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Gao M, Manos J, Whiteley G, Zablotska-Manos I. Antibiofilm Agents for the Treatment and Prevention of Bacterial Vaginosis: A Systematic Narrative Review. J Infect Dis 2024; 230:e508-e517. [PMID: 38680027 PMCID: PMC11420799 DOI: 10.1093/infdis/jiae134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Bacterial vaginosis (BV) is difficult to eradicate due to BV biofilms protecting BV bacteria (Gardnerella, Prevotella, and other genera). With the growing understanding of biofilms, we systematically reviewed the current knowledge on the efficacy of anti-BV biofilm agents. METHODS We searched literature in the Scopus, Medline, and Embase databases for empirical studies investigating substances for the treatment of BV biofilms or prevention of their recurrence and their efficacy and/or safety. RESULTS Of 201 unique titles, 35 satisfied the inclusion criteria. Most studies (89%) reported on preclinical laboratory research on the efficacy of experimental antibiofilm agents (80%) rather than their safety. Over 50% were published within the past 5 years. Agents were classified into 7 groups: antibiotics, antiseptics, cationic peptides, enzymes, plant extracts, probiotics, and surfactants/surfactant components. Enzymes and probiotics were most commonly investigated. Earlier reports of antibiotics having anti-BV biofilm activity have not been confirmed. Some compounds from other classes demonstrated promising anti-BV biofilm efficacy in early studies. CONCLUSIONS Further research is anticipated on successful antibiofilm agents. If confirmed as effective and safe in human clinical trials, they may offer a breakthrough in BV treatment. With rising antibiotic resistance, antibiofilm agents will significantly improve the current standard of care for BV management.
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Affiliation(s)
- Michael Gao
- Faculty of Medicine and Health, Sydney Medical School, University of Sydney, Westmead, NSW, Australia
- Faculty of Medicine and Health, Westmead Clinical School, Westmead, NSW, Australia
| | - Jim Manos
- Infection Immunity and Inflammation, Faculty of Medicine and Health, School of Medical Sciences, University of Sydney, Westmead, NSW, Australia
- Sydney Institute of Infectious Diseases, The University of Sydney, Westmead, NSWAustralia
| | - Greg Whiteley
- Infection Immunity and Inflammation, Faculty of Medicine and Health, School of Medical Sciences, University of Sydney, Westmead, NSW, Australia
- Sydney Institute of Infectious Diseases, The University of Sydney, Westmead, NSWAustralia
- School of Medicine, Western Sydney University, Campbelltown, NSW, Australia
- Whiteley Corporation, North Sydney, NSW, Australia
| | - Iryna Zablotska-Manos
- Sydney Institute of Infectious Diseases, The University of Sydney, Westmead, NSWAustralia
- Faculty of Medicine and Health, Westmead Clinical School, Westmead, NSW, Australia
- Western Sydney Sexual Health Centre, Parramatta, NSW, Australia
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Abbe C, Mitchell CM. Bacterial vaginosis: a review of approaches to treatment and prevention. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1100029. [PMID: 37325243 PMCID: PMC10264601 DOI: 10.3389/frph.2023.1100029] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Bacterial vaginosis (BV) is a common cause of vaginitis worldwide and is associated with serious reproductive health outcomes, including increased risk of preterm birth, sexually transmitted infections, and pelvic inflammatory disease. The current and only FDA-approved treatment regimens for BV are antibiotics, such as metronidazole and clindamycin. Antibiotics provide a short-term cure for bacterial vaginosis; however, fail to provide a consistent long-term cure for many women. Fifty to eighty percent of women experience a BV recurrence within a year of completing antibiotic treatment. This may be because after antibiotic treatment, beneficial strains of Lactobacillus, such as L. crispatus, do not recolonize the vagina. In the absence of an effective long-term cure, patients, providers, and researchers are exploring different approaches to treatment and prevention, resulting in a rapid evolution of perspectives on BV pathogenesis and approaches to management. Current areas of investigation for BV management include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption. Behavioral modifications that may help include smoking cessation, condom use and hormonal contraception. Additional strategies considered by many people include dietary modification, non-medical vaginally applied products, choice of lubricant, and treatments from medical practices outside of allopathic medicine. This review aims to provide a comprehensive and up to date outline of the landscape of ongoing and potential treatment and prevention strategies for BV.
