Resistance Fixsen
Table 1 Reviewed URTI-related published studies (1994–2016)
Authors Date/Journal Description Treatment Cohort/Patients Outcome assess-
ment
Outcome Conclusion
Randomised Controlled Trials
de Lange et al 1994/
BMJ
Randomised,
double-blind,
placebo-controlled
clinical trial
Homeopathy
versus placebo
Daily assessed
symptom score
175 children with
frequently
recurring URTIs
Number of
antibiotic courses,
and number of
adenoidectomies
and tonsillectomies
over 1 year of
follow-up
Improvements in
both groups, but
fewer
adenoidectomies
in homeopathic
treatment group
Homeopathy offers
little more than
careful counselling
of children with
URTIs, but some
effects noted
Diefenbach et al 1997/
Z Allgemeinmed
Randomised,
double-blind,
placebo-controlled
clinical trial
Homeopathic
combination
BRONCHISELECT
versus placebo
258 patients
presenting with
acute URTI/
bronchitis
Number of days of
coughing,
and degree of
expectoration and
dysphagia
After 3 weeks,
homeopathic
group had <days
of coughing than
placebo
Expectoration and
dysphagia went
better under verum
Therapy with
BRONCHISELECT is
effective
Steinsbekk et al 2007/
Preventive
Medicine
Randomised
controlled trial
Homeopathic care
versus self-
prescribed
homeopathic
medicine
208 children below
the age of 10 years
Results of
prescribed
homeopathic
medicine in the
prevention of
childhood URTIs
No significant
differences in
clinical effects
between SPH and
HC for primary
outcomes
No evidence for
clinically relevant
effect of
homeopathic care
versus a
homeopathic
medicine
prescribed by
child's parents
Zanasi et al 2014/
Pulm Pharmacol
Ther
Double blind,
placebo controlled
clinical trial
ST versus
homeopathic
cough syrup
80 patients Cough severity
and. sputum
viscosity
Cough diminished
in all groups but at
4 and 7 days, cough
severity was
significantly lower
in the homeopathic
group than in the
placebo
The homeopathic
syrup is a valid
remedy for the
management of
acute cough
inducedbyURTIs
Thinesse-Mallwitz
et al
2015/
Forsch
Komplementä
rmed
Randomised,
controlled,
multinational
clinical trial
ST plus IFC for 7
days
523 patients (1–65
years)
265 IFC group, 258
ST group, with
feverish URTIs.
Effectiveness and
safety of
homeopathic IFC as
add-on therapy to
usual care in URTI
patients
IFC group used less
symptomatic
medication;
symptoms were
alleviated 1–2 days
earlier
IFC reduced used of
SC medication
accelerated
resolution, and was
safe in use
(Continued)
Homeopathy
Homeopathy in the Age of Antimicrobial Resistance Fixsen
Table 1 (Continued)
Authors Date/Journal Description Treatment Cohort/Patients Outcome assess-
ment
Outcome Conclusion
Van Haselen et al 2016/Glob Pediatr
Health
Randomised,
controlled,
multinational
clinical trial
ST plus a IFC for 7
days
261 children (<12
years) patients
Clinical
effectiveness of
homeopathic add-
on therapy in
paediatric group
with URTIs
Less symptoms and
faster symptoms
resolution, fewer
fevers from day 3
onwards in
homeopathic
group
IFC as add-on
treatment reduced
disease severity,
shortened
symptom
resolution, and was
safe in use
Jong et al 2016/Multidiscip
Respir Med
Multi-centre
randomised
controlled trial
CalSuli-4–02 or a
comparator
homeopathic
product for 3 weeks
200 children
aged 6ywith(
three acute URTIs
during previous 6
months
Frequency of acute
URTIs 3 and
6 months post-
treatment,
Changes in
symptoms,
treatment
satisfaction,
antibiotic use,
safety and
tolerability also
considered
Decrease in
antibiotic use in
both treatment
groups.
