probiotics in vaginal infections

Role of Probiotics

Outline

Vaginal ecosystem Estrogen and recurrent UTI in women What are probiotics and how do they work? Current proposed uses and a look at some of

the evidence Issues in prescribing their use

Health vaginal ecosystem

Dynamic Equilibrium exists between: Epithelium Normal colonizing organisms (mostly

Lactobacilli SPP.) Local secretory and celluar immune factors Vaginal pH maintained

acidic (3.8 ~ 4.2) creates unfavourable environment for pathogen

Normal Vaginal flora

LACTOBACILLI Gram positive rods Excrete hydrogen peroxide Present in 100% of women with normal flora Affects adherence of epithelial cells Protect against bacterial/candidal infections

Facultative organisms

Diphtheriods Coagolase negative Staphycococci Streptococci E. coli Ureaplasma urealyticum Mycoplasma hominis

Anaerobic organisms

Present in low, non-pathogenic concentrations Peptostreptococus Bacteroides Fusobaterium Mobiluncus Gardnerella (40% - 60%) in normal secretions

Estrogen; ↑ epithelial glycogen Lactobacilli; glycogen -> lactic acid Lactic acid maintains acid pH

Abnormal pH (over 4.2) aggravating factors:

trauma low estrogen menses alkaline seminal fluid

alters vaginal ecosystem causes epithelial desquamation

estrogen

Glycogen

Lactic acidH2O2

Lactobacillus

Normal vaginal flora; protective role

• 1 billion each year (Reid, 2003) • > 300 million cases annually worldwide

(Reid 2001. Am J Clin Nutr 73: S437-S443)

• Each episode: on average 6 days of symptoms• Sequelae: pyelonephritis --> preterm birth• Uropathogens: E. coli (approx. 70%),

Enterobacteriacae Enterococcus faecalis, Staphylococcus spp.

• Increasing drug resistance among uropathogens

UTI in women

UTI: Escherichia coli Gram negatives Staphylococcus aureus

BV: "lactobacilli deficiency syndrome" Gardnerella vaginalis, Atopobium vaginae, anaerobes, Mycoplasma hominis, Ureaplasma urealyticum

Yeast vaginit is: Candida albicans

Female GU Tract Infections: Disturbance of normal vaginal flora

Identification of cultured vaginal lactobacilli using tDNA-PCR

Verhelst R. et al. BMC Microbiol. 2005, 5: 61

Vaginal smears graded by Gram stain Species Normal (439) Disturbed (68) H2O2 production Lactobacillus crispatus 48.3 7.4 +++ Lactobacillus jensenii 25.3 38.2 ++ Lactobacillus gasseri 23.5 39.7 ++ Lactobacillus iners 20.5 27.9 + Lactobacillus vaginalis 11.6 4.4 ++ Lactobacillus coleohominis 3.4 1.5 Lactobacillus reuteri 1.4 0.0 ++ Lactobacillus fermentum 1.1 1.5 + Lactobacillus rhamnosus 0.9 4.4 + Lactobacillus casei 0.9 2.9 Lactobacillus delbrueckii 0.7 1.5 ++ Lactobacillus kalixensis 0.2 0.0 Lactobacillus pontis 94% 0.2 0.0 Lactobacillus salivarius 0.2 0.0 + Lactobacillus mucosae 0.0 2.9 Lactobacillus oris 0.0 2.9 Lactobacillus nagelii 0.0 1.5

The 'right' lactobacilli?

The vagina is not a steady state ecosystem.

Menstruation cyclic changes in the vaginal environment Levels of estrogen and progesterone alter, Changing the environment for lactobacilli by influencing

cell surface receptor expression levels of glyocgen and glucose as substrate levels of vaginal pH

Estrogen protective: BV prevalence lower in women using oral contraception

(Yen et al. 2003) BV lower during pregnancy (3rd trimester) (Hay et al. 1994) Clinical trials with estradiol cure of BV, restoration pH, ...

(Kanne & Jenny 1991, Parent et al. 1996, Ozkinay et al. 2005)

Risk factors for BV

Race/ethnicity (black women at higher risk): In Africa: > 50% of women have BV (Paxton et al. 1998) L. iners instead of L. crispatus? (Anukam et al. 2005) genetic differences in epithelial surface molecules

--> different adherence?