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Affiliation(s)
- Carmen Abbe
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States
| | - Caroline M. Mitchell
- Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA, United States
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3
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Tomás M, Sousa LGV, Oliveira AS, Gomes CP, Palmeira-de-Oliveira A, Cavaleiro C, Salgueiro L, Cerca N, Martinez-de-Oliveira J, Palmeira-de-Oliveira R. Vaginal Sheets with Thymbra capitata Essential Oil for the Treatment of Bacterial Vaginosis: Design, Characterization and In Vitro Evaluation of Efficacy and Safety. Gels 2023; 9:gels9040293. [PMID: 37102907 PMCID: PMC10137747 DOI: 10.3390/gels9040293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/05/2023] Open
Abstract
We aimed to incorporate Thymbra capitata essential oil (TCEO), a potent antimicrobial natural product against bacterial vaginosis (BV)-related bacteria, in a suitable drug delivery system. We used vaginal sheets as dosage form to promote immediate relief of the typical abundant vaginal discharge with unpleasant odour. Excipients were selected to promote the healthy vaginal environment reestablishment and bioadhesion of formulations, while the TCEO acts directly on BV pathogens. We characterized vaginal sheets with TCEO in regard to technological characterization, predictable in vivo performance, in vitro efficacy and safety. Vaginal sheet D.O (acid lactic buffer, gelatine, glycerine, chitosan coated with TCEO 1% w/w) presented a higher buffer capacity and ability to absorb vaginal fluid simulant (VFS) among all vaginal sheets with EO, showing one of the most promising bioadhesive profiles, an excellent flexibility and structure that allow it to be easily rolled for application. Vaginal sheet D.O with 0.32 µL/mL TCEO was able to significantly reduce the bacterial load of all in vitro tested Gardnerella species. Although vaginal sheet D.O presented toxicity at some concentrations, this product was developed for a short time period of treatment, so this toxicity can probably be limited or even reversed when the treatment ends.
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Affiliation(s)
- Mariana Tomás
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, 6201-506 Covilhã, Portugal
| | - Lúcia G. V. Sousa
- Laboratory of Research in Biofilms Rosário Oliveira (LIBRO), Centre of Biological Engineering (CEB), University of Minho, 4710-057 Braga, Portugal
- LABBELS—Associate Laboratory, 4710-057 Braga, Portugal
| | - Ana Sofia Oliveira
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, 6201-506 Covilhã, Portugal
| | - Carolina P. Gomes
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, 6201-506 Covilhã, Portugal
| | - Ana Palmeira-de-Oliveira
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, 6201-506 Covilhã, Portugal
- Labfit-HPRD Health Products Research and Development, Lda Edifício UBIMedical, Estrada Municipal 506, 6200-281 Covilhã, Portugal
| | - Carlos Cavaleiro
- CIEPQPF, Chemical Process Engineering and Forest Products Research Centre, University of Coimbra, 3030-790 Coimbra, Portugal
- Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Lígia Salgueiro
- CIEPQPF, Chemical Process Engineering and Forest Products Research Centre, University of Coimbra, 3030-790 Coimbra, Portugal
- Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Nuno Cerca
- Laboratory of Research in Biofilms Rosário Oliveira (LIBRO), Centre of Biological Engineering (CEB), University of Minho, 4710-057 Braga, Portugal
- LABBELS—Associate Laboratory, 4710-057 Braga, Portugal
| | - José Martinez-de-Oliveira
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, 6201-506 Covilhã, Portugal
| | - Rita Palmeira-de-Oliveira
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, 6201-506 Covilhã, Portugal
- Labfit-HPRD Health Products Research and Development, Lda Edifício UBIMedical, Estrada Municipal 506, 6200-281 Covilhã, Portugal
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4
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Chow K, Wooten D, Annepally S, Burke L, Edi R, Morris SR. Impact of (recurrent) bacterial vaginosis on quality of life and the need for accessible alternative treatments. BMC Womens Health 2023; 23:112. [PMID: 36934289 PMCID: PMC10024842 DOI: 10.1186/s12905-023-02236-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 02/20/2023] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND Bacterial vaginosis (BV) is one of the most common vaginal dysbiosis in women aged 15-44 years old. METHODS We administered a cross-sectional, single timepoint survey to women ages 18 years or older and who have had bacterial vaginosis (BV). Women completed an anonymous online survey evaluating the impact of BV on their quality of life, how effective different types of treatments were and the amount of self-diagnosed vs. provider diagnosed BV episodes they had. RESULTS 62 participants completed the anonymous online survey. With a self-reported median number of BV episodes in the past year was 4 (IQR 1-7). Among these women 69.8% reported BV had a negative impact on their sexual health, 67.7% on their physical health, 74.6% on their mental health. More than half of the respondents had used probiotics with oral Lactobacillus sp. (53.2%), mainly by oral route, and over a third had used vaginal boric acid (37.1%). Most women were unaware of Lactobacillus crispatus. Lactobacillus probiotics were more likely to be tried by women who were negatively impacted by BV for overall quality of life (p = 0.033), sexual health (p = 0.002), and mental health (p = 0.006) while boric acid use was more likely to be used by women who were negatively impacted by BV for their sexual health (p = 0.008). CONCLUSIONS BV is associated with negative quality of life and the women most impacted are seeking alternative treatments such as probiotics (Lactobacillus) and boric acid. There needs to be improvements in BV treatment that include alternative therapy options that have demonstrated efficacy with standardized composition, formulation and dosage.
