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Lyu J, Gao M, Zhao S, Liu X, Zhao X, Zou Y, Zhong Y, Ge L, Zhang H, Huang L, Fan S, Xiao L, Zhang X. From whole genomes to probiotic candidates: A study of potential lactobacilli strains selection for vaginitis treatment. Heliyon 2024; 10:e30495. [PMID: 38765070 PMCID: PMC11098787 DOI: 10.1016/j.heliyon.2024.e30495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/12/2024] [Accepted: 04/29/2024] [Indexed: 05/21/2024] Open
Abstract
Vaginitis, characterized by pathogenic invasion and a deficiency in beneficial lactobacilli, has recognized lactobacilli supplementation as a novel therapeutic strategy. However, due to individual differences in vaginal microbiota, identifying universally effective Lactobacillus strains is challenging. Traditional methodologies for probiotic selection, which heavily depend on extensive in vitro experiments, are both time-intensive and laborious. The aim of this study was to pinpoint possible vaginal probiotic candidates based on whole-genome screening. We sequenced the genomes of 98 previously isolated Lactobacillus strains, annotating their genes involved in probiotic metabolite biosynthesis, adherence, acid/bile tolerance, and antibiotic resistance. A scoring system was used to assess the strains based on their genomic profiles. The highest-scoring strains underwent further in vitro evaluation. Consequently, two strains, Lactobacillus crispatus LG55-27 and Lactobacillus gasseri TM13-16, displayed an outstanding ability to produce d-lactate and adhere to human vaginal epithelial cells. They also showed higher antimicrobial activity against Gardnerella vaginalis, Escherichia coli, Candida albicans, Staphylococcus aureus, and Pseudomonas aeruginosa compared to reference Lactobacillus strains. Their resilience to acid and bile environments highlights the potential for oral supplementation. Oral and vaginal administration of these two strains were tested in a bacterial vaginosis (BV) rat model at various doses. Results indicated that combined vaginal administration of these strains at 1 × 106 CFU/day significantly mitigated BV in rats. This research offers a probiotic dosage guideline for vaginitis therapy, underscoring an efficient screening process for probiotics using genome sequencing, in vitro testing, and in vivo BV model experimentation.
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Affiliation(s)
- Jinli Lyu
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, 518036, China
- BGI-Shenzhen, Shenzhen, 518083, China
| | - Mengyu Gao
- BGI-Shenzhen, Shenzhen, 518083, China
- Shenzhen Engineering Laboratory of Detection and Intervention of Human Intestinal Microbiome, BGI-Shenzhen, Shenzhen, 518083, China
| | - Shaowei Zhao
- BGI-Shenzhen, Shenzhen, 518083, China
- Shenzhen Engineering Laboratory of Detection and Intervention of Human Intestinal Microbiome, BGI-Shenzhen, Shenzhen, 518083, China
| | - Xinyang Liu
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Xinlong Zhao
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Yuanqiang Zou
- BGI-Shenzhen, Shenzhen, 518083, China
- Shenzhen Engineering Laboratory of Detection and Intervention of Human Intestinal Microbiome, BGI-Shenzhen, Shenzhen, 518083, China
| | - Yiyi Zhong
- BGI Precision Nutrition (Shenzhen) Technology Co., Ltd, Shenzhen, 518083, China
| | - Lan Ge
- BGI Precision Nutrition (Shenzhen) Technology Co., Ltd, Shenzhen, 518083, China
| | - Hiafeng Zhang
- BGI Precision Nutrition (Shenzhen) Technology Co., Ltd, Shenzhen, 518083, China
| | - Liting Huang
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Shangrong Fan
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Liang Xiao
- BGI-Shenzhen, Shenzhen, 518083, China
- Shenzhen Engineering Laboratory of Detection and Intervention of Human Intestinal Microbiome, BGI-Shenzhen, Shenzhen, 518083, China
| | - Xiaowei Zhang
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, 518036, China
- BGI-Shenzhen, Shenzhen, 518083, China
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Minooei F, Kanukunta AR, Mahmoud MY, Gilbert NM, Lewis WG, Lewis AL, Frieboes HB, Steinbach-Rankins JM. Mesh and layered electrospun fiber architectures as vehicles for Lactobacillus acidophilus and Lactobacillus crispatus intended for vaginal delivery. BIOMATERIALS ADVANCES 2023; 154:213614. [PMID: 37659215 PMCID: PMC10873095 DOI: 10.1016/j.bioadv.2023.213614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/04/2023]
Abstract
Bacterial vaginosis (BV) is a recurrent condition that affects millions of women worldwide. The use of probiotics is a promising alternative or an adjunct to traditional antibiotics for BV prevention and treatment. However, current administration regimens often require daily administration, thus contributing to low user adherence and recurrence. Here, electrospun fibers were designed to separately incorporate and sustain two lactic acid producing model organisms, Lactobacillus crispatus (L. crispatus) and Lactobacillus acidophilus (L. acidophilus). Fibers were made of polyethylene oxide and polylactic-co-glycolic acid in two different architectures, one with distinct layers and the other with co-spun components. Degradation of mesh and layered fibers was evaluated via mass loss and scanning electron microscopy. The results show that after 48 h and 6 days, cultures of mesh and layered fibers yielded as much as 108 and 109 CFU probiotic/mg fiber in total, respectively, with corresponding daily recovery on the order of 108 CFU/(mg·day). In addition, cultures of the fibers yielded lactic acid and caused a significant reduction in pH, indicating a high level of metabolic activity. The formulations did not affect vaginal keratinocyte viability or cell membrane integrity in vitro. Finally, mesh and layered probiotic fiber dosage forms demonstrated inhibition of Gardnerella, one of the most prevalent and abundant bacteria associated with BV, respectively resulting in 8- and 6.5-log decreases in Gardnerella viability in vitro after 24 h. This study provides initial proof of concept that mesh and layered electrospun fiber architectures developed as dissolving films may offer a viable alternative to daily probiotic administration.
