1. Prevention of UTIs: Role of Hormones & Probiotics
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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
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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
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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
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5. Facultative organisms
Diphtheriods
Coagolase negative Staphycococci
Streptococci
E. coli
Ureaplasma urealyticum
Mycoplasma hominis
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6. Anaerobic organisms Present in low, non-pathogenic concentrations
Peptostreptococus
Bacteroides
Fusobaterium
Mobiluncus
Gardnerella (40% - 60%) in normal secretions
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7. Normal vaginal flora; protective role
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 acid
H2O2
Lactobacillus
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8. UTI in women 1 billion each year (Reid, 2003)
> 300 million cases annually worldwide (Reid 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
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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
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10. Which are the 'right' lactobacilli
Which are the 'right' lactobacilli? Identification of cultured vaginal lactobacilli using tDNA-PCR
Verhelst R. et al. BMC Microbiol. 2005, 5: 61
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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)
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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?
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13. Sequelae of BV (and UTI)
HSV2 infection (Cherpes TL CID 40: 1422)
HIV shedding (Cu-Uvin S CID 33: 894, Sewankambo Lancet 350: 546)
--> perinatal mother-child HIV-transmission
--> sexual HIV-transmission
susceptibility for HIV-infection
infection with CT and HPV (da Silva CS GOInvest. 58: 189)
early loss after IVF (Eckert LO IDOG 11: 11-17)
associated with recurrent UTI (Hooton TM IJAA 17: )
associated with PID, postpartum endometritis, ...
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14. Bacterial vaginosis (BV)
Number
of germs
Bacterial vaginosis
Normal
Lactobacillus
Symptoms
Gardnerellavaginalis
Anaerobes pH pH
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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:
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.
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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
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17. Probiotics Lactobacillus sp. Streptococcus sp. Bifidobacterium sp.
reuteri
casei
ramnosus
acidophilus
Streptococcus sp.
Bifidobacterium sp.
infantis
lactis
longum
breve
bifidum
Sacharomyces boulardii (non-human)
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18. History of Probiotics Pasteur (1877) Metchnikoff (1907)
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.
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21. Probiotics; Potential Mechanisms of Action
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
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22. 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
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23. Probiotics: Proposed uses
Ratings: A: strong B: good C: fair
Rating the Evidence
Floch et al (2006)
Natural Standard (2006)
Infectious diarrhea A B
AntiBx-associated diarrhea C
Diarrhea prevention
IBS
Atopic dermatitis/Allergy B?
B/C
Ulcerative colitis
H pylori infection
Bacterial vaginosis
UTIs
Floch, et al. Recommendations for Probiotic Use. J Clin Gastro. 40(3). 2006
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24. Probiotics: Prescribing
Which organism to use?
Which product?
For what conditions?
What dose?
How long?
Any side effects to be aware of?
How much does it cost?
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25. Vaginal probiotics; Clinical trials
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:
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26. Vaginal probiotics; Clinical trials
Vaccination against nonspecific BV; Double-blind study of Gynatren
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 as concerns its therapeutical effect
Vaccination with Gynatren is effective to prevent recurrences of nonspecific vaginosis.
Siboulet A. Gynakol Rundsch. 1991;31(3):
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27. 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
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28. 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
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29. 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:
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) ~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.
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30. 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.
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31. 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.
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32. 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 (> 105 cfu/ml) 96% vs 53%
Use of lactobacilli and antibiotic in the eradication of BV in black African women is efficacious.
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33. 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 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
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34. 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:
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:
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35. 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 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)
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36. 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
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37. Probiotics vs 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
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38. 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
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39. 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.
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