‘Appetite disorder’
and ‘child’s
activities' improved
more in the CalSuli-
4–02 group
Suggests potential
of CalSuli-4–02 as
antibiotic option
Siqueira et al 2016/Homeopathy Randomised,
placebo-controlled
clinical trial
Homeopathic
complex, placebo
or InfluBio
600 children Number of fluand
acute respiratory
infection
symptomatic
episodes in 1 year
First year: 30.5% of
children in the
placebo group
developed 3 or
more fluandacute
respiratory
infection episodes,
and no episodes in
either
homeopathic
groups
Homeopathic
prophylactic
potential should be
investigated in
further studies
Jacobs and Taylor 2016/Comp Ther
Med
Randomised,
placebo-controlled
clinical trial
Homeopathic
cough syrup or
placebo.
medication given
as needed by
parents for 3 days
261 children 2–5
years with URTIs
Change in
symptoms
one hour after each
dose
Improvements in
sneezing, cough
and the composite
cold score
significantly >at
1st and 2nd
assessments for
homeopathic
group compared
with placebo group
Homeopa thic syrup
appeared to be
effective in
reducing the
severity of cold
symptoms on first
day after starting
treatment
Homeopathy
Homeopathy in the Age of Antimicrobial Resistance Fixsen
Table 1 (Continued)
Authors Date/Journal Description Treatment Cohort/Patients Outcome assess-
ment
Outcome Conclusion
Observational Studies
Herzberger and
Weiser
1997/Biomed Ther Prospective, multi-
centre
observational
study
Engystol in
combination with
other therapies
application, global
evaluation
1,479 cases treated
by 154 physicians
Application,
effectiveness and
tolerability of
Engystol
Half of the patients
improved in 1–4
days
Prophylactic
effects of Engystol
were ver y good,
and tolerability was
excellent
Riley et al 2001/J Altern
Complement Med
Outcomes study Homeopathy
versus SC
456 patients Clinical and
subjective
improvement in
the complaints
Clinical and
subjective
improvement after
14 days in 82.6% of
homeopathy group
and 68% of
conventional
treatment group
Clear superiority of
homeopathy over
conventional
treatment
Rabe et al 2004/
Int J Clin Pract
Outcomes study Homeopathic
complex Gripp-
Heel compared
with SC
485 patients Effectiveness of
homeopathic
remedy Gripp-Heel
for mild viral
infection
Success
rate ¼78.1%
homeopathic
group and 52.2%
SC. 88.9%
homeopathic
group versus 38.8%
SC rated ‘very
good’
Better satisfaction
scores for Gripp-
Heel therapy group
than SC
Ammerschlager
et al
2005/Res
Complement Nat
Class Med
Multi-centre,
prospective, active-
controlled
study
Euphorbium
complex compared
with
xylometazoline
nasal drops
Patients with URTIs To demonstrate
non-inferiority of
the homeopathic
complex remedy to
xylometazoline
Clinically relevant
reductions disease-
specific symptoms
were observed with
both therapies
Favorab le
outcomes for
homeopathic
Euphorbium.
Tolerabilit y was
good with for both
therapies
Schmiedel and
Klein
2006/Explore Observational
study of 85 GP
practices
Germany
Complex
homeopathic
Engystol versus
conventional
treatment
397 patients A range of variables
plus improvement
time
Improvement in
77.1% patients
using Engystol,
versus 61.7% for
control in 3 days
Engystol may be a
useful component
of an integrated
symptomatic
therapy for the
common cold
(Continued)
Homeopathy
Homeopathy in the Age of Antimicrobial Resistance Fixsen
Table 1 (Continued)
Authors Date/Journal Description Treatment Cohort/Patients Outcome assess-
ment
Outcome Conclusion
Haidvogl et al 2007/BMC
Complement
Altern Med
International, multi
centre,
comparative
cohort outcome
study
Homeopathic
versus
conventional
treatment of acute
respiratory and ear
complaints
1,577 patients Proportion of
patients
experiencing
“complete
recovery”or “major
improvement”in
each treatment
group
Onset of
improvement
7 days post
treatment faster
with homeopathic
treatment in
children
(p¼0.0488) and
adults
(p¼0.0001)
Homeopathic
treatment of acute
respiratory and ear
complaints was not
inferior to
conventional
treatment
Zanasi et al 2015/Multidiscip
Respir Med
Prospective
observational
study
ST with
homeopathic
cough syrup versus
cough syrup only
85 children Whether
antibiotics had a
role in reducing the
severity duration
and resolution of
cough, and safety
of two treatments
Cough diminished
in all groups, but
adverse events
were >in group on
antibiotics
Antibiotics did not
improve cough
reduction but
increased side
effects
Beghi and Morselli-
Labate
2016/Multidiscip
Respir Med
Observational
study longitudinal
Oscillococcinum 459 patients,
followed up 1 and
10 years
Role of
Oscillococcinum in
preventing RTIs
Reduction in the
frequency of onset
of RTIs occurred in
both groups, but
homeopathic
group
improvement in
first year was
significantly bet ter
Homeopathic
medicine may have
apositiveeffectin
preventing RTIs
Abbrevia tions: IFC, Influcid; RTI, respiratory tract infection; SC, standard care; ST, standard treatment; URTI, upper respiratory tract infection.