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Affiliation(s)
- Farnaz Minooei
- Department of Chemical Engineering, University of Louisville Speed School of Engineering, Louisville, KY 40202, USA.
| | - Abhinav R Kanukunta
- Department of Bioengineering, University of Louisville Speed School of Engineering, Louisville, KY 40202, USA.
| | - Mohamed Y Mahmoud
- Department of Bioengineering, University of Louisville Speed School of Engineering, Louisville, KY 40202, USA; Department of Toxicology and Forensic Medicine, Faculty of Veterinary Medicine, Cairo University, Egypt.
| | - Nicole M Gilbert
- Department of Pediatrics, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO 63110, USA; Center for Women's Infectious Disease Research, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Warren G Lewis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA; Glycobiology Research and Training Center, University of California San Diego, La Jolla, CA, USA
| | - Amanda L Lewis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA; Glycobiology Research and Training Center, University of California San Diego, La Jolla, CA, USA.
| | - Hermann B Frieboes
- Department of Bioengineering, University of Louisville Speed School of Engineering, Louisville, KY 40202, USA; Center for Predictive Medicine, University of Louisville, 505 S. Hancock St., Louisville, KY 40202, USA; Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY 40202, USA; UofL Health - Brown Cancer Center, University of Louisville, KY 40202, USA.
| | - Jill M Steinbach-Rankins
- Department of Bioengineering, University of Louisville Speed School of Engineering, Louisville, KY 40202, USA; Center for Predictive Medicine, University of Louisville, 505 S. Hancock St., Louisville, KY 40202, USA; Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY 40202, USA; Department of Microbiology and Immunology, University of Louisville School of Medicine, Louisville, KY, USA.
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Herold SE, Kyser AJ, Orr MG, Mahmoud MY, Lewis WG, Lewis AL, Steinbach-Rankins JM, Frieboes HB. Release Kinetics of Metronidazole from 3D Printed Silicone Scaffolds for Sustained Application to the Female Reproductive Tract. BIOMEDICAL ENGINEERING ADVANCES 2023; 5:100078. [PMID: 37123989 PMCID: PMC10136949 DOI: 10.1016/j.bea.2023.100078] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
Sustained vaginal administration of antibiotics or probiotics has been proposed to improve treatment efficacy for bacterial vaginosis. 3D printing has shown promise for development of systems for local agent delivery. In contrast to oral ingestion, agent release kinetics can be fine-tuned by the 3D printing of specialized scaffold designs tailored for particular treatments while enhancing dosage effectiveness via localized sustained release. It has been challenging to establish scaffold properties as a function of fabrication parameters to obtain sustained release. In particular, the relationships between scaffold curing conditions, compressive strength, and drug release kinetics remain poorly understood. This study evaluates 3D printed scaffold formulation and feasibility to sustain the release of metronidazole, a commonly used antibiotic for BV. Cylindrical silicone scaffolds were printed and cured using three different conditions relevant to potential future incorporation of temperature-sensitive labile biologics. Compressive strength and drug release were monitored for 14d in simulated vaginal fluid to assess long-term effects of fabrication conditions on mechanical integrity and release kinetics. Scaffolds were mechanically evaluated to determine compressive and tensile strength, and elastic modulus. Release profiles were fitted to previous kinetic models to differentiate potential release mechanisms. The Higuchi, Korsmeyer-Peppas, and Peppas-Sahlin models best described the release, indicating similarity to release from insoluble or polymeric matrices. This study shows the feasibility of 3D printed silicone scaffolds to provide sustained metronidazole release over 14d, with compressive strength and drug release kinetics tuned by the fabrication parameters.
