Probiotics in vaginal infections

1. Role of Probiotics

2. 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

3. 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

4. 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

5. Facultative organisms
 Diphtheriods
 Coagolase negative Staphycococci
 Streptococci
 E. coli
 Ureaplasma urealyticum
 Mycoplasma hominis

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

7. Normal vaginal flora; protective role
 Estrogen; ↑ epithelial glycogen
Lactic acid
 Lactobacilli; glycogen -> lactic acid
H 2O 2
 Lactic acid maintains acid pH
Lactobacillus
 Abnormal pH (over 4.2)
Glycogen
 aggravating factors:
 trauma
 low estrogen
estroge
n  menses
 alkaline seminal fluid
 alters vaginal ecosystem
 causes epithelial desquamation

8. UTI in women
• 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

9. Female GU Tract Infections:
Disturbance of normal vaginal flora
 UTI: Escherichia coli
Gram negatives
Staphylococcus aureus
 BV: "lactobacilli deficiency syndrome"
Gardnerella vaginalis, Atopobium vaginae, anaerobes,
Mycoplasma hominis, Ureaplasma urealyticum
 Yeast vaginitis: Candida albicans

10. The 'right' lactobacilli?
Identification of cultured vaginal lactobacilli using tDNA-PCR
Vaginal smears graded by Gram stain
Species Normal (439) Disturbed (68) H2O2 produc tion
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
Lactobac illus reuteri 1.4 0.0 ++
Lactobacillus fermentum 1.1 1.5 +
Lactobac illus rhamnosus 0.9 4.4 +
Lactobacillus casei 0.9 2.9
Lac tobacillus delbrueckii 0.7 1.5 ++
Lactobac illus 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
Verhelst R. et al. BMC Microbiol. 2005, 5: 61

11. Risk factors for BV
 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)

12. 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?

13. Sequelae of BV (and UTI)
↑ 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 ...

14. Bacterial vaginosis (BV)
Number
Bacterial
of germs Normal
vaginosis
Lactobacillus
Symptoms
Gardnerell
a vaginalis
Anaerobes
pH 4.0 - 4.5 pH 5.0 - 6.0

15. Estrogens: Clinical trials
 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-year
Lactobacilli 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 flora.

16. Probiotics: definitions
 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

17. Probiotics
 Lactobacillus sp.
 reuteri
 casei
 ramnosus
 acidophilus
 Streptococcus sp.
 Bifidobacterium sp.
 infantis
 lactis
 longum
 breve
 bifidum
 Sacharomyces boulardii (non-human)

18. 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.

19. Probiotics: Potential MOA
 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

20. Probiotics: Proposed uses
 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

21. Probiotics: Prescribing
 Which organism to use?
 Which product?
 For what conditions?
 What dose?
 How long?
 Any side effects to be aware of?
 Cost of therapy?

22. Vaginal probiotics: Clinical trials
 Treatment of BV with lactobacilli
Hallen A, et al. Sex Transm Dis. 1992, 19:146-148.
• 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.

23. Vaginal probiotics: Clinical trials
 Vaccination against nonspecific BV; Double-blind study of
Gynatren
Siboulet A. Gynakol Rundsch. 1991;31(3):153-160
• 167 patients with nonspecific BV vaccinated with Gynatren, a
Lactobacillus 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 .

24. Vaginal probiotics: Clinical trials
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

25. Vaginal synbiotics: Clinical trials
 Therapy of bacterial vaginosis (BV) using exogenously-
applied L. acidophili 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 significant increase in the number of lactobacilli

26. Vaginal synbiotics: Clinical trials
 The effectiveness of live lactobacilli 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 flora can be significantly
enhanced by the administration of live lactobacilli in
combination with low dose estriol.

27. Non-Vaginal probiotics: Clinical
trials with Yoghurt
 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 bacteriology
Significant 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.

28. 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 vaginitis.
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.

29. Non-Vaginal probiotics: Clinical
trials
 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 d
Cure rate of BV; 88% vs 40% (p < 0.001).
Recovery of Lactobacillus sp. counts (> 10 5 cfu/ml) 96% vs
53%
•Use of lactobacilli and antibiotic in the eradication of BV in
black African women is efficacious .

30. 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 women
Oral capsules of L. rhamnosus GR-1 and L. fermentum RC-14
given daily for 60 days
Restoration from asymptomatic BV microflora to a normal
lactobacilli colonized microflora; 37% vs 13% (P=0.02).
A significant increase in vaginal lactobacilli at day 28 and 60
A significant depletion in yeast at day 28
A significant reduction in coliforms at day 28, 60 and 90 for
lactobacilli-treated subjects

31. Non-Vaginal probiotics: Clinical
trials
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

32. Vaginal probiotic products
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)

33. Vaginal probiotics: Rationale to
develop
 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

34. Probiotics vs antibiotics
 Antibiotics
damage commensal microflora.
can increase the occurrence of resistant bacteria
can have adverse side effects
 Probiotics
can be used in adjunction to antibiotics to restore
the commensal microflora

35. Probiotics: Practical Issues
 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

36. 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.