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Affiliation(s)
- Karen Chow
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Darcy Wooten
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Sindhuja Annepally
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Leah Burke
- Department of Medicine, University of California San Diego, San Diego, CA, USA.
| | - Rina Edi
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Sheldon R Morris
- Department of Medicine, University of California San Diego, San Diego, CA, USA
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5
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Guo X, Jing T, Li X, Liu Z, Chen Y, Li Y, Xu Y, Gao H. Effects of Boric Acid Gel on Vaginal Candida albicans Infections and the Local Immune System in Mice. Front Immunol 2022; 13:950215. [PMID: 35958550 PMCID: PMC9362737 DOI: 10.3389/fimmu.2022.950215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
The objective was to determine the effect of 5% boric acid gel on vaginal Candida albicans (CA) infections in mice and its effect on the local immune system (i.e., Th1, Th2, and Th17). Female mice were divided into four groups, with 10 mice in each group. Mycelial suspensions were administered into the vaginal lumen close to the cervix in groups B, F, and M. Mice in group B were given boric acid gel, and group F was treated with fluconazole gel for 30 min every 12 h. Group M was treated with sterile water, and group N was not given treatment. After the seventh day of treatment, each group was observed with the naked eye, and vaginal lavage fluid and vaginal tissue were collected. Expression levels of cytokines were measured using enzyme-linked immunosorbent assays (ELISA) and immunohistochemistry. Periodic acid Schiff (PAS) staining was used to measure the fungi in vaginal tissues. There were no significant changes in group M. In groups B and F, there was less vaginal injury and less exudate, with group B doing better than group F. The numbers of CA colonies were higher in groups B, F, and M than in group N (P < 0.01). There was less vaginal colonization of CA in group B than in group F (P < 0.01). After the seventh day of treatment, levels of IFN-γ, IL-17, IL-6, TGF-β, IL-4, and IL-10 were significantly greater in groups B, F, and M than in group N (P < 0.001); levels of IFN-γ, IL-17, IL-6, and TGF-β in groups B and F were higher than those of group M (P < 0.01), while IL-4 and IL-10 levels were significantly lower (P < 0.001). The trends of cytokine increases and decreases were more significant in group B than in group F (P < 0.05). Immunohistochemical results were similar to ELISA results. PAS staining revealed that boric acid inhibited hyphal reproduction. The boric acid significantly reduced the symptoms associated with CA vaginal infection. It inhibited the CA growth, prevented vaginal lesions, promoted the secretion of Th1 and Th17 cytokines, and reduced Th2 cytokines.