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Affiliation(s)
- Sydney E. Herold
- Department of Bioengineering, University of Louisville, Louisville, KY, USA
| | - Anthony J. Kyser
- Department of Bioengineering, University of Louisville, Louisville, KY, USA
| | - Margaret G. Orr
- Department of Chemical Engineering, Bucknell University, Lewisburg, PA, USA
| | - Mohamed Y. Mahmoud
- Department of Bioengineering, University of Louisville, Louisville, KY, USA
- Department of Toxicology and Forensic Medicine, Faculty of Veterinary Medicine, Cairo University, Egypt
| | - Warren G. Lewis
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, California USA
- Glycobiology Research and Training Center, University of California San Diego, La Jolla, California USA
| | - Amanda L. Lewis
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, California USA
- Glycobiology Research and Training Center, University of California San Diego, La Jolla, California USA
| | - Jill M. Steinbach-Rankins
- Department of Bioengineering, University of Louisville, Louisville, KY, USA
- Department of Pharmacology and Toxicology, University of Louisville, Louisville, KY, USA
- Department of Microbiology and Immunology, University of Louisville, Louisville, KY, USA
| | - Hermann B. Frieboes
- Department of Bioengineering, University of Louisville, Louisville, KY, USA
- Department of Pharmacology and Toxicology, University of Louisville, Louisville, KY, USA
- Center for Predictive Medicine, University of Louisville, Louisville, KY, USA
- UofL Health – Brown Cancer Center, University of Louisville, KY, USA
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Kyser AJ, Masigol M, Mahmoud MY, Ryan M, Lewis WG, Lewis AL, Frieboes HB, Steinbach-Rankins JM. Fabrication and characterization of bioprints with Lactobacillus crispatus for vaginal application. J Control Release 2023; 357:545-560. [PMID: 37076014 PMCID: PMC10696519 DOI: 10.1016/j.jconrel.2023.04.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 04/21/2023]
Abstract
Bacterial vaginosis (BV) is characterized by low levels of lactobacilli and overgrowth of potential pathogens in the female genital tract. Current antibiotic treatments often fail to treat BV in a sustained manner, and > 50% of women experience recurrence within 6 months post-treatment. Recently, lactobacilli have shown promise for acting as probiotics by offering health benefits in BV. However, as with other active agents, probiotics often require intensive administration schedules incurring difficult user adherence. Three-dimensional (3D)-bioprinting enables fabrication of well-defined architectures with tunable release of active agents, including live mammalian cells, offering the potential for long-acting probiotic delivery. One promising bioink, gelatin alginate has been previously shown to provide structural stability, host compatibility, viable probiotic incorporation, and cellular nutrient diffusion. This study formulates and characterizes 3D-bioprinted Lactobacillus crispatus-containing gelatin alginate scaffolds for gynecologic applications. Different weight to volume (w/v) ratios of gelatin alginate were bioprinted to determine formulations with highest printing resolution, and different crosslinking reagents were evaluated for effect on scaffold integrity via mass loss and swelling measurements. Post-print viability, sustained-release, and vaginal keratinocyte cytotoxicity assays were conducted. A 10:2 (w/v) gelatin alginate formulation was selected based on line continuity and resolution, while degradation and swelling experiments demonstrated greatest structural stability with dual genipin and calcium crosslinking, showing minimal mass loss and swelling over 28 days. 3D-bioprinted L. crispatus-containing scaffolds demonstrated sustained release and proliferation of live bacteria over 28 days, without impacting viability of vaginal epithelial cells. This study provides in vitro evidence for 3D-bioprinted scaffolds as a novel strategy to sustain probiotic delivery with the ultimate goal of restoring vaginal lactobacilli following microbiological disturbances.
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Affiliation(s)
- Anthony J Kyser
- Department of Bioengineering, University of Louisville Speed School of Engineering, Louisville, KY 40202, USA.
| | - Mohammadali Masigol
- Center for Predictive Medicine, University of Louisville, Louisville, KY 40202, USA.
| | - Mohamed Y Mahmoud
- Center for Predictive Medicine, University of Louisville, Louisville, KY 40202, USA; Department of Toxicology and Forensic Medicine, Faculty of Veterinary Medicine, Cairo University, Egypt.
| | - Mark Ryan
- Department of Bioengineering, University of Louisville Speed School of Engineering, Louisville, KY 40202, USA.
| | - Warren G Lewis
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA; Glycobiology Research and Training Center, University of California San Diego, La Jolla, CA, USA.
| | - Amanda L Lewis
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA; Glycobiology Research and Training Center, University of California San Diego, La Jolla, CA, USA.
| | - Hermann B Frieboes
- Department of Bioengineering, University of Louisville Speed School of Engineering, Louisville, KY 40202, USA; Center for Predictive Medicine, University of Louisville, Louisville, KY 40202, USA; Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY 40202, USA; UofL Health - Brown Cancer Center, University of Louisville, KY 40202, USA.
| | - Jill M Steinbach-Rankins
- Department of Bioengineering, University of Louisville Speed School of Engineering, Louisville, KY 40202, USA; Center for Predictive Medicine, University of Louisville, Louisville, KY 40202, USA; Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY 40202, USA; Department of Microbiology and Immunology, University of Louisville School of Medicine, Louisville, KY, USA.