Homeopathy
Homeopathy in the Age of Antimicrobial Resistance Fixsen
Table 2 URTI-related published studies using complex homeopathic remedies (1997–2016)
Authors Description Treatment Cohort Medical ingredients Conclusion
Diefenbach M et al (1997) RCT
Acute URTI/bronchitis
BRONCHISELECT or
placebo
258 patients Drosera D3, Bryonia D4,
Tartarus stibiatus D4,
Spongia D6 Ipecacuanha
D4
Therapy with
BRONCHISELECT is
effective
Zanasi A et al (2014) RCT
Acute cough arising from URTIs
Homeopathic syrup versus
placebo in treating cough
arising from URTIs
80 patients Anemone pulsatilla 6 CH,
Rumex crispus 6 CH,
Bryonia dioica 3 CH
Ipecacuanha 3 CH, Spongia
tosta 3 CH, Sticta
pulmonaria 3 CH
Antimonium tartaricum 6
CH, Myocarde 6 CH, Coccus
cacti 3 CH, Drosera MT
Homeopathic syrup was
able to effectively reduce
cough severity and sputum
viscosity
Thinesse-Mallwitz et al
(2016)
RCT
Acute influenza þURTI
ST or ST plus homeopathic
medication (Influcid) for 7
days
523 patients Aconitum napellus D3
Gelsemium sempervirens
D3 Cephaelis,
Ipecacuanha D3
Phosphorus D5 Bryonia D2
Eupatorium perfoliatum
D1
IFC reduced use of SC
medication accelerated
resolution and was safe in
use
van Haselen et al (2016) RCT
Acute URTI
(patients <12 years)
ST or ST plus homeopathic
medication (Influcid) for 7
days
261 children Aconitum napellus D3
Gelsemium sempervirens
D3 Cephaelis, Ipecacuanha
D3 Phosphorus D5 Bryonia
D2 Eupatorium perfoliatum
D1
IFC treatment reduced
disease severity,
shortened symptom
resolution,andwassafein
use
Jong et al (2016) RCT
URTIs (prevention)
CalSuli-or another
complex homeopathic
product
200 children Calcium carbonicum
Hahnemanni D6, Calcium
fluoratum D6, Calcium
phosphoricum D6 and
Sulfur jodatum D12.
Control ¼Gentiana D1,
Aconitum D6, Bryonia D6,
Ferrum phosphoricum
D12, and Acidum
sarcolacticum D12
Suggests potential of
CalSuli-4–02 as antibiotic
option
Taylor and Jacobs (2016) RCT
Severity and recovery time
URTI/cold sxs
Homeopathic cough syrup
(Hyland’s cold and cough
4 kids) or placebo
261 children (2–5 years) Allium Cepa 6X, Hepar
Sulph Calc 12X, Natrum
Muriaticum 6X,
Phosphorous 12X,
Pulsatilla 6X, Sulfur 12X,
Hydrastis 6x
Homeopathic syrup
appeared to be effective in
reducing the severity of
cold sympto ms on first day
after starting treatment
(Continued)
Homeopathy
Homeopathy in the Age of Antimicrobial Resistance Fixsen
Table 2 (Continued)
Authors Description Treatment Cohort Medical ingredients Conclusion
Siqueira et al (2016) RCT
Homeopathic prophylactic
potential
InfluBio homeopathic
complex or placebo
600 children Influbio ¼purified
influenza virus 30c
Homeopathic
complex ¼Streptococcus
and Staphylococcus)and
inactivated influenza
virus 30c
Homeopathic
prophylactic potential
should be investigated in
further studies
Observational
Herzberger and Weiser
(1997)
Prospective, multi centre
observational study
Engystol in combination
with other therapies
1479 cases treated by 154
physicians
SulfurD4,D10,Asclepias
vincetoxicum D6, D10,
D30.