Frequency and kind of intercourse: new male sexual partner more male sexual partners female sexual partner

* Sexual intercourse once a week was the only risk factor associated with loss of H2O2 producing lactobacilli. (Vallor et al. 2001)

--> BV is STD? or raise of pH?

Risk factors for BV

↑ HSV2 infection (Cherpes TL 2005. CID 40: 1422)

↑ HIV shedding (Cu-Uvin S. 2004. CID 33: 894, Sewankambo. 1997. Lancet 350: 546)

--> ↑ Perinatal mother-child HIV-transmission --> ↑ Sexual HIV-transmission↑ Susceptibility for hiv-infection↑ Infection with CT and HPV (da silva CS. 2004. Goinvest. 58: 189)

↑ Early loss after IVF (Eckert LO. 2003. IDOG 11: 11-17)

Associated with recurrent UTI (Hooton TM. 2001. IJAA 17: 259-268)

Associated with PID, postpartum endometritis ...

Sequelae of BV (and UTI)

Bacterial vaginosis

Number of germs

Normal

Symptoms

Lactobacil lus

Gardnerella vaginalisAnaerobes

pH 4.0 - 4.5 pH 5.0 - 6.0

Bacterial vaginosis (BV)

A controlled trial of intravaginal estriol in postmenopausal women with recurrent UTIs

Raz R, Stamm WE. N Engl J Med 1993, 329:753-756

•93 postmenopausal women with a history of recurrent UTIs•Randomized, double-blind, placebo-controlled trial of

topical intravaginal estriol cream UTI incidence; 0.5 vs. 5.9 episodes per patient-yearLactobacil l i restoration after one month; 61% vs 0% Vaginal pH declined (from 5.5 to 3.8) Vaginal Enterobacteriaceae fell from 67 to 31% with estriol but unchanged (from 67 to 63 %) with placebo

•prevents recurrent UTI in postmenopausal women, probably by modifying the vaginal f lora.

Estrogens: Clinical trials

World Health Organization: “live microorganisms which when administered in adequate amounts confer a health benefit on the host”

A bacterial strain that: survives the stomach acid and bile adheres to intestinal lining grows and establishes temporary residence in the intestines imparts health benefits

R Fuller. Probiotics: The Scientific Basis. London: Chapman and Halls. 1992

Probiotics: definitions

Probiotics Lactobacillus sp.

reuteri casei ramnosus acidophilus

Streptococcus sp. Bifidobacterium sp.

infantis lactis longum breve bifidum

Sacharomyces boulardii (non-human)

Probiotics: History

Pasteur (1877) antagonistic interaction between bacterial strains non-pathogenic bacteria should be used to control pathogenic

bacteria

Metchnikoff (1907) lactic fermentation of milk arrested putrefaction consumption of fermented products would offer the same benefit

to humans longevity in Bulgarian peasants was due to ingestion of “soured

milks”

1980’s Fuller establishes first definition of probiotics.

Inhibition of adhesion Immunomodulation Production of antimicrobial substances Modification of toxins or toxin receptors Competition for nutrients Reduction in bacterial translocation Anti-inflammatory signaling within the epithelium

Probiotics: Potential MOA

Infectious diarrhea Antibiotic-associated diarrhea IBD, IBS, and pouchitis Necrotizing Enterocolitis Bacterial vaginosis Recurrent UTI’s Atopic diseases Immune system enhancement H pylori infections Dental caries Radiation induced diarrhea Cardiovascular risk reduction Constipation Rheumatoid arthritis

Probiotics: Proposed uses

Which organism to use? Which product? For what conditions? What dose? How long? Any side effects to be aware of? Cost of therapy?

Probiotics: Prescribing

Treatment of BV with lactobacilli

• 60 women with BV double blind, placebo-controlled trial• Immediately after completion of treatment,

16/28 women treated with lactobacilli had normal vaginal wet smear results

none of the 29 women treated with placebo.

• Only 3 of the women who received the Lactobacillus suppository were free of BV after the subsequent menstruation.

Hallen A, et al. Sex Transm Dis. 1992, 19:146-148.