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Dedeloudi A, Siamidi A, Pavlou P, Vlachou M. Recent Advances in the Excipients Used in Modified Release Vaginal Formulations. MATERIALS 2022; 15:ma15010327. [PMID: 35009472 PMCID: PMC8745980 DOI: 10.3390/ma15010327] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 12/10/2022]
Abstract
The formulation of an ideal vaginal drug delivery system (DDS), with the requisite properties, with respect to safety, efficacy, patient compliance, aesthetics, harmonization with the regulatory requirements, and cost, requires a meticulous selection of the active ingredients and the excipients used. Novel excipients defined by diversity and multifunctionality are used in order to ameliorate drug delivery attributes. Synthetic and natural polymers are broadly used in pharmaceutical vaginal formulations (solid, semi-solid dosage forms, implantable devices, and nanomedicines) with a promising perspective in improving stability and compatibility issues when administered topically or systemically. Moreover, the use of biopolymers is aiming towards formulating novel bioactive, biocompatible, and biodegradable DDSs with a controllable drug release rate. Overviewing vaginal microenvironment, which is described by variable and perplexed features, a perceptive choice of excipients is essential. This review summarizes the recent advances on the excipients used in modified vaginal drug delivery formulations, in an attempt to aid the formulation scientist in selecting the optimal excipients for the preparation of vaginal products.
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Affiliation(s)
- Aikaterini Dedeloudi
- Department of Pharmacy, Division of Pharmaceutical Technology, School of Health Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (A.D.); (A.S.)
| | - Angeliki Siamidi
- Department of Pharmacy, Division of Pharmaceutical Technology, School of Health Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (A.D.); (A.S.)
| | - Panagoula Pavlou
- Laboratory of Chemistry-Biochemistry-Cosmetic Science, Department of Biomedical Sciences, University of West Attica, 28 Ag. Spyridonos Str., 12243 Egaleo, Greece;
| | - Marilena Vlachou
- Department of Pharmacy, Division of Pharmaceutical Technology, School of Health Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (A.D.); (A.S.)
- Correspondence: ; Tel.: +30-2107274674
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Verstraelen H, Vieira-Baptista P, De Seta F, Ventolini G, Lonnee-Hoffmann R, Lev-Sagie A. The Vaginal Microbiome: I. Research Development, Lexicon, Defining "Normal" and the Dynamics Throughout Women's Lives. J Low Genit Tract Dis 2022; 26:73-78. [PMID: 34928256 PMCID: PMC8719517 DOI: 10.1097/lgt.0000000000000643] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This series of articles, titled The Vaginal Microbiome, written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the current findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS A database search of PubMed was performed, using the search terms "vaginal microbiome" (VMB) with "research," "normal," "neonate," "puberty," "adolescent," "menopause," and "ethnicities," as well as "human microbiome project." Full article texts were reviewed. Reference lists were screened for additional articles. RESULTS In the last 2 decades, many studies applying molecular techniques were performed, intending to characterize the vaginal microbiota. These studies advanced our understanding of how vaginal health is defined. The first article in this series focuses on the advancement of VMB research, technical definitions, the definition of "normal" VMB, and the dynamics of VMB throughout women's lives. CONCLUSIONS Understanding how microorganisms inhabiting the vagina interact with each other and with the host is important for a more complete understanding of vaginal health. The clinical application of microbial community sequencing is in its beginning, and its interpretation regarding practical clinical aspects is yet to be determined.
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Affiliation(s)
- Hans Verstraelen
- Department of Obstetrics & Gynaecology, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Pedro Vieira-Baptista
- Hospital Lusíadas Porto, Porto, Portugal
- Lower Genital Tract Unit, Centro Hospitalar de São João, Porto, Portugal
- LAP, a Unilabs Company, Porto, Portugal
| | - Francesco De Seta
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Gary Ventolini
- Professor of Obstetrics and Gynecology, Distinguish University, Professor School of Medicine, Texas Tech University Health Sciences Center Permian Basin, Odessa, TX
| | - Risa Lonnee-Hoffmann
- Department of Obstetrics and Gynecology, St Olavs University Hospital, Trondheim, Norway
- Institute for Clinical and Molecular Medicine, Norwegian University for Science and Technology, Trondheim, Norway
| | - Ahinoam Lev-Sagie
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Carson L, Merkatz R, Martinelli E, Boyd P, Variano B, Sallent T, Malcolm RK. The Vaginal Microbiota, Bacterial Biofilms and Polymeric Drug-Releasing Vaginal Rings. Pharmaceutics 2021; 13:pharmaceutics13050751. [PMID: 34069590 PMCID: PMC8161251 DOI: 10.3390/pharmaceutics13050751] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/26/2022] Open
Abstract
The diversity and dynamics of the microbial species populating the human vagina are increasingly understood to play a pivotal role in vaginal health. However, our knowledge about the potential interactions between the vaginal microbiota and vaginally administered drug delivery systems is still rather limited. Several drug-releasing vaginal ring products are currently marketed for hormonal contraception and estrogen replacement therapy, and many others are in preclinical and clinical development for these and other clinical indications. As with all implantable polymeric devices, drug-releasing vaginal rings are subject to surface bacterial adherence and biofilm formation, mostly associated with endogenous microorganisms present in the vagina. Despite more than 50 years since the vaginal ring concept was first described, there has been only limited study and reporting around bacterial adherence and biofilm formation on rings. With increasing interest in the vaginal microbiome and vaginal ring technology, this timely review article provides an overview of: (i) the vaginal microbiota, (ii) biofilm formation in the human vagina and its potential role in vaginal dysbiosis, (iii) mechanistic aspects of biofilm formation on polymeric surfaces, (iv) polymeric materials used in the manufacture of vaginal rings, (v) surface morphology characteristics of rings, (vi) biomass accumulation and biofilm formation on vaginal rings, and (vii) regulatory considerations.