Prophylactic effects of
Engystol were very good
Rabe et al (2004) Cohort study Homeopathic complex
Gripp-Heel or standard
care
485 patients Aconitum napellus 4X,
Bryonia alba 4X, Lachesis
mutus 12X, Eupatorium
perfoliatum 3X,
Phosphorus 5X
Better satisfaction scores
for Gripp-Heel therapy
group than control
Ammerschlager et al
(2005)
Cohort study Euphorbium complex or
xylometazoline nasal
drops
URTI patients Euphorbium complex Favourable outcomes for
Euphorbium. Tolerability
was good with for both
therapies
Schmiedel and Klein
(2006)
Observational study of 85 GP
practices
Engystol versus
conventional treatments
397 patients See Herzberger and
Weiser 1997
This homeopathic
treatment may be a useful
component of an
integrated symptomatic
therapy for the common
cold
Beghi and Morselli-Labate
(2016)
Observational study
longitudinal
Role of the
Oscillococcinum in
preventing RTIs
459 patients, followed up
1 and 10 years
Oscillococcinum once a
week for 8 months per
year
Reduction in the
frequency of onset of RTIs
occurred in both groups,
but homeopathic group
improvement in first year
was significantly greater
Abbrevia tions: IFC, Influcid; RCT, randomised controlled trial; SC , standard care; ST, standard treatment; URTI, upper respiratory tract infection.
Homeopathy
Homeopathy in the Age of Antimicrobial Resistance Fixsen
receiving homeopathic treatment was reported in all the
RCTs and observational trials in which this was measured;
however, the timescale for symptom improvement varied,
for example fever28 improved/resolved faster than cough.13
In Rabe et al’s study, treatment with the homeopathic
remedy complex Gripp-Heel was perceived by patients with
mild viral infections to be more successful, with greater
tolerability and compliance than conventional treatment.
About 67.9% of patients were considered by physicians to
be asymptomatic at the end of Gri pp-Heel therapy, compared
with 47.9% in the control group.86 In Zanasi et al’s placebo-
controlled RCT,13 80 patients were treated for acute cough
with placebo or the homeopathic syrup. While cough scores
decreased over time in each group, cough severity was
significantly lower in the homeopathic group than in the
placebo group after 4 and 7 days (p<0.001 and p¼0.023,
respectively). A controlled multinational clinical trial con-
ducted by Thinesse-Mallwitz et al74 in Germany and the
Ukraine compared the effectiveness, safety and tolerability
of IFC as an add-on treatment, with standard care (SC) alone,
in the prevention of recurrent acute URTIs. The IFC group
(265 patients) that was given homeopathy experienced
significantly faster improvement than those who had
received conventional treatment alone.74
Another study by Jong et al79 measured the effectiveness,
safety and tolerability of a homeopathic medicinal complex in
the prevention of recurrent acute URTIs in children. The trial,
which took place in four outpatient paediatric clinics, involved
children under six, with a known susceptibility to acute URTIs.
Children were randomly divided into two groups, one group
receiving the homeopathic combination remedy CalSuli-4–02
and the other (the control group) receiving another homeo-
pathic product, for 3 weeks. The main outcome measure was
frequency of acute URTIs occurring within 3 and 6 months
following treatment. Another outcome measure was a reduc-
tion in antibiotic use. Both ‘appetite disorder’and ‘child’s
activities’improved in both arms of the trial, but more
significantly in the CalSuli-4–02 group.
While results of the above studies are disadvantaged by
limited cohort size, others such as the large-scale interna-
tional comparative outcome study by Haidvogl et al87 of
1,577 adults and children from eight different countries are
less disputable. In this study, individualised h omeopathy and
SC were compared in the treatment of acute respiratory and
ear complaints. Treatment with homeopathy was associated
with significantly faster onset of improvement in the first
week, while adverse drug reactions occurred more fre-
quently only in the adult group receiving conventional
treatment. Results at 14 days were similar in both groups.