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Affiliation(s)
- Xiaoyu Guo
- Department of Clinical Medicine, Hebei University of Engineering, Handan, China
| | - Tingting Jing
- Department of Clinical Medicine, Hebei University of Engineering, Handan, China
| | - Xiaojing Li
- Affiliated Hospital of Hebei University of Engineering, Handan, China
- *Correspondence: Xiaojing Li, ; Zhao Liu,
| | - Zhao Liu
- Department of Dermatology, Affiliated Hospital of Hebei University of Engineering, Handan, China
- *Correspondence: Xiaojing Li, ; Zhao Liu,
| | - Yongxue Chen
- Department of Anesthesiology, Handan Central Hospital, Handan, China
| | - Yiquan Li
- Department of Health Services, Logistics University of People’s Armed Police Force, Tianjin, China
| | - Yanyan Xu
- Department of Dermatology, Affiliated Hospital of Hebei University of Engineering, Handan, China
| | - Hongqi Gao
- Affiliated Hospital of Hebei University of Engineering, Handan, China
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6
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Rolfs J. Common Infections Encountered in Obstetrics/Gynecology. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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7
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Comparative Fungicidal Activities of N-Chlorotaurine and Conventional Antiseptics against Candida spp. Isolated from Vulvovaginal Candidiasis. J Fungi (Basel) 2022; 8:jof8070682. [PMID: 35887439 PMCID: PMC9322802 DOI: 10.3390/jof8070682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/01/2022] [Accepted: 06/09/2022] [Indexed: 02/01/2023] Open
Abstract
N-chlorotaurine (NCT), the N-chloro derivative of the amino acid taurine, is a long-lived oxidant produced by stimulated human leucocytes. NCT has antimicrobial activities which are generally enhanced in the presence of organic material. The aim of this study was to investigate fungicidal effects of NCT and conventional antiseptics against Candida isolated from vulvovaginal candidiasis (VVC). Chlorhexidine (CHX, 1.6%), octenidine dihydrochloride (OCT, 0.08%), povidone iodine (PVP-I, 8%), boric acid (8%), and NCT (0.1% (5.5 mM)) were evaluated against forty-four Candida isolates, according to European Standard methods, at 30, 60, 90, and 120 min and 24 h in the presence of skim milk as an organic material. CHX, OCT, and PVP-I showed rapid fungicidal activity against all Candida isolates with 5–6 log10 reduction of viable counts after 30 min, whereas boric acid and NCT needed 1 h against Candida albicans and 2 h against non-albicans Candida for a significant 3 log10 reduction. NCT showed fungicidal activity (defined as ≥4 log10 reduction) against C. albicans within 90 min and C. non–albicans within 24 h. Based upon all presently available data, including our results, NCT could be used as a new agent for treatment of local fungal infections such as VVC.
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8
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Lin WC, Chen YR, Chuang CM, Chen JY. A Cationic Amphipathic Tilapia Piscidin 4 Peptide-Based Antimicrobial Formulation Promotes Eradication of Bacterial Vaginosis-Associated Bacterial Biofilms. Front Microbiol 2022; 13:806654. [PMID: 35444633 PMCID: PMC9015711 DOI: 10.3389/fmicb.2022.806654] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
Bacterial vaginosis (BV) is prevalent among women of reproductive age and has a high rate of recurrence, which can be largely attributed to ineffective BV biofilm eradication by current first-line antibiotics. In this study, we report that the Nile tilapia piscidin 4 (TP4) exhibits broad-spectrum antimicrobial and antibiofilm activity against BV-associated bacteria, but not beneficial lactobacilli. In addition, BV-associated Gardnerella vaginalis remains susceptible to TP4 even after continual exposure to the peptide for up to 22 passages. Gardnerella vaginalis and Streptococcus anginosus are both biofilm-forming BV-associated bacteria, and we found that combining TP4 peptide and disodium EDTA with the biofilm-disrupting agent, chitosan, can eradicate biofilms formed by single or mixed G. vaginalis and S. anginosus. In addition, long-term storage of TP4 peptide in chitosan did not diminish its bactericidal activity toward G. vaginalis. Preformulation studies were performed using High performance liquid chromatography (HPLC) and Circular Dichroism (CD). The long-term stability of TP4 peptide was assessed under various conditions, such as different temperatures and ionic strengths, and in the presence of H2O2 and lactic acid. When exposed to sodium dodecyl sulfate (SDS), TP4 maintained its secondary structure at various temperatures, salt and disodium EDTA concentrations. Furthermore, the TP4 microbicide formulation significantly reduced the colonization density of BV-associated bacteria in mice infected with single or mixed bacteria (G. vaginalis and S. anginosus). The TP4 microbicide formulation showed biocompatibility with beneficial human vaginal lactobacilli and female reproductive tissues in C57BL/6 mice. These results suggest that the TP4 microbicide formulation could be a promising topical microbicide agent for BV treatment.