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Affiliation(s)
- Louise Carson
- School of Pharmacy, Queen’s University Belfast, Belfast BT9 7BL, UK; (L.C.); (P.B.)
| | - Ruth Merkatz
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Elena Martinelli
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Peter Boyd
- School of Pharmacy, Queen’s University Belfast, Belfast BT9 7BL, UK; (L.C.); (P.B.)
| | - Bruce Variano
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Teresa Sallent
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Robert Karl Malcolm
- School of Pharmacy, Queen’s University Belfast, Belfast BT9 7BL, UK; (L.C.); (P.B.)
- Correspondence:
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Bastianelli C, Farris M, Bianchi P, Benagiano G. The effect of different contraceptive methods on the vaginal microbiome. Expert Rev Clin Pharmacol 2021; 14:821-836. [PMID: 33863265 DOI: 10.1080/17512433.2021.1917373] [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] [Indexed: 12/14/2022]
Abstract
Introduction: Following a historical overview, the effect of different contraceptive methods on vaginal microbiome has been reviewed and summarized.Areas covered: Effects of combined hormonal contraceptives (oral or vaginal) and of progestin only (injectable and implantable), intrauterine devices/systems (copper- or levonorgestrel-releasing), on vaginal microbiome. In addition, mention is made of vaginal rings releasing antiviral drugs and lactic acid.Expert opinion: The vaginal microbiota (VM) is unique in that it is normally dominated by Lactobacillus species providing a degree of protection against infections; this however may vary, depending on the species and strains of Lactobacillus. Bacterial Vaginosis represents the most common dysbiosis of the VM and its prevalence can be influenced by use of contraception. Available evidence indicates that, under the influence of oral or systemically administered female sex hormones, there is apromotion of vaginal eubiosis, with aprevalence of ahealthy VM in which Lactobacilli predominate.
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Affiliation(s)
- Carlo Bastianelli
- Department of Maternal & Child Health, Gynecology and Urology, Sapienza, University of Rome, Rome, Italy
| | - Manuela Farris
- Department of Maternal & Child Health, Gynecology and Urology, Sapienza, University of Rome, Rome, Italy.,Italian Association for Demographic Education, AIED, Rome, Italy
| | - Paola Bianchi
- Department of Medico-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Giuseppe Benagiano
- Department of Maternal & Child Health, Gynecology and Urology, Sapienza, University of Rome, Rome, Italy
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Tomás M, Palmeira-de-Oliveira A, Simões S, Martinez-de-Oliveira J, Palmeira-de-Oliveira R. Bacterial vaginosis: Standard treatments and alternative strategies. Int J Pharm 2020; 587:119659. [PMID: 32687973 DOI: 10.1016/j.ijpharm.2020.119659] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/24/2020] [Accepted: 07/13/2020] [Indexed: 12/23/2022]
Abstract
Bacterial vaginosis (BV) affects many women and has a high influence on their self-esteem, being associated with huge discomfort and changes in the routines, especially the sexual life. International guidelines recommend the administration of metronidazole, clindamycin or tinidazole orally or intravaginally as the standard treatment. However, the treatment with these antibiotics is associated with high levels of failure and recurrence rates. These may be associated with antibiotic resistance, the inability to eradicate the polymicrobial biofilms, and failure to reestablish acidic pH and the lactobacillus-dominated commensal flora. Therefore, it is emergent to study alternative strategies to replace or to be combined with standard therapies in order to prevent and treat BV more efficiently. Alternative strategies may include antimicrobial substances (other antimicrobials, antiseptics and natural compounds) or substances that aim to reestablish the physiologic vaginal environment (probiotics, prebiotics and acidifying agents) while improving the local immunity response. Besides, the development of formulation strategies and new dosage forms and drug delivery systems can improve treatment efficacy and overcome some limitations associated with conventional products.
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Affiliation(s)
- Mariana Tomás
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Avenida, Infante D. Henrique, 6200-506 Covilhã, Portugal
| | - Ana Palmeira-de-Oliveira
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Avenida, Infante D. Henrique, 6200-506 Covilhã, Portugal; Labfit-HPRD Health Products Research and Development, Lda Edifício UBIMedical, Estrada Municipal 506, 6200-281 Covilhã, Portugal
| | - Sérgio Simões
- CNC-Center for Neurosciences and Cell Biology, University of Coimbra, 3004-531 Coimbra, Portugal
| | - José Martinez-de-Oliveira
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Avenida, Infante D. Henrique, 6200-506 Covilhã, Portugal
| | - Rita Palmeira-de-Oliveira
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Avenida, Infante D. Henrique, 6200-506 Covilhã, Portugal; CNC-Center for Neurosciences and Cell Biology, University of Coimbra, 3004-531 Coimbra, Portugal.