The authors concluded that homeopathy was not inferior to
conventional treatment in ear and acute respiratory
infections.
Complications of URTIs
Complications of URTIs are not the primary focus of this
article; however, in clinical practice they remain the most
common causes of antibiotic prescriptions21,37,88 and as
such warrant some attention in this review. Searches
revealed a good number of studies in which homeopathy
had been used for the URTI-related disorders with promising
outcomes, including AOM (ear infections),9,81,83,89 rhino-
pharyngitis,90,91 sinusitis,92–95 and tonsillitis.15,96 In a study
by Trichard et al comparing homeopathic and antibiotic
treatment strategies for rhinopharyngitis in children,
homeopathy yielded significantly better results than anti-
biotics in terms of both medical effectiveness (reduced
number of episodes and number of complications) and
improved quality of life with significantly less time taken
off work for parents.90 A randomised, double-blind study by
Friese and Zabalotnyi92 investigated the efficacy and toler-
ability of a homeopathic combination remedy for the treat-
ment of acute rhinosinusitis. One hundred and forty-four
patients with acute rhinosinusitis were treated either with a
homeopathic remedy (n¼72) or placebo (n¼72). In the
treatment group, the average sum score dropped from
initially 12.1 1.6 to 5.9 2.0 points after 7 days. In the
placebo group, it decreased from 11.7 1.6 to 11.0 2.9
points (p<0.001). After 21 days, 90.3% of the homeopathic
treatment group was free from complaints, whereas in 88.9%
of the placebo group the complaints remained unchanged or
became worse. The authors concluded that the homeopathic
product allowed an effect ive and tolerabl e treatment of acute
rhinosinusitis.
There have been several studies indicating the effectiveness
of homeopathy for both acute and chronic tonsillopharyngitis.
Friese et al97 performed a multi-centre, randomised, placebo-
controlled, double-blinded study on 158 paediatric patients
affected byacute non-streptococcal tonsillitis. The studygroup
received Tonsilotren hourly until onset of improvement, then
three times a day, while the control group received placebo.
Typical tonsillitis symptoms included swallowing difficulties,
throat pain and redness, salivation and fever. By day 4, the
study group showed a significantly higher rate of decrease in
symptoms than the placebo group. By day 6, 92.4% of study
patients showed full recovery or moderate improvement,
compared with the 43.1% in the control group, with a dete-
rioration rate of 3.8% in the study group against 22.8% in the
control group.
A more recent, international, RCT of the homeopathic
combination remedy SilAtro-5–90 (brand name: Tonsilot-
ren) was performed in multiple settings by Palm et al.96 Two
hundred and fifty-six patients aged 6 to 60 years with
moderate recurrent tonsillitis (RT) were given either the
homeopathic preparation in addition to standard sympto-
matic treatment or ST alone. The test group received Tonsi-
lotren for three treatment periods of 8 weeks, each
treatment period being followed by an 8- to 12-week period
without the ho meopathic preparation. The primar y outcome
measure was the estimated rate of diagnosed acute throat
infections per year, with other outcome measures being
severity of RT symptoms and the antibiotics required due
to acute throat infections. Occurrence of RT symptoms was
seen in a significantly lower percentage of patients in the test
group compared with the control group. There was also a
reduction in antibiotics used due to acute throat infections.
The authors conclude that an integrative treatment
Homeopathy
Homeopathy in the Age of Antimicrobial Resistance Fixsen
approach, in which SilAtro-5–90 or Tonsilotren is given
alongside mainstream symptomatic treatment, could be of
therapeutic benefit to patients with a history of RT.