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Affiliation(s)
- Wen-Chun Lin
- Marine Research Station, Institute of Cellular and Organismic Biology, Academia Sinica, Jiaushi, Taiwan
| | - Yun-Ru Chen
- Academia Sinica Protein Clinic, Institute of Biological Chemistry, Academia Sinica, Taipei, Taiwan
| | - Chi-Mu Chuang
- College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jyh-Yih Chen
- Marine Research Station, Institute of Cellular and Organismic Biology, Academia Sinica, Jiaushi, Taiwan
- *Correspondence: Jyh-Yih Chen,
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9
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Lazar AD, Gushcha SG, Koіeva KKA, Muratov VN. FEATURES OF THE INFLUENCE ON ALLOCHTHONOUS MICROORGANISMS OF SPECIFIC BIOLOGICALLY ACTIVE COMPONENTS OF PACKAGED MINERAL WATERS. BULLETIN OF PROBLEMS BIOLOGY AND MEDICINE 2022. [DOI: 10.29254/2077-4214-2022-3-166-345-349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- A. D. Lazar
- SI «Ukrainian Scientific-Research Institute of Medical Rehabilitation and Balneology, the Ministry of Public Health of Ukraine»
| | - S. G. Gushcha
- SI «Ukrainian Scientific-Research Institute of Medical Rehabilitation and Balneology, the Ministry of Public Health of Ukraine»
| | - Koі K. A. Koіeva
- SI «Ukrainian Scientific-Research Institute of Medical Rehabilitation and Balneology, the Ministry of Public Health of Ukraine»
| | - V. N. Muratov
- O.V. Bogatsky Physical-Chemical Institute National Academy of Sciences of Ukraine
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Armstrong-Buisseret L, Brittain C, Kai J, David M, Anstey Watkins J, Ozolins M, Jackson L, Abdali Z, Hepburn T, Griffiths F, Montgomery A, Daniels J, Manley A, Dean G, Ross JDC. Lactic acid gel versus metronidazole for recurrent bacterial vaginosis in women aged 16 years and over: the VITA RCT. Health Technol Assess 2022; 26:1-170. [DOI: 10.3310/zzkh4176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background
Bacterial vaginosis is a common and distressing condition associated with serious comorbidities. Antibiotic treatment is usually clinically effective in the short term, but recurrence is common and side effects can occur.
Objectives
The objective is to assess whether or not intravaginal lactic acid gel is clinically effective and cost-effective for treating recurrent bacterial vaginosis compared with oral metronidazole (Flagyl, Sanofi).
Design
This was an open-label, multicentre, parallel-arm, randomised (1 : 1) controlled trial.
Setting
This took place in one general practice and 19 sexual health centres in the UK.
Participants
Women aged ≥ 16 years with bacterial vaginosis symptoms and one or more episode(s) within the past 2 years took part.
Interventions
The interventions were 5 ml of intravaginal lactic acid gel taken once daily for 7 days (intervention) or 400-mg oral metronidazole tablets taken twice daily for 7 days (control).
Main outcome measures
The primary outcome was the resolution of bacterial vaginosis symptoms 14 days after randomisation. The secondary outcomes were time to first recurrence of symptoms; number of recurrences and treatment courses over 6 months; microbiological resolution on microscopy of vaginal smears at week 2; time to resolution of symptoms; tolerability, adherence and acceptability of the treatment; prevalence of concurrent sexually transmitted infections; quality of life; and cost-effectiveness.
Results
Recruitment stopped prior to reaching the target of 1900 participants on recommendation from the Data Monitoring Committee and Trial Steering Committee after a planned review of the results indicated that the research question had been answered. Overall, 518 participants were randomised and primary outcome data were available for 409 participants (79%; 204 in the metronidazole arm, 205 in the lactic acid gel arm). Participant-reported symptom resolution at week 2 was higher with metronidazole (143/204; 70%) than with lactic acid gel (97/205; 47%) (adjusted risk difference –23.2%, 95% confidence interval –32.3% to –14.0%). Recurrence in 6 months in a subset of participants who had initial resolution and were available for follow-up was similar across arms (metronidazole arm: 51/72, 71%; lactic acid gel arm: 32/46, 70%). A higher incidence of some side effects was reported with metronidazole than with lactic acid gel (nausea 32% vs. 8%; taste changes 18% vs. 1%; diarrhoea 20% vs. 6%, respectively). At week 2, the average cost per participant with resolved symptoms was £86.94 (metronidazole), compared with £147.00 (lactic acid gel). Some participants preferred using lactic acid gel even if they perceived it to be less effective than metronidazole.