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Tietz K, Klein S. In Vitro Methods for Evaluating Drug Release of Vaginal Ring Formulations-A Critical Review. Pharmaceutics 2019; 11:pharmaceutics11100538. [PMID: 31623277 PMCID: PMC6836189 DOI: 10.3390/pharmaceutics11100538] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/09/2019] [Accepted: 10/14/2019] [Indexed: 12/28/2022] Open
Abstract
The vagina is a promising site for both local and systemic drug delivery and represents an interesting administration route for compounds with poor oral bioavailability. Whereas most of the currently marketed dosage forms were designed as immediate release formulations, intravaginal rings (IVRs) offer the possibility of a controlled vaginal drug delivery over several weeks or months. For a long time, the development of IVRs was limited to steroid-releasing formulations. Recently, IVRs have witnessed a surge of new interest as promising delivery systems for microbicides. Therefore, various novel IVR designs have been introduced. To ensure that only safe and effective IVRs will be administered to patients, it is important to properly distinguish between IVRs with desired and undesired release performance. In vitro methods for evaluating drug release of IVRs that present with sufficient predictive capacity for in vivo drug release, and discriminatory power with regard to IVRs quality, are an essential tool for this purpose. The objective of the present review article is to present the current status of in vitro drug release testing of IVRs and to critically discuss current compendial and non-official in vitro drug release methods with regard to their discriminatory power and in vivo predictivity.
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Affiliation(s)
- Katharina Tietz
- Center of Drug Absorption and Transport, Institute of Biopharmaceutics and Pharmaceutical Technology, Department of Pharmacy, Felix-Hausdorff-Str. 3, University of Greifswald, Greifswald 17489, Germany
| | - Sandra Klein
- Center of Drug Absorption and Transport, Institute of Biopharmaceutics and Pharmaceutical Technology, Department of Pharmacy, Felix-Hausdorff-Str. 3, University of Greifswald, Greifswald 17489, Germany.
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11
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Sobel JD, Kaur N, Woznicki NA, Boikov D, Aguin T, Gill G, Akins RA. Conventional oral and secondary high dose vaginal metronidazole therapy for recurrent bacterial vaginosis: clinical outcomes, impacts of sex and menses. Infect Drug Resist 2019; 12:2297-2307. [PMID: 31413606 PMCID: PMC6661983 DOI: 10.2147/idr.s213853] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 06/19/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose Oral metronidazole therapy is the standard of care for bacterial vaginosis (BV), yet it has alarming rates of recurrence and refractory responses among recurrent BV (RBV) patients. This study addresses whether high dose vaginal metronidazole therapy (HDM) is beneficial in RBV patients who fail after standard of care (SOC) therapy, whether diagnostic test scores proximal to the HDM predict clinical outcome, and whether menses, coitus, or race influences therapy outcome. Patients and methods A total of 90 patients with RBV were given SOC and tracked 74 for up to 9 months. Refractory or recurrent patients (57) with symptomatic BV were given HDM and followed for up to 8 months. Patients were evaluated by Amsel criteria, Nugent score, and a qPCR assay that assesses the Lactobacillus content. Results HDM achieved at least short-term remission in 68% of the patients who were refractory to or recurred after SOC and provided a 10-day increase in the mean duration of remission among patients who eventually recurred (p=0.027). Patients with prolonged dysbiosis (pH >5 or Amsel 4) before symptomatic recurrence were more likely to recur after subsequent HDM. Most recurrence happened within 10 days of menses, but sex in this cohort was not associated with clinical outcome. Mean diagnostic BV scores of African American patients in remission were inferior to scores of a small cohort of Caucasian patients in remission. Conclusion Encouraging results obtained with HDM justify a prospective, randomized study to determine if follow-up HDM is beneficial among a broader cohort of women failing conventional oral metronidazole therapy.
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Affiliation(s)
- Jack D Sobel
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, MI, USA
| | - Navkiranjot Kaur
- Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit MI, USA
| | - Nicole A Woznicki
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, MI, USA
| | - Dina Boikov
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, MI, USA
| | - Tina Aguin
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Gurveer Gill
- Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit MI, USA
| | - Robert A Akins
- Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit MI, USA
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12
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Abstract
Sixteen years ago, when we published the first molecular characterization of the vaginal microbiota, little did we know the vast numbers of species that would be detected in this niche. As exciting as these discoveries have been, what have they and more recent advances contributed to how vaginal health and disease are managed? This review provides a brief discussion of the potential, but so far limited, applications that have arisen from microbiome research. Calls for innovation have been made before but to little avail.
