file.newsgroup.med.59322 Maven / Gradle / Ivy
From: [email protected] (Gordon Rubenfeld)
Subject: Re: Candida(yeast) Bloom, Fact or Fiction
[email protected] writes:
>to candida blooms following the use of broad-spectrum antibiotics? Gorden
>Rubenfeld, through e-mail, has assured me that most physicians recognize
>the chance of candida blooms occuring after broad-spectrum antibiotic use
>and they therefore reinnoculate their patients with *good* bacteria to
>restore competetion for candida in the body. I do not believe that this is
>yet a standard part of medical practice.
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.
>not give give her advise to use the OTC anti-fungal creams. Since candida
>colonizes primarily in the ano-rectal area, GI symptoms should be more common
>than vaginal problems after broad-spectrum antibiotic use.
Except that it isn't. At least symptomatically apparent disease.
>Medicine has not, and probalby never will be, practiced this way. There
>has always been the use of conventional wisdom. A very good example is
>kidney stones. Conventional wisdom(because clinical trails have not been
>done to come up with an effective prevention), was that restricitng the
>intake of calcium and oxalates was the best way to prevent kidney stones
>from forming. Clinical trials focused on drugs or ultrasonic blasts to
>breakdown the stone once it formed. Through the recent New England J of
>Medicine article, we now know that conventional wisdom was wrong,
>increasing calcium intake is better at preventing stone formation than is
>restricting calcium intake.
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 . . .
>The conventional wisdom in animal husbandry has been that animals need to
>be reinnoculated with *good* bacteria after coming off antibiotic therapy.
>If it makes sense for livestock, why doesn't it make sense for humans
>David? We are not talking about a dangerous treatment(unless you consider
>yogurt dangerous). If this were a standard part of medical practice, as
>Gordon R. says it is, then the incidence of GI distress and vaginal yeast
>infections should decline.
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.
I'm lost!