Both small- and large-scale studies suggest that homeop-
athy may reduce the prescribing of antibiotics for acute URTIs
and their sequelae.28,83,98,99 As part of an EPI3 nationwide
survey of primary care practice in France, the progress of 518
adults and children with URTIs (79.3% with rhinopharyngi-
tis) treated by either general practitioners (GPs) certified to
use homeopathy (GP-Hom) or GPs who used conventional
medicine only (GP-CM) was compared. Patients in the GP-
Hom group showed significantly lower consumption of
antibiotics (odds ratio [OR] ¼0.43, 95% confidence interval
[CI]: 0.27–0.68) and antipyretic/anti-inflammatory drugs
(OR ¼0.54, 95% CI: 0.38–0.76), with similar outcomes.91
Prophylactic and Long-Term Effects
CAM therapies that are proven safe can be used to strengthen
the self-healing capacities of the organism (preventive and
curative health promotion).100 Several studies examined for
this review suggest prophylactic, as well as short-term,
potential for the products or remedies under review. In
Siqueira et al’s14 trial, 600 children aged 1 to 5 years were
randomly distributed to three groups and prescribed either a
homeopathic complex, placebo or InfluBi o. The number of flu
and acute respiratory infections in each group in a year
(2009–2010) was then recorded. While the number of epi-
sodes overall was small, 30.5% of the placebo group devel-
oped three or more acute infections in the post-intervention
year, whereas there were no recorded episodes in those
receiving the homeopathic complex and only one episode
in the group receiving InfluBio. A 2016 observational study
by Beghi and Morselli-Labate,72 conducted over a 10-year
period in Italy, suggested that the regular use of the homeo-
pathic medicine Oscillococcinum during the winter months
could play a role in the prevention of respiratory tract
infections. In comparison with the control group, patients
who took Oscillo coccinum once a week for 8 months per year
had a greater reduction in the average infectious episodes
during the study compared with the year before inclusion,
independent of age and class.
An observational study from 1998 to 2008 by Rossi et al78
assessed the outcome of homeopathic treatment in 551
children under 14 years of age. Respiratory infections (337
cases, 61%) were the most frequently observed diseases. The
Glasgow Homeopathic Hospital Outcome Score (GHHOS)
was used to assess outcome. After homeopathic treatment,
68% of children with respiratory disease showed a strong
improvement or attained a resolution of their problems. The
authors concluded that improvement or resolution of symp-
toms is more likely in patients with problems in t he URT than
other categories (e.g. dermatological, digestive, psychologi-
cal) and in patients followed up for at least 12 months.
Another observationa l study, by Witt et al,95 showed long-
term improvements in patients seeking homeopathic treat-
ment for sinusitis. The treatment group (a sub-group of a
large multi-centred observational study) included 134
adults treated by 62 physicians. All patients had suffered
from chronic sinusitis (CS) for over 9 years, almost all (97.0%)
of whom had previously been treated with conventional
medicine. Self-reported scores showed both physical and
mental improvements persisting for 8 years. The authors
point to the need for more explanatory studies to establish
the extent to which these effects could be due to lifestyle
regulation, placebo, or context effects associated with the
treatment. Also of interest is a multi-centre observational
study, performed in India by Nayak et al,93 which sought to
test the therapeutic usefulness of homeopathic medicine in
the management of CS in 550 patients. The chronic sinusitis
assessment score (CSAS) was used to assess symptom sever-
ity. The authors of this study found statistically significant
reductions in CSAS after 3 and 6 months of treatment, along
with improved radiological appearance. No complications
were observed during treatment. Their conclusion is that
homeopathic treatment could be effective for patients with
CS but controlled trials were required for further validation.
Combination versus Single Homeopathic Remedies
The studies featured in this review adopt a range of
approaches to prescribing, both from the perspective of
control and selection of single or combination remedies
with varying constituents (see ►Table 2). Of the seven
RCTs in this review using combination remedies, four were
placebo-controlled. The active controls used in the other two
studies varied: Thinesse-Mallwitz et al’s team28,74 compared
treatment with the homeopathic medication IFC with ST,
while Jong et al79 compared CalSuli with another complex
homeopathic product. Siqueira et al14 used placebo, but also
compared the product InfluBio (purified influenza virus
30c) with a homeopathic nosode complex Streptococcus,
Staphylococcus and inactivated influenza virus 30c.
The constituents contained in the homeopathic complexes
(most of them brand-named products) cover a wide range of
remedies. Many of these remedies are derived from plant
sources, and their propensity to alleviate or resolve the symp-
toms of URTIs and their complications have been discussed at
length in the homeopathic clinical literature. Homeopathic
compounds and syrups contained up to nine different consti-
tuents, generally in low potencies.13,14,74,79,101 Despite wide
variations in the remedies chosen, some clear ‘favourites’
emerged, the most commonly used remedies being Bryonia
(6 studies),Phosphorus (4 studies), Ipecacuanha (4studies)and
Sulfur (3 studies).