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Affiliation(s)
- Gregor Reid
- Departments of Microbiology & Immunology, and Surgery (Urology), Western University, and Lawson Health Research Institute, 268 Grosvenor Street, London, ON, N6A 4V2, Canada
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13
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Hearps AC, Tyssen D, Srbinovski D, Bayigga L, Diaz DJD, Aldunate M, Cone RA, Gugasyan R, Anderson DJ, Tachedjian G. Vaginal lactic acid elicits an anti-inflammatory response from human cervicovaginal epithelial cells and inhibits production of pro-inflammatory mediators associated with HIV acquisition. Mucosal Immunol 2017; 10:1480-1490. [PMID: 28401934 DOI: 10.1038/mi.2017.27] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 02/24/2017] [Indexed: 02/04/2023]
Abstract
Inflammation in the female reproductive tract (FRT) is associated with increased HIV transmission. Lactobacillus spp. dominate the vaginal microbiota of many women and their presence is associated with reduced HIV acquisition. Here we demonstrate that lactic acid (LA), a major organic acid metabolite produced by lactobacilli, mediates anti-inflammatory effects on human cervicovaginal epithelial cells. Treatment of human vaginal and cervical epithelial cell lines with LA (pH 3.9) elicited significant increases in the production of the anti-inflammatory cytokine IL-1RA. When added simultaneously or prior to stimulation, LA inhibited the Toll-like receptor agonist-elicited production of inflammatory mediators IL-6, IL-8, TNFα, RANTES, and MIP3α from epithelial cell lines and prevented IL-6 and IL-8 production by seminal plasma. The anti-inflammatory effect of LA was mediated by the protonated form present at pH≤3.86 and was observed with both L- and D-isomers. A similar anti-inflammatory effect of LA was observed in primary cervicovaginal cells and in an organotypic epithelial tissue model. These findings identify a novel property of LA that acts directly on epithelial cells to inhibit FRT inflammation and highlights the potential use of LA-containing agents in the lower FRT as adjuncts to female-initiated strategies to reduce HIV acquisition.
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Affiliation(s)
- A C Hearps
- Centre for Biomedical Research, Burnet Institute, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Monash University, Melbourne, Victoria, Australia
| | - D Tyssen
- Centre for Biomedical Research, Burnet Institute, Melbourne, Victoria, Australia
| | - D Srbinovski
- Centre for Biomedical Research, Burnet Institute, Melbourne, Victoria, Australia.,Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - L Bayigga
- Departments of Obstetrics and Gynecology, Microbiology and Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - D J D Diaz
- Centre for Biomedical Research, Burnet Institute, Melbourne, Victoria, Australia.,Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - M Aldunate
- Centre for Biomedical Research, Burnet Institute, Melbourne, Victoria, Australia.,Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - R A Cone
- Department of Biophysics, Johns Hopkins University, Baltimore, Maryland, USA
| | - R Gugasyan
- Centre for Biomedical Research, Burnet Institute, Melbourne, Victoria, Australia.,Department of Immunology, Monash University, Melbourne, Victoria, Australia
| | - D J Anderson
- Departments of Obstetrics and Gynecology, Microbiology and Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - G Tachedjian
- Centre for Biomedical Research, Burnet Institute, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Monash University, Melbourne, Victoria, Australia.,Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia.,School of Science, College of Science, Engineering and Health, RMIT University, Melbourne, Victoria, Australia
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14
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李 锦, 宋 亚, 寻 添, 谭 穗, 刘 叔. [Lactic acid inhibits the formation of semen-derived amyloid fibrils]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:907-913. [PMID: 28736366 PMCID: PMC6765509 DOI: 10.3969/j.issn.1673-4254.2017.07.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To investigate the inhibitory effect of lactic acid on semen-derived amyloid (SEVI) fibril formation. METHODS PAP248-286 (2 mg/mL) was incubated with 4.0, 2.0, 1.0, 0.5, 0.25, and 0.125 mg/mL of lactic acid. After incubation for different times, aliquots were drawn from each sample for Thioflavin T (ThT) and Congo red staining to monitor semen-derived amyloid fibril formation. The β sheet structure formation of PAP248-286 was measured by circular dichroism spectrum, and the morphology of amyloid fibrils incubated with or without lactic acid was observed with transmission electron microscopy (TEM). The enhancing effect of amyloid fibril incubated with lactic acid at different time points was determined using virus infection assay. PAP248-286 (2 mg/mL) was incubated with dilutions of vaginal secretion from healthy women, and amyloid fibril formation was detected with ThT and Congo red staining. RESULTS Lactic acid inhibited SEVI fibril formation in a dose-dependent manner in vitro. Lactic acid at 0.5 mg/mL completely inhibited 2 mg/mL SEVI fibril formation within 48 h. After incubation for 48 h, lactic acid at 1 mg/mL inhibited the formation of β-sheet structure of SEVI (2 mg/mL) and completely inhibited 2 mg/mL PAP248-286 aggregation as observed with TEM. In the presence of lactic acid, PAP248-286 lost the ability to enhance virus infection. Vaginal secretion inhibited SEVI fibril formation in a dose-dependent manner, and virtually no SEVI fibril occurred after incubation of 2 mg/mL PAP248-286 with 67% vaginal secretion. CONCLUSION Lactic acid inhibits SEVI fibril formation in vitro.
