

  Nor is it mine.  What I tried to explain to Marty was that it is clearly
understood that antibiotic exposure is a risk factor for fungal infections
- which is not the same as saying bacteria prevent fungal infections. 
Marty made this sound like a secret  known only to veternarians and
biochemists.  Anyone who has treated a urinary tract infection knowns
this. At some centers pre-op liver transplant patients receive bowel
decontamination directed at retaining "good" anaerobic flora in an attempt
to prevent fungal colonization in this soon-to-be high risk group.  I also
use lactobacillus to treat enteral nutrition associated diarrhea (that may
be in part due to alterations in gut flora).  However, it is NOT part of
my routine practice to "reinnoculate" patients with "good" bacteria after
antibiotics.  I have seen no data on this practice preventing or treating
fungal infections in at risk patients.  Whether or not it is a "logical
extension" from the available observations I'll leave to those of you who
base strong opinions and argue over such speculations in the absence of
clinical trials. 
  One place such therapy has been described is in treating particularly
recalcitrant cases of C. difficile colitis (NOT a fungal infection). There
are case reports of using stool (ie someone elses) enemas to repopulate
the patients flora.  Don't try this at home. 


  Except that it isn't. At least symptomatically apparent disease.


  Seems like this is an excellent argument for ignoring anecdotal
conventional wisdom (a euphemism for no data) and doing a good clinical
trial, like: 

AU   Dismukes-W-E.  Wade-J-S.  Lee-J-Y.  Dockery-B-K.  Hain-J-D.
TI   A randomized, double-blind trial of nystatin therapy for the
     candidiasis hypersensitivity syndrome [see comments]
SO   N-Engl-J-Med.  1990 Dec 20.  323(25).  P 1717-23.
     psychological tests. RESULTS. The three active-treatment regimens
     and the all-placebo regimen
     significantly reduced both vaginal and systemic symptoms (P less than
     0.001), but nystatin did not reduce the systemic symptoms
     significantly more than placebo. [ . . . ]
     CONCLUSIONS. In women with presumed candidiasis
     hypersensitivity syndrome, nystatin does not reduce systemic or
     psychological symptoms significantly more than placebo. Consequently,
     the empirical recommendation of long-term nystatin therapy for such
     women appears to be unwarranted.

  Does this trial address every issue raised here, no.  Jon Noring was not
surprised at this negative trial since they didn't use *Sporanox* (despite
Crook's recommendation for Nystatin).  Maybe they didn't avoid those
carbohydrates . . . 


  Marty, you've also changed the terrain of the discussion from empiric
itraconazole for undocumented chronic fungal sinusitis with systemic
hypersensitivity symptoms (Noring syndrome) to the yoghurt and vitamin
therapy of undocumented candida enteritis (Elaine Palmer syndrome) with
systemic symptoms.  There is significant difference between the cost and
risk of these two empiric therapeutic trials.  Are we talking about "real"
candida infections, the whole "yeast connection" hypothesis, the efficacy
of routine bacterial repopulation in humans, or the ability of anecdotally
effective therapies (challenged by a negative randomized trial) to confirm
an etiologic hypothesis (post hoc ergo propter hoc).  We can't seem to
focus in on a disease, a therapy, or a hypothesis under discussion. 