The findings from this review suggest at least equivalence
between complex homeopathy and conventional treatment
for uncomplicated cases of URTIs. In all but one study, the
homeopathic products under evaluation yielded favourable
results by way of milder symptoms and shorter duration of
acute illness, and several had led to reduced use of anti-
biotics. Given the ease and convenience of this type of
prescribing, the distress associated with acute URTIs,97 the
need to reduce reliance on antibiotics and the known side
effects of pharmaceutical OTC products, there is a case for
using tried and tested combin ation remedies to treat uncom-
plicated cases of URTIs. On the other hand, the quality of the
body of evidence on non-individualised homeopathic
Homeopathy
Homeopathy in the Age of Antimicrobial Resistance Fixsen
treatment is low, and the risk of bias in existing RCTs is
high.64 The variable constituents of each product (some of
which contained eight or more homeopathic ingredients)
call into question the specific action of these products on
URTIs, especially given the short-lived nature of this condi-
tion in otherwise healthy children and adults. In addition,
some products such as Engystol have been tested in several
studies with different results.64,85,102 It is important that
combination remedies continue to be subject to rigorous
trials, which test the efficacy and safety of such com-
pounds.28,74,79 Dose frequency and duration of use also
need to be considered to eliminate accidental provings or
‘remedy exhaustion’.
a
Acute illnesses produce different
symptoms in patients, and more research is required to
establish which products suit particular scenarios and at
which stage of illness they are most effective.
Mathie et al’s recently published article suggests that the
model validity of placebo-controlled trials of non-individua-
lised homeopathic treatment is lower than that of indivi-
dualised treatment.103 In a follow-up article, the authors
conclude that better designed and more rigorous RCTs are
needed to develop an evidence base that can decisively
provide reliable effect estimates of non-individualised
homeopathic treatment;64 however, neither individualised
nor non-individualised RCTs featuring homeopathy score
well in terms of model validity or risk of bias.
Conclusion
With the emergence of antimicrobial resistance (AMR),
respiratory infections have become more difficult to treat.
Inappropriate use of antibiotics and other antimicrobials
leads to the growth and spread of resistant bacteria, which
colonise the airways and can affect the entire community.88
The push to limit AMR requires a consolidated, concerted
effort by multiple stakeholders.104 Effective strategies are
needed to restrict the use of antibiotics without harming
those who truly need these medications. While lifestyle and
nutrition play a significant part in their control, homeopathy
presents a low cost, holistic adjunct or alternative for many
common infections. The clinical trials examined in this
article showed variations in size, location, cohort types,
type of intervention and outcome measures, which make
comparisons and generalisations problematic. Nevertheless,
combined evidence from these and other studies suggests
that homeopathic treatment can exert biological effects with
fewer adverse events and broader therapeutic opportunities
than conventional medicine in the treatment of URTIs.56,105
Given the cost implications of treating URTIs and their
complications in children, and the relative absence of effec-
tive alternatives without potential side effects, the use of
non-individualised homeopathic compounds tailored for the
paediatric population merits further investigation, including
through large-scale cohort studies.
The quantity of peer-reviewed homeopathic research is
small when compared with conventional medicinal
research. There are many gaps in evidence, but recent
studies support the view that homeopathy could be at
least as effective as an ST, with effects that can be differ-
entiated from placebo106,107 and can fill existing effective-
ness gaps in the conventional medical treatment of URTIs
and their complications.9Importantly for global health,
studies such as those presented in this article suggest that
patients given homeopathic treatment and who follow
sensible disease avoidance measures may avoid infections
ormaybeabletoreducerelianceonconventionalmedica-
tion, including antibiotics.9,91 Inthemeantime,themost
important evidence still arises from practical clinical
experience and from the successful treatment of millions
of patients.
WiththeadventofAMR,homeopathywouldappear
tohavearoletoplaybothinofferingalternativetreat-
ment for URTIs and the possibility of the prevention of
recurring infections associated with the URT. Further
research is required to establish the best means of achiev-
ing this; however, prioritising studies of paediatric and
elderly populations would seem a path forward for the
reduction in antibiotic use and the on-going risk of
resistance.
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