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Affiliation(s)
- 锦清 李
- 南方医科大学 药学院,广东 广州 510515School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - 亚丽 宋
- 南方医科大学 南方医院妇产科生殖医学中心,广东 广州 510515Reproductive Medical Center, Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 添荣 寻
- 南方医科大学 药学院,广东 广州 510515School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - 穗懿 谭
- 南方医科大学 药学院,广东 广州 510515School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - 叔文 刘
- 南方医科大学 药学院,广东 广州 510515School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
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Verstraete G, Vandenbussche L, Kasmi S, Nuhn L, Brouckaert D, Van Renterghem J, Grymonpré W, Vanhoorne V, Coenye T, De Geest BG, De Beer T, Remon JP, Vervaet C. Thermoplastic polyurethane-based intravaginal rings for prophylaxis and treatment of (recurrent) bacterial vaginosis. Int J Pharm 2017; 529:218-226. [PMID: 28663088 DOI: 10.1016/j.ijpharm.2017.06.076] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 06/21/2017] [Accepted: 06/22/2017] [Indexed: 10/19/2022]
Abstract
The aim of the present study was to develop thermoplastic polyurethane (TPU)-based intravaginal rings (IVRs) for prophylaxis and treatment of bacterial vaginosis via hot melt extrusion/injection molding. Therefore, different TPU grades were processed in combination with lactic acid or metronidazole, targeting a sustained lactic acid release over a 28day-period and sustained metronidazole release over 4-7days. Hot melt extrusion of lactic acid/TPU combinations required a lower extrusion temperature due to the plasticizing properties of lactic acid, evidenced by the lower glass transition temperature (Tg) and cross-over point (Ttanδ=1) values. NIR-chemical imaging data showed a homogenous distribution of lactic acid in TPU matrices at drug loads up to 30% (w/w). The addition of metronidazole did not lower processing temperatures, as the active pharmaceutical ingredient remained crystalline in the TPU matrix. Hydrophobic TPUs with a low ratio between the soft and hard segments (SS/HS ratio) in the polymer structure were suitable carriers for the lactic acid-eluting device over a 28-day period, while hydrophilic TPUs were needed to achieve the required release rate of metronidazole-eluting IVRs. IVRs manufactured with a TPU grade having a higher SS/HS ratio and lactic acid/TPU ratio exhibited a more elastic behavior. The addition of 25% (w/w) metronidazole did not affect the mechanical properties of the IVRs. Hydrophilic TPUs were most prone to biofilm formation by Candida albicans and Staphylococcus aureus, but the incorporation of metronidazole in the device prevented biofilm formation. Based on the drug eluting performance and mechanical tests, a mixture of lactic acid and Tecoflex™ EG-93A (20/80, w/w) and a combination of metronidazole and Tecophilic™ SP-93A-100 (25/75, w/w) were selected to design IVRs for the prophylaxis and treatment of bacterial vaginosis, respectively. Slug mucosal irritation tests predicted low irritation potency for both devices.
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Affiliation(s)
- G Verstraete
- Laboratory of Pharmaceutical Technology, Ghent University, Ghent, Belgium
| | - L Vandenbussche
- Laboratory of Pharmaceutical Technology, Ghent University, Ghent, Belgium
| | - S Kasmi
- Laboratory of Pharmaceutical Technology, Ghent University, Ghent, Belgium
| | - L Nuhn
- Laboratory of Pharmaceutical Technology, Ghent University, Ghent, Belgium
| | - D Brouckaert
- Laboratory of Pharmaceutical Process Analytical Technology, Ghent University, Ghent, Belgium
| | - J Van Renterghem
- Laboratory of Pharmaceutical Process Analytical Technology, Ghent University, Ghent, Belgium
| | - W Grymonpré
- Laboratory of Pharmaceutical Technology, Ghent University, Ghent, Belgium
| | - V Vanhoorne
- Laboratory of Pharmaceutical Technology, Ghent University, Ghent, Belgium
| | - T Coenye
- Laboratory of Pharmaceutical Microbiology, Ghent University, Ghent, Belgium
| | - B G De Geest
- Laboratory of Pharmaceutical Technology, Ghent University, Ghent, Belgium
| | - T De Beer
- Laboratory of Pharmaceutical Process Analytical Technology, Ghent University, Ghent, Belgium
| | - J P Remon
- Laboratory of Pharmaceutical Technology, Ghent University, Ghent, Belgium
| | - C Vervaet
- Laboratory of Pharmaceutical Technology, Ghent University, Ghent, Belgium.
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16
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Highly efficient treatment of aerobic vaginitis with simple acidic buffered gels: The importance of pH and buffers on the microenvironment of vaginas. Int J Pharm 2017; 525:175-182. [DOI: 10.1016/j.ijpharm.2017.04.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/31/2017] [Accepted: 04/11/2017] [Indexed: 01/09/2023]
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17
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The role of lactic acid production by probiotic Lactobacillus species in vaginal health. Res Microbiol 2017; 168:782-792. [PMID: 28435139 DOI: 10.1016/j.resmic.2017.04.001] [Citation(s) in RCA: 272] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 04/03/2017] [Accepted: 04/03/2017] [Indexed: 12/12/2022]
Abstract
Vaginal eubiosis is characterised by beneficial lactobacillus-dominated microbiota. In contrast, vaginal dysbiosis (e.g. bacterial vaginosis, BV), characterised by an overgrowth of multiple anaerobes, is associated with an increased risk of adverse urogenital and reproductive health outcomes. A major distinguishing feature between the vaginal environment in states of eubiosis and dysbiosis is a high concentration of lactic acid, produced by lactobacilli, that acidifies the vagina in eubiosis versus a sharp drop in lactic acid and an increase in pH in dysbiosis. Here we review the antimicrobial, antiviral and immunomodulatory properties of lactic acid and the use of lactic acid and lactobacilli probiotics in preventing or treating BV.
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