Limitations
Loss to follow-up for collection of the primary outcome data was 21% and was similar in both arms. There is a risk of bias owing to missing outcome data at 3 and 6 months post treatment.
Conclusions
A higher initial response was seen with metronidazole than with lactic acid gel, but subsequent treatment failure was common with both. Lactic acid gel was less cost-effective than metronidazole. In general, women disliked taking repeated courses of metronidazole and preferred lactic acid gel, even when they were aware that it was less likely to provide symptom resolution. In the absence of effective curative therapy, further evaluation of non-antibiotic treatments to control the symptoms of recurrent bacterial vaginosis is required to improve quality of life for these patients. Further microbiological analysis of vaginal samples would be useful to identify additional factors affecting response to treatment.
Trial registration
Current Controlled Trials ISRCTN14161293.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Joe Kai
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Miruna David
- Clinical Microbiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jocelyn Anstey Watkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mara Ozolins
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Louise Jackson
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Zainab Abdali
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
| | - Alan Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alice Manley
- Department of Genitourinary Medicine, Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jonathan DC Ross
- Department of Genitourinary Medicine, Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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11
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Mittelstaedt R, Kretz A, Levine M, Handa VL, Ghanem KG, Sobel JD, Powell A, Tuddenham S. Data on Safety of Intravaginal Boric Acid Use in Pregnant and Nonpregnant Women: A Narrative Review. Sex Transm Dis 2021; 48:e241-e247. [PMID: 34561373 PMCID: PMC10100571 DOI: 10.1097/olq.0000000000001562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Intravaginal boric acid (IBA) represents one of the only options available to treat azole-resistant vulvovaginal candidiasis (VVC) and is included as part of multiple national guidelines (including the United Kingdom and the United States) for the treatment of VVC or recurrent bacterial vaginosis. Novel products using IBA are under development for treatment and suppression of VVC and bacterial vaginosis. Use of over-the-counter or clinician-prescribed IBA in reproductive-aged women is already widespread and may increase further if drug resistance in VVC rises. However, IBA is not a Food and Drug Administration-approved drug, and safety data are sparse. Given these factors, it is important to understand the currently available data on the safety of IBA use. Herein, we set out to synthesize human and animal data (converting, where appropriate, dose and serum values to standard units to facilitate comparison) to answer 2 key questions: (1) What are the data on the safety of IBA use for women? and (2) What are the data on the safety of IBA use in pregnancy? We find that, despite gaps, available data suggest IBA use is safe, at least when used in doses commonly described in the literature as being prescribed by clinicians. Information on harms in pregnancy is limited, and data remain insufficient to change current guidelines, which recommend IBA avoidance in pregnancy.
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Affiliation(s)
| | - Alyssa Kretz
- Johns Hopkins School of Medicine, Medical School
| | - Michael Levine
- University of California Los Angeles School of Medicine, Department of Emergency Medicine
| | - Victoria L. Handa
- Johns Hopkins School of Medicine, Department of Gynecology and Obstetrics
| | - Khalil G. Ghanem
- Johns Hopkins School of Medicine, Division of Infectious Disease
| | - Jack D. Sobel
- Wayne State University, Division of Infectious Disease
| | - Anna Powell
- Johns Hopkins School of Medicine, Department of Gynecology and Obstetrics
| | - Susan Tuddenham
- Johns Hopkins School of Medicine, Division of Infectious Disease
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Liu Q, Liu Z, Zhang C, Xu Y, Li X, Gao H. Effects of 3% Boric Acid Solution on Cutaneous Candida albicans Infection and Microecological Flora Mice. Front Microbiol 2021; 12:709880. [PMID: 34557169 PMCID: PMC8453016 DOI: 10.3389/fmicb.2021.709880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/25/2021] [Indexed: 12/24/2022] Open
Abstract