Vaginal probiotics: Clinical trials

Vaccination against nonspecific BV; Double-blind study of Gynatren

• 167 patients with nonspecific BV vaccinated with Gynatren, a Lactobacil lus vaccine double-blind, randomized, placebo-controlled trial

• During the study period of 14 months, vaccination was significantly better than the placebo with regard to its therapeutical effect.

• Vaccination with Gynatren is effective to prevent recurrences of nonspecific vaginosis .

Siboulet A. Gynakol Rundsch. 1991;31(3):153-160


An audit of Gynatren (a L. acidophilus lyophilisate) vaccination in women with recurrent bacterial vaginosis.

Pattman RS et al. Int J STD AIDS. 1994, 5: 299

Bacterial vaginitis: protection against infection and secretory immunoglobulin levels in the vagina after immunization therapy with Gynatren.

Ruttgers H. Gynecol Obstet Invest. 1988, 26: 240-9

Effect of Lactobacillus immunotherapy on genital infections in women (Solco Trichovac/Gynatren).

Karkut G. Geburtshilfe Frauenheilkd. 1984, 44: 311-4

Randomized double-blind study on the prevention of reinfection in trichomoniasis using Solco Trichovac vaccination.

Litschgi M. Gynakol Rundsch. 1982, 22: 70-3


Therapy of bacterial vaginosis (BV) using exogenously- applied L. acidophil i and a low dose of estriol : a

placebo-controlled multicentric clinical trial. Parent D, et al. Arzneimittelforschung. 1996, 46: 68-73

•Vaginal tablets (Gynoflor) containing 50 mg of a lyophilisate of viable, H2O2-producing L. acidophilus (>107 CFU/tablet) and 0.03 mg estriol•32 non-menopausal women with BV•6-day therapy with 1~2 vaginal tablets daily

cure rate 2 wks after the start of therapy ; 77% vs 25%

cure rate 4 wks after the start of therapy ; 88% vs. 22%

•A signif icant increase in the number of lactobacil l i

Vaginal synbiotics: Clinical trials

The effectiveness of l ive lactobacil l i in combination with low dose estriol (Gynoflor) to restore the vaginal

flora after treatment of vaginal infections. Ozkinay E, et al. Brit. J. Obstetr. Gynaecol. 2005, 112: 234-40

•Randomised, placebo-controlled, double-blind clinical trial•360 women with vaginal infections

•Restoration therapy with live lactobacilli in combination with low dose estriol (n = 240) or placebo (n = 120)

2~7 days after the end of the anti-infective therapy•Follow up at 3~7 days and 4~6 weeks after the end of the restoration therapy •Restoration of the vaginal f lora can be signif icantly

enhanced by the administration of live lactobacilli in combination with low dose estriol.

Vaginal synbiotics: Clinical trials

Ecological treatment of bacterial vaginosis. Chimura T, et al. Jpn J Antibiot. 1995, Mar;48: 432-6

• 11 women with BV: intravaginal application of 5 ml of commercial yoghurt (pH 4.3).

• Evaluation after 3 days: vaginal discharge and bacteriologySignificant decrease of vaginal discharge and redness Vaginal pH was lowered significantly. Overall bacteriological effects: 6 (54.5%) were

eradicated, 3 were partly eradicated, 2 were replaced. • Lactobacillus therapy was effective in both clinical and bacteriological responses.

Non-Vaginal probiotics: Clinical trials with Yoghurt

Bacterial vaginosis in pregnancy treated with yoghurt. Neri A, et al. Acta Obstet Gyecol Scand 1993, 72: 17-22

•32 women with BV in the first trimester of pregnancy were treated with intravaginal application of yoghurt .

•The result was favorable.

Ingestion of yogurt containing Lactobacillus acidophilus as prophylaxis for candidal vaginit is.

Hilton E, et al. Ann Intern Med 1992, 116: 353-7

•Daily ingestion of 8 ounces of yogurt containing L. acidophilus decreased both candidal colonization and infection.

Non-Vaginal probiotics: Clinical trials with Yoghurt

Augmentation of antimicrobial MDZ therapy of BV with oral probiotic L. rhamnosus GR-1 and L. reuteri RC-14: randomized, double-blind, placebo controlled trial.