To determine the effect of 3% boric acid solution on cutaneous infections with Candida albicans (CA) in mice and its effect on skin microflora. Female mice were divided into three groups, with 18 mice in each group. Two injection sites were randomly selected, and 0.1 mL of CA mycelium suspension was injected into the epidermis and dermis of the back of mice. Group N was treated with sterile water for injection (SWFI). We observed the clinical manifestations, fungal fluorescence microscopic examination and colony count. Group B were hydropathically compressed with 3% boric acid solution for 30 min every 12 h. Group M was treated with SWFI, and group N was not treated. One week later, each group was observed with naked eyes, and skin samples were collected. The effect of boric acid on skin microflora was measured using Internal Transcribed Spacer Identification (ITS) and 16S rRNA genes. There were no significant changes in group M. In group B, the degree of skin injury was alleviated, the wounds healed markedly, and the exudate amount decreased. The effective rate of group B (83%) was significantly higher than that of group M (25%) (P < 0.05). The relative average abundance of Candida (P < 0.0001) and CA (P < 0.05) in group B was significantly lower than that in group M. Compared with group M, the microbial richness of group B changed little, but the diversity decreased. The flora structure of group B was significantly different from that of group M, but like that of group N. In group B, the abundance of Proteobacteria (P < 0.001), Enterobacteriaceae (P < 0.001), and Escherichia-Shigella (P < 0.001) was significantly greater, and the abundance of Firmicutes (P < 0.001), Staphylococcaceae (P < 0.001), and Staphylococcus (P < 0.001) were significantly lower. The 3% boric acid solution significantly reduced the symptoms of skin infection with Candida albicans. It inhibited the growth of Candida albicans and CA, reduced the diversity of skin microorganisms, increased the abundance of Proteobacteria, Enterobacteriaceae, Escherichia-Shigella, and reduced the abundance of Firmicutes, Staphylococcaceae, Staphylococcus.
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Affiliation(s)
- Qing Liu
- Department of Clinical Medicine, Hebei University of Engineering, Handan, China
| | - Zhao Liu
- Department of Dermatology, Affiliated Hospital of Hebei University of Engineering, Handan, China
| | - Changlin Zhang
- Department of Clinical Medicine, Hebei University of Engineering, Handan, China
| | - Yanyan Xu
- Department of Dermatology, Affiliated Hospital of Hebei University of Engineering, Handan, China
| | - Xiaojing Li
- Department of Dermatology, Affiliated Hospital of Hebei University of Engineering, Handan, China
| | - Hongqi Gao
- Department of Dermatology, Affiliated Hospital of Hebei University of Engineering, Handan, China
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Gavilanes-Martínez MA, Coral-Garzón A, Cáceres DH, García AM. Antifungal activity of boric acid, triclosan and zinc oxide against different clinically relevant Candida species. Mycoses 2021; 64:1045-1052. [PMID: 33969547 PMCID: PMC8373697 DOI: 10.1111/myc.13302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/10/2021] [Accepted: 05/03/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The genus Candida includes about 200 different species, but only a few are able to produce disease in humans. The species responsible for the highest proportion of human infections is Candida albicans. However, in the last two decades there has been an increase in the proportion of infections caused by other Candida species, including C. glabrata (Nakaseomyces glabrata), C. parapsilosis, C. tropicalis, C. krusei (Pichia kudriavzevi) and more recently C. auris. Decolonisation of patients has been used as an infection control strategy for bacterial infections, but information about decolonisation products used in clinical practice for Candida and other fungal pathogens is limited. Compounds with antimicrobial activity, such as triclosan (TR), boric acid (BA) and zinc oxide (ZO), are mainly used in personal care products. These products can be used for long periods of time without an abrasive skin effect and are a possible alternative for patient decolonisation in healthcare settings. OBJECTIVE The aim of this study was to evaluate the antifungal activity of boric acid (BA), triclosan (TR) and zinc oxide (ZO), individually and combined, against clinically relevant Candida species. MATERIALS AND METHODS Compounds to be screened for antifungal activity were evaluated at different concentrations, alone, and combined, using a well diffusion assay. The statistical evaluation was performed using analysis of variance (ANOVA) and a post hoc analysis using the multiple comparisons method. RESULTS Individually, BA and TR showed antifungal activity against all Candida species evaluated but ZO did not show any antifungal activity. Mixtures of BA [5%]-TR [0.2%]; BA [5%]-TR [0.3%]; BA [5%]-TR [0.2%]-ZO [8.6%]; and BA [5%]-TR [0.2%]-ZO [25%] yielded the highest antifungal activity. An increased antifungal effect was observed in some mixtures when compared with individual compounds. CONCLUSIONS We demonstrated antifungal activity of BA and TR against multiple Candida species, including against a clade of the emerging healthcare-associated pathogen C. auris. Additionally, this study shows enhancement of the antifungal effect and no antagonism among the mixtures of these compounds. Further research is needed to determine whether these compounds can reduce the burden of Candida on skin.
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Affiliation(s)
- Marly Alejandra Gavilanes-Martínez
- Departamento de Farmacia, Facultad de Ciencias Farmacéuticas y Alimentarias, Universidad de Antioquia, Medellín, Colombia
- Unidad de Biología Celular y Molecular, Corporación para Investigaciones Biológicas -CIB, Medellín, Colombia
| | - Alejandra Coral-Garzón
- Unidad de Biología Celular y Molecular, Corporación para Investigaciones Biológicas -CIB, Medellín, Colombia
| | - Diego H Cáceres
- Mycotic Diseases Branch, Centers for Disease Control and Prevention - CDC, Atlanta, GA, USA
- Department of Medical Microbiology, Radboud University Medical Center and Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - Ana María García
- Departamento de Farmacia, Facultad de Ciencias Farmacéuticas y Alimentarias, Universidad de Antioquia, Medellín, Colombia
- Unidad de Biología Celular y Molecular, Corporación para Investigaciones Biológicas -CIB, Medellín, Colombia
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Rizzo AE, Gordon JC, Berard AR, Burgener AD, Avril S. The Female Reproductive Tract Microbiome-Implications for Gynecologic Cancers and Personalized Medicine. J Pers Med 2021; 11:546. [PMID: 34208337 PMCID: PMC8231212 DOI: 10.3390/jpm11060546] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/30/2021] [Accepted: 06/05/2021] [Indexed: 11/17/2022] Open
Abstract
The microbial colonization of the lower female reproductive tract has been extensively studied over the past few decades. In contrast, the upper female reproductive tract including the uterine cavity and peritoneum where the ovaries and fallopian tubes reside were traditionally assumed to be sterile under non-pathologic conditions. However, recent studies applying next-generation sequencing of the bacterial 16S ribosomal RNA gene have provided convincing evidence for the existence of an upper female reproductive tract microbiome. While the vaginal microbiome and its importance for reproductive health outcomes has been extensively studied, the microbiome of the upper female reproductive tract and its relevance for gynecologic cancers has been less studied and will be the focus of this article. This targeted review summarizes the pertinent literature on the female reproductive tract microbiome in gynecologic malignancies and its anticipated role in future research and clinical applications in personalized medicine.
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Affiliation(s)
- Anthony E. Rizzo
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH 44106, USA; (A.E.R.); (J.C.G.)
| | - Jennifer C. Gordon
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH 44106, USA; (A.E.R.); (J.C.G.)
| | - Alicia R. Berard
- Department of Obstetrics and Gynecology, University of Manitoba, Winnipeg, MB R3E 0W2, Canada;
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Adam D. Burgener
- Department of Obstetrics and Gynecology, University of Manitoba, Winnipeg, MB R3E 0W2, Canada;
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, OH 44106, USA
- Case Comprehensive Cancer Center, Cleveland, OH 44106, USA
- Department of Pathology, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Stefanie Avril
- Case Comprehensive Cancer Center, Cleveland, OH 44106, USA
- Department of Pathology, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
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Bradfield Strydom M, Walpola RL, Khan S, Ware RS, Tiralongo E. Evidence-based update on Australasian pharmaceutical prescribing approaches for recurrent vulvovaginal candidiasis. Aust N Z J Obstet Gynaecol 2021; 61:496-499. [PMID: 34081319 DOI: 10.1111/ajo.13376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/15/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
Recurrent vulvovaginal candidiasis (RVVC) is a subtype of vulvovaginal candidiasis, with debilitating effects on physical and emotional well-being affecting up to 10% of Australian women. Current evidence suggests that the induction and maintenance approach for RVVC is not particularly effective with post-treatment relapse rates as high as 57%. Frequently accessed Australasian RVVC prescribing resources and guidelines were examined showing a variety of adaptations of current evidence-based induction and maintenance therapies, making it difficult to select best treatment in clinical practice. The ways to introduce more clarity and consistency into these guidelines are outlined.
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Affiliation(s)
- Moira Bradfield Strydom
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, Queensland, Australia
| | - Ramesh Lahiru Walpola
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Sohil Khan
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Robert S Ware
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Evelin Tiralongo
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, Queensland, Australia
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