Anukam K, et al. Microbes Infect. 2006

•125 premenopausal women with BV •Oral MDZ (500 mg) bid for 7 d + oral L. rhamnosus GR-1 (1x109)

and L. reuteri RC-14 (1x109) or placebo bid for 30 dCure rate of BV; 88% vs 40% (p < 0.001). Recovery of Lactobacil lus sp. counts (> 10 5 cfu/ml) 96% vs

53%•Use of lactobacilli and antibiotic in the eradication of BV in

black African women is eff icacious.

Non-Vaginal probiotics: Clinical trials

Oral use of L. rhamnosus GR-1 and L. fermentum RC-14 significantly alters vaginal flora: randomized, placebo-controlled trial in 64 healthy women.

Reid G, et al. FEMS Immunol Med Microbiol. 2003, 35: 131-4

64 healthy womenOral capsules of L. rhamnosus GR-1 and L. fermentum RC-14

given daily for 60 daysRestoration from asymptomatic BV microflora to a normal

lactobacil l i colonized microflora; 37% vs 13% (P=0.02). A significant increase in vaginal lactobacil l i at day 28 and 60A significant deplet ion in yeast at day 28A significant reduction in coliforms at day 28, 60 and 90 for

lactobacilli-treated subjects


In vitro testing of Lactobacillus acidophilus NCFM as a possible probiotic for the urogenital probiotic applications.

Reid G. Int Dairy J. 2000, 10: 415-9 Oral probiotics can resolve UTI.

Reid G. FEMS Immunol 2001, 30:49-52

Assessment of the capacity of lactobacilli to inhibit growth of uropathogens.

Osset J et al. JID 2001, 183: 485-91

Probiotic feeding reduces UTI in preterm infants. Dani C et al. Biol Neonate 2002, 82: 103-8

Probiotics: alternative treatment in urology. Hoesl & Altwein. Eur Urol 2005, 47: 288-96


CTV-05: L. crispatus 108 cfu/capsule (Chrisope Tech., La & Gynelogix, Colo.)

Fem-Dophilus: L. rhamnosus GR-1™ and L. reuteri RC-14™ (Urex Biotech)

Florajen: L. acidophilus 2 x 1010/capsule (American Lifeline, Wisconsin)

Gy-Na-Tren: L. acidophilus 2 x 109 cfu/capsule (Vitalis, Nederland)

Gynoflor: L. acidophilus 107 cfu + 0.03 mg estriol/tablet (Mithra, Liège, from Grünenthal,

produced by Medinova (Zürich, S)

Infemin: L. crispatus, L. acidophilus, L. fermentum, L. rhamnosus, all at 109 cfu/ml

(Pierre Fabre Sante, Boulogne, France)

Intrafresh: vaginal probiotic pessarium: PEG + L. acidophilus (BioCare, UK)

Lacto AC: 10 species/capsule. TJCP: The Jordan Prentice Co., Fl.

LactoFem: L. Rhamosus, L. acidophilus both at 109/capsule (Mithra, Belgium)

Trenev Trio (Vitals, Nederland)

Vaginal probiotic products

Clear hypothesis about role of lactobacilli Clearly established protective role of lactobacilli Lactobacilli are predominant in the vagina. Application can be topical

reaching high inocula no organoleptic considerations

Easy to perform clinical trials: Easy sampling Easy re-isolation of probiotic lactobacilli

after application Already available

Vaginal probiotics: Rationale to develop

Antibioticsdamage commensal microflora.can increase the occurrence of resistant bacteriacan have adverse side effects

Probiotics can be used in adjunction to antibiotics to restore

the commensal microflora

Probiotics vs antibiotics

Not FDA regulated Quality control is poor 80% of preparations tested had 1% or less of the bacterial

concentration on the label Numerous preparations on the market

Which strains work best? Do different strains work better for different diseases? Do combinations work better than single strains?

May need several months of therapy to see an effect Likely stop working after discontinued Concentration (dose) highly variable

Probiotics: Practical Issues

Conclusions

The use of probiotics in prevention of UTI is promising. Should be used carefully and cautiously, and only on the

basis of strong scientific evidence. Response is species specific; the success of one

species of Lactobacillus in a certain application does not imply that all related strains of this species will be capable of producing a comparable response.

Carefully conducted double-blind, placebo-controlled studies to document the individual efficacy of each specific organism for each potential clinical application are needed.

probiotics in vaginal infections

